Assessment of mild traumatic brain injury with the King-Devick Test® in an emergency department sample

The reliability and validity of brief cognitive screening tools used in traumatic brain injury: A systematic review

Reliable and valid cognitive screening tools are essential in the assessment of those with traumatic brain injury (TBI). Yet, there is no consensus about which tool should be used in clinical practice. This systematic review assessed psychometric properties of cognitive screening tools for detecting cognitive impairment in TBI. Inclusion criteria were: peer-reviewed validation studies of a cognitive screening tool(s); with a sample of adults aged 18-80 diagnosed with TBI (mild-severe); and with psychometrics consistent with COSMIN guidelines. Published literature was retrieved from MEDLINE, Web of Science Core Collection, EMBASE, CINAHL, and PsycINFO on 27 January 2022. A narrative synthesis was performed. Thirty-four studies evaluated the psychometric properties of a total of 22 cognitive screening tools, in a variety of languages. Properties assessed included structural validity, internal consistency, reliability, criterion validity (or diagnostic test accuracy), convergent/divergent validity, and discriminant validity. The Montreal Cognitive Assessment (MoCA) and the Mini Mental State Examination (MMSE) were the most widely validated cognitive screening tools for use in TBI. The MoCA had the most promising evidence of its psychometric properties, which has implications for clinical practice. Future research should aim to follow standard criteria for psychometric studies to allow meaningful comparisons across the literature.

Classification of short and long term mild traumatic brain injury using computerized eye tracking

Accurate, and objective diagnosis of brain injury remains challenging. This study evaluated useability and reliability of computerized eye-tracker assessments (CEAs) designed to assess oculomotor function, visual attention/processing, and selective attention in recent mild traumatic brain injury (mTBI), persistent post-concussion syndrome (PPCS), and controls. Tests included egocentric localisation, fixation-stability, smooth-pursuit, saccades, Stroop, and the vestibulo-ocular reflex (VOR). Thirty-five healthy adults performed the CEA battery twice to assess useability and test-retest reliability. In separate experiments, CEA data from 55 healthy, 20 mTBI, and 40 PPCS adults were used to train a machine learning model to categorize participants into control, mTBI, or PPCS classes. Intraclass correlation coefficients demonstrated moderate (ICC > .50) to excellent (ICC > .98) reliability (p < .05) and satisfactory CEA compliance. Machine learning modelling categorizing participants into groups of control, mTBI, and PPCS performed reasonably (balanced accuracy control: 0.83, mTBI: 0.66, and PPCS: 0.76, AUC-ROC: 0.82). Key outcomes were the VOR (gaze stability), fixation (vertical error), and pursuit (total error, vertical gain, and number of saccades). The CEA battery was reliable and able to differentiate healthy, mTBI, and PPCS patients reasonably well. While promising, the diagnostic model accuracy should be improved with a larger training dataset before use in clinical environments.

Concussion in Non-athletes: Assessment of Cognition and Symptomatology (CONTACTS) study protocol - an exploratory cohort study investigating the utility of sports concussion assessment tools and salivary microRNAs to diagnose concussion in NHS patients

INTRODUCTION

Concussion is a complex pathophysiological process with a wide range of non-specific signs and symptoms. There are currently no objective diagnostic tests to identify concussion, and diagnosis relies solely on history and examination. Recent research has identified a unique panel of microRNAs (miRNAs) that distinguish between concussed and non-concussed rugby players. This study aims to assess the diagnostic utility of salivary miRNAs in concussion for a sample of UK National Health Service patients and whether well-established sports-related concussion (SRC) assessment tools may be translated into the emergency department (ED).

METHODS AND ANALYSIS

Concussion in Non-athletes: Assessment of Cognition and Symptomatology is a single-centre, prospective, two-phase cohort study. The concussed cohort will consist of participants with maxillofacial trauma and concurrent concussion. The control cohort will consist of participants with isolated limb trauma and no evidence of concussion. Participants will be recruited in the ED and saliva samples will be taken to identify the presence of miRNAs. The SRC assessments being investigated include the Sports Concussion Assessment Test, Fifth Edition (SCAT5), the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and the ImPACT Quick. Follow-up will be at 24-48 hours in-hospital and remotely via telephone and email at 14 days and 6 months.

