Effectiveness of the Brains Ahead! Intervention: 6 Months Results of a Randomized Controlled Trial in School-Aged Children With Mild Traumatic Brain Injury

How completely are randomized controlled trials of non-pharmacological interventions following concussion reported? A systematic review

PURPOSE

The study aimed to examine the reporting completeness of randomized controlled trials (RCTs) of non-pharmacological interventions following concussion.

METHODS

We searched MEDLINE, Embase, PsycInfo, CINAHL, and Web of Science up to May 2022. Two reviewers independently screened studies and assessed reporting completeness using the Template for Intervention Description and Replication (TIDieR), Consensus on Exercise Reporting Template (CERT), and international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) checklists. Additional information was sought my study authors where reporting was incomplete. Risk of bias (ROB) was assessed with the Cochrane ROB-2 Tool. RCTs examining non-pharmacological interventions following concussion.

RESULTS

We included 89 RCTs (n = 53 high ROB) examining 11 different interventions for concussion: sub-symptom threshold aerobic exercise, cervicovestibular therapy, physical/cognitive rest, vision therapy, education, psychotherapy, hyperbaric oxygen therapy, transcranial magnetic stimulation, blue light therapy, osteopathic manipulation, and head/neck cooling. Median scores were: TIDieR 9/12 (75%; interquartile range (IQR) = 5; range: 5-12), CERT 17/19 (89%; IQR = 2; range: 10-19), and i-CONTENT 6/7 (86%; IQR = 1; range: 5-7). Percentage of studies completely reporting all items was TIDieR 35% (31/89), CERT 24% (5/21), and i-CONTENT 10% (2/21). Studies were more completely reported after publication of TIDieR (t87 = 2.08; p = 0.04) and CERT (t19 = 2.72; p = 0.01). Reporting completeness was not strongly associated with journal impact factor (TIDieR: rs = 0.27; p = 0.01; CERT: rs = -0.44; p = 0.06; i-CONTENT: rs = -0.17; p = 0.48) or ROB (TIDieR: rs = 0.11; p = 0.31; CERT: rs = 0.04; p = 0.86; i-CONTENT: rs = 0.12; p = 0.60).

CONCLUSION

RCTs of non-pharmacological interventions following concussion demonstrate moderate to good reporting completeness, but are often missing key components, particularly modifications, motivational strategies, and qualified supervisor. Reporting completeness improved after TIDieR and CERT publication, but publication in highly cited journals and low ROB do not guarantee reporting completeness.

Performance of glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) biomarkers in predicting CT scan results and neurological outcomes in children with traumatic brain injury (BRAINI-2 paediatric study): protocol of a European prospective multicentre study

INTRODUCTION

In light of the burden of traumatic brain injury (TBI) in children and the excessive number of unnecessary CT scans still being performed, new strategies are needed to limit their use while minimising the risk of delayed diagnosis of intracranial lesions (ICLs). Identifying children at higher risk of poor outcomes would enable them to be better monitored. The use of the blood-based brain biomarkers glial fibrillar acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) could help clinicians in this decision. The overall aim of this study is to provide new knowledge regarding GFAP and UCH-L1 in order to improve TBI management in the paediatric population.

METHODS AND ANALYSIS

We will conduct a European, prospective, multicentre study, the BRAINI-2 paediatric study, in 20 centres in France, Spain and Switzerland with an inclusion period of 30 months for a total of 2880 children and adolescents included. To assess the performance of GFAP and UCH-L1 used separately and in combination to predict ICLs on CT scans (primary objective), 630 children less than 18 years of age with mild TBI, defined by a Glasgow Coma Scale score of 13-15 and with a CT scan will be recruited. To evaluate the potential of GFAP and UCH-L1 in predicting the prognosis after TBI (secondary objective), a further 1720 children with mild TBI but no CT scan as well as 130 children with moderate or severe TBI will be recruited. Finally, to establish age-specific reference values for GFAP and UCH-L1 (secondary objective), we will include 400 children and adolescents with no history of TBI.

ETHICS AND DISSEMINATION

This study has received ethics approval in all participating countries. Results from our study will be disseminated in international peer-reviewed journals. All procedures were developed in order to assure data protection and confidentiality.

TRIAL REGISTRATION NUMBER

NCT05413499.

Investigating the Student in Returning to Learn After Concussion: A Systematic Review and Meta-Analysis

PURPOSE

Examine concussion effects on academic outcomes, including student perspectives.

METHODS

This study included a systematic review and meta-analysis examining post-concussion school attendance, academic performance, perceptions of academic difficulty, and accommodations for students in elementary through college settings. The analysis considered pre- and post-injury factors, along with injury factors that contribute to post-concussion academic outcomes.

