Trajectories and Risk Factors for Pediatric Postconcussive Symptom Recovery

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.

Trajectories of Daily Postconcussion Symptoms in Children

OBJECTIVES

To identify trajectories of daily postconcussion symptoms (PCS) from the acute postinjury period to symptom resolution among concussed children and examine demographic factors and acute PCS associated with the identified symptom trajectories.

SETTING AND PARTICIPANTS

Seventy-nine participants with a concussion were enrolled within 72 hours of injury and completed a daily survey that assessed PCS from enrollment until symptom resolution.

DESIGN

This was a prospective cohort study among concussed children aged 11-17 years.

MAIN MEASURES

Children rated their concussion symptoms daily using the Post-Concussion Symptom Scale. Symptom duration was assessed using participants' date of symptom resolution and coded as a dichotomous variable: (1) PCS duration 14 days or less or (2) PCS duration longer than 14 days.

RESULTS

Of the 79 participants, most were male ( n = 53, 67%), injured during a sporting activity ( n = 67, 85%), or had PCS that persisted for more than 14 days post-injury ( n = 41, 52%). Group-based trajectory modeling yielded 4 trajectory groups: (1) low acute/resolved PCS ( n = 39, 49%), (2) moderate/persistent PCS ( n = 19, 24%), (3) high acute/persistent PCS ( n = 13, 16%), and (4) high acute/resolved PCS ( n = 8, 10%). No significant associations were found between demographic factors and the trajectory group. A higher symptom burden at injury was associated with an increased odds of being in the high acute/resolved or high acute/persistent recovery groups than being in the low acute/resolved group (odds ratio [OR] 1.39, 95% CI = 1.11-1.74; OR = 1.33, 95% CI = 1.11-1.60, respectively), as was a higher symptom severity at injury (OR = 1.09, 95% CI = 1.03-1.15; OR = 1.06, 95% CI = 1.02-1.11, respectively).

CONCLUSION

Our findings may help clinicians identify concussed children on slower recovery trajectories, and implement early, individualized treatment plans that foster optimal recovery for concussed children.

The Relationship Between Parental and Family Functioning and Post-Concussive Symptoms After Pediatric Mild Traumatic Brain Injury: A Scoping Review

This scoping review aimed to address the following questions: (1) Does mild traumatic brain injury (mTBI) result in more parental distress or poorer family functioning than other injuries? (2) Does pre-injury or acute parental distress and family functioning predict post-concussive symptoms (PCS) after mTBI? and (3) Do acute PCS predict later parental distress and family functioning? The subjects of this review were children/adolescents who had sustained an mTBI before age 18 and underwent assessment of PCS and parent or family functioning. MEDLINE®, PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and CENTRAL databases were searched to identify original, empirical, peer-reviewed research published in English. PCS measures included parent- and child-reported symptom counts and continuous scales. Parent and family measures assessed parental stress, psychological adjustment, anxiety, psychiatric history, parent-child interactions, family burden, and general family functioning. A total of 11,163 articles were screened, leading to the inclusion of 15 studies, with 2569 participants (mTBI = 2222; control = 347). Collectively, the included articles suggest that mTBI may not result in greater parental distress or poorer family functioning than other types of injuries. Pre-injury or acute phase parental and family functioning appears to predict subsequent PCS after mTBI, depending on the specific family characteristic being studied. Early PCS may also predict subsequent parental and family functioning, although findings were mixed in terms of predicting more positive or negative family outcomes. The available evidence suggests that parent and family functioning may have an important, perhaps bidirectional, association with PCS after pediatric mTBI. However, further research is needed to provide a more thorough understanding of this association.

Fatigue recovery and connected factors following paediatric concussion

OBJECTIVE

Using a biopsychosocial framework and the three-factor fatigue model, we aimed to (1) plot recovery of fatigue over the 3 months following paediatric concussion and (2) explore factors associated with persisting fatigue during the first 3 months postconcussion.

METHODS

240 children and adolescents aged 5-18 years (M=11.64, SD=3.16) completed assessments from time of injury to 3 months postinjury. Separate linear mixed effects models were conducted for child and parent ratings on the PedsQL-Multidimensional Fatigue Scale to plot recovery across domains (General, Cognitive, Sleep/Rest) and Total fatigue, from 1 week to 3 months postinjury. Two-block hierarchical regression analyses were then conducted for parent and child ratings of fatigue at each time point, with age, sex and acute symptoms in block 1 and child and parent mental health variables added to block 2.

RESULTS

There was a significant reduction in both child and parent ratings across the 3 months postinjury for all fatigue domains (all p<0.001). For both child and parent fatigue ratings, child mental health was the most significant factor associated with fatigue at all time points. Adding child and parent mental health variables in the second block of the regression substantially increased the variance explained for both child and parent ratings of fatigue.

