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Marbil MG, Ware AL, Galarneau JM, Minich NM, Hershey AD, Orr SL, Defta DM, Taylor HG, Bigler ED, Cohen DM, Mihalov LK, Bacevice A, Bangert BA, Yeates KO. Longitudinal trajectories of posttraumatic headache after pediatric mild traumatic brain injury. Cephalalgia 2023; 43:3331024231161740. [PMID: 37177818 DOI: 10.1177/03331024231161740] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE This prospective, longitudinal cohort study examined the trajectory, classification, and features of posttraumatic headache after pediatric mild traumatic brain injury. METHODS Children (N = 213; ages 8.00 to 16.99 years) were recruited from two pediatric emergency departments <24 hours of sustaining a mild traumatic brain injury or mild orthopedic injury. At 10 days, three months, and six months postinjury, parents completed a standardized questionnaire that was used to classify premorbid and posttraumatic headache as migraine, tension-type headache, or not otherwise classified. Multilevel mixed effects models were used to examine posttraumatic headache rate, severity, frequency, and duration in relation to group, time postinjury, and premorbid headache, controlling for age, sex, and site. RESULTS PTH risk was greater after mild traumatic brain injury than mild orthopedic injury at 10 days (odds ratio = 197.41, p < .001) and three months postinjury (odds ratio = 3.50, p = .030), especially in children without premorbid headache. Posttraumatic headache was more frequent after mild traumatic brain injury than mild orthopedic injury, β (95% confidence interval) = 0.80 (0.05, 1.55). Groups did not differ in other examined headache features and classification any time postinjury. CONCLUSIONS Posttraumatic headache risk increases after mild traumatic brain injury relative to mild orthopedic injury for approximately three months postinjury, but is not clearly associated with a distinct phenotype.
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Affiliation(s)
- Mica Gabrielle Marbil
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Ashley L Ware
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- Department of Psychology, Georgia State University, Atlanta, GA, USA
| | | | - Nori Mercuri Minich
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
- Rainbow Babies & Children's Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Andrew D Hershey
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Serena L Orr
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dana M Defta
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - H Gerry Taylor
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Erin D Bigler
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Daniel M Cohen
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Leslie K Mihalov
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Ann Bacevice
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Barbara A Bangert
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Mucha A, Pardini JE, Herring SA, Murphy J, Elbin RJ, Bauer RM, Schmidt JD, Resch JE, Broshek DK. Persisting symptoms after concussion: Considerations for active treatment. PM R 2022; 15:663-673. [PMID: 36507616 DOI: 10.1002/pmrj.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Anne Mucha
- UPMC Centers for Rehab Services, UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Jamie E Pardini
- Departments of Internal Medicine and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Stanley A Herring
- Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Justin Murphy
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - R J Elbin
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, Arkansas, USA
| | - Russell M Bauer
- Department of Clinical & Health Psychology, University of Florida Department of Clinical & Health Psychology, Gainesville, Florida, USA
| | - Julianne D Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, Georgia, USA
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Donna K Broshek
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Relationship Between Self-Reported Concomitant Depressive and Anxiety Symptoms and the Post-Concussion Symptoms Scale (PCSS). J Int Neuropsychol Soc 2022; 28:1064-1074. [PMID: 34895377 DOI: 10.1017/s135561772100134x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The current study explored how affective disturbances, particularly concomitant anxiety and depressive symptoms, impact baseline symptom self-reporting on the Post-Concussion Symptoms Scale (PCSS) in college athletes. METHODS Athletes were separated into four groups (Healthy Control (HC) (n = 581), Depression Only (n = 136), Anxiety Only (n = 54), Concomitant Depression/Anxiety (n = 62)) based on their anxiety and depression scores. Groups were compared on Total PCSS Score as well as 5 PCSS Symptom Cluster scores (Cognitive, Physical, Affective, Sleep, and Headache). RESULTS The three affective groups reported significantly greater symptomatology than HCs, with the Concomitant group showing the highest symptomatology scores across all clusters. The depressive symptoms only group also reported significantly elevated symptomatology, compared to HCs, on every symptom cluster except headache. The anxiety symptoms only group differed from HCs on only the cognitive symptoms cluster. Additionally, the Concomitant group reported significantly increased PCSS symptomatology, in terms of total scores and all 5 symptom clusters, compared to the depressive symptoms only and anxiety symptoms only groups. CONCLUSIONS Our findings suggest that athletes experiencing concomitant depressive/anxiety symptoms report significantly greater levels of symptomatology across all 5 PCSS symptom clusters compared to HCs. Further, results suggest that athletes experiencing concomitant affective disturbance tend to report greater symptomatology than those with only one affective disturbance. These findings are important because, despite the absence of concussion, the concomitant group demonstrated significantly elevated symptomatology at baseline. Thus, future comparisons with post-concussion data should account for this increased symptomatology, as test results may be skewed by affective disturbances at baseline.
