Variations in Mechanisms of Injury for Children with Concussion

Sport and Recreation Related Concussion in Children: National Concussion Surveillance System

INTRODUCTION

Concussions sustained during sports and recreational activities are a concern for young athletes. The purpose of this study was to estimate past 12-month sport- and recreation-related (SRR) traumatic brain injuries (TBIs) among a sample of children.

METHODS

Pilot data from the Centers for Disease Control and Prevention's National Concussion Surveillance System were analyzed. National Concussion Surveillance System utilized a cross-sectional random-digit-dial telephone survey using computer-assisted telephone interviewing to collect self/proxy-reported data from 2018 to 2019. Adults with children aged 5-17 in the household were asked about head injuries sustained by their children. Estimates were stratified by sociodemographic and injury circumstance characteristics. Data analysis occurred from April 2022 to July 2023.

RESULTS

Utilizing a tiered case definition developed by the Centers for Disease Control and Prevention, an estimated 6.9% (95% confidence interval [CI], 6.0%-7.8%) of the sample's 5-17-year-old children sustained at least one probable or possible SRR-TBI in the previous 12 months; 3.3% (95% CI, 2.7%-4.0%) of the children sustained at least one probable SRR-TBI. An estimated 63.6% (95% CI, 58.1%-69.0%) of all reported TBIs were attributed to SRR activities. Of the SRR-TBIs reported, 41.1% (95% CI, 33.0%-49.2%) were experienced while playing contact sports. Symptoms did not resolve for 8 or more days or had not resolved at the time of the interview for 18.1% (95% CI, 13.0%-23.1%) of the children's most recent SRR-TBI.

CONCLUSIONS

Many proxy-reported TBIs among children aged 5-17 years were due to sports and recreational activities. Athletic trainers and healthcare providers can play a role in the prevention, identification, and management of SRR-TBIs in their respective environments.

Pediatric Concussions in Contact Sports: A 10-Year Retrospective Analysis of Mechanisms and Associated Symptoms

Background

Concussions make up a significant proportion of sports injuries. This study aimed to describe the mechanisms of injury and associated symptoms of pediatric patients diagnosed with concussions (age range, 4-17 years) from contact sports.

Hypothesis

Mechanisms of injury would differ based on sex and age, with female athletes and younger athletes aged 4 to 11 years sustaining fewer concussions from player-to-player contact.

Study Design

Descriptive epidemiology study.

Methods

The National Electronic Injury Surveillance System was queried for all contact sport concussions presented to United States emergency departments. The sports analyzed included basketball, football, soccer, hockey, rugby, and lacrosse. Descriptive data, mechanisms of injury, and associated symptoms were analyzed for each sport. Differences in the number of concussions sustained by year and sport, the severity of the injury, and associated symptoms were compared using chi-square test, and differences in proportion were calculated for mechanisms of injury stratified by sex and age.

Results

A total of 12,602 youth athletes sustained concussions between 2012 and 2021. Most patients were male (78.5%), with a mean age of 13.48 years. Football concussions were the most common, with 45.32% of the concussions. The mechanism of injury was largely sport-specific, with player-to-player contact the most common overall. Older male athletes were more likely to have concussions from player-to-player contact, whereas younger athletes were more impacted by head-to-ground mechanisms. Symptom presentation was not sport-specific, and headache and dizziness were the most common presentation at 41.2% and 26.2%, respectively.

Conclusion

The most important overall mechanism of injury was player-to-player contact, especially in older male youth athletes, whereas younger athletes were more likely to be concussed due to head-to-ground injuries.

Characteristics of Pediatric Concussion across Different Mechanisms of Injury in 5 through 12-Year-Olds

OBJECTIVE

To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and nonsport or recreation-related concussion (non-SRRC) in patients 5 through 12 years old, an understudied population in youth concussion.

STUDY DESIGN

This observational study included patients aged 5 through 12 years presenting to a specialty care concussion setting at ≤28 days postinjury from 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Posthoc pairwise comparisons were employed for all analyses (α = 0.017).

RESULTS

One thousand one hundred forty-one patients reported at ≤28 days of injury (female = 42.9%, median age = 11, interquartile range (IQR) = 9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (P < .001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 2 and 3 days later than SRC (P < .001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (P < .001) compared with RRC and SRC (P < .001).

CONCLUSIONS

In concussion patients 5 through 12 years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury.

Geographic characteristics of sport- and non-sport-related concussions presenting to emergency departments in the United States

BACKGROUND

Concussion is a type of traumatic brain injury (TBI) that can be sustained through sport-related and non-sport-related (e.g., motor vehicle accidents, falls, assaults) mechanisms of injury (MOI). Variations in concussion incidence and MOI may be present throughout the four geographic regions (Midwest, Northeast, South, West) of the United States. However, there is limited evidence exploring concussion cause and diagnosis patterns based on geographic region and MOI. These factors have implications for better understanding the burden of concussion and necessary efforts that can translate to the mitigation of safety concerns.

PURPOSE

The purpose of this study was to identify patterns of sport-related concussion (SRC) and non-sport-related concussion (NSRC) across the four geographic regions of the United States.

METHODS

A descriptive epidemiology study of patient visits to the emergency department (ED) for concussion between 2010 and 2018, using publicly available data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) was conducted. The exposure of interest was geographic region while the main outcome measures were concussion diagnosis and MOI. Descriptive statistics were calculated using population-weighted frequencies and percentages. The association between geographic region and MOI (SRC vs. NSRC) was analyzed using logistic regression models. Odds ratios (OR) presented with 95% confidence intervals (CI) were included. Univariate analyses were conducted followed by multivariable analyses adjusting for sex, age, race/ethnicity, and primary source of payment. Statistical significance was set a priori at p < 0.05 for all analyses.

RESULTS

From 2010 to 2018, 1,161 visits resulted in a concussion diagnosis, representing an estimated 7,111,856 visits nationwide. A greater proportion of concussion diagnoses occurred within EDs in the South (38.2%) followed by the West (25.8%), Midwest (21.4%), and Northeast (14.6%). Compared to the West region, patients visiting the ED in the Midwest (OR = 0.75, 95% CI = 0.57-0.98) and Northeast (OR = 0.71, 95% CI = 0.51-0.98) had a lower odds of being diagnosed with a concussion. More patients sustained a NSRC MOI (94.3%) compared to SRC MOI (5.7%). For both mechanisms, the South region had the highest population-weighted frequency of SRC (n = 219,994) and NSRC diagnoses (n = 2,495,753). Univariate and multivariable logistic regression analyses did not reveal statistically significant associations for geographic region and MOI (p > 0.05).

CONCLUSION

Our findings showed that the Midwest and Northeast regions had a lower odds of concussion diagnoses in EDs. Overall, the vast majority of concussions were not sport-related, which has public health implications. These findings improve our understanding of how concussion injuries are being sustained geographically nationwide and help to explain care-seeking patterns for concussion in the ED setting.

Social vulnerability and traumatic brain injury hospitalizations from sports and recreation among pediatric patients in the United States

PURPOSE

This study examined the associations between individual as well as neighborhood social vulnerability and sports and recreation-related traumatic brain injury (SR-TBI) hospitalizations among pediatric patients in the U.S.

METHODS

We obtained 2009, 2010 and 2011 hospitalization data in the U.S. from the National Inpatient Sample (NIS) database, linked it to 2010 neighborhood social vulnerability index (SVI) data from the Centers for Disease Prevention and Control (CDC), and assigned U.S. hospitals to one of four SVI quartiles. SR-TBI outcomes studied include: odds of hospitalization, length of stay (LOS), and discharge to post-acute care (DTPAC).

