Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms

Marching Band Injuries in Children Presenting to Emergency Departments in the United States, 2012-2021: A Trebling Tale

Marching band is both a sport and a performance art. Organized athletics like American football, soccer, and cheerleading all have established epidemiologic trends of injury, including stigmata from head trauma. Despite the potential for mild to severe injury, there is a paucity of data on marching band-related morbidity. We examined the National Electronic Injury Surveillance System from 2012 to 2021 to describe demographic information and injury patterns. There were an estimated 20 335 marching band injuries (95% confidence interval: 12 892-27 777). The majority of injuries occurred in females (70%), and those aged 14 to 18 years (85%). Fifty percent of all injuries occurred in the lower extremity, and soft tissue injuries were the most frequently observed diagnosis (49%). Mild traumatic brain injury accounted for 6% of all injuries. Of marching band injury, 98% did not require escalation of care. Based on these findings, we suggest targeted public health intervention by sports medicine teams.

Longitudinal neurocognitive trajectories and risk factors in the first three months following pediatric concussion

OBJECTIVE

To identify differential trajectories of neurocognitive outcomes following pediatric concussion and investigate predictors associated with patterns of recovery up to 3 months.

METHODS

74 participants aged 8-17 years completed attention/working memory, processing speed, and executive function measures at 2 weeks, 1 month, and 3 months post-injury. We used principal component analysis to generate a composite of information processing. Group-based trajectory modeling identified latent trajectories. Multinominal logistic regression was used to examine associations between risk factors and trajectory groups.

RESULTS

We identified three trajectories of neurocognitive outcomes. The medium (54.6%) and high improving groups (35.8%) showed ongoing increase in information processing, while the low persistent group showed limited change 3 months post-injury. This group recorded below average scores on Digit Span Forward and Backward at 3 months. History of pre-injury headache was significantly associated with the persistent low scoring group, relative to the medium improving (p = 0.03) but not the high improving group (p = 0.09).

CONCLUSIONS

This study indicates variability in neurocognitive outcomes according to three differential trajectories, with groups partially distinguished by preexisting child factors (history of frequent headaches). Modelling that accounts for heterogeneity in individual outcomes is essential to identify clinically meaningful indices that are indicative of children requiring intervention.

Association of Psychological Resilience, Cognitive Reserve, and Brain Reserve with Post-Concussive Symptoms in Children with Mild Traumatic Brain Injury and Orthopedic Injury: An A-CAP Study

Protective factors, including psychological resilience, cognitive reserve, and brain reserve, may be positively associated with recovery after pediatric mild traumatic brain injury (mTBI) but are yet to be studied concurrently. We sought to examine these factors as moderators of post-concussive symptoms (PCS) in pediatric mTBI compared with mild orthopedic injury (OI). Participants included 967 children (633 mTBI, 334 OI) aged 8-16.99 years, recruited from 5 Canadian pediatric emergency departments as part of a prospective longitudinal cohort study. At 10 days post-injury, psychological resilience was measured using the Connor-Davidson Resilience Scale and brain reserve was measured using total brain volume derived from structural magnetic resonance imaging. Cognitive reserve was measured at 3 months post-injury using IQ scores from the Wechsler Abbreviated Scale of Intelligence-Second Edition. Cognitive and somatic PCS were measured using child and parent ratings on the Health and Behavior Inventory, completed weekly for 3 months and biweekly to 6 months. Analyses involved generalized least-squares regression models using restricted cubic splines. Covariates included age at injury, sex, racialized identity, material and social deprivation, pre-injury migraine and concussion history, and retrospective pre-injury PCS. Psychological resilience moderated group differences in parent-reported PCS. At 30 days post-injury, estimated group differences in parent-reported cognitive and somatic PCS (mTBI > OI) were larger at higher (75th percentile) resilience scores (Est = 2.25 [0.87, 3.64] and Est = 2.38 [1.76, 3.00], respectively) than at lower (25th percentile) resilience scores (Est = 1.44 [0.01, 2.86] and Est = 2.08 [1.45, 2.71], respectively). Resilience did not moderate group differences in child-reported PCS but was negatively associated with child-reported PCS in both groups (ps ≤ 0.001). Brain reserve (i.e., total brain volume [TBV]) also moderated group differences, but only for parent-reported somatic PCS (p = 0.018). Group difference (mTBI > OI) at 30 days was larger at smaller (25th percentile) TBV (Est = 2.78 [2.17, 3.38]) than at larger (75th percentile) TBV (Est = 1.95 [1.31, 2.59]). TBV was not associated with parent-reported cognitive PCS or child-reported PCS. IQ did not moderate PCS in either group but had a significant non-linear association in both groups with child-reported somatic PCS (p = 0.018) and parent-reported PCS (p < 0.001), with higher PCS scores at both lower and higher IQs. These findings suggest that higher resilience predicts fewer PCS, but less strongly after mTBI than OI; greater brain reserve may reduce the effect of mTBI on somatic PCS; and cognitive reserve has an unexpected curvilinear association with PCS across injury types. The results highlight the importance of protective factors as predictors of recovery and potential targets for intervention following pediatric mTBI.

Magnetoencephalography for the pediatric population, indications, acquisition and interpretation for the clinician

Magnetoencephalography (MEG) is an imaging technique that enables the assessment of cortical activity via direct measures of neurophysiology. It is a non-invasive and passive technique that is completely painless. MEG has gained increasing prominence in the field of pediatric neuroimaging. This dedicated review article for the pediatric population summarizes the fundamental technical and clinical aspects of MEG for the clinician. We discuss methods tailored for children to improve data quality, including child-friendly MEG facility environments and strategies to mitigate motion artifacts. We provide an in-depth overview on accurate localization of neural sources and different analysis methods, as well as data interpretation. The contemporary platforms and approaches of two quaternary pediatric referral centers are illustrated, shedding light on practical implementations in clinical settings. Finally, we describe the expanding clinical applications of MEG, including its pivotal role in presurgical evaluation of epilepsy patients, presurgical mapping of eloquent cortices (somatosensory and motor cortices, visual and auditory cortices, lateralization of language), its emerging relevance in autism spectrum disorder research and potential future clinical applications, and its utility in assessing mild traumatic brain injury. In conclusion, this review serves as a comprehensive resource of clinicians as well as researchers, offering insights into the evolving landscape of pediatric MEG. It discusses the importance of technical advancements, data acquisition strategies, and expanding clinical applications in harnessing the full potential of MEG to study neurological conditions in the pediatric population.

Discovery of Alpha-1-Antichymotrypsin as a Marker of Delayed Recovery from Concussion in Children

Of the four million children who experience a concussion each year, 30-50% of children will experience delayed recovery, where they will continue to experience symptoms more than two weeks after their injury. Delayed recovery from concussion encompasses emotional, behavioral, physical, and cognitive symptoms, and as such, there is an increased focus on developing an objective tool to determine risk of delayed recovery. This study aimed to identify a blood protein signature predictive of delayed recovery from concussion in children. Plasma samples were collected from children who presented to the Emergency Department at the Royal Children's Hospital, Melbourne, within 48h post-concussion. This study involved a discovery and validation phase. For the discovery phase, untargeted proteomics analysis was performed using single window acquisition of all theoretical mass spectra to identify blood proteins differentially abundant in samples from children with and without delayed recovery from concussion. A subset of these proteins was then validated in a separate participant cohort using multiple reaction monitoring and enzyme linked immunosorbent assay. A blood protein signature predictive of delayed recovery from concussion was modeled using a Support Vector Machine, a machine learning approach. In the discovery phase, 22 blood proteins were differentially abundant in age- and sex-matched samples from children with (n = 9) and without (n = 9) delayed recovery from concussion, six of whom were chosen for validation. In the validation phase, alpha-1-ACT was shown to be significantly lower in children with delayed recovery (n = 12) compared with those without delayed recovery (n = 28), those with orthopedic injuries (n = 7) and healthy controls (n = 33). A model consisting of alpha-1-ACT concentration stratified children based on recovery from concussion with an 0.88 area under the curve. We have identified that alpha-1-ACT differentiates between children at risk of delayed recovery from those without delayed recovery from concussion. To our knowledge, this is the first study to identify alpha-1-ACT as a potential marker of delayed recovery from concussion in children. Multi-site studies are required to further validate this finding before use in a clinical setting.

Quality of Life in Youth Soccer Players After Mild Traumatic Brain Injury

CONTEXT

Pediatric mild traumatic brain injuries (mTBIs) represent an evolving field of interest in youth athletics. Although most players recover within 4 weeks, some have symptoms that last longer. Little is known about youth health-related quality of life (HRQoL) after mTBI.

