Academic Performance Following Sport-Related Concussions in Children and Adolescents: A Scoping Review

Parent-Reported Academic Outcomes After a Mild Traumatic Brain Injury in the Pediatric Population

BACKGROUND

Millions of children are diagnosed with a traumatic brain injury (TBI) each year, most being mild TBI (mTBI). The effect of mTBIs on academic performance is of significant importance. We investigate mTBI's impact on parent-reported academic outcomes in school-aged pediatric participants.

METHODS

This cross-sectional survey study queried parents (N = 285) regarding letter grade performance and the presence or absence of academic accommodations before and after an mTBI, including complicated mTBI (c-mTBI, or mTBI with radiographic abnormality).

RESULTS

We found a parent-reported decline in letter grades following c-mTBI (p < .001), with no significant change following uncomplicated mTBIs. Degree and length of recovery were also associated with grade changes (p < .05). Those with no academic accommodations prior to the injury showed significant decreases in grades after injury regardless of post-injury accommodation status (p < .05).

IMPLICATIONS OF SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

This study underscores the need for an improved framework of support to maximize academic performance of children following mTBI, especially in those with a c-mTBI and still recovering from their injury.

CONCLUSION

Our study identifies children who are at risk for adverse academic outcomes following mTBI. We encourage efforts to better support school nurses in this effort, including improved communication between health care teams and school teams.

Variables associated with days of school missed following concussion: results from the Sport Concussion Outcomes in PEdiatrics (SCOPE) study

OBJECTIVE

To understand factors associated with missed academic time after concussion to improve support for patients. Our goal was to assess patient-specific predictors of total school time lost after pediatric/adolescent concussion.

STUDY DESIGN

We performed a prospective cohort study of children and adolescents (8-18 years of age) seen within 14 days of concussion from seven pediatric medical centers across the United States. We collected outcomes via the Concussion Learning Assessment & School Survey (CLASS) and constructed a multivariable predictive model evaluating patient factors associated with school time loss.

RESULTS

167 patients participated (mean age = 14.5 ± 2.2 years; 46% female). Patients were assessed initially at 5.0 ± 3.0 days post-injury and had a final follow-up assessment 24.5 ± 20.0 days post-concussion. Participants missed a median of 2 days of school (IQR = 0.5-4), and 21% reported their grades dropped after concussion. Higher initial symptom severity rating (β = 0.06, 95% CI = 0.03-0.08, p < 0.001) and perception of grades dropping after concussion (β = 1.37, 95% CI = 0.28-2.45, p = 0.01) were significantly associated with more days of school time missed after concussion. Those who reported their grades dropping reported missing significantly more school (mean = 5.0, SD = 4.7 days missed of school) than those who reported their grades did not drop (mean = 2.2, SD = 2.6 days missed of school; p < 0.001; Cohen's d = 0.87).

CONCLUSIONS

Children and adolescents reported missing a median of 2 days of school following concussion, and more missed school time after a concussion was associated with more severe concussion symptoms and perception of grades dropping. These findings may support recommendations for minimal delays in return-to-learn after concussion.

Student concussion symptoms and tailored accommodations during use of a return to learn program in 13 public high schools

BACKGROUND

Youth concussion is common but there is a paucity of information on symptoms students report to school personnel and a gap in understanding what accommodations schools can provide.

OBJECTIVE

To examine symptoms and provision of temporary accommodations in schools for students reporting concussion symptoms.

DESIGN

Secondary data analysis of a trial implementing an evidence-based student-centered return to learn (RTL) program.

SETTING

Thirteen public high schools during the 2021-2022 academic year.

PARTICIPANTS

Sixty-two students diagnosed with concussion who reported symptoms to school personnel.

INTERVENTIONS

The school-based RTL program, which consists of up to four weekly check-ins with an RTL champion who evaluates symptoms and recommends symptom-tailored accommodations.

MAIN OUTCOME MEASURES

Symptom profile, accommodation type, and accommodation duration.

