Predictors of clinical recovery from concussion: a systematic review

Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York

There has been an increased focus and awareness of head injury and sport-related concussion (SRC) across all sports from the medical and scientific communities, sports organisations, legislators, the media and the general population. Soccer, in particular, has been a focus of attention due to the popularity of the game, the frequency of SRC and the hypothesised effects of repetitive heading of the ball. Major League Soccer, US Soccer and the National Women’s Soccer League jointly hosted a conference entitled, ‘Head Injury in Soccer: From Science to the Field’, on 21–22 April 2017 in New York City, New York. The mission of this conference was to identify, discuss and disseminate evidence-based science related to the findings and conclusions of the fifth International Conference on Concussion in Sport held by the Concussion in Sport Group and apply them to the sport of soccer. In addition, we reviewed information regarding the epidemiology and mechanism of head injuries in soccer at all levels of play, data regarding the biomechanics and effects of repetitive head impacts and other soccer-specific considerations. We discussed how to release the information raised during the summit to key stakeholders including athletes, parents, coaches and healthcare providers. We identified future areas for research and collaboration to enhance the health and safety of soccer (football) players.

American Medical Society for Sports Medicine position statement on concussion in sport

Sport-related concussion (SRC) is a common injury in recreational and organised sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment and management of SRC. In addition to a growing need for knowledgeable healthcare professionals to provide evidence-based care for athletes with SRC, media attention and legislation have created awareness and, in some cases, fear about many issues and unknowns surrounding SRC. The American Medical Society for Sports Medicine (AMSSM) formed a writing group to review the existing literature on SRC, update its previous position statement, and to address current evidence and knowledge gaps regarding SRC. The absence of definitive outcomes-based data is challenging and requires relying on the best available evidence integrated with clinical experience and patient values. This statement reviews the definition, pathophysiology and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short-term and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The AMSSM is committed to best clinical practices, evidence-based research and educational initiatives that positively impact the health and safety of athletes.

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.

A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes

Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.

Recent Advances in Pediatric Concussion and Mild Traumatic Brain Injury

Concussions after a head injury among children continues to be a substantial public health concern. An increasing number of concussions are being managed initially by primary care physicians. The diagnosis of concussion remains a clinical diagnosis despite the availability of ancillary tests such as computerized neuropsychological testing, advanced imaging, and blood biomarkers. Clinically, overlooking other injuries and comorbidities may lead to prolonged recovery for the patient. Addressing concussions in a multidisciplinary approach may help in reducing recovery time for patients. Retirement from sport in the pediatric population remains a controversial issue lacking evidenced-based studies.

Posttraumatic headache in pediatrics: an update and review

PURPOSE OF REVIEW

Headache following concussion and mild traumatic brain injury is very common in pediatrics. There is significant concern about appropriate management of acute and persistent headache following mild head injuries in children among affected youth, their families and care providers.

RECENT FINDINGS

The current article will review definitions and diagnoses of posttraumatic headache (PTHA), recent research regarding risk factors for persistence of postconcussion symptoms and headaches, current recommendations for the evaluation of youth with PTHA, recent data regarding efficacy of treatment options for PTHA, and current recommendations for the treatment of acute and persistent PTHA.

SUMMARY

PTHA is common following concussion in pediatrics. Some of the most consistent risk factors for persistent symptoms following concussion include female sex, adolescent age, prior concussion with prolonged recovery, prior headache history and high number of acute symptoms, particularly migrainous symptoms, following concussion. There are few prospective studies of the treatment of PTHA in pediatrics; however, a recent study found that short-term use of ibuprofen for those with acute PTHA following concussion may be associated with lower risk of symptoms and better function 1 week after injury. Currently complete rest or cocooning following concussion is not recommended as it may actually be associated with longer recovery time; a gradual return to cognitive and physical activity appears to be most effective strategy but more study is needed.

Rehabilitation of an Adolescent Equestrian Athlete With a History of Multiple Concussions: A Case Report Describing an Adapted Return-to-Sport Protocol

BACKGROUND

Equestrian riding is a sport with a high risk of concussion. Currently, the literature guiding rehabilitation for concussions in equestrian athletes is limited, especially for directing return to sport.

CASE DESCRIPTION

In this case report, a 14-year-old female equestrian athlete presented to physical therapy following her third concussion in 3 years. Her primary complaints were headaches, dizziness, difficulty concentrating, light sensitivity, and neck pain. On examination, the patient demonstrated reproduction of symptoms during testing of the vestibular-ocular reflex, showed a 3-line symptomatic loss on the dynamic visual acuity test, and had impairments in the joint position error test (1/5 correct on the left, 4/5 correct on the right) and a Balance Error Scoring System (BESS) score of 38/60 errors. A return-to-riding protocol was adapted from general return-to-sport guidelines and tailored to meet the unique demands of the patient's equestrian sport. The protocol included phased progression through no activity, light aerobic activity, moderate aerobic activity, sport-specific nonjumping skills, sport-specific jumping skills, full practice, and return to competition. During the protocol, the patient participated in 8 physical therapy sessions over 4 weeks for vestibular training, aerobic conditioning, and cervical and core exercises, as well as equestrian exercises at her stables.

