The evaluation and management of acute concussion differs in young children: Table 1

The Effect of Impact Seizure on the Recovery of Children and Adolescents With Concussion: A Matched Case-Control Study

OBJECTIVE

Management of sport-related and recreation-related concussions (SRCs) in children and adolescents is challenging as brain maturation affects prognosis. However, impact seizure was removed as a prognosis modifying factor in children and adolescents with SRCs in the 2017 consensus statement on concussion in sport, based mostly on adult literature. Therefore, this study evaluates the association of impact seizure on the recovery in children and adolescents with SRCs.

DESIGN

Retrospective matched case-control study.

SETTING

Tertiary pediatric sports medicine service, from January 1, 2015, to June 30, 2022.

PATIENTS

A cohort of 452 patients, aged 7 to 18 years, with new episode of SRC was seen. From this cohort, 396 patients were included in the analysis, including 22 with impact seizures. Controls were generated using the propensity score matching approach. Patients with moderate or severe traumatic brain injury or incomplete treatment were excluded.

INDEPENDENT VARIABLE

Impact seizure during SRC.

MAIN OUTCOME MEASURES

Primary outcome was recovery duration in number of days.

RESULTS

The median recovery duration was longer in the cases (73 days, interquartile range [IQR] = 38-143 days) as compared with controls (49.5 days, IQR = 30.5-93.5 days). There was no difference in patients with prolonged recovery (ie >28 days) between both groups (OR 1.6, 95% CI, 0.4-6.6, P = 0.505).

CONCLUSIONS

Impact seizures prolonged the recovery duration in children and adolescents with SRCs and therefore have a potential concussion modifying prognostic role. These findings could help provide evidence-based management principles for children and adolescents with SRCs in subsequent concussion consensus statements.

Comparing return to play protocols after sports-related concussion among international sporting organisations

BACKGROUND

Return to play (RTP) protocols are an important part of recovery management following a sport-related concussion (SRC) and can prevent athletes from returning to competition too early and thereby avoid prolonged recovery times. To assist sporting organizations in the development of RTP guidelines, the Concussion in Sports Group (CISG) provides scientific-based recommendations for the management of SRC in its consensus statement on concussion in sport.

OBJECTIVES

This study investigates commonalities and differences among current RTP protocols of international sporting organizations and examines the implementation of the most recent CISG recommendations.

METHODS

Concussion guidelines and medical rules of 12 international sporting organizations from contact, collision and combat sports were accessed via the organizations websites and compared regarding the management of SRC and the RTP decision.

RESULTS

Only six of the included organizations developed and published their own concussion guidelines, which included an RTP protocol on their website. The number of steps until RTP was similar across the different protocols. Each protocol required at least one medical examination before clearing an athlete to RTP. A high variation among organizations was found for initial resting period after injury, the implementation of sport-specific training drills and the time needed to complete the protocol before returning to competition. At the date of this study (9 September 2023), none of the accessible RTP protocols were updated to include the latest version of the CISG consensus statement.

CONCLUSION

To improve the safety of athletes after a head injury, sporting organizations should develop sport-specific guidelines according to the latest CISG consensus statement, and this should be updated regularly. Implementation is especially important in combat sports, where there is a high incidence of head injury. Thus, there is a requirement for the most up-to-date concussion management protocols in these sports.

Academic adjustments and concussion recoveries in NCAA student-athletes: a LIMBIC MATARS investigation

OBJECTIVE

The aim of this study was to investigate the association between academic adjustments and recovery from sport-related concussions (SRCs) in collegiate athletes.

MATERIALS AND METHODS

A retrospective medical chart review was performed between the 2015-2016 and 2019-2020 sport seasons at 11 Long-term Impact of Military-relevant Brain Injury Consortium Military and Tactical Athlete Research Study (LIMBIC MATARS) sites. Days between injury and symptom resolution, and injury and return to sport (dependent variables) for collegiate athletes who did or did not receive academic adjustments (independent variable) were analyzed using Mann-Whitney U tests.

RESULTS

The number of days between date of injury and symptom-resolution between those who did (median = 9 [interquartile range = 5,16]) and did not have (7[3,12]) academic adjustments were statistically different (z=-2.76, p < 0.01, r=-0.17). However, no differences were observed between days to return to sport among those who did (14[10,22]) and did not (13[8,20]) receive assigned academic adjustments (z= -1.66, p = 0.10, r= -.10).

CONCLUSIONS

Recovery trajectories were similar between athletes diagnosed with a SRC who did or did not receive academic adjustments.. Our findings suggest academic adjustments supported recovery for those who needed academic adjustments. Clinicians and healthcare professionals should assist and support collegiate athletes after SRCs on an individual basis, including academic adjustments when appropriate based on patient presentation.

"You Can't Fix Your Brain": Exploring concussion experiences of children and parents

PURPOSE

To explore the experiences, information needs and preferences of children who have had a concussion and their parents who have cared for them.

DESIGN

Qualitative description.

METHODS

Semi-structured qualitative interviews were conducted via Zoom with children who have had a concussion between ages 5 and 16 years and parents who have cared for a child with a concussion. Interviews were audio-recorded and transcribed.

RESULTS

Fourteen interviews were conducted with children and parents who have experiences with concussion. Four major themes were identified: (1) mechanism of injury and concussion symptoms experienced by children, (2) parent concerns, emotions, and health care experience with child's concussion, (3) concussions affect more than just your head and, (4) health information seeking, and preferences of parents and children related to concussion. Children and their parents have unique experiences, information needs and preferences regarding concussion.

PRACTICE IMPLICATIONS

This information offers valuable insights about developing resources about childhood concussion that parents and children will find useful and relevant. This research has direct relevance to healthcare professionals who may encounter children with concussion in their daily practice so they can ensure the needs of children and families are being met. Our findings will be used to create the content for an innovative knowledge translation tool about pediatric concussion.