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Maki K, Doan Q, Sih K, Stillwell K, Chun A, Meckler G. A randomized controlled pilot study of intranasal lidocaine in acute management of paediatric migraine and migraine-like headache. Paediatr Child Health 2022; 27:340-345. [DOI: 10.1093/pch/pxac054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
This study was aimed to determine the sample size required to conduct an efficacy randomized controlled trial (RCT) to evaluate superiority of intranasal (IN) lidocaine to placebo as an analgesic option for children presenting to the paediatric emergency department (PED) with migraine or posttraumatic headache with migraine features and to evaluate study protocol feasibility.
Study Design
This study is a double-blind RCT of children aged 7 to 16 years at a single-centre PED. Thirty-two participants were randomized to receive either IN 2% lidocaine or 0.9% sodium chloride. The primary outcome measure was the proportion of subjects with a Verbal Numeric Rating Scale pain score of <4 at 30 and 60 minutes post-IN therapy. Primary outcome data were analyzed using a test of differences between proportions. Secondary objectives included assessing the feasibility of our study protocol by evaluating recruitment rates, adverse drug events, and PED length of stay (LOS).
Results
Six of 17 participants in the lidocaine group and 2 of 15 in the placebo group were treated successfully. Using these proportions with 95% confidence intervals and 80% power, the sample size required to find a significant difference between proportions would be 67 participants per arm. Our enrolment rate was 55% and there were no serious adverse drug events. The median PED LOS was similar between groups.
Conclusion
We determined the sample size required to conduct a definitive RCT to evaluate the superiority of IN lidocaine to placebo and found the study protocol is feasible but identified important considerations in PED migraine trial design.
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Affiliation(s)
- Kate Maki
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
| | - Quynh Doan
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
| | - Kendra Sih
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
| | - Karly Stillwell
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
| | - Alaina Chun
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
| | - Garth Meckler
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
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King JA, Rodriquez B, Kim I, Nimmer M, Nelson LD, Szabo A, Dong H, Thomas D. Incidence of Neck Pain in Patients With Concussion in a Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1185-e1191. [PMID: 34570080 PMCID: PMC8934308 DOI: 10.1097/pec.0000000000002544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of the study were (1) to determine the frequency of neck pain in patients diagnosed with mild traumatic brain injury (mTBI) or concussion in a pediatric level 1 trauma center emergency department (ED), (2) to identify variables associated with neck pain in this population, and (3) to report on aspects of care received in the ED including imaging and medication use. METHODS This is a retrospective chart review of 652 patients presenting to a pediatric ED with diagnosis of concussion/mTBI. Charts were reviewed for the following information: baseline demographic information, mechanism of injury, cause of mTBI, presence or absence of neck pain, point tenderness in the neck on physical examination, and whether the patient followed up within our health system in the 6 months after injury. Charts were also reviewed for other concussion-related symptoms, medication given in the ED, imaging performed in the ED, cervical spine clearance in the ED, and referrals made. For those patients who did have follow-up appointments within our system, additional chart review was performed to determine whether they sought follow-up treatment for symptoms related to concussion/neck pain and the duration of follow-up. Statistical analyses focused on the prevalence of neck pain in the sample. We subsequently explored the degree to which neck pain was associated with other collected variables. RESULTS Of 652 patients, 90 (13.8%) reported neck pain. Acceleration/deceleration injury and motor vehicle accident were predictive of neck pain. Neck pain was less common in those reporting nausea and vomiting. Direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables, this was no longer statistically significant. Patients with neck pain were older than those without neck pain. Patients with neck pain were more likely to receive ibuprofen or morphine and undergo imaging of the spine. They were also more likely to receive a referral and follow-up with neurosurgery. There was no significant difference between groups with respect to concussion-related follow-up visits or follow-up visits to a dedicated concussion clinic. CONCLUSIONS Neck pain is a common symptom in pediatric patients with mTBI, although it was more likely in older patients and those presenting with acceleration/deceleration mechanisms. Although patients with neck pain were more likely to receive a referral and follow-up with neurosurgery, they were not more likely to have concussion-related follow-up visits. Indeed, most patients had no follow-up visits related to their concussion, which supports the notion that concussion is a self-limiting condition.