RESULTS

A total of 46 (74.2%) students received accommodation for ≤2 weeks and 16 (25.8%) students received accommodation for 3 (21.0%) or 4 (4.8%) weeks. Sixty-two students experienced an average of 11.2 unique symptoms during week 1. Compared to students whose symptoms resolved within the first 2 weeks, students who received accommodation for 3 or 4 weeks reported higher initial total symptom severity score (p = .02), and higher initial average severity per symptom (p = .01) at week 1. Physical symptoms were most common and received corresponding accommodations most often (75/90 reports: 83.3% of occurrences). In total, 674 (nearly 11 accommodations per student) weekly accommodations were offered.

CONCLUSIONS

Students with concussion report a large number and type of symptoms that necessitate symptom-tailored academic accommodations. High school implementation of an evidence-based RTL program may aid in identifying and addressing many RTL needs after concussion, including potential identification of students with concussion who will require longer-term support.

The Impact of Sports Injuries on the Academic Performance and Mental Health of High School Students in Jeddah

Objectives This study aimed to investigate the effects of sports injuries on the academic performance and mental health of high school students in Jeddah. Materials and methods This cross-sectional study utilized a closed-ended electronic questionnaire (e-questionnaire) sent to students from four international high schools in Jeddah. The e-questionnaire included questions assessing the level of academic courses, the frequency and types of sports injuries encountered, and the impact of these injuries on both academic performance and mental health. The chi-square test was used to establish relationships between categorical variables, with a p-value threshold of <0.05 determining statistical significance. Results Of the 117 high school students who participated in the study, 56.4% (n=66) were male and 43.6% (n=51) were female. Approximately 83.8% (n=98) of students engaged in sports. Interestingly, 65.0% (n=76) reported experiencing a sports injury during their high school years, with 73.7% (n=56) of these injuries occurring during school-related activities. These sports injuries significantly affected students' academic performance and mental health, impacting 65.8% (n=50) and 76.1% (n=51) of respondents, respectively. Major consequences included delayed assignments (96%, n=48 ), missed exams (88%, n=44), suicidal thoughts (56.9%, n=29), and self-harm thoughts (23.5%, n=12). Surprisingly, only 25.4% (n=17) of students received support from their schools. Furthermore, when support was provided, it was primarily in the form of medical assistance, with a notable lack of mental health support. Conclusion Our study revealed a significant gap in the school support system for students, which requires urgent attention. High school students are highly active and often experience sports-related injuries, particularly during school activities. These injuries can profoundly affect students' academic performance and mental health. Therefore, the findings of our study are essential for raising awareness among students, parents, and teachers about sports injury management. Additionally, although our study focused solely on private international schools, it is crucial for stakeholders in both government and private education sectors to address this issue at a broader level, ensuring adequate support for students facing such injuries. This will help protect the well-being and safety of future students.

Longitudinal neurocognitive trajectories and risk factors in the first three months following pediatric concussion

OBJECTIVE

To identify differential trajectories of neurocognitive outcomes following pediatric concussion and investigate predictors associated with patterns of recovery up to 3 months.

METHODS

74 participants aged 8-17 years completed attention/working memory, processing speed, and executive function measures at 2 weeks, 1 month, and 3 months post-injury. We used principal component analysis to generate a composite of information processing. Group-based trajectory modeling identified latent trajectories. Multinominal logistic regression was used to examine associations between risk factors and trajectory groups.

RESULTS

We identified three trajectories of neurocognitive outcomes. The medium (54.6%) and high improving groups (35.8%) showed ongoing increase in information processing, while the low persistent group showed limited change 3 months post-injury. This group recorded below average scores on Digit Span Forward and Backward at 3 months. History of pre-injury headache was significantly associated with the persistent low scoring group, relative to the medium improving (p = 0.03) but not the high improving group (p = 0.09).