Annual Baseline King-Devick Oculomotor Function Testing Is Needed Due to Scores Varying by Age

Objective: To document baseline King-Devick (K-D) oculomotor function scores for male and female participants aged between 4 and 20 years old. Methods: Utilising a cross section of schools, rugby clubs and gymnastic clubs, 1936 participants (1300 male, 636 female) completed the spiral-bound K-D test for the identification of disturbed oculomotor function. Results: This study identified that overall, the baseline scores of the K-D test became faster by 1.4 (0.3 to 4.5) s per year, when compared with the previous age group in the same number of reading card groups. When comparing normative values of the original K-D validation study with the same age groups of the current cohort, participants aged 6 to 11 years recorded a faster baseline time (range 3.5 to 8.6 s), while those in the 12 to 14 years. age group recorded slower baseline times (range −3.9 to −7.9 s). Discussion: In general, there were age group differences, but not sex differences, for K-D test times in the current cohort. Analysis of single card times, across all age groups, showed changes likely due to improved reading time. Conclusion: The results support the need for individualised annual pre-injury baseline testing of the K-D test.

Association of impulsivity, physical development, and mental health to perceptual-motor control after concussion in adolescents

HIGHLIGHTS

After SRC, adolescents had deficits in action boundary perception accuracy, while reporting higher depression symptoms and impulsivity, including attention and cognitive instability components.Certain domains of impulsivity were predictive of action boundary perception accuracy and each perception actualization measure in the concussed group.ADD/ADHD history, anxiety scores, and physical development ratings were also significant predictors of perceptual-motor accuracy and actualization time.

What Do Parents Need to Know About Concussion? Developing Consensus Using the Delphi Method

OBJECTIVE

Many schools and sports leagues provide preseason concussion education to parents/guardians, and in some jurisdictions, it is required for interscholastic sports participation. However, directives about content are absent or vague. The purpose of this study was to obtain expert consensus about what parents/guardians need to know to about concussion.

DESIGN

A modified Delphi process with nationally recognized expert panel members was used to obtain consensus about parent/guardian behaviors relevant to concussion prevention, identification, and management and knowledge domains relevant to performance of those behaviors.

RESULTS

Sixteen parent/guardian behaviors and 24 knowledge domains were identified. However, consensus was not achieved regarding whether it is realistic to expect parents/guardians to perform approximately one-third of the behaviors that experts agreed mattered. This variability may reflect underlying uncertainty about the capacities of some parents/guardians to put knowledge into action or the belief that there are other barriers to action. Furthermore, for most knowledge domains, there was a lack of agreement about whether or not there could be a "correct" answer on the basis of current scientific knowledge.

CONCLUSIONS

These findings raise practical and ethical questions: how can we expect parents/guardians to help prevent, identify, or manage concussion if they cannot have all the information required to engage in these behaviors due to lack of scientific consensus? This issue is not unique to concussion. Best practices for risk communication and shared decision-making can inform how we think about educating parents/guardians about concussion inside and outside of the health care setting.

Concussion in collegiate athletics: A link to academic achievement

Context

After concussion, many different symptoms can occur and persist that can affect daily functioning. Many of these symptoms could have implications in an athlete’s ability to return to academics. Unlike return to play, return to academics is less studied and less regulated. There is little research examining the effects of concussion on grade point average (GPA) and results have been inconsistent.

Objective

To examine the effects of concussion on college GPA.

Design

Retrospective observational study

Setting

University laboratory

Participants

Division I athletes after their first concussion (n = 26) and Division I athletes without a history of concussion (n = 30).

Main Outcome Measures

GPA and demographic information was obtained for the semester before injury, the semester of injury, and the semester after injury.

Results

Statistical analysis using generalized linear mixed model analysis revealed a significant interaction ( p < 0.05) of group (concussion vs. control) by time, with the concussed group having a significant decrease in GPA from semester before injury to semester of injury, and a significant main effect for sex ( p < 0.05) with females having higher GPAs than males.

Conclusions

Since the cognitive demands of academics can potentially exacerbate symptomology of concussion, the identification of students at risk for difficulties is critical.

The influence of fatiguing exercise on Sport Concussion Assessment Tool (SCAT) scoring in a female pediatric population

There is currently a lack of information available about the effect that exercise fatigue may have on Child Sport Concussion Assessment Tool (SCAT) scoring in a pediatric population. Objective: The goal of this study was to examine the influence of a fatiguing bout of aerobic exercise on Child Sport Concussion Assessment Tool (SCAT) scoring in an adolescent female sporting population. Methods: A prospective, observational-based, test-retest study design was used to collect Child SCAT data from thirty healthy 9-12 year old physically active females during two testing sessions that occurred a minimum of 7 days apart. Within each testing session, each child completed a fatiguing bout of aerobic exercise, and the Child SCAT was administered: (1). Pre-exercise and (2). Post-exercise. Parametric and non-parametric testing was used to compare aerobic exercise test results and pre- vs. post-exercise Child SCAT data. Test-retest reliability was evaluated using intra-class correlation coefficient (ICC 3,1) analysis. Results: No significantly differences were noted between pre- and post-exercise Child SCAT data during either test day. ICC values suggested that a majority of the individual components of the Child SCAT demonstrated poor test-retest reliability. Conclusion: Clinicians using the Child SCAT as a sideline assessment tool during youth sport should have confidence that individual component scores are uninfluenced by aerobic exercise completed immediately prior to assessment. But, clinicians should also be cautioned against using Child SCAT data from consecutive testing days when making decisions about patient recovery and return-to-sport timelines.

Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence

Return to activity (RTA) and return to school (RTS) are important issues in pediatric concussion management. This study aims to update CanChild's 2015 RTA and RTS protocols, on the basis of empirical data and feedback collected from our recently completed prospective cohort study, focusing on concussed children and their caregivers; systematic review of evidence published since 2015; and consultation with concussion management experts. The new protocols highlight differences from the earlier versions, mainly, (1) symptom strata to allow quicker progression for those who recover most quickly; (2) a shortened rest period (24-48 hours) accompanied by symptom-guided activity; (3) the recommendation that children progress through the stages before they are symptom free, if symptoms have decreased and do not worsen with activity; (4) specific activity suggestions at each stage of the RTA protocol; (5) recommendations for the amount of time to spend per stage; and (6) integration of RTS and RTA.

Maximizing Recovery From Concussions for Youth Participating in Sports and Recreational Activities

Concussions have become a public health issue. This public health concern has drawn the attention of many states in which laws were created to address concussions safety, recognition of signs and symptoms, immediate removal, medical clearance, and return-to-play protocols. Most state legislation focused on student athletes participating in organized sports. However, the rise in concussion can be directly attributed to children, youth, and adolescents participating in nonsports-related events. Maximizing recovery from a concussion involves implementing education programs that focus on recognition of symptoms, treatment, and return-to-learn options. Treatment strategies used to address concussed youth include physical and cognitive rest and minimizing external stimuli that can increase symptoms. Because learning is a direct outcome for all youth, a return-to-learn protocol based on a collaborative school-based team approach is suggested.