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Affiliation(s)
| | | | | | - Mark Nimmer
- Division of Emergency Medicine, Department of Pediatrics
| | | | - Aniko Szabo
- Division of Biostatistics, Department of Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Huaying Dong
- Division of Emergency Medicine, Department of Pediatrics
| | - Danny Thomas
- Division of Emergency Medicine, Department of Pediatrics
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Patterson Gentile C, Aguirre GK, Arbogast KB, Master CL. Relationship between Visually Evoked Effects and Concussion in Youth. J Neurotrauma 2022; 39:841-849. [PMID: 35166126 PMCID: PMC9225424 DOI: 10.1089/neu.2021.0475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increased sensitivity to light is common after concussion. Viewing a flickering light can also produce uncomfortable somatic sensations like nausea or headache. We examined effects evoked by viewing a patterned, flickering screen in a cohort of 81 uninjured youth athletes and 84 concussed youth. We used Multiple correspondence analysis and identified two primary dimensions of variation: the presence or absence of visually evoked effects and variation in the tendency to manifest effects that localized to the eyes (e.g., eye watering) versus more generalized neurological effects (e.g., headache). Based on these two primary dimensions, we grouped participants into three categories of evoked symptomatology: no effects, eye-predominant effects, and brain-predominant effects. A similar proportion of participants reported eye-predominant effects in the uninjured (33.3%) and concussed (32.1%) groups. By contrast, participants who experienced brain-predominant effects were almost entirely from the concussed group (1.2% of uninjured, 35.7% of concussed). The presence of brain-predominant effects was associated with a higher concussion symptom burden and reduced performance on visio-vestibular tasks. Our findings indicate that the experience of negative constitutional, somatic sensations in response to a dynamic visual stimulus is a salient marker of concussion and is indicative of more severe concussion symptomatology. We speculate that differences in visually evoked effects reflect varying levels of activation of the trigeminal nociceptive system.
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Affiliation(s)
- Carlyn Patterson Gentile
- Department of Pediatrics, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Injury Research and Prevention, Children”s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Geoffrey K. Aguirre
- Department of Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Department of Pediatrics, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Injury Research and Prevention, Children”s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L. Master
- Department of Pediatrics, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Injury Research and Prevention, Children”s Hospital of Philadelphia, Philadelphia, Pennsylvania
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7
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Patterson Gentile C, Shah R, Irwin SL, Greene K, Szperka CL. Acute and chronic management of posttraumatic headache in children: A systematic review. Headache 2021; 61:1475-1492. [PMID: 34862612 DOI: 10.1111/head.14236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/19/2021] [Accepted: 09/20/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The goal of this paper is to provide a compilation of the evidence for the treatment of posttraumatic headache (PTH) in the pediatric population. Headache features and timing of therapy were considered. BACKGROUND Headache is the most common symptom following mild traumatic brain injury (mTBI), affecting more than 80% of children and adolescents. It is unclear whether treatment for PTH should be tailored based on headache characteristics, particularly the presence of migraine features, and/or chronicity of the headache. METHODS Systematic literature searches of PubMed, Embase, Scopus, and Cochrane databases (1985-2021, limited to English) were performed, and key characteristics of included studies were entered into RedCAP® (Prospero ID CRD42020198703). Articles and conference abstracts that described randomized controlled trials (RCTs), cohort studies, retrospective analyses, and case series were included. Participants included youth under 18 years of age with acute (<3 months) and persistent (≥3 months) PTH. Studies that commented on headache improvement in response to therapy were included. RESULTS Twenty-seven unique studies met criteria for inclusion describing abortive pharmacologic therapies (9), preventative pharmacotherapies (5), neuromodulation (1), procedures (5), physical therapy and exercise (6), and behavioral therapy (2). Five RCTs were identified. Studies that focused on abortive pharmacotherapies were completed in the first 2 weeks post-mTBI, whereas other treatment modalities focused on outcomes 1 month to over 1-year post-injury. Few studies reported on migrainous features (7), personal history of migraine (7), or family history of migraine (3). CONCLUSIONS There is limited evidence on the timing and types of therapies that are effective for treating PTH in the pediatric population. Prospective studies that account for headache characteristics and thoughtfully address the timing of therapies and outcome measurement are needed.
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Affiliation(s)
- Carlyn Patterson Gentile
- Pediatric Headache Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Shah
- School of Arts and Sciences, University of Richmond, Richmond, Virginia, USA
| | - Samantha L Irwin
- UCSF Child & Adolescent Headache Program, San Francisco, California, USA
| | - Kaitlin Greene
- Doernbecher Children's Hospital Child and Adolescent Headache Program, Division of Pediatric Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Christina L Szperka
- Pediatric Headache Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Murray TR, Ferderer T, Gehred A, Rose SC. Treatment of Post-traumatic Headaches in Children: A Systematic Review. Semin Pediatr Neurol 2021; 40:100935. [PMID: 34749911 DOI: 10.1016/j.spen.2021.100935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022]
Abstract
Post-traumatic headache is a secondary headache disorder beginning within 7 days of head injury. We conducted a systematic review of the evidence for treatment of post-traumatic headache in children. Of 2169 unique articles screened, 12 were included. Most studies pertained to headaches after concussion. The authors of seven studies examined the effect of medications, 4 studied nonpharmacological therapies, and 1 studied the reduction of medication usage. Much of the evidence came from retrospective chart reviews, had low level of evidence, and had fair risk of bias. High-quality randomized controlled treatment trials are needed to guide the clinical management of this condition.