RESULTS

We found associations between race/ethnicity and all SR-TBI outcomes; however, sex, primary payer, and neighborhood overall SVI were only associated with LOS. Compared to White children, Native American children had almost three times higher odds of hospitalization for SR-TBI (OR: 2.82, 95% CI: 1.30, 6.14), 27% longer LOS (β: 27.06, 95% CI: 16.56, 38.51), but 99.9% lower odds of DTPAC (OR: 0.001, 95% CI: 0.00, 0.01). Compared to children with private insurance, children with public insurance had 11% longer LOS (β: 10.83, 95% CI: 8.65, 13.05). Hospitalization in neighborhood with higher overall SVI was associated with longer LOS (p < 0.0001).

CONCLUSIONS

These findings suggest that individual and neighborhood social vulnerability can have a significant impact on the health outcomes of children, especially in the context of SR-TBI.

Reduced Concussion Symptom Burden in Early Adolescent Athletes Using a Head-Neck Cooling Device

OBJECTIVE

To determine whether an investigational head-neck cooling device, Pro2cool, can better reduce symptom severity compared with standard postconcussion care in early adolescent athletes after a sports-related concussion.

DESIGN

Prospective, longitudinal, randomized trial design conducted over a 28-day period.

SETTING

Six pediatric medical centers in Ohio and Michigan.

PARTICIPANTS

The study enrolled 167 male and female 12- to 19-year-old athletes who experienced a sports-related concussion within 8 days of study enrollment and registering a Sports Concussion Assessment Tool 5 (SCAT5) composite score >7.

INTERVENTIONS

Pro2cool, an investigational head-neck cooling therapy device, was applied at 2 postinjury time points compared with postconcussion standard of care only.

MAIN OUTCOME MEASURES

Baseline SCAT5 composite symptom severity scores were determined for all subjects. Sports Concussion Assessment Tool 5 scores for concussed athletes receiving cooling treatment were analyzed across 6 independent postenrollment time points compared with subjects who did not receive cooling therapy and only standard care. Adverse reactions and participate demographics were also compared.

RESULTS

Athletes who received Pro2cool cooling therapy (n = 79) experienced a 14.4% greater reduction in SCAT5 symptom severity scores at the initial visit posttreatment, a 25.5% greater reduction at the 72-hour visit posttreatment, and a 3.4% greater reduction at the 10-day visit compared with subjects receiving only standard care (n = 88). Overall, 36 adverse events (increased blood pressure, decreased pulse, and dizziness) were reported, with 13 events associated with the device, of which 3 were classified as moderate in severity.

CONCLUSIONS

This study demonstrates the efficacy and safety of head and neck cooling for the management of concussion symptoms in adolescent athletes of an age group for which little to no prior data are available.

mTBI evaluation, management, and referral to allied healthcare: practices of first-line healthcare professionals

PRIMARY OBJECTIVE

To gain an understanding of current evaluation practices, post-injury recommendations, and referrals to allied healthcare professions (AHP) by first-line healthcare professionals (FHPs) providing care for people with mild traumatic brain injury (mTBI).

RESEARCH DESIGN

Survey study.

METHODS AND PROCEDURES

Physicians, physician assistants, nurse practitioners, nurses, and athletic trainers (n = 126) completed an online survey, including Likert scale and free response question relating to mTBI evaluation, management, and referral practices.

MAIN OUTCOMES AND RESULTS

FHPs surveyed reported being confident in their ability to evaluate patients with suspected mTBI, relying most heavily on patient-reported symptoms and physical signs as methods of evaluation. Most FHPs reported making recommendations to compensate for the symptoms experienced following mTBI diagnosis. In contrast, FHPs expressed challenges in the evaluation and management of symptoms associated with mTBI along with limited knowledge of and referrals to AHPs.

CONCLUSIONS

Overall, FHPs feel confident in the diagnosis of mTBI but experience assessment and management challenges. AHPs are underutilized on mTBI management teams calling for a need for multidisciplinary collaboration on research, education, and rehabilitation efforts to optimally care for people experiencing mTBI symptoms.

Factors That May Influence Americans' Views on When Children Should Start Playing Tackle Football

CONTEXT

American football is associated with the largest number of emergency department visits for pediatric sport-related traumatic brain injury, including concussions. Tackling is responsible for almost two-thirds of football concussions. Some have recommended implementing age restrictions on tackling in youth football.

OBJECTIVE

To determine whether the public would support age restrictions and the factors that may drive such support.

DESIGN

Cross-sectional study.

SETTING

Summer wave of Porter Novelli's 2020 US ConsumerStyles survey.

PARTICIPANTS

A total of 4053 adults.

MAIN OUTCOME MEASURE(S)

Respondents answered questions about a good age for children to start playing tackle football, past football playing history, concerns about safety, and the benefits and risks of playing football.

RESULTS

Most respondents believed that middle (32.8%) or high (27.8%) school was a good age to start playing tackle football. About 1 in 5 (19.8%) respondents reported that children should never play tackle football. Certain groups of individuals were more likely to support children starting to play tackle football at high school age or above or to say that they should never play tackle football, including those with a bachelor's degree or higher (rate ratio [RR]HS+ = 1.41, 95% CI = 1.14, 1.76; RRNEVER = 2.70, 95% CI = 1.93, 3.78), those who did not have children under 18 (RRHS+ = 1.54, 95% CI = 1.26, 1.90; RRNEVER = 1.54, 95% CI = 1.14, 2.07), those who were not football fans (RRNEVER = 3.07, 95% CI = 2.32, 4.06), and those who were very (RRHS+ = 3.94, 95% CI = 2.87, 5.42; RRNEVER = 11.52, 95% CI = 7.32, 18.15) or somewhat (RRHS+ = 1.88, 95% CI = 1.41, 2.52) concerned about the safety of children.

CONCLUSION

Despite acknowledging the benefits of playing football, many adults expressed concern about safety and endorsed high school age and older or never as a good age to start playing tackle football, highlighting a disconnect with current football program practices regarding age.

Increased brain age and relationships with blood-based biomarkers following concussion in younger populations

OBJECTIVE

Brain age is increasingly being applied to the spectrum of brain injury to define neuropathological changes in conjunction with blood-based biomarkers. However, data from the acute/sub-acute stages of concussion are lacking, especially among younger cohorts.

METHODS

Predicted brain age differences were independently calculated in large, prospectively recruited cohorts of pediatric concussion and matched healthy controls (total N = 446), as well as collegiate athletes with sport-related concussion and matched non-contact sport controls (total N = 184). Effects of repetitive head injury (i.e., exposure) were examined in a separate cohort of contact sport athletes (N = 82), as well as by quantifying concussion history through semi-structured interviews and years of contact sport participation.

RESULTS

Findings of increased brain age during acute and sub-acute concussion were independently replicated across both cohorts, with stronger evidence of recovery for pediatric (4 months) relative to concussed athletes (6 months). Mixed evidence existed for effects of repetitive head injury, as brain age was increased in contact sport athletes, but was not associated with concussion history or years of contact sport exposure. There was no difference in brain age between concussed and contact sport athletes. Total tau decreased immediately (~ 1.5 days) post-concussion relative to the non-contact group, whereas pro-inflammatory markers were increased in both concussed and contact sport athletes. Anti-inflammatory markers were inversely related to brain age, whereas markers of axonal injury (neurofilament light) exhibited a trend positive association.

CONCLUSION

Current and previous findings collectively suggest that the chronicity of brain age differences may be mediated by age at injury (adults > children), with preliminary findings suggesting that exposure to contact sports may also increase brain age.