OUTCOMES

At the final evaluation, the patient reported no symptoms at rest, with exercise, or when testing vestibular-ocular reflex. Improvements were noted in the dynamic visual acuity test, joint position error, and BESS, with changes in the BESS exceeding minimal detectable change. The patient completed the full return-to-riding protocol in 8 weeks and was able to return to equestrian competition without complaints.

DISCUSSION

This case report describes the physical therapy management of an adapted return-to-sport protocol for an equestrian athlete with a history of multiple sport-related concussions.

LEVEL OF EVIDENCE

Therapy, level 5. J Orthop Sports Phys Ther 2018;48(12):934-942. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8214.

Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review

Background

Elite athletes can experience a diverse range of symptoms following post-concussive injury. The impact of sport-related concussion on specific mental health outcomes is unclear in this population.

Objective

The aim was to appraise the evidence base regarding the association between sport-related concussion and mental health outcomes in athletes competing at elite and professional levels.

Methods

A systematic search of PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane, and Cinahl databases was conducted.

Results

A total of 27 studies met inclusion criteria for review. Most of the included studies (67%, n = 18) were published in 2014 or later. Study methodology and reporting varied markedly. The extant research has been conducted predominantly in North America (USA, n = 23 studies; Canada, n = 3), often in male only (44.4%, n = 12) and college (70.4%, n = 19) samples. Depression is the most commonly studied mental health outcome (70.4%, n = 19 studies). Cross-sectional retrospective studies and studies including a control comparison tend to support an association between concussion exposure and depression symptoms, although several studies report that these symptoms resolved in the medium term (i.e. 1 month) post-concussion. Evidence for anxiety is mixed. There are insufficient studies to draw conclusions for other mental health domains.

Conclusion

Consistent with current recommendations to assess mood disturbance in post-concussive examinations, current evidence suggests a link between sports-related concussion and depression symptoms in elite athletes. Causation cannot be determined at this stage of enquiry because of the lack of well-designed, prospective studies. More research is required that considers a range of mental health outcomes in diverse samples of elite athletes/sports.

Electronic supplementary material

The online version of this article (10.1007/s40279-017-0810-3) contains supplementary material, which is available to authorized users.

Return to Learn After Sport-Related Concussion: A Survey of Secondary School and Collegiate Athletic Trainers

CONTEXT

Recent recommendations have emphasized return-to-learn (RTL) protocols to aid athletes in recovery from sport-related concussion (SRC) but have been based primarily on anecdotal evidence.

OBJECTIVE

To investigate the RTL practices of certified athletic trainers (ATs) after an SRC.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 1083 individuals (27%) from a random sample of 4000 ATs in the National Athletic Trainers' Association membership database completed an electronic survey. Participants consisted of 729 self-identified secondary school ATs (SSATs; 67.3%; experience = 14.0 ± 9.7 years) and 354 self-identified collegiate ATs (CATs; 32.7%; experience = 13.4 ± 9.7 years).

MAIN OUTCOME MEASURE(S)

We used χ² analyses to assess respondent differences related to current knowledge, current practices, and available resources. Independent t tests were used to compare SSATs and CATs on years of certification and annual number of SRCs evaluated.

RESULTS

Of our total respondents, 41.2% (n = 446) correctly indicated the absence of evidence-based RTL guidelines. Whereas most (73.9%, n = 800) respondents had an established RTL policy, only 38.1% (n = 413) used such guidelines in their clinical practice. Most (97.1%, n = 708) SSATs and 82.2% (n = 291) of CATs had access to (a) mental health professional(s); however, minorities of SSATs (21.4%, n = 156) and CATs (37.0%, n = 131) never accessed these resources to care for concussed student-athletes.

CONCLUSIONS

Our results suggested that, despite the absence of empirical evidence, most surveyed ATs incorporated some form of RTL protocol in their SRC management policy. The varying AT knowledge, clinical practices, and resources highlighted by our results should be considered when creating or refining an RTL protocol.

Persistent Postconcussion Symptoms After Injury

: media-1vid110.1542/5828371885001PEDS-VA_2018-0939Video Abstract OBJECTIVES: We examined whether preinjury, demographic, and family factors influenced vulnerability to postconcussion symptoms (PCSs) persisting the year after mild traumatic brain injury (mTBI).

METHODS

Children with mTBI (n = 119), complicated mild traumatic brain injury (cmTBI) (n = 110), or orthopedic injury (OI) (n = 118), recruited from emergency departments, were enrolled in a prospective, longitudinal cohort study. Caregivers completed retrospective surveys to characterize preinjury demographic, child, and family characteristics. PCSs were assessed using a validated rating scale. With multivariable general linear models adjusted for preinjury symptoms, we examined predictors of PCSs 3, 6, and 12 months after injury in children ages 4 to 8, 9 to 12, and 13 to 15 years at injury. With logistic regression, we examined predictors of chronic PCSs 1 year after traumatic brain injury.

RESULTS

Postinjury somatic, emotional, cognitive, and fatigue PCSs were similar in the mTBI and cmTBI groups and significantly elevated compared with the OI group. PCS trajectories varied with age and sex. Adolescents had elevated PCSs that improved; young children had lower initial symptoms and less change. Despite similar preinjury PCSs, girls had elevated symptoms across all time points compared with boys. PCS vulnerability factors included female sex, adolescence, preinjury mood problems, lower income, and family discord. Social capital was a protective factor. PCSs persisted in 25% to 31% of the traumatic brain injury group and 18% of the OI group at 1 year postinjury. The odds of chronic PCSs were almost twice as high in girls as in boys and were >4 times higher in young children with cmTBI than in those with mTBI.