CONCLUSION

Our findings confirm that fatigue improves during the first 3 months postconcussion and highlights the importance of considering child and parent mental health screening when assessing patients with persisting postconcussive symptoms.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Academic Accommodations for Middle and High School Students Following a Concussion: Perspectives of Teachers and School Administrators

BACKGROUND

An estimated 1 in 5 adolescents have sustained a concussion in North America. Teachers and school administrators are responsible for implementing academic accommodations and other supports for optimal return to learn following a concussion. The primary objective of this study was to describe the prevalence and feasibility of providing academic accommodations to students following concussion from the perspectives of middle and high school teachers and school administrators.

METHODS

A cross-sectional survey was administered to teachers and school administrators (grades 7-12) across Canada online via REDCap. Participants were recruited via word-of-mouth and social media sampling. Survey responses were analyzed descriptively using proportions.

RESULTS

The survey was completed by 180 educators (138 teachers and 41 school administrators), of whom 86% had previously provided academic accommodations to students following concussion, and 96% agreed that students should have access to accommodations following concussion. Some accommodations (eg, breaks, extra time) were provided more often and were more feasible to provide than others (eg, no new learning, reduced bright light). Educators reported limited preparation time and limited school personnel support to assist students following concussion.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

The most feasible accommodations should be prioritized, ensuring students are supported within the school environment.

CONCLUSIONS

Teachers and school administrators confirmed the importance of providing accommodations to students following concussion.

Parental Factors Associated With Recovery After Mild Traumatic Brain Injury: A Systematic Review

While parental factors have been shown to potentially influence recovery after mild traumatic brain injury (mTBI) in children, both the strength and direction of the relationships remain unclear. We performed a systematic review regarding the association between parental factors and recovery after mTBI. PubMed, CINHL, Embase, PsychINFO, Web of Science, ProQuest, Cochrane Central, and Cochrane databases were queried for articles published between September 1, 1970, and September 10, 2022, reporting any parental factor and its association with recovery after mTBI in children younger than 18 years old. The review included both quantitative and qualitative studies published in English. Regarding the directionality of the association, only studies that assessed the effects of parental factors on recovery after mTBI were included. Study quality was assessed using a five-domain scale created by the Cochrane Handbook and the Agency for Healthcare Research and Quality. The study was prospectively registered with PROSPERO (CRD42022361609). Of 2050 studies queried, 40 met inclusion criteria, and 38 of 40 studies used quantitative outcome measures. Across 38 studies, 24 unique parental factors and 20 different measures of recovery were identified. The most common parental factors studied were socioeconomic status/income (SES; n = 16 studies), parental stress/distress (n = 11), parental level of education (n = 9), pre-injury family functioning (n = 8), and parental anxiety (n = 6). Among all associations between parental factors and recovery reported, having a family history of a neurologic disease (i.e., migraine, epilepsy, neurodegenerative disease; 5/6 significant associations reported, 83%), parental stress/distress (9/11, 82%), parental anxiety (4/6, 67%), parental level of education (5/9, 56%), and SES/income (11/19, 57.9%) were shown to have the strongest evidence reporting significant associations with recovery, while a family history of psychiatric disease (3/6, 50%) and pre-injury family functioning (4/9, 44%) showed mixed results. Evidence regarding other parental factors including parental sex, race/ethnicity, insurance status, parental history of concussion, family litigation status, family adjustment levels, and family psychosocial adversity were limited, as studies investigating such factors were few. The current review highlights literature describing several parental factors that significantly influence recovery from mTBI. It will likely be useful for future studies to incorporate parental SES, education, stress/distress, anxiety, quality of parent-child relationships, and parenting style when examining modifying factors in recovery after mTBI. Future studies should also consider how parental factors may serve as potential interventions or policy levers to optimize sport concussion-related policy and return-to-play guidelines.

Post-Concussive Symptoms in Preschool Children up to Three Months Post-Injury

BACKGROUND AND AIMS

Post-concussive symptoms (PCS) are central to the assessment and management of mild traumatic brain injury (mTBI); however, this remains poorly understood in children aged ≤5 years. The study aimed to explore individual PCS, pattern of parents' PCS report over time, proportion of symptomatic children, and variables associated with parents' report of PCS in their preschool child after a mTBI.

METHODS

Children aged 2-5 years with either a mTBI (n=13) or limb injury (n=6) were recruited from the emergency department (ED). Parent ratings of child PCS were assessed at ED presentation, at one month, and at three months post-injury. Injury (e.g. injury group, pain), child (e.g. pre-existing behavior, symptoms), and parent (e.g. parental stress, education) characteristics were considered when investigating variables that may be relevant to parent report of PCS.

RESULTS

The number of total, physical, and sleep PCS were significantly higher after mTBI, with a significant decrease in physical and sleep PCS over time. The proportion of symptomatic children was comparable between injury groups at each time point. Acute pain and pre-injury symptoms were significantly associated with parents' acute PCS report in the mTBI group. Further research is needed on variables that may be relevant to parents' PCS report at follow-up.

