Head Impact Exposure in Hawaiian High School Football: Influence of Adherence Rates on a Helmetless Tackling and Blocking Training Intervention

CONTEXT

High school football remains a popular, physically demanding sport despite the known risks for acute brain and neck injury. Impacts to the head also raise concerns about their cumulative effects and long-term health consequences.

OBJECTIVE

To examine the effectiveness of a helmetless tackling training program to reduce head impact exposure in football participants.

DESIGN

A three-year, quasi-experimental, prospective cohort (clinicaltrials.gov #NCTXXX) study.

SETTING

Honolulu (XXX, XXX) area public and private secondary schools with varsity and junior varsity football.

PATIENTS OR OTHER PARTICIPANTS

Football participants (n=496) ages 14 to 18 years old. Intervention(s) Participants wore new football helmets furnished with head impact sensor technology. Teams employed a season-long helmetless tackling and blocking intervention in Years 2 and 3 consisting of a 3-phase, systematic progression of 10 instructional drills.

MAIN OUTCOME MEASURE(S)

Head impact frequency per athlete exposure (ImpAE), location, and impact magnitude per participant intervention adherence levels (60% and 80%).

RESULTS

An overall regression analysis revealed a significant negative association between ImpAE and adherence (p=0.003, beta=-1.21, SE=0.41). In year 3, a longitudinal data analysis of weekly ImpAE data resulted in an overall difference between the adherent and non-adherent groups (p=0.040 at 80%; p=0.004 at 60%), mainly due to decreases in top and side impacts. Mean cumulative impact burden for the adherent group (n=131: 2,105.84g ± 219.76,) was significantly (p=0.020) less than the non-adherent group (n=90: 3,158.25g ± 434.80) at the 60% adherence level.

CONCLUSIONS

Participants adhering to the intervention on at least a 60% level experienced a 34% to 37% significant reduction in the number of head impacts (per exposure) through the season. These results provide additional evidence that a helmetless tackling and blocking training intervention (utilizing the HuTT® program) reduces head impact exposure in high school football players. Adherence to an intervention is crucial for achieving intended outcomes.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury

OBJECTIVE

To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings.

DESIGN

Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus.

PARTICIPANTS

The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations.

RESULTS

The first two Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.'

CONCLUSIONS

New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Univariate and Multivariate Base Rates of Score Elevations, Reliable Change, and Inter-Rater Discrepancies in the BRIEF-A Standardization Samples

The Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) is a standardized rating scale of subjective executive functioning. We provide univariate and multivariate base rates (BRs) for scale/index scores in the clinical range (T scores ≥65), reliable change, and inter-rater information not included in the Professional Manual. Participants were adults (ages = 18-90 years) from the BRIEF-A self-report (N = 1,050) and informant report (N = 1,200) standardization samples, as well as test-retest (n = 50 for self, n = 44 for informant) and inter-rater (n = 180) samples. Univariate BRs of elevated T scores were low (self-report = 3.3%-15.4%, informant report = 4.5%-16.3%). Multivariate BRs revealed the common occurrence of obtaining at least one elevated T-score across scales (self-report = 26.5%-37.3%, informant report = 22.7%-30.3%), whereas virtually none had elevated scores on all scales. Test-retest scores were highly correlated (self = .82-.94; informant = .91-.96). Inter-rater correlations ranged from .44 to .68. Significant (p < .05) test-retest T-score differences ranged from 7 to 12 for self-report, from 6 to 8 for informant report, and from 16 to 21 points for inter-rater T-score differences. Applications of these findings are discussed.

Fenfluramine treatment is associated with improvement in everyday executive function in preschool-aged children (<5 years) with Dravet syndrome: A critical period for early neurodevelopment

OBJECTIVE

To evaluate whether fenfluramine (FFA) is associated with improvement in everyday executive function (EF)-self-regulation-in preschool-aged children with Dravet syndrome (DS).

METHODS

Children with DS received placebo or FFA in one of two phase III studies (first study: placebo, FFA 0.2 mg/kg/day, or FFA 0.7 mg/kg/day added to stiripentol-free standard-of-care regimens; second study: placebo or FFA 0.4 mg/kg/day added to stiripentol-inclusive regimens). Everyday EF was evaluated at baseline and Week 14-15 for children aged 2-4 years with parent ratings on the Behavior Rating Inventory of Executive Function®-Preschool (BRIEF®-P); raw scores were transformed to T-scores and summarized in Inhibitory Self-Control Index (ISCI), Flexibility Index (FI), Emergent Metacognition Index (EMI), and Global Executive Composite (GEC). Clinically meaningful improvement and worsening were defined using RCI ≥ 90% and RCI ≥ 80% certainty, respectively. The associations between placebo vs FFA combined (0.2, 0.4, and 0.7 mg/kg/day) or individual treatment groups and the likelihood of clinically meaningful change in BRIEF®-P indexes/composite T-scores were evaluated using Somers'd; pairwise comparisons were calculated by 2-sided Fisher's Exact tests (p ≤ 0.05) and Cramér's V.

RESULTS

Data were analyzed for 61 evaluable children of median age 3 years (placebo, n = 22; FFA 0.2 mg/kg/day, n = 15; 0.4 mg/kg/day [with stiripentol], n = 10; 0.7 mg/kg/day, n = 14 [total FFA, n = 39]). Elevated or problematic T-scores (T ≥ 65) were reported in 55% to 86% of patients at baseline for ISCI, EMI, and GEC, and in ∼33% for FI. Seventeen of the 61 children (28%) showed reliable, clinically meaningful improvement (RCI ≥ 90% certainty) in at least one BRIEF®-P index/composite, including a majority of the children in the FFA 0.7 mg/kg/day group (9/14, 64%). Only 53% of these children (9/17) also experienced clinically meaningful reduction (≥50%) in monthly convulsive seizure frequency, including 6/14 patients in the FFA 0.7 mg/kg/day group. Overall, there were positive associations between the four individual treatment groups and the likelihood of reliable, clinically meaningful improvement in all BRIEF®-P indexes/composite (ISCI, p = 0.001; FI, p = 0.005; EMI, p = 0.040; GEC, p = 0.002). The FFA 0.7 mg/kg/day group showed a greater likelihood of reliable, clinically meaningful improvement than placebo in ISCI (50% vs 5%; p = 0.003), FI (36% vs 0%; p = 0.005), and GEC (36% vs 0%; p = 0.005). For EMI, the FFA 0.7 mg/kg/day group showed a greater likelihood of reliable, clinically meaningful improvement than the FFA 0.2 mg/kg/day group (29% vs 0%; p = 0.040), but did not meet the significance threshold compared with placebo (29% vs 5%; p = 0.064). There were no significant associations between treatment and the likelihood of reliable, clinically meaningful worsening (p > 0.05).