RESULTS

The systematic review showed that students with concussion miss more school days and perceive higher levels of academic difficulty, but results about academic performance varied. Meta-analysis yielded small concussion effects on school absence and academic performance and moderate effects on perceptions of academic difficulty. Female sex, older age, history of migraine, prior concussions, severe or persistent symptoms, vestibular-ocular motor, and cognitive disruptions are risk factors, but these moderators were not identified in the meta-analysis due to lack of effect sizes.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

This study confirmed negative concussion effects on academic absences, performance, and perceptions of academic difficulty. Identified contributing factors will guide future practices to support students returning to learn after concussion.

CONCLUSIONS

Negative impacts to academics from concussion may be amplified by complicating factors. Future investigations are needed to confirm risk factors and mitigating effects of early identification and post-injury supports.

Prediction Models for Neurocognitive Outcome of Mild Traumatic Brain Injury in Children: A Systematic Review

Mild traumatic brain injury (mTBI) is highly prevalent in children. Recent literature suggests that children with mTBI are at considerable risk of persisting neurocognitive deficits, threatening post-injury child development. Nevertheless, clinical tools for early identification of children at risk are currently not available. This systematic review aims to describe the available literature on neurocognitive outcome prediction models in children with mTBI. Findings are highly relevant for early identification of children at risk of persistent neurocognitive deficits, allowing targeted treatment of these children to optimize recovery. The electronic literature search was conducted in PubMed, EMBASE, CINAHL, Cochrane, PsychINFO and Web of Science on February 9, 2022. We included all studies with multi-variate models for neurocognitive outcome based on original data from only children (age <18 years) with mTBI. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, two authors independently performed data extraction and risk of bias analysis using the Prediction model Risk of Bias Assessment Tool (PROBAST). This systematic review identified eight original studies (nine articles) reporting prediction models for neurocognitive outcome, representing a total of 1033 children diagnosed with mTBI (mean age at injury = 10.5 years, 37.6% girls). Neurocognitive outcome assessment took place between 1 month and 7 years post-injury. Models were identified with significant predictive value for the following outcomes: memory, working memory, inhibition, processing speed, and general neurocognitive functioning. Prediction performance of these models varied greatly between weak and substantial (R² = 10.0%-54.7%). The best performing model was based on demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening to predict the presence of a deficit in general neurocognitive functioning at 12 months post-injury. This systematic review reflects the absence of robust prediction models for neurocognitive outcome of children with mTBI. The findings indicate that demographic factors, pre-morbid factors as well as acute and subacute clinical factors have relevance for neurocognitive outcome. Based on the available evidence, evaluation of demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening may have the best potential to predict neurocognitive outcome in children with mTBI. The findings underline the importance of future research contributing to early identification of children at risk of persisting neurocognitive deficits.

Nonpharmacological interventions for treating fatigue in adolescents: A systematic review and narrative synthesis of randomised controlled trials

OBJECTIVE

Fatigue is common in adolescence and can be highly disabling if experienced persistently, with adverse psychosocial outcomes. There is a need to better understand what nonpharmacological treatments are available for adolescents suffering with persistent fatigue. The current review systematically identified, synthesised, and evaluated the evidence regarding nonpharmacological interventions for fatigue in adolescents, focusing on evaluating effectiveness, describing intervention components, and mapping interventions onto the behaviour change technique taxonomy (BCTT).

METHODS

CENTRAL, EMBASE, PsycINFO, PubMed, and Web of Science were systematically searched for articles including (1) adolescents aged 10-19 years old, (2) fatigue as a primary or secondary outcome, (3) nonpharmacological interventions, and (4) randomised controlled trials. Study screening, data extraction, quality assessment, and BCTT mapping were performed independently by two reviewers. Findings were presented as a narrative synthesis, with interventions ranked by promise.

RESULTS

5626 papers were identified and double-screened, resulting in the inclusion of 21 articles reporting 16 trials. Five interventions were classified as likely promising. Interventions often involved psychoeducation, cognitive behavioural therapy, and/or physical activity, incorporating various BCTT domains, most commonly shaping knowledge, repetition and substitution, and goals and planning. However, there did not seem to be any observable differences between fatigue-targeted and non-fatigue-targeted interventions. Overall study quality was mixed, particularly in relation to power and outcome measures.

CONCLUSION

There are several promising nonpharmacological interventions for adolescent fatigue, although further work is needed to determine effectiveness. Future trials need to ensure design rigour, focusing on adequate powering, validated outcome measures, and adhering to best practice reporting guidelines.