CONCLUSIONS

This study indicates variability in neurocognitive outcomes according to three differential trajectories, with groups partially distinguished by preexisting child factors (history of frequent headaches). Modelling that accounts for heterogeneity in individual outcomes is essential to identify clinically meaningful indices that are indicative of children requiring intervention.

Concussion symptom presentation and clinical recovery among pediatric athletes: comparing concussions sustained during school and summer months

OBJECTIVE

We examined post-concussion symptom presentation, exercise, and sleep among pediatric athletes who sustained concussion during the school year vs. summer months.

METHODS

We evaluated athletes 6-18 years old within 21-days of concussion. They reported symptoms (Health and Behavior Inventory), with cognitive/somatic domain sub-scores calculated, and indicated if they had exercised or experienced sleep problems since injury. We grouped patients by injury season: summer months (June-August) vs. school year (September-May).

RESULTS

350 patients (14.4 ± 2.4 years old; 37% female; initial visit 8.8 ± 5.3 days post-concussion) were seen for care: 24% sustained a concussion during summer months, 76% during the school year. Lower cognitive (median = 7 [IQR = 1, 15] vs. 9.5 [4, 17]; p = 0.01), but not somatic (7 [2.5, 11] vs. 8 [4, 13]; p = 0.06), HBI scores were observed for patients injured during the summer. Groups were similar in proportion exercising (16% vs 17%) and endorsing sleep problems (29% vs 31%). After adjustments, sustaining a concussion during the summer predicted total (β=-3.43; 95%CI = -6.50, -0.36; p = 0.029) and cognitive (β = -2.29; 95%CI = -4.22, -0.36; p = 0.02), but not somatic (β=-1.46; 95%CI = -2.84, -0.08; p = 0.04), symptom severity.

CONCLUSION

Pediatric patients with concussion may present with greater cognitive symptoms during the school year, compared to summer months.

Assessment of post-concussion emotional symptom load using PCSS and PROMIS instruments in pediatric patients

OBJECTIVES

The purpose of this study is to evaluate the utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depressive symptom domains in conjunction with the Post-Concussion Symptom Scale (PCSS)for identifying pediatric patients with emotional symptoms following a concussion, and to identify predictors of higher emotional symptom loads.

METHODS

We recruited English-speaking patients aged 8-17 years presenting to a tertiary-care concussion clinic from 2014 to 2018 (n = 458). Demographics and clinical data including PCSS, injury date, previous history of anxiety/depression, and Vestibular/Ocular-Motor Screen (VOMS) were collected from patients' electronic medical records. Participants completed surveys in the PROMISTM Pediatric Item Bank v1.1-Anxiety and Depressive Symptoms domains at their initial clinic visit. Multivariable linear regression identified predictors of higher emotional symptom loads.

RESULTS

Overall, 425 (92.8%) reported ≥1 emotional symptom on either PROMIS or PCSS. Predictors of higher emotional symptom loads were abnormal VOMS, female sex, history of anxiety or depression, and longer time since injury.

CONCLUSION

Our results suggest that adding PROMIS anxiety and depressive symptom surveys to pediatric concussion evaluations may identify more children with emotional symptoms, allowing clinicians to better direct post-concussion treatment and incorporate psychological support for patients if necessary. Future studies should examine whether earlier identification of emotional symptoms with these tools facilitates recovery and improves short- and/or long-term psychological outcomes in pediatric concussion.

Consensus statement: An evidence-based review of exercise, rehabilitation, rest, and return to activity protocols for the treatment of concussion and mild traumatic brain injury

BACKGROUND

Early diagnosis and appropriate management of concussion/mild traumatic brain injury (mTBI) is critical for preventing poor outcomes and minimizing health care burden. Current clinical guidelines for concussion management focus mostly on diagnosis and return to cognitive and physical activity but provide limited guidance on the use of specific therapeutic interventions.

OBJECTIVE

To systematically review the available evidence on therapeutic interventions for concussion/mTBI and develop an evidence-based consensus statement on the use of these interventions in clinical practice.