OBJECTIVES

To characterize youth HRQoL after soccer-related mTBI and to identify predictors of individual differences in HRQoL recovery.

DESIGN

Prospective cohort study.

SETTING

Youth soccer.

PARTICIPANTS

Soccer players, aged 8 to 17 years, who sustained an mTBI (n = 23) or orthopaedic injury (OI, n = 24) or remained uninjured (n = 23) during a single season.

MAIN OUTCOME MEASURE(S)

We assessed HRQoL via the Pediatric Quality of Life Inventory, version 4.0, and postconcussive symptoms via the Health and Behavior Index. Serial assessments occurred at 24 to 48 hours, 7 days, 30 days, and 90 days postinjury via telephone interview.

RESULTS

At 7 days postinjury, the mTBI and OI groups had poorer total HRQoL (F2,67 = 11.35, P < .001) than the uninjured control group. At 7 days, the mTBI group had the poorest psychosocial HRQoL, whereas the OI group had the poorest physical HRQoL. Differences between the mTBI and uninjured control groups resolved by 30 days. Within the mTBI group, players with significant postconcussive symptoms at 7 days had poorer total (F1,21 = 23.071, P ≤ .001; F1,21 = 5.798, P = .028), psychosocial (F1,21 = 16.488, P = < .001; F1,21 = 5.050, P = .039), and physical (F1,21 = 21.671, P = < .001; F1,21 = 5.119, P = .038) HRQoL at 7 and 30 days, respectively, than players with minimal symptoms; these differences resolved by 90 days.

CONCLUSIONS

As a group, youth soccer players who sustained mTBI had transient impairments in HRQoL that resolved by 30 days. A subset of players with significant postconcussive symptoms at 7 days postinjury had poorer HRQoL for at least 30 days postinjury than those whose postconcussive symptoms had resolved within a week of injury. This suggests ongoing recovery in this subset at 30 days and the potential utility of HRQoL as a measure of recovery.

The Effects of Injury Type on Health-Related Quality of Life in Youth Athletes: A Cross-Sectional Analysis

OBJECTIVE

The relationship between health-related quality of life (HRQoL) and injury type has not been analyzed for young athletes. We hypothesized that there would be no difference in HRQoL between injured athletes, injured nonathletes, and normative data for healthy youth (NDHY) or among athletes with acute, overuse, or concussion injuries.

DESIGN

Cross-sectional clinical cohort.

SETTING

Primary care sports medicine clinics at 3 academic institutions.

PARTICIPANTS

Patients aged 8 to 18 years presenting with injury.

INDEPENDENT VARIABLES

Injury type and athletic participation.

MAIN OUTCOME MEASURES

Health-related quality of life measured 1 month after injury through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric-25 v2.0 assessed pain interference, peer relationships, depression, fatigue, anxiety, and mobility. One-way analysis of variance was performed with P values of <0.05 considered significant. Concussion Learning Assessment and School Survey (CLASS) evaluated academic performance.

RESULTS

Three hundred fifty-seven patients (36% male), with average age of 14.2 years, completed HRQoL and CLASS surveys following injury. There were 196 overuse injuries (55%), 119 acute injuries (33%), and 42 concussions (12%). Ninety-four percent were athletes. Six percent were nonathletes; 90.5% of concussed patients reported grades worsening. Concussed athletes reported more fatigue (P = 0.008) compared with other injury types but no worse than NDHY. Athletes with overuse injuries had lower mobility (P = 0.005) than other injury types and NDHY. Patients with lower HRQoL were female, older age, or required surgery. No other domains had significant differences by injury type nor did HRQoL differ between the athletes, nonathletes, and NDHY.

CONCLUSIONS

With the exception of injuries requiring surgery, HRQoL of injured young athletes was similar to NDHY in most domains.

Change in health-related quality of life and functional disability over time post-concussion in youth

PURPOSE

Concussions can have detrimental on children's cognitive, emotional, behavioral, and/or social functioning. We sought to examine changes in health-related quality of life (HRQOL) and functional disability from pre-injury to 1-week post-concussion, and to symptom resolution among youth ages 11-17 with a concussion.

METHODS

In this prospective, longitudinal cohort study, 83 concussed youth, ages 11-17, self-reported post-concussion symptoms daily as well as HRQOL and functional disability at baseline (pre-injury, retrospective), 1-week post-concussion, and symptom resolution. We modeled changes in overall and sub-scale HRQOL and functional disability scores over time from pre-injury to 1-week post-concussion and from 1-week post-concussion to symptom resolution using a piecewise linear mixed model, adjusting for potential covariables. Estimated fixed effects with a corresponding adjusted coefficient (beta), along with their 95% confidence intervals are presented.

RESULTS

Overall HRQOL worsened from pre-injury to 1-week post-injury (β = - 5.40, 95%CI - 9.22, - 1.58) but did not change from 1-week post-injury to symptom resolution. Physical HRQOL worsened from pre-injury to 1-week post-injury (β = - 9.90, 95%CI - 14.65, - 5.14) but improved from 1-week post-injury to symptom resolution (β = 1.64, 95%CI 0.50, 2.78), while psychosocial HRQOL showed no change over time. Functional disability worsened from pre-injury to 1-week post-injury (β = 8.36, 95%CI 5.93, 10.79) but with no change from 1-week post-injury to symptom resolution. Youth with symptom duration > 14 days reported worse HRQOL and functional disability than those who recovered in ≤ 14 days and greater daily post-concussion symptom scores were associated with worse HRQOL and functional disability.

CONCLUSION

Concussions have a negative impact on overall and physical HRQOL and functional disability in youth acutely post-injury. Ratings of HRQOL could be used to inform clinical treatment decisions to assist with the recovery process.

Concurrent Psychosocial Concerns and Post-Concussive Symptoms Following Pediatric mTBI: An A-CAP Study

OBJECTIVES

To measure the association between psychosocial problems and persistent post-concussive symptoms (PCS) in youth who were seen in the emergency department with mild traumatic brain injury (mTBI) or orthopedic injury (OI).

METHODS

From a larger prospective cohort study, Advancing Concussion Assessment in Pediatrics (A-CAP), 122 child-guardian pairs who presented to the emergency department with mTBI (N = 70) or OI (N = 52) were recruited for this cross-sectional sub-study. Each pair completed 2 measures assessing PCS burden at 2 weeks, 3 months, and 6 months post-injury. At one visit, pairs concurrently completed MyHEARTSMAP, a comprehensive, psychosocial self-assessment tool to evaluate 4 domains of mental wellness.

RESULTS

When measured at the same visit, children who self-reported moderate or severe Psychiatry domain concerns concurrently experienced a greater burden of cognitive symptoms (β = 5.49; 0.93-10.05) and higher overall PCS count (β = 2.59; 0.70-4.48) after adjusting for covariables, including retrospective pre-injury symptoms and injury group. Additionally, reports indicating mild Function domain severity were associated with increased cognitive (β = 3.34; 95% CI: 0.69-5.99) and somatic symptoms (β = 6.79; 2.15-11.42) and total symptom count (β = 1.29; 0.18-2.39).

CONCLUSION

Increasing severity in multiple domains of mental health is associated with more PCS in youth. While the differences in PCS between the mTBI and OI groups appeared somewhat larger for children with more mental health concerns, the interaction was not statistically significant; larger sample sizes are needed to evaluate the moderating effect of psychosocial difficulties on post-concussion symptoms.

Blood biomarkers of secondary outcomes following concussion: A systematic review

Introduction

Blood biomarkers have been identified as an alternative tool for predicting secondary outcomes following concussion. This systematic review aimed to summarize the literature on blood biomarkers of secondary outcomes following concussion in both pediatric and adult cohorts.

Methods

A literature search of Embase, Medline and PubMed was conducted. Two reviewers independently assessed retrieved studies to determine inclusion in systematic review synthesis.

Results

A total of 1771 unique studies were retrieved, 58 of which were included in the final synthesis. S100B, GFAP and tau were identified as being associated with secondary outcomes following concussion. Seventeen percent of studies were performed in a solely pediatric setting.

Conclusions

Validation of biomarkers associated with secondary outcomes following concussion have been largely limited by heterogeneous study cohorts and definitions of concussion and mTBI, presenting a hurdle for translation of these markers into clinical practice. Additionally, there was an underrepresentation of studies which investigated pediatric cohorts. Adult markers are not appropriate for children, therefore pediatric specific markers of secondary outcomes following concussion present the biggest gap in this field.