Fatigue in young patients with acquired brain injury in the rehabilitation setting: Categorizing and interpreting fatigue severity levels

PURPOSE

Fatigue in patients with acquired brain injury (ABI) is common. However, to better target fatigue, clear ways to categorize/interpret fatigue-severity in individual patients are lacking. This study aims to determine/categorize fatigue severity among children, adolescents, and young adults with ABI.

METHODS

This cross-sectional study included young patients admitted to outpatient rehabilitation and their parents. To determine fatigue, the PedsQL™Multidimensional-Fatigue-Scale was used (MFS, scores 0-100, lower scores = higher fatigue, patient-/parent-reported). Based on scores from a reference population, four categories were formed: "1 = no/little fatigued" to "4 = severely-more fatigued."

RESULTS

All scores were lower than those from the reference population, with comparisons in the adolescent and young adult groups reaching statistical significance (p < .05). The proportions of patients in category 4 were: 9%/50%/58% among children/adolescents/young adults, showing that many patients were "severely-more fatigued"-than the reference population.

CONCLUSIONS

Measuring fatigue and categorizing fatigue severity looks promising for clinical practice and could help to better target fatigue.

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

Mood Disorders in Young People With Acquired Brain Injury: An Integrated Model

Purpose/Objective

Young people with paediatric acquired brain injury (pABI) are twice as likely to develop a mood disorder as their peers, frequently have significant unmet socio-emotional needs, and are at over double the risk of going on to use adult mental health services. Recent years have seen significant advances in the development of interventions for young people with mood disorders. However, evidence-based approaches to mood disorders in pABI are lacking and surprisingly little work has evaluated clinical and neuro-developmental models of mood disorders in this population.

Method

We review the literature regarding key mechanisms hypothesised to account for the increased vulnerability to mood disorders in pABI: First, we summarise the direct neurocognitive consequences of pABI, considering the key areas of the brain implicated in vulnerability to mood disorders within a neurodevelopmental framework. Second, we outline five key factors that contribute to the heightened prevalence of mood disorders in young people following ABI. Finally, we synthesise these, integrating neuro-cognitive, developmental and systemic factors to guide clinical formulation.

Results and Implications

We present a framework that synthesises the key mechanisms identified in our review, namely the direct effects of pABI, neurocognitive and neuroendocrine factors implicated in mood and anxiety disorders, maladaptive neuroplasticity and trauma, structural and systemic factors, and psychological adjustment and developmental context. This framework is the first attempt to provide integrated guidance on the multiple factors that contribute to elevated life-long risk of mood disorders following pABI.

Rehabilitation for children with chronic acquired brain injury in the Child in Context Intervention (CICI) study: study protocol for a randomized controlled trial

Background

Pediatric acquired brain injury (pABI) is associated with long-term cognitive, behavioral, social, and emotional problems, which may affect the quality of life, school, and family functioning. Yet, there is a lack of evidence-based community-centered rehabilitation programs for chronic pABI and these children do not systematically receive comprehensive rehabilitation. The Child In Context Intervention (CICI) study is a pragmatic randomized controlled trial (RCT) for children with chronic pABI, which aims to evaluate the effectiveness of an individualized and goal-oriented intervention targeting everyday functioning of the child and family.

Methods

Children aged 6–16 years with MRI/CT-verified intracranial abnormalities will be included in the CICI study if they have persistent self- or parent-reported cognitive, emotional, and/or behavioral challenges 1 year or more after insult and attend school regularly. A total of 70 families will be randomized 1:1 to an intervention or a control group. The intervention consists of seven family sessions, one parent seminar, and four school sessions delivered over approximately 6 months. The parent seminar will be held in person, and the other sessions will mainly be video based. The children’s and families’ self-reported major challenges in everyday life will be targeted using SMART goals. Evidence-based strategies, when available, will be applied to achieve the goals, combined with psychoeducation. Goal attainment scaling (GAS) will be used to evaluate goal attainment. Data is collected at baseline and after approximately 6 and 9 months. External assessors are blinded to group allocation. Primary outcomes are parent-reported brain injury symptoms in children and parenting self-efficacy at 9 months of follow-up. Secondary outcomes include child-reported brain injury symptoms, quality of life, executive functioning in daily life, parent emotional symptoms, family functioning, and unmet family health care needs. A process evaluation will be conducted.

Discussion

The current study provides an innovative approach to rehabilitation for children in the chronic phase of ABI and their families. This complex intervention may contribute to the development of evidence-based, high-quality rehabilitation for a large patient group, which is underrepresented in clinical research. It may also improve collaboration between specialized rehabilitation facilities, schools, and local health care services. Inclusion for the trial started in April 2021.