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Affiliation(s)
- Thomas R Murray
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - Tanner Ferderer
- The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH
| | | | - Sean C Rose
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH.
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Sex Differences and Reporting of SCAT-5 Concussion Symptoms in Adolescent Athletes. Clin J Sport Med 2021; 31:e229-e234. [PMID: 31985537 DOI: 10.1097/jsm.0000000000000788] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 08/21/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To elucidate specific symptoms that may differ between adolescent female and male athletes after a sports-related concussion (SRC) and identify symptoms that may require greater clinical attention by medical and athletic staff. DESIGN Prospective. SETTING This study is part of a larger research project conducted at clinics in the North Texas Concussion Network (ConTex) Registry. PARTICIPANTS Subjects (N = 491) aged 12 to 18 years who sustained a diagnosed SRC within 30 days of clinic visit. INDEPENDENT VARIABLES Sex (female vs male). Covariates included age, race, current mood (anxiety and depression), learning disability/ADHD, and time to clinic. MAIN OUTCOME MEASURES Twenty-two individual postconcussion symptoms as measured by the Post-Concussion Symptom Scale from the Sport Concussion Assessment Tool-5 (SCAT-5). RESULTS Girls endorsed higher levels of anxiety and depression symptoms at initial clinic visit. analysis of covariance results revealed that girls had significantly greater symptom severity of headache, dizziness, sensitivity to light, sensitivity to noise, pressure in the head, feeling slowed down, fatigue, and drowsiness than boys. Ordinal logistic regression results also revealed that girls had significantly greater predicted odds of higher symptom severity on these 8 symptoms and in trouble concentrating than boys. CONCLUSIONS Closer examination of specific symptoms with attention to patients' current levels of anxiety and depression symptoms may better inform medical and athletic staff to anticipate and address symptoms that may present greater challenges for adolescent girls than boys.
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Rose SC, Anderson W, Feinberg D, Ganesh A, Green L, Jaffee M, Kaplen M, Lorincz M, De Luigi A, Patel D, Tsao JW, Lee E, Webb A. Quality Improvement in Neurology: Concussion Quality Measurement Set. Neurology 2021; 97:537-542. [PMID: 34321361 DOI: 10.1212/wnl.0000000000012537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/10/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sean C Rose
- Nationwide Childrens Hospital and The Ohio State University, Columbus, OH
| | | | | | | | - Lauren Green
- University of Southern California, Los Angeles, CA
| | | | | | | | | | | | | | - Erin Lee
- American Academy of Neurology, Minneapolis, MN
| | - Adam Webb
- Emory University School of Medicine, Decatur, GA
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Salberg S, Sgro M, Brady RD, Noel M, Mychasiuk R. The Development of Adolescent Chronic Pain following Traumatic Brain Injury and Surgery: The Role of Diet and Early Life Stress. Dev Neurosci 2020; 42:2-11. [PMID: 32653883 DOI: 10.1159/000508663] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/13/2020] [Indexed: 12/30/2022] Open
Abstract
Pain is evolutionarily necessary for survival in that it reduces tissue damage by signaling the body to respond to a harmful stimulus. However, in many circumstances, acute pain becomes chronic, and this is often dysfunctional. Adolescent chronic pain is a growing epidemic with an unknown etiology and limited effective treatment options. Given that the relationship between acute pain and chronic pain is not straightforward, there is a need to better understand the factors that contribute to the chronification of pain. Since early life factors are critical to a variety of outcomes in the developmental and adolescent periods, they pose promise as potential mechanisms that may underlie the transition from acute to chronic pain. This review examines two early life factors: poor diet and adverse childhood experiences (ACEs); they may increase susceptibility to the development of chronic pain following surgical procedures or traumatic brain injury (TBI). Beyond their high prevalence, surgical procedures and TBI are ideal models to prospectively understand mechanisms underlying the transition from acute to chronic pain. Common themes that emerged from the examination of poor diet and ACEs as mechanisms underlying this transition included: prolonged inflammation and microglia activation leading to sensitization of the pain system, and stress-induced alterations to hypothalamic-pituitary-adrenal axis function, where cortisol is likely playing a role in the development of chronic pain. These areas provide promising targets for interventions, the development of diagnostic biomarkers, and suggest that biological treatment strategies should focus on regulating the neuroinflammatory and stress responses in an effort to modulate and prevent the development of chronic pain.