CONCLUSIONS

A significant minority of children with mTBI and OI have PCSs that persisted 1 year after injury.

Identifying Persistent Postconcussion Symptom Risk in a Pediatric Sports Medicine Clinic

BACKGROUND

Although most children report symptom resolution within a month of a concussion, some patients experience persistent postconcussion symptoms (PPCS) that continues for more than 1 month. Identifying patients at risk for PPCS soon after an injury can provide useful clinical information.

PURPOSE

To determine if the Predicting Persistent Post-concussive Problems in Pediatrics (5P) clinical risk score, an emergency department (ED)-derived and validated tool, is associated with developing PPCS when obtained in a primary care sports concussion setting.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We conducted a study of patients seen at a pediatric sports medicine concussion clinic between May 1, 2013, and October 1, 2017, who were <19 years of age and evaluated within 10 days of a concussion. The main outcome was PPCS, defined as symptoms lasting >28 days. Nine variables were used to calculate the 5P clinical risk score, and we assessed the association between the 5P clinical risk score and PPCS occurrence. The secondary outcome was total symptom duration.

RESULTS

We examined data from 230 children (mean age, 14.8 ± 2.5 years; 50% female; mean time from injury to clinical assessment, 5.6 ± 2.7 days). In univariable analyses, a greater proportion of those who developed PPCS reported feeling slowed down (72% vs 44%, respectively; P < .001), headache (94% vs 72%, respectively; P < .001), sensitivity to noise (71% vs 43%, respectively; P < .001), and fatigue (82% vs 51%, respectively; P < .001) and committed ≥4 errors in tandem stance (33% vs 7%, respectively; P < .001) than those who did not. Higher 5P clinical risk scores were associated with increased odds of developing PPCS (adjusted odds ratio [OR], 1.62 [95% CI, 1.30-2.02]) and longer symptom resolution times (β = 8.40 [95% CI, 3.25-13.50]). Among the individual participants who received a high 5P clinical risk score (9-12), the majority (82%) went on to experience PPCS. The area under the curve for the 5P clinical risk score was 0.75 (95% CI, 0.66-0.84). After adjusting for the effect of covariates, fatigue (adjusted OR, 2.93) and ≥4 errors in tandem stance (adjusted OR, 7.40) were independently associated with PPCS.

CONCLUSION

Our findings extend the potential use for an ED-derived clinical risk score for predicting the PPCS risk into the sports concussion clinic setting. While not all 9 predictor variables of the 5P clinical risk score were independently associated with the PPCS risk in univariable or multivariable analyses, the combination of factors used to calculate the 5P clinical risk score was significantly associated with the odds of developing PPCS. Thus, obtaining clinically pragmatic risk scores soon after a concussion may be useful for early treatments or interventions to mitigate the PPCS risk.

Clinical Findings in a Multicenter MRI Study of Mild TBI

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

Sex Differences in Common Sports Injuries

Common sports injuries include bone stress injuries (BSIs), anterior cruciate ligament (ACL) injuries, and concussions. Less commonly recognized are the specific sex differences in epidemiology, risk factors, and outcomes of these conditions by sex. An understanding of these factors can improve their clinical management, from prescribing appropriate prehabilitation to guiding postinjury rehabilitation and return to play. This narrative review summarizes the sex differences in the diagnosis and management of BSIs, ACL injuries, and concussions. Although BSIs are more common in female athletes, risk factors for both sexes include prior injury and relative energy deficiency in sport (RED-S). Risk factors in female athletes include smaller calf girth, femoral adduction, and higher rates of loading. Female athletes are also at greater risk for developing ACL injuries in high school and college, but their injury rate is similar in professional sports. Increased lateral tibial slope, smaller ACL size, and suboptimal landing mechanics are additional risk factors more often present in female athletes. Male athletes are more likely to have ACL surgery and have a higher rate of return to sport. Concussions occur more commonly in female athletes; however, female athletes are also more likely to report concussions. Male athletes more commonly sustain concussion through contact with another player. Female athletes more commonly sustain injury from contact with playing equipment. Managing post-concussion symptoms is important, and female athletes may have prolonged symptoms. An understanding of the sex-specific differences in these common sports injuries can help optimize their prehabilitation and rehabilitation. LEVEL OF EVIDENCE: IV.