SIGNIFICANCE

In this preschool-aged DS population with high baseline everyday EF impairment, FFA treatment for 14-15 weeks was associated with dose-dependent, clinically meaningful improvements in regulating behavior, emotion, cognition, and overall everyday EF. These clinically meaningful improvements in everyday EF were not entirely due to seizure frequency reduction, suggesting that FFA may have direct effects on everyday EF during the early formative years of neurodevelopment.

Stakeholder perspectives on navigating the pediatric concussion experience: Exploring the needs for improved communication across the care continuum

BACKGROUND

For children, the post-concussion return to school process is a critical step towards achieving positive health outcomes. The process requires integration between healthcare professionals, parents, and school personnel.

OBJECTIVE

This research team conducted focus groups with stakeholders including parents, education personnel, school nurses, external healthcare providers (nurses) and athletic trainers to identify communication patterns between healthcare providers outside of the school setting and school personnel.

METHODS

Data from focus groups were analyzed using a Thematic Analysis approach. Researchers used an inductive (bottom-up) coding process to describe semantic themes and utilized a critical realist epistemology.

RESULTS

We identified four key themes within focus group data: (1) lack of effective communication between hospital and outpatient healthcare providers to school personnel; (2) parents who were strong advocates had improved communication with healthcare professionals and garnered more accommodations for their children; (3) non-school professionals and families were often confused about who the point of contact was at a given school; and (4) differing experiences for athletes vs. non-athletes.

CONCLUSION

This study suggests gaps in communication between healthcare and school professionals when children return to school following a concussion. Improving communication between healthcare providers and school staff will require a multi-faceted approach.

A-215 Comparability of BRIEF2 and BRIEF-A Self-Report in Young Adults

Objective: The Behavior Rating Inventory of Executive Function (BRIEF) captures perceptions of an individual’s executive functioning in their everyday environment. Two self-report forms span late adolescence into early adulthood: BRIEF2 (ages 11-18) and BRIEF-Adult (ages 18-90). We compared responses on these forms in young adults to evaluate their continuity in this transitional age range.

Method: Participants were 77 college students [age M(SD)= 18.45(0.64), 66% female], without psychiatric or serious medical conditions, who completed the BRIEF2 and BRIEF-A forms in counterbalanced order. Mean scores on shared clinical scales (Inhibit, Self-Monitor, Shift, Emotional Control, Working Memory, Plan/Organize) and Global Executive Composite (GEC) were examined using MANOVA and correlations; T scores were examined in the subsample of 18-year-olds (n=47).

Results: For mean ratings, planned univariate follow-up tests with Bonferroni correction were significant only for the Inhibit scale [F(1,76) = 14.69, p &lt; .001, Cohen’s d = -0.44]. Other effect sizes were &lt; 0.3. Scales correlated well (r range .63 to .82, p &lt; .001). T-score analyses yielded similarly strong relationships (r range .58 to .84), but with significant differences on Emotional Control (d = 0.53) and Plan/Organize (d = -0.47).

Conclusions: Results indicate good correspondence between self-report on the BRIEF2 and BRIEF-A in young adults, with few differences and generally small effect sizes. Nonetheless, statistical corrections should be employed if merging datasets using both BRIEF2 and BRIEF-A, or when examining changes in individuals followed from adolescence into adulthood using the two forms of the BRIEF.

Application of the RE-AIM Framework for the Pediatric Mild Traumatic Brain Injury Evaluation and Management Intervention: A Study Protocol for Program Evaluation

Background

Children who experience a mild Traumatic Brain Injury (mTBI) may encounter cognitive and behavioral changes that often negatively impact school performance. Communication linkages between the various healthcare systems and school systems are rarely well-coordinated, placing children with an mTBI at risk for prolonged recovery, adverse impact on learning, and mTBI re-exposure. The objective of this study is to rigorously appraise the pediatric Mild Traumatic Brain Injury Evaluation and Management (TEaM) Intervention that was designed to enhance diagnosis and management of pediatric mTBI through enhanced patient discharge instructions and communication linkages between school and primary care providers.

Methods

This is a combined randomized and 2 × 2 quasi-experimental study design with educational and technology interventions occurring at the clinician level with patient and school outcomes as key endpoints. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework will be utilized as a mix methods approach to appraise a multi-disciplinary, multi-setting intervention with the intent of improving outcomes for children who have experienced mTBI.

Discussion

Utilization of the RE-AIM framework complemented with qualitative inquiry is suitable for evaluating effectiveness of the TEaM Intervention with the aim of emphasizing priorities regarding pediatric mTBI. This program evaluation has the potential to support the knowledge needed to critically appraise the impact of mTBI recovery interventions across multiple settings, enabling uptake of the best-available evidence within clinical practice.

Enhanced interpretation of the BRIEF2: multivariate base rates of elevated scores in the standardization samples

The Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2) is a standardized rating (self, parent, and teacher) scale of executive functioning in children and adolescents. Here, we provide multivariate base rate (MBR) information (for the Self, Parent, and Teacher forms), which is not included in the BRIEF2 Professional Manual. Participants were children and adolescents for the BRIEF2 Self-Report (ages = 11-18; N = 803), Parent-Report (ages = 5-18; N = 1,400), and Teacher-Report (ages = 5-18; N = 1,400) standardization samples. We focused on cumulative (e.g., % of sample with oneor more elevated scores) MBRs across scales, which were examined at three elevation levels on each form: T≥ 60, ≥65, and ≥70. Across forms, MBRs predictably decreased with increasing number of elevated scores and at higher cutoffs. The cumulative MBR of having at least one score at T≥ 60 was common (37.5-42.2%), but less frequent at T≥ 70 (15.4-17.4%). The probability of having elevated scores on all scales was very low, irrespective of form, age, or elevation threshold (T≥ 60 = 2.4-4.4%; T≥ 65 = 1.0-1.4%; T≥ 70 = 0.0-0.7%). There was no clinically meaningful relation between demographic factors (age, gender, race, and parental education) and MBRs. These data provide clinicians and researchers with an enhanced way of concurrently interpreting multiple BRIEF2 scales.