Exploring Gaps in Concussion Knowledge and Knowledge Translation Among Coaches of Youth Female Hockey

OBJECTIVE

To better understand the level of concussion knowledge of youth female hockey coaches and to identify preferred methods of knowledge translation for this population.

DESIGN

Cross-sectional survey.

SETTING

Participants independently completed written surveys before in-person concussion information sessions or online surveys through link provided in emails.

PARTICIPANTS

Convenience sampling yielded 130 coaches of youth female hockey from Canada.

MAIN OUTCOME MEASURES

Knowledge level on concussion, resources from which coaches obtained information on concussion, opinions on the current level of concussion knowledge, and knowledge translation.

RESULTS

Coaches demonstrated adequate knowledge on concussion, achieving 84% correct on true-false questions and 92% correct on symptom identification accuracy. However, coaches showed limited awareness of concussion specific to mechanisms for injury (identification) and postconcussion symptoms. Internet resources were rated as the most used resources for concussion yet were not rated very helpful. Nonetheless, coaches indicated online courses and web sites as the most preferred method for concussion knowledge translation.

CONCLUSIONS

Youth female hockey coaches have overall adequate knowledge of concussion; however, gaps in knowledge do exist. Future efforts to raise the concussion knowledge among coaches of female youth hockey should include information specific to the mechanism of injury, along with sign and symptom identification, with particular attention paid to emotional symptoms. Given the reported preferences and the widespread availability of the Internet, further exploration and research validation of online courses and web sites tailored to the youth female hockey community is encouraged.

What Comes First: Return to School or Return to Activity for Youth After Concussion? Maybe We Don't Have to Choose

Objectives: Return to School (RTS) and Return to Activity/Play (RTA) protocols are important in concussion management. Minimal evidence exists as to sequence and whether progression can occur simultaneously. Experts recommend that children/youth fully return to school before beginning RTA protocols. This study investigates recovery trajectories of children/youth while following RTA and RTS protocols simultaneously, with the following objectives: (1) to compare rates and patterns of progression through the stages of both protocols; (2) to evaluate symptom trajectories of youth post-concussion while progressing through stages of RTS and RTA; and (3) to propose a new model for concussion management in youth that involves the integration of Return to Activity and Return to School protocols. Methods: In a 3-year prospective-cohort study of 139 children/youth aged 5-18 years with concussive injury, self-reported symptoms using PCSS and stage of protocols were evaluated every 48 h using electronic surveys until full return to school and activity/sport were attained. Information regarding school accommodation and achievement was collected. Results: Sample mean age is 13 years, 46% male. Youth are returning to school with accommodations significantly quicker than RTA (p = 0.001). Significant negative correlations between total PCSS score and stage of RTS protocol were found at: 1-week (r = -0.376, p < 0.0001; r = -0.317, p = 0.0003), 1-month (r = -0.483, p < 0.0001; r = -0.555, p < 0.0001), and 3-months (r = -0.598, p < 0.0001; r = -0.617, p < 0.0001); indicating lower symptom scores correlated with higher guideline stages. Median full return to school time is 35 days with 21% of youth symptomatic at full return. Median return time to full sport competition is 38 days with 15% still symptomatic. Sixty-four percent of youth reported experiencing school problems during recovery and 30% at symptom resolution, with 31% reporting a drop in their grades during recovery and 18% at study completion. Conclusions: Children/youth return to school faster than they return to play in spite of the self-reported, school-related symptoms they experience while moving through the protocols. Youth can progress simultaneously through the RTS and RTA protocols during stages 1-3. Considering the numbers of youth having school difficulties post-concussion, full contact sport, stage 6, of RTA, should be delayed until full and successful reintegration back to school has been achieved. In light of the huge variability in recovery, determining how to resume participation in activities despite ongoing symptoms is still the challenge for each individual child. There is much to be learned with further research needed in this area.

Diagnosis of Concussion in the Pediatric Emergency Department

Pediatric visits to the Emergency Department (ED) for concussion are common and increasing. ED clinicians evaluating children with concussion should first ensure the absence of more serious injuries requiring immediate intervention, such as intracranial hemorrhage or cervical spine injury. In the ED setting, signs and symptoms of concussion are sometime subtle and often overlooked. A thorough physical exam is warranted but may be normal. Imaging and laboratory studies have no role in concussion diagnosis and should be reserved for cases where an injury requiring immediate intervention is suspected. Symptom management may include avoiding symptom-triggers (such as bright lights triggering headaches) and/or specific treatments such as nonsteroidal anti-inflammatories or antiemetics. Discharge instructions should include a recommendation for a brief period of rest, followed by outpatient management for return-to-activity decisions in conjunction with a primary care provider.

The Role of Neuropsychology in the Evaluation of Concussion

Neuropsychologists play an important role in the clinical evaluation of many children and adolescents who have sustained concussions. This paper discusses clinical approaches and concerns in conducting neuropsychological evaluations of middle and high school aged students during the acute, subacute, and more chronic phases of concussion recovery. Issues of baseline testing and validity assessment are reviewed. Typical clinical recommendations arising from the neuropsychological evaluation are outlined, with an emphasis on the relationship between test findings and common academic accommodations.

Diagnosis of Concussion in the Hospital

A significant number of children who are admitted to the hospital with traumatic injuries also have concussion symptoms. Yet, the optimal or standard pathway of care for children with concussion in the hospital setting is not known. Diagnosing concussion in hospital is important because planning of therapies and perioperative anesthetic care is needed in order to minimize risks that could impede recovery. So too is a clinical practice guideline that enables triage, diagnosis, management, and continuity of care for children in hospital with concussion. Therefore, in this review we provide a practical approach to the diagnosis and management of concussion in the hospital, and emphasize the importance of a standardized neurological assessment and multidisciplinary care to identify concussion and its comorbidities, and appropriate follow up care after discharge. Discharge planning should provide education about concussion, encourage compliance with therapies, and importantly, aim to ensure continuity in care through post hospital follow up, particularly for children with high symptom burdens and co-existing mental health conditions.