CONCLUSION

Preliminary findings suggest a general trauma response after a mTBI or limb injury, but acute physical and sleep PCS may help differentiate the injury groups. Injury and premorbid child variables may be relevant to parents' report of acute PCS in their child. Additional research is needed to investigate PCS in preschoolers and variables that may predict parents' PCS report.

Recovery in children ages 5-10 years at three months post-concussion

Some children and adolescents have persistent concussion symptoms that extend beyond the typical 3-4 week recovery window. Our understanding about what to expect when recovery is atypical, particularly in elementary-age children, is incomplete because there are very few targeted studies of this age group in the published literature. Aims were to identify lingering symptoms that present at three months post-concussion and to determine what factors are associated with prolonged recovery in an elementary-age group. Participants were 123 children aged 5-10 years who were seen at specialized concussion clinics, divided into expected and late recovery groups. Parents rated concussion symptoms on a scale from the Sideline Concussion Assessment Tool-5 (SCAT-5). The most frequent symptoms were headache, irritability, feeling more emotional, and sensitivity to noise. Stepwise logistic regression determined that female sex and total symptom burden at initial visit, but not any specific symptom, predicted prolonged recovery. Clinicians are advised to carefully monitor children who report numerous symptoms after concussion, particularly when the concussed children are girls.

Risk factors for prolonged recovery from concussion in young patients

Objectives

For young patients sustaining concussion, assessing recovery is vital in determining safe return to play. Identifying risk factors may aid clinicians in recognising patients at risk for prolonged recovery. The study objective is to identify risk factors for prolonged (>28 days) and extended (>90 days) recovery (defined as symptom duration) and analyse how these risk factors differ between the two groups.

Methods

We retrospectively analysed electronic health record data (n=4937) among patients aged 10–18 years collected at Nationwide Children’s Hospital Sports Medicine concussion clinics between 1 July 2012 and 30 June 2019. Data collected included patient demographics, comorbidities (eg, prior psychiatric diagnoses, prior concussions) and injury characteristics (eg, loss of consciousness, injury setting). We examined patient risk factors for prolonged (>28 days) and/or extended (>90 days) recovery using modified Poisson regression models.

Results

Factors associated with increased risk of prolonged recovery from concussion included prior concussions (adjusted risk ratio (ARR) 1.19, 95% CI 1.02 to 1.38) for two concussions (ARR 1.36, 95% CI 1.14 to 1.61), for >3, and higher initial symptom score (ARR 2.57, 95% CI 2.34 to 2.83) for postconcussion symptom (PCS) scores 21–60 (ARR 2.89, 95% CI 2.54 to 3.29), for PCS>60. Risk factors for extended recovery included history of concussion (ARR 1.50, 95% CI 1.09 to 2.06) for two concussions (ARR 1.75, 95% CI 1.17 to 2.62), for >3 and older age (15–18 years, ARR 1.11, 95% CI 1.05 to 1.18). Additionally, comorbid attention deficit hyperactivity disorder increased risk of prolonged recovery (ARR 1.14, 95% CI 1.01 to 1.29) while anxiety increased risk for extended recovery (ARR 1.47, 95% CI 1.10 to 1.95).

Conclusion

Overall, risk factors for prolonged recovery differ somewhat from risk factors for extended recovery. For patients who present to clinic with concussion, mental health is an important consideration which may impact the timeline for symptom recovery.

Exploring Heterogeneity of Stepped Collaborative Care Treatment Response Trajectories after Adolescent Sports Injury Concussion

Objective: Few clinical trials of posttraumatic interventions have utilized symptom trajectory modeling to explore heterogeneity of treatment responses. The goal of this investigation was to conduct a secondary analysis of a randomized clinical trial of stepped collaborative care for adolescents with sports and recreational related concussion and persistent symptoms of >1 month.Method: Trajectory modeling was used to examine the impact of randomization to the intervention as well as demographic, clinical, and injury characteristics on adolescent post-concussive symptom trajectories. Two hundred male and female adolescents were assessed >1 month after a concussion, and then 3-, 6- and 12-months later with a standardized measure of concussive symptoms, the Health and Behavior Inventory (HBI). Multinomial logistic regression was used to compare the association between intervention, demographic, clinical and injury characteristics with trajectory group membership.Results: Four post-concussive symptom trajectories emerged: recovery, remitting, low-persistent, and high-persistent. In adjusted analyses randomization to the intervention condition was associated with significantly greater odds of HBI recovery trajectory group membership (OR 3.29 95% CI 1.06-10.28). Female gender and prior concussion history were associated with significantly greater odds of high-persistent trajectory group membership relative to all other trajectories. Greater odds of high-persistent versus recovery group trajectory membership was observed for adolescents with a pre-injury history of anxiety and/or depressive disorders.Conclusions: Stepped collaborative care was associated with an increased odds of recovery versus high-persistent post-concussive symptom trajectories, while readily identifiable baseline characteristics were associated high-persistent symptoms. Future post-concussive clinical trials and practice improvement efforts could incorporate these observations.

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.