Improved everyday executive functioning following profound reduction in seizure frequency with fenfluramine: Analysis from a phase 3 long-term extension study in children/young adults with Dravet syndrome

OBJECTIVE

Individuals with Dravet syndrome (DS) experience frequent pharmacoresistant seizures beginning in infancy. Most exhibit poor neurodevelopmental outcomes including motor function difficulties, behavior problems, and cognitive impairment. Cognitive deficits in children with DS have been associated with seizure frequency and antiseizure medication (ASM) use. Recent research in children and young adults with DS has begun to examine the role of executive functions (EFs), as these include higher-order cognitive functions and may mediate the relationship between risk factors and cognitive impairment. Current conceptualizations, however, of EFs involve the broader self-regulation of cognitive, behavioral, and emotional domains. We explored relationships between reduction in convulsive seizure frequency and everyday EFs in a subset of children and young adults with DS treated with adjunctive fenfluramine for 1 year.

METHODS

This is a post-hoc analysis of data from children and young adults with Dravet syndrome aged 5-18 years who participated in a phase 3 randomized, placebo-controlled clinical trial (core study) followed by completion of at least 1 year of fenfluramine treatment in an open-label extension (OLE) study. Eligible children and young adults started the OLE study at 0.2 mg/kg/day fenfluramine and were titrated to optimal seizure control and tolerability (maximum daily dose: 26 mg/day). Parents/caregivers documented convulsive seizure frequency per 28 days (i.e., monthly convulsive seizure frequency [MCSF]) by electronic diary. A parent/caregiver for each child also completed the Behavior Rating Inventory of Executive Function (BRIEF®) parent form, a questionnaire capturing parents'/caregivers' perceptions of everyday EF that was included as a safety measure to assess treatment-related adverse effects on EF during the trial. Ratings on BRIEF® were mapped to the current edition, the BRIEF®2 parent form, and were used to calculate T-scores for the Behavior Regulation Index (BRI), Emotion Regulation Index (ERI), Cognitive Regulation Index (CRI), and Global Executive Composite (GEC). Change in BRIEF®2 T-scores from baseline in the core study to Year 1 of the OLE study was calculated. Spearman's rho correlation coefficients assessed associations between change in BRIEF®2 indexes/composite T-scores and percentage change in MCSF. Children and young adults were divided into 2 groups based on percentage of MCSF reduction achieved from pre-randomization baseline in the core study to Year 1 of the OLE study: <50% and ≥50% MCSF reduction. Changes in the distribution of BRIEF®2 indexes/composite T-scores were compared between MCSF reduction groups using Mann-Whitney U tests. The proportions of children and young adults in these groups who showed clinically meaningful improvement in everyday EF, defined as Reliable Change Index (RCI) values ≥95% certainty relative to a reference population of neurotypically developing healthy volunteers, were then assessed by cross-tabulations and Somers' D tests (p ≤ 0.05). When there was a significant meaningful improvement in an index score, post-hoc analyses using the same statistical methods were conducted to evaluate the individual BRIEF®2 scales composing that index. Supplemental analyses examined the proportions of patients in MCSF reduction groups <25% and ≥75% who achieved clinically meaningful improvement or worsening in everyday EF using RCI values ≥95% certainty and ≥80% certainty, respectively, relative to the reference population.

RESULTS

At the time of analysis, 58 children and young adults (mean age: 11 ± 4 years) had reached OLE Year 1 of fenfluramine treatment with a 75% median percentage reduction in seizure frequency from pre-randomization baseline. Overall, there was a significant correlation between change in MCSF and change in BRIEF®2 T-scores for ERI (p = 0.008), but not for BRI, CRI, or GEC (p > 0.05). At OLE Year 1, 78% (n = 45) of total children/young adults had ≥50% MCSF reduction (50% [n = 29] achieved ≥75% MCSF reduction) and 22% (n = 13) of total children/young adults had <50% MCSF reduction (12% [n = 7] showed <25% MCSF reduction). The ≥50% MCSF reduction group was significantly more likely to achieve clinically meaningful improvement (RCI ≥ 95% certainty) in ERI (p = 0.002) and in CRI (p = 0.001) than the <50% MCSF reduction group. There were no significant differences in the proportions of children and young adults in the 2 MCSF reduction groups showing clinically meaningful worsening (RCI ≥ 80% certainty) on the BRIEF®2 indexes/composite.

SIGNIFICANCE

In children and young adults with DS, the magnitude of reduction in MCSF after long-term treatment with adjunctive fenfluramine was associated with clinically meaningful levels of improvement in everyday EF. Seventy-eight percent (78%) of children and young adults treated with adjunctive fenfluramine for 1 year in the OLE study achieved ≥50% reduction in MCSF, for a magnitude of efficacy associated with a significantly greater likelihood of experiencing clinically meaningful improvement in emotion regulation and cognitive regulation.

Characteristics of Pediatric Mild Traumatic Brain Injury and Recovery in a Concussion Clinic Population

IMPORTANCE

Pediatric mild traumatic brain injury (TBI) and concussion are a public health challenge with up to 30% of patients experiencing prolonged recovery. Pediatric patients presenting to concussion clinics often have ongoing impairments and may be at increased risk for persistent symptoms. Understanding this population is critical for improved prognostic estimates and optimal treatment.

OBJECTIVE

To describe pediatric patients presenting to concussion clinics and characterize factors associated with their recovery.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included patients enrolled at multicenter concussion specialty clinics from the Four Corners Youth Consortium from December 2017 to July 2019, with up to 12-month follow-up. Patients were eligible if they were aged 5 to 18.99 years with a diagnosis of mild TBI or concussion presenting to participating clinics within 8 weeks of injury. Patients were excluded if the patient or their parents were unable to read or sign the consent document, or if the patient had a Glasgow Coma Scale score less than 13 or a penetrating injury. Data were analyzed from February 2019 to April 2020.

EXPOSURES

Diagnosis of mild TBI or concussion.

MAIN OUTCOMES AND MEASURES

This study used National Institute of Neurological Disorders and Stroke common data elements, including data on demographic characteristics, injury details, history, neurological and neuropsychological assessments, and treatment.

