Sport-related Concussion Clinical Profiles

Concussion history associated with adolescent psychological distress but not hazardous gambling: a cross-sectional study

BACKGROUND

Sustaining multiple concussions over one's lifetime may be associated with behavioral and mood changes beyond the acute phase of injury. The present cross-sectional study examined the relationship between concussion history, the incidence of current moderate-severe psychological distress, and lifetime adolescent hazardous gambling in high school students.

METHODS

Four-hundred fifty-nine high school students from southern Sweden (age: 16.81 ± 0.83, 58.2% male) completed a survey assessing concussion history (0,1,2…>8), psychological distress using the Kessler-6 scale, and lifetime hazardous gambling using the NODS-CLiP scale.

RESULTS

Participants who self-reported three or more concussions were more likely to endorse moderate-severe symptoms of psychological distress than those with no concussion history while controlling for covariates, OR = 2.71, 95% CI [1.19, 6.18]. In contrast, concussion history was not associated with hazardous gambling after controlling for confounding variables.

CONCLUSIONS

Self-reporting three or more concussions was associated with increased current psychological distress beyond the acute phase of injury among high school students. Adolescents who have sustained multiple concussions should undergo mental health evaluations beyond the acute phase of injury to identify and treat psychological distress, but probing for hazardous gambling may not be clinically relevant in this previously concussed adolescent population.

Examining Acute Symptoms After Sport-Related Concussion in Collegiate Athletes With Preinjury Migraines

OBJECTIVE

To examine whether a personal history of migraines is associated with worse acute symptom burden after sport-related concussion (SRC).

DESIGN

Retrospective cohort study.

SETTING

National Collegiate Athletic Association Division III collegiate programs.

PARTICIPANTS

Collegiate athletes from a prospective concussion surveillance system between 09, 2014, and 01, 2023.

INTERVENTION

Preinjury migraines (yes/no) were self-reported by athletes.

MAIN OUTCOME MEASURES

Post-Concussion Symptom Scale (PCSS) were collected within 3 days postinjury. Mann-Whitney U tests compared total PCSS scores and individual symptom scores between athletes with and without preinjury migraines. Chi-squared tests were used to compare proportions of athletes endorsing individual symptoms (ie, item score ≥1) between 2 groups. Multivariable regression analyzed potential predictors of PCSS scores.

RESULTS

Of 1190 athletes with SRC, 93 (7.8%) reported a preinjury history of migraines. No significant difference in total PCSS scores was found between athletes with and without preinjury migraines (22.0 ± 16.4 vs 20.5 ± 15.8, U = 48 719.0, P = 0.471). Athletes with preinjury migraines reported greater severity of "sensitivity to light" (1.59 ± 1.59 vs 1.23 ± 1.41, P = 0.040) and "feeling more emotional" (0.91 ± 1.27 vs 0.70 ± 1.30; P = 0.008) and were more likely to endorse "feeling more emotional" (45.2% vs 29.5%, P = 0.002). No differences were found across all other symptoms, including headaches (migraine = 87.1% vs no migraine = 86.3%, P = 0.835). In a multivariable model, a history of migraine was not a significant predictor of acute PCSS scores, but those with a history of psychological disorders (β = 0.12, P <0 .001) and greater number of days to symptom evaluation (β = 0.08, P = 0.005) had higher PCSS scores.

CONCLUSIONS

Collegiate athletes with a pre-existing history of migraines did not have higher acute symptom burden after SRC.

Post-concussion Return to Shooting Progression for Military Service Members: A Scoping Review and Conceptual Framework

INTRODUCTION

There are established protocols for staged return to physical activity in sport and military settings following concussion. Currently, there is no evidence-based staged return to shooting protocol in use by the U.S. military despite the unique challenges and stresses shooting places on the vestibular-ocular and cognitive systems often disrupted by a concussion. The primary purpose of this scoping review was to summarize available evidence and current practices on return to shooting post-concussion, with the goal of optimizing an evidence-based return to shooting protocol for military service members. Our secondary aim was to identify individuals who may benefit from a return to shooting progression.

MATERIALS AND METHODS

A comprehensive search of PubMed, SPORTDiscus, and Google Scholar was performed from the earliest dates to April 2023. A gray literature (Google) search was also performed. Articles were included if they studied a population with concussion, addressed return to shooting, and were written in English. Articles were excluded if they discussed health conditions other than concussion, focused on non-shooting interventions, did not use human subjects, or were written in a language other than English.

RESULTS

Our search strategy yielded 134 articles: 1 article met our inclusion and exclusion criteria, whereas the other 133 articles were rejected. The gray literature search yielded one item.

CONCLUSIONS

Based on our results, there is insufficient evidence to inform current practices on return to shooting post-concussion. In the absence of a published return to shooting protocol, we offer recommendations for identifying individuals who may benefit from a return to shooting progression and a revised version of a U.S. Army Special Operations Command Return to Range Progression. This protocol follows a conceptual framework for progression for variables such as environment, weapon type/caliber, and shooter position/movement. Further research is needed on identifying individuals who may benefit from a return to shooting protocol and safely and effectively progressing these individuals through a return to shooting protocol post-concussion.

Clinical Trajectories of Comorbidity Associated With Military-Sustained Mild Traumatic Brain Injury: Pre- and Post-Injury

BACKGROUND AND OBJECTIVE

In the US military, traumatic brain injury (TBI) is of distinct importance, at home and in the deployed setting, and is considered a "signature injury of the wars in Afghanistan and Iraq." Since 2000, an estimated 468 424 service members (SMs) have been diagnosed with at least one TBI. We examined the clinical trajectories of a group of 18 comorbidities before and after a military-sustained mild TBI (mTBI).

METHODS

Without making assumptions on causality, a group of 18 conditions often co-occurring with mTBI were identified through literature review and TBI subject matter workgroup consensus. Using data from Military Health System Data Repository, we identified SMs whose first lifetime military mTBI occurred between October 1, 2016, and October 30, 2019. Correlation analyses were used to determine the linear relationship between comorbidities prior to and after mTBI diagnosis. Changes in the period prevalence of comorbidities was calculated.

RESULTS

We identified 42 018 SMs with a first lifetime military mTBI, of which 77.6% had at least one comorbidity. Identified SMs were mostly young (46.1% ages 18-24 years), male (81.4%), and White (64.1%). Up to 180 days prior to an mTBI, the most frequently identified conditions were sleep-related conditions (21.7%), headaches (19.4%), posttraumatic stress disorders (PTSDs) (17.8%), anxiety disorders (11.3%), and cervicogenic disorders (eg, cervicalgia) (10.9%). In the period following mTBI diagnosis, the prevalence of diagnosed conditions increased, especially for visual disturbances (327.2%), cognitive conditions (313.9%), vestibular conditions (192.6%), those related to headache (152.2%), and hearing (72.9%). Sleep-related conditions showed moderate positive correlation with a group of co-occurring conditions, led by cognitive conditions (ϕc = 0.50), anxiety disorders (ϕc = 0.42), PTSDs (ϕc =0.43), and headaches and related conditions (ϕc = 0.38).

CONCLUSION

Results indicate that caring for SMs with mild TBI requires a holistic approach, one that considers the complex nature of SM conditions, prior to sustaining their mTBI, as well as after injury. We found a complex correlation of conditions that suggest SMs with mTBI are undergoing a multifaceted experience, one that may require the development of a targeted multidimensional clinical practice recommendation and practice.

The Association Among Clinical Profiles, Modifiers, and Prolonged Recovery in Adolescents With Sport-Related Concussion

OBJECTIVE

The purposes were to (1) describe the prevalence of clinical profiles and modifiers, (2) examine the association between clinical profiles and prolonged recovery, and (3) examine the interaction between clinical profiles and modifiers and prolonged recovery in adolescents with sport-related concussion (SRC).

DESIGN

Retrospective, cross-sectional.

SETTING

Interdisciplinary specialty sports concussion clinic.

PATIENTS

Patients (n = 299) aged 12 to 19 years who were diagnosed with SRC within 30 days of injury.

INDEPENDENT VARIABLES

Clinical profiles and modifiers were decided by the clinical judgment of the clinical neuropsychologist and sports medicine physician, using data from the Clinical Profile Screen and information gathered from the clinical interview, neurocognitive, and vestibular and ocular motor testing.

MAIN OUTCOME MEASURES

Prolonged recovery was defined as ≥28 days from the date of injury to the date of clearance.

RESULTS

The most common clinical profiles were migraine (34.8%) and cognitive-fatigue (23.4%). There were no significant relationships between clinical profiles and prolonged recovery (Wald = 5.89, df = 4, P = 0.21). The presence of a modifier did not significantly affect the relationship between clinical profiles and prolonged recovery ( = 6.5, df = 5, P = 0.26). The presence of any modifier yielded a 10-day increase in median recovery time within the cognitive/fatigue clinical profile (Wilcoxon rank-sum = 268.5, P = 0.01).

CONCLUSIONS

Although patients with a clinical profile and modifier may not experience prolonged recovery, they may experience longer recovery time than patients with a clinical profile and no modifier.

Cognitive, Sleep-Arousal, Physical, and Affective Domain Scores on the Post-Concussion Symptom Scale: Added Utility in Detecting Symptom Elevations among Student-Athletes with a Remote History of Concussion

OBJECTIVE

The evaluation of self-reported symptoms is a standard component of concussion assessment and management. Clinicians typically evaluate a total symptom severity score rather than scores corresponding to specific symptom domains (i.e., cognitive, sleep-arousal, physical, and affective symptoms). This study examined (i) whether elevations in specific symptom domains would be missed when interpreting only the total symptom severity score and (ii) if a single symptom domain elevation was more common than having elevated symptoms across multiple domains.