An Evaluation of Post-Concussion Return to School Guidelines: A Survey of Massachusetts School Nurses

Although all states have legislation pertaining to youth sports concussion, most of these laws focus on return-to-play procedures; only a few address return-to-learn (RTL) accommodations for students who have experienced a concussion. To address this gap in the legislation, some states and nongovernmental organizations have developed RTL guidelines to advise school personnel, parents, and health care providers on best practices for accommodating students' postconcussion reintegration into academic activity. In 2018, the Massachusetts Department of Public Health (MDPH) developed RTL guidelines which were disseminated to school nurses (SNs) at all public and nonpublic middle and high schools in the state. In 2020, the MDPH engaged the Injury Prevention Center at Boston Medical Center to survey Massachusetts SNs to assess the usefulness of the guidelines. The response rate was 63%; 92% found the booklet extremely useful or moderately useful; and 70% endorsed that the booklet fostered collaboration among stakeholders.

Improving outcome after paediatric concussion: challenges and possibilities

The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.

Adults are not older adolescents: comparing physical therapy findings among adolescents, young adults and older adults with persistent post-concussive symptoms

OBJECTIVE

Individuals with persistent post-concussive symptoms (PPCS) may present with a myriad of physical symptoms. There is limited research available comparing the presence of examination findings among individuals with PPCS from different age groups.

METHODS

Retrospective case-control chart review of 481 patients with PPCS and 271 non-trauma controls. Physical assessments were categorized as ocular, cervical, and vestibular/balance. Differences in presentation were compared between PPCS and controls as well as between individuals with PPCS in three age groups: adolescents, young adults, and older adults.

RESULTS

All three PPCS groups had more abnormal oculomotor findings than their age-matched counterparts. When comparing PPCS patients from different age groups, no differences were seen in prevalence of abnormal smooth pursuits or saccades; however, adolescents with PPCS had more abnormal cervical findings and a lower prevalence of abnormal NPC, vestibular and balance findings.

CONCLUSION

Patients with PPCS presented with a different constellation of clinical findings based on their age. Adolescents were more likely to demonstrate evidence of cervical injury compared to younger and older adults, and adults were more likely to present with vestibular findings and impaired NPC. Adults with PPCS were more likely to present with abnormal oculomotor findings compared to adults with non-traumatic causes of dizziness.

Disparities in Adherence to Concussion Clinical Care Recommendations in a Pediatric Population

OBJECTIVE

To characterize the relationship of sociodemographic factors to adherence to provider recommendations for pediatric concussion.

SETTING

Primary care (PC) practices within the Children's Hospital of Philadelphia network.

PARTICIPANTS

Patients aged 5 to 18 years old who presented to any PC site for concussion from September 26, 2019, to December 31, 2019.

DESIGN

Retrospective medical record review.

MAIN MEASURES

The primary outcome was adherence to follow-up recommendations as defined by (1) continued follow-up until provider clearance to return to full activity; (2) no more than 2 no-show visits; and (3) for those referred to specialty care (SC), attending at least 1 visit. We compared adherence by race/ethnicity, insurance, age, sex, injury mechanism, and repeat head injury using bivariate and multivariate analyses. A secondary outcome of referral to SC was compared by sociodemographic factors.

RESULTS

A total of 755 patients were included. Overall, 80.5% of the patients met adherence criteria. Following adjustment, non-Hispanic Black patients and publicly insured/self-pay patients were less likely to adhere to recommendations than non-Hispanic White patients (adjusted odds ratio [AOR] = 0.60; 95% CI, 0.37-1.00) and privately insured patients (AOR = 0.48; 95% CI, 0.30-0.75), respectively. When assessing differences in referral to SC, non-Hispanic Black patients and publicly insured/self-pay patients were more likely to receive a referral than their non-Hispanic White peers (OR = 1.56; 95% CI, 1.00-2.45) and privately insured patients (OR = 1.56; 95% CI, 1.05-2.32), respectively.

CONCLUSION

This study highlights disparities in adherence to concussion care recommendations, with non-Hispanic Black and publicly insured/self-pay patients less likely to adhere to follow-up recommendations than non-Hispanic White and privately insured patients, respectively. These disparities may impact recovery trajectories. Future studies should aim to identify specific individual- and system-level barriers preventing adherence to care in order to ultimately inform targeted interventions to achieve equity in care delivery and outcomes.

Emergency department visits for mild traumatic brain injury in early childhood

BACKGROUND

Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury (mTBI) has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED).

METHODS

The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion.

RESULTS

National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was "unspecified injury of head" (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children's hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children's hospitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid.

CONCLUSIONS

Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.

Pupillary Light Response Deficits in 4-Week-Old Piglets and Adolescent Children after Low-Velocity Head Rotations and Sports-Related Concussions

Neurological disorders and traumatic brain injury (TBI) are among the leading causes of death and disability. The pupillary light reflex (PLR) is an emerging diagnostic tool for concussion in humans. We compared PLR obtained with a commercially available pupillometer in the 4 week old piglet model of the adolescent brain subject to rapid nonimpact head rotation (RNR), and in human adolescents with and without sports-related concussion (SRC). The 95% PLR reference ranges (RR, for maximum and minimum pupil diameter, latency, and average and peak constriction velocities) were established in healthy piglets (N = 13), and response reliability was validated in nine additional healthy piglets. PLR assessments were obtained in female piglets allocated to anesthetized sham (N = 10), single (sRNR, N = 13), and repeated (rRNR, N = 14) sagittal low-velocity RNR at pre-injury, as well as days 1, 4, and 7 post injury, and evaluated against RRs. In parallel, we established human PLR RRs in healthy adolescents (both sexes, N = 167) and compared healthy PLR to values obtained <28 days from a SRC (N = 177). In piglets, maximum and minimum diameter deficits were greater in rRNR than sRNR. Alterations peaked on day 1 post sRNR and rRNR, and remained altered at day 4 and 7. In SRC adolescents, the proportion of adolescents within the RR was significantly lower for maximum pupil diameter only (85.8%). We show that PLR deficits may persist in humans and piglets after low-velocity head rotations. Differences in timing of assessment after injury, developmental response to injury, and the number and magnitude of impacts may contribute to the differences observed between species. We conclude that PLR is a feasible, quantifiable involuntary physiological metric of neurological dysfunction in pigs, as well as humans. Healthy PLR porcine and human reference ranges established can be used for neurofunctional assessments after TBI or hypoxic exposures (e.g., stroke, apnea, or cardiac arrest).

Sports-Related Concussions and Adverse Health Behaviors Among Middle and High School Students

BACKGROUND

Concussions affect millions of youths in the United States each year, and there is concern about long-term health effects from this injury.

PURPOSE

To examine the association between sports- or physical activity-related concussion and health risk behaviors among middle and high school students in 9 states.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Data from the 2019 middle school and high school Youth Risk Behavior Survey were used for this analysis. Nine states were identified that included the same question on concussion and similar questions on health risk behaviors in their 2019 Youth Risk Behavior Survey. Students were asked to self-report whether they had ≥1 sports- or physical activity-related concussions during the 12 months preceding the survey. Self-reported concussion was the primary outcome of interest. Other variables included sex, race/ethnicity, played on a sports team, were physically active 5 or more days/week, ever tried cigarette smoking, ever used an electronic vapor product, academic grades, drank alcohol, were in a physical fight, seriously considered attempting suicide, made a suicide plan, and attempted suicide.

RESULTS

Among the 9 states, 18.2% of middle school students and 14.3% of high school students self-reported ≥1 sports- or physical activity-related concussions. Among both middle school and high school students, the prevalence of ≥1 sports- or physical activity-related concussions was higher among students who played on a sports team, were physically active 5 or more days per week, had ever tried cigarette smoking, had ever used an electronic vapor product, had seriously considered attempting suicide, had made a suicide plan, and had attempted suicide compared with those who had not engaged in those behaviors. The prevalence of sports- or physical activity-related concussion was consistently higher among middle school students than high school students across sex, race/ethnicity, and adverse health behaviors.

CONCLUSION

Middle school students with a history of concussion warrant attention as an at-risk population for concussions and adverse health behaviors. Health care providers may consider screening students for adverse health behaviors during preparticipation examinations and concussion evaluations.