The role of family and personal psychiatric history in postconcussion syndrome following sport-related concussion: a story of compounding risk

OBJECTIVE Sport-related concussion (SRC) has become a major public health concern. Prolonged recovery after SRC, named postconcussion syndrome (PCS), has been associated with several biopsychosocial factors, yet the role of both family and personal psychiatric histories requires investigation. In a cohort of concussed high school athletes, the authors examined the role(s) of family and personal psychiatric histories in the risk of developing PCS. METHODS A retrospective cohort study of 154 high school athletes with complete documentation of postconcussion symptom resolution or persistence at 6 weeks was conducted. PCS was defined as 3 or more symptoms present 6 weeks after SRC. Three groups were defined: 1) positive family psychiatric history and personal psychiatric history (FPH/PPH), 2) positive FPH only, and 3) negative family and personal psychiatric histories (controls). Three bivariate regression analyses were conducted: FPH/PPH to controls, FPH only to controls, and FPH/PPH to FPH. Post hoc bivariate regression analyses examined specific FPH pathologies and PCS. RESULTS Athletes with FPH/PPH compared with controls had an increased risk of PCS (χ² = 8.90, p = 0.018; OR 5.06, 95% CI 1.71-14.99). Athletes with FPH only compared with controls also had an increased risk of PCS (χ² = 6.04, p = 0.03; OR 2.52, 95% CI 1.20-5.30). Comparing athletes with FPH/PPH to athletes with FPH only, no added PCS risk was noted (χ² = 1.64, p = 0.247; OR 2.01, 95% CI 0.68-5.94). Among various FPH diagnoses, anxiety (χ² = 7.48, p = 0.021; OR 2.99, 95% CI 1.36-6.49) and bipolar disorder (χ² = 5.13, p = 0.036; OR 2.74, 95% CI 1.14-6.67) were significantly associated with the presence of PCS. CONCLUSIONS Concussed high school athletes with FPH/PPH were greater than 5 times more likely to develop PCS than controls. Athletes with only FPH were over 2.5 times more likely to develop PCS than controls. Those with an FPH of anxiety or bipolar disorder are specifically at increased risk of PCS. These results suggest that not only are athletes with FPH/PPH at risk for slower recovery after SRC, but those with an FPH only-especially anxiety or bipolar disorder-may also be at risk. Overall, this study supports taking a detailed FPH and PPH in the management of SRC.

Psychological Resilience as a Predictor of Persistent Post-Concussive Symptoms in Children With Single and Multiple Concussion

OBJECTIVES

To evaluate the relationship of psychological resilience to persistent post-concussive symptoms (PCS) in children with a history of single or multiple concussions, as well as orthopedic injury (OI).

METHODS

Participants (N=75) were children, ages 8-18 years, who sustained a single concussion (n=24), multiple concussions (n=25), or an OI (n=26), recruited from a tertiary care children's hospital. All participants sustained injuries at least 6 months before recruitment, with an average time since injury of 32.9 months. Self-reported psychological resilience was measured using the Connor-Davidson Resilience Scale, and both self- and parent-reported PCS were measured using the Post-Concussion Symptom Inventory. Hierarchical regression analyses examined psychological resilience as a predictor of PCS, both as a main effect and as a moderator of group differences.

RESULTS

Multiple concussions and low psychological resilience were both significant predictors of persistent PCS. Resilience was not a significant moderator of group differences in PCS.

CONCLUSIONS

Sustaining multiple concussions may increase a child's risk of persistent PCS; however, high psychological resilience may serve as a protective factor, regardless of the number or type of injuries sustained. These findings provide support for developing and testing interventions aimed at increasing psychological resilience as a potential means of improving outcomes for children suffering from persistent PCS after concussion. (JINS, 2018, 24, 759-768).

Preinjury Migraine History as a Risk Factor for Prolonged Return to School and Sports following Concussion

Having a preexisting migraine disorder might be a risk factor for a prolonged recovery following a sport-related concussion. We examined whether having a migraine history was associated with a prolonged return to academics and athletics following a concussion. High school and collegiate athletes (n = 1265; 42% female) who sustained a sport-related concussion were monitored by athletic trainers using a web-based surveillance system that collects information about concussion recovery. Nonparametric Kolmogorov-Smirnov tests (KS) were used to compare days to return to academics/athletics across groups due to non-normally distributed outcome variables and unequal distributions of scores between groups. Chi-squared tests were used to examine the proportion of players who had not returned to academics/athletics at 7, 14, and 21 days post-injury stratified by self-reported migraine history. There were 117 athletes (9.2%) who reported a preinjury migraine history. Athletes with a history of migraine took a median of 6 days to return to academics (mean [M] = 10.6, standard deviation [SD] = 14.2) and 15.5 days to return to athletics (M = 23.8, SD = 30.8), while those with no migraine history took a median of 5 days to return to academics (M = 7.5, SD = 10.9) and 14 days to return to athletics (M = 19.4, SD = 19.4). There were no statistically significant differences in days to return to school or athletics between the groups (KS p > 0.05). However, a lower percentage of athletes with a history of migraine had returned to school after 7 days (57% vs. 68%, χ2 = 5.53, p = 0.02), 14 days (75% vs. 88%, χ2 = 14.21, p < 0.001), and 21 days post-injury (89% vs. 94%, χ2 = 4.90, p = 0.03). Stratifying the analyses by sex showed that this effect was significant in girls and women with preexisting migraines, but not boys and men with preexisting migraines. There were no group differences in recovery rates when examining return to athletics. Athletes with a preinjury migraine history may be at an elevated risk for a protracted return to school after concussion, especially girls and women.

Feasibility of a postacute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a randomised controlled study

Objective

The utility of structured exercise for rehabilitation purposes early in the postacute phase (ie, beyond the initial 24–48 hours of advised rest) following sport-related concussion (SRC) remains largely unexplored. This study examined the feasibility of implementing a standardised aerobic exercise (AE) intervention in the postacute stage of SRC recovery in a sample of adolescent students with SRC compared with usual care.