LITERATURE SURVEY

A systematic literature search was performed first in 2018 and 2019, and again in 2022, to identify relevant original research on these interventions. A total of 6303 articles were retrieved through the systematic literature search and screened for inclusion. Eighty articles met inclusion criteria and were included in this review and consensus process.

METHODOLOGY

A multispecialty panel was convened to explore management of concussion/mTBI. Interventions evaluated included rest, exercise, rehabilitation, and return to activity (RTA) protocols. Studies were assessed for relevance and methodologic quality and were voted upon to develop an evidence-based consensus statement on the therapeutic appropriateness of these interventions for concussion/mTBI. A meta-analysis was not performed.

SYNTHESIS

There was sufficient evidence to recommend exercise as an appropriate therapy for adolescents with acute concussion/mTBI. In other age groups and for other therapeutic modalities, although some studies demonstrated benefits for some of the interventions, mixed results and study limitations prevented the panel from drawing firm conclusions on the efficacy of those interventions. The panel found evidence of detrimental effects from strict rest and high-intensity physical activity.

CONCLUSIONS

The panel recommended exercise as an appropriate therapy for acute concussion in adolescents. The evidence on other therapeutic interventions for concussion/mTBI remains limited to small randomized controlled trials and observational studies of moderate to low quality. The panel found no strong evidence to support or recommend against the other evaluated interventions but found most interventions to be safe when used judiciously and in consideration of individual patient needs. High-quality randomized studies with sufficient power are needed to evaluate the effects of rest, rehabilitation, and RTA protocols for the management of concussion/mTBI.

Improving outcome after paediatric concussion: challenges and possibilities

The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.

Management of sports-related concussion in the emergency department

Sports-related concussion is a common presentation to the emergency department, with increasing evidence of short and long-term morbidity. The heterogeneity of symptoms and clinical outcomes, alongside a lack of familiarity with current guidance, can present significant challenges to clinicians. This article presents an overview of the current literature concerning assessment and management of sports-related concussion in the emergency department and outlines a framework for graduated return to activity as based upon the current national guidance.

Does Sleep Quality Influence Recovery Outcomes After Postconcussive Injury in Children and Adolescents?

OBJECTIVE

To determine whether objective parameters of sleep quality differ throughout recovery between children and adolescents who experienced an early return to school (RTS) and those who had a delayed RTS or did not return at all during the study period.

SETTING

Sleep parameters reflective of sleep quality were evaluated in participants' natural sleeping habitat throughout 9 weeks postinjury.

PARTICIPANTS

Ninety-four children and adolescents (aged 5-18 years) with diagnosed concussion.

DESIGN

Prospective cohort. Participants followed RTS protocols.

MAIN MEASURES

Actigraphy-derived estimates of total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), average arousal length (AAL), and number of arousals (NOAs) per hour were assessed. The length of time from injury until RTS was determined for each participant. Participants were categorized into an early RTS or delayed RTS group based on their time to RTS.

RESULTS

Both TST and SE were significantly greater in the early RTS group. WASO duration, AAL, and NOAs were significantly greater in the delayed RTS group. Differences between RTS groups were most apparent during weeks 1 to 5 postinjury.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Participants who returned to school earlier had significantly better objective sleep quality than participants who experienced a delayed RTS. This study provides evidence in support of a relationship between sleep quality and time to RTS in children and adolescents with concussion. Considering early monitoring of sleep, education regarding sleep hygiene, and access to age-appropriate sleep interventions may be helpful in pediatric concussion recovery.

Effect of RISE bundle implementation on school adoption of a student-centered return-to-learn program in Washington state

BACKGROUND

Appropriate concussion care in school is vital for full recovery, but school return-to-learn (RTL) programs are lacking and vary in quality. Establishing student-centered RTL programs may reduce disparities in RTL care.

OBJECTIVE

To examine the effect of RISE Bundle (Return to Learn Implementation Bundle for Schools) implementation on high school adoption of a student-centered RTL program.