Multicentre, randomised clinical trial of paediatric concussion assessment of rest and exertion (PedCARE): a study to determine when to resume physical activities following concussion in children

INTRODUCTION

Rest until symptom-free, followed by a progressive stepwise return to activities, is often prescribed in the management of paediatric concussions. Recent evidence suggests prolonged rest may hinder recovery, and early resumption of physical activity may be associated with more rapid recovery postconcussion. The primary objective is to determine whether the early reintroduction of non-contact physical activity beginning 72 hours postinjury reduces postconcussive symptoms at 2 weeks in children following an acute concussion as compared with a rest until asymptomatic protocol.

METHODS AND ANALYSIS

This study is a randomised clinical trial across three Canadian academic paediatric emergency departments. A total of 350 participants, aged 10-17.99 years, who present within 48 hours of an acute concussion, will be recruited and randomly assigned to either the study intervention protocol (resumption of physical activity 72 hours postconcussion even if experiencing symptoms) or physical rest until fully asymptomatic. Participants will document their daily physical and cognitive activities. Follow-up questionnaires will be completed at 1, 2 and 4 weeks postinjury. Compliance with the intervention will be measured using an accelerometer (24 hours/day for 14 days). Symptoms will be measured using the validated Health and Behaviour Inventory. A linear multivariable model, adjusting for site and prognostically important covariates, will be tested to determine differences between groups. The proposed protocol adheres to the RCT-CONSORT guidelines.

DISCUSSION

This trial will determine if early resumption of non-contact physical activity following concussion reduces the burden of concussion and will provide healthcare professionals with the evidence by which to recommend the best timing of reintroducing physical activities.

TRIAL REGISTRATION NUMBER

Trial identifier (Clinicaltrials.gov) NCT02893969.

Risk Factors for Prolonged Symptoms of Mild Traumatic Brain Injury: A Pediatric Sports Concussion Clinic Cohort

OBJECTIVE

To examine predictors of prolonged symptom duration from mild traumatic brain injury (mTBI) in a pediatric sports medicine specialty clinic cohort as these predictors may be distinct in this population.

DESIGN

Retrospective chart review.

SETTING

Outpatient specialty clinic.

PATIENTS

Charts of 549 patients (age range: 10-18 years) with concussions were reviewed in an outpatient clinic that predominantly managed sports-related injuries (77.3%). Patients (n = 431) included in the final analysis met the criteria for mTBI and were symptomatic at their first visit.

ASSESSMENT OF RISK FACTORS

Patient history, injury, and recovery variables were evaluated.

MAIN OUTCOME MEASURES

Predictors of prolonged time to reach self-reported symptom recovery were evaluated using Cox proportional hazards.

RESULTS

Median time to symptom recovery of the 431 patients who presented to clinic with symptoms was 40 days (full clinic sample median = 34 days). Analyses identified 3 unique predictors of symptom recovery: loss of consciousness (LOC) [hazard ratio (HR) = 0.56, P < 0.0001], female sex (HR = 0.57, P < 0.0001), and concussion symptom score at first clinic visit (HR = 0.76, P < 0.0001).

CONCLUSIONS

Prolonged duration of mTBI symptoms in patients who present to a pediatric sports-based concussion clinic is related to initial symptom severity, female sex, and LOC.

Concussion in adolescent rugby union players: comprehensive acute assessment protocol and development of the SSC concussion passport to monitor long-term health

Introduction

Sports-related concussion (SRC) can be challenging to diagnose, assess and manage. Much of the SRC research is conducted on adults. The assessment of SRC should aim to identify deficits using a detailed multimodal assessment; however, most studies investigating the effects of SRC use diagnostic tools in isolation. It is likely that a combination of diagnostic tests will improve diagnostic accuracy. In this study, we aim to investigate how concussion affects adolescent rugby players and how a variety of diagnostic tools interact with each other as participants recover from their injury. The study will also determine the logistics of recording an individual’s concussion history on a virtual ‘Concussion Passport’ that would remain with the individual throughout their sporting career to allow monitoring of long-term health.

Methods and analysis

All rugby players (n=211) from the Senior Cup Teams of five schools in Dublin, Ireland will be invited to participate in the study. Baseline testing will be performed at the Sports Surgery Clinic, Dublin (SSC) before the rugby season commences. Participants will be followed up over the course of the rugby season. At baseline and at each postconcussion visit, participants will complete the following: Questionnaire, Sports Concussion Assessment Tool 3, Balance Error Scoring System, Computerised Neurocognitive Testing, Vestibulo-ocular assessment, King Devick test, Graded exercise test, Blood tests, Neck strength, FitBit.

Ethics and dissemination

Ethical approval was obtained from the Sports Surgery Clinic Research Ethics Committee (Approval number: SSC 0020). On completion of the study, further papers will be written and published to present the results of the various tests.

Trial registration number

NCT03624634.

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.

Characterizing Hospitalizations for Pediatric Concussion and Trends in Care

BACKGROUND

Children hospitalized for concussion may be at a higher risk for persistent symptoms, but little is known about this subset of children.

OBJECTIVE

Delineate a cohort of children admitted for concussion, describe care practices received, examine factors associated with prolonged length of stay (LOS) or emergency department (ED) readmission, and investigate changes in care over time.

DESIGN, SETTING

Retrospective analysis of data submitted by 40 pediatric hospitals to the Pediatric Health Information System.

PATIENTS

Children 0 to 17 years old admitted with a primary diagnosis of concussion from 2007 to 2014.

MEASUREMENTS

Descriptive statistics characterized this cohort and care practices delivered, logistic regression identified factors associated with a LOS of =2 days and ED readmission, and trend analyses assessed changes in care over time.

RESULTS

Of the 10,729 children admitted for concussion, 68.7% received intravenous pain or antiemetic medications. Female sex, adolescent age, and having government insurance were all associated (P = .02) with increased odds of LOS = 2 days and ED revisit. Proportions of children receiving intravenous ondansetron (slope = 1.56, P = .001) and ketorolac (slope = 0.61, P < .001) increased over time, and use of neuroimaging (slope = -1.75, P < .001) decreased.

CONCLUSIONS

Although concussions are usually selflimited, hospitalized children often receive intravenous therapies despite an unclear benefit. Factors associated with prolonged LOS and ED revisit were similar to predictors of postconcussive syndrome. Since there has been an increased use of specific therapeutics, prospective evaluation of their relationship with concussion recovery could lay the groundwork for evidenced-based admission criteria and optimize recovery.

