The role of early intervention in improving the level of activities and participation in youths after mild traumatic brain injury: a scoping review

Macular, Choroidal, and Peripapillary Perfusion Changes in Mild and Moderate Traumatic Brain Injury Using Optical Coherence Tomography and Angiography

Introduction: To compare the retinal and choroidal architecture and microvasculature between patients with mild or moderate traumatic brain injury (TBI) and controls with normal cognition using optical coherence tomography (OCT) and OCT angiography (OCTA). Methods: Patients with a documented history of TBI, and age-matched and sex-matched controls were recruited. The primary outcome measures were differences between OCT parameters, including the choroidal vascularity index, and between OCTA superficial capillary plexus metrics, including foveal avascular zone (FAZ) circularity, 3.0 mm × 3.0 mm and 6.0 mm × 6.0 mm macular vessel density and perfusion density, and 4.5 mm × 4.5 mm peripapillary capillary perfusion density and capillary flux index. Results: Sixty-seven eyes of 36 patients with TBI and 72 eyes of 36 control patients met the inclusion criteria. Twelve patients (33.3%) had a diagnosis of mild TBI without loss of consciousness (LOC), 21 (58.3%) had mild TBI with LOC, and 3 (8.3%) had moderate TBI. There was a significant reduction in FAZ circularity and in 3.0 mm × 3.0 mm macular OCTA vessel density and perfusion density in patients with TBI. In cases with TBI associated with posttraumatic stress disorder, all macular OCTA parameters were significantly reduced. There was an increase in the choroidal vascularity index across the severity of TBI; however, it was reduced in those with more than 1 TBI (P = .03). Conclusions: There was a reduction in macular perfusion in eyes of patients with mild or moderate TBI. The choroidal vascularity index helps differentiate subtle effects of more severe or mild repeated TBI. Further prospective investigation will evaluate OCT imaging and OCTA imaging as a noninvasive screening modalities to assess changes in retinal and choroidal microvasculature.

Cognitive functions and symptoms predicting later use of psychiatric services following mild traumatic brain injury in school-age

OBJECTIVE

To investigate whether neuropsychological test performance or presence of some specific injury symptoms at 1-3 months following pediatric mild traumatic brain injury (mTBI) can help to identify the children at risk for developing post-traumatic psychiatric symptoms.

METHODS

Data from 120 children and adolescents aged 7-15 years, treated at Turku University Hospital between 2010 and 2016 due to mTBI, and who had undergone neuropsychological evaluation at 1-3 months following injury, were enrolled from the hospital records. Neuropsychological test performancesand injury symptom reports were retrospectively retrieved from the patient files.

RESULTS

Slow information processing speed (p = 0.044), emotion regulation deficit (p = 0.014), impulsivity (p = 0.013), verbal processing difficulties (p = 0.042) and headache (p = 0.026) were independent predictors for having later contact in psychiatric care.

CONCLUSIONS

Neuropsychological examination containing measure of information processing speed, injury symptom interview, and parental questionnaires on behavioural issues of the child at 1-3 months following mTBI seems to be useful in detecting children with risk for post traumatic psychiatric symptoms. Targeted support and guidance for this group of children and adolescents and their families are recommended to prevent the development of an unfavorable psychosocial outcome.

Computed Tomography Lesions and Their Association with Global Outcome in Young People with Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) can be accompanied by structural damage to the brain. Here, we investigated how the presence of intracranial traumatic computed tomography (CT) pathologies relates to the global functional outcome in young patients one year after mTBI. All patients with mTBI (Glasgow Coma Scale: 13-15) ≤24 years in the multi-center, prospective, observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study were included. Patient demographics and CT findings were assessed at admission, and the Glasgow Outcome Scale Extended (GOSE) was evaluated at 12 months follow-up. The association between a "positive CT" (at least one of the following: epidural hematoma, subdural hematoma, traumatic subarachnoid hemorrhage (tSAH), intraventricular hemorrhage, subdural collection mixed density, contusion, traumatic axonal injury) and functional outcome (GOSE) was assessed using multi-variable mixed ordinal and logistic regression models. A total of 462 patients with mTBI and initial brain CT from 46 study centers were included. The median age was 19 (17-22) years, and 322 (70%) were males. CT imaging showed a traumatic intracranial pathology in 171 patients (37%), most commonly tSAH (48%), contusions (40%), and epidural hematomas (37%). Patients with a positive CT scan were less likely to achieve a complete recovery 12 months post-injury. The presence of any CT abnormality was associated with both lower GOSE scores (odds ratio [OR]: 0.39 [0.24-0.63]) and incomplete recovery (GOSE <8; OR: 0.41 [0.25-0.68]), also when adjusted for demographical and clinical baseline factors. The presence of intracranial traumatic CT pathologies was predictive of outcome 12 months after mTBI in young patients, which might help to identify candidates for early follow-up and additional care.