Methods

Symptomatic adolescents with SRC were randomised to one of two groups: Aerobic Exercise (n=8) or Usual Care (n=7). The AE intervention, beginning on day 6 postinjury, comprised eight sessions with progressive increases in intensity and duration on a cycle ergometer. Usual care consisted of rest followed by physician-advised progressions in activity levels in an unsupervised setting. All participants were evaluated by physician at weeks 1, 2, 3 and 4 postconcussion. Outcome measures included: (1) Intervention feasibility: symptom status pre-post exercise sessions and completion of intervention and (2) Clinical recovery: symptom status at weeks 1, 2, 3 and 4 postinjury and medical clearance date.

Results

All participants completed the exercise sessions as part of the AE intervention and symptom exacerbation was not associated with any exercise session. The AE group experienced greater symptom resolution compared with the Usual Care Group across the recovery timeline.

Conclusion

A structured AE protocol appears to be safe and feasible to administer in the postacute stage of SRC recovery in adolescents and should be explored as part of a full Phase III Clinical Trial.

Concussion

Concussions are a common injury for which patients often present first to primary care physicians. They can affect the day-to-day function of patients in school and work, as well as in sports and recreational activities. Recognizing common physical signs and symptoms after injury facilitates timely diagnosis and treatment, permitting initiation of an active management approach to recovery while preventing secondary injury. For persons with persistent symptoms, active rehabilitation may be utilized, with the goal of returning patients to full function.

Predictors of Long-Term Psychosocial Functioning and Health-Related Quality of Life in Children and Adolescents With Prior Concussions

OBJECTIVES

Individual differences in long-term psychosocial functioning after concussions in children and adolescents are poorly understood. The aim of the study was to investigate potential predictors of long-term psychosocial functioning and health-related quality of life in youth after prior concussion.

METHODS

Participants (N=75; mean age=14.3 years old; 52% girls) with one prior concussion (n=24), multiple prior concussions (n=24), or a prior orthopedic injury and no concussion (n=27) were seen on average 2.7 years after their most recent injury. Psychosocial functioning was assessed using the self-report versions of the Behavior Assessment System for Children (BASC-2; Anxiety and Depression scales only), the Strengths and Difficulties Questionnaire, and the Pediatric Quality of Life Inventory TM 4.0. Pre-existing conditions (attention problems, learning difficulties, mood concerns, anxiety concerns, and migraines) were reported by parents using a checklist and examined as predictors of long-term functioning. Other potential predictors included age at testing, sex, time between most recent injury and testing, and number of prior concussions.

RESULTS

The groups did not differ significantly on long-term psychosocial functioning. Moreover, only pre-existing mood concerns or attention problems significantly predicted psychosocial adjustment.

CONCLUSIONS

Children's functioning before a concussion is critical to understanding outcome. Pre-injury attention and mood concerns should be assessed in clinical settings to prevent and treat long-term psychosocial problems after concussion. (JINS, 2018, 24, 540-548).

Traumatic Brain Injury-Related Symptoms Reported by Parents: Clinical, Imaging, and Host Predictors in Children with Impairments in Consciousness Less than 24 Hours

This study examined the relationship between acute neuroimaging, host and injury factors, and parent-reported traumatic brain injury (TBI)-related symptoms in children with noncritical head injury at two weeks and three months after injury. Data were collected prospectively on 45 subjects aged three to 16 years old enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. Subjects had rapid recovery of mental status (Glasgow Coma Score [GCS] = 15 within 24 h), and had no clinical need for neurosurgical intervention. Intra- or extra-axial magnetic resonance imaging (MRI) lesions were categorized using Common Data Elements (CDE) definitions. Host and acute injury factors including neurobehavioral history, race, extracranial injuries, loss of consciousness (LOC), and GCS were analyzed while controlling for pre-injury symptoms, age, sex, and socioeconomic status. Parent-reported cognitive and somatic symptoms were measured by the Health and Behavior Inventory (HBI). Forty-nine percent of children had MRI lesions, most of which were relatively small. LOC predicted increased cognitive and somatic symptoms at two weeks. At three months, pre-injury neurobehavioral history predicted increased cognitive and somatic symptoms. Neuroimaging findings did not predict parent-reported symptom severity, except at three months where extra-axial lesions were associated with less severe cognitive symptoms. While structural MRI lesions do not predict increased parent-reported symptoms in this population, age-specific child performance measures may be more sensitive outcome measures and require further study. Children with pre-injury neurobehavioral problems have more severe symptoms at three months and thus may benefit from longer follow-up and monitoring after traumatic brain injury.

Implementation of the 2017 Berlin Concussion in Sport Group Consensus Statement in contact and collision sports: a joint position statement from 11 national and international sports organisations

The 2017 Berlin Concussion in Sport Group Consensus Statement provides a global summary of best practice in concussion prevention, diagnosis and management, underpinned by systematic reviews and expert consensus. Due to their different settings and rules, individual sports need to adapt concussion guidelines according to their specific regulatory environment. At the same time, consistent application of the Berlin Consensus Statement's themes across sporting codes is likely to facilitate superior and uniform diagnosis and management, improve concussion education and highlight collaborative research opportunities. This document summarises the approaches discussed by medical representatives from the governing bodies of 10 different contact and collision sports in Dublin, Ireland in July 2017. Those sports are: American football, Australian football, basketball, cricket, equestrian sports, football/soccer, ice hockey, rugby league, rugby union and skiing. This document had been endorsed by 11 sport governing bodies/national federations at the time of being published.

