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Hanalioglu D, Hanalioglu S, Arango JI, Adelson PD. Current evidence for pharmacological management of pediatric concussion: a systematic review. Childs Nerv Syst 2023; 39:1831-1849. [PMID: 37208486 DOI: 10.1007/s00381-023-05960-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 04/13/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE Mild traumatic brain injury (mTBI) is a global public health problem and its current management is limited to rest and symptom management. Despite frequent use of drugs for symptom control, there is a lack of consensus on the optimal pharmacological management of post-concussive symptoms. We reviewed the relevant literature to compile the evidence about the pharmaceutical management of pediatric mTBI. METHODS We performed a systematic review of the literature available in PubMed, Cochrane CENTRAL, and ClinicalTrials.Gov as well as through citation tracing. A modified PICO framework was used for the construction of search strategy and eligibility criteria. Risk of bias was assessed using RoB-2 tool for randomized and ROBINS-I for non-randomized studies. RESULTS A total of 6260 articles were screened for eligibility. After exclusions, a total of 88 articles received full text review. A total of 15 reports representing 13 studies (5 randomized clinical trials, 1 prospective randomized cohort study, 1 prospective cohort study, and 6 retrospective cohort studies) met the eligibility criteria and were included in the review. We identified 16 pharmacological interventions in a total of 931 pediatric patients with mTBI. Amytriptiline (n = 4), ondansetron (n = 3), melatonin (n = 3), metoclopramide (n = 2), magnesium (n = 2), and topiramate (n = 2) were investigated in multiple studies. All RCTs were relatively of small size (n ≤ 33/group). CONCLUSION The available evidence supporting pharmacological intervention in pediatric mild traumatic brain injury is scarce. We propose a framework to facilitate future collaborative research efforts to test and validate various pharmacological interventions for acute and persistent post-concussive symptoms in children.
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Affiliation(s)
- Damla Hanalioglu
- Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Pediatric Emergency Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sahin Hanalioglu
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Jorge I Arango
- Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - P David Adelson
- Department of Neurosurgery, Rockefeller Neuroscience Institute at WVU Medicine, Morgantown, WV, USA.
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Feinberg C, Carr C, Zemek R, Yeates KO, Master C, Schneider K, Bell MJ, Wisniewski S, Mannix R. Association of Pharmacological Interventions With Symptom Burden Reduction in Patients With Mild Traumatic Brain Injury: A Systematic Review. JAMA Neurol 2021; 78:596-608. [PMID: 33464290 DOI: 10.1001/jamaneurol.2020.5079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Mild traumatic brain injury (TBI) is experienced by 55.9 million people globally each year. The symptoms of mild TBI are diverse and sometimes long-lasting, requiring frequent use of pharmacological interventions to mitigate them. A thorough understanding of the data supporting pharmacological interventions is important for decision-making among clinicians treating this common injury. Objective To systematically review studies of pharmacological interventions and their associations with symptom burden reduction among patients with mild TBI and to use an evidence-based model to identify potential directions for future research that may aid in clinical decision-making. Evidence Review A systematic review was performed in PubMed, Scopus, and Web of Science. Search strings modified for the advanced search interfaces of each search engine were developed in consultation with a librarian and included combinations of search terms, such as brain concussion, post-concussion syndrome, mild traumatic brain injury, and pharmacological treatment. Articles published between January 1, 2000, and July 1, 2020, were analyzed. Studies were included if (1) they were clinical studies with discrete analyses of participants with mild TBI or complicated mild TBI, (2) they were assessments of a pharmacological intervention, (3) they included human participants, and (4) they were published in a peer-reviewed journal in the English language. Studies were excluded if the severity of TBI among participants could not be ascertained (ie, inadequate definition of mild TBI) and the inclusion criteria for the study required intracranial hemorrhage. A total of 23 studies examining 20 pharmacological interventions met the inclusion criteria. Risk of bias was assessed using the Cochrane Risk of Bias for Randomized Trials (for randomized clinical trials) and the Cochrane Risk of Bias in Non-Randomized Studies of Interventions (for all other studies). Data were analyzed from June to September 2020. Findings A total of 1495 articles were identified; of those, 131 articles were excluded as duplicates. Titles and abstracts were screened for inclusion and exclusion criteria among the remaining 1364 articles, and 134 of those articles received a full-text review. After exclusions, 23 studies (11 randomized clinical trials, 7 prospective observational studies, 3 retrospective observational studies, and 2 case studies) examining 20 pharmacological interventions were identified for inclusion in the systematic review. Studies included 22 distinct participant populations comprising 8277 participants with mild TBI and 45 participants without TBI. Among 23 total studies, 8 studies specifically addressed the pediatric population, 9 studies had a low risk of bias, and 16 studies reported symptom burden reduction. Of the 20 pharmacological interventions examined in the studies, methylphenidate, sertraline hydrochloride, ondansetron, amitriptyline, and melatonin were the only medications included in multiple studies. Conclusions and Relevance This systematic review found a limited number of high-quality, clinically meaningful studies, particularly among children and individuals in the acute stage of injury; therefore, performing an evidence-based analysis that would inform clinical decision-making was not possible. Future studies are needed to focus on standardizing measures and increasing sample sizes (including large multicenter clinical trials) to generate a body of research that may provide additional options for the treatment of patients with mild TBI.
