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Lima Santos JP, Kontos AP, Holland CL, Suss SJ, Stiffler RS, Bitzer HB, Colorito AT, Shaffer M, Skeba A, Iyengar S, Manelis A, Brent D, Shirtcliff EA, Ladouceur CD, Phillips ML, Collins MW, Versace A. The Role of Puberty and Sex on Brain Structure in Adolescents With Anxiety Following Concussion. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2024; 9:285-297. [PMID: 36517369 DOI: 10.1016/j.bpsc.2022.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- João Paulo Lima Santos
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony P Kontos
- Department of Orthopaedic Surgery/UPMC Sports Concussion Program, University of Pittsburgh, Pennsylvania
| | - Cynthia L Holland
- Department of Orthopaedic Surgery/UPMC Sports Concussion Program, University of Pittsburgh, Pennsylvania
| | - Stephen J Suss
- Department of Orthopaedic Surgery/UPMC Sports Concussion Program, University of Pittsburgh, Pennsylvania
| | - Richelle S Stiffler
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hannah B Bitzer
- Department of Psychology, Florida International University, Miami, Florida
| | - Adam T Colorito
- Department of Psychology, Florida International University, Miami, Florida
| | - Madelyn Shaffer
- Department of Psychology, Florida International University, Miami, Florida
| | - Alexander Skeba
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Satish Iyengar
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anna Manelis
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David Brent
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Psychiatry, UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania
| | - Elizabeth A Shirtcliff
- Center for Translational Neuroscience and Department of Psychology, University of Oregon, Eugene, Oregon
| | - Cecile D Ladouceur
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary L Phillips
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael W Collins
- Department of Orthopaedic Surgery/UPMC Sports Concussion Program, University of Pittsburgh, Pennsylvania
| | - Amelia Versace
- Department of Psychiatry, Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Radiology, Magnetic Resonance Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania.
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van Velkinburgh JC, Herbst MD, Casper SM. Diffusion tensor imaging in the courtroom: Distinction between scientific specificity and legally admissible evidence. World J Clin Cases 2023; 11:4477-4497. [PMID: 37469746 PMCID: PMC10353495 DOI: 10.12998/wjcc.v11.i19.4477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/26/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023] Open
Abstract
Interest and uptake of science and medicine peer-reviewed literature by readers outside of a paper’s topical subject, field or even discipline is ever-expanding. While the application of knowledge from one field or discipline to others can stimulate innovative solutions to problems facing modern society, it is also fraught with danger for misuse. In the practice of law in the United States, academic papers are submitted to the courts as evidence in personal injury litigation from both the plaintiff (complainant) and defendant. Such transcendence of an academic publication over disciplinary boundaries is immediately met with the challenge of application by a group that inherently lacks in-depth knowledge on the scientific method, the practice of evidence-based medicine, or the publication process as a structured and internationally synthesized process involving peer review and guided by ethical standards and norms. A modern-day example of this is the ongoing conflict between the sensitivity of diffusion tensor imaging (DTI) and the legal standards for admissibility of evidence in litigation cases of mild traumatic brain injury (mTBI). In this review, we amalgamate the peer-reviewed research on DTI in mTBI with the court’s rationale underlying decisions to admit or exclude evidence of DTI abnormalities to support claims of brain injury. We found that the papers which are critical of the use of DTI in the courtroom reflect a primary misunderstanding about how diagnostic biomarkers differ legally from relevant and admissible evidence. The clinical use of DTI to identify white matter abnormalities in the brain at the chronic stage is a valid methodology both clinically as well as forensically, contributes data that may or may not corroborate the existence of white matter damage, and should be admitted into evidence in personal injury trials if supported by a clinician. We also delve into an aspect of science publication and peer review that can be manipulated by scientists and clinicians to publish an opinion piece and misrepresent it as an unbiased, evidence-based, systematic research article in court cases, the decisions of which establish precedence for future cases and have implications on future legislation that will impact the lives of every citizen and erode the integrity of science and medicine practitioners.
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Affiliation(s)
| | - Mark D Herbst
- Diagnostic Radiology, Independent Diagnostic Radiology Inc, St Petersburg, FL 33711, United States
| | - Stewart M Casper
- Personal Injury Law, Casper & DeToledo LLC, Stamford, CT 06905, United States
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Lima Santos JP, Jia-Richards M, Kontos AP, Collins MW, Versace A. Emotional Regulation and Adolescent Concussion: Overview and Role of Neuroimaging. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6274. [PMID: 37444121 PMCID: PMC10341732 DOI: 10.3390/ijerph20136274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/16/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023]
Abstract
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.
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Affiliation(s)
- João Paulo Lima Santos
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.J.-R.); (A.V.)
| | - Meilin Jia-Richards
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.J.-R.); (A.V.)
| | - Anthony P. Kontos
- Department of Orthopaedic Surgery, UPMC Sports Concussion Program, University of Pittsburgh, Pittsburgh, PA 15213, USA; (A.P.K.); (M.W.C.)
| | - Michael W. Collins
- Department of Orthopaedic Surgery, UPMC Sports Concussion Program, University of Pittsburgh, Pittsburgh, PA 15213, USA; (A.P.K.); (M.W.C.)
| | - Amelia Versace
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.J.-R.); (A.V.)