ETHICS AND DISSEMINATION

Ethical approval was granted in February 2021 by the West Midlands Coventry & Warwickshire Research Ethics Committee (ref 20/WM/0299). The investigators intend to submit their study findings for publication in peer-reviewed journals and to disseminate study findings via presentation at academic meetings. The results will also form part of a doctorate thesis, registered at the University of Birmingham.

Norm-Based Cutoffs as Predictors of Prolonged Recovery After Adolescent Sport-Related Concussion

OBJECTIVES

To identify predictors of prolonged recovery (ie, >28 days) using patient demographic factors and healthy, norm-based cutoffs on a multimodal test battery in adolescents after sport-related concussions (SRCs).

DESIGN

Retrospective cohort. Patients were deemed recovered after successful completion of return-to-play/school protocols and received medical clearance.

SETTING

Community concussion clinic.

PATIENTS

Male and female adolescent student athletes diagnosed with a SRC and evaluated within 1 week of injury.

INDEPENDENT VARIABLES

Patient demographics, medical history, injury description, computerized neurocognitive testing, vestibular/ocular testing, and symptoms at initial clinical visit.

MAIN OUTCOME MEASURES

Performance on clinical testing to predict recovery duration, classified as normal (<28 days) or prolonged (>28 days).

RESULTS

A total of 201 adolescent student athletes (age = 15.3 ± 1.4 years) were included (female 35%). Average recovery duration for the entire cohort was 22.3 ± 13.3 days, with 22% (n = 45) of adolescent student athletes taking >28 days to recover. The final model was 88.3% accurate in classifying normal and prolonged recovery. Predictor variables included sex, loss of consciousness, history of ocular disorder, history of concussion, performance on visual motor speed composite, visual motion sensitivity symptom provocation and near point of convergence distance, number-naming total time, and symptom count.

CONCLUSIONS

These findings suggest that using norm-based cutoffs from cognitive, oculomotor, and vestibulo-ocular testing and symptom reporting, clinicians can accurately predict a prolonged recovery (sensitivity = 81%) and normal recovery (specificity = 83%) in an adolescent, SRC cohort.

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

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

Evaluating the construct validity of the King-Devick test in a psychological outpatient clinical sample

The King-Devick test (K-D) has demonstrated sensitivity as a screener measure of ocular motor and cognitive problems. Despite its empirical support in the assessment of patients with certain injuries and disorders (e.g., concussion, reading disorders), less is known about the construct validity of the K-D. This study examined this topic in an outpatient, diagnostically heterogeneous clinical sample. A total of 70 individuals seen for an outpatient psychoeducational evaluation completed the K-D in addition to measures of intellectual abilities, speeded reading ability, simple and sustained attention, and executive functioning. Pearson correlation coefficients revealed that poorer K-D performance was associated with poorer processing speed, speeded reading ability and response time to target stimuli (r = .26-.31, p < .05). K-D performance was unrelated to other intellectual abilities, other aspects of attention, or executive functioning (all p > .05). Results suggest that the K-D demonstrates good convergent and discriminant validity in a heterogeneous outpatient clinical sample including individuals with attention-deficit hyperactivity disorder, specific learning disorders, and a number of different depressive and anxiety disorders. Findings support its wider use as a measure of reading ability and processing speed in clinical contexts.

A systematic review of acute concussion assessment selection in research

Background: Several organisations developed guidelines and assessments for aiding in the diagnosis of concussions. The growing number of concussion assessments increases the difficulty for researchers and clinicians to determine the best method of concussion diagnosis. Purpose: To systematically review the current assessments selected for acute sports-related concussion. Methods: Academic Search Premier, CINHAL, MEDLINE, PsycINFO and SPORTDiscus were searched. English-language, peer-review published studies of acute (<72 h) concussion assessments were included. Results: A total of 31 studies met inclusion criteria (of 291 evaluated); 27 studies provided sufficient information to be included in the descriptive statistics of the assessments. Six of these assessments were used in at least three studies. Only 12 percent of the population studied was female. The age range for these assessments was 9-67 years, although most participants ranged in age between 18 and 35 years. Conclusion: There is a need for a 'gold' standard concussion assessment to enable consistency across research and clinical outcomes. We found a large discrepancy between the number of males and females assessed, suggesting that future studies are needed to determine if these current assessments identify concussion signs and symptoms unique to females. Further studies are needed to determine which assessments are appropriate and valid for youth athletes.