METHOD

Adolescent student-athletes (N = 1,008) with concussion history (i.e., ≥6 months since last concussion) completed the Post-Concussion Symptom Scale (PCSS). The PCSS total score and cognitive, sleep-arousal, physical, and affective domain scores were calculated. To determine if symptoms were elevated, scores were compared to normative data matched on gender and pre-existing conditions, with scores considered elevated if they were ≥84th percentile. The frequency of total and domain score elevations were calculated and stratified by gender and number of prior concussions (i.e., 1 or ≥2 prior concussions).

RESULTS

Overall, 26% of student-athletes had an elevated symptom domain score without being elevated on the total score. The most common symptom presentation was to have a single elevated symptom domain (21%), followed by two (11%), three (8%), or four elevated domains (6%).

CONCLUSIONS

Interpreting PCSS symptom domains may be beneficial in detecting student-athletes with elevated symptoms following a remote concussion. Roughly a quarter of student-athletes have domain-specific symptom elevations that would be missed by interpreting the total score alone.

Nominal Differences in Acute Symptom Presentation and Recovery Duration of Sport-Related Concussion Between Male and Female Collegiate Athletes in the PAC-12

BACKGROUND

Sport-related concussion (SRC) is a heterogenous injury that often presents with varied symptoms and impairment. Recently, research has focused on identifying subtypes, or clinical profiles of concussion to be used in assessing and treating athletes with SRC. The purpose of this study was to investigate sex differences in clinical profiles, recovery duration, and initial symptom severity after SRC in a cohort of collegiate athletes in the Pacific-12 Conference (Pac-12).

METHODS

This prospective cohort study examined post-SRC symptoms, recovery, and return-to-play times using data from the Pac-12 CARE Affiliated Program and Pac-12 Health Analytics Program. Clinical profiles reported by student-athletes were defined by the number (> 50%) of specific symptoms frequently reported for each profile. Generalized linear mixed models were used to examine associations among sex, clinical profiles, time-to-recovery, and return-to-play times.

RESULTS

479 concussion incidents met inclusion criteria. The probabilities of initial presentation of each clinical profile, initial injury severity scores, and recovery times within a profile did not differ between sexes (p = 0.33-0.98). However, both males and females had > 0.75 probabilities of exhibiting cognitive and ocular profiles. Initial injury severity score was a strong nonlinear predictor of initial number of clinical profiles (p < 0.0001), which did not differ between sexes. The number of clinical profiles was also a nonlinear predictor of time-to-recovery (p = 0.03) and return-to-play times (p < 0.0001).

CONCLUSIONS

Initial symptom severity was strongly predictive of the number of acute clinical profiles experienced post-SRC. As the number of clinical profiles increased, time-to-recovery and time to return-to-play also increased. Factors other than sex may be better associated with acute symptom presentation post-concussion as no sex differences were found in reported clinical profiles or recovery. Understanding the number and type of clinical profiles experienced post-SRC may help inform concussion diagnostics and management.

The role of concussion history and biological sex on baseline concussion clinical profile symptoms in adolescent rugby players

BACKGROUND

Accurate concussion monitoring requires access to preinjury baseline data. This is particularly important in adolescent athletes who have a high risk of concussion and are prone to prolonged recovery. As Rugby Union is governed by similar laws for men and women, it is also an ideal population to rigorously examine the impact of biological sex on concussion symptoms.

AIMS

To evaluate self-reported concussion symptoms at baseline in adolescent rugby union players, and examine if subtype-specific symptoms are affected by concussion history and biological sex.

METHODS

Adolescent rugby union players aged 16-18 years were recruited during the 2022-2023 playing season. Participants completed a series of questionnaires covering post-concussion symptoms, concussion clinical profiles, anxiety, depression and fear avoidance behaviours. Independent variables of interest in analysis were biological sex and concussion history.

RESULTS

149 participants (75% male) were included. 42% (63/149) reported at least one previous concussion (average time since concussion: 18.7 months, range 1-72). Adolescents with a concussion history reported significantly higher scores than those with no history, across two clinical profiles (ocular and sleep), concussion symptom severity, and depression, all based on medium effect sizes (SMD 0.3-0.5). Females had significantly higher scores across cognitive/fatigue, ocular and sleep clinical profiles, concussion symptoms, anxiety and depression, each with large effect sizes (SMD > 0.5).

CONCLUSIONS

Concussion history and sex are associated with higher baseline scores on specific concussion clinical profile, concussion symptom severity, and anxiety symptoms. These findings highlight the importance of considering baseline differences when interpreting post-injury clinical profile symptoms in adolescent rugby players. (Trial registration: ACTRN12622000931774).

Impact of Sex and Pubertal Development on Anxiety in Adolescents After Concussion

Concussion often results in psychological symptoms, including anxiety. Post-concussion anxiety has been well documented, although much of this research has focused on collegiate athletes. The purpose of this study was to compare (1) anxiety symptoms in concussed and healthy controls over time and (2) to explore sex differences in post-concussion anxiety within the context of pubertal development. Participants (N = 126, mean age = 15.1 years old), including concussed (n = 86) and healthy adolescents (n = 40), completed the Pubertal Development Scale (PDS) and the Screen for Child Anxiety and Related Disorders (SCARED-C). The concussed groups completed SCARED-C at three visits (<10 days, 4 weeks, 3 months). Results of an analysis of covariance (ANCOVA) and multi-variate analysis of covariance (MANCOVA) found concussed adolescents reported higher SCARED-C total, generalized, and panic anxiety scores than healthy controls, after controlling for sex, age, and PDS score (PDSS). A three-way mixed ANCOVA examined the effects of sex, PDSS, time, and their interaction on SCARED-C total score in concussed adolescents while controlling for age. There was a significant three-way interaction between sex, age, and PDSS on SCARED-C total score while controlling for age. Overall, we observed increased anxiety in concussed adolescents, compared with controls, as well as greater post-concussion anxiety reported by females compared with males, including within PDSS groups. Concussion providers should be prepared to receive training to administer well-validated measures of psychopathology and should consider that female adolescents, compared with males, regardless of pubertal development, may be at greater risk for post-concussion anxiety.

The Role of Puberty and Sex on Brain Structure in Adolescents With Anxiety Following Concussion

BACKGROUND

Adolescence represents a window of vulnerability for developing psychological symptoms following concussion, especially in girls. Concussion-related lesions in emotion regulation circuits may help explain these symptoms. However, the contribution of sex and pubertal maturation remains unclear. Using the neurite density index (NDI) in emotion regulation tracts (left/right cingulum bundle [CB], forceps minor [FMIN], and left/right uncinate fasciculus), we sought to elucidate these relationships.

METHODS

No adolescent had a history of anxiety and/or depression. The Screen for Child Anxiety Related Emotional Disorders and Children's Depression Rating Scale were used at scan to assess anxiety and depressive symptoms in 55 concussed adolescents (41.8% girls) and 50 control adolescents with no current/history of concussion (44% girls). We evaluated if a mediation-moderation model including the NDI (mediation) and sex or pubertal status (moderation) could help explain this relationship.

RESULTS

Relative to control adolescents, concussed adolescents showed higher anxiety (p = .003) and lower NDI, with those at more advanced pubertal maturation showing greater abnormalities in 4 clusters: the left CB frontal (p = .002), right CB frontal (p = .011), FMIN left-sided (p = .003), and FMIN right-sided (p = .003). Across all concussed adolescents, lower NDI in the left CB frontal and FMIN left-sided clusters partially mediated the association between concussion and anxiety, with the CB being specific to female adolescents. These effects did not explain depressive symptoms.

CONCLUSIONS

Our findings indicate that lower NDI in the CB and FMIN may help explain anxiety following concussion and that adolescents at more advanced (vs less advanced) status of pubertal maturation may be more vulnerable to concussion-related injuries, especially in girls.

Traumatic Brain Injury in Mice Generates Early-Stage Alzheimer's Disease Related Protein Pathology that Correlates with Neurobehavioral Deficits

Traumatic brain injury (TBI) increases the long-term risk of neurodegenerative diseases, including Alzheimer's disease (AD). Here, we demonstrate that protein variant pathology generated in brain tissue of an experimental TBI mouse model is similar to protein variant pathology observed during early stages of AD, and that subacute accumulation of AD associated variants of amyloid beta (Aβ) and tau in the TBI mouse model correlated with behavioral deficits. Male C57BL/6 mice were subjected to midline fluid percussion injury or to sham injury, after which sensorimotor function (rotarod, neurological severity score), cognitive deficit (novel object recognition), and affective deficits (elevated plus maze, forced swim task) were assessed post-injury (DPI). Protein pathology at 7, 14, and 28 DPI was measured in multiple brain regions using an immunostain panel of reagents selectively targeting different neurodegenerative disease-related variants of Aβ, tau, TDP-43, and alpha-synuclein. Overall, TBI resulted in sensorimotor deficits and accumulation of AD-related protein variant pathology near the impact site, both of which returned to sham levels by 14 DPI. Individual mice, however, showed persistent behavioral deficits and/or accumulation of toxic protein variants at 28 DPI. Behavioral outcomes of each mouse were correlated with levels of seven different protein variants in ten brain regions at specific DPI. Out of 21 significant correlations between protein variant levels and behavioral deficits, 18 were with variants of Aβ or tau. Correlations at 28 DPI were all between a single Aβ or tau variant, both of which are strongly associated with human AD cases. These data provide a direct mechanistic link between protein pathology resulting from TBI and the hallmarks of AD.