Trial registration

ClinicalTrials.govNCT04798859. Registered on March 15, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06048-8.

Psychoeducational Interventions and Postconcussive Recovery in Children and Adolescents: A Rapid Systematic Review

OBJECTIVE

The purpose of this rapid systematic review was to identify and synthesize results of empirical studies that have examined psychoeducational interventions provided to children and adolescents aged 5-19 recovering from a concussion and their families.

METHODS

This study followed the PRISMA guidelines adjusted for a rapid systematic review. We searched three databases (EMBASE, PsycInfo and MEDLINE) with key terms for concussion (or mild traumatic brain injury - mTBI), the intervention (psychoeducation, instructions, and reassurance) and the target population (children and adolescents aged 5 to 19). Our search strategy generated 2225 unique records and seven were included. We performed a quality appraisal on the included studies using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Results indicated that psychoeducational interventions had satisfactory feasibility results. Caregivers generally found the intervention to be useful to determine return to play (n=2) and understand consequences following a concussion (n=1). However, results from studies on post-concussive symptom improvement (n=4) and post-intervention concussion knowledge (n=2) showed variability and mixed findings. Methodological quality was low for most studies.

CONCLUSIONS

This present review shows that there are very few published studies on psychoeducational interventions offered to children, adolescents, and families for the post-concussion management. Current evidence suggests that those interventions are useful in guiding caregivers during their child's recovery. However, the impact of psychoeducational interventions on post-concussive recovery seems to be less clear.

Pediatric versus adult paradigms for management of adolescent injuries within a regional trauma system

BACKGROUND

We aimed to examine process and outcome indicators for adolescents with specific injury patterns managed in pediatric versus adult paradigms within the same trauma system.

METHODS

Adolescents (15-17 years old) admitted to the region's adult trauma center (ATC) or pediatric trauma center (PTC) with an abdominal injury, femur fracture or traumatic brain injury (TBI) were reviewed retrospectively. Global and injury-specific process and outcome indicators were compared.

RESULTS

Of 141 ATC and 69 PTC patients, injury patterns differed significantly with more TBI and abdominal injuries at the ATC and femur fractures at the PTC. Overall injury severity was greater at the ATC. Patients with solid organ injuries appeared more likely to undergo embolization or splenectomy at the ATC; however, higher injury grade and later time period were the only variables significantly associated with this. Computed tomography (CT) was used significantly more frequently at the ATC overall, most notable with panscanning and head CTs for major TBI. Time to operative management did not differ for patients with isolated femur fractures. Neuropsychological follow up after minor TBI was documented more often at the PTC than the ATC; there was no difference for those with more severe TBIs.

CONCLUSIONS

Management varies for adolescents between PTCs and ATCs with more exposure to radiation and less neuropsychological follow-up of less severe TBIs at the ATC. This presents distinct opportunities to identify best policies for triage and sharing of management practices within a single regional inclusive trauma system in order to optimize short and long-term outcomes for this population.

TYPE OF STUDY

Retrospective cohort.

LEVEL OF EVIDENCE

Level IV.

Epidemiology of traumatic brain injury in children 15 years and younger in South-Eastern Norway in 2015-16. Implications for prevention and follow-up needs

OBJECTIVE

This retrospective study aimed to describe the volume, severity, and injury mechanism of all hospital-admitted pediatric traumatic brain injury (pTBI) at Oslo University Hospital (OUH), emphasizing consequences for prevention and factors indicating a need for follow-up programs.

METHOD

Data were extracted from the OUH Trauma registry on 176 children, 0-15 years old, admitted to OUH in 2015 and 2016 with a pTBI diagnosis. The dataset contains demographic data, injury mechanism, type, and severity (Glasgow coma scale, GCS; abbreviated injury scale, AIS; injury severity score, ISS), ICD-10 diagnosis codes, level of treatment, and destination of discharge.

RESULTS

79.5% had mild, 9% moderate, and 11.4% severe TBI. The incidence of hospital-treated pTBI in Oslo was 29 per 100,000 per year. The boy: girl ratio was 1.9:1, but in the young teenage group (14-15 years), the ratio was 1:1. Intracranial injury (ICI) identified on CT/MRI was associated with extended hospital stays, with a median of 6 days compared to 1 day for patients without ICI. 27% of the patients assessed as mild TBI at admission had ICI. Children below eight years of age had a higher incidence of moderate and severe ICI from trauma (53% v.s. 28% in children ≥ eight years).

CONCLUSION

The injury characteristics of hospital-treated pTBI are in line with other European countries, but we find the boy-girl ratio different as young teenage girls seem to be catching up with the boys. ICI and length of stay should be considered when deciding which patients need follow-up and rehabilitation.