Clinical Findings in a Multicenter MRI Study of Mild TBI

Background: Uncertainty continues to surround mild traumatic brain injury (mTBI) diagnosis, symptoms, prognosis, and outcome due in part to a lack of objective biomarkers of injury and recovery. As mTBI gains recognition as a serious public health epidemic, there is need to identify risk factors, diagnostic tools, and imaging biomarkers to help guide diagnosis and management. Methods: One hundred and eleven patients (15-50 years old) were enrolled acutely after mTBI and followed with up to four standardized serial assessments over 3 months. Each encounter included a clinical exam, neuropsychological assessment, and magnetic resonance imaging (MRI). Chi-square and linear mixed models were used to assess changes over time and determine potential biomarkers of mTBI severity and outcome. Results: The symptoms most frequently endorsed after mTBI were headache (91%), not feeling right (89%), fatigue (86%), and feeling slowed down (84%). Of the 104 mTBI patients with a processed MRI scan, 28 (27%) subjects had white matter changes which were deemed unrelated to age, and 26 of these findings were deemed unrelated to acute trauma. Of the neuropsychological assessments tested, 5- and 6-Digit Backward Recall, the modified Balance Error Scoring System (BESS), and Immediate 5-Word Recall significantly improved longitudinally in mTBI subjects and differentiated between mTBI subjects and controls. Female sex was found to increase symptom severity scores (SSS) at every time point. Age ≥ 25 years was correlated with increased SSS. Subjects aged ≥ 25 also did not improve longitudinally on 5-Digit Backward Recall, Immediate 5-Word Recall, or Single-Leg Stance of the BESS, whereas subjects < 25 years improved significantly. Patients who reported personal history of depression, anxiety, or other psychiatric disorder had higher SSS at each time point. Conclusions: The results of this study show that 5- and 6-Digit Backward Recall, the modified BESS, and Immediate 5-Word Recall should be considered useful in demonstrating cognitive and vestibular improvement during the mTBI recovery process. Clinicians should take female sex, older age, and history of psychiatric disorder into account when managing mTBI patients. Further study is necessary to determine the true prevalence of white matter changes in people with mTBI.

Sport related concussion - Potential for biomarkers to improve acute management

Sport-related concussion is a common form of mild traumatic brain injury that is now recognised as a serious health issue. Growing evidence suggests concussion may result in long-term and severe neurological disabilities. Recent research into the diagnosis and management of concussion may provide new approaches to concussion management that limit the potential long-term adverse effects of concussion. This paper summarises the problem of sport-related concussion and reviews key factors (sex, age, genetics) that may modify concussion outcomes. Current sport-related concussion tools are described. Analysis of emerging methods of acute concussion diagnosis using objective fluid and neuroimaging biomarkers is provided. These new concussion biomarkers have the potential to change management of sport-related concussion.

Neurosensory Deficits Vary as a Function of Point of Care in Pediatric Mild Traumatic Brain Injury

Neurosensory abnormalities are frequently observed following pediatric mild traumatic brain injury (pmTBI) and may underlie the expression of several common concussion symptoms and delay recovery. Importantly, active evaluation of neurosensory functioning more closely approximates real-world (e.g., physical and academic) environments that provoke symptom worsening. The current study determined whether symptom provocation (i.e., during neurosensory examination) improved classification accuracy relative to pre-examination symptom levels and whether symptoms varied as a function of point of care. Eighty-one pmTBI were recruited from the pediatric emergency department (PED; n = 40) or outpatient concussion clinic (n = 41), along with matched (age, sex, and education) healthy controls (HC; n = 40). All participants completed a brief (∼ 12 min) standardized neurosensory examination and clinical questionnaires. The magnitude of symptom provocation upon neurosensory examination was significantly higher for concussion clinic than for PED patients. Symptom provocation significantly improved diagnostic classification accuracy relative to pre-examination symptom levels, although the magnitude of improvement was modest, and was greater in the concussion clinic. In contrast, PED patients exhibited worse performance on measures of balance, vision, and oculomotor functioning than the concussion clinic patients, with no differences observed between both samples and HC. Despite modest sample sizes, current findings suggest that point of care represents a critical but highly under-studied variable that may influence outcomes following pmTBI. Studies that rely on recruitment from a single point of care may not generalize to the entire pmTBI population in terms of how neurosensory deficits affect recovery.