CARE4Kids Study: Endophenotypes of Persistent Post-Concussive Symptoms in Adolescents: Study Rationale and Protocol

Treatment of youth concussion during the acute phase continues to evolve, and this has led to the emergence of guidelines to direct care. While symptoms after concussion typically resolve in 14-28 days, a portion (∼20%) of adolescents endorse persistent post-concussive symptoms (PPCS) beyond normal resolution. This report outlines a study implemented in response to the National Institute of Neurological Diseases and Stroke call for the development and initial clinical validation of objective biological measures to predict risk of PPCS in adolescents. We describe our plans for recruitment of a Development cohort of 11- to 17-year-old youth with concussion, and collection of autonomic, neurocognitive, biofluid, and imaging biomarkers. The most promising of these measures will then be validated in a separate Validation cohort of youth with concussion, and a final, clinically useful algorithm will be developed and disseminated. Upon completion of this study, we will have generated a battery of measures predictive of high risk for PPCS, which will allow for identification and testing of interventions to prevent PPCS in the most high-risk youth.

Perceptions of personal control and treatment efficacy of sport-related concussions in collegiate athletes

OBJECTIVE

The purpose of this study was to examine healthy collegiate athletes' perceptions of personal control and beliefs regarding the treatment efficacy related to sport-related concussion (SRC) along with identifying factors that may be associated with these perceptions.

METHODS

This cross-sectional study included collegiate athletes (n = 956) between the age of 18-26 years. Participants completed a 10- to 15-min survey regarding their demographics, diagnosed SRC history, SRC knowledge, and Perceptions of Concussion Inventory for Athletes (PCI-A). Chi-squared analysis and multivariable logistic regressions were conducted to identify factors associated with the PCI-A outcomes of personal control and treatment efficacy perceptions.

RESULTS

24.2% of respondents reported higher perceptions of personal control, while 77.3% reported higher perceptions of treatment efficacy. The multivariable logistic regression revealed males had higher odds of greater perceptions of personal control (OR = 1.50; 95% CI: 1.10-2.03), while those with a history of diagnosed SRC had lower odds of having favorable treatment efficacy beliefs (OR: 0.69; 95% CI: 0.50-0.96).

CONCLUSIONS

This study established that collegiate athletes generally have lower perceptions of personal control and higher perceptions of treatment efficacy related to SRC recovery. Comprehensive SRC education should be expanded for individuals to understand that they have power over their own health outcomes and that SRC is a treatable injury.

Estimating the Relationship Between the Symptom-Free Waiting Period and Injury Rates After Return-to-Play from Concussion: A Simulation Analysis Using CARE Consortium Data

BACKGROUND

A key component of return-to-play (RTP) from sport-related concussion is the symptom-free waiting period (SFWP), i.e., the period during which athletes must remain symptom-free before permitting RTP. Yet, the exact relationship between SFWP and post-RTP injury rates is unclear.

OBJECTIVE

We design computational simulations to estimate the relationship between the SFWP and rates of repeat concussion and non-concussion time-loss injury up to 30 days post-RTP for male and female collegiate athletes across 13 sports.

METHODS

We leverage N = 735 female and N = 1,094 male post-injury trajectories from the National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium.

RESULTS

With a 6-day SFWP, the mean [95% CI] rate of repeat concussion per 1,000 simulations was greatest in ice hockey for females (20.31, [20.16, 20.46]) and American football for males (24.16, [24.05, 24.28]). Non-concussion time-loss injury rates were greatest in field hockey for females (153.66, [152.59, 154.74]) and wrestling for males (247.34, [246.20, 248.48]). Increasing to a 13-day SFWP, ice hockey for females (18.88, [18.79, 18.98]) and American football for males (23.16, [23.09, 24.22]) exhibit the greatest decrease in repeat concussion rates across all sports within their respective sexes. Field hockey for females (143.24, [142.53, 143.94]) and wrestling for males (237.73, [236.67, 237.90]) exhibit the greatest decrease in non-concussion time-loss injury rates. Males receive marginally smaller reductions in injury rates for increased SFWP compared to females (OR = 1.003, p ≤ 0.002).

CONCLUSION

Longer SFWPs lead to greater reductions in post-RTP injury rates for athletes in higher risk sports. Moreover, SFWPs should be tailored to sport-specific post-RTP injury risks.

A Common Data Element-Based Adjudication Process for mTBI Clinical Profiles: A Targeted Multidomain Clinical Trial Preliminary Study

INTRODUCTION

The primary purpose of this study was to examine the prevalence and percent agreement of clinician-identified mild traumatic brain injury (mTBI) clinical profiles and cutoff scores for selected Federal Interagency Traumatic Brain Injury Research common data elements (CDEs). A secondary purpose was to investigate the predictive value of established CDE assessments in determining clinical profiles in adults with mTBI.

MATERIALS AND METHODS

Seventy-one (23 males; 48 females) participants (M = 29.00, SD = 7.60, range 18-48 years) within 1-5 months (M = 24.20, SD = 25.30, range 8-154 days) of mTBI completed a clinical interview/exam and a multidomain assessment conducted by a licensed clinician with specialized training in concussion, and this information was used to identify mTBI clinical profile(s). A researcher administered CDE assessments to all participants, and scores exceeding CDE cutoffs were used to identify an mTBI clinical profile. The clinician- and CDE-identified clinical profiles were submitted to a multidisciplinary team for adjudication. The prevalence and percent agreement between clinician- and CDE-identified clinical profiles was documented, and a series of logistic regressions with adjusted odds ratios were performed to identify which CDE assessments best predicted clinician-identified mTBI clinical profiles.

RESULTS

Migraine/headache, vestibular, and anxiety/mood mTBI clinical profiles exhibited the highest prevalence and overall percent agreement among CDE and clinician approaches. Participants exceeding cutoff scores for the Global Severity Index and Headache Impact Test-6 assessments were 3.90 and 8.81 times more likely to have anxiety/mood and migraine/headache profiles, respectively. The Vestibular/Ocular Motor Screening vestibular items and the Pittsburgh Sleep Quality Index total score were predictive of clinician-identified vestibular and sleep profiles, respectively.

CONCLUSIONS

The CDEs from migraine/headache, vestibular, and anxiety/mood domains, and to a lesser extent the sleep modifier, may be clinically useful for identifying patients with these profiles following mTBI. However, CDEs for cognitive and ocular may have more limited clinical value for identifying mTBI profiles.

Visuo-vestibular and cognitive connections of the vestibular neuromatrix are conserved across age and injury populations

BACKGROUND AND PURPOSE

Given the prevalence of vestibular dysfunction in pediatric concussion, there is a need to better understand pathophysiological disruptions within vestibular and associated cognitive, affective, and sensory-integrative networks. Although current research leverages established intrinsic connectivity networks, these are nonspecific for vestibular function, suggesting that a pathologically guided approach is warranted. The purpose of this study was to evaluate the generalizability of the previously identified "vestibular neuromatrix" in adults with and without postconcussive vestibular dysfunction to young athletes aged 14-17.

METHODS

This retrospective study leveraged resting-state functional MRI data from two sites. Site A included adults with diagnosed postconcussive vestibular impairment and healthy adult controls and Site B consisted of young athletes with preseason, postconcussion, and postseason time points (prospective longitudinal data). Adjacency matrices were generated from preprocessed resting-state data from each sample and assessed for overlap and network structure in MATLAB.

RESULTS

Analyses indicated the presence of a conserved "core" network of vestibular regions as well as areas subserving visual, spatial, and attentional processing. Other vestibular connections were also conserved across samples but were not linked to the "core" subnetwork by regions of interest included in this study.

CONCLUSIONS

Our results suggest that connections between central vestibular, visuospatial, and known intrinsic connectivity networks are conserved across adult and pediatric participants with and without concussion, evincing the significance of this expanded, vestibular-associated network. Our findings thus support this network as a workable model for investigation in future studies of dysfunction in young athlete populations.

Ocular motor disorders in children and adults with mTBI: a scoping review protocol

INTRODUCTION

Ocular motor function is susceptible to neurological injury because it requires a large portion of brain circuitry including every lobe of the brain, brainstem, thalamus, basal ganglia, cerebellum, cranial nerves and visual tracts. While reports of a high frequency of ocular motor dysfunctions after mild traumatic brain injury (mTBI) span multidisciplinary journals, there is no scoping review of the signs, diagnostic assessments and criteria, and appropriate management of ocular motor disorders post-mTBI. Post-mTBI ocular motor dysfunction has been reported to respond to active treatment. The objective of this scoping review is to map the available evidence on the diagnostic assessment and treatment modalities currently used in the management of mTBI-related ocular motor disorders in children and adults. This scoping review also aims to identify gaps in the current literature and provide suggestions for future research.

METHODS AND ANALYSIS

This review will include populations with reported concussion and/or mTBI without restrictions on age, race, sex or time since injury. The review will evaluate the reported symptoms related to ocular motor dysfunction, types of assessments and diagnostic criteria used, reported treatments, and the level of evidence supporting the reported treatments. This review will exclude literature on brain injury of non-traumatic aetiology and moderate/severe traumatic brain injury. Ocular motor dysfunction after mTBI appears in journals across multiple disciplines. Thus, multiple databases will be evaluated including Pubmed, Embase, PEDro, OVID, Clinical Key, Google Scholar and REHABDATA. Literature will be searched from inception to present day. Evidence sources will include experimental study designs including randomised controlled trials, non-randomised controlled trials and interrupted time-series. Additionally, analytical observational studies including prospective and retrospective cohort studies, case series, cross-sectional studies and clinical practice guidelines will be considered for inclusion. Data will be extracted on clinical presentation, frequency, assessment, diagnostic criteria management strategies and outcomes of concussion and mTBI-related ocular motor disorders.

ETHICS AND DISSEMINATION

This scoping review will use data from existing publications and does not require ethical approval by an institutional review board. Results will be disseminated through publication in a peer-reviewed scientific journal and presented at relevant conferences and as part of future workshops with professionals involved with diagnosis and management of patients with mTBI.