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Affiliation(s)
- Sabrina Salberg
- Department of Neuroscience, Central Clinical School/Monash University, Melbourne, Victoria, Australia
| | - Marissa Sgro
- Department of Neuroscience, Central Clinical School/Monash University, Melbourne, Victoria, Australia
| | - Rhys D Brady
- Department of Neuroscience, Central Clinical School/Monash University, Melbourne, Victoria, Australia
| | - Melanie Noel
- Department of Psychology, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute/The University of Calgary, Calgary, Alberta, Canada
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School/Monash University, Melbourne, Victoria, Australia,
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12
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Abstract
Purpose
Sport-related concussion is a significant public health concern that requires a multidisciplinary team to appropriately manage. Athletes often report dizziness and imbalance following concussion, and these symptoms can predict increased time to recover. Vestibular diagnostic evaluations provide important information regarding the athlete's oculomotor, gaze stability, and balance function in order to identify deficits for rehabilitation. These measures also describe objective function helpful for determining when an athlete is ready to return to play. The purpose of this clinical focus article is to provide background on the current understanding of the effects of concussion on the peripheral and central vestibular system, as well as information on a protocol that can be used for acute concussion assessment. Case studies describing 3 common postconcussion presentations will highlight the usefulness of this protocol.
Conclusion
Sport-related concussion is a highly visible disorder with many symptoms that may be evaluated in the vestibular clinic. A thoughtful protocol evaluating the typical presentation of these patients may help guide the multidisciplinary team in determining appropriate management and clearance for return to sport.
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Abstract
Concussion is an ongoing concern for health care providers. The incidence rates continue to be high and the rate of recovery is variable due to potential risk factors. With no valid biomarkers, diagnosis and assessment of concussion remain a clinical challenge. The heterogeneity in presentation following injury provides an additional level of complexity, requiring the screening and evaluation of diverse body systems, including oculomotor, vestibular, autonomic, psychiatric, cervical, and cognitive symptoms. While a few tools, such as the Vestibular/Ocular Motor Screening and Balance Error Scoring System, have been developed specifically for concussion, the vast majority of tests are adapted from other conditions. Further complicating the process is the overlapping and interactive nature of the multiple domains of postconcussion presentation. This commentary illustrates how clinicians can conceptualize the multiple profiles that present following concussion and describes tools that are available to assist with screening and evaluation of each area. The multifaceted nature of concussion warrants broad clinical screening skills and an interdisciplinary approach to management. J Orthop Sports Phys Ther 2019;49(11):787-798. doi:10.2519/jospt.2019.8855.
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14
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Sufrinko A, McAllister-Deitrick J, Elbin RJ, Collins MW, Kontos AP. Family History of Migraine Associated With Posttraumatic Migraine Symptoms Following Sport-Related Concussion. J Head Trauma Rehabil 2019; 33:7-14. [PMID: 28520665 PMCID: PMC5693792 DOI: 10.1097/htr.0000000000000315] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine whether family history of migraine increased the likelihood of posttraumatic migraine (PTM) symptom presentation in adolescents following concussion, and examine the influence of family history of migraine and PTM on postinjury outcomes. SETTING Outpatient concussion clinic. PARTICIPANTS A total of 153 patients with concussion (103 males and 50 females) aged 15.72 ± 1.48 years (range 12-18 years). DESIGN Cross-sectional, observational study of patients presenting for initial evaluation 4.72 ± 3.05 days (range 1-14) postinjury. MAIN MEASURES Computerized neurocognitive testing, symptom report, and vestibular/oculomotor screening. RESULTS Patients with a family history of migraine were 2.6 times (odds ratio = 2.60, confidence interval = 1.35-5.02, P = .003) more likely to present with PTM compared with patients without a family history. Results of multivariate analyses of covariance, controlling for concussion history, revealed significant main effects for PTM on (1) Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)/Post-Concussion Symptom Scale (PCSS) (F = 15.43, P <.001) and (2) Vestibular/Ocular Motor Screening (VOMS) (F = 8.52, P < .001). There was no main effect for family history of migraine on ImPACT/PCSS (P = .22) and VOMS (P = .83) or interaction between family history of migraine and PTM on ImPACT/PCSS (P = .84) and VOMS (P = .52). CONCLUSION Family history of migraine is associated with PTM symptoms following sport-related concussion, suggesting a genetic predisposition for migraine may serve as a catalyst or trigger for onset of PTM. However, only presence of PTM, rather than family history of migraine, was related to worse neurocognitive and vestibular/oculomotor outcomes.
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Affiliation(s)
- Alicia Sufrinko
- UPMC Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pennsylvania (Drs Sufrinko, McAllister-Deitrick, Collins, and Kontos); and Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville (Dr Elbin)
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15
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Schneider KJ. Concussion part II: Rehabilitation - The need for a multifaceted approach. Musculoskelet Sci Pract 2019; 42:151-161. [PMID: 30745095 DOI: 10.1016/j.msksp.2019.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 12/09/2018] [Accepted: 01/15/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit. PURPOSE The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion. IMPLICATIONS Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.