Sport Concussion and the Female Athlete

Sport concussion (SC) has emerged as a major health concern in the medical community and general public owing to increased research and media attention, which has primarily focused on male athletes. Female athletes have an equal, if not increased, susceptibility to SC. An ever-growing body of research continues to compare male and female athletes in terms of SC before and after an injury. Clinicians must be cognizant of this literature to make evidence-based clinical decision when providing care to female athletes and discern between dated and/or unsupported claims in terms of SC.

Assessing the effects of concussion using the C3Logix Test Battery: An exploratory study

The C3Logix is a computerized concussion assessment tool that measures a wider array of symptoms (i.e., balance and oculomotor functioning) than other computerized batteries. Although the C3Logix has been used increasingly by athletic organizations at all levels of play, its utility within the concussion population has not been extensively examined. The current study aimed to determine whether the C3Logix is sensitive to the effects of concussion. A total of 54 student-athletes enrolled at a large southern university completed the C3Logix at baseline and within days following a suspected concussion (mean = 2.93, SD = 3.14). Dependent-samples t-tests revealed that relative to their baselines, following concussion, athletes both reported significantly greater postconcussive symptoms and performed more poorly on measures of reaction time and computer-measured balance. Decrements in processing speed, visual acuity, and clinician-observed errors on tests of balance also trended toward significance. Results suggest that inclusion of measures of balance and oculomotor functioning in the assessment of concussion may provide additional clinical utility above and beyond domains typically measured by computerized concussion assessments.

Baseline King-Devick scores for adults are not generalizable; however, age and education influence scores

OBJECTIVE

To establish normative values for the King-Devick (K-D) test to be used as a reference for determining impairment related to concussion when individual baseline scores are lacking.

METHOD

Baseline K-D scores were collected for 243 participants aged 18-86.

RESULTS

The mean age of subjects was 40.46; range 18-86 years. The mean time was 42.2 seconds; 26.19-75.96 seconds. There was a relationship (r = 0.376) between K-D score and age; scores increased (worsened) with age. There was also a relationship between score and education with scores decreasing as education increased (r = -0.194; p = 0.002). The K-D score was not influenced by sex or concussion history. A regression equation using education and age to predict K-D time explained 0.418 of the variance in K-D test time.

CONCLUSION

Although this research established a relationship between K-D score and age and education, the range in scores was too broad to establish normative values. In the absence of a baseline score, the use of a regression equation considering age and education level may provide some indication of expected score. However, the most reliable use of the test as a screen for impairment following concussion involves the use of a baseline test.

Characteristics of the King-Devick test in the assessment of concussed patients in the subacute and later stages after injury

Although the King-Devick (K-D) test has been used frequently in assessing sports related concussion early after injury, its characteristics over time after injury and in patients with prolonged persistent symptoms are unknown. The purpose of this paper was to: evaluate the ability of the K-D Test to distinguish patients seen early after concussion from those with symptoms persisting more than 3 months compared to controls, assess changes in the K-D test times over time after concussion, and determine the relationship of K-D times to the Stroop Color and Word Test scores. We performed cross-sectional comparisons of patients with recent concussive brain injury (acute group) and those with symptoms persisting more than 3 months to healthy controls on the K-D test, the Sports Concussion Assessment Tool 3 (SCAT3), and the Stroop Color and Word Test. Longitudinal comparisons of the acute group over time within the first month after injury were also made. Post-concussive syndrome (PCS) patients had significantly higher K-D times compared to controls (p = 0.01), while the acute group did not differ from controls(p = 0.33). K-D times at the second visit for the acute group were similar to those of controls (54.7 vs. 49.6, p = 0.31). While SCAT3 scores improved over time in the acute group, the K-D scores did not change between the first and second visit (55.2 vs. 54.7, p = 0.94). K-D scores correlated significantly with the Stroop scores for all three participant groups. The K-D test is likely useful very early after concussion in conjunction with baseline scores, and while scores in PCS patients remain elevated, they can be confounded by factors such as pre-morbid depression and medication use. High correlations with Stroop scores also suggest that performance on the K-D test can by proxy provide additional insight about cognitive function and predict performance on more cognitively demanding tasks.