Vestibular perceptual testing from lab to clinic: a review

Not all dizziness presents as vertigo, suggesting other perceptual symptoms for individuals with vestibular disease. These non-specific perceptual complaints of dizziness have led to a recent resurgence in literature examining vestibular perceptual testing with the aim to enhance clinical diagnostics and therapeutics. Recent evidence supports incorporating rehabilitation methods to retrain vestibular perception. This review describes the current field of vestibular perceptual testing from scientific laboratory techniques that may not be clinic friendly to some low-tech options that may be more clinic friendly. Limitations are highlighted suggesting directions for additional research.

Concussion History and the Emotional and Behavioral Dyscontrol Domains of Health-Related Quality of Life in College Students

CONTEXT

Injury or illness can affect individual perceptions of health status and health-related quality of life (HRQOL). Concussion can result in different symptoms, impairments, and functional limitations that have been found to lower HRQOL. Furthermore, concussion is known to influence the emotional and behavioral dyscontrol domains of HRQOL in pediatric populations; however, this has yet to be explored in other populations.

OBJECTIVE

To compare individuals with and those without a concussion history and (1) HRQOL and (2) the emotional and behavioral dyscontrol domains of HRQOL in college students.

DESIGN

Cross-sectional study.

SETTING

University laboratory setting.

PATIENTS OR OTHER PARTICIPANTS

Of a total of 252 participants (155 women; age = 19.95 ± 1.53 years), 76 (30.2%) had a history of concussion and 176 (69.8%) did not. For participants with a history of concussion, the mean time since injury was 5.29 ± 2.77 years.

MAIN OUTCOME MEASURE(S)

The Patient-Reported Outcome Measures Information System (PROMIS) Global Health, version 1.1, and Quality of Life in Neurological Disorders Emotional and Behavioral Dyscontrol Short Form (Neuro-QOL).

RESULTS

No differences were seen between median scores in individuals with and those without a history of concussion in the PROMIS Physical Health (13.0 versus 14.0; P = .24), PROMIS Mental Health (12.0 versus 12.0; P = .99), and Neuro-QOL (16.0 versus 16.0; P = .47) scores. Additionally, when gender was controlled, the associations between a history of concussion and PROMIS Physical Health score (odds ratio [OR] = 1.04; 95% CI = 0.43, 2.52), PROMIS Mental Health score (OR = 0.66; 95% CI = 0.13, 3.25), and Neuro-QOL score (OR = 1.16; 95% CI = 0.66, 2.04) were not significant.

CONCLUSIONS

Preliminary findings suggested that the emotional and behavioral dyscontrol domains were not influenced by a concussion history of > 1 year in college-aged participants. Future researchers should continue to explore specific HRQOL domains affected by concussion as well as the influences of prior mental health conditions and behavioral dysfunction after a subsequent injury.

Changes in State and Trait Anxiety Throughout Concussion Recovery in High School- and College-Aged Individuals

CONTEXT

Researchers have indicated that individuals may experience anxiety symptoms after concussion. A potential mechanism for these presentations is shifts in anxiety throughout recovery.

OBJECTIVE

To examine the levels of state and trait anxiety in individuals after concussion throughout recovery compared with the levels in individuals serving as uninjured matched control participants.

DESIGN

Prospective cohort study.

SETTING

University laboratory.

PATIENTS OR OTHER PARTICIPANTS

Seventy-eight high school- and college-aged individuals (concussion group = 39, age = 18.4 ± 2.3 years; matched control group = 39, age = 18.4 ± 2.3 years) were enrolled.

MAIN OUTCOME MEASURE(S)

The State-Trait Anxiety Inventory was administered within 72 hours of injury (day 0: first test session), 5 days (±1 day) after the first test session (day 5), and at the time of full medical clearance (+2 days). Separate 2 × 3 repeated-measures analyses of variance were used to investigate differences in state and trait anxiety for each group throughout recovery.

RESULTS

State and trait anxiety were higher in the concussion group than in the control group at day 0, day 5, and full medical clearance. For state anxiety, we observed a group × time interaction (F2,150 = 10.45, P < .001, ƞp2 = 0.12). For trait anxiety, we did not note an interaction (F1.74,150 = 1.5, P = .22, ƞp2 = 0.02) but did find main effects for time (F1.74,150 = 25.7, P < .001, ƞp2 = 0.3) and group (F1,75 = 7.23, P = .01, ƞp2 = 0.09).

CONCLUSIONS

Participants with concussion experienced higher levels of state anxiety throughout recovery than matched control individuals. Although trait anxiety was higher in the concussion group and decreased over time, no interaction was seen, demonstrating that concussion may not affect this aspect of personality. Postinjury anxiety may result from increased state anxiety, and clinicians should screen for and manage these symptoms throughout recovery.

Effectiveness of interventions for the improvement of mental health and well-being post-concussion: a systematic review

OBJECTIVE

To identify and assess the effectiveness and quality of interventions targeted at improving mental health, well-being, and psychosocial impairments post-concussion.

DATA SOURCES

EBSCOHost, SPORTSDiscus, PsychINFO, Medline (Web of Science), PubMed, and Embase databases.

REVIEW METHODS

This systematic review is reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement in exercise, rehabilitation, sport medicine and sports science (PERSiST). Articles were included if they: (1) were randomized controlled trials or repeated measures pre-posttest study designs, (2) reported mild traumatic brain injury (mTBI) or concussion injury, and (3) evaluated interventions targeting mental health, well-being, and psychosocial impairments post-injury.

RESULTS

Twenty-three studies were included which evaluated interventions targeting mental health, well-being, and psychosocial impairments post-concussion. Interventions included cognitive rehabilitation (n = 7), psychotherapy (n = 7), psychoeducational (n = 3), neurocognitive training (n = 4), neurocognitive training combined with cognitive rehabilitation (n = 1), and psychotherapy combined with cognitive rehabilitation (n = 1). The seven (100%) cognitive rehabilitation intervention studies and four of the five (80%) neurocognitive training intervention studies observed significant improvements in mental health and well-being outcomes.

CONCLUSIONS

Cognitive rehabilitation and neurocognitive training may be the most effective interventions for mental health and well-being impairments post-concussion. Researchers and clinicians should continue to explore the effectiveness of these interventions, specifically in populations most impacted by concussion (i.e. athletes).

Multisystem recovery after sport-related concussion in adolescent rugby players: a prospective study protocol

INTRODUCTION

Sport-related concussion is one of the most common injuries in adolescent rugby players with evidence of prolonged recovery in some concussed athletes. Concussion is a complex pathophysiological process that can affect a variety of subsystems with multifactorial presentation. Most research on adolescents recovery after concussion focuses on neurocognitive functioning and symptom outcomes over the short term. There is a need to explore concussion recovery over time across multiple subsystems in adolescent rugby players.

METHODS AND ANALYSIS

This prospective study will use sensorimotor and oculomotor outcomes in adolescent male and female rugby players aged 16-18 years. Players will be recruited from school or club rugby teams across the province of Ulster. Baseline assessment will be undertaken at the start of the playing season and will include questionnaires, Quantified Y Balance Test and Pupillary Light Reflex. Players who sustain a concussive event will be reassessed on all outcomes at 3 days, 7 days, 14 days, 23 days, 90 days, 180 days and 365 days postconcussion. For serial outcome data, we will examine response curves for each participant and make comparisons between known groups. We will use logistic regression to explore any association between demographic variables and recovery. The strength of the predictive model will be determined using R2, p values and ORs, with 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been granted for this study from Ulster University Research Ethics Committee (REC/14/0060). This study will be published in an open-access research journal on completion.

TRIAL REGISTRATION NUMBER

ACTRN12622000931774p.

The National Football League and traumatic brain injury: blood-based evaluation at the game

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Emotional Regulation and Adolescent Concussion: Overview and Role of Neuroimaging

Emotional dysregulation symptoms following a concussion are associated with an increased risk for emotional dysregulation disorders (e.g., depression and anxiety), especially in adolescents. However, predicting the emergence or worsening of emotional dysregulation symptoms after concussion and the extent to which this predates the onset of subsequent psychiatric morbidity after injury remains challenging. Although advanced neuroimaging techniques, such as functional magnetic resonance imaging and diffusion magnetic resonance imaging, have been used to detect and monitor concussion-related brain abnormalities in research settings, their clinical utility remains limited. In this narrative review, we have performed a comprehensive search of the available literature regarding emotional regulation, adolescent concussion, and advanced neuroimaging techniques in electronic databases (PubMed, Scopus, and Google Scholar). We highlight clinical evidence showing the heightened susceptibility of adolescents to experiencing emotional dysregulation symptoms following a concussion. Furthermore, we describe and provide empirical support for widely used magnetic resonance imaging modalities (i.e., functional and diffusion imaging), which are utilized to detect abnormalities in circuits responsible for emotional regulation. Additionally, we assess how these abnormalities relate to the emotional dysregulation symptoms often reported by adolescents post-injury. Yet, it remains to be determined if a progression of concussion-related abnormalities exists, especially in brain regions that undergo significant developmental changes during adolescence. We conclude that neuroimaging techniques hold potential as clinically useful tools for predicting and, ultimately, monitoring the treatment response to emotional dysregulation in adolescents following a concussion.

Neurophysiological Markers to Guide Return to Sport After Sport-Related Concussion

SUMMARY

Sport-related concussion (SRC) has been defined as a subset of mild traumatic brain injury (mTBI), without structural abnormalities, reflecting a functional disturbance. Over the past decade, SRC has gained increasing awareness and attention, which coincides with an increase in incidence rates. Because this injury has been considered one of the most challenging encounters for clinicians, there is a need for objective biomarkers to aid in diagnosis (i.e., presence/severity) and management (i.e., return to sport) of SRC/mTBI.The primary aim of this article was to present state-of-the-art neurophysiologic methods (e.g., electroencephalography, magnetoencephalography, transcranial magnetic stimulation, and autonomic nervous system) that are appropriate to investigate the complex pathophysiological process of a concussion. A secondary aim was to explore the potential for evidence-based markers to be used in clinical practice for SRC management. The article concludes with a discussion of future directions for SRC research with specific focus on clinical neurophysiology.