RESULTS

A total of 600 patients were consecutively enrolled, among whom 324 (54.0%) were female and 435 (72.5%) were adolescents (ie, aged 13-18 years). A higher proportion of girls and women (248 patients [76.5%]) were adolescents compared with boys and men (187 patients [67.8%]) (P = .02), and girls and women reported significantly more preexisting anxiety compared with boys and men (80 patients [26.7%] vs 46 patients [18.7%]; P = .03). Significantly more adolescents reported preexisting migraines compared with preadolescents (82 patients [20.9%] vs 15 patients [10.9%]; P = .01). Girls and women recovered more slowly than boys and men (persistent symptoms after injury: week 4, 217 patients [81.6%] vs 156 patients [71.2%]; week 8, 146 patients [58.9%] vs 89 patients [44.3%]; week 12, 103 patients [42.6%] vs 58 patients [30.2%]; P = .01). Patients with history of migraine or anxiety or depression recovered more slowly than those without, regardless of sex.

CONCLUSIONS AND RELEVANCE

These findings suggest that identification of subgroups of pediatric patients with mild TBI or concussion at risk for prolonged recovery could aid in better prognostic estimates and more targeted treatment interventions.

A commentary for neuropsychologists on CDC's guideline on the diagnosis and management of mild traumatic brain injury among children

Objective: In 2018, the Centers for Disease Control Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children. This commentary summarizes the key recommendations in the CDC Pediatric mTBI Guideline most relevant for neuropsychologists and discusses research gaps and topics that should receive attention in future iterations of the Guideline.Method: We described the methods used to develop the Guideline, which included a comprehensive Systematic Review. We also distilled and presented key practice strategies reflected in Guideline.Results: To optimize care of pediatric patients with mTBI, neuropsychologists should: use validated, age-appropriate symptom scales, assess evidence-based risk factors for prolonged recovery, provide patients with instructions on return to activity customized to their symptoms, and counsel patients to return gradually to nonsports activities after a short period of rest. Future iterations of the Guideline should encompass a review and guidance on care of patients with psychiatric and psychological difficulties, as well as the potential use of imaging to assess patients with persistent symptoms. Expanded research on mTBI among girls, children age 8 and under, and effective treatments for pediatric mTBI will be beneficial to inform care practices.Conclusions: Recommendations in the CDC Pediatric mTBI Guideline highlight multiple opportunities for neuropsychologists to take action to improve the care of young patients with mTBI and to advance research in the field. Multiple resources and tools are available to support implementation of these recommendations into clinical practice.

Reproducibility of cognitive endpoints in clinical trials: lessons from neurofibromatosis type 1

Objective

Rapid developments in understanding the molecular mechanisms underlying cognitive deficits in neurodevelopmental disorders have increased expectations for targeted, mechanism‐based treatments. However, translation from preclinical models to human clinical trials has proven challenging. Poor reproducibility of cognitive endpoints may provide one explanation for this finding. We examined the suitability of cognitive outcomes for clinical trials in children with neurofibromatosis type 1 (NF1) by examining test‐retest reliability of the measures and the application of data reduction techniques to improve reproducibility.

Methods

Data were analyzed from the STARS clinical trial (n = 146), a multi‐center double‐blind placebo‐controlled phase II trial of lovastatin, conducted by the NF Clinical Trials Consortium. Intra‐class correlation coefficients were generated between pre‐ and post‐performances (16‐week interval) on neuropsychological endpoints in the placebo group to determine test‐retest reliabilities. Confirmatory factor analysis was used to reduce data into cognitive domains and account for measurement error.

Results

Test‐retest reliabilities were highly variable, with most endpoints demonstrating unacceptably low reproducibility. Data reduction confirmed four distinct neuropsychological domains: executive functioning/attention, visuospatial ability, memory, and behavior. Test‐retest reliabilities of latent factors improved to acceptable levels for clinical trials. Applicability and utility of our model was demonstrated by homogeneous effect sizes in the reanalyzed efficacy data.

Interpretation

These data demonstrate that single observed endpoints are not appropriate to determine efficacy, partly accounting for the poor test‐retest reliability of cognitive outcomes in clinical trials in neurodevelopmental disorders. Recommendations to improve reproducibility are outlined to guide future trial design.

Fatigue After Concussion: Do Children and Their Parents Report the Same Changes?

Purpose

Fatigue is a commonly reported complaint after concussion; however, fatigue is multi-faceted and a child’s experience of fatigue may differ from their parent’s observations. Differences in self and parent report of post-concussive changes in fatigue were examined.

Methods

Participants were 266 patients (Mean age=13.49, SD=2.75, range 5–18) seen in a concussion clinic. The PedsQL Multidimensional Fatigue Scale (MFS) was completed. Dependent variables were: General Fatigue, Cognitive Fatigue, Sleep Fatigue, and Total Fatigue. Pearson correlations, paired-tests, and repeated measures MANOVA evaluated differences.

Results

Self- and parent-report scores were correlated (r range=.33 to .66, p< .01). Change in fatigue differed by rater (F(1, 247)=6.79, p=.01, ηp2=.03). For General and Sleep Fatigue, self- and parent report were not statistically different. For Cognitive Fatigue, self-report was significantly worse than parent report. Adolescents (13-18) reported higher Cognitive Fatigue than older children (8-12), t(255)=2.263, p=.02. Parents did not observe a difference between age-groups for Cognitive Fatigue. There were non-significant trends toward female adolescents reporting more change in Cognitive Fatigue.

Conclusion

Children and parents agree that fatigue worsens during concussion recovery. However, parents may not observe the effect of fatigue on cognitive activities (i.e., schoolwork), specifically among adolescents. Thus, self-report of symptom experience after concussion should be an essential part of a post-concussive evaluation. Future studies would benefit from examination of the functional impact of worsened fatigue following concussion.

Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population

IMPORTANCE

The natural progression of symptom change and recovery remains poorly defined in children after concussion.

OBJECTIVES

To describe the natural progression of symptom change by age group (5-7, 8-12, and 13-18 years) and sex, as well as to develop centile curves to inform families about children after injury recovery.

DESIGN, SETTING, AND PARTICIPANTS

Planned secondary analysis of a prospective multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics). The setting was 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Participants were aged 5 to 18 years with acute concussion, enrolled from August 1, 2013, to May 31, 2015, and data analyses were performed between January 2018 and March 2018.

EXPOSURES

Participants had a concussion consistent with the Zurich Consensus Statement on Concussion in Sport diagnostic criteria and 85% completeness of the Postconcussion Symptom Inventory (PCSI) at each time point.