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Affiliation(s)
| | | | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada.,Department of Emergency Medicine, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Keith Owen Yeates
- Department of Psychology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christina Master
- Sports Medicine and Performance Center, Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Division of Orthopaedics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kathryn Schneider
- Sport Injury Prevention Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Faculty of Kinesiology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Bell
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia
| | - Stephen Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Mannix R, Zemek R, Yeates KO, Arbogast K, Atabaki S, Badawy M, Beauchamp MH, Beer D, Bin S, Burstein B, Craig W, Corwin D, Doan Q, Ellis M, Freedman SB, Gagnon I, Gravel J, Leddy J, Lumba-Brown A, Master C, Mayer AR, Park G, Penque M, Rhine T, Russell K, Schneider K, Bell M, Wisniewski S. Practice Patterns in Pharmacological and Non-Pharmacological Therapies for Children with Mild Traumatic Brain Injury: A Survey of 15 Canadian and United States Centers. J Neurotrauma 2019; 36:2886-2894. [PMID: 31025612 DOI: 10.1089/neu.2018.6290] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Given the lack of evidence regarding effective pharmacological and non-pharmacological interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals [CI]) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation, and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI: 42,68]) and acetaminophen (59%; [95% CI: 46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI: 0,8]). The most common non-pharmacological interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI: 33,53]) and cervical spine exercises (29% [95%CI: 21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.
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Affiliation(s)
- Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Keith Owen Yeates
- Department of Psychology, Faculty of Kinesiology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Kristy Arbogast
- Division of Emergency Medicine, Sports Medicine and Performance Center, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shireen Atabaki
- Division of Emergency Medicine, Children's National Health System, Washington, District of Columbia
| | - Mohammed Badawy
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas
| | - Miriam H Beauchamp
- Department of Psychology, University of Montréal and Ste-Justine Research Center, Montréal, Canada
| | - Darcy Beer
- Section of Pediatric Emergency Medicine, University of Manitoba, Children's Hospital of Winnipeg, Winnipeg, Manitoba, Canada
| | - Steven Bin
- UCSF School of Medicine, Division of Pediatric Emergency Medicine, San Francisco, California
| | - Brett Burstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montréal Children's Hospital, McGill University Health Centre, Montréal, Quebec, Canada
| | - William Craig
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Dan Corwin
- Division of Emergency Medicine, Sports Medicine and Performance Center, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Quynh Doan
- Children's Research Institute, Division of Emergency Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Ellis
- Department of Surgery and Pediatrics, Section of Neurosurgery, University of Manitoba, Pan Am Concussion Program, Winnipeg, Manitoba, Canada
| | - Stephen B Freedman
- Stephen B. Freedman Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Isabelle Gagnon
- School of Physical and Occupational Therapy, McGill University; Trauma Programs, Montréal Children's Hospital, McGill University Health Center, Montréal, Quebec, Canada
| | - Jocelyn Gravel
- Division of Emergency Medicine, University of Montréal and Ste-Justine Research Center, Montréal, Canada
| | - John Leddy
- UBMD Department of Orthopaedics and Sports Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Angela Lumba-Brown
- Departments of Emergency Medicine and Pediatrics, Concussion and Brain Performance Center, Stanford University, Stanford, California
| | - Christina Master
- Division of Orthopaedics, Sports Medicine and Performance Center, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew R Mayer
- The Mind Research Network/LBERI and Departments of Psychology, Neurology, and Psychiatry, University of New Mexico, Albuquerque, New Mexico
| | - Grace Park
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Michelle Penque
- Pediatrics Division of Emergency Medicine, and Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Tara Rhine
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kelly Russell
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital of Winnipeg, Winnipeg, Manitoba, Canada
| | - Kathryn Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael Bell
- Department of Pediatrics and Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Stephen Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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