Tele-Active Rehabilitation for Youth With Concussion: Evidence-Based and Theory-Informed Intervention Development

BACKGROUND

Active rehabilitation involving subsymptom threshold exercise combined with education and support promotes recovery in youth with concussion but is typically delivered in person, which may limit accessibility for families because of a lack of services in their communities or logistical challenges to attending in-person sessions.

OBJECTIVE

This paper describes the evidence-based and theory-informed development of the Tele-Active Rehabilitation (Tele-AR) intervention for pediatric concussion, which was specifically designed for remote service delivery.

METHODS

The intervention was designed by clinician-researchers with experience in pediatric concussion rehabilitation following the Medical Research Council guidance for developing complex interventions. Development involved a critical review of the literature to identify existing evidence, the expansion of the theoretical basis for active rehabilitation, and the modeling of the intervention process and outcomes.

RESULTS

Tele-AR is a 6-week home exercise and education and support program facilitated through weekly videoconferencing appointments with a clinician. Exercise consists of low- to moderate-intensity subsymptom threshold aerobic activity and coordination drills that are individualized to participant needs and interests (prescribed for 3 days per week). Education includes the evidence-supported Concussion & You self-management program, which covers topics related to energy management, nutrition, hydration, sleep hygiene, and return to activity. Elements of self-determination theory are incorporated to support motivation and engagement. We present a logic model describing predicted intervention effects using a biopsychosocial conceptualization of outcomes after concussion.

CONCLUSIONS

The Tele-AR intervention may help to increase access to care that improves recovery and promotes a timely return to activity in youth with concussion. Future research is needed to evaluate the feasibility and efficacy of this approach.

Greater symptom burden results in reduced exercise tolerance in adolescents following concussion

OBJECTIVES

To explore the relationship between symptoms and exercise tolerance in adolescents following concussion.

METHODS

A retrospective analysis of 417 adolescents who attended a concussion service between January 2015 and April 2021 was performed, with 149 meeting eligibility criteria for inclusion. Post-Concussion Symptom Scale (PCSS) and graded exercise tolerance time (min) were assessed at initial and follow-up visits. Spearman's correlation was used to examine the relationship between PCSS scores and exercise time.

RESULTS

Adolescents (n = 149, 13.9 ± 1.7 years, 66.4% male) presented at 28.6 ± 19.7 days post-injury. Statistically significant correlations were identified between initial (r = -0.36, p < .001) and follow-up (r = -0.41, p < .001) PCSS scores and exercise time among all participants. Initial PCSS and initial exercise time were inversely correlated for males (r = -0.24, p = .018) and females (r = -0.22, p = .127). Follow-up PCSS and follow-up exercise time were inversely correlated for males (r = -0.30, p = .003) and females (r = -0.35, p = .014).

CONCLUSION

There is a statistically significant relationship between higher PCSS and poorer exercise time and both factors should be considered together to provide the most accurate assessment, particularly in females.

Acute and Long-Term Services for Elementary and Middle School Children With Early Childhood Brain Injury

Purpose The purpose of this study was to investigate the rates of referral to and receipt of acute and long-term services and identify factors that could impact these rates for children who experienced an acquired brain injury (ABI) during early childhood who are now in elementary and middle school. Method This was a retrospective chart review and prospective phone survey of 29 caregivers of children with ABIs. Results Acutely, two thirds of this sample received hospital-based rehabilitation services, but only 44.8% of families reported receiving ABI-specific education or a referral to educational or rehabilitation services at the time of discharge. At an average of 8.5 years postinjury, children in this sample were largely reported to be performing positively in school. While special education rates did not change significantly over time, 20.7% of the sample reported having unmet educational needs. Additionally, service receipt decreased over time. Various injury and educational factors influenced rates of long-term special education and service receipt. Conclusions This study contributes to the emerging literature focusing on long-term outcomes of children with ABI. The results reinforce that children who experience an ABI in early childhood are unlikely to receive ABI-specific education or referrals to educational and rehabilitation services during their acute-care stay and, in the chronic stages of recovery, present with educational and therapy needs that can go unmet. To improve long-term service access for children who experience an early ABI, pathways need to be established within the acute-care setting for education and referrals that connect the child and family to treatment within early intervention and educational systems. Maintaining these pathways long term, particularly for potential social-behavioral and cognitive-communication concerns, could increase access to appropriate services and, thus, decrease unmet needs for children with ABI.

Activities and Participation in the First 6 Months After Mild Traumatic Brain Injury in Children and Adolescents

OBJECTIVE

To investigate the natural course of activities and participation of children up to 6 months after a mild traumatic brain injury (mTBI).

METHODS

A prospective longitudinal cohort study with complete data sets of 231 children diagnosed with mTBI and their caregivers.

MAIN MEASURES

Activities and participation assessed with the Child and Adolescent Scale of Participation (CASP) and the Children's Assessment of Participation and Enjoyment (CAPE) measured at 2 weeks, 3 months, and 6 months post-mTBI. Because of a ceiling effect, the primary outcome measure (CASP) was divided into deviant (not maximum score) or full functioning.

