Variations in Mechanisms of Injury for Children with Concussion

Influence of insurance type on rate and type of initial concussion-related medical visits among youth

Background

A growing number of studies report increased concussion-related health care utilization in recent years, but factors impacting care-seeking behaviors among youth following a concussion are not well described. This study aimed to evaluate the influence of insurance type on the rate and type of initial concussion visits and the time from injury to the initial visit in youth.

Methods

We extracted and analyzed initial concussion-related medical visits for youth ages 10 to 17 from electronic health records. Patients must have visited Nationwide