A Description of Suspected Concussions in Football-Related Activities among K-12 Students in Utah

The circumstances and nature of concussions among youth who play tackle, flag, or touch football are not well understood. This study used data from Utah's Student Injury Reporting System (SIRS) to explore suspected concussions among K-12 students sustained during participation in football-related activities (tackle, flag, or touch football). Descriptive statistics and chi-square analyses showed that 54.7% of suspected concussions due to football-related activity were among elementary and middle school and 41.3% were among high school students. Most suspected concussions resulted from being struck by or against something (81.9%) and occurred during school-sanctioned games and practices (37.9%), lunch, lunch recess, and recess (34.8%), or physical education class (22.7%). The type of school activity and context for suspected concussions varied by school level. School nurses and others in Utah may use study findings to customize concussion prevention efforts by school level and activity.

Use of sport-related concussion information sources among parents of United States middle school children

OBJECTIVE

Parents may use various information sources to obtain information about sport-related concussions (SRC). This study examined SRC-related information sources used by parents of United States middle school children (age: 10-15 years).

METHODS

A panel of 1083 randomly selected U.S. residents, aged ≥18 years and identifying as parents of middle school children, completed an online questionnaire capturing parental and child characteristics, and utilization and perceived trustworthiness of various sources of SRC-related information. Multivariable logistic regression models identified factors associated with utilizing each source. Adjusted odds ratios (OR) with 95% confidence intervals (95%CIs) excluding 1.00 were deemed significant.

RESULTS

Doctors/healthcare providers (49.9%) and other healthcare-related resources (e.g., Centers for Disease Control and Prevention, WebMD) (37.8%) were common SRC-related information sources; 64.0% of parents utilized ≥1 of these sources. Both sources were considered "very" or "extremely" trustworthy for SRC-related information among parents using these sources (doctors/healthcare providers: 89.8%; other healthcare-related resources: 70.9%). A 10-year increase in parental age was associated with higher odds of utilizing doctors/healthcare providers (adjusted odd ratio (OR_adjusted) = 1.09, 95%CI: 1.02-1.16) and other healthcare-related resources (OR_adjusted = 1.11, 95%CI: 1.03-1.19). The odds of utilizing doctors/healthcare providers (OR_adjusted = 0.58, 95%CI: 0.40-0.84) and other healthcare-related resources (OR_adjusted = 0.64, 95%CI: 0.44-0.93) were lower among parents whose middle school children had concussion histories versus the parents of children who did not have concussion histories.

CONCLUSION

One-third of parents did not report using doctors/healthcare providers or other healthcare-related resources for SRC-related information. Factors associated with underutilization of these sources may be targets for future intervention. Continuing education for healthcare providers and educational opportunities for parents should highlight accurate and up-to-date SRC-related information.

Trends in Traumatic Brain Injury Related to Consumer Products Among U.S. School-aged Children Between 2000 and 2019

INTRODUCTION

Consumer product‒related traumatic brain injury in children is common, but long-term trends have not been well characterized. Understanding the long-term trends in consumer product‒related traumatic brain injury may inform prevention efforts. The study objective is to examine the trends in consumer product‒related traumatic brain injury in school-aged children.

METHODS

Data were extracted from the National Electronic Injury Surveillance System-All Injury Program for initial emergency department visits for consumer product‒related traumatic brain injury (2000-2019) in school-aged children and analyzed in 2021.

RESULTS

Approximately 6.2 million children presented to emergency department with consumer product‒related traumatic brain injury during 2000-2019. Consumer product‒related traumatic brain injury increased from 4.5% of overall consumer product‒emergency department visits in 2000 to 12.3% in 2019, and its incidence rate (cases per 100,000 population) was higher in males (681.2; 95% CI=611.2, 751.2) than in females (375.8; 95% CI=324.1, 427.6). The annual percentage change in consumer product‒related traumatic brain injury was 3.6% from 2000 to 2008, 13.3% from 2008 to 2012, and ‒2.0% through 2019. Average annual percentage change was higher in females (5.1%; 95% CI=3.4, 6.8) than in males (2.8%; 95% CI=1.6, 3.9). Consumer product‒related traumatic brain injury increased from 2000 to 2012 in females and then remained stable. In males, annual percentage change increased from 2008 to 2012 and then declined through 2019.

CONCLUSIONS

Traumatic brain injury incidence rate in school-aged children increased from 2000 to 2019, peaked in 2012, and then declined in males but not in females. Percentage increases were highest in females. Prevention strategies should continue, with a specific focus on reducing consumer product‒related traumatic brain injury in female children.

Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada

BACKGROUND

We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada.

METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped.

RESULTS

Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically.

CONCLUSIONS

The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion.

IMPACT

This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Assault-Related Concussion in a Pediatric Population

OBJECTIVES

The aim of this study was to compare demographic characteristics, medical care, and outcomes among patients with assault-related concussion (ARC) versus sports and recreation-related concussion (SRC).

METHODS

We conducted a retrospective chart review of 124 patients (62 ARC, 62 SRC) aged 8 to 17 years presenting to the care network of a large tertiary care pediatric hospital between July 1, 2012, and June 30, 2014 with a concussion diagnosis at time of presentation. We abstracted patient demographics, initial medical care visit characteristics, and outcome data, and compared proportions using χ2 testing and Fisher exact test and medians using Wilcoxon rank sum test.

RESULTS

Patients with ARC were more likely to be Black, publicly insured, and present first for care to the emergency department. Significantly fewer patients with ARC received visio-vestibular testing at initial visit (27% vs 74%, P < 0.001). During recovery, the total number of reported physical, cognitive, emotional, and sleep symptoms did not differ between groups; however, more than twice as many patients with ARC reported decline in grades postinjury compared with patients with SRC (47% vs 20%, P = 0.012). There were trends toward prolonged symptom recovery and time to physician clearance for full return to activities among patients with ARC compared with SRC.

CONCLUSIONS

This study highlights potential disparities in the initial evaluation and outcomes of pediatric concussion patients based on mechanism of injury. Patients with ARC were less likely to receive a concussion-specific diagnostic evaluation and reported a greater impact on educational outcomes, suggesting differences in concussion diagnosis and management among assault-injured patients. Further examination in larger populations with prospective studies is needed to address potential inequities in concussion care and outcomes among patients with ARC.

Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment

Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.

Test-Retest Reliability of a Semi-Structured Interview to Aid in Pediatric Traumatic Brain Injury Diagnosis

OBJECTIVE

Retrospective self-report is typically used for diagnosing previous pediatric traumatic brain injury (TBI). A new semi-structured interview instrument (New Mexico Assessment of Pediatric TBI; NewMAP TBI) investigated test-retest reliability for TBI characteristics in both the TBI that qualified for study inclusion and for lifetime history of TBI.

METHOD

One-hundred and eight-four mTBI (aged 8-18), 156 matched healthy controls (HC), and their parents completed the NewMAP TBI within 11 days (subacute; SA) and 4 months (early chronic; EC) of injury, with a subset returning at 1 year (late chronic; LC).

RESULTS

The test-retest reliability of common TBI characteristics [loss of consciousness (LOC), post-traumatic amnesia (PTA), retrograde amnesia, confusion/disorientation] and post-concussion symptoms (PCS) were examined across study visits. Aside from PTA, binary reporting (present/absent) for all TBI characteristics exhibited acceptable (≥0.60) test-retest reliability for both Qualifying and Remote TBIs across all three visits. In contrast, reliability for continuous data (exact duration) was generally unacceptable, with LOC and PCS meeting acceptable criteria at only half of the assessments. Transforming continuous self-report ratings into discrete categories based on injury severity resulted in acceptable reliability. Reliability was not strongly affected by the parent completing the NewMAP TBI.