The effect of birth order on length of hospitalization for pediatric traumatic brain injury: an analysis of the 1987 Finnish birth cohort

Purpose

This study examines the relationship between birth order and length of hospitalization due to pediatric traumatic brain injury (TBI).

Methods

We prospectively followed 59,469 Finnish newborns from 1987 until age 18 years. Data on first diagnosis of TBI was recorded within the 1987 Finnish Birth Cohort (FBC). Hospitalization period was divided into two categories: 2 days or less and more than 2 days. The latter was considered in this study as longer hospitalization.

Results

Compared with first born siblings, later born siblings had an increased risk of a longer hospitalization for TBI (12.7% of fourth or higher born birth children diagnosed with TBI were hospitalized for 2 or more days, 11.3% of first born, 10.4% of third born and 9.0% of second born). Fourth or higher born children were more likely to experience a repeat TBI; 13.4% of fourth or higher born children diagnosed with TBI had 2–3 TBIs during the study period compared to 9% of third born, 7.8% of second born and 8.8% of the first born. Injuries in the traffic environment and falls were the most common contributors to pediatric TBI and occurred most frequently in the fourth or higher birth category; 29.3% of TBIs among fourth or higher birth order were due to transport accidents and 21% were due to falls.

Conclusions

This study revealed a significant increase in risk for longer hospitalization due to TBI among later born children within the same sibling group. The study provides epidemiological evidence on birth order as it relates to TBI, and its potential to help to explain some of the statistical variability in pediatric TBI hospitalization over time in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00919-x.

Factor structure and measurement invariance of post-concussion symptom ratings on the Health and Behaviour Inventory across time, raters, and groups: An A-CAP study

OBJECTIVES

To validate the two-factor structure (i.e., cognitive and somatic) of the Health and Behaviour Inventory (HBI), a widely used post-concussive symptom (PCS) rating scale, through factor analyses using bifactor and correlated factor models and by examining measurement invariance (MI).

METHODS

PCS ratings were obtained from children aged 8-16.99 years, who presented to the emergency department with concussion (n = 565) or orthopedic injury (OI) (n = 289), and their parents, at 10-days, 3-months, and 6-months post-injury. Item-level HBI ratings were analyzed separately for parents and children using exploratory and confirmatory factor analyses (CFAs). Bifactor and correlated models were compared using various fit indices and tested for MI across time post-injury, raters (parent vs. child), and groups (concussion vs. OI).

RESULTS

CFAs showed good fit for both a three-factor bifactor model, consisting of a general factor with two subfactors (i.e., cognitive and somatic), and a correlated two-factor model with cognitive and somatic factors, at all time points for both raters. Some results suggested the possibility of a third factor involving fatigue. All models demonstrated strict invariance across raters and time. Group comparisons showed at least strong or strict invariance.

CONCLUSIONS

The findings support the two symptom dimensions measured by the HBI. The three-factor bifactor model showed the best fit, suggesting that ratings on the HBI also can be captured by a general factor. Both correlated and bifactor models showed substantial MI. The results provide further validation of the HBI, supporting its use in childhood concussion research and clinical practice.

Family Burden in Adolescents With Refractory Postconcussion Symptoms

OBJECTIVE

A significant minority of adolescents will have persistent postconcussion symptoms after an injury, potentially having a negative impact on family functioning. However, the reasons for a family's negative impact are not clearly understood. The objective of this study was to determine whether preinjury/demographic factors, injury characteristics, and/or worse postinjury symptoms are associated with higher levels of family stress in youth with refractory postconcussion symptoms.

SETTING

Pediatric refractory concussion clinic in a tertiary care center.

PARTICIPANTS

A total of 121 adolescents (13-18 years old) who were 1 to 12 months postconcussion.

MEASURES

Primary outcome was the mean stress rating on the Family Burden of Injury Interview (FBII), a 27-item questionnaire rating the impact on a family as a result of an injury. Preinjury/demographic and injury details were collected. Youth and their parents also completed measures of postconcussion symptoms, depression, anxiety, and behavioral problems.

RESULTS

Participants had a mean age of 16.0 years (SD = 1.3), of which, 65% identified as female, and were on an average 5.2 months (SD = 2.4) postconcussion. FBII ratings were not significantly correlated with demographics, preinjury functioning, injury severity, duration of persistent postconcussion problems (ie, time since injury), or self-reported postconcussion symptoms. Greater family burden (higher FBII ratings) significantly correlated with worse parent-reported postconcussion symptoms, worse psychological functioning (self-reported depression, parent-reported anxiety, and depression), and worse behavioral functioning (parent-reported conduct problems and peer problems). A multiple linear regression model revealed that parent-perceived postconcussion cognitive symptoms (β = .292, t = 2.56, P = .012) and parent-perceived peer problems (β = .263, t = 2.59, P = .011) were significantly associated with family burden ( F8,105 = 6.53; P < .001; R2 = 0.35).

CONCLUSION

Families of youth with refractory postconcussion symptoms can experience a negative impact. The severity of reported family burden in those with slow recovery from concussion was significantly associated with parents' perception of their child's cognitive symptoms and peer problems. These results could provide support for family-based interventions in this population.

Experiences of Children and Youth With Concussion: A Qualitative Study

IMPORTANCE

Concussions are common among children and youth. To date, the pediatric concussion literature has focused on quantitative reports of the effects of concussion and return-to-activity guidelines. However, the subjective experiences of children and youth returning to occupations postconcussion have largely been ignored. An understanding of these experiences is critical to inform effective concussion management.

OBJECTIVE

To investigate the experiences of children and youth returning to occupations after sustaining a concussion and the impacts on their future engagement in occupation.

DESIGN

Qualitative interpretive description was used for data analysis and interpretation.

SETTING

Community.

PARTICIPANTS

Children and youth ages 11 to 18 yr from a cohort study were recruited to be interviewed about their experiences of engaging in occupations postconcussion.

OUTCOMES AND MEASURES

Interviews were conducted 3 to 24 mo postconcussion, transcribed verbatim, and analyzed using interpretive description to identify themes.

RESULTS

Eight children and youth (5 male, 3 female) were included. Analyses revealed three themes of the experiences of children and youth returning to occupations after concussion: diverse experiences of concussion, knowledge is key to concussion management, and concussions affect occupational engagement.

CONCLUSIONS AND RELEVANCE

This study highlights the importance of considering a person's needs to enable effective concussion treatment plans. The results suggest the need for an occupation-based framework to guide interventions in pediatric concussion management. What This Article Adds: Our findings indicate that children and youth report variable recovery patterns, a lack of knowledge about concussion recovery, and a negative effect of concussion on occupational engagement.

Improving subacute management of post concussion symptoms: a pilot study of the Melbourne Paediatric Concussion Scale parent report

Aim:

To pilot a modification of the Post Concussion Symptom Inventory, the Melbourne Paediatric Concussion Scale (MPCS) and examine its clinical utility.

Materials & methods:

A total of 40 families of concussed children, aged 8–18 years, were recruited from the emergency department. Parent responses to the MPCS in the emergency department and 2-weeks post injury determined child symptomatic status. Association between MPCS symptom endorsement and symptomatic group status was examined.

Results:

All additional MPCS items were endorsed by at least 25% of the parents of symptomatic children at 2 weeks. MPCS items were classified into nine symptom domains, with most falling in mood, neurological, autonomic and vestibular domains.

Conclusion:

The additional items and domain classifications in the MPCS have the potential to improve subacute diagnostic precision, monitoring of clinical recovery and identification of appropriate interventions post pediatric concussion.

Paediatric post-concussive symptoms: symptom clusters and clinical phenotypes

OBJECTIVE

To assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity.

METHODS

We performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5-17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings.

RESULTS

3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2-14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%-72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity.

CONCLUSION

Post-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes.While I agree with the use of the british spelling of Paediatric throughout, this groups actual name is with the American English Spelling.

Healthcare utilization and costs associated with persistent post-concussive symptoms

OBJECTIVE

To describe the healthcare utilization and costs associated with the interdisciplinary treatment of pediatric persistent post-concussive symptoms (PPCS).

METHODS

A retrospective chart review was conducted with 461 youth referred by community physicians to an interdisciplinary pediatric PPCS outpatient clinic in Ontario, Canada. Healthcare utilization parameters included accessibility, continuity, comprehensiveness, and service productivity. Direct healthcare costs included those incurred by physicians and other interdisciplinary services. Indirect costs per client included travel to the clinic and caregiver productivity loss. Data analyses were completed using descriptive statistics.