MAIN OUTCOMES AND MEASURES

The primary outcome was symptom change, defined as current rating minus preinjury rating (delta score), at presentation and 1, 2, 4, 8, and 12 weeks after injury, measured using the PCSI. Symptoms were self-rated for ages 8 to 18 years and rated by the child and parent for ages 5 to 7 years. The secondary outcome was recovery, defined as no change in symptoms relative to current preinjury PCSI ratings (delta score = 0). Mixed-effects models incorporated the total score, adjusting for random effects (site and participant variability), fixed-effects indicators (age, sex, time, age by time interaction, and sex by time interaction), and variables associated with recovery. Recovery centile curves by age and sex were computed.

RESULTS

A total of 3063 children (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 60.7% male) completed the primary outcome; 2716 were included in the primary outcome analysis. For the group aged 5 to 7 years, symptom change primarily occurred the first week after injury; by 2 weeks, 75.6% of symptoms had improved (PCSI change between 0 and 2 weeks, -5.3; 95% CI, -5.5 to -5.0). For the groups aged 8 to 12 years and 13 to 18 years, symptom change was prominent the first 2 weeks but flattened between 2 and 4 weeks. By 4 weeks, 83.6% and 86.2% of symptoms, respectively, had improved for the groups aged 8 to 12 years (PCSI change between 0 and 4 weeks, -9.0; 95% CI, -9.6 to -8.4) and 13 to 18 years (PCSI change between 0 and 4 weeks, -28.6; 95% CI, -30.8 to -26.3). Sex by time interaction was significant only for the adolescent group (β = 0.32; 95% CI, 0.21-0.43; P < .001). Most adolescent girls had not recovered by week 12.

CONCLUSIONS AND RELEVANCE

Symptom improvement primarily occurs in the first 2 weeks after concussion in children and in the first 4 weeks after concussion in preadolescents and male adolescents. Female adolescents appear to have protracted recovery. The derived recovery curves may be useful for evidence-based anticipatory guidance.

Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children

Importance

Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States.

Objective

To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI.

Evidence Review

The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015.

Findings

The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment.

Conclusions and Relevance

This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

IMPORTANCE

In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study.

OBJECTIVE

To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI.

EVIDENCE REVIEW

Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search.

FINDINGS

Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking.

CONCLUSIONS AND RELEVANCE

This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

National Institute of Neurological Disorders and Stroke and Department of Defense Sport-Related Concussion Common Data Elements Version 1.0 Recommendations

Through a partnership with the National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, and Department of Defense, the development of Sport-Related Concussion (SRC) Common Data Elements (CDEs) was initiated. The aim of this collaboration was to increase the efficiency and effectiveness of clinical research studies and clinical treatment outcomes, increase data quality, facilitate data sharing across studies, reduce study start-up time, more effectively aggregate information into metadata results, and educate new clinical investigators. The SRC CDE Working Group consisted of 32 worldwide experts in concussion from varied fields of related expertise divided into three Subgroups: Acute (<72 h post-concussion), Subacute (3 days-3 months post-concussion) and Persistent/Chronic (>3 months post-concussion). To develop CDEs, the Subgroups reviewed various domains, then selected from, refined, and added to existing CDEs, case report forms and field-tested data elements from national registries and funded research studies. Recommendations were posted to the NINDS CDE Website for Public Review from February 2017 to April 2017. Following an internal Working Group review of recommendations, along with consideration of comments received from the Public Review period, the first iteration (Version 1.0) of the NINDS SRC CDEs was completed in June 2017. The recommendations include Core and Supplemental-Highly Recommended CDEs for cognitive data elements and symptom checklists, as well as other outcomes and end-points (e.g., vestibular, oculomotor, balance, anxiety, depression), and sample case report forms (e.g., injury reporting, demographics, concussion history) for domains typically included in clinical research studies. The NINDS SRC CDEs and supporting documents are publicly available on the NINDS CDE website www.commondataelements.ninds.nih.gov . Widespread use of CDEs by researchers and clinicians will facilitate consistent SRC clinical research and trial design, data sharing, and metadata retrospective analysis.

Returning to School Following Sport-Related Concussion

Following sport-related concussion, the priorities for student athletes are return to school and extracurricular activities. Consensus-based practice recommendations emphasize rest and gradual resumption of activities. Specific evidence-based recommendations are not available. This article provides recommendations, strategies, and a general approach to the recovery process. Most youth recover clinically and return to their normal activities within the first month following injury. It is best to avoid prolonged time off from school and restrictions on social and recreational activities because these might result in adverse consequences, such as life stress, depression, and falling behind in school.

What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic review

Objective

To evaluate the evidence regarding (1) factors affecting return to school (RTS) and (2) strategies/accommodations for RTS following a sport-related concussion (SRC) in children and adolescents.

Design

A systematic review of original studies specifically addressing RTS following concussion in the paediatric and sporting context.

Data sources

MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid) electronic databases and the grey literature OpenGrey, ClinicalTrials.gov and Google Advanced.

Eligibility criteria

Studies were included if they were original research on RTS following SRC in children aged 5–18 years published in English between 1985 and 2017.

Results

A total of 180 articles were identified; 17 articles met inclusion criteria. Several factors should be considered for RTS after concussion, including: symptomatology; rest following injury; age/grade; and course load. On RTS after concussion, 17%–73% of students were provided academic accommodations or experienced difficulty with RTS. Students were more likely to obtain academic accommodations in schools with a concussion policy if they had a medical RTS letter and had regular medical follow-up after concussion.

Conclusions

Schools should have a concussion policy and offer individualised academic accommodations to students recovering from SRC on RTS; a medical letter should be provided to facilitate provision/receipt of academic accommodations; students should have early, regular medical follow-up following SRC to help with RTS and monitor recovery; students may require temporary absence from school after SRC; clinicians should assess risk factors/modifiers that may prolong recovery and require more intensive academic accommodations.

PROSPERO registration number

CRD42016039184.

What is the difference in concussion management in children as compared with adults? A systematic review

AIM

To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC.

RESULTS

A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5-12 years.

SUMMARY/CONCLUSIONS

This systematic review recommends that in children: child and adolescent age-specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016:CRD42016039184.

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale

This article presents the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). The Sport Concussion Assessment Tool was introduced in 2004, following the 2nd International Conference on Concussion in Sport in Prague, Czech Republic. Following the 4th International Consensus Conference, held in Zurich, Switzerland, in 2012, the SCAT 3rd edition (Child SCAT3) was developed for children aged between 5 and12 years. Research to date was reviewed and synthesised for the 5th International Consensus Conference on Concussion in Sport in Berlin, Germany, leading to the current revision of the test, the Child SCAT5. This article describes the development of the Child SCAT5.