Educational Initiative to Standardize Concussion Management in Pediatric Primary Care

Pediatric primary care providers report limited training and tools to manage concussion. We developed a learning community intervention for a large independent pediatric practice association affiliated with a university hospital to standardize concussion management and improve the use of consensus-based guidelines. The learning community included in-person and online didactics, followed by a web-based reinforcement platform to educate and train clinicians on our treatment algorithm and decision support tools. Chart reviews before and after the intervention demonstrated significant increases in the use of standardized symptom rating scales (19.6% to 69.3%; P < .001), balance assessment (2.3% to 37.6%; P < .001), and scheduled follow-up (41.8% to 61.2%; P < .001), with an increase in delivery of our entire best practice bundle from 3.5% to 28.1% ( P < .001). A multimodal educational intervention can effect change among pediatric primary care providers and help align their management practices with consensus-based guidelines.

Impact of Early Follow-Up Intervention on Parent-Reported Postconcussion Pediatric Symptoms: A Feasibility Study

OBJECTIVES

To investigate the effectiveness and feasibility of early intervention telephone counseling with parents in limiting postconcussion symptoms and impacts on children and youth.

SETTING

Recruitment occurred postdischarge from one pediatric emergency department.

PARTICIPANTS

Sixty-six parents of children aged 5 to 16 years with a diagnosis of a concussion injury.

DESIGN

A pilot, randomized controlled study compared the efficacy of telephone counseling (reviewing symptom management and return to activity with parents at 1 week and 1 month postinjury) with usual care (no formalized follow-up).

MAIN MEASURES

The Post-Concussion Symptom Inventory and the Family Burden of Injury Interview administered with parents by a blinded therapist at 3 months postinjury.

RESULTS

No significant difference between the groups at 3 months postinjury in postconcussion symptoms (P = .67) and family stress (P = .647).

CONCLUSION

The findings suggest that the early counseling intervention strategy trialed herein may not be effective for children and youth who experience significant postconcussion symptoms. Further research is needed to determine whether more intensive and integrated care would better serve children.

Returning Adolescents to Driving after Sports-Related Concussions: What Influences Physician Decision-Making

OBJECTIVE

To determine which data collected on an initial patient clinic visit for a sports-related concussion (SRC) might influence physicians to clear an adolescent to return to drive (RTD) after injury.

STUDY DESIGN

Retrospective cohort study of 189 adolescents with a SRC referred to a hospital-based concussion clinic between June 1, 2015, and May 31, 2016. Subjects were ≥16 years with a valid driver's license (median age = 16, IQR [16, 17]). Concussion evaluations included Post-Concussion Symptom Scale, modified Balance Error Scoring System, and postinjury computerized neurocognitive testing (CNT). Clearance for RTD was the main outcome. Statistical comparisons were conducted with Mann-Whitney U and χ² tests and logistic regression.

RESULTS

In multivariable analysis, odds of being fully cleared to drive were 5.9-fold greater among patients who were administered CNT. Stated symptoms of "headache" and "sensitivity to light" were statistically significantly associated with RTD clearance. For a subset of 113 individuals undergoing CNT, each additional 10-millisecond decrease in simple reaction time was associated with 9% greater odds of being cleared to drive. Each additional 10-millisecond decrease in choice reaction time was associated with 4% greater odds of being cleared to drive.

CONCLUSIONS

CNT and associated reaction time measures may facilitate a physician's objective decision-making. Making a RTD determination for adolescents recovering from an SRC should be a core component of a physician's assessment.

A Novel Approach to Assessing Head Injury Severity in Pediatric Patient Falls

INTRODUCTION

Pediatric patient falls with head-to-floor impact have the greatest potential for injury.

METHODS

An objective measure of head injury severity, the Head Injury Criterion (HIC₁₅), was calculated from anthropometric and biomechanical components of patient falls. A secondary aim was to compare HIC₁₅ levels with the hospital's subjective assignment of level of harm (1-9 scale) used for regulatory reports.

RESULTS

Adverse event reports yielded a sample of 49 falls from heights of 72.5 to 1793.0 cm by children ages 11 months through 17 years. Contact velocity from beginning to end was 2.81 to 6.16 ms. Mean acceleration was 19.5 to 95.3g. HIC₁₅ levels of impact ranged from 26.4 to 1,330.0, and mean force upon contact was 2.0 to 9.8 N/kg body mass. Seven (14.3%) children's HIC₁₅ levels exceeded age-specific thresholds, with no follow-up scheduled. Hospital-assigned levels of harm were not correlated with HIC₁₅ levels (r = .23, R² = .05, p = .12).

DISCUSSION

A point-of-care computerized HIC₁₅ algorithm would be useful for diagnostic and follow-up decisions.

Response of School Districts to the New York State Concussion Awareness and Management Act: Review of Policies and Procedures

BACKGROUND

By 2014, all states implemented concussion laws that schools must translate into daily practice; yet, limited knowledge exists regarding implementation of these laws. We examined the extent to which concussion management policies and procedure (P&P) documents of New York State school districts comply with the State's Concussion Awareness and Management Act (the Act). We also aimed to identify barriers to compliance.

METHODS

Forty-seven school districts provided P&P documents. We examined compliance with the Act and the relationship between compliance and each district's demographics.

RESULTS

Compliance varied across school districts, with higher overall compliance in large city school districts compared to county districts. However, there was low compliance for several critical items. We found no statistically significant relationship between compliance and demographics.

CONCLUSIONS

School districts need to increase compliance with concussion legislation to ensure the adequate implementation necessary for the law to impact health and educational outcomes. The results provide important information to individuals charged with the responsibility of implementation and ultimately reducing the negative outcomes associated with brain injuries in schools.

Impact of Exercise on Clinical Symptom Report and Neurocognition after Concussion in Children and Adolescents

Recovery from concussion in childhood is poorly understood, despite its importance in decisions regarding return to normal activity. Resolution of post-concussive symptoms (PCS) is widely employed as a marker of recovery in clinical practice; however, it is unclear whether subtle impairments persist only to re-emerge in the context of increased physical or cognitive demands. This study aimed to examine the effect of strenuous exercise on clinical symptom report and neurocognition in children and adolescents after PCS resolution after concussion. We recruited children and adolescents with concussion (n = 30) on presentation to an Emergency Department (ED). At Day 2 and Day 10 post-self-reported symptom resolution, participants completed a strenuous exercise protocol, and pre- and post-exercise assessment of PCS and neurocognition. Results demonstrated an overall reduction in PCS from Day 2 to Day 10 post-symptom resolution, with no evidence of symptom increase after strenuous exercise at either time point. Neurocognitive performance was linked to task complexity: on less cognitively demanding tasks, processing speed was slower post-exercise and, unexpectedly, slower on Day 10 than Day 2, while for more demanding tasks (new learning), Day 2 exercise resulted in faster responses, but Day 10 processing speed post-exercise was slower. In summary, we found the expected recovery pattern for PCS, regardless of exercise, while for neurocognition, recovery was dependent on the degree of cognitive demand, and there was an unexpected reduction in performance from Day 2 to Day 10. Findings provide some suggestion that premature return to normal activities (e.g., school) may slow neurocognitive recovery.