CONCLUSIONS

Categorical reporting of TBI characteristics in children and adolescents can aid clinicians in retrospectively obtaining reliable estimates of TBI severity up to a year post-injury. However, test-retest reliability is strongly impacted by the initial data distribution, selected statistical methods, and potentially by patient difficulty in distinguishing among conceptually similar medical concepts (i.e., PTA vs. confusion).

Classification Criteria and Rates of Persistent Postconcussive Symptoms in Children: A Systematic Review and Meta-Analysis

OBJECTIVE

To provide a systematic review of studies examining the proportion of children with persistent postconcussive symptoms (PPCS) and to examine potential moderators of prevalence.

STUDY DESIGN

Searches were conducted in MEDLINE, Embase, PsycINFO, Scopus, and Cochrane Central Register of Controlled Trials on April 16, 2020. Criteria for study inclusion were children aged <18 years with concussion or mild traumatic brain injury, operational definition of PPCS, assessment of postconcussive symptoms at least 4 weeks postinjury, sample sizes and proportion with PPCS available, and study published in English. Definition of PPCS, sample size, proportion of participants identified with PPCS, child sex and age at injury, time postinjury, premorbid symptoms, diagnosis (concussion or mild traumatic brain injury), and study publication year were extracted from each article. Study quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Thirteen studies, with a total of 5307 participants, were included in our analysis. The proportion of children identified with PPCS was 35.1% (weighted average; 95% CI, 26.3%-45.0%). The prevalence of PPCS was higher in older and female children who presented for care at concussion clinics, and in more recent publications.

CONCLUSIONS

Approximately one-third of children with concussion/mild traumatic brain injury will experience PPCS. Age, sex, and point of care could help identify children at high risk for PPCS.

Pediatric Sports-Related Concussion: An Approach to Care

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

Challenges and opportunities in diagnosing and managing mild traumatic brain injury in rural settings

INTRODUCTION

There is some evidence to suggest that Americans living in rural areas are at increased risk for sustaining a traumatic brain injury (TBI) compared to those living in urban areas. In addition, once a TBI has been sustained, rural residents have worse outcomes, including a higher risk of death. Individuals living in rural areas tend to live farther from hospitals and have less access to TBI specialists. Aside from these factors, little is known what challenges healthcare providers practicing in rural areas face in diagnosing and managing TBI in their patients and what can be done to overcome these challenges.

METHODS

Seven focus groups and one individual interview were conducted with a total of 18 healthcare providers who mostly practiced in primary care or emergency department settings in rural areas. Providers were asked about common mechanisms of TBI in patients that they treat, challenges they face in initial and follow-up care, and opportunities for improvement in their practice.

RESULTS

The rural healthcare providers reported that common mechanisms of injury included sports-related injuries for their pediatric and adolescent patients and work-related accidents, motor vehicle crashes, and falls among their adult patients. Most providers felt prepared to diagnose and manage their patients with TBI, but acknowledged a series of challenges they face, including pushback from parents, athletes, and coaches and lack of specialists to whom they could refer. They also noted that patients had their own barriers to overcome for timely and adequate care, including lack of access to transportation, difficulties with cost and insurance, and denial about the seriousness of the injury. Despite these challenges, the focus group participants also outlined benefits to practicing in a rural area and several ways that their practice could improve with support.

CONCLUSION

Rural healthcare providers may be comfortable diagnosing, treating, and managing their patients who present with a suspected TBI, but they also face many challenges in their practice. In this study it was continually noted that there was lack of resources and a lack of awareness, or recognition of the seriousness of TBI, among the providers' patient populations. Education about common symptoms and the need for evaluation after an injury is needed. The use of telemedicine, an increasingly common technology, may help close some gaps in access to services. People living in rural areas may be at increased risk for TBI. Healthcare providers who work in these areas face many challenges but have found ways to successfully manage the treatment of this injury in their patients.

Prevalence of Suspected Concussions Among K-12 Students in Utah: Findings From Utah's Student Injury Reporting System

BACKGROUND

To inform prevention strategies, this study provides incidence, factors, and actions taken when a suspected concussion occurred in K-12 schools in Utah.

METHODS

Data were collected using Utah's Student Injury Reporting System (SIRS) from the academic years 2011-2012 to 2018-2019. SIRS is a unique online system that tracks injuries that occur in the school setting among K-12 students in Utah. Descriptive statistics were computed to characterize students with a suspected concussion. Chi-square (χ² ) analysis looking at characteristics by school level was also conducted.

RESULTS

Over 63,000 K-12 students in Utah sustained an injury at school during the study period. Suspected concussions comprised 10% of all injuries. The prevalence of concussions was highest among males (60.6%) and elementary school students (42.6%) and most often occurred outdoors (57.6%) or on a playground/playfield (33.9%), and in sports- and recreation-related activities (75.1%) (specifically contact sports, 24.0%). Most students with a suspected concussion were absent 1 day or less from school (71.4%) but about 68% were seen by a medical professional. Further, there were differences by school level. Females and students playing contact sports had a higher percentage of suspected concussions as school level increased, whereas males and concussions sustained during school hours had a lower percentage of suspected concussions as school level increased.

CONCLUSIONS

SIRS enables schools in Utah to identify groups at risk for concussion, as well as activities most commonly associated with these injuries, within the school environment. Using this information, schools may implement targeted prevention strategies to protect students.

Greater symptom burden results in reduced exercise tolerance in adolescents following concussion

OBJECTIVES

To explore the relationship between symptoms and exercise tolerance in adolescents following concussion.

METHODS

A retrospective analysis of 417 adolescents who attended a concussion service between January 2015 and April 2021 was performed, with 149 meeting eligibility criteria for inclusion. Post-Concussion Symptom Scale (PCSS) and graded exercise tolerance time (min) were assessed at initial and follow-up visits. Spearman's correlation was used to examine the relationship between PCSS scores and exercise time.

RESULTS

Adolescents (n = 149, 13.9 ± 1.7 years, 66.4% male) presented at 28.6 ± 19.7 days post-injury. Statistically significant correlations were identified between initial (r = -0.36, p < .001) and follow-up (r = -0.41, p < .001) PCSS scores and exercise time among all participants. Initial PCSS and initial exercise time were inversely correlated for males (r = -0.24, p = .018) and females (r = -0.22, p = .127). Follow-up PCSS and follow-up exercise time were inversely correlated for males (r = -0.30, p = .003) and females (r = -0.35, p = .014).

CONCLUSION

There is a statistically significant relationship between higher PCSS and poorer exercise time and both factors should be considered together to provide the most accurate assessment, particularly in females.

Gaps in concussion management across school-aged children

OBJECTIVE

Examine how demographic and injury factors impact identification and management of concussion in students.

METHODS

Prospective observational cohort. Pre-K - 12th grade students within a large, urban school district reported to school with concussion during 2015-2019. Participants were grouped into Elementary/Middle School (E/MS) and High School (HS) and compared by sex, concussion history, injury setting and mechanism, time to medical evaluation and clearance, absences, and recommended accommodations.

RESULTS

154 E/MS and 230 HS students reported to school with physician-diagnosed concussion. E/MS students experienced fewer concussions at school and from sports than HS. More E/MS males than females sustained concussions, while this difference was reversed for HS. Time-to-evaluation was longer for E/MS, specifically female E/MS students and those injured outside of school. E/MS males were cleared more quickly than females. In contrast, no differences were found between sexes for HS by injury setting, mechanism of injury, or management factors.

CONCLUSION

Differences observed in E/MS students by demographic and injury factors are not observed in HS students. Younger students, particularly females or those not injured in school or sports, may be at risk for delayed identification and prolonged time to clearance. Future research should further characterize concussion management in E/MS children.

The Association Between School District-Based Policies Related to Concussions and Concussions Among High School Students

BACKGROUND

Little is known about the effectiveness of school district concussion policies on reducing the concussion prevalence among students.