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4
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McDonald MA, Tayebi M, McGeown JP, Kwon EE, Holdsworth SJ, Danesh-Meyer HV. A window into eye movement dysfunction following mTBI: A scoping review of magnetic resonance imaging and eye tracking findings. Brain Behav 2022; 12:e2714. [PMID: 35861623 PMCID: PMC9392543 DOI: 10.1002/brb3.2714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/11/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022] Open
Abstract
Mild traumatic brain injury (mTBI), commonly known as concussion, is a complex neurobehavioral phenomenon affecting six in 1000 people globally each year. Symptoms last between days and years as microstructural damage to axons and neurometabolic changes result in brain network disruption. There is no clinically available objective biomarker to diagnose the severity of injury or monitor recovery. However, emerging evidence suggests eye movement dysfunction (e.g., saccades and smooth pursuits) in patients with mTBI. Patients with a higher symptom burden and prolonged recovery time following injury may show higher degrees of eye movement dysfunction. Likewise, recent advances in magnetic resonance imaging (MRI) have revealed both white matter tract damage and functional network alterations in mTBI patients, which involve areas responsible for the ocular motor control. This scoping review is presented in three sections: Section 1 explores the anatomical control of eye movements to aid the reader with interpreting the discussion in subsequent sections. Section 2 examines the relationship between abnormal MRI findings and eye tracking after mTBI based on the available evidence. Finally, Section 3 communicates gaps in our knowledge about MRI and eye tracking, which should be addressed in order to substantiate this emerging field.
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Affiliation(s)
- Matthew A McDonald
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Mātai Medical Research Institute, Gisborne, New Zealand
| | - Maryam Tayebi
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Joshua P McGeown
- Mātai Medical Research Institute, Gisborne, New Zealand.,Auckland University of Technology Traumatic Brain Injury Network, Auckland, New Zealand
| | - Eryn E Kwon
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Mātai Medical Research Institute, Gisborne, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Samantha J Holdsworth
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Mātai Medical Research Institute, Gisborne, New Zealand.,Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Eye Institute, Auckland, New Zealand
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Ware AL, Yeates KO, Tang K, Shukla A, Onicas AI, Guo S, Goodrich-Hunsaker N, Abdeen N, Beauchamp MH, Beaulieu C, Bjornson B, Craig W, Dehaes M, Doan Q, Deschenes S, Freedman SB, Goodyear BG, Gravel J, Ledoux AA, Zemek R, Lebel C. Longitudinal white matter microstructural changes in pediatric mild traumatic brain injury: An A-CAP study. Hum Brain Mapp 2022; 43:3809-3823. [PMID: 35467058 PMCID: PMC9294335 DOI: 10.1002/hbm.25885] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 01/07/2023] Open
Abstract
In the largest sample studied to date, white matter microstructural trajectories and their relation to persistent symptoms were examined after pediatric mild traumatic brain injury (mTBI). This prospective, longitudinal cohort study recruited children aged 8–16.99 years with mTBI or mild orthopedic injury (OI) from five pediatric emergency departments. Children's pre‐injury and 1‐month post‐injury symptom ratings were used to classify mTBI with or without persistent symptoms. Children completed diffusion‐weighted imaging at post‐acute (2–33 days post‐injury) and chronic (3 or 6 months via random assignment) post‐injury assessments. Mean diffusivity (MD) and fractional anisotropy (FA) were derived for 18 white matter tracts in 560 children (362 mTBI/198 OI), 407 with longitudinal data. Superior longitudinal fasciculus FA was higher in mTBI without persistent symptoms relative to OI, d (95% confidence interval) = 0.31 to 0.37 (0.02, 0.68), across time. In younger children, MD of the anterior thalamic radiations was higher in mTBI with persistent symptoms relative to both mTBI without persistent symptoms, 1.43 (0.59, 2.27), and OI, 1.94 (1.07, 2.81). MD of the arcuate fasciculus, −0.58 (−1.04, −0.11), and superior longitudinal fasciculus, −0.49 (−0.90, −0.09) was lower in mTBI without persistent symptoms relative to OI at 6 months post‐injury. White matter microstructural changes suggesting neuroinflammation and axonal swelling occurred chronically and continued 6 months post injury in children with mTBI, especially in younger children with persistent symptoms, relative to OI. White matter microstructure appears more organized in children without persistent symptoms, consistent with their better clinical outcomes.