Randomized placebo-controlled study of lovastatin in children with neurofibromatosis type 1

OBJECTIVE

To assess the efficacy of lovastatin on visuospatial learning and attention for treating cognitive and behavioral deficits in children with neurofibromatosis type 1 (NF1).

METHODS

A multicenter, international, randomized, double-blind, placebo-controlled trial was conducted between July 2009 and May 2014 as part of the NF Clinical Trials Consortium. Children with NF1 aged 8-15 years were screened for visuospatial learning or attention deficits (n = 272); 146 children demonstrated deficits at baseline and were randomly assigned to lovastatin (n = 74; 40 mg/d) or placebo (n = 70). Treatment was administered once daily for 16 weeks. Primary outcomes were total errors on the Cambridge Neuropsychological Test Automated Battery Paired Associate Learning task (visuospatial learning) and the Score subtest from the Test of Everyday Attention for Children (sustained attention). Secondary outcomes measured executive function, attention, visuospatial skills, behavior, and quality of life. Primary analyses were performed on the intention-to-treat population.

RESULTS

Lovastatin had no significant effect on primary outcomes after 16 weeks of treatment: visuospatial learning (Cohen d = -0.15, 95% confidence interval -0.47 to 0.18) or sustained attention (Cohen d = 0.19, 95% confidence interval -0.14 to 0.53). Lovastatin was well tolerated, with no increase in reported adverse events compared to placebo.

CONCLUSIONS

Lovastatin administered once daily for 16 weeks did not improve visuospatial learning or attention in children with NF1 and is not recommended for amelioration of cognitive deficits in this population.

CLINICALTRIALSGOV IDENTIFIER

This study was registered at ClinicalTrials.gov (NCT00853580) and Australian New Zealand Clinical Trials Registry (ACTRN12607000560493).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that for children with NF1, lovastatin does not improve visuospatial learning or attention deficits.

Subconcussive Head Impact Exposure and White Matter Tract Changes over a Single Season of Youth Football

Purpose To examine the effects of subconcussive impacts resulting from a single season of youth (age range, 8-13 years) football on changes in specific white matter (WM) tracts as detected with diffusion-tensor imaging in the absence of clinically diagnosed concussions. Materials and Methods Head impact data were recorded by using the Head Impact Telemetry system and quantified as the combined-probability risk-weighted cumulative exposure (RWE_CP). Twenty-five male participants were evaluated for seasonal fractional anisotropy (FA) changes in specific WM tracts: the inferior fronto-occipital fasciculus (IFOF), inferior longitudinal fasciculus, and superior longitudinal fasciculus (SLF). Fiber tracts were segmented into a central core and two fiber terminals. The relationship between seasonal FA change in the whole fiber, central core, and the fiber terminals with RWE_CP was also investigated. Linear regression analysis was conducted to determine the association between RWE_CP and change in fiber tract FA during the season. Results There were statistically significant linear relationships between RWE_cp and decreased FA in the whole (R² = 0.433; P = .003), core (R² = 0.3649; P = .007), and terminals (R² = 0.5666; P < .001) of left IFOF. A trend toward statistical significance (P = .08) in right SLF was observed. A statistically significant correlation between decrease in FA of the right SLF terminal and RWE_CP was also observed (R² = 0.2893; P = .028). Conclusion This study found a statistically significant relationship between head impact exposure and change of FA fractional anisotropy value of whole, core, and terminals of left IFOF and right SLF's terminals where WM and gray matter intersect, in the absence of a clinically diagnosed concussion. ^© RSNA, 2016.

Subconcussive impacts and imaging findings over a season of contact sports

The effect of repeated subconcussive head impacts in youth and high school sports on the developing brain is poorly understood. Emerging neuroimaging data correlated with biomechanical exposure metrics are beginning to demonstrate relationships across a variety of modalities. The long-term consequences of these changes are unknown. A review of the currently available literature on the effect of subconcussive head impacts on youth and high school-age male football players provides compelling evidence for more focused studies of these effects in these vulnerable populations.

Concussions are known to cause clinical symptoms, which are especially concerning for youth and high school athletes. However, the effects of repeated head impacts that do not cause a diagnosed concussion, known as subconcussive head impacts, are currently unknown. Recent research has identified similar changes in the brain following repeated nonconcussive impacts to the head, once thought to be caused only by the occurrence of concussion with the presence of clinical symptoms. Similarly, many reports suggest that a higher exposure to head impacts is associated with a greater amount of structural and/or functional changes in the brain. Given the similar effects on the brain, with or without symptoms, more work is needed to determine the long-term effects of subconcussive head impacts on individual athletes, particularly in the youth and high school age population.

Abnormalities in Diffusional Kurtosis Metrics Related to Head Impact Exposure in a Season of High School Varsity Football

The purpose of this study was to determine whether the effects of cumulative head impacts during a season of high school football produce changes in diffusional kurtosis imaging (DKI) metrics in the absence of clinically diagnosed concussion. Subjects were recruited from a high school football team and were outfitted with the Head Impact Telemetry System (HITS) during all practices and games. Biomechanical head impact exposure metrics were calculated, including: total impacts, summed acceleration, and Risk Weighted Cumulative Exposure (RWE). Twenty-four players completed pre- and post-season magnetic resonance imaging, including DKI; players who experienced clinical concussion were excluded. Fourteen subjects completed pre- and post-season Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). DKI-derived metrics included mean kurtosis (MK), axial kurtosis (K axial), and radial kurtosis (K radial), and white matter modeling (WMM) parameters included axonal water fraction, tortuosity of the extra-axonal space, extra-axonal diffusivity (D_e axial and radial), and intra-axonal diffusivity (D_a). These metrics were used to determine the total number of abnormal voxels, defined as 2 standard deviations above or below the group mean. Linear regression analysis revealed a statistically significant relationship between RWE combined probability (RWE_CP) and MK. Secondary analysis of other DKI-derived and WMM metrics demonstrated statistically significant linear relationships with RWE_CP after covariate adjustment. These results were compared with the results of DTI-derived metrics from the same imaging sessions in this exact same cohort. Several of the DKI-derived scalars (D_a, MK, K axial, and K radial) explained more variance, compared with RWE_CP, suggesting that DKI may be more sensitive to subconcussive head impacts. No significant relationships between DKI-derived metrics and ImPACT measures were found. It is important to note that the pathological implications of these metrics are not well understood. In summary, we demonstrate a single season of high school football can produce DKI measurable changes in the absence of clinically diagnosed concussion.