METHODS

Data from the 2016 School Health Policies and Practices Study and 2017 Youth Risk Behavior Survey for 10 school districts were linked. The outcome variable was having a sports- or physical activity-related concussion during the 12 months before of the survey. Exposure variables were 2 district policies, including district-funded professional development and prioritizing return to the classroom before returning to athletics. Logistic regression models estimated the odds of a concussion among students in districts with one, both, or neither policy (referent).

RESULTS

In districts with district-funded professional development, the odds of students self-reporting ≥2 sports- or physical activity-related concussions were 1.4 times higher than in districts with neither policy. In districts with a policy prioritizing a return to the classroom before returning to athletics, the odds of students self-reporting ≥2 concussions were significantly lower (OR = 0.6) than in districts with neither policy.

CONCLUSION

School district concussion policies may have positive effects by identifying and reducing multiple concussions among students.

Learning and Attention Deficit/Hyperactivity Disorders as Risk Factors for Prolonged Concussion Recovery in Children and Adolescents

OBJECTIVE

Examine pre-existing learning disorders (LD) and attention deficit/hyperactivity disorders (ADHD) as risk factors for prolonged recovery and increased symptomology following pediatric mild traumatic brain injury (mTBI).

METHODS

We conducted a retrospective cohort study of children/adolescents (5-17 years) with mTBI who presented to a Children's Minnesota Concussion Clinic between April 2018 and March 2019. Differences across strata of pre-existing conditions (present vs. absent) in time to recovery measures were estimated via Kaplan-Meier and Cox proportional hazards analyses and differences in symptom trajectories were examined via linear mixed-effects regression models. Regression models were adjusted for age, sex and other confounders.

RESULTS

In our cohort of 680 mTBI patients, those with LD (n = 70) or ADHD (n = 107) experienced significantly longer median durations of symptoms (58 and 68 days, respectively) than those without (43 days). Accordingly, LD was significantly associated with delayed symptom recovery (adjusted hazard ratio (aHR) = 1.63, 95% CI: 1.16-2.29), return to school (1.47, 1.08-2.00), and return to physical activity (1.50, 1.10-2.04). Likewise, ADHD was associated with delayed recovery (1.69, 1.28-2.23), return to school (1.52, 1.17-1.97) and physical activity (1.55, 1.19-2.01). Further, patients with LD or ADHD reported, on average, significantly more concussion symptoms and higher vision symptom scores throughout recovery versus those without. There was no evidence that concussion or vision symptom recovery trajectories varied over time between those with/without LD or ADHD (joint P-interactions > 0.05).

CONCLUSION

Pre-existing LD and ADHD are risk factors for prolonged and more symptomatic mTBI recovery in youth. These results can inform clinical concussion management and recovery expectations.

What About the Little Ones? Systematic Review of Cognitive and Behavioral Outcomes Following Early TBI

There is increasing empirical focus on the effects of early traumatic brain injuries (TBI; i.e., before the age of six years) on child development, but this literature has never been synthetized comprehensively. This systematic review aimed to document the cognitive, academic, behavioral, socio-affective, and adaptive consequences of early TBI. Four databases (Medline, PsycNET, CINAHL, PubMed) were systematically searched from 1990 to 2019 using key terms pertaining to TBI and early childhood. Of 12, 153 articles identified in the initial search, 43 were included. Children who sustain early TBI are at-risk for a range of difficulties, which are generally worse when injury is sustained at a younger age, injury severity is moderate to severe, and injury mechanisms are non-accidental. Early childhood is a sensitive period for the emergence and development of new skills and behaviors, and brain disruption during this time is not benign. Research, clinical management, intervention, and prevention efforts should be further developed with consideration of the unique characteristics of the early childhood period.

Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada

BACKGROUND

Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.

MATERIALS AND METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC.

RESULTS

194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care.

CONCLUSION

Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.

Examining brain white matter after pediatric mild traumatic brain injury using neurite orientation dispersion and density imaging: An A-CAP study

•

We examined white matter microstructure after pediatric mTBI using NODDI and DTI.

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Children with mTBI did not significantly differ from those with OI on any metrics.

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Minor alterations, if any, may be present in children at the post-acute stage after mTBI.

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Large longitudinal studies are needed to understand long-term brain changes post injury.

Background

Pediatric mild traumatic brain injury (mTBI) affects millions of children annually. Diffusion tensor imaging (DTI) is sensitive to axonal injuries and white matter microstructure and has been used to characterize the brain changes associated with mild traumatic brain injury (mTBI). Neurite orientation dispersion and density imaging (NODDI) is a diffusion model that can provide additional insight beyond traditional DTI metrics, but has not been examined in pediatric mTBI. The goal of this study was to employ DTI and NODDI to gain added insight into white matter alterations in children with mTBI compared to children with mild orthopedic injury (OI).

Methods

Children (mTBI n = 320, OI n = 176) aged 8–16.99 years (12.39 ± 2.32 years) were recruited from emergency departments at five hospitals across Canada and underwent 3 T MRI on average 11 days post-injury. DTI and NODDI metrics were calculated for seven major white matter tracts and compared between groups using univariate analysis of covariance controlling for age, sex, and scanner type. False discovery rate (FDR) was used to correct for multiple comparisons.

Results

Univariate analysis revealed no significant group main effects or interactions in DTI or NODDI metrics. Fractional anisotropy and neurite density index in all tracts exhibited a significant positive association with age and mean diffusivity in all tracts exhibited a significant negative association with age in the whole sample.

Conclusions

Overall, there were no significant differences between mTBI and OI groups in brain white matter microstructure from either DTI or NODDI in the seven tracts. This indicates that mTBI is associated with relatively minor white matter differences, if any, at the post-acute stage. Brain differences may evolve at later stages of injury, so longitudinal studies with long-term follow-up are needed.

Characteristics of Diagnosed Concussions in Children Aged 0 to 4 Years Presenting to a Large Pediatric Healthcare Network

OBJECTIVE

The aim of the study was to comprehensively describe the natural history of concussion in early childhood between 0 and 4 years.

METHODS

Retrospective cohort study of 329 patients aged 0 to 4 years, with an International Classification of Diseases, Ninth Revision, concussion diagnosis in the Children's Hospital of Philadelphia healthcare network from October 1, 2013, to September 30, 2015. Clinical data were abstracted from the Children's Hospital of Philadelphia electronic health record, which captured all clinical care visits and injury characteristics.

RESULTS

Nearly 9 (86.6%) of 10 patients sought care in the emergency department or urgent care setting, most commonly on the day of injury (56.2%) and as a result of a fall (64.4%). More than two-thirds (64.4%) of patients or their parent/caregiver reported somatic symptoms (ie, vomiting or headache), whereas close to half (49.2%) reported sleep issues. One of 5 patients identified emotional symptoms (21.9%) or visio-vestibular dysfunction (20.4%). Many patients also experienced symptoms not included in standard assessment tools including personality changes (34.0%) and change in appetite (12.8%).

CONCLUSIONS

These results provide insight into the clinical characteristics of concussion in early childhood up to 4 years of age. Because assessment in this group relies heavily on parent/caregiver symptom reporting, rather than patient self-report, these results will aid clinicians with the challenge of diagnosing concussions in this population. These findings highlight the need to develop additional tools to adequately and systematically assess common signs and symptoms of concussion in early childhood that may not be included in standard assessment scales routinely used in older adolescents and adults.