Immediate Removal From Activity After Sport-Related Concussion Is Associated With Shorter Clinical Recovery and Less Severe Symptoms in Collegiate Student-Athletes

BACKGROUND

Timely removal from activity after concussion symptoms remains problematic despite heightened awareness. Previous studies indicated potential adverse effects of continuing to participate in physical activity immediately after sustaining a concussion. Hypothesis/Purpose: The purpose was to determine the effect of timing of removal from play after concussion on clinical outcomes. It was hypothesized that immediate removal from activity after sport-related concussion (SRC) would be associated with less time missed from sport, a shorter symptomatic period, and better outcomes on acute clinical measures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were reported from the National Collegiate Athletic Association and Department of Defense Grand Alliance: Concussion Awareness, Research, and Education (CARE) Consortium. Participants with 506 diagnosed SRCs from 18 sports and 25 institutions and military service academies were analyzed and classified as either immediate removal from activity (I-RFA) or delayed removal from activity (D-RFA). Outcomes of interest included time missed from sport attributed to their SRC, symptom duration, and clinical assessment scores.

RESULTS

There were 322 participants (63.6%) characterized as D-RFA. I-RFA status was associated with significantly less time missed from sport ( R² change = .022-.024, P < .001 to P = .001) and shorter symptom duration ( R² change = .044-.046, P < .001 [all imputations]) while controlling for other SRC recovery modifiers. These athletes missed approximately 3 fewer days from sport participation. I-RFA athletes had significantly less severe acute SRC symptoms and were at lower risk of recovery taking ≥14 days (relative risk = .614, P < .001, small-medium effect size) and ≥21 days (relative risk = .534, P = .010, small effect size).

CONCLUSION

I-RFA is a protective factor associated with less severe acute symptoms and shorter recovery after SRC. Conveying this message to athletes, coaches, and others involved in the care of athletes may promote timely injury reporting.

Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion

Objective

To determine whether earlier time to initiation of aerobic exercise following acute concussion is associated with time to full return to (1) sport and (2) school or work.

Methods

A retrospective stratified propensity score survival analysis of acute (≤14 days) concussion was used to determine whether time (days) to initiation of aerobic exercise post-concussion was associated with, both, time (days) to full return to (1) sport and (2) school or work.

Results

A total of 253 acute concussions [median (IQR) age, 17.0 (15.0–20.0) years; 148 (58.5%) males] were included in this study. Multivariate Cox regression models identified that earlier time to aerobic exercise was associated with faster return to sport and school/work adjusting for other covariates, including quintile propensity strata. For each successive day in delay to initiation of aerobic exercise, individuals had a less favourable recovery trajectory. Initiating aerobic exercise at 3 and 7 days following injury was associated with a respective 36.5% (HR, 0.63; 95% CI, 0.53–0.76) and 73.2% (HR, 0.27; 95% CI, 0.16–0.45) reduced probability of faster full return to sport compared to within 1 day; and a respective 45.9% (HR, 0.54; 95% CI, 0.44–0.66) and 83.1% (HR, 0.17; 95% CI, 0.10–0.30) reduced probability of faster full return to school/work. Additionally, concussion history, symptom severity, LOC deleteriously influenced concussion recovery.

Conclusion

Earlier initiation of aerobic exercise was associated with faster full return to sport and school or work. This study provides greater insight into the benefits and safety of aerobic exercise within the first week of the injury.

Effect of concussion history on symptom burden and recovery following pediatric sports-related concussion

OBJECTIVE The aim of this study was to examine differences in symptom burden and duration until physician-documented clinical recovery among pediatric patients with sports-related concussion (SRC) with and without a history of concussion. METHODS A retrospective chart review was performed for all pediatric patients (7-19 years old) referred to the Pan Am Concussion Program in Winnipeg, Canada, with an SRC and evaluated < 30 days postinjury between September 1, 2013, and August 1, 2015. RESULTS A total of 322 patients with SRC (64.91% male, mean age 13.96 years) who were evaluated a median of 7 days (interquartile range [IQR] 5-11 days) postinjury were included. Patients without a history of concussion endorsed significantly fewer concussion symptoms at initial assessment (median 5.5 symptoms, IQR 1-10 symptoms) than those with a previous concussion (median 7 symptoms, IQR 2-13.25 symptoms; p = 0.036). The median Post-Concussion Symptom Scale scores were 9 (IQR 1-23) for patients with no concussion history and 13 (IQR 3-33) for those with a history of concussion (p = 0.032). For patients with no previous concussion, the median number of days until physician-documented clinical recovery was 23 (IQR 15-44 days) compared with 25 days (IQR 18-43 days) for those with a history of concussion (p = 0.281). There was no significant difference in the proportion of patients who experienced delayed time until physician-documented clinical recovery (> 1 month postinjury) between the groups (p = 0.584). CONCLUSIONS Although a history of concussion may be associated with increased symptom burden following pediatric SRC, there was no difference in the time until physician-documented clinical recovery. Pediatric patients with SRC who have a history of concussion should be managed on an individualized basis. Future work is needed to examine the short- and long-term effects of multiple concussions in children and adolescents.