Reliability Testing of the Balance Error Scoring System in Children Between the Ages of 5 and 14

OBJECTIVE

Pediatric concussion is an extensive public health concern with a complex clinical presentation. Balance assessment has been well-studied in the adult population, but has been limited in children. We aimed to assess the reliability and minimum detectable change (MDC) of the Balance Error Scoring System (BESS) in healthy children.

DESIGN

This prospective observational study included 373 healthy children aged 5 to 14. Interrater reliability was assessed by having 4 assessors review videos of 50 random subjects distributed evenly by age and sex across the entire cohort. Intrarater reliability was performed by having assessors review videos of other assessors' live evaluations. Test-retest reliability was obtained by comparing BESS scores as recorded live at the 2 separate time points by the same rater.

SETTING

Local elementary and junior high schools.

PARTICIPANTS

Three hundred and seventy three healthy children between the ages of 5 and 14.

INTERVENTIONS

The BESS was performed on all children.

MAIN OUTCOME MEASURES

Intraclass Correlation Coefficients (ICCs) and MDC Scores.

RESULTS

The overall interrater ICC was determined to be 0.93 [95% confidence interval (CI), 0.79-0.97] and intrarater ICC was 0.96 (95% CI, 0.95-0.97) with individual intrarater ICCs ranging between 0.69 and 0.99. The test-retest reliability was 0.90 (95% CI, 0.88-0.92). The MDCs were 9.6, 4.6, and 7.3 points at the 95% CIs for interrater, intrarater, and test-retest comparisons, respectively. No learning effect was seen.

CONCLUSIONS

The BESS demonstrates excellent reliability in the pediatric population without evidence of a learning effect.

Return to Drive Counseling After Sports-Related Concussion: A Quality Improvement Project

Introduction

Concussion is a common injury in adolescent athletes, many of whom also drive. Counseling athletes and their families about driving risks post concussion is a potentially significant intervention. The aim of this quality improvement project was to increase driving recommendations for concussed athletes in a pediatric sports medicine clinic.

Methods

Patients in this quality improvement project were seen in the sports medicine concussion clinic between February 2014 and August 2015. We determined how often driving recommendations were documented through a retrospective chart review. Once the "return to drive" project was introduced to the sports medicine staff, multiple interventions were completed including handing out flyers to remind families about driving and creating changes to the electronic medical record.

Results

At baseline, 9.3% of visits had driving recommendations documented. After an intervention requiring clinical documentation in the electronic medical record, 97% of patients received driving recommendations.

Conclusions

The quality improvement effort was successful at increasing the frequency of delivery of appropriate driving recommendations provided to concussed athletes.

A Normative Dataset of the Balance Error Scoring System in Children Aged Between 5 and 14

OBJECTIVE

Pediatric head injuries occur commonly and are being reported in increasing numbers. Balance testing is a key component in the evaluation of suspected concussion, and the balance error scoring system (BESS) is likely the most well-known and widely used measure. To date, normative BESS scores for adults have been reported but not for children.

DESIGN

Normative data for BESS scores and modified BESS scores were created in a cohort of healthy children. Potential variables were analyzed as predictors of BESS performance.

SETTING

Local elementary and junior high schools.

PARTICIPANTS

A total of 373 healthy children between the ages of 5 and 14.

INTERVENTIONS

The BESS was performed on all children.

ASSESSMENT OF RISK FACTORS

Gender, body mass index percentile, previous concussions, athletic participation, age, and the parental opinion of child's balance ability were examined as factors associated with the BESS score.

MAIN OUTCOME MEASURES

BESS scores.

RESULTS

Normative data are reported, stratified by age groups of 5 to 7 years, 8 to 10 years, and 11 to 14 years of age, for both BESS and modified BESS. Median BESS scores are 23 for children aged 5 to 7, 18 for children aged 8 to 10, and 16 for children aged 11 to 14. Median modified BESS scores are 8 for children age 5 to 7, 5 for children age 8 to 10, and 4 for children age 11 to 14. Increasing age and positive parental opinion regarding their child's balance ability were independently correlated with decreasing BESS scores (P < 0.01).

CONCLUSIONS

The normative data on BESS scores for healthy children reported here provide age-stratified reference values for suspected balance alterations.

Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment

OBJECTIVE

To examine the influence of age, sex, attention-deficit hyperactivity disorder (ADHD) status, previous history of concussion, and days since injury on postconcussion postural control assessment in adolescents who have suffered a concussion.

DESIGN

Prospective cohort study.

SETTING

Hospital-based outpatient clinic.

PARTICIPANTS

Seventy-one participants (42 males; 29 females) with mean age 14.14 ± 2.44.

INDEPENDENT VARIABLES

Age, sex, previous concussion history, ADHD status, total and severity of postconcussion symptoms, and days since injury.

MAIN OUTCOME MEASURES

Total Balance Error Scoring System score, path length, center-of-pressure (COP) area, sample entropy, and Romberg quotient.

RESULTS

Pearson product-moment correlation coefficients were calculated to test for potential associations between the continuous participant characteristics and the postural control variables. Spearman correlation was used to test the association between symptom severity and the postural control variables. Standard multiple regression was used to model the extent to which participant characteristics accounted for the variance in the postural sway variables. Age was significantly associated with all of the postural sway variables except COP area for the eyes open condition and sample entropy in the anterior-posterior direction for the eyes closed condition. Sex, ADHD status, and previous concussion history did not significantly predict postural control scores.

CONCLUSIONS

Age significantly influences scores on common postconcussion postural control assessments.

CLINICAL RELEVANCE

This study demonstrates that age is a critical factor that needs to be accounted for to improve the clinical appropriateness and utility of current postconcussion postural control assessments.