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Affiliation(s)
- Ashley L Ware
- Department of Psychology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Keith Owen Yeates
- Department of Psychology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ken Tang
- Independent Statistical Consulting, Richmond, British Columbia, Canada
| | - Ayushi Shukla
- Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Adrian I Onicas
- Department of Psychology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,IMT School for Advanced Studies Lucca, Lucca, Italy
| | - Sunny Guo
- Department of Psychology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Nishard Abdeen
- Department of Radiology, University of Ottawa, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Miriam H Beauchamp
- Department of Psychology, University of Montreal & CHU Sainte-Justine Hospital Research Center, Montréal, Québec, Canada
| | - Christian Beaulieu
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Bruce Bjornson
- Division of Neurology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; 2. BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - William Craig
- University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Mathieu Dehaes
- Department of Radiology, Radio-oncology and Nuclear Medicine, Institute of Biomedical Engineering, University of Montreal; CHU Sainte-Justine Research Center, Montréal, Québec, Canada
| | - Quynh Doan
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sylvain Deschenes
- CHU Sainte-Justine Research Center; Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Montréal, Québec, Canada
| | - Stephen B Freedman
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bradley G Goodyear
- Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, University of Montréal, Montréal, Québec, Canada
| | - Andrée-Anne Ledoux
- Department of Cellular and Molecular Medicine, University of Ottawa, & Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Catherine Lebel
- Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Lima Santos JP, Kontos AP, Holland CL, Stiffler RS, Bitzer HB, Caviston K, Shaffer M, Suss Jr. SJ, Martinez L, Manelis A, Iyengar S, Brent D, Ladouceur CD, Collins MW, Phillips ML, Versace A. The role of sleep quality on white matter integrity and concussion symptom severity in adolescents. NEUROIMAGE: CLINICAL 2022; 35:103130. [PMID: 35917722 PMCID: PMC9421495 DOI: 10.1016/j.nicl.2022.103130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/29/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
Poor sleepers showed lower NDI in several tracts relative to good sleepers. The effect of sleep quality was significant after seven days between injury and scan. Good sleepers showed no differences relative to non-concussed controls. Significant relationship between low NDI, poor sleep, and higher symptom severity. Being female and low NDI significantly correlate with higher severity of symptoms.
Background Sleep problems are common after concussion; yet, to date, no study has evaluated the relationship between sleep, white matter integrity, and post-concussion symptoms in adolescents. Using self-reported quality of sleep measures within the first 10 days of injury, we aimed to determine if quality of sleep exerts a main effect on white matter integrity in major tracts, as measured by diffusion Magnetic Resonance Imaging (dMRI), and further examine whether this effect can help explain the variance in post-concussion symptom severity in 12- to 17.9-year-old adolescents. Methods dMRI data were collected in 57 concussed adolescents (mean age[SD] = 15.4[1.5] years; 41.2 % female) with no history of major psychiatric diagnoses. Severity of post-concussion symptoms was assessed at study entry (mean days[SD] = 3.7[2.5] days since injury). Using the Pittsburgh Sleep Quality Index (PSQI), concussed adolescents were divided into two groups based on their quality of sleep in the days between injury and scan: good sleepers (PSQI global score ≤ 5; N = 33) and poor sleepers (PSQI global score > 5; N = 24). Neurite Orientation Dispersion and Dispersion Index (NODDI), specifically the Neurite Density Index (NDI), was used to quantify microstructural properties in major tracts, including 18 bilateral and one interhemispheric tract, and identify whether dMRI differences existed in good vs poor sleepers. Since the interval between concussion and neuroimaging acquisition varied among concussed adolescents, this interval was included in the analysis along with an interaction term with sleep groups. Regularized regression was used to identify if quality of sleep-related dMRI measures correlated with post-concussion symptom severity. Due to higher reported concussion symptom severity in females, interaction terms between dMRI and sex were included in the regularized regression model. Data collected in 33 sex- and age-matched non-concussed controls (mean age[SD] = 15.2[1.5]; 45.5 % female) served as healthy reference and sex and age were covariates in all analyses. Results Relative to good sleepers, poor sleepers demonstrated widespread lower NDI (18 of the 19 tracts; FDR corrected P < 0.048). This group effect was only significant with at least seven days between concussion and neuroimaging acquisition. Post-concussion symptoms severity was negatively correlated with NDI in four of these tracts: cingulum bundle, optic radiation, striato-fronto-orbital tract, and superior longitudinal fasciculus I. The multiple linear regression model combining sex and NDI of these four tracts was able to explain 33.2 % of the variability in symptom severity (F[7,49] = 4.9, P < 0.001, Adjusted R2 = 0.332). Relative to non-concussed controls, poor sleepers demonstrated lower NDI in the cingulum bundle, optic radiation, and superior longitudinal fasciculus I (FDR corrected P < 0.040). Conclusions Poor quality of sleep following concussion is associated with widespread lower integrity of major white matter tracts, that in turn helped to explain post-concussion symptom severity in 12–17.9-year-old adolescents. The effect of sleep on white matter integrity following concussion was significant after one week, suggesting that acute sleep interventions may need this time to begin to take effect. Our findings may suggest an important relationship between good quality of sleep in the days following concussion and integrity of major white matter tracts. Moving forward, researchers should evaluate the effectiveness of sleep interventions on white matter integrity and clinical outcomes following concussion.
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