Sex & gender considerations in concussion research

The study of concussion, a common form of mild traumatic brain injury, has received increased notice over the last decade. Recently, more researchers have been addressing the historic paucity of attention over sex and gender influences on recovery outcomes after concussion. This development has led to exciting progress in our understanding of concussion incidence and outcomes. In this review, we will report on new findings from varying studies on sex differences in the epidemiology of concussion and clinical manifestations of mild traumatic brain injury/concussion, further discussing some key issues related to the integration of sex and gender in concussion research in a broad range of contexts, with recommendations to guide future research, along with sex- and gender-sensitive policy considerations.

Connectomic markers of symptom severity in sport-related concussion: Whole-brain analysis of resting-state fMRI

Concussion is associated with significant adverse effects within the first week post-injury, including physical complaints and altered cognition, sleep and mood. It is currently unknown whether these subjective disturbances have reliable functional brain correlates. Resting-state functional magnetic resonance imaging (rs-fMRI) has been used to measure functional connectivity of individuals after traumatic brain injury, but less is known about the relationship between functional connectivity and symptom assessments after a sport concussion. In this study, rs-fMRI was used to evaluate whole-brain functional connectivity for seventy (70) university-level athletes, including 35 with acute concussion and 35 healthy matched controls. Univariate analyses showed that greater symptom severity was mainly associated with lower pairwise connectivity in frontal, temporal and insular regions, along with higher connectivity in a sparser set of cerebellar regions. A novel multivariate approach also extracted two components that showed reliable covariation with symptom severity: (1) a network of frontal, temporal and insular regions where connectivity was negatively correlated with symptom severity (replicating the univariate findings); and (2) a network with anti-correlated elements of the default-mode network and sensorimotor system, where connectivity was positively correlated with symptom severity. These findings support the presence of connectomic signatures of symptom complaints following a sport-related concussion, including both increased and decreased functional connectivity within distinct functional brain networks.

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Analyzed relationship between resting brain function and symptoms of concussion

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Whole-brain analysis, using both univariate and multivariate methods

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Symptoms associated with lower connectivity for frontal/temporal/insular network

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Symptoms associated with higher connectivity for default-mode/sensorimotor network

Initial symptom presentation after high school football-related concussion varies by time point in a season: an initial investigation

Background

Schedule-based and in-season factors (e.g., competition type) have been shown to be associated with symptom reporting patterns and injury severity in sport-related concussion (SRC). To determine if acute neurocognitive and symptom presentation following SRC differ by time point within a high school football season.

Methods

Multicenter ambispective cohort of high school football players who sustained a SRC (N = 2594). Timing (early, mid, and late season) of SRC was based on median dates for the start of the pre-season, regular season, and playoffs of each states’ football schedules. Analysis of covariance (ANCOVA) investigated differences across season period groups for: (1) neurocognitive test scores, (2) total symptom scores (TSS), and (3) individual symptom increases from baseline within 1-week post-injury.

Results

Significant group differences were observed in TSS, F(2, 2589) = 15.40, p <  0.001, η_p² = 0.01, and individual symptom increases from baseline, F(2, 2591) = 16.40, p <  0.001, η_p² = 0.01. Significant increases were seen from baseline to both midseason and late season in both TSS, χ² = 24.40, p <  0.001, Φ = 0.10 and individual symptoms, χ² = 10.32, p = 0.006, Φ = 0.10. Post hoc tests indicated a linear trend, with late-season injured athletes reporting approximately twice the TSS (13.10 vs. 6.77) and new symptoms (5.70 vs. 2.68) as those with early-season injuries.

Conclusion

In a cohort of American high school football student-athletes, those suffering SRC in the late-season time period had increased acute symptom burden. SRC sustained later in-season may require more conservative management.

Population-based cohort study of the impacts of mild traumatic brain injury in adults four years post-injury

There is increasing evidence that some people can experience persistent symptoms for up to a year following mild TBI. However, few longitudinal studies of mild TBI exist and the longer-term impact remains unclear. The purpose of this study is to determine if there are long-term effects of mild traumatic brain injury (TBI) four-years later. Adults (aged ≥16 years) identified as part of a TBI incidence study who experienced a mild-TBI four-years ago (N = 232) were compared to age-sex matched controls (N = 232). Sociodemographic variables, prior TBI and symptoms were assessed at the time of injury. Four years post-injury participants completed the Rivermead Post-Concussion Symptom Questionnaire, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index and the Participation Assessment with Recombined Tools. Analysis of covariance was used to compare differences between TBI cases four years post-injury and controls, controlling for prior TBI and depression. A multiple regression model was used to identify the predictors of increased symptoms and reduced participation. The mild-TBI sample experienced significantly increased self-reported cognitive symptoms (F = 19.90, p = <0.01) four years post-injury than controls. There were no differences between the groups for somatic (F = 0.02, p = 0.89) or emotional symptoms (F = 0.31, p = 0.58). Additionally, the mild-TBI group reported significantly poorer community participation across all three domains: productivity (F = 199.07, p = <0.00), social relations (F = 13.93, p = <0.00) and getting out and about (F = 364.69, p = <0.00) compared to controls. A regression model accounting for 41% of the variance in cognitive symptoms in TBI cases revealed a history of TBI, receiving acute medical attention and baseline cognitive symptoms, sleep quality, anxiety and depression were predictive of outcome. The results indicate that whilst somatic and emotional symptoms resolve over time, cognitive symptoms can become persistent and that mild TBI can impact longer-term community participation. Early intervention is needed to reduce the longer-term impact of cognitive symptoms and facilitate participation.