Reporting of Concussion Symptoms by a Nationwide Survey of United States Parents of Middle School Children

This cross-sectional study assessed concussion symptom knowledge of parents of middle school (MS) children (aged 10-15 years) through a free-response item that solicited concussion symptoms and compared findings to a pre-validated scale-based measure. A self-administered online questionnaire was sent to a panel of randomly selected United States residents who were recruited by a third-party company, aged ≥ 18 years, and identified as parents of MS children. Via a free-response item, parents listed what they believed were concussion symptoms. Multiple sections later, parents identified potential concussion symptoms via a scale measure, which featured 25 items (22 actual symptoms, three distractor symptoms) with three response options: yes, no, maybe. Free-response item responses were coded into specific symptoms. The 1062 eligible parents that provided complete data commonly identified the symptoms of dizziness (90.2%), blurred vision (87.4%), and balance problems (86.4%) on the scale-based measure. However, these and other symptoms were less commonly identified via the free-response item (dizziness: 44.4%; blurred vision: 16.5%; balance problems: 3.5%). Concussion symptoms commonly reported via the scale-based measure were reported less frequently within the free-response item. Future research must explore strategies to help clinicians working with parents and their children to measure and assess concussion symptom reporting and knowledge.

The biological significance and clinical utility of emerging blood biomarkers for traumatic brain injury

HUIBREGTSE, M.E, Bazarian, J.J., Shultz, S.R., and Kawata K. The biological significance and clinical utility of emerging blood biomarkers for traumatic brain injury. NEUROSCI BIOBEHAV REV XX (130) 433-447, 2021.- Blood biomarkers can serve as objective measures to gauge traumatic brain injury (TBI) severity, identify patients at risk for adverse outcomes, and predict recovery duration, yet the clinical use of blood biomarkers for TBI is limited to a select few and only to rule out the need for CT scanning. The biomarkers often examined in neurotrauma research are proteomic markers, which can reflect a range of pathological processes such as cellular damage, astrogliosis, or neuroinflammation. However, proteomic blood biomarkers are vulnerable to degradation, resulting in short half-lives. Emerging biomarkers for TBI may reflect the complex genetic and neurometabolic alterations that occur following TBI that are not captured by proteomics, are less vulnerable to degradation, and are comprised of microRNA, extracellular vesicles, and neurometabolites. Therefore, this review aims to summarize our understanding of how biomarkers for brain injury escape the brain parenchymal space and appear in the bloodstream, update recent research findings in several proteomic biomarkers, and characterize biological significance and examine clinical utility of microRNA, extracellular vesicles, and neurometabolites.

Factors associated with concussion symptom knowledge and attitudes towards concussion care-seeking among parents of children aged 5-10 years

BACKGROUND

Understanding parents' concussion-related knowledge and attitudes will contribute to the development of strategies that aim to improve concussion prevention and sport safety for elementary school children. This study investigated the association between parent- and child-related factors and concussion symptom knowledge and care-seeking attitudes among parents of elementary school children (aged 5-10 years).

METHODS

Four hundred parents of elementary school children completed an online questionnaire capturing parental and child characteristics; concussion symptom knowledge (25 items, range = 0-50; higher = better knowledge); and concussion care-seeking attitudes (five 7-point scale items, range = 5-35; higher = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher score levels. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) excluding 1.00 were deemed statistically significant.

RESULTS

Select parent and child characteristics were associated with higher score levels for both outcomes. For example, odds of better knowledge level in parents were higher with increased age (10-year increase aOR = 1.59; 95% CI = 1.10-2.28), among females (aOR = 3.90; 95% CI = 2.27-6.70), and among white/non-Hispanics (aOR = 1.79; 95%CI = 1.07-2.99). Odds of more positive concussion care-seeking attitude levels were higher among parents with a college degree (aOR = 1.98; 95%CI = 1.09-3.60). Child sports participation was not associated with higher score levels for either outcome.

CONCLUSIONS

Certain elementary school parent characteristics were associated with parents' concussion symptom knowledge and care-seeking attitudes. While the findings suggest providing parents with culturally and demographically relevant concussion education might be helpful, they also emphasize the importance of ensuring education/prevention regardless of their children's sports participation. Practical Applications: Pediatric healthcare providers and elementary schools offer an optimal community-centered location to reach parents with this information within various communities.

Influence of insurance type on rate and type of initial concussion-related medical visits among youth

Background

A growing number of studies report increased concussion-related health care utilization in recent years, but factors impacting care-seeking behaviors among youth following a concussion are not well described. This study aimed to evaluate the influence of insurance type on the rate and type of initial concussion visits and the time from injury to the initial visit in youth.

Methods

We extracted and analyzed initial concussion-related medical visits for youth ages 10 to 17 from electronic health records. Patients must have visited Nationwide Children’s Hospital’s (NCH) concussion clinic at least once between 7/1/2012 and 12/31/2017. We evaluated the trends and patterns of initial concussion visits across the study period using regression analyses.

Results

Of 4955 unique concussion visits included, 60.1% were males, 80.5% were white, and 69.5% were paid by private insurance. Patients’ average age was 13.9 years (SD = 3.7). The rate of the initial concussion visits per 10,000 NCH visits was consistently higher in privately insured than publicly insured youth throughout the study period (P < .0001). Privately insured youth had greater odds of initial concussion visits to sports medicine clinics (AOR = 1.45, 95% CI = 1.20, 1.76) but lower odds of initial concussion visits to the ED/urgent care (AOR = 0.74, 95% CI = 0.60, 0.90) than publicly insured youth. Days from injury to initial concussion visit significantly decreased among both insurance types throughout the study (P < .0001), with a greater decrease observed in publicly insured than privately insured youth (P = .011).

Conclusions

Results on the differences in the rate, type, and time of initial concussion-related visits may help inform more efficient care of concussion among youth with different types of insurance.

Epidemiology of Chronic Effects of Traumatic Brain Injury

Although many patients diagnosed with traumatic brain injury (TBI), particularly mild TBI, recover from their symptoms within a few weeks, a small but meaningful subset experience symptoms that persist for months or years after injury and significantly impact quality of life for the person and their family. Factors associated with an increased likelihood of negative TBI outcomes include not only characteristics of the injury and injury mechanism, but also the person’s age, pre-injury status, comorbid conditions, environment, and propensity for resilience. In this article, as part of the Brain Trauma Blueprint: TBI State of the Science framework, we examine the epidemiology of long-term outcomes of TBI, including incidence, prevalence, and risk factors. We identify the need for increased longitudinal, global, standardized, and validated assessments on incidence, recovery, and treatments, as well as standardized assessments of the influence of genetics, race, ethnicity, sex, and environment on TBI outcomes. By identifying how epidemiological factors contribute to TBI outcomes in different groups of persons and potentially impact differential disease progression, we can guide investigators and clinicians toward more-precise patient diagnosis, along with tailored management, and improve clinical trial designs, data evaluation, and patient selection criteria.

Evaluation and Management of Pediatric Concussion in the Acute Setting

ABSTRACT

Concussion, a type of mild traumatic brain injury, is a common injury encountered by providers caring for pediatric patients in the emergency department (ED) setting. Our understanding of the pathophysiologic basis for symptom and recovery trajectories for pediatric concussion continues to rapidly evolve. As this understanding changes, so do recommendations for optimal management of concussed youth. As more and more children present to EDs across the country for concussion, it is imperative that providers caring for children in these settings remain up-to-date with diagnostic recommendations and management techniques. This article will review the definition, epidemiology, pathophysiology, diagnosis, and management of pediatric concussion in the ED setting.

Critical Elements of Return to Learn for Students With Concussion: A Scoping Review

OBJECTIVE

To identify critical elements of return to learn (RTL) for students with concussion and examine the state of the peer-reviewed published literature through a scoping review.

METHODS

Three electronic databases were systematically searched, and reference lists screened for articles addressing components of RTL protocols and accommodations for students with concussion. In total, 100 articles met inclusion criteria, including 56 empirical studies and 44 expert articles.