RESULTS

The median age of clients was 15 years (range = 3 to 18). The median wait time for an initial PPCS clinic physician consultation was 71 days, and less than 2 months for other interdisciplinary services. Eighty-two percent of clients were referred to at least one other service after an initial physician consultation. Occupational therapy received the highest proportion of referrals (79%). Total median direct costs per client were approximately $915, with a final accumulated cost of $532 623 for all clients. Caregiver productivity loss was approximately $387 per family.

CONCLUSIONS

Our findings suggest that interdisciplinary PPCS care represents an accessible, comprehensive and cost-saving healthcare model from the client and societal perspectives.

Post-Concussion and Post-Traumatic Stress Symptoms after Pediatric Traumatic Brain Injury: Shared Vulnerability Factors?

Following pediatric traumatic brain injury (TBI), post-concussion symptoms (PCS) and post-traumatic stress symptoms (PTSS) occur commonly; however, it is unknown to what degree they overlap. The study examined PCS and PTSS persisting 7 weeks after injury in children and adolescents ages 8-15 years with TBI (n = 89) or extracranial injury (EI; n = 40) after vehicle collisions. TBI was divided into mild, complicated-mild/moderate, and severe groups. Parents retrospectively rated children's pre-injury symptoms and behavior problems, and children completed self-report measures after injury. PCS and PTSS total scores were significantly correlated in TBI and EI groups, respectively, for child (rs = 0.75; rs = 0.44), and adolescent (rs = 0.61; rs = 0.67) cohorts. Generalized linear models examined whether injury type and severity, age, sex, and pre-injury symptom ratings predicted PCS and PTSS total scores and factor scores. Specific PCS and PTSS factor scores were elevated in different TBI severity groups, with most frequent problems following mild or severe TBI. PCS did not differ by age; however, girls had more emotional symptoms than boys. Only PTSS were predicted by pre-injury externalizing behavior. Significant age by sex interactions indicated that adolescent girls had more total, avoidance, and hyperarousal PTSS symptoms than younger girls or all boys. PCS and PTSS significantly overlapped in both TBI and EI groups, highlighting shared persistent symptoms after injury. Shared vulnerability factors included female sex, milder TBI, and poorer pre-injury adjustment. Older age was a unique vulnerability factor for PTSS. Psychological health interventions after injury should be customized to address comorbid symptoms.

Condition-specific health-related quality of life amongst amateur athletes six months and one-year following sport-related concussion: A prospective, follow-up

OBJECTIVE

To prospectively investigate the condition-specific health-related quality of life (HRQoL) of athletes six months and one-year following sport-related concussion.

DESIGN

Prospective, longitudinal study.

SETTING

Clinical research centre at university school of public health.

PARTICIPANTS

Amateur athletes who were diagnosed with sport-related concussion within one-week after presenting to a hospital emergency department were recruited along with sex-, age-, and activity-matched, non-concussed, control athletes. Concussion and control participants were assessed six months and one-year following sport-related concussion and study enrolment, respectively.

MAIN OUTCOME MEASURES

Participants completed the Post-Concussion Symptom Scale and five condition-specific HRQoL patient-reported outcome measures - Headache Impact Test-6, Fatigue Severity Scale, Neck Disability Index, Generalised Anxiety Disorder-7, and Dizziness Handicap Inventory. We performed Frequentist and Bayesian mixed-design analyses of variance to compare the concussion group and control group at both assessments and quantify whether there was greater evidence in favour of the null hypothesis compared with the alternative hypothesis.

RESULTS

At six-month and one-year assessments, the concussion group (n = 47; male = 72%; mean (SD) age = 22.68 (5.07)) and the control group (n = 47; male = 72%; mean (SD) age = 23.81 (4.60)) reported similar clinical symptom severity scores and condition-specific HRQoL. The proportion of athletes in the concussion group with clinically-impaired scores was similar to the proportion of non-concussed athletes with clinically-impaired scores. At six-month and one-year assessments, there was moderate-to-very strong evidence that there was no difference between concussion and control participants' perceptions of the effects of headache, fatigue, neck pain, anxiety, and dizziness on HRQoL.

CONCLUSION

There was moderate-to-very strong evidence in favour of no difference between the concussion and control groups on symptom severity scores and condition-specific HRQoL patient-reported outcome measures at six-month and one-year assessments. These results suggest that condition-specific HRQoL returns to the levels of non-concussed individuals within six months following sport-related concussion.

Mild traumatic brain injury is associated with dysregulated neural network functioning in children and adolescents

Mild traumatic brain injury is highly prevalent in paediatric populations, and can result in chronic physical, cognitive and emotional impairment, known as persistent post-concussive symptoms. Magnetoencephalography has been used to investigate neurophysiological dysregulation in mild traumatic brain injury in adults; however, whether neural dysrhythmia persists in chronic mild traumatic brain injury in children and adolescents is largely unknown. We predicted that children and adolescents would show similar dysfunction as adults, including pathological slow-wave oscillations and maladaptive, frequency-specific, alterations to neural connectivity. Using magnetoencephalography, we investigated regional oscillatory power and distributed brain-wide networks in a cross-sectional sample of children and adolescents in the chronic stages of mild traumatic brain injury. Additionally, we used a machine learning pipeline to identify the most relevant magnetoencephalography features for classifying mild traumatic brain injury and to test the relative classification performance of regional power versus functional coupling. Results revealed that the majority of participants with chronic mild traumatic brain injury reported persistent post-concussive symptoms. For neurophysiological imaging, we found increased regional power in the delta band in chronic mild traumatic brain injury, predominantly in bilateral occipital cortices and in the right inferior temporal gyrus. Those with chronic mild traumatic brain injury also showed dysregulated neuronal coupling, including decreased connectivity in the delta range, as well as hyper-connectivity in the theta, low gamma and high gamma bands, primarily involving frontal, temporal and occipital brain areas. Furthermore, our multivariate classification approach combined with functional connectivity data outperformed regional power in terms of between-group classification accuracy. For the first time, we establish that local and large-scale neural activity are altered in youth in the chronic phase of mild traumatic brain injury, with the majority presenting persistent post-concussive symptoms, and that dysregulated interregional neural communication is a reliable marker of lingering paediatric ‘mild’ traumatic brain injury.

Trajectories and Risk Factors for Pediatric Postconcussive Symptom Recovery

BACKGROUND

Persistent postconcussive symptoms (PCS) are poorly understood in children. Research has been limited by an assumption that children with concussion are a homogenous group.

OBJECTIVE

To identify (i) distinctive postconcussive recovery trajectories in children and (ii) injury-related and psychosocial factors associated with these trajectories.

METHODS

This study is part of a larger prospective, longitudinal study. Parents of 169 children (5-18 yr) reported their child's PCS over 3 mo following concussion. PCS above baseline levels formed the primary outcome. Injury-related, demographic, and preinjury information, and child and parent mental health were assessed for association with trajectory groups. Data were analyzed using group-based trajectory modeling, multinomial logistic regression, and chi-squared tests.

RESULTS

We identified 5 postconcussive recovery trajectories from acute to 3 mo postinjury. (1) Low Acute Recovered (26.6%): consistently low PCS; (2) Slow to Recover (13.6%): elevated symptoms gradually reducing; (3) High Acute Recovered (29.6%): initially elevated symptoms reducing quickly to baseline; (4) Moderate Persistent (18.3%): consistent, moderate levels of PCS; (5) Severe Persistent (11.8%): persisting high PCS. Higher levels of child internalizing behaviors and greater parental distress were associated with membership to the Severe Persistent group, relative to the Low Acute Recovered group.

CONCLUSION

This study indicates variability in postconcussive recovery according to 5 differential trajectories, with groups distinguished by the number of reported symptoms, levels of child internalizing behavior problems, and parental psychological distress. Identification of differential recovery trajectories may allow for targeted early intervention for children at risk of poorer outcomes.

Protocol for a randomised clinical trial of multimodal postconcussion symptom treatment and recovery: the Concussion Essentials study

INTRODUCTION

While most children recover from a concussion shortly after injury, approximately 30% experience persistent postconcussive symptoms (pPCS) beyond 1-month postinjury. Existing research into the treatment of pPCS have evaluated unimodal approaches, despite evidence suggesting that pPCS likely represent an interaction across various symptom clusters. The primary aim of this study is to evaluate the effectiveness of a multimodal, symptom-tailored intervention to accelerate symptom recovery and increase the proportion of children with resolved symptoms at 3 months postconcussion.