Patient-Specific Alterations in CO2 Cerebrovascular Responsiveness in Acute and Sub-Acute Sports-Related Concussion

Background

Preliminary studies suggest that sports-related concussion (SRC) is associated with alterations in cerebral blood flow (CBF) regulation. Here, we use advanced magnetic resonance imaging (MRI) techniques to measure CBF and cerebrovascular responsiveness (CVR) in individual SRC patients and healthy control subjects.

Methods

15 SRC patients (mean age = 16.3, range 14–20 years) and 27 healthy control subjects (mean age = 17.6, range 13–21 years) underwent anatomical MRI, pseudo-continuous arterial spin labeling (pCASL) MRI and model-based prospective end-tidal targeting (MPET) of CO₂ during blood oxygenation level-dependent (BOLD) MRI. Group differences in global mean resting CBF were examined. Voxel-by-voxel group and individual differences in regional CVR were examined using statistical parametric mapping (SPM). Leave-one-out receiver operating characteristic curve analysis was used to evaluate the utility of brain MRI CO₂ stress testing biomarkers to correctly discriminate between SRC patients and healthy control subjects.

Results

All studies were tolerated with no complications. Traumatic structural findings were identified in one SRC patient. No significant group differences in global mean resting CBF were observed. There were no significant differences in the CO₂ stimulus and O₂ targeting during BOLD MRI. Significant group and patient-specific differences in CVR were observed with SRC patients demonstrating a predominant pattern of increased CVR. Leave-one-out ROC analysis for voxels demonstrating a significant increase in CVR was found to reliably discriminate between SRC patients and healthy control subjects (AUC of 0.879, p = 0.0001). The optimal cutoff for increased CVR declarative for SRC was 1,899 voxels resulting in a sensitivity of 0.867 and a specificity of 0.778 for this specific ROC analysis. There was no correlation between abnormal voxel counts and Postconcussion Symptom Scale scores among SRC patients.

Conclusion

Acute and subacute SRCs are associated with alterations in CVR that can be reliably detected by brain MRI CO₂ stress testing in individual patients.

Team versus individual sport participation as a modifying factor in the development of post-concussion syndrome after first concussion: A pilot study

Identification of modifying factors that influence the development of post-concussion syndrome (PCS) following sport-related concussion (SRC) has drawn considerable interest. In this pilot study, we investigate the effect of team vs. individual sport participation on the development of PCS in a sample of 136 high school and college student-athletes. Controlling for several confounding variables, we employed a binary logistic regression and chi-squared test. Results of this pilot study indicate that participation in team versus individual sport is not a significant factor in the development of PCS. The identification of other forms of protective mechanisms is discussed.

The modern landscape of sport-related concussion research: key achievements and future directions

The study of contact and collision sport athletes at risk for concussion began approximately three decades ago. Since then, sport-related concussion (SRC) research across several medical specialties has helped to develop consensus guidelines for clinical management through interdisciplinary efforts. The modern landscape of SRC research includes large-scale investigations to define the natural history of concussion and identify factors that should guide prevention, diagnosis, and treatment specific to the individual patient. We now know that the clinical and physiologic effects of concussion are related but independent constructs deserving further scientific exploration. This has sparked research that incorporates advanced neuroimaging, fluid biomarkers, biomechanics, and genomics, in addition to standard clinical outcomes. Additionally, translational research has informed our understanding of optimal rehabilitation strategies and led to a shift from the "complete rest" approach to earlier, active management interventions after concussion. Collectively, these advancements are likely to substantially improve patient outcomes after SRC and, ultimately, may prove beneficial for identifying and appropriately managing those at risk for longer-term difficulties associated with repetitive head impact exposure. The broader public health implications of improving sports safety and encouraging developmentally appropriate participation among youth and adolescents are a particularly important byproduct of continued research into SRC.

Psychiatric Sequelae of Concussions

PURPOSE OF REVIEW

The purpose of this study was to review the frequency, risk factors, phenomenology, and course of prolonged recovery from concussion and of psychiatric sequelae in pediatric populations.

RECENT FINDINGS

Youth with prolonged recovery from concussions have higher initial symptoms, a history of multiple and/or recent concussions, and a tendency to somatization. Depression, post-traumatic stress disorder, behavioral disorders, and perhaps, suicidal behavior disorder are more common as both short- and longer-term sequelae of concussions. The weight of evidence supports a graduated return to function as compared to prolonged rest, which may actually impede recovery. For those with prolonged recovery, cognitive behavior therapy aimed at education about concussions, improving coping, problem-solving, sleep hygiene, and dealing with anxiety and depression provided in a collaborative care model is superior to usual care. Concussed youth have an increased risk of psychiatric symptoms and sleep disturbance that can be prevented or treated with proper management.