RESULTS

Four key components to RTL protocols were identified: RTL teams, management approaches, outcome measurement, and accommodations. Both bodies of literature agree on the importance of RTL teams, but evidence for specific monitoring tools and management approaches is less robust. Accommodations have been better addressed by experts than empirical evaluation. Empirical studies are largely cross-sectional, and many are survey based. Just 24 include student perspectives. Publication of expert literature has declined in frequency, as empirical studies have become more common.

CONCLUSION

This scoping review describes the current landscape of RTL and provides guidance toward expanding the empirical literature to systematically determine best practices to serve students with concussion.

Clinical Outcomes of Pediatric Acute Sport- and Non-Sport-Related Concussions

OBJECTIVES

The objectives were to examine clinical characteristics, length of recovery, and the prevalence of delayed physician-documented recovery, compare clinical outcomes among those with sport-related concussion (SRC) and non-sport-related concussion (nSRC), and identify risk factors for delayed recovery.

METHODS

Included patients (8-18 years) were assessed ≤14 days post-injury at a multidisciplinary concussion program and diagnosed with an acute SRC or nSRC. Physician-documented clinical recovery was defined as returning to pre-injury symptom status, attending full-time school without symptoms, completing Return-to-Sport strategy as needed, and normal physical examination. Delayed physician-documented recovery was defined as >28 days post-injury.

RESULTS

Four hundred and fifteen patients were included (77.8% SRC). There was no difference in loss of consciousness (SRC: 9.9% vs nSRC: 13.0%, p = 0.39) or post-traumatic amnesia (SRC: 24.1% vs SRC: 31.5%, p = 0.15) at the time of injury or any differences in median Post-Concussion Symptom Scale scores (SRC: 20 vs nSRC: 23, p = 0.15) at initial assessment. Among those with complete clinical follow-up, the median physician-documented clinical recovery was 20 days (SRC: 19 vs nSRC: 23; p = 0.37). There was no difference in the proportion of patients who developed delayed physician-documented recovery (SRC: 27.7% vs nSRC: 36.1%; p = 0.19). Higher initial symptom score increased the risk of delayed physician-documented recovery (IRR: 1.39; 95% CI: 1.29, 1.49). Greater material deprivation and social deprivation were associated with an increased risk of delayed physician-documented recovery.

CONCLUSIONS

Most pediatric concussion patients who undergo early medical assessment and complete follow-up appear to make a complete clinical recovery within 4 weeks, regardless of mechanism.

Factors associated with concussion-symptom knowledge and attitudes toward concussion care seeking in a national survey of parents of middle-school children in the US

BACKGROUND

Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion-symptom knowledge and care-seeking attitudes among parents of MS children (aged 10-15 years).

METHODS

A panel of 1224 randomly selected U.S. residents, aged ≥ 18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion-symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 point (range: 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range: 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) (excluding 1.00) were deemed statistically significant.

RESULTS

Median scores were 39 (interquartile range: 32-44) for symptom knowledge and 32 (interquartile range: 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71), and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99) and in older parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47).

CONCLUSION

Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion-symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention.

Comparing prevalence estimates of concussion/head injury in U.S. children and adolescents in national surveys

BACKGROUND AND OBJECTIVES

Reports on pediatric lifetime concussions/head injuries (LCHI) from national surveys have offered estimates on prevalence that range from 2.5% to 18% in the general population. The purpose of this study is to examine national surveys to compare methodologies and limitations pertaining to LCHI data collection.

METHODS

Three nationally representative surveys that measure LCHI in children, including the National Survey of Children's Health, the National Health Interview Survey, and the Monitoring the Future Survey were examined. Children were grouped by ages 3-17 years and adolescent ages 13-17 years, stratified by selected demographic characteristics. Participants in the surveys included parents (NSCH and NHIS) and adolescents (MTF survey). The primary outcome measure is an estimate of LCHI in children.

RESULTS

Estimates of prevalence of LCHI ranged from 3.6% to 7.0% for children ages 3-17 years and from 6.5% to 18.3% for adolescents 13-17 years. Survey modality, question wording, and respondent may contribute to differing estimates. Prevalence showed consistent variation by age, sex, and race/ethnicity across surveys. Associations were inconsistent between LCHI and insurance status, parental education, and household primary language.

CONCLUSIONS

Although there are methodological differences in capturing pediatric LCHI across surveys, the prevalence estimates and correlational associations generated can offer awareness about the burden of these injuries and insights to research and clinical care.

It is time to rewrite state youth sports concussion laws

Between 2009 and 2014, all 50 states and the District of Columbia passed legislation to improve the recognition and management of youth concussed in sports. These laws can include requirements for concussion training for school athletic personnel, concussion education for children and their parents, return-to-play (RTP) procedures, and medical clearance to for RTP. Concussion can impact academic learning and performance in children and adolescents. Postconcussion academic accommodations during recovery can be an important component of secondary prevention for mitigating the sequalae of head injury. Few state youth concussion laws, however, include provision of postconcussion return-to-learn (RTL) accommodations and most of those that do address RTL apply to student athletes only. Concussions may occur in youth who are not participating in organised sports (eg, falls, traffic crashes) and thus may not be subjected to RTL accommodations, even if the state mandates such procedures for athletes. Low income and students of colour may be more likely to have non-sports concussions than their more affluent and white peers, thus potentially creating demographic disparities in the benefits of RTL procedures. State youth sports concussion laws should be revised so that they include RTL provisions that apply to all students, athletes and non-athletes alike.

Epidemiology of Injuries in Ultimate (Frisbee): A Systematic Review

Ultimate is a high-intensity, non-contact team sport played with a flying disc (e.g., frisbee). Despite the growing popularity of ultimate worldwide, there is limited information about the epidemiology of injury in the sport. The purpose of this review is to provide a comprehensive overview and synthesis of the literature on the epidemiology of injury in ultimate. A comprehensive search of the literature was conducted in five electronic databases (i.e., MEDLINE, Embase, AMED, SPORTDiscus, and AusportMed). All databases were searched from inception to 1 July 2020. A total of eleven studies were included and qualitatively synthesized. Injury incidence rate estimates ranged from 0.4 to 84.9 injuries per 1000 athlete-exposures. The lifetime prevalence of any injury and concussion were 100% and 26%, respectively. The most commonly injured body region was the lower limb, with the knee and thigh being the most frequently injured anatomical locations. The most frequent injury types were muscle injuries and superficial contusions. The most common injury situation was direct contact with another player. There is a substantial risk of injury in ultimate, in particular muscle strains and joint sprains to the knee and shoulder areas. Development and implementation of effective, sport-specific injury prevention initiatives, including improved injury risk management and sport safety culture, should be a priority to reduce the burden of injury in ultimate.

Persistent alterations in cerebrovascular reactivity in response to hypercapnia following pediatric mild traumatic brain injury

Much attention has been paid to the effects of mild traumatic brain injury (mTBI) on cerebrovascular reactivity in adult populations, yet it remains understudied in pediatric injury. In this study, 30 adolescents (12-18 years old) with pediatric mTBI (pmTBI) and 35 age- and sex-matched healthy controls (HC) underwent clinical and neuroimaging assessments during sub-acute (6.9 ± 2.2 days) and early chronic (120.4 ± 11.7 days) phases of injury. Relative to controls, pmTBI reported greater initial post-concussion symptoms, headache, pain, and anxiety, resolving by four months post-injury. Patients reported increased sleep issues and exhibited deficits in processing speed and attention across both visits. In grey-white matter interface areas throughout the brain, pmTBI displayed increased maximal fit/amplitude of a time-shifted end-tidal CO2 regressor to blood oxygen-level dependent response relative to HC, as well as increased latency to maximal fit. The alterations persisted through the early chronic phase of injury, with maximal fit being associated with complaints of ongoing sleep disturbances during post hoc analyses but not cognitive measures of processing speed or attention. Collectively, these findings suggest that deficits in the speed and degree of cerebrovascular reactivity may persist longer than current conceptualizations about clinical recovery within 30 days.