Sleep/Wake Disorders After Sports Concussion: Risks, Revelations, and Interventions

SUMMARY

Sleep-wake disturbances (SWDs) are among the most prevalent, persistent, and often disregarded sequelae of traumatic brain injury. Identification and treatment of SWDs in patients with traumatic brain injury is important and can complement other efforts to promote maximum functional recovery. SWDs can accentuate other consequences of traumatic brain injury, negatively affect mood, exacerbate pain, heighten irritability, and diminish cognitive abilities and the potential for recovery. The risk for sports injuries increases when athletes are sleep deprived. Sleep deprivation increases risk-taking behaviors, predisposing to injuries. SWDs are an independent risk factor for prolonged recovery after sports-related concussion. SWDs following sports-related concussion have been shown to impede recovery, rehabilitation, and return to preinjury activities.

Targeted multidomain intervention for complex mTBI: protocol for a multisite randomized controlled trial in military-age civilians

Background

Mild traumatic brain injury (mTBI) affects ~18,000 military personnel each year, and although most will recover in 3-4 weeks, many experience persisting symptoms and impairment lasting months or longer. Current standard of care for U.S. military personnel with complex mTBI involves initial (<48 h) prescribed rest, followed by behavioral (e.g., physical activity, sleep regulation, stress reduction, hydration, nutrition), and symptom-guided management. There is growing agreement that mTBI involves different clinical profiles or subtypes that require a comprehensive multidomain evaluation and adjudication process, as well as a targeted approach to treatment. However, there is a lack of research examining the effectiveness of this approach to assessing and treating mTBI. This multisite randomized controlled trial (RCT) will determine the effectiveness of a targeted multidomain (T-MD) intervention (anxiety/mood, cognitive, migraine, ocular, vestibular; and sleep, autonomic) compared to usual care (behavioral management) in military-aged civilians with complex mTBI.

Methods

This study employs a single-blinded, two-group repeated measures design. The RCT will enroll up to 250 military-aged civilians (18-49 yrs) with a diagnosed complex mTBI within 8 days to 6 months of injury from two concussion specialty clinics. The two study arms are a T-MD intervention and a usual care, behavioral management control group. All participants will complete a comprehensive, multidomain clinical evaluation at their first clinical visit. Information gathered from this evaluation will be used to adjudicate mTBI clinical profiles. Participants will then be randomized to either the 4-week T-MD or control arm. The T-MD group will receive targeted interventions that correspond to the patient's clinical profile (s) and the control group will receive behavioral management strategies. Primary outcomes for this study are changes from enrollment to post-intervention on the Neurobehavioral Symptom Inventory (NSI), Patient Global Impression of Change (PGIC), and functional near-infrared spectroscopy (fNIRS). Time to return to activity (RTA), and healthcare utilization costs will also be assessed.

Discussion

Study findings may inform a more effective approach to treat complex mTBI in military personnel and civilians, reduce morbidity, and accelerate safe return-to-duty/activity.

Ethics and dissemination

The study is approved by the University of Pittsburgh Institutional Review board and registered at clinicaltrials.gov. Dissemination plans include peer-reviewed publications and presentations at professional meetings.

Clinical Trial Registration

www.clinicaltrials.gov, identifier: NCT04549532.

Traumatic brain injury in mice generates early-stage Alzheimer's disease related protein pathology that correlates with neurobehavioral deficits

Traumatic brain injury (TBI) increases the long-term risk of neurodegenerative diseases, including Alzheimer's disease (AD). Here, we demonstrate that protein variant pathology generated in brain tissue of an experimental TBI mouse model is similar to protein variant pathology observed in human ADbrains, and that subacute accumulation of two AD associated variants of amyloid beta (Aβ) and tau in the TBI mouse model correlated with behavioral deficits. Male C57BL/6 mice were subjected to midline fluid percussion injury or to sham injury, after which sensorimotor function (rotarod, neurological severity score), cognitive deficit (novel object recognition), and affective deficits (elevated plus maze, forced swim task) were assessed at different days post-injury (DPI). Protein pathology at 7, 14, and 28 DPI was measured in multiple brain regions using an immunostain panel of reagents selectively targeting different neurodegenerative disease-related variants of Aβ, tau, TDP-43, and alpha-synuclein. Overall, TBI resulted in sensorimotor deficits and accumulation of AD-related protein variant pathology near the impact site, both of which returned to sham levels by 14 DPI. Individual mice, however, showed persistent behavioral deficits and/or accumulation of selected toxic protein variants at 28 DPI. Behavioral outcomes of each mouse were correlated with levels of seven different protein variants in ten brain regions at specific DPI. Out of 21 significant correlations between protein variant levels and behavioral deficits, 18 were with variants of Aβ or tau. Correlations at 28 DPI were all between a single Aβ or tau variant, both of which are strongly associated with human AD cases. These data provide a direct mechanistic link between protein pathology resulting from TBI and the hallmarks of AD.

Primary and Secondary Risk Factors Associated With Concussion Symptom Clusters in Collegiate Athletes: Results From the NCAA-DoD Grand Alliance CARE Consortium

Background

There is a broad and diverse range of symptoms after a concussion, from irritability to nausea. This heterogeneity of symptoms is a challenge for clinicians managing the different presentations among injuries. Prior research has investigated the structure of postconcussive symptoms to determine if they can be grouped into clusters of related symptoms.

Purpose/Hypothesis

The purpose of this study was to identify symptom clusters during the acute phase after a sports-related concussion using exploratory factor analysis and to understand the relationship between risk factors for postconcussion symptoms (ie, demographics, injury characteristics, mental health, and sleep qualities) and different symptom clusters. We hypothesized that certain factors would be predictive of specific symptom clusters.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Collegiate athletes (N = 1104) from the Concussion, Assessment, Research, and Education (CARE) Consortium completed the Sport Concussion Assessment Tool-Third Edition symptom assessment tool 24 to 48 hours after concussion. Exploratory factor analysis was conducted on the symptom evaluation to determine symptom clusters 24 to 48 hours after concussion. Regression analysis was used to examine the effects of pre- and postinjury characteristics.

Results

Exploratory factor analysis revealed a 4-cluster structure for acute postconcussive symptoms that explained 62% of the variance in symptom reporting: vestibular-cognitive, migrainous, cognitive fatigue, and affective. Delayed reporting, less sleep before assessment, female sex, and being hurt outside of competition (during practice/training) was correlated with increased symptoms for 4 symptom clusters. Depression predicted higher vestibular-cognitive and affective symptoms. Amnesia was correlated with higher vestibular-cognitive and migrainous symptoms, whereas migraine history was associated with more migrainous and affective symptoms.

Conclusion

Symptoms can be grouped into 1 of 4 distinct clusters. Certain variables were associated with increased symptoms across multiple clusters and may be indicative of greater injury severity. Other factors (ie, migraine history, depression, amnesia) were associated with a more specific symptom presentation and may be mechanistically related to concussion outcomes and biological markers.

The Implementation of a Return-to-Play Protocol with Standardized Physical Therapy Referrals in a Collegiate Football Program: PT's Role in Return-to-Play, A Clinical Commentary

Sport-related concussions (SRCs) are multi-faceted injuries requiring coordinated care for return-to-play (RTP). Although the number of concussions in collegiate football is increasing annually, there is poor standardization among RTP protocols. Recent evidence suggests there is an increased risk of lower extremity injury, neuropsychiatric consequences, and re-injury after SRC, and risk factors for a prolonged recovery from SRC have also been identified. Evidence demonstrates a faster RTP and improved outcomes with early physical therapy intervention; however, this is not yet common practice in the treatment of acute SRC. There is little guidance available on the development and implementation of a multidisciplinary RTP rehabilitation protocol for SRC that incorporates standardized physical therapy. By describing an evidence-based RTP protocol with standardized physical therapy management, and measures taken to implement this protocol, this clinical commentary aims to identify steps in treating SRC that can be used to improve recovery. The purpose of this commentary is to: a) survey the current state of standardization of RTP protocols in collegiate football; b) highlight the development and implementation of a RTP protocol with standardized physical therapy referral and management in an NCAA Division II collegiate football program; and c) describe results of a full-season pilot study, including time to evaluation, time to RTP, rate of re-injury or lower extremity injury, and the clinical significance of protocol implementation.

Level of Evidence

Level V.

Combined Neurocognitive and Exercise Tolerance Testing Improves Objectivity of Buffalo Concussion Treadmill Test

CONTEXT

The Buffalo Concussion Treadmill Test (BCTT) is a standard assessment of exercise tolerance utilized for exercise prescription following concussion and to inform decisions regarding return to play. One limitation of the BCTT is that interpretation of test results is dependent on individuals' self-report of symptom exacerbation with exertion. Symptoms following concussion are significantly underreported or unreported. Combining objective neurocognitive assessment with exercise tolerance testing may enable clinicians to objectively identify those requiring further assessment or rehabilitation before return to play. The purpose of this study was to investigate how performance on a neurocognitive assessment battery is affected by provocative exercise testing.

DESIGN

Prospective cohort study, pretest/posttest.

METHODS

A total of 30 participants included 13 women (43.3%), age 23.4 (1.93) years, height 173.56 (10) cm, weight 77.35 (16.3) kg, and 11 (36.7%) with history of concussion. All participants completed a neurocognitive assessment battery, including the Stroop Test and standardized assessments of working memory, attention, and information processing speed/accuracy in single-task (seated position) and dual-task conditions (walking on a treadmill at 2.0 miles per hour). The neurocognitive assessment battery was performed at baseline and after the standard BCTT test protocol.