METHODS

A convenience sample of fourteen (4 rural and 10 urban) small and large Washington (WA) State public high schools were enrolled in a stepped-wedge study with baseline, end of study, and monthly measures over the 2021-2022 academic year. Schools identified an RTL champion who led RISE Bundle implementation in 6-week steps. Concussion knowledge and impact of RTL program on concussion care were examined.

RESULTS

Ten schools (71.4%) successfully completed RISE Bundle implementation and established a functional RTL program. Self-reported concussion knowledge from RTL Champions increased post intervention. Establishing RTL programs facilitated provision of tailored accommodations, and perceived variation and inequities in RTL care were reduced.

CONCLUSION

RISE Bundle implementation proved feasible, supported the establishment of a functional RTL program, and perceived to reduce disparities in concussion care in rural and urban WA State public high schools of varying sizes.

Return-to-learn after concussion in Washington state public high schools during the COVID-19 pandemic

Aim: To understand academic support structures for Washington state public high school students with concussion during the COVID-19 pandemic. Materials & methods: Prospective, repeated cross-sectional study of 21 schools in 2020 and 2021. Results: About 28% of schools reported not providing any return-to-learn (RTL) accommodations for students with concussion throughout the COVID-19 pandemic. RTL accommodation provision was associated with larger student body size ( β = 0.002) and higher graduation rate ( β = 0.261) but was not associated with presence of RTL school policy. About 38.1% of schools received no guidance on how to provide RTL accommodations during the COVID-19 pandemic, and many reported that students with concussion struggled more. Conclusion: Schools struggled to provide RTL accommodations for students with concussion during the COVID-19 pandemic, highlighting the need for evidence-based guidance and resource allocation to vulnerable schools.

School performance in youth after a concussion

Objective

This study aimed to identify school problems and levels of cognitive activity in youths aged 5-18 years with a concussion during the recovery stages of return to school (RTS).

Study Design

In a prospective cohort, participants completed in-person assessments at three time points: First Visit Post-injury, Symptom Resolution Visit, and Follow-Up Visit. These time points varied based on the participants' recovery progress. The post-concussion symptom scale (PCSS) and a cognitive activity scale were completed every 2 days until symptom resolution was achieved. Participants and their parents completed a school questionnaire detailing how their concussion had impacted their school learning/performance and their level of concern about their injury as well as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).

Results

Sixty-three percent (N = 44/70) of participants returned to school by the First Visit Post-injury (average 7.7 days following injury), and of these, 50% (N = 22) were experiencing school problems. Sixty-five participants (out of 70) returned to school at the Follow-Up Visit, and of these, 18% reported school problems. There was a significant difference in the school problems reported by parents and youth. At the First Visit Post-injury, the youth reported more problems (p = 0.02), and the In-Person Symptom Resolution Visit with parents reported more problems (p = 0.01). The cognitive activity score increased, while the PCSS score decreased from RTS Stage 1 to Stage 5.

Conclusions

This study identified that 50% of youth experienced school problems at the First Visit Post-injury, whereas only 18% reported school problems at the Follow-Up Visit. There is a significant difference in the perception of school problems reported by youth and their parents at different stages of recovery. The amount and complexity of cognitive activity increased with decreasing symptoms and increasing RTS stage. Findings can guide youth with a concussion and their parents in supporting a cautious return to school with accommodations. Healthcare providers and researchers can use this knowledge to better support youth in their return to school and understand the importance of gathering information from youth and their parents to gain the best insight into recovery.

Association of concussion with high school academic standing: sex, school grade and race as stratifiers

INTRODUCTION

The purpose was to examine the association between concussion history and academic standing among high school students, and whether the association varies by sex, school grade and race/ethnicity.

METHODS

Data from the 2019 Youth Risk Behaviour Survey were used for our cross-sectional study. Exposure was self-reported history of concussions in the past 12 months. Outcome was self-reported academic standing in the past 12 months. Poisson regression was used to analyse the exposure-outcome association, and whether there were differences by our stratifying variables.