METHODS AND ANALYSIS

In this open-label, assessor-blinded, randomised clinical trial, children with concussion aged 8-18 years will be recruited from The Royal Children's Hospital (The RCH) emergency department, or referred by a clinician, within 17 days of initial injury. Based on parent ratings of their child's PCS at ~10 days postinjury, symptomatic children (≥2 symptoms at least 1-point above those endorsed preinjury) will undergo a baseline assessment at 3 weeks postinjury and randomised into either Concussion Essentials (CE, n=108), a multimodal, interdisciplinary delivered, symptom-tailored treatment involving physiotherapy, psychology and education, or usual care (UC, n=108) study arms. CE participants will receive 1 hour of intervention each week, for up to 8 weeks or until pPCS resolve. A postprogramme assessment will be conducted at 3 months postinjury for all participants. Effectiveness of the CE intervention will be determined by the proportion of participants for whom pPCS have resolved at the postprogramme assessment (primary outcome) relative to the UC group. Secondary outcome analyses will examine whether children receiving CE are more likely to demonstrate resolution of pPCS, earlier return to normal activity, higher quality of life and a lower rate of utilisation of health services, compared with the UC group.

ETHICS AND DISSEMINATION

Ethics were approved by The RCH Human Research Ethics Committee (HREC: 37100). Parent, and for mature minors, participant consent, will be obtained prior to commencement of the trial. Study results will be disseminated at international conferences and international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000418370; pre-results.

Lack of Sleep Among Adolescent Athletes Is Associated With a Higher Prevalence of Self-Reported History of Anxiety and Depression

Purpose: To study mental health, sleep duration, and daytime sleepiness in young athletes. Methods: A cross-sectional questionnaire study was conducted. The main outcome measures included sleep duration and daytime sleepiness. Results: Study participants included 756 athletes with a mean age of 13.5 years. A total of 39% (n = 296/756) reported not meeting current sleep recommendations for age. Athletes >12 years and with a self-reported anxiety and/or depression history were less likely to meet sleep recommendations and showed higher daytime sleepiness (adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] [1.2, 1.4], β [SE] = 3.06 [0.74], respectively). Athletes with goal-oriented reasons for playing versus enjoyment (52% vs. 35%, aOR = 1.70, 95% CI [1.12, 2.58]) were less likely to meet sleep recommendations. Night time internet access and weeknight homework hours were negatively associated with sleep recommendations (aOR = 1.68, 95% CI [1.68, 2.47] and aOR = 3.11, 95% CI [1.82, 5.3]) and positively associated with daytime sleepiness (β [SE] = 1.44 [0.45] and 2.28 [0.59]). Conclusions: Many young athletes are not meeting sleep recommendations. Associated factors include mental health, reasons for play, internet access, and homework demand.

Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion

OBJECTIVES

To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion.

STUDY DESIGN

Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury.

RESULTS

Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009).

CONCLUSIONS

Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.

Association between premorbid neuropsychological conditions and pediatric mild traumatic brain injury/concussion recovery time and symptom severity: a systematic review

OBJECTIVE

The objective of this review was to identify associations between premorbid neuropsychological conditions and pediatric mild traumatic brain injury/concussion recovery time and symptom severity.

INTRODUCTION

There is a lack of evidence-based clinical guidelines for the care of children with a premorbid neuropsychological condition who have sustained a mild traumatic brain injury, also known as concussion. This necessitates inquiry for any associations that may exist, which may contribute to an enhanced understanding of injury recovery patterns.

INCLUSION CRITERIA

Participants included children ages six through 18 years with any diagnosed or self-reported premorbid neuropsychological condition(s) and mild traumatic brain injury/concussion. Participants with concomitant intracranial or extra-axial head injury found on diagnostic imaging were excluded. Outcomes for this review included recovery time or symptom(s) severity post-concussion. Studies considered for review were analytical observational studies, including retrospective, prospective, cross-sectional or longitudinal cohort studies or case-control studies, as well as descriptive observational study designs, including case series, individual case reports and descriptive cross-sectional studies.

METHODS

A comprehensive search was undertaken in January 2018 for both published and unpublished studies utilizing an a priori protocol. Major databases searched included CINAHL, Embase, PubMed, Psychology and Behavioral Sciences Collection and PsycINFO. Other sources searched for unpublished and gray literature included the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar, ProQuest Dissertations and Theses Global: Sciences and Engineering Collection and MedNar. Additional searches of government websites and reports targeting healthcare or sports-related concussions included Australian Sports Commission, Canadian Institutes for Health Research, the National Health Service of the United Kingdom, the U.S. Department of Health and Human Services: Agency for Healthcare Research and Quality, and the U.S. Department of Health and Human Services: Centers for Disease Control and Prevention. Critical appraisal and data extraction were completed by two independent reviewers. Validation of methodologic quality was performed utilizing standardized tools from the Joanna Briggs Institute, and any disputes were resolved through discussion. Due to significant heterogeneity among studies, a meta-analysis could not be conducted. Therefore, extracted data are reported in a narrative synthesis.

RESULTS

A total of 12 studies (one analytical cross-sectional, two case-control and nine cohort) with 2,973 participants met inclusion criteria. Results of the findings among premorbid conditions varied. However, statistically significant associations with prolonged recovery or increased symptom severity were identified in children with pre-concussion histories of learning disabilities or poor academic achievement; anxiety, depression, mood disorders or other psychiatric illnesses; prior head injuries; somatization (in females); sleep disorders (in males); and the presence of multiple neuropsychological conditions.

CONCLUSIONS

Due to heterogeneity among studies and limitations of the review, findings suggest that clinicians providing post-concussive care may consider the presence of premorbid neuropsychological conditions, specifically learning disabilities or poor academic achievement; anxiety, depression, mood disorders or other psychiatric illnesses; prior head injuries; somatization; sleep disorders; or the presence of multiple neuropsychological conditions as potential contributors to prolonged recovery times or increased symptom severity in children and adolescents with mild traumatic brain injuries.

Mood-related changes in children and adolescents with persistent concussion symptoms following a six-week active rehabilitation program

PRIMARY OBJECTIVE

The purpose of this study is to explore changes in mood in youth with persistent post-concussion symptoms following participation in a six-week active rehabilitation program.

RESEARCH DESIGN

A pre-post test design was used.

METHODS AND PROCEDURES

Participants (N = 40 children and adolescents with concussion symptoms >2 weeks post-injury) were recruited from the concussion services at an urban children's rehabilitation hospital and the community. The program consisted of individualized low-intensity aerobic exercise, sport-specific drills, relaxation exercises and comprehensive education and support. The 6 week program was completed by participants in their home or local community with weekly check-ins with the research team. Data were analyzed using descriptive statistics and linear regressions.

MAIN OUTCOMES AND RESULTS

Outcome measures included the Beck Youth Inventories (youth), and the Child Behavior Checklist (parents). Results indicated significant improvements in anger and anxiety post-intervention with anger reduction being more pronounced in girls.

CONCLUSIONS

Active rehabilitation interventions may have positive effects on mood in youth recovering from concussion. Clinicians may wish to consider addressing anxiety and anger management strategies as part of comprehensive concussion management in youth.

Sleep Parameters and Overnight Urinary Melatonin Production in Children With Persistent Post-concussion Symptoms

BACKGROUND

Sleep disturbance is common after a mild traumatic brain injury (mTBI) in children, yet its biology is poorly understood. We aimed to explore sleep-related problems (SRPs), sleep-activity patterns, and endogenous melatonin production in children with different recovery trajectories following mTBI. We hypothesized that children with delayed recovery would have more SRPs and abnormal sleep-activity patterns, which would correlate with lower overnight melatonin production.

METHODS

In this prospective controlled cohort study, we enrolled 83 children with persistent symptoms, 26 children who had clinically recovered following mTBI, and 25 healthy controls. SRPs were evaluated using the sleep subscale of the Post-Concussion Symptom Inventory. Sleep actigraphy was performed for five to seven days at 37 (S.D. 7) days post-injury. Health-related quality of life and mood disturbance was assessed using the Child Health Questionnaire and the Behavior Assessment System for Children, respectively. Endogenous melatonin production was assessed using overnight urine collection.

RESULTS

The groups were similar in age (13.9 [S.D. 2.6] years) and sex (52% female). Regression analysis demonstrated increased SRP in the symptomatic group (9.0; 95% confidence interval: 7.6, 11.1) compared with the recovered group (1.6; 95% confidence interval: 1.0, 2.4) and controls (2.0; 95% confidence intervals: 1.2, 3.2). Actigraphy parameters and urinary melatonin levels were not significantly different between groups. Neither SRPs nor actigraphy parameters correlated with anxiety and depression scores.

CONCLUSIONS

Although children with persistent post-concussion symptoms reported more SRPs, this was not related to actigraphy sleep parameters or melatonin production. Further research is warranted to understand the pathophysiology of post-traumatic sleep disturbance.