RESULTS

BCTT: Average percentage of heart rate maximum (%HRmax) = 93.97% (4.8%); average maximum rating of perceived exertion = 18.6 (1.5). Time-based performance in single-task and dual-task conditions significantly improved from baseline (P < .05) following maximal exercise testing on the BCTT for the following neurocognitive assessments: concentration-reverse digits, Stroop congruent, and Stroop incongruent.

CONCLUSIONS

Healthy participants demonstrated improvements across multiple domains of neurocognitive performance following the exercise tolerance testing on the BCTT. Understanding normal responses in neurocognitive performance for healthy individuals following exercise tolerance testing may allow clinicians to more objectively monitor the trajectory of recovery following sports-related concussion.

Concussion in Ladies Gaelic Football: Self-reported History, Clinical Profiles, and Management Behavior

OBJECTIVE

To describe the prevalence, characteristics, and management behavior of self-reported sport-related concussion (SRC) in Ladies Gaelic Football (LGF) players.

DESIGN

Cross-sectional study.

SETTING

Online survey distributed to LGF clubs throughout Ireland.

PARTICIPANTS

Elite and nonelite adult LGF players (n = 657).

INTERVENTIONS

Participants were recruited by convenience sampling and answered an online survey. Questions on demographic characteristics, SRC history, symptoms, injury characteristics, and management behavior after SRCs that occurred while playing LGF during the previous season were included.

MAIN OUTCOME MEASURES

Overall concussion history, occurrence of an SRC during the previous LGF season, clinical profile scores, characteristics (eg mechanism and setting), and management behavior (eg following a graded RTP program) after SRCs that occurred during the previous season.

RESULTS

Approximately one-fifth (17.5%) of participants sustained a suspected or diagnosed SRC during the previous season, which was higher among elite (26.1%) than nonelite (15.3%) players ( P < 0.01). The highest scoring clinical profiles were the ocular and migraine profiles. Only 3.5% of respondents adhered to all SRC management recommendations. Although players who reported a medically diagnosed versus a suspected SRC more often followed these guidelines, SRC management beyond the initial phase of injury remained inadequate.

CONCLUSION

SRC is common in LGF; however, adherence to recommended management guidelines is poor, even among players who receive medical assistance. In particular, few LGF athletes receive clinical concussion care beyond the initial diagnosis and acute management phase. Further research is needed to examine the underlying reasons for poor SRC management in LGF, which will guide the development of future sport-specific interventions.

Understanding racial differences in computerized neurocognitive test performance and symptom-reporting to deliver culturally competent patient-centered care for sport-related concussion

OBJECTIVE

This study examined neurocognitive performance and symptoms between concussed Black and White collegiate athletes at baseline, post-injury, and change from baseline to post-injury.

METHOD

The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) was used to measure neurocognitive performance and four concussion symptom clusters for 235 concussed collegiate athletes. Between-groups differences were documented at baseline and post-injury, along with change in scores for sex/race, and sport/race groups, using ANOVAs. Baseline scores, and days-to-post-test were covariates in post-injury comparisons. Symptom endorsement by race was evaluated using chi-square analyses.

RESULTS

At baseline, group comparisons by race and sex showed that Black male/female athletes scored lower on reaction time (RT; p = .008), White females scored higher on verbal memory (VerbMem; p = .001), Black females scored lower on visual motor processing speed (VMS; p = .001), and Black football athletes scored slower/poorer on RT (p = .001) and VMS (p = .006). Post-injury, Black males scored lower on visual memory (VisMem; p = .005) and VMS (p = .002), and Black football athletes scored slower on VMS (p = .005), whereas White non-football athletes scored higher on VerbMem (p = .002) and reported fewer symptoms. Significant time-by-sport/race interactions were found for VerbMem (p < .001), VisMem (p < .001) and reported symptoms. With respect to post-injury symptom scores/endorsement, Black athletes scored significantly higher for physical (p = .01) and sleep (p = .01) symptoms.

CONCLUSION

These findings drive the conversation of how subjective measures of symptoms, and objective clinical concussion measures, may relate to the concussion recovery process and providing a culturally competent clinical management approach for diverse patients.

Sex Differences on the Concussion Clinical Profiles Screening in Adolescents With Sport-Related Concussion

CONTEXT

Sex differences influence symptom presentations after sport-related concussion and may be a risk factor for certain concussion clinical profiles.

OBJECTIVE

To examine sex differences on the Concussion Clinical Profile Screen (CP Screen) in adolescents after sport-related concussion.

DESIGN

Cross-sectional study.

SETTING

A concussion specialty clinic.

PATIENTS OR OTHER PARTICIPANTS

A total of 276 adolescent (age = 15.02 ± 1.43 years; girls = 152 [55%]) athletes with a recently diagnosed concussion (≤30 days).

MAIN OUTCOME MEASURE(S)

The 5 CP Screen profiles (anxiety mood, cognitive fatigue, migraine, vestibular, ocular) and 2 modifiers (neck, sleep), symptom total, and symptom severity scores were compared using a series of Mann-Whitney U tests between boys and girls.

RESULTS

Girls (n = 152) scored higher than boys (n = 124) on the cognitive fatigue (U = 7160.50, z = -3.46, P = .001) and anxiety mood (U = 7059, z = -3.62, P < .001) factors but not on the migraine (U = 7768, z = -2.52, P = .01) factor. Girls also endorsed a greater number of symptoms (n = 124; U = 27233, z = -3.33, P = .001) and scored higher in symptom severity (U = 7049, z = -3.60, P < .001) than boys.

CONCLUSIONS

Among adolescents, symptom endorsement on the CP Screen varied based on sex, and clinicians need to be aware of these differences, especially when evaluating postconcussion presentation in the absence of baseline data.

Symptom Provocation Following Post-concussion Computerized Neurocognitive Testing and Its Relationship to Other Clinical Measures of Concussion

OBJECTIVE

The objective of this study was to document the prevalence of post-computerized neurocognitive test (post-CNT) increases in symptoms in athletes with sport-related concussion, and to examine the effect of post-CNT symptom increases on concussion neurocognitive and vestibular/ocular motor clinical outcomes.

METHODS

This was a retrospective analysis of medical records from a concussion specialty clinic. Two hundred and three athletes (M = 16.48 ± 1.97 years; 44% [90/203] female) completed a clinical visit for concussion within 30 days of injury (M = 7.73 ± 5.54 days). Computerized neurocognitive testing (the Immediate Post-concussion Assessment and Cognitive Testing: ImPACT), the Post-Concussion Symptom Scale (PCSS), and the Vestibular Ocular Motor Screening (VOMS) were the main outcome measures for the current study.

RESULTS

Sixty-nine percent (141/203) of the sample did not report significant increases in PCSS scores following post-concussion CNT and were classified into a No Provocation (NO PROV) group. Thirty-one percent (62/203) of participants did report a significant increase in symptoms following post-concussion CNT and were classified into a Provocation (PROV) group. Neurocognitive performance was similar between groups. However, the PROV group reported significantly higher scores on the VOMS symptom items than the NO PROV group.

CONCLUSIONS

The majority of adolescent athletes can complete a post-concussion CNT without experiencing significant increases in concussion symptoms. Individuals that report symptom increases from completing a post-concussion CNT are more likely to exhibit increased vestibular/ocular motor symptoms. These findings underscore the relationship between the clinical findings from both CNT and vestibular/ocular motor measures following concussion.

Is Overparenting Associated with Adolescent/Young Adult Emotional Functioning and Clinical Outcomes Following Concussion?

Overparenting (O-P), or "helicopter" parenting, has warranted increased attention across the past decade. It is characterized as being overly involved, protective, and low on granting autonomy, and is associated with deleterious psychosocial outcomes outside of the concussion literature. This study examined the association of overparenting and patient emotional distress and clinical outcomes (i.e., symptoms, neurocognitive test scores, recovery time) post-concussion. Adolescents/young adult concussion patients (injury < 30 days) and parents (N = 101 child-parent dyads) participated. Patient participants completed measures of depression, anxiety, stress, and concussion clinical outcomes while parents concurrently completed an overparenting measure. Results of a general linear model found that overparenting was associated with higher anxiety and stress report of the child. Overparenting had a significant positive correlation with concussion recovery, although of a small magnitude. Emotional distress level, but not overparenting, was moderately associated with worse performance on clinical outcomes, including neurocognitive testing, vestibular/ocular motor dysfunction, and concussion symptom severity.

Clusters of conditions among US service members diagnosed with mild TBI from 2017 through 2019

Background

Many US Military Service Members (SMs) newly diagnosed with mild Traumatic Brain Injury (mTBI) may exhibit a range of symptoms and comorbidities, making for a complex patient profile that challenges clinicians and healthcare administrators. This study used clustering techniques to determine if conditions co-occurred as clusters among those newly injured with mTBI and up to one year post-injury.

Methods

We measured the co-occurrence of 41 conditions among SMs diagnosed with mTBI within the acute phase, one or three months post-mTBI diagnosis, and chronic phase, one year post-mTBI diagnosis. Conditions were identified from the literature, clinical subject matter experts, and mTBI care guidelines. The presence of conditions were based on medical encounters recorded within the military health care data system. Through a two-step approach, we identified clusters. Principal component analysis (PCA) determined the optimal number of clusters, and hierarchical cluster analyses (HCA) identified the composition of clusters. Further, we explored how the composition of these clusters changed over time.