Do children and adolescent ice hockey players with and without a history of concussion differ in robotic testing of sensory, motor and cognitive function?

Background

KINARM end point robotic testing on a range of tasks evaluating sensory, motor and cognitive function in children/adolescents with no neurologic impairment has been shown to be reliable. The objective of this study was to determine whether differences in baseline performance on multiple robotic tasks could be identified between pediatric/adolescent ice hockey players (age range 10–14) with and without a history of concussion.

Methods

Three hundred and eighty-five pediatric/adolescent ice hockey players (ages 10–14) completed robotic testing (94 with and 292 without a history of concussion). Five robotic tasks characterized sensorimotor and/or cognitive performance with assessment of reaching, position sense, bimanual motor function, visuospatial skills, attention and decision-making. Seventy-six performance parameters are reported across all tasks.

Results

There were no significant differences in performance demonstrated between children with a history of concussion [median number of days since last concussion: 480 (range 8–3330)] and those without across all five tasks. Performance by the children with no history of concussion was used to identify parameter reference ranges that spanned 95 % of the group. All 76 parameter means from the concussion group fell within the normative reference ranges.

Conclusions

There are no differences in sensorimotor and/or cognitive performance across multiple parameters using KINARM end point robotic testing in children/adolescents with or without a history of concussion.

Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network

IMPORTANCE

Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained.

OBJECTIVE

To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury.

DESIGN, SETTING, AND PARTICIPANTS

In this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Children's Hospital of Philadelphia's (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected.

MAIN OUTCOMES AND MEASURES

Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion.

RESULTS

A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay patients [24%]).

CONCLUSIONS AND RELEVANCE

The findings suggest estimates of concussion incidence based solely on ED visits underestimate the burden of injury, highlight the importance of the primary care setting in concussion care management, and demonstrate the potential for EHR systems to advance research in this area.

Patterns of Recovery Following Sport-Related Concussion in Children and Adolescents

Time to symptom resolution, return to school, and return to play after a sport-related concussion in children and adolescents (8-17 years of age) was examined using a retrospective cohort design. A total of 198 patients aged 8 to 17 years were included, with a mean age of 13.5 years (SD = 2.2). Patients aged 8 to 12 years were symptom-free in a median of 12.0 (range 1-60) days whereas 13- to 17-year olds were symptom-free in a median of 14.0 (range 1-300) days (P = .04). Patients aged 8 to 12 years returned to learn in a median of 4.0 (range 0-30) days compared with 2.5 (range 0-55.0) days in 13- to 17-year-olds (P = .86). Patients aged 8 to 12 years returned to play in a median of 14.0 (range 4-75) days compared with a median of 19.5 (range 5-75) days in 13- to 17-year-olds (P = .06). These results indicate that children and adolescents generally take 2 to 4 weeks to recover from a sport-related concussion.

Age Differences in Recovery After Sport-Related Concussion: A Comparison of High School and Collegiate Athletes

CONTEXT

Younger age has been hypothesized to be a risk factor for prolonged recovery after sport-related concussion, yet few studies have directly evaluated age differences in acute recovery.

OBJECTIVE

To compare clinical recovery patterns for high school and collegiate athletes.

DESIGN

Prospective cohort study.

SETTING

Large, multicenter prospective sample collected from 1999-2003 in a sports medicine setting.

SUBJECTS

Concussed athletes (n = 621; 545 males and 76 females) and uninjured controls (n = 150) participating in high school and collegiate contact and collision sports (79% in football, 15.7% in soccer, and the remainder in lacrosse or ice hockey).

MAIN OUTCOME MEASURE(S)

Participants underwent evaluation of symptoms (Graded Symptom Checklist), cognition (Standardized Assessment of Concussion, paper-and-pencil neuropsychological tests), and postural stability (Balance Error Scoring System). Athletes were evaluated preinjury and followed serially at several time points after concussive injury: immediately, 3 hours postinjury, and at days 1, 2, 3, 5, 7, and 45 or 90 (with neuropsychological measures administered at baseline and 3 postinjury time points).

RESULTS

Comparisons of concussed high school and collegiate athletes with uninjured controls suggested that high school athletes took 1 to 2 days longer to recover on a cognitive (Standardized Assessment of Concussion) measure. Comparisons with the control group on other measures (symptoms, balance) as well as direct comparisons between concussed high school and collegiate samples revealed no differences in the recovery courses between the high school and collegiate groups on any measure. Group-level recovery occurred at or before 7 days postinjury on all assessment metrics.

CONCLUSIONS

The findings suggest no clinically significant age differences exist in recovery after sport-related concussion, and therefore, separate injury-management protocols are not needed for high school and collegiate athletes.

Diagnosis and management of paediatric concussion

Heightened recognition of concussions and concerns about their sequelae in children has become an increasing community and public health concern. Biomarkers and clinical tests are being explored, but the diagnosis of concussion in the emergency department continues to be based on clinical signs and symptoms. While the majority of children go on to recover from post-concussive symptoms within 2 weeks, it is unclear which patients with concussion will go on to develop short- or long-term sequelae. A number of more or less evidence-based guidelines have become available which seek to guide clinicians on how to manage children post-concussion. In general, care after the emergency department is focused on reducing the risk of re-injury and rest until cerebral recovery with a graduated return to school and then play.

Cognitive and physical symptoms of concussive injury in children: a detailed longitudinal recovery study

BACKGROUND

Recovery from concussion sustained in childhood and adolescence is poorly understood. We explored patterns of recovery for neurocognition and postconcussive symptoms following concussion in children and adolescents.

METHODS

Using a prospective, longitudinal design, we collected baseline data on 728 children and adolescents aged 10-17 years. 10 participants sustained a concussive injury (n=10) in the 12 months following baseline testing and they were reviewed at day 5, 10 and 30 postconcussion. Assessments included the CogSport for Kids computerised test battery to evaluate neurocognitive function and self-report, and parent measures of postconcussive symptoms. At day 30, parents also completed measures rating their child's quality of life and executive functions.

RESULTS

Children and adolescents displayed a gradual reduction in postconcussive symptoms over the 30 days following injury. At day 5, 87% of participants were reporting physical and cognitive symptoms, with a generalised reduction in all symptoms by day 10 (40% of participants). On the computerised measure, reaction time was slower after concussion, but returned to baseline levels by day 30. At day 30, 10% of participants demonstrated ongoing postconcussive symptoms. Number of previous concussions was related to speed of symptom resolution.