King-Devick Test identifies real-time concussion and asymptomatic concussion in youth athletes

Background

Sports concussion has an annual incidence of approximately 3.8 million. Over half go unreported and a substantial number may be asymptomatic. A rapid, cost-effective, and reliable tool that facilitates diagnosis of concussion is needed. The King-Devick (K-D) test is a vision-based tool of rapid number naming for assessment of concussion. In this study, we evaluated the utility of the K-D test in real time for identification of symptomatic concussion in youth athletes and to determine if similar impairment (subclinical concussion) exists in youth athletes without an obvious head injury or symptoms.

Methods

Youth hockey players underwent K-D testing preseason, postseason, and immediately after suspected concussion. Additional testing was performed in a subgroup of nonconcussed athletes immediately before and after a game to determine effects of fatigue on K-D scores.

Results

Among 141 players tested, 20 had clinically diagnosed concussion. All 20 had immediate postconcussion K-D times >5 seconds from baseline (average 7.3 seconds) and all but 2 had worse postseason scores (46.4 seconds vs 52.4 seconds, p < 0.05, Wilcoxon signed rank test). Nonconcussed athletes saw minimal improvement postseason (43.9 seconds vs 42.1 seconds, p < 0.05) and 51 nonconcussed players assessed before and after a game revealed no significant time change as a result of fatigue.

Conclusions

Rapid number naming using the K-D test accurately identifies real-time, symptomatic concussion in youth athletes. Scores in concussed players may remain abnormal over time. Athletes should undergo preseason and postseason K-D testing, with additional evaluation real time to inform the assessment of suspected concussion.

Classification of Evidence

This study provides Class III evidence that the K-D test accurately identifies real-time concussions in youth athletes.

Clinical Evaluation of the Concussed Athlete: A View From the Sideline

CONTEXT

The sideline assessment of concussion is challenging, given its variable presentations, the limited sensitivity and specificity of sideline assessment tools, and how the presentation of the injury evolves over time. In addition, the diagnostic process, as well as the tools used to assess and manage concussion, continue to progress as research and what we know about concussion advance. This paper focuses on the initial assessment on the sideline by reviewing the concussion-evaluation literature, drawing from clinical experience to emphasize a standardized approach, and underscoring the importance of both familiarity with the athlete and clinical judgment.

OBJECTIVE

To review the evidence regarding the clinical assessment of sport-related concussion on the sideline. Additional considerations included making same-day return-to-play decisions, the sensitivity and specificity of sideline testing, and the importance of ongoing assessment and follow-up of injured athletes.

DATA SOURCES

I conducted a systematic literature review of the assessment of concussion on the sideline. The PubMed and MEDLINE databases were searched using the key term athletic injuries with concussion and mild traumatic brain injury. The search was refined by adding the key terms sideline assessment and on-field assessment. In addition, select additional position statements and guidelines on concussion were included in the review.

RESULTS

The PubMed search using athletic injuries and concussion as key terms produced 1492 results. Refining the search by sideline assessment and on-field assessment produced 29 and 35 results, respectively. When athletic injuries and traumatic brain injury were combined, 1912 results were identified. Refining the search by sideline assessment and on-field assessment led to 28 and 35 results, respectively. Only papers that were English-language titles, original work, and limited to human participants and included sideline assessments of sport-related concussion in athletes older than 13 years were considered for this discussion. A total of 96 papers were reviewed, including systematic reviews, consensus guidelines, and position statements.

CONCLUSIONS

The sideline assessment of sport-related concussion is challenging given the elusiveness and variability of presentation, reliance on athlete-reported symptoms, and the varying specificity and sensitivity values of sideline assessment tools. In addition, the recognition of injury and assessment often occur in a time-pressured environment, requiring rapid disposition and decision making. Clinicians should begin the evaluation by assessing for cervical spine injury, intracranial bleeding, and other injuries that can present in a similar fashion or in addition to concussion. The sideline concussion evaluation should consist of a symptom assessment and a neurologic examination that addresses cognition (briefly), cranial nerve function, and balance. Emerging tools that assess visual tracking may provide additional information. The sensitivity and specificity of commonly implemented sideline assessment tools are generally good to very good, especially for symptom scores and cognitive evaluations performed within 48 hours of injury, and they are improved when a baseline evaluation is available for comparison. Serial assessments are often necessary as objective signs and symptoms may be delayed. A standardized assessment is paramount in evaluating the athlete with a suspected concussion, but there is no replacement for being familiar with the athlete and using clinical judgment when the athlete seems "not right" despite a "normal" sideline assessment. Ultimately, the clinician should err on the side of caution when making a return-to-play decision.