The Effect of Sport-Related Concussion Injuries on Concussion Symptoms and Health-Related Quality of Life in Male and Female Adolescent Athletes: A Prospective Study

BACKGROUND

Sport-related concussions (SRCs) are associated with short-term disablement, characterized as increased concussion symptoms and lower health-related quality of life (HRQoL). However, there are limited longitudinal data detailing how an SRC affects disablement beyond short-term injury recovery.

PURPOSE

To longitudinally assess the effect of SRCs on symptoms and HRQoL in high school athletes through the 12 months after injury.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The 125 participants included high school athletes who sustained an SRC (female patients, 36%; mean ± SD age, 15.9 ± 1.1 years). The Post-concussion Symptom Scale (PCSS) from the Sport Concussion Assessment Tool-3 and the Pediatric Quality of Life Inventory 4.0 (PedsQL) were completed at enrollment and repeated at 24 to 72 hours (onset) and at 7 days (D7) after the SRC; on the date of return to play (RTP); and at 3, 6, and 12 months (M12) after the SRC. Scores at each time point were compared with the athletes' own baseline via linear mixed models for repeated measures, controlling for age, sex, and history of previous SRC and with patient as a random effect.

RESULTS

Relative to baseline, female patients reported higher PCSS symptom and severity scores at onset (P < .001) and D7 (P < .001), while scores were not higher (P > .05) for RTP through M12. As compared with baseline, male patients reported higher PCSS scores at onset (P < .001) and D7 (P = .003) and severity scores at onset (P < .001) and D7 (P = .016), while the symptom and severity scores were not higher (P > .05) at RTP through M12. Female participants reported lower PedsQL physical scores at onset (P = .006), while scores were not lower (P > .05) from D7 through M12. Female psychosocial scores were not lower (P > .05) at any time after the SRC, while the total PedsQL score was lower at onset (P = .05) but not from D7 through M12. Male physical scores were lower at onset (P < .001) and D7 (P = .001) but not lower (P > .05) from RTP through M12. Male psychosocial and PedsQL scores were unchanged (P > .05) from baseline at onset through M12.

CONCLUSION

After an SRC, high school athletes reported initial disablement (increased symptoms and lower HRQoL) through their RTP. However, after RTP, no similar disablement was detected through 12 months after injury.

Default mode network anatomy and function is linked to pediatric concussion recovery

Objective

To determine whether anatomical and functional brain features relate to key persistent post–concussion symptoms (PPCS) in children recovering from mild traumatic brain injuries (mTBI), and whether such brain indices can predict individual recovery from PPCS.

Methods

One hundred and ten children with mixed recovery following mTBI were seen at the concussion clinic at Neurology department Alberta Children’s Hospital. The primary outcome was the Post–Concussion Symptom Inventory (PCSI, parent proxy). Sleep disturbance scores (PCSI subdomain) and the Neurocognition Index (CNS Vital Signs) were also measured longitudinally. PPCS was assessed at 4 weeks postinjury and 8–10 weeks postinjury. Gray matter volumes were assessed using magnetic resonance imaging (MRI) and voxel‐based morphometry at 4 weeks postinjury. Functional connectivity was estimated at the same timepoint using resting‐state MRI. Two complementary machine learning methods were used to assess if the combination of gray matter and functional connectivity indices carried meaningful prognostic information.

Results

Higher scores on a composite index of sleep disturbance, including fatigue, were associated with converging decreases in gray matter volume and local functional connectivity in two key nodes of the default mode network: the posterior cingulate cortex and the medial prefrontal cortex. Sleep‐related disturbances also significantly correlated with reductions in functional connectivity between these brain regions. The combination of structural and functional brain indices associated to individual variations in the default mode network accurately predicted clinical outcomes at follow‐up (area under the curve = 0.86).

Interpretation

These results highlight that the function–structure profile of core default mode regions underpins sleep‐related problems following mTBI and carries meaningful prognostic information for pediatric concussion recovery.

Lifelong consequences of brain injuries during development: From risk to resilience

Traumatic brain injuries in children represent a major public health issue and even relatively mild injuries can have lifelong consequences. However, the outcomes from these injuries are highly heterogeneous, with most individuals recovering fully, but a substantial subset experiencing prolonged or permanent disabilities across a number of domains. Moreover, brain injuries predispose individuals to other kinds of neuropsychiatric and somatic illnesses. Critically, the severity of the injury only partially predicts subsequent outcomes, thus other factors must be involved. In this review, we discuss the psychological, social, neuroendocrine, and autonomic processes that are disrupted following traumatic brain injury during development, and consider the mechanisms the mediate risk or resilience after traumatic brain injury in this vulnerable population.

Longitudinal Assessment of Cortical Excitability in Children and Adolescents With Mild Traumatic Brain Injury and Persistent Post-concussive Symptoms

Introduction: Symptoms following a mild traumatic brain injury (mTBI) usually resolve quickly but may persist past 3 months in up to 15% of children. Mechanisms of mTBI recovery are poorly understood, but may involve alterations in cortical neurophysiology. Transcranial Magnetic Stimulation (TMS) can non-invasively investigate such mechanisms, but the time course of neurophysiological changes in mTBI are unknown. Objective/Hypothesis: To determine the relationship between persistent post-concussive symptoms (PPCS) and altered motor cortex neurophysiology over time. Methods: This was a prospective, longitudinal, controlled cohort study comparing children (8-18 years) with mTBI (symptomatic vs. asymptomatic) groups to controls. Cortical excitability was measured using TMS paradigms at 1 and 2 months post injury. The primary outcome was the cortical silent period (cSP). Secondary outcomes included short interval intracortical inhibition (SICI) and facilitation (SICF), and long-interval cortical inhibition (LICI). Generalized linear mixed model analyses were used to evaluate the effect of group and time on neurophysiological parameters. Results: One hundred seven participants (median age 15.1, 57% female) including 78 (73%) with symptomatic PPCS and 29 with asymptomatic mTBI, were compared to 26 controls. Cortical inhibition (cSP and SICI) was reduced in the symptomatic group compared to asymptomatic group and tended to increase over time. Measures of cortical facilitation (SICF and ICF) were increased in the asymptomatic group and decreased over time. TMS was well tolerated with no serious adverse events. Conclusions: TMS-assessed cortical excitability is altered in children following mild TBI and is dependent on recovery trajectory. Our findings support delayed return to contact sports in children even where clinical symptoms have resolved.

Academic outcomes following adolescent sport-related concussion or fracture injury: A prospective cohort study

Objectives

The objectives were 1) to compare the effects of adolescent sport-related concussion (SRC) and sport-related extremity fracture (SRF) on academic outcomes including change in school grades and school attendance; and 2) to determine which specific academic accommodations were most helpful during recovery from these injuries.

Methods

A prospective cohort study was conducted to compare changes in school grades, school attendance and academic accommodations among students (grades 8–12) with an SRC or SRF. School grades were extracted from student immediate pre- and post-injury report cards. Students completed attendance log books and an exit interview to determine which accommodations were helpful and how accommodating they perceived their school to be during their recovery.

Results

Overall, 124 students (92 with SRC and 32 with SRF) submitted both pre- and post-injury report cards. Students who sustained an SRC or SRF experienced similar decreases in grades post-injury (SRC: -1.0%; 95% CI: -2.1, 0.1 and SRF: -0.9%: 95% CI: -2.1, 0.3). Students with an SRC missed significantly more days of school compared to those with an SRF (median of 4 days [IQR: 1, 7] versus 1 day [IQR: 0, 4], p<0.0001). In total, 60/113 (53.1%) SRC students reported their school to be very accommodating while only 31/77 (40.3%) SRF students reported their school to be very accommodating (p = 0.082).

Conclusions

Students who sustain an SRC miss significantly more days of school but demonstrate similar changes in school grades post-injury compared to those with an SRF. Future studies are needed to identify the pre- and post-injury factors associated with poor academic functioning following concussion and identify measures that can be taken to help optimize academic outcomes in these patients.

Health-related quality of life following adolescent sports-related concussion or fracture: a prospective cohort study

OBJECTIVE

The longitudinal effects of sports-related concussion (SRC) in adolescents on health-related quality of life (HRQOL) remain poorly understood. Hence, the authors established two objectives of this study: 1) compare HRQOL outcomes among adolescents with an acute SRC or a sports-related extremity fracture (SREF) who were followed up until physician-documented clinical recovery; and 2) identify the clinical variables associated with worse HRQOL among adolescent SRC patients.