CONCLUSIONS

At 5 days postconcussion, the majority of children and adolescents experienced debilitating postconcussive symptoms. However, by 30 days postinjury, 90% demonstrated recovery to normal for both neurocognition and postconcussive symptoms.

Test-retest reliability of KINARM robot sensorimotor and cognitive assessment: in pediatric ice hockey players

BACKGROUND

Better diagnostic and prognostic tools are needed to address issues related to early diagnosis and management of concussion across the continuum of aging but particularly in children and adolescents. The purpose of the current study was to evaluate the reliability of robotic technology (KINARM robot) assessments of reaching, position sense, bimanual motor function, visuospatial skills, attention and decision making in youth ice hockey players (ages 10-14).

METHODS

Thirty-four male children attended two testing days, one week apart. On day one, each subject completed five tasks on the robot with two examiners (alternating examiner sequence); the 2(nd) examiner followed the same procedure as the 1(st) immediately afterwards. One consistent examiner tested subjects one week later. This is a test-retest reliability study. The robotic tasks characterize sensorimotor and/or cognitive performance; 63 parameters from 5 tasks are reported. Session 1 was the 1(st) time the subject performed the 5 tasks, session 2 the 2(nd) time on day 1, and session 3 one week following.

RESULTS

Intra-class correlation coefficients ranged from 0.06 to 0.91 and 0.09 to 0.90 for session 1 to 2 and 2 to 3, respectively. Bland-Altman plots showed agreement in a majority of the parameters and a learning effect in 25 % and 24 % of parameters in session 1 vs 2 and 1 vs 3, respectively but none for session 2 vs 3. Of those that showed a learning effect, only 8 % of parameters in session 1 vs 2 and 10 % in session 1 vs 3 had a clinical relevance measure ≥ 0.8.

CONCLUSIONS

The relative homogeneity of the sample and the effect of learning seen in some of the task parameters appears to have negatively impacted the intra-class correlation coefficients from session 1 to 2, with less impact for 2 to 3. The Bland-Altman analysis supports good absolute reliability in healthy male children with no neurological impairment ranging in age from 10 to 14. The clinically relevant learning effect seen, in a small number of parameters could be addressed by creating a learning effect adjustment factor and/or implementing a practice session, which would eliminate the learning effect.

The Diagnosis and Management of Concussion in Children and Adolescents

BACKGROUND

Concussion is a complex brain injury that results in more than 100,000 emergency department visits for school-aged children each year in the United States. All 50 US states have passed concussion legislation designed to promote safety in youth sports. Most of these laws require medical clearance by a licensed health care provider before returning to sport, which may have contributed to an increase in pediatric subspecialty referrals, particularly referrals to the child neurologist.

METHODS

We reviewed the literature on pediatric concussion.

RESULTS

This review summarizes the current knowledge and recommendations for concussion diagnosis and management in children and adolescents, athletes and nonathletes. It highlights concussion epidemiology, pathophysiology, advances in neuroimaging, and potential health risks including second impact syndrome and chronic traumatic encephalopathy. It also underscores clinical areas where evidence is lacking.

CONCLUSIONS

The diagnosis and management of concussion requires specific considerations in children. Further concussion research must be done to minimize injury risk and to optimize medical care for this common problem.

A Balanced Protocol for Return to School for Children and Youth Following Concussive Injury

BACKGROUND

Few protocols exist for returning children/youth to school after concussion. Childhood concussion can significantly affect school performance, which is vital to social development, academic learning, and preparation for future roles. The goal of this knowledge translation research was to develop evidence based materials to inform physicians about pediatric concussion.

METHODS

The Return to School (RTS) concussion protocol was developed following the National Institute for Health and Care Excellence procedures.

RESULTS

Based on a scoping review, and stakeholder opinions, an RTS protocol was developed for children/youth. This unique protocol focuses on school adaptation in 4 main areas: (a) timetable/attendance, (b) curriculum, (c) environmental modifications, and (d) activity modifications.

CONCLUSION

A balance of cognitive rest and timely return to school need to be considered for returning any student to school after a concussion. Implementation of these new recommendations may be an important tool in prevention of prolonged absence from school and academic failure while supporting brain recovery.

The diagnosis of concussion in a pediatric emergency department

OBJECTIVES

To compare the proportion of children diagnosed with a concussion by pediatric emergency physicians vs the proportion who met criteria for this injury as recommended by Zurich Fourth International Conference on Concussion consensus statement and to determine clinical variables associated with a physician diagnosis of a concussion.

STUDY DESIGN

This was a prospective, cross-sectional study conducted at a tertiary care pediatric emergency department. We enrolled children ages 5 through 17 who presented with a head injury and collected data on demographics, mechanism of injury, head injury-related symptoms/signs, physician diagnosis, and discharge advice.

RESULTS

We identified 495 children whose mean age was 10.1 years (SD 3.4 years); 308 (62.2%) were male. Emergency physicians diagnosed concussion in 200 (40.4%; 95% CI 36.1, 44.7) children, and 443 (89.5%; 95% CI 86.8, 92.2) met criteria for concussion in accordance with the Zurich consensus statement (P<.0001). Age≥10 years (OR 1.8), presentation≥1 day after injury (OR 2.4), injury from collision sports (OR 5.6), and symptoms of headache (OR 2.2) or amnesia (OR 3.4) were the variables significantly associated with an emergency physician's diagnosis of concussion.

CONCLUSIONS

Pediatric emergency physicians diagnosed concussion less often relative to international consensus-based guidelines and used a limited number of variables to make this diagnosis compared with current recommendations. Thus, pediatric emergency physicians may be missing cases of concussion and the corresponding opportunity to provide critical advice for cognitive and physical management.

Concussion management in collegiate student-athletes: return-to-academics recommendations

Concussions in collegiate athletics can affect student-athletes both on the field and in the classroom. As policies are made to outline return-to-play decisions and timelines, this article will make the case that return-to-academics should also be included and follow a step-wise protocol. Complete cognitive rest is a cornerstone of concussion recovery and slow reintroduction to academics should precede return-to-play. The college structure allows for student-athletes to begin small doses of cognitive activity after the recommended complete cognitive rest. It is recommended that return-to-academics involves a team approach to help the student-athlete navigate the responsibilities of course work while healing from a brain injury.