RESULTS

Friedman's, Cochran's Q, and McNemar's tests (CASP) and repeated-measures analyses of variance (CAPE) showed significant increases in activities and participation between 2 weeks and 3 and 6 months after mTBI. Based on the parents' perspective, 67% of the children returned to full functioning at 6 months postinjury, with only 38% of the children describing themselves as functioning at their premorbid level.

DISCUSSION

Findings indicate that most children return to maximum level of activities and participation over time after mTBI. In a substantial number of children, however, the level of activities and participation at 6 months postinjury is evaluated as lower than that of peers. The importance of investigating predictors for child and caregiver perspectives is emphasized.

Process evaluation of 'Brains Ahead!': an intervention for children and adolescents with mild traumatic brain injury within a randomized controlled trial

OBJECTIVE

To investigate whether the 'Brains Ahead! Intervention for children and adolescents with mild traumatic brain injury' was implemented as intended. In addition, involvement in and satisfaction with the intervention among patients, caregivers and professionals delivering the intervention were studied.

DESIGN

Mixed methods, prospective study.

PARTICIPANTS

Children with mild traumatic brain injury and their caregivers, allocated to the intervention group of the randomized controlled trial in the 'Brains Ahead!' study, and the two professionals providing the intervention.

INTERVENTION

The intervention consists of a standardized and individualized psychoeducational session with written take-home information, and follow-up telephone call(s).

MAIN MEASURES

Registration forms, evaluation questionnaires for patients and caregivers and semi-structured interviews for professionals.

DATA ANALYSIS

Qualitative data were categorized based on content. Quantitative data were reported as descriptive statistics.

RESULTS

Fifty-five patients and caregivers out of 60 study-participants attended both sessions. All elements of the intervention were delivered to 53 study-participants. Evaluation questionnaires were completed by 21 of the 31 patients aged 12 years and older, and by 41 caregivers. Overall, the sessions were considered useful by 19 patients, 40 caregivers and both professionals. Reassurance, creating a better understanding and recognition of symptoms were rated as important aspects. On a scale from 1 to 10, the intervention was rated by children, caregivers and professionals with 7.6 (SD 1.2), 8.1 (SD .9) and 8.0 (SD .0), respectively.

CONCLUSION

The 'Brains Ahead!' intervention was largely implemented as intended and the process evaluation revealed that it is considered feasible according to patients, caregivers and professionals.

Predictors of activities and participation six months after mild traumatic brain injury in children and adolescents

OBJECTIVE

This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI).

METHODS

A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors.

RESULTS

Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045).

DISCUSSION

Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Review of the Management of Pediatric Post-Concussion Syndrome-a Multi-Disciplinary, Individualized Approach

PURPOSE OF REVIEW

Post-concussion syndrome (PCS), when the patient's concussion symptoms last longer than 4-6 weeks, affects 10-30% of concussion patients. PCS presents a significant source of morbidity to patients and a management challenge to providers. In this review, we present the current evidence and best management approaches for pediatric PCS.

RECENT FINDINGS

There is limited high-quality evidence in pediatric PCS. There is some evidence supporting pharmaceutical management of post-traumatic headaches, cognitive symptoms, and emotional symptoms. Vestibular-ocular dysfunction should be evaluated and managed appropriately. Neuropsychological recovery is expected, but requires appropriate attention to Return to Learn. Emotional symptoms are common in PCS and the evidence supports treatment with cognitive behavioral therapy. PCS presents a unique therapeutic challenge affecting multiple domains for patients-physical, sleep, cognitive, and emotional. Successful management of PCS requires a multi-disciplinary and individualized approach. There remains a significant need for further research, specifically looking into the outcomes and effective interventions in pediatric PCS.

The Brains Ahead! intervention for children and adolescents with mild traumatic brain injury and their caregivers: rationale and description of the treatment protocol

PURPOSE:

Approximately 20% of the children and adolescents after mild traumatic brain injury will not fully recover. They suffer long-term postconcussive symptoms and may experience limitations in activities and participation. Research suggests that early psychoeducational interventions may prevent long-term postconcussive symptoms. The Brains Ahead! intervention was developed to prevent long-term symptoms and, furthermore, to establish a more successful return to activities and participation after mild traumatic brain injury in children and adolescents. The intervention is currently being evaluated in a multicenter randomized controlled trial.

RATIONALE:

Providing individualized information and personal advice in addition to standardized information about the injury and possible consequences early after the injury may enable patients and caregivers to recognize and anticipate on relevant symptoms at an early stage and to prevent problems in activities and participation.

THEORY INTO PRACTICE:

The Brains Ahead! intervention is a psychoeducational intervention for children and adolescents who sustained a mild traumatic brain injury and for their caregivers. The patients will receive a partially standardized and partially individualized psychoeducational session and a telephone follow-up within the first two to eight weeks after the injury.