METHODS

The authors conducted a prospective cohort study of adolescents with acute SRC and those with acute SREF who underwent clinical assessment and follow-up at tertiary subspecialty clinics. Longitudinal patient-reported HRQOL was measured at the time of initial assessment and at each follow-up appointment by using the adolescent version (age 13-18 years) of the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale and Cognitive Functioning Scale.

RESULTS

A total of 135 patients with SRC (60.0% male; mean age 14.7 years; time from injury to initial assessment 6 days) and 96 patients with SREF (59.4% male; mean age 14.1 years; time from injury to initial assessment 8 days) participated in the study. At the initial assessment, the SRC patients demonstrated significantly worse cognitive HRQOL and clinically meaningful impairments in school and overall HRQOL compared to the SREF patients. Clinical variables associated with a worse HRQOL among SRC patients differed by domain but were significantly affected by the patients' initial symptom burden and the development of delayed physician-documented clinical recovery (> 28 days postinjury). No persistent impairments in HRQOL were observed among SRC patients who were followed up until physician-documented clinical recovery.

CONCLUSIONS

Adolescent SRC is associated with temporary impairments in HRQOL that have been shown to resolve in patients who are followed up until physician-documented clinical recovery. Future studies are needed to identify the clinicopathological features that are associated with impaired HRQOL and to assess whether the initiation of multidisciplinary, targeted rehabilitation strategies would lead to an improvement in HRQOL.

Gender differences in quality of life and symptom expression during recovery from concussion

Pediatric concussion is a significant health concern for parents, medical providers, and schools. This study was designed to gain insight into gender differences in perspectives of children and adolescents recovering from concussion. Specifically, the study explored whether males and females reported different symptom loads for physical symptoms and quality of life after concussion. The Pediatric Life After Concussion Evaluation Scale (PLACES) and the Post Concussion Symptom Scale (PCSS) were completed by 277 participants ages 9-21, with a mean age of 14.8 years. The sample was 47.5% female and 52.5% male. The study showed that overall, females reported more physical and somatic symptoms (Total PCSS, p = .001), worse quality of life during recovery (PLACES, p = .008), difficulty with cognition (p = .001), and elevated emotional symptoms than males (p = .02). When an interaction between gender and time since injury was considered, there were significant interactions for the PCSS, with females experiencing higher physical and cognitive symptom load during the period spanning 1-12 weeks (1-4 weeks: M = 33.18, SD = 27.03; 5-11 weeks: M = 15.0, SD = 16.76). However, for those individuals experiencing symptoms for longer than 12 weeks, males expressed a higher physical and cognitive symptom load (M = 32.36, SD = 26.59). Findings indicate that there are gender differences in the expression of symptoms and perceptions of quality of life after concussion.

Current State of the Literature on Psychological and Social Sequelae of Sports-Related Concussion in School-Aged Children and Adolescents

Considerably less attention has been paid to psychological and social sequelae of concussion in youth athletes compared with neurocognitive outcomes. This narrative review consolidates the literature on postconcussive emotional and psychosocial functioning in school-aged children and adolescents, highlighting athlete-specific findings. MEDLINE and PsycINFO databases were queried for pediatric concussion studies examining psychological and/or social outcomes, and 604 studies met search criteria (11 of those specific to sport). Results were organized into domains: emotional and social dysfunction, behavioral problems, academic difficulties, sleep disturbance, headache, and quality of life. The small body of literature regarding psychological and social issues following pediatric concussion suggests behavioral disturbances at least temporarily disrupt daily life. Extrapolation from samples of athletes and nonathletes indicates postconcussive anxiety and depressive symptoms appear, although levels may be subclinical. Social and academic findings were less clear. Future well-controlled and adequately powered research will be essential to anticipate concussed athletes’ psychosocial needs.

Service and support needs following pediatric brain injury: perspectives of children with mild traumatic brain injury and their parents

OBJECTIVE

To provide a qualitative examination of the service and support needs of children who have had a mild traumatic brain injury (mTBI), and their parents, in order to improve clinical services.

METHODS

Semi-structured interviews were conducted with 9 children (8-12 years; M = 10.6 years, SD = 0.8) and their parents (n = 9) 29-55 days (M = 34 days; SD = 9.3) after presenting to an Australian Paediatric Emergency Department (PED) for mTBI. Children's post-concussive symptoms (PCS) were additionally measured using the Post-Concussive Symptom Inventory (PCSI). Audio recordings were transcribed, and a thematic analysis was conducted.

RESULTS

Post-injury needs were reflected in four main themes: Communication; Family Burden; Continuity of Care; and Social and Community Support. These themes reflected children's and parents' needs for information, emotional/social/community support, and follow-up care. Both the children's and parents' needs, and the extent to which they were met, appeared to be related to the severity and duration of the child's PCS.

CONCLUSIONS

Dedicated pediatric mTBI follow-up services that build on family's resources and meet their individual needs for information, emotional support, and referral may assist in optimizing post-injury outcomes.

Persistent Postconcussion Symptoms After Injury

: media-1vid110.1542/5828371885001PEDS-VA_2018-0939Video Abstract OBJECTIVES: We examined whether preinjury, demographic, and family factors influenced vulnerability to postconcussion symptoms (PCSs) persisting the year after mild traumatic brain injury (mTBI).

METHODS

Children with mTBI (n = 119), complicated mild traumatic brain injury (cmTBI) (n = 110), or orthopedic injury (OI) (n = 118), recruited from emergency departments, were enrolled in a prospective, longitudinal cohort study. Caregivers completed retrospective surveys to characterize preinjury demographic, child, and family characteristics. PCSs were assessed using a validated rating scale. With multivariable general linear models adjusted for preinjury symptoms, we examined predictors of PCSs 3, 6, and 12 months after injury in children ages 4 to 8, 9 to 12, and 13 to 15 years at injury. With logistic regression, we examined predictors of chronic PCSs 1 year after traumatic brain injury.

RESULTS

Postinjury somatic, emotional, cognitive, and fatigue PCSs were similar in the mTBI and cmTBI groups and significantly elevated compared with the OI group. PCS trajectories varied with age and sex. Adolescents had elevated PCSs that improved; young children had lower initial symptoms and less change. Despite similar preinjury PCSs, girls had elevated symptoms across all time points compared with boys. PCS vulnerability factors included female sex, adolescence, preinjury mood problems, lower income, and family discord. Social capital was a protective factor. PCSs persisted in 25% to 31% of the traumatic brain injury group and 18% of the OI group at 1 year postinjury. The odds of chronic PCSs were almost twice as high in girls as in boys and were >4 times higher in young children with cmTBI than in those with mTBI.

CONCLUSIONS

A significant minority of children with mTBI and OI have PCSs that persisted 1 year after injury.

Health-Related Quality of Life Following Concussion in Collegiate Student-Athletes With and Without Concussion History

The purpose of this study was to compare global and specific health-related quality of life (HRQOL) throughout concussion recovery between those with and without concussion history. Student-athletes diagnosed with concussion completed global (Short Form-12v2; SF-12) and specific (Hospital Anxiety and Depression Scale: HADS) HRQOL assessments at baseline, 24-48 h, asymptomatic, return-to-play, and 6-months post-injury. Baseline scores were compared to post-injury time points for SF-12 subscores (physical and mental; PCS-12, MCS-12) and HADS subscores (depression and anxiety; HADS-D, HADS-A). We conducted a 2 × 5 mixed model ANOVA for group (with and without concussion history) and time (four post-injury assessments compared to baseline). We did not observe interaction or main effects for group, except those with concussion history had worse HADS-D subscores than those without concussion history. PCS-12 subscores were worse at 24-48 h, asymptomatic, and return-to-play compared to baseline, but returned to baseline 6-months post-injury. MCS-12 subscores did not differ at any time points. HADS-D subscores worsened 24-48 h post-injury, but improved for additional assessments compared to baseline. HADS-A improved post-injury compared to baseline at asymptomatic, return-to-play, and 6-month assessments, but was similar to baseline 24-48 h post-injury. HRQOL physical aspects slightly worsened post-injury and restored to baseline after returning to play.

Concussion clinic presentation and symptom duration for pediatric sports-related concussions following Ohio concussion law

In 2013, Ohio enacted a law to mitigate consequences of pediatric sports-related concussions. This study aimed to describe changes in clinic visits and symptom duration for pediatric sports-related concussions before and after this law. 3,133 new visits by 2,861 unique patients (10-18 years) presenting between April 2012 and April 2015 for sports-related concussions within 30 days of injury were included. There were 937 (29.9%), 1,132 (36.1%) and 1,064 (34.0%) concussion visits for pre-law, immediate-post law, and post-law periods, respectively. A greater proportion of concussion visits was observed among females from pre-law to post-law (P < 0.0001). No differences were observed across the three periods in symptom scores at injury (P = 0.5028) or at first clinic visit (P = 0.5686). However, patients presented to concussion clinics significantly earlier (17.6 vs. 22.8 days, P < 0.0001) and had quicker recovery (26.5 vs. 40.6 days, P < 0.0001) post-law than pre-law.