Short-term neurocognitive and symptomatic outcomes following mild traumatic brain injury: A prospective multi-centre observational cohort study

OBJECTIVE

To determine the short-term cognitive and symptomatic outcome following mild traumatic brain injury.

METHODS

Setting: Emergency Departments of two UK tertiary referral hospitals.

PARTICIPANTS

Adult patients presenting to the Emergency Departments of the Royal London Hospital and Salford Royal Hospital with suspected traumatic brain injury within 24 hours and Glasgow Coma Score > 8. A non-TBI comparison group included adult patients with no head or neck injury.

DESIGN

Prospective multi-centre cohort study.

MAIN MEASURES

The Standardized Assessment of Concussion (SAC), the Concussion Symptom Inventory (CSI) and total number of symptoms, measured at baseline and 72 hours.

RESULTS

This study enrolled 189 patients with and 51 patients without TBI. Patients with TBI had marked cognitive impairment which persisted at 72 hours (SAC score at baseline = 25 [23-27] vs 72 hours = 25 [22-27]; p = 0.1). Patients with TBI had persistent high symptom severity, although this had decreased at 72 hours (CSI score at baseline = 9 [4-22] vs 72 hours = 5 [1-19], p = 0.002). A similar pattern was observed with the total number of symptoms (baseline = 4 [2-8] vs 72 hours = 0 [0-4]; p < 0.001). Patients with TBI had worse neurocognitive function, higher overall symptom severity and higher total number of symptoms compared with patients without TBI. Patients without TBI' neurocognitive function and symptom severity remained constant, but the number of symptoms reduced between baseline and 72 hours.

CONCLUSION

There is a cognitive deficit and symptom burden in patients with mild TBI presenting to the Emergency Department which persists at 72 hours.

Treatment of Head and Neck Injuries in the Helmeted Athlete

Sport-related concussion treatment includes three major phases: initial evaluation at the time of the injury, treatment while the patient is symptomatic, and evaluation of the readiness for a gradual return to participation. Each concussion evaluation should include similar elements: assessment of symptoms, assessment of cognitive ability, assessment of coordination (of the eyes, upper extremities, and lower extremities), and assessment for additional injuries. The spine-boarding recommendations from the American College of Emergency Physicians, National Association of EMS Physicians, and National Athletic Trainers' Association have changed. These recommendations include both decreased use of spinal immobilization and removal of the helmet and shoulder pads prior to securing the athlete to the board when sufficient numbers of trained providers are present. Preseason training and pregame meetings or "medical time outs" should become standard practice for the sidelines medical team (including the athletic trainer, team physician, emergency response personnel, and possibly others).

Pediatric Posttraumatic Headache

Concussion and mild traumatic brain injury are common injuries in pediatrics, and posttraumatic headache is the most common complaint following them. Although most children and teens recover from a simple, isolated concussion without incidents within 1-2 weeks, some develop symptoms that can last for months. It is important to manage both acute and persistent posttraumatic headaches appropriately to speed recovery, minimize disability, and maximize function. In this article, we review the definitions, epidemiology, and current recommendations for the evaluation and treatment of acute and persistent posttraumatic headaches. Although this is still a developing field and there is much that we still need to learn about concussion and the best strategies to prevent and treat these injuries and their sequelae, we hope that this review will help providers to understand the current evidence and treatment recommendations to improve care for children with concussion and mild traumatic brain injury.

Clinical Traumatic Brain Injury in the Preclinical Setting

Traumatic brain injury (TBI) is the leading cause of death and disability for people under 45 years of age. Clinical TBI is often the result of disparate forces resulting in heterogeneous injuries. Preclinical modeling of TBI is a vital tool for studying the complex cascade of metabolic, cellular, and molecular post-TBI events collectively termed secondary injury. Preclinical models also provide an important platform for studying therapeutic interventions. However, modeling TBI in the preclinical setting is challenging, and most models replicate only certain aspects of clinical TBI. This chapter details the most widely used models of preclinical TBI, including the controlled cortical impact, fluid percussion, blast, and closed head models. Each of these models replicates particular critical aspects of clinical TBI. Prior to selecting a preclinical TBI model, it is important to address what aspect of human TBI is being sought to evaluate.