Results

Of the 42,018 SMs with mTBI, 23,478 (55.9%) had at least one condition of interest one-month post-injury, 26,831 (63.9%) three months post-injury, and 29,860 (71.1%) one year post injury. Across these three periods, six clusters were identified. One cluster included vision, cognitive, ear, and sleep disorders that occurred one month, three months, and one year post-injury. Another subgroup included psychological conditions such as anxiety, depression, PTSD, and other emotional symptoms that co-occurred in the acute and chronic phases post-injury. Nausea and vomiting symptoms clustered with cervicogenic symptoms one month post-injury, but later shifted to other clusters. Vestibular disorders clustered with sleep disorders and headache disorders one-month post-injury and included numbness and neuropathic pain one year post-injury. Substance abuse symptoms, alcohol disorders, and suicidal attempt clustered one year post-injury in a fifth cluster. Speech disorders co-occurred with headache disorders one month and one year post-injury to form a sixth cluster.

Conclusion

PCA and HCA identified six distinct subgroups among newly diagnosed mTBI patients during the acute and chronic phases post-injury. These subgroups may help clinicians better understand the complex profile of SMs newly diagnosed with mTBI.

Effects of docosahexaenoic acid and eicosapentaoic acid supplementation on white matter integrity after repetitive sub-concussive head impacts during American football: Exploratory neuroimaging findings from a pilot RCT

Context

Repetitive sub-concussive head impacts (RSHIs) are common in American football and result in changes to the microstructural integrity of white matter. Both docosahexaenoic acid (DHA) and eicosapentaoic acid (EPA) supplementation exerted neuroprotective effects against RSHIs in animal models and in a prior study in football players supplemented with DHA alone.

Objective

Here, we present exploratory neuroimaging outcomes from a randomized controlled trial of DHA + EPA supplementation in American football players. We hypothesized that supplementation would result in less white matter integrity loss on diffusion weighted imaging over the season.

Design setting participants

We conducted a double-blind placebo-controlled trial in 38 American football players between June 2019 and January 2020.

Intervention

Participants were randomized to the treatment (2.442 g/day DHA and 1.020 g/day EPA) or placebo group for five times-per-week supplementation for 7 months. Of these, 27 participants were included in the neuroimaging data analysis (n = 16 placebo; n = 11 DHA + EPA).

Exploratory outcome measures

Changes in white matter integrity were quantified using both voxelwise diffusion kurtosis scalars and deterministic tractography at baseline and end of season. Additional neuroimaging outcomes included changes in regional gray matter volume as well as intra-regional, edge-wise, and network level functional connectivity. Serum neurofilament light (NfL) provided a peripheral biomarker of axonal damage.

Results

No voxel-wise between-group differences were identified on diffusion tensor metrics. Deterministic tractography using quantitative anisotropy (QA) revealed increased structural connectivity in ascending corticostriatal fibers and decreased connectivity in long association and commissural fibers in the DHA+EPA group compared to the placebo group. Serum NfL increases were correlated with increased mean (ρ = 0.47), axial (ρ = 0.44), and radial (ρ = 0.51) diffusivity and decreased QA (ρ = -0.52) in the corpus callosum and bilateral corona radiata irrespective of treatment group. DHA + EPA supplementation did preserve default mode/frontoparietal control network connectivity (g = 0.96, p = 0.024).

Conclusions

These exploratory findings did not provide strong evidence that DHA + EPA prevented or protected against axonal damage as quantified via neuroimaging. Neuroprotective effects on functional connectivity were observed despite white matter damage. Further studies with larger samples are needed to fully establish the relationship between omega-3 supplementation, RSHIs, and neuroimaging biomarkers.

Trial registration

ClinicalTrials.gov-NCT04796207.

Interdisciplinary Rehabilitation for Concussion Recovery (i-RECOveR): protocol of an investigator-blinded, randomised, case series with multiple baseline design to evaluate the feasibility and preliminary efficacy of a 12-week treatment for persistent post-concussion symptoms

BACKGROUND

Up to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored.

METHODS

Fifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews.

DISCUSSION

Results from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes.

TRIAL REGISTRATION

ANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118.

Characterizing the evolution of oculomotor and vestibulo-ocular function over time in children and adolescents after a mild traumatic brain injury

Background

Impairments to oculomotor (OM) and vestibulo-ocular reflex (VOR) function following pediatric mTBI have been demonstrated but are poorly understood. Such impairments can be associated with more negative prognosis, affecting physical and mental wellbeing, emphasizing the need to more fully understand how these evolve.

Objectives

to determine i) the extent to which performance on clinical and computerized tests of OM and VOR function varies over time in children and adolescents at 21 days, 3-, and 6-months post-mTBI; ii) the proportion of children and adolescents with mTBI presenting with abnormal scores on these tests at each timepoint.

Design

Prospective longitudinal design.

Setting

Tertiary care pediatric hospital.

Participants

36 participants with mTBI aged 6 to18.

Procedures

Participants were assessed on a battery of OM and VOR tests within 21 days, at 3- and 6-months post injury.

Outcome measures

Clinical measures: Vestibular/ocular motor screening tool (VOMS) (symptom provocation and performance); Computerized measures: reflexive saccade test (response latency), video head impulse test (VOR gain), and dynamic visual acuity test (LogMAR change).

Analysis

Generalized estimating equations (parameter estimates and odd ratios) estimated the effect of time. Proportions above and below normal cut-off values were determined.

Results

Our sample consisted of 52.8% females [mean age 13.98 (2.4) years, assessed on average 19.07 (8–33) days post-injury]. Older children performed better on visual motion sensitivity (OR 1.43, p = 0.03) and female participants worse on near point of convergence (OR 0.19, p = 0.03). Change over time (toward recovery) was demonstrated by VOMS overall symptom provocation (OR 9.90, p = 0.012), vertical smooth pursuit (OR 4.04, p = 0.03), voluntary saccade performance (OR 6.06, p = 0.005) and right VOR gain (0.068, p = 0.013). Version performance and VOR symptom provocation showed high abnormal proportions at initial assessment.

Discussion

Results indicate impairments to the VOR pathway may be present and driving symptom provocation. Vertical smooth pursuit and saccade findings underline the need to include these tasks in test batteries to comprehensively assess the integrity of OM and vestibular systems post-mTBI.

Implications

Findings demonstrate 1) added value in including symptom and performance-based measures in when OM and VOR assessments; 2) the relative stability of constructs measured beyond 3 months post mTBI.

Return-to-Activity: Exploration of Occupational Therapy in Outpatient Adult Concussion Rehabilitation

Literature is sparse related to how occupational therapy advances symptom management and role-activity resumption after concussion. We aim to describe the occupational therapy process of evaluation and intervention for adults with a history of concussion(s) and persisting symptoms. The qualitative descriptive study used focus groups of expert occupational therapy practitioners across practice settings. Content analysis with a deductive strategy, open coding, and an unconstrained matrix was used to determine the process portion of a logic model outlining how expert practitioners framed their approach to rehabilitation. Thirteen expert occupational therapy practitioners informed the development of a logic model describing the occupational therapy process linking resources to activities of evaluation and intervention enabling people to return to their everyday life roles at their highest capacity. This study yields a description of how occupational therapy practitioners, across practice settings, aid individuals in returning to everyday activities and life roles after concussion(s).

Factor Structure for the Sport Concussion Assessment Tool Symptom Scale in Adolescents After Concussion

OBJECTIVE

To examine the factor structure of the Sport Concussion Assessment Tool-5 (SCAT5) symptom scale in adolescents on their initial presentation to a concussion clinic within the typical recovery period after concussion (ie, <30 days). We hypothesize that the SCAT5 symptoms represent various clinically meaningful groups. A secondary purpose was to examine the effects of sex on the factor structure of the SCAT5 symptom scale.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

Tertiary, institutional.

PATIENTS

Nine hundred eighty-one adolescents (45% women) aged between 13 and 18 years.

INDEPENDENT VARIABLES

Adolescents completed the SCAT5 symptom scale.

MAIN OUTCOME MEASURES

The factor structure of SCAT5 examined using a principal axis factor analysis.

RESULTS

A 5-factor structure model explained 61% of the variance in symptoms. These 5 factors are identified as Energy (17%), Mental Health (13%), Migrainous (13%), Cognitive (9%), and Vestibulo-Ocular (9%). A similar 5-factor model emerged for each sex, and the proportion of variance in symptoms explained by the 5-factor model was comparable between the sexes.

CONCLUSIONS

The findings of this report indicate that the SCAT5 symptoms aggregated into 5 delineated factors, and these factors were largely consistent across the sexes. The delineation of symptoms into 5 factors provides preliminary validation for the presence of different concussion phenotypes. Confirmatory factor analysis is warranted to examine the applicability and clinical utility of the use of the 5-factor structure in a clinical setting.

Characteristics of concussion subtypes from a multidomain assessment

OBJECTIVE

The aim of this study was to analyze the best combination of clinical variables associated with concussion subtypes using a multidomain assessment comprising medical history; symptoms; and cognitive, ocular, and vestibular impairment in a cohort of patients presenting to a concussion specialty clinic.

METHODS

Adolescent patients (n = 293) completed demographics and medical history, Concussion Clinical Profiles Screening, Immediate Post-Concussion Assessment and Cognitive Testing, and vestibular ocular motor screening at their first visit (mean 7.6 ± 7.8 days postinjury) to a concussion specialty clinic. Each participant was adjudicated to have one or more subtype (anxiety/mood, cognitive, migraine, ocular, and vestibular) by a healthcare professional based on previously published criteria. A series of backward, stepwise logistic regressions were used to identify significant predictors of concussion subtypes, and predictive probabilities from the logistic regression models were entered into area under the receiver operating characteristic curve (AUC) models.

RESULTS

Each of 5 logistic regression models predicting primary subtypes accounted for 28%-50% of the variance (R2 = 0.28-0.50, p < 0.001) and included 2-8 significant predictors per model. Each of the models significantly differentiated the primary subtype from all other subtypes (AUC = 0.76-0.94, p < 0.001).