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Affiliation(s)
- Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, KNB3300D 2500 University Drive NW, University of Calgary, Calgary, Alberta, T2N 1N4, Canada.
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16
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Schneider KJ. Concussion - Part I: The need for a multifaceted assessment. Musculoskelet Sci Pract 2019; 42:140-150. [PMID: 31133539 DOI: 10.1016/j.msksp.2019.05.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Concussion is among the most commonly occurring sport and recreation injuries in today's society. An understanding of the heterogenous nature of concussion will assist in directing a multifaceted and comprehensive interdisciplinary assessment following injury. PURPOSE The purpose of this masterclass article is to summarize the current state of the evidence in the area of concussion, describe typical symptom presentations and assessment techniques that may assist in directing appropriate management following concussion. IMPLICATIONS A comprehensive assessment including a thoughtful differential diagnosis will assist the clinician to direct care appropriately and efficiently in individuals who have suffered a concussion.
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Affiliation(s)
- Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, Hotchkiss Brain Institute, Alberta Children's Hospital Research Institute, University of Calgary, KNB3300D 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.
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Abstract
OBJECTIVE To characterize the presence and degree of postconcussion lightheadedness in relation to postconcussion vertigo and dizziness, and to determine whether lightheadedness influences overall symptom duration. DESIGN Prospective, cohort design. SETTING Nationwide Children's Hospital, Sports Concussion Clinic. PARTICIPANTS Five hundred ten patients (9-19 years of age) within 30 days of concussion injury. MAIN OUTCOME MEASURES Patient ratings (scale 0-6) of multiple postconcussion symptoms including lightheadedness, vertigo, and dizziness, reported from the day of clinic evaluation and recalled from the day of concussion. RESULTS Postconcussion lightheadedness occurred commonly relative to vertigo. Lightheadedness was recalled more than vertigo (70.8% vs 48.6%, P < 0.001) on concussion day and reported more than vertigo (47.1% vs 24.1%, P < 0.001) on the day of clinic evaluation. Principal component analysis demonstrated strong correlations among lightheadedness, vertigo, balance difficulties, difficulty concentrating, mental fogginess, and difficulty remembering, relative to other postconcussion symptoms. When present on the day of clinic evaluation, these highly correlated symptoms predicted prolonged concussion recovery [P = 0.028; Hazard Ratio (HR) = 1.2]. Female sex (P = 0.04; HR = 1.23), emotional symptoms recalled from the day of concussion (P = 0.007; HR = 1.23), and cephalalgic symptoms (P < 0.001; HR = 1.34) reported on the day of clinic evaluation also predicted prolonged concussion recovery. CONCLUSIONS Not all postconcussion dizziness is vertigo. Postconcussion lightheadedness is common and, when present at the time of clinic evaluation, can influence concussion recovery. CLINICAL RELEVANCE Distinguishing postconcussion lightheadedness from vertigo may help to inform clinical treatment and concussion research design. This study adds to the growing body of evidence that supports an association between concussion and autonomic dysfunction.
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Kwan V, Vo M, Noel M, Yeates K. A Scoping Review of Pain in Children after Traumatic Brain Injury: Is There More Than Headache? J Neurotrauma 2018; 35:877-888. [PMID: 29207908 DOI: 10.1089/neu.2017.5281] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Headache is a common source of pain in children after traumatic brain injury (TBI); however, relatively little is known about nonheadache pain in this pediatric population. The present review seeks to map the extant literature to determine the prevalence, characteristics, and impact of nonheadache pain in children post-TBI of all severities. We found that of 109 studies published on pain in children after a TBI, 95 (87%) were focused exclusively on headache pain and only 14 (13%) reported on nonheadache pain or overall pain, with half (n = 7) in the form of case studies. Overall, the level of evidence was low, with only three level 1 high-quality prospective studies. In one study, over half (57.1%) of adolescents who experienced persistent pain post-TBI reported pain in multiple body sites (e.g., back, lower limb, and neck).1 For each additional noncephalic pain site, the risk for developing chronic migraine is also increased. Nevertheless, pain in body regions other than the head is often not assessed systematically in pediatric TBI research. Findings of the current review suggest that pain assessment in children post-TBI needs improvement, given that pain is linked to worse recovery, poorer quality of life, and can be long-lasting. More rigorous examination of nonheadache pain and its role in impeding recovery in children post-TBI is imperative and has the potential to improve the care and management of children with TBI. We conclude with recommendations for pain assessment, discuss gaps in the literature, and highlight directions for future research.