RESULTS

Having a history of concussion in the past 12 months was significantly associated with a higher risk of poor academic standing during the same period, and the association varied by race/ethnicity.

DISCUSSION

Youth with a history of concussion may be at risk for poorer academic standing, indicating to the importance of prevention. Future studies are needed to examine the interaction of race/ethnicity on the presented association.

Physician recommended school accommodations and student outcomes following a mild traumatic brain injury among youth with persistent post-concussive symptoms

BACKGROUND

Post-concussion return-to-learn (RTL) guidelines include implementation of school accommodations. Yet, little is known about physician recommendations for school accommodations and their impact, particularly among youth experiencing persistent post-concussive symptoms (PPCS).

OBJECTIVE

We examined the association between physician recommended school accommodations and student outcomes among youth experiencing PPCS.

METHODS

Data from a randomized comparative effectiveness trial was used. Physician recommended school accommodations (≤90 days post-injury) were collected via chart abstraction. Grade point average was extracted from school records. Reports of problems at school, concussion symptoms, health-related quality of life (HRQOL), anxiety symptoms, and depressive symptoms were collected by survey (at baseline, three months, and 12 months post study entry).

RESULTS

Of 200 participants (Mage = 14.7, 62% female), 86% were recommended school accommodations. Number of recommended school accommodations was positively associated with number of school problems at three months (aRR 1.18, 95% CI:1.12-1.24) and 12 months (aRR 1.11, 95% CI:1.05-1.18). No significant associations were found between recommended school accommodations and GPA, HRQOL, anxiety symptoms, or depressive symptoms.

CONCLUSIONS

Physicians recommend more school accommodations for students experiencing more school problems post-concussion. Appropriate implementation of RTL recommendations made by physicians by fostering partnerships among physicians, students, and schools may be needed to achieve student-centered RTL.

Effect of Collaborative Care for Persistent Postconcussive Symptoms on Academic Function: A Randomized Clinical Trial

BACKGROUND

There is limited long-term data on the course of school-related problems and academic needs for youth with persistent post-concussive symptoms (PPCS).

METHODS

This was a randomized trial comparing collaborative care to usual care for 200 youth 11-18 years of age with PPCS. In this report, the main outcomes were academic functioning, GPA, school absences, date of return to school, and school days missed.

RESULTS

Youth were mean age of 14.7 (SD = 1.7), 62.0% female. New or worsening academic problems occurred in half of participants in both groups at 12 months after injury. Students were most concerned about grades and falling behind. There were no significant differences by study group on school problems or GPA, but number of days missed was lower in the collaborative care group compared at 3 months (12.5 [SD = 14.5] vs 16.1 days [20.4] adjusted relative risk [aRR] 0.67 [95% CI: 0.61, 0.74; p < .001]), 6 months (14.5 [22.1] vs 19.3 [26.6] aRR 0.77 [95% CI: 0.71, 0.84; p < .001]), and 12 months (16.9 [25.4] vs 19.6 [27.7], aRR 0.68 [95% CI: 0.62, 0.74; p < .001]).

CONCLUSIONS

Youth with PPCS are at high risk of school problems in the year after injury.

The Nocebo Effect and Pediatric Concussion

While placebo effects are well recognized within clinical medicine, "nocebo effects" have received much less attention. Nocebo effects are problems caused by negative expectations derived from information or treatment provided during a clinical interaction. In this review, we examine how nocebo effects may arise following pediatric concussion and how they may worsen symptoms or prolong recovery. We offer several suggestions to prevent, lessen, or eliminate such effects. We provide recommendations for clinicians in the following areas: terminology selection, explicit and implicit messaging to patients, evidence-based recommendations, and awareness of potential biases during clinical interactions. Clinicians should consider the empirically grounded suggestions when approaching the care of pediatric patients with concussion.