CONCLUSIONS

These findings suggest that each concussion subtype can be identified using specific outcomes from a multidomain assessment. Clinicians can employ such an approach to better identify and monitor recovery from subtypes as well as guide interventions.

Defining Biological Phenotypes of Mild Traumatic Brain Injury Using Saliva MicroRNA Profiles

Concussion is a heterogeneous injury that relies predominantly on subjective symptom reports for patient assessment and treatment. Developing an objective, biological test could aid phenotypic categorization of concussion patients, leading to advances in personalized treatment. This prospective multi-center study employed saliva micro-ribonucleic acid (miRNA) levels to stratify 251 individuals with concussion into biological subgroups. Using miRNA biological clusters, our objective was to assess for differences in medical/demographic characteristics, symptoms, and functional measures of balance and cognition. The miRNAs that best defined each cluster were used to identify physiological pathways that characterized each cluster. The 251 participants (mean age: 18 ± 7 years; 57% male) were optimally grouped into 10 clusters based on 22 miRNA levels. The clusters differed in age (χ² = 19.1, p = 0.024), days post-injury at the time of saliva collection (χ² = 22.6; p = 0.007), and number of prior concussions (χ² = 17.6, p = 0.040). The clusters also differed in symptom reports for fatigue (χ² = 17.7; p = 0.039), confusion (χ² = 22.3; p = 0.008), difficulty remembering (χ² = 22.0; p = 0.009), and trouble falling asleep (χ² = 17.2; p = 0.046), but not objective balance or cognitive performance (p > 0.05). The miRNAs that defined concussion clusters regulate 16 physiological pathways, including adrenergic signaling, estrogen signaling, fatty acid metabolism, GABAergic signaling, synaptic vesicle cycling, and transforming growth factor (TGF)-β signaling. These results show that saliva miRNA levels may stratify individuals with concussion based on underlying biological perturbations that are relevant to both symptomology and pharmacological targets. If validated in a larger cohort, miRNA assessment could aid individualized, biology-driven concussion treatment.

Ambulatory Assessment in Concussion Clinical Care and Rehabilitation

Concussion is a mild traumatic brain injury that is characterized by a wide range of physical, emotional, and cognitive symptoms as well as neurocognitive, vestibular, and ocular impairments that can negatively affect daily functioning and quality of life. Clinical consensus statements recommend a targeted, clinical profile-based approach for management and treatment. This approach requires that clinicians utilize information obtained via a clinical interview and a multi-domain assessment battery to identify clinical profile(s) (e.g., vestibular, mood/anxiety, ocular, migraine, cognitive fatigue) and prescribe a corresponding treatment/rehabilitation program. Despite this comprehensive approach, the clinical picture can be limited by the accuracy and specificity of patient reports (which often conflate timing and severity of symptomology), as well as frequency and duration of exposure to symptom exacerbating environments (e.g., busy hallways, sitting in the back seat of a car). Given that modern rehabilitation programs leverage the natural environment as a tool to promote recovery (e.g., expose-recover approach), accurate characterization of the patient clinical profile is essential to improving recovery outcomes. Ambulatory assessment methodology could greatly benefit concussion clinical care by providing a window into the symptoms and impairments experienced by patients over the course of their daily lives. Moreover, by evaluating the timing, onset, and severity of symptoms and impairments in response to changes in a patient's natural environment, ambulatory assessments can provide clinicians with a tool to confirm clinical profiles and gauge effectiveness of the rehabilitation program. In this perspective report, we review the motivations for utilizing ambulatory assessment methodology in concussion clinical care and report on data from a pilot project utilizing smart phone-based, ambulatory assessments to capture patient reports of symptom severity, environmental exposures, and performance-based assessments of cognition for 7 days following their initial evaluation.

Temporal Differences in Concussion Symptom Factors in Adolescents following Sports-Related Concussion

OBJECTIVE

To evaluate temporal differences in concussion symptoms up to 30 days following a sports-related concussion.

STUDY DESIGN

Adolescent and young adult athletes (n = 782) were separated based on time since injury at presentation as Early (0-7 days; n = 321, age: 15.4 ± 1.9 years, 51.7% female), Middle (8-14 days; n = 281, age: 15.8 ± 2.2 years, 54.8% female), and Late (15-30 days; n = 180, age: 15.6 ± 1.8 years, 52.8% female). All participants completed the 22-item Post-Concussion Symptom Scale at first visit. A confirmatory factor analysis was completed separately for each time since injury cohort using a 4-component model reported previously.

RESULTS

The confirmatory factor analysis model fit was acceptable for Early, Middle, and Late (using cognitive-migraine-fatigue, affective, sleep, and somatic factors). Both affective (change = 0.30; P = .01; Cohen d = 0.30) and sleep (change = 0.51; P ≤ .001; Cohen d = 0.47) factors were significantly greater in the Late group compared with the Early, but not Middle, groups. The previously reported 4-factor symptom model, including cognitive-migraine-fatigue, affective, somatic, and sleep factors, was appropriate for adolescents up to 30 days' postinjury. However, adolescents who presented between 15 and 30 days' postinjury reported greater affective and sleep symptoms than those who presented within 1 week.

CONCLUSIONS

Clinicians should consider these temporal differences when evaluating concussion symptoms in adolescents, as greater affective and sleep symptoms can be predictive of prolonged recovery/persistent complications.

Resting State Functional Connectivity between Dorsal Attentional Network and Right Inferior Frontal Gyrus in Concussed and Control Adolescents

Concussion among adolescents continues to be a public health concern. Yet, the differences in brain function between adolescents with a recent concussion and adolescents with no history of concussion are not well understood. Although resting state functional magnetic resonance imaging (fMRI) can be a useful tool in examining these differences, few studies have used this technique to examine concussion in adolescents. Here, we investigate the differences in the resting state functional connectivity of 52 adolescents, 38 with a concussion in the previous 10 days (mean age = 15.6; female = 36.8%), and 14 controls with no concussion history (mean age = 15.1; female = 57.1%). Independent component analysis and dual regression revealed that control adolescents had significantly greater functional connectivity between the dorsal attention network (DAN) and right inferior frontal gyrus (RIFG) compared to concussed adolescents (p-corrected < 0.001). Specifically, there was a positive DAN-RIFG connectivity in control, but not concussed, adolescents. Our findings indicate that concussion is associated with disrupted DAN-RIFG connectivity, which may reflect a general, nonspecific response to injury.

Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review

Objective:

Concussion is a common yet heterogenous injury. Approximately 15–30% of cases present with persistent post-concussion symptoms (PPCS), continuing 4 weeks or more post-injury in children, youth, and adolescents, and 3 months or more in adults. There are known bidirectional links between PPCS and mental health outcomes. The focus of this scoping review is to explore the literature on mental health outcomes in individuals experiencing PPCS. Research objectives were to explore: (1) the mental health outcomes of individuals with PPCS and types of assessments used to identify mental health outcomes this group, and (2) how mental health outcomes compare in terms of similarities and differences among pediatric and adult populations with PPCS.

Method

Ovid MEDLINE; EMBASE; CINAHL, and PsycInfo databases were searched. After title and abstract screening of 11,920 studies, 481 articles were reviewed. Twenty-five papers met inclusion criteria. Results were organized by mental health outcomes of pediatric and adult populations, separately.

Results

There was a significantly higher number of studies devoted to adult populations. Of the 25 studies, 19 (76%) focused on adults, while six (24%) focused on adolescents. In adult populations, studies focused on symptoms of: anxiety (n = 2), depression (n = 8), and anxiety and depression (n = 9). Two studies assessed other emotional outcomes (10.5%). Within pediatric populations, an equal number of studies explored symptoms of: anxiety (n = 2), depression (n = 2), and anxiety and depression (n = 2). No studies focused on other emotional outcomes. Studies ranged greatly in methods, design, and control group. Most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.

Discussion

This review contributes to the understanding of mental health outcomes in those experiencing PPCS. Mental health and PPCS requires greater attention in pediatric populations, and consider strategies for those experiencing PPCS and mental health impacts. Future studies should consider including a wider range of emotional outcomes in their design, not limited to anxiety and depression. Study results may lead to improvements and research in the identification, assessment, and management of PPCS and mental health.

Identifying Trends of Dysautonomia Signs and Symptoms Associated with Protracted Concussion Recovery during the Buffalo Concussion Treadmill Test: A Retrospective Study

Objective:

To identify trends of provoked dysautonomia signs and symptoms during the Buffalo Concussion Treadmill Test (BCTT).

Subjects:

This is a retrospective cohort study of 101 patient charts post-concussion who were screened for suspected dysautonomia.

Methods:

Patients with suspected dysautonomia were assessed for exercise intolerance using a BCTT. Symptoms and rate of perceived exertion were recorded on a standardized form. Digital pulse oximetry was used to collect heart rate (HR) and oxygen saturation. Descriptive analyses were conducted on BCTT results.

Results:

Of 101 patient charts, 57 were excluded from analysis, including four patients who completed the BCTT by asymptomatically reaching the target HR zone for their estimated HR max. The remaining 44 patients demonstrated: 35 (79.5%) poor HR stabilization defined as a drop or plateau in HR during exercise, 28 (63.8%) exacerbated concussion symptoms, 13 (29.5%) autonomic nervous system response such as hot flushed sensation, 12 (27.3%) rebound symptoms during recovery phases, and 8 (18.2%) desaturation of 90% or below. The mean delta (80% expected HR max – 80% achieved HR max) on the initial test was 80.66 (± 23.08) beats per minute.

Conclusions:

This study is the first to identify trends of signs and symptoms during the BCTT in an expanded population with suspected dysautonomia after concussion. Future studies are indicated to validate these findings and contribute to development of modified termination criteria for the BCTT in individuals with suspected dysautonomia associated with protracted concussion recovery.