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Affiliation(s)
- Vivian Kwan
- University of Calgary, Calgary, Alberta, Canada
| | - Mai Vo
- University of Alberta, Edmonton, Alberta, Canada
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Shaw L, Morozova M, Abu-Arafeh I. Chronic post-traumatic headache in children and adolescents: systematic review of prevalence and headache features. Pain Manag 2017; 8:57-64. [PMID: 29192541 DOI: 10.2217/pmt-2017-0019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The aim of this systematic review is to determine the prevalence and clinical features of chronic post-traumatic headache (CPTH) in children and adolescents. Literature search of PubMed, Embase, Cochrane databases and Google Scholar was carried out for all studies reporting on CPTH in children and young people under the age of 18 years between January 1980 and November 2016. Search command included post-traumatic headache, postconcussion syndrome, child and adolescent. Demographic data, diagnostic criteria of headache disorders, occurrence of headache after head injury and headache phenotypes were collected. The prevalence of nonspecific 'chronic headache' after head injury in children was 39% and prevalence of CPTH, as defined by the International Classification of Headache Disorders (2004), was 7.6% (95% CI: 5.9-9.7). Migraine-like headache was the most common presentation followed by tension-type headache. Other children had either mixed or unclassified headache disorders.
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Affiliation(s)
- Lauren Shaw
- Department of Paediatrics, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK
| | - Maria Morozova
- Paediatric Neurosciences Unit, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Ishaq Abu-Arafeh
- Department of Paediatrics, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK.,Paediatric Neurosciences Unit, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK
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Ellis MJ, Cordingley D, Girardin R, Ritchie L, Johnston J. Migraine with Aura or Sports-Related Concussion: Case Report, Pathophysiology, and Multidisciplinary Approach to Management. Curr Sports Med Rep 2017; 16:14-18. [PMID: 28067735 DOI: 10.1249/jsr.0000000000000323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The evaluation and management of athletes presenting with clinical features of migraine headache with aura in the setting of sports-related head trauma is challenging. We present a case report of a 15-yr-old boy with a history of migraine with visual aura that developed acute visual disturbance and headache after a head injury during an ice hockey game. The patient underwent comprehensive assessment at a multidisciplinary concussion program, including neuro-ophthalmological examination, neurocognitive testing, and graded aerobic treadmill testing. Clinical history and multidisciplinary assessment was consistent with the diagnosis of coexisting sports-related concussion and migraine with brainstem aura. The authors discuss the pearls and pitfalls of managing patients who develop migraine headache with visual aura after sports-related head injury and the value of a comprehensive multidisciplinary approach to this unique patient population.
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Affiliation(s)
- Michael J Ellis
- 1Department of Surgery, University of Manitoba, Manitoba, Canada, 2Department of Pediatrics and Child Health, University of Manitoba, Manitoba, Canada, 3Section of Neurosurgery, University of Manitoba, Manitoba, Canada, 4Pan Am Concussion Program, University of Manitoba, Manitoba, Canada, 5Children's Hospital Research Institute of Manitoba, Manitoba, Canada; 6Canada North Concussion Network, Winnipeg, Manitoba, Canada; 7Department of Clinical Health Psychology, University of Manitoba, Manitoba, Canada, 8Department of Medicine and Ophthalmology, University of Manitoba, Manitoba, Canada, 9Department of Neurology, University of Manitoba, Manitoba, Canada
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Rose SC, Schaffer CE, Young JA, McNally KA, Fischer AN, Heyer GL. Utilization of conventional neuroimaging following youth concussion. Brain Inj 2017; 31:260-266. [DOI: 10.1080/02699052.2016.1235285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sean C. Rose
- Division of Pediatric Neurology, Nationwide Children’s Hospital and Department of Neurology, The Ohio State University, Columbus, OH, USA
| | | | - Julie A. Young
- Division of Sports Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kelly A. McNally
- Division of Pediatric Psychology and Neuropsychology, Nationwide Children’s Hospital and Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | | | - Geoffrey L. Heyer
- Division of Pediatric Neurology, Nationwide Children’s Hospital and Department of Neurology, The Ohio State University, Columbus, OH, USA
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Collins MW, Kontos AP, Okonkwo DO, Almquist J, Bailes J, Barisa M, Bazarian J, Bloom OJ, Brody D, Cantu R, Cardenas J, Clugston J, Cohen R, Echemendia R, Elbin R, Ellenbogen R, Fonseca J, Gioia G, Guskiewicz K, Heyer R, Hotz G, Iverson GL, Jordan B, Manley G, Maroon J, McAllister T, McCrea M, Mucha A, Pieroth E, Podell K, Pombo M, Shetty T, Sills A, Solomon G, Thomas DG, Valovich McLeod TC, Yates T, Zafonte R. Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery 2016; 79:912-929. [PMID: 27741219 PMCID: PMC5119544 DOI: 10.1227/neu.0000000000001447] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.