Detection of Subtle Cognitive Changes after mTBI Using a Novel Tablet-Based Task

This study examined the potential for novel tablet-based tasks, modeled after eye tracking techniques, to detect subtle sensorimotor and cognitive deficits after mild traumatic brain injury (mTBI). Specifically, we examined whether performance on these tablet-based tasks (Pro-point and Anti-point) was able to correctly categorize concussed versus non-concussed participants, compared with performance on other standardized tests for concussion. Patients admitted to the emergency department with mTBI were tested on the Pro-point and Anti-point tasks, a current standard cognitive screening test (i.e., the Standard Assessment of Concussion [SAC]), and another eye movement-based tablet test, the King-Devick(®) (KD). Within hours after injury, mTBI patients showed significant slowing in response times, compared with both orthopedic and age-matched control groups, in the Pro-point task, demonstrating deficits in sensorimotor function. Mild TBI patients also showed significant slowing, compared with both control groups, on the Anti-point task, even when controlling for sensorimotor slowing, indicating deficits in cognitive function. Performance on the SAC test revealed similar deficits of cognitive function in the mTBI group, compared with the age-matched control group; however, the KD test showed no evidence of cognitive slowing in mTBI patients, compared with either control group. Further, measuring the sensitivity and specificity of these tasks to accurately predict mTBI with receiver operating characteristic analysis indicated that the Anti-point and Pro-point tasks reached excellent levels of accuracy and fared better than current standardized tools for assessment of concussion. Our findings suggest that these rapid tablet-based tasks are able to reliably detect and measure functional impairment in cognitive and sensorimotor control within hours after mTBI. These tasks may provide a more sensitive diagnostic measure for functional deficits that could prove key to earlier detection of concussion, evaluation of interventions, or even prediction of persistent symptoms.

The Acute Management of Sport Concussion in Pediatric Athletes

During the past two decades the focus on sport concussion has increased significantly. Young athletes represent the most vulnerable population to sustain a sport concussion yet receive the least amount of attention. Specifically, young athletes who sustain a sport concussion can go unrecognized and continue to participate in sport putting them at an increased risk for a more significant injury. The purpose of this review is to provide a clinical framework for the evaluation and management of sport concussion. In addition, this review provides considerations for health care professionals in regard to clinical measures and follow-up strategies during the acute phase following concussion in young concussed athletes following injury.

Who Gets Head Trauma or Recruited in Mild Traumatic Brain Injury Research?

Mild traumatic brain injury (mTBI) is a public health problem. Outcome from mTBI is heterogeneous in part due to pre-injury individual differences that typically are not well described or understood. Pre-injury health characteristics of all consecutive patients (n=3023) who underwent head computed tomography due to acute head trauma in the emergency department of Tampere University Hospital, Finland, between August 2010 and July 2012 were examined. Patients were screened to obtain a sample of working age adults with no pre-injury medical or mental health problems who had sustained a "pure" mTBI. Of all patients screened, 1990 (65.8%) fulfilled the mTBI criteria, 257 (8.5%) had a more severe TBI, and 776 (25.7%) had a head trauma without obvious signs of brain injury. Injury-related data and participant-related data (e.g., age, sex, diagnosed diseases, and medications) were collected from hospital records. The most common pre-injury diseases were circulatory (39.4%-43.2%), neurological (23.7%-25.2%), and psychiatric (25.8%-27.5%) disorders. Alcohol abuse was present in 18.4%-26.8%. The most common medications were for cardiovascular (33.1%-36.6%), central nervous system (21.4%-30.8%), and blood clotting and anemia indications (21.5%-22.6%). Of the screened patients, only 2.5% met all the enrollment criteria. Age, neurological conditions, and psychiatric problems were the most common reasons for exclusion. Most of the patients sustaining an mTBI have some pre-injury diseases or conditions that could affect clinical outcome. By excluding patients with pre-existing conditions, the patients with known risk factors for poor outcome remain poorly studied.