Medical-School Partnership in Guiding Return to School Following Mild Traumatic Brain Injury in Youth

Mild traumatic brain injury is recognized as a prevalent and significant risk concern for youth. Appropriate school return is particularly challenging. The medical and school systems must be prepared partners to support the school return of the student with mild traumatic brain injury. Medical providers must be trained in assessment and management skills with a focused understanding of school demands. Schools must develop policies and procedures to prepare staff to support a gradual return process with the necessary academic accommodations. Ongoing communication between the family, student, school, and medical provider is essential to supporting recovery. A systematic gradual return to school process is proposed including levels of recommended activity and criteria for advancement. Targets for intervention are described with associated strategies for supporting recovery. A 10-element Progressive Activities of Controlled Exertion (PACE) model for activity-exertion management is introduced to manage symptom exacerbation. A strong medical-school partnership will maximize outcomes for students with mild traumatic brain injury.

Additional Post-Concussion Impact Exposure May Affect Recovery in Adolescent Athletes

Repeat concussion has been associated with risk for prolonged and pronounced clinical recovery in athletes. In this study of adolescent athletes, we examined whether an additional head impact within 24 h of a sports-related concussion (SRC) is associated with higher symptom burden and prolonged clinical recovery compared with a single-injury group. Forty-two student-athletes (52% male, mean age = 14.9 years) diagnosed with an SRC in a concussion clinic were selected for this study: (1) 21 athletes who sustained an additional significant head impact within 24 h of the initial injury (additional-impact group); (2) 21 single-injury athletes, age and gender matched, who sustained only one discrete concussive blow to the head (single-injury group). Groups did not differ on initial injury characteristics or pre-injury risk factors. The effect of injury status (single- vs. additional-impact) was examined on athlete- and parent-reported symptom burden (at first clinic visit) and length of recovery (LOR). Higher symptom burden was reported by the athletes and parents in the additional-impact group at the time of first visit. The additional-impact group also had a significantly longer LOR compared with the single-injury group. These findings provide preliminary, hypothesis-generating evidence for the importance of immediate removal from play following an SRC to protect athletes from re-injury, which may worsen symptoms and prolong recovery. The retrospective study design from a specialized clinical sample points to the need for future prospective studies of the relationship between single- and additional-impact injuries on symptom burden and LOR.

Academic effects of concussion in children and adolescents

OBJECTIVE

The aim of this work is to study the nature and extent of the adverse academic effects faced by students recovering from concussion.

METHOD

A sample of 349 students ages 5 to 18 who sustained a concussion and their parents reported academic concerns and problems (eg, symptoms interfering, diminished academic skills) on a structured school questionnaire within 4 weeks of injury. Postconcussion symptoms were measured as a marker of injury severity. Results were examined based on recovery status (recovered or actively symptomatic) and level of schooling (elementary, middle, and high school).

RESULTS

Actively symptomatic students and their parents reported higher levels of concern for the impact of concussion on school performance (P < .05) and more school-related problems (P < .001) than recovered peers and their parents. High school students who had not yet recovered reported significantly more adverse academic effects than their younger counterparts (P < .05). Greater severity of postconcussion symptoms was associated with more school-related problems and worse academic effects, regardless of time since injury (P < .001).

CONCLUSIONS

This study provides initial evidence for a concussion's impact on academic learning and performance, with more adverse effects reported by students who had not yet recovered from the injury. School-based management with targeted recommendations informed by postinjury symptoms may mitigate adverse academic effects, reduce parent and student concerns for the impact of the injury on learning and scholastic performance, and lower the risk of prolonged recovery for students with active postconcussion symptoms.

Multimodal evaluation and management of children with concussion: using our heads and available evidence

BACKGROUND

Significant attention has been focused on concussions in children, but a dearth of research evidence exists supporting clinical evaluation and management.

AIM

The primary objective of this review paper is to describe a multimodal, developmentally adapted, standardized concussion assessment and active rehabilitation approach for children as young as 5 years old.

METHODS

This study reviews the CDC-funded research programme, including the development of tools for post-concussion symptom assessment involving the child and parent, measurement of specific neurocognitive functions and assessment of dynamic cognitive exertional effects.

RESULTS

A clinical approach to active, individualized, moderated concussion rehabilitation management is presented, including a 10-step guide to symptom management, with a specific focus on the school challenges faced by the recovering student.

CONCLUSION

To better inform concussion practice across the developmental age spectrum, a significant need exists for further research evidence to refine clinical assessment methods and develop effective treatment approaches.

Abnormal white matter integrity related to head impact exposure in a season of high school varsity football

The aim of this study was to determine whether the cumulative effects of head impacts from a season of high school football produce magnetic resonance imaging (MRI) measureable changes in the brain in the absence of clinically diagnosed concussion. Players from a local high school football team were instrumented with the Head Impact Telemetry System (HITS™) during all practices and games. All players received pre- and postseason MRI, including diffusion tensor imaging (DTI). Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was also conducted. Total impacts and risk-weighted cumulative exposure (RWE), including linear (RWELinear), rotational (RWERotational), and combined components (RWECP), were computed from the sensor data. Fractional, linear, planar, and spherical anisotropies (FA, CL, CP, and CS, respectively), as well as mean diffusivity (MD), were used to determine total number of abnormal white matter voxels defined as 2 standard deviations above or below the group mean. Delta (post-preseason) ImPACT scores for each individual were computed and compared to the DTI measures using Spearman's rank correlation coefficient. None of the players analyzed experienced clinical concussion (N=24). Regression analysis revealed a statistically significant linear relationship between RWECP and FA. Secondary analyses demonstrated additional statistically significant linear associations between RWE (RWECP and RWELinear) and all DTI measures. There was also a strong correlation between DTI measures and change in Verbal Memory subscore of the ImPACT. We demonstrate that a single season of football can produce brain MRI changes in the absence of clinical concussion. Similar brain MRI changes have been previously associated with mild traumatic brain injury.

The Relation Between Testing Environment and Baseline Performance in Child and Adolescent Concussion Assessment

BACKGROUND

Previous research has demonstrated differences in cognitive performance when baseline concussion assessment is performed in a group versus an individual setting. Accurate baseline assessment is imperative when such data are used to make clinical decisions regarding cognitive and symptom recovery after concussion.