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Affiliation(s)
- Michael W. Collins
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony P. Kontos
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jon Almquist
- Fairfax Family Practice Comprehensive Concussion Center, Fairfax, Virginia
| | - Julian Bailes
- Department of Neurosurgery, NorthShore University Health System, Chicago, Illinois
| | - Mark Barisa
- Baylor Institute for Rehabilitation, Frisco, Texas
| | - Jeffrey Bazarian
- Department of Emergency Medicine, University of Rochester, Rochester, New York
| | - O. Josh Bloom
- Carolina Sports Concussion Clinic, Cary, North Carolina
| | - David Brody
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Robert Cantu
- Dr. Robert C. Cantu Concussion Center, Emerson Hospital, Boston University, Concord, Massachusetts
| | - Javier Cardenas
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
| | - Jay Clugston
- Community Health and Family Medicine, University of Florida, Gainesville, Florida
| | - Randall Cohen
- Athletics Department, University of Arizona, Tucson, Arizona
| | - Ruben Echemendia
- Psychological and Neurobehavioral Associates, State College, Pennsylvania
| | - R.J. Elbin
- Office for Sports Concussion Research, University of Arkansas, Fayetteville, Arkansas
| | - Richard Ellenbogen
- Department of Neurological Surgery University of Washington, Seattle, Washington
| | - Janna Fonseca
- Carolina Sports Concussion Clinic, Cary, North Carolina
| | - Gerard Gioia
- Division of Neuropsychology, Children’s National Health System, Washington, District of Columbia
| | - Kevin Guskiewicz
- College of Arts and Sciences, University of North Carolina, Chapel Hill, North Carolina
| | - Robert Heyer
- Carolinas Medical Center, Charlotte, North Carolina
| | - Gillian Hotz
- Neuroscience Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Grant L. Iverson
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barry Jordan
- Neurorehabilitation, Burke Rehabilitation & Research, White Plains, New York
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Joseph Maroon
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Michael McCrea
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anne Mucha
- University of Pittsburgh Medical Center Centers for Rehabilitation Services, Pittsburgh, Pennsylvania
| | - Elizabeth Pieroth
- Neurological Institute, NorthShore University Health System, Chicago, Illinois
| | - Kenneth Podell
- Houston Methodist Concussion Center, Houston Methodist Hospital, Houston, Texas
| | - Matthew Pombo
- Department of Orthpoedics, Emory University Healthcare, Atlanta, Georgia
| | - Teena Shetty
- Department of Neurology, Hospital for Special Surgery, Weill Cornell Medical College, New York City, New York
| | - Allen Sills
- Department of Neurosurgery, Vanderbilt University, Vanderbilt Sports Concussion Center, Nashville, Tennessee
| | - Gary Solomon
- Department of Neurosurgery, Vanderbilt University, Vanderbilt Sports Concussion Center, Nashville, Tennessee
| | - Danny G. Thomas
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Pediatric Emergency Medicine, Children’s Hospital of Wisconsin, Wauwatosa, Wisconsin
| | | | - Tony Yates
- Pittsburgh Steelers, Pittsburgh, Pennsylvania
| | - Ross Zafonte
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Specific Factors Influence Postconcussion Symptom Duration among Youth Referred to a Sports Concussion Clinic. J Pediatr 2016; 174:33-38.e2. [PMID: 27056449 DOI: 10.1016/j.jpeds.2016.03.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/21/2016] [Accepted: 03/02/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic. STUDY DESIGN A retrospective cohort study was conducted to evaluate several potential predictors of symptom duration via a Cox proportional hazards analyses. The individual postconcussion symptom scores were highly correlated, so these symptoms were analyzed in the statistical model as coefficients derived from principal component analyses. RESULTS Among 1953 youth with concussion, 1755 (89.9%) had dates of reported symptom resolution. The remainder (10.1%) were lost to follow-up and censored. The median time to recovery was 18 days (range 1-353 days). By 30 days, 72.6% had recovered; by 60 days, 91.4% had recovered; and by 90 days, 96.8% had recovered. Several variables in a multivariate Cox model predicted postconcussion symptom duration: female sex (P < .001, hazard ratio [HR] = 1.28), continued activity participation (P = .02, HR = 1.13), loss of consciousness (P = .03, HR = 1.18), anterograde amnesia (P = .04, HR = 1.15), premorbid headaches (P = .03, HR = 1.15), symptom components from the day of concussion (emotion, P = .03, HR = 1.08), and the day of clinic evaluation (cognitive-fatigue, P < .001, HR = 1.22; cephalalgic, P < .001, HR = 1.27; emotional, P = .05, HR = 1.08; arousal-stimulation, P = .003, HR = 1.1). In univariate analyses, greater symptom scores generally predicted longer symptom durations. Worsening of symptoms from the day of concussion to the day of clinic evaluation also predicted longer recovery (P < .001, HR = 1.59). CONCLUSIONS Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic.
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