Predictors of Long-Term Psychosocial Functioning and Health-Related Quality of Life in Children and Adolescents With Prior Concussions

OBJECTIVES

Individual differences in long-term psychosocial functioning after concussions in children and adolescents are poorly understood. The aim of the study was to investigate potential predictors of long-term psychosocial functioning and health-related quality of life in youth after prior concussion.

METHODS

Participants (N=75; mean age=14.3 years old; 52% girls) with one prior concussion (n=24), multiple prior concussions (n=24), or a prior orthopedic injury and no concussion (n=27) were seen on average 2.7 years after their most recent injury. Psychosocial functioning was assessed using the self-report versions of the Behavior Assessment System for Children (BASC-2; Anxiety and Depression scales only), the Strengths and Difficulties Questionnaire, and the Pediatric Quality of Life Inventory TM 4.0. Pre-existing conditions (attention problems, learning difficulties, mood concerns, anxiety concerns, and migraines) were reported by parents using a checklist and examined as predictors of long-term functioning. Other potential predictors included age at testing, sex, time between most recent injury and testing, and number of prior concussions.

RESULTS

The groups did not differ significantly on long-term psychosocial functioning. Moreover, only pre-existing mood concerns or attention problems significantly predicted psychosocial adjustment.

CONCLUSIONS

Children's functioning before a concussion is critical to understanding outcome. Pre-injury attention and mood concerns should be assessed in clinical settings to prevent and treat long-term psychosocial problems after concussion. (JINS, 2018, 24, 540-548).

Traumatic Brain Injury-Related Symptoms Reported by Parents: Clinical, Imaging, and Host Predictors in Children with Impairments in Consciousness Less than 24 Hours

This study examined the relationship between acute neuroimaging, host and injury factors, and parent-reported traumatic brain injury (TBI)-related symptoms in children with noncritical head injury at two weeks and three months after injury. Data were collected prospectively on 45 subjects aged three to 16 years old enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. Subjects had rapid recovery of mental status (Glasgow Coma Score [GCS] = 15 within 24 h), and had no clinical need for neurosurgical intervention. Intra- or extra-axial magnetic resonance imaging (MRI) lesions were categorized using Common Data Elements (CDE) definitions. Host and acute injury factors including neurobehavioral history, race, extracranial injuries, loss of consciousness (LOC), and GCS were analyzed while controlling for pre-injury symptoms, age, sex, and socioeconomic status. Parent-reported cognitive and somatic symptoms were measured by the Health and Behavior Inventory (HBI). Forty-nine percent of children had MRI lesions, most of which were relatively small. LOC predicted increased cognitive and somatic symptoms at two weeks. At three months, pre-injury neurobehavioral history predicted increased cognitive and somatic symptoms. Neuroimaging findings did not predict parent-reported symptom severity, except at three months where extra-axial lesions were associated with less severe cognitive symptoms. While structural MRI lesions do not predict increased parent-reported symptoms in this population, age-specific child performance measures may be more sensitive outcome measures and require further study. Children with pre-injury neurobehavioral problems have more severe symptoms at three months and thus may benefit from longer follow-up and monitoring after traumatic brain injury.

The association of premorbid neuropsychological conditions with pediatric mild traumatic brain injury/concussion recovery time and symptom severity: a systematic review protocol

REVIEW QUESTION

The question of this review is: What is the association of premorbid neuropsychological conditions with mild traumatic brain injury/concussion recovery time and symptom severity in children?

Lived Experiences of Adolescent Athletes Following Sport-Related Concussion

Background:

Previous studies have identified the effect of sport-related concussion on health-related quality of life through the use of patient-reported outcome measures. However, there has been little research exploring the underlying mechanisms that influence these perceptions of health-related quality of life among adolescent athletes who have sustained a sport-related concussion.

Purpose:

To explore the psychosocial aspects of concussion among adolescent athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 12 interscholastic athletes (4 girls, 8 boys; mean ± SD age, 15.7 ± 1.7 years; grade level, 10.2 ± 1.4) were interviewed via a semistructured interview protocol between 15 and 30 days postinjury. Data analysis was guided by the consensual qualitative research tradition. Themes and categories emerged through consensus by a 3-person research team, and bias was minimized through the use of multiple-analyst triangulation.

Results:

Participants identified numerous postconcussion symptoms that resulted in increasing difficulty with emotions (eg, irritable, easily frustrated), roles at school (eg, concentration difficulties, fatigue), and roles in their social environment (eg, letting the team down, not being able to contribute to sport). As a result, participants expressed how they tried to minimize or mask symptoms to decrease the potential of being viewed differently by their peers.

Conclusion:

Adolescent athletes perceived a significant effect of sport-related concussion on numerous areas of psychosocial and emotional health and well-being. Anticipatory guidance—with education regarding the possible signs and symptoms, risk factors, and recovery expectations following a concussion—is important to include in postinjury management. A better understanding of sport-related concussion and expected recovery could help to improve perceptions of this injury among interscholastic athletes. Additionally, best practices should be identified to assist health care professionals and school personnel in the development of temporary adjustments or formal academic adjustment policies in the secondary school setting, therefore ensuring that the patients receive the support that they need to maintain their roles as students.

A Multifactorial Approach to Sport-Related Concussion Prevention and Education: Application of the Socioecological Framework

OBJECTIVE

To offer an overview of sport-related concussion (SRC) prevention and education strategies in the context of the socioecological framework (SEF). Athletic trainers (ATs) will understand the many factors that interact to influence SRC prevention and the implications of these interactions for effective SRC education.

BACKGROUND

Concussion is a complex injury that is challenging to identify and manage, particularly when athletes fail to disclose symptoms to their health care providers. Education is 1 strategy for increasing disclosure. However, limited information addresses how ATs can integrate the many factors that may influence the effectiveness of SRC education into their specific settings. Public health models provide an example through the SEF, which highlights the interplay among various levels of society and sport that can facilitate SRC prevention strategies, including education.

DESCRIPTION

For ATs to develop appropriate SRC prevention strategies, a framework for application is needed. A growing body of information concerning SRC prevention indicates that knowledge alone is insufficient to change concussion-related behaviors. The SEF allows this information to be considered at levels such as policy and societal, community, interpersonal (relationships), and intrapersonal (athlete). The use of such a framework will facilitate more comprehensive SRC prevention efforts that can be applied in all athletic training practice settings. Clinical Applications: Athletic trainers can use this information as they plan SRC prevention strategies in their specific settings. This approach will aid in addressing the layers of complexity that exist when developing a concussion-management policy and plan.

Factors that predict discharge recommendations following paediatric mild traumatic brain injury

PRIMARY OBJECTIVE

To investigate factors that predict discharge recommendations for children and adolescents who present to an Australian paediatric Emergency Department (ED) following a mild traumatic brain injury (mTBI).

RESEARCH DESIGN

Retrospective data base analysis.

METHODS

The study retrospectively analysed an ED database to test the relationship between injury risk factors (symptoms, Glasgow Coma Scale, prior TBI, mechanism of injury and Computed Tomography scan), non-injury risk factors (sex, age, socio-economic status (SES)) and discharge recommendations of 2807 children and adolescents (0-18 years) who presented to a children's hospital ED over a three year period with mTBI.

RESULTS

Univariate analyses indicated a statistically significant association of discharge recommendations with age, SES, mechanism of injury and vomiting. However, multivariate analyses indicated vomiting and mechanism of injury were the only statistically significant risk factor associated with discharge recommendations, when controlling for other risk factors.

CONCLUSIONS

The current study suggests vomiting and mechanism of injury are the only risk factors predicting discharge recommendations for children and adolescents with mTBI.

Pediatric Mild Traumatic Brain Injury and Population Health: An Introduction for Nursing Care Providers

Despite increasing injury prevalence of traumatic brain injury (TBI) in children, most injuries in children are mild in severity. Even mild injuries can result in long-term or chronic effects not apparent until the child ages, resulting in increased economic burden and overall lifetime costs related to injury. Early recognition of TBI is essential for ongoing evaluation and management of acute symptoms and reduction of chronic health effects. Providing early interventions to manage acute and postconcussive symptoms and reducing health disparities in children with mild TBI can minimize adverse events that impact health-related quality of life for the injured child and their family and increase overall population health.