HYPOTHESIS

The use of similar standardized test administration procedures and test conditions across group and individual settings results in no differences in cognitive performance or symptom reporting.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 939 participants (aged 5-18 years), including 313 tested individually and 626 tested in a group setting, matched on age, sex, and attention-deficit/hyperactivity disorder status, were administered concussion baseline assessment using the desktop version of the Immediate Post-Concussion Assessment and Cognitive Testing and a new pediatric measure, the Multimodal Assessment of Cognition & Symptoms for Children. Cognitive performance, symptom reports, and rates of invalid performance were compared between settings.

RESULTS

No significant differences were found between individual and group testing settings for the age-based Learning and Memory Accuracy composite and Response Speed composite standard scores on the Multimodal Assessment of Cognition & Symptoms for Children. Accounting for age and sex, adolescents' performance on the Immediate Post-Concussion Assessment and Cognitive Testing revealed no differences between settings on the 4 composite raw scores (Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time). Furthermore, symptom reporting was similar between settings on both measures. Rates of invalid performance did not differ between the 2 administration groups for either age group. There was an interaction effect for invalid performance between attention-deficit/hyperactivity disorder and setting in younger children (aged 5-12 years), with higher rates of invalid performance for children in the group setting with attention-deficit/hyperactivity disorder compared with those without, although there were no differences in the individual setting.

CONCLUSION

In this sample, children given a baseline assessment in a group setting performed no differently than children tested individually when standardized administration procedures were used by trained test administrators. Previous evidence suggesting differences between settings may be attributable to the variability in test administration and supervision rather than the environment itself. The importance of standardized procedures and proper supervision during baseline concussion assessment is supported by these findings.

Psychometric characteristics of the postconcussion symptom inventory in children and adolescents

Psychometric characteristics of the Postconcussion Symptom Inventory (PCSI) were examined in both concussed (n = 633) and uninjured (n = 1,273) 5 to 18 year olds. Parent- and self-report forms were created with developmentally appropriate wording and content. Factor analyses identified physical, cognitive, emotional, and sleep factors; that did not load strongly or discriminate between groups were eliminated. Internal consistency was strong for the total scales (α = 0.8-0.9). Test-retest reliability for the self-report forms was moderate to strong (intraclass coeffecients, ICCs = 0.65-0.89). Parent and self-report concordance was moderate (r = .44-.65), underscoring the importance of both perspectives. Convergent validity with another symptom measure was good (r = .8). Classification analyses indicated greater discriminability from parent report, but caveats to this are presented. With strong psychometric characteristics, the four versions of the PCSI capture important postconcussion symptoms and can be utilized to track recovery from pediatric concussion and guide treatment recommendations.

Use of modified acute concussion evaluation tools in the emergency department

OBJECTIVES

Accurate recognition of pediatric concussion in the emergency department (ED) is important to ensure appropriate management for safe recovery. The study objective was to determine whether the Centers for Disease Control and Prevention's Acute Concussion Evaluation (ACE) tools, modified for ED use, improved patient follow-up and post-injury behaviors.

METHODS

The original ACE tools (ACE, ACE Care Plan) were modified for ED use via Delphi methodology with an expert panel and implemented in 2 urban pediatric EDs for patients aged 5 to 21 years evaluated within 24 hours of a head injury. Pre- (February 2009 to July 2009) and post- (December 2009 to June 2010) implementation, patient phone surveys were conducted 1, 2, and 4 weeks after ED discharge. Reported rates of patient follow-up and recovery measures were analyzed. ED clinician adherence was assessed.

RESULTS

During the study, 164 patients were enrolled pre-implementation and 190 post-implementation. The mean patient age was 10.6 years (SD, 3.7); 65% were males, 49% were African American, and 46% were Caucasian. Post-implementation, 58% of patients received the modified ACE diagnostic tool and 84% received the modified ACE discharge instructions. Follow-up was improved at all time points (32% vs 61% at week 4; P < .001; odds ratio, 3.4; 95% confidence interval, 2.1-5.4). Post-implementation, parental recall of discharge instructions was significantly increased, patient's mean total post-concussion symptom score was significantly higher, and report of return to normal activity was significantly longer.

CONCLUSIONS

The ACE tools, modified for ED use, were successfully implemented in the pediatric ED. Post-implementation, increased patient follow-up and improved recall of and adherence to ED discharge recommendations was demonstrated.

National Athletic Trainers' Association position statement: management of sport concussion

OBJECTIVE

To provide athletic trainers, physicians, and other health care professionals with best-practice guidelines for the management of sport-related concussions.

BACKGROUND

An estimated 3.8 million concussions occur each year in the United States as a result of sport and physical activity. Athletic trainers are commonly the first medical providers available onsite to identify and evaluate these injuries.

RECOMMENDATIONS

The recommendations for concussion management provided here are based on the most current research and divided into sections on education and prevention, documentation and legal aspects, evaluation and return to play, and other considerations.

Everyday executive function in standard-risk acute lymphoblastic leukemia survivors

We aimed to evaluate parent-rated executive function (EF) in pediatric standard risk acute lymphoblastic leukemia (SR-ALL) survivors compared to a healthy comparison (HC) group. We hypothesized that SR-ALL survivors would have greater reported executive dysfunction compared to HC, and that those younger at the time of treatment would demonstrate greater EF difficulties. A sample of 256 SR-ALL survivors evaluated an average nine years after treatment were compared to HC matched for gender, assessment age, and maternal education. Profile analysis was used to compare the groups across EF scales on the BRIEF. The prevalence of clinical elevations in the groups was compared via chi square, and odds ratios were calculated. Regression models were applied to examine the role of age at diagnosis and age at assessment in reported EF. Results indicated that SR-ALL survivors' mean scores of EF are similar to HC, except for flexibility and initiation. Survivors were rated as having clinical impairments with flexibility, initiation, working memory, and emotional control at rates two to three times that of HC. The risk of working memory and self-monitoring deficits was greater in survivors who were older when assessed. There was no relationship between age at diagnosis or treatment regimen on EF. These findings suggest sparing of extensive and severe EF deficits in SR-ALL survivors overall. However, a subset of survivors displays clinically significant executive dysfunction. There appears to be a heightened susceptibility to disrupted metacognitive functions as survivors age. This has implications for how we monitor neurocognitive development and functioning of SR-ALL survivors, and highlights opportunities for cognitive interventions.

Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology

OBJECTIVE

To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article.

METHODS

We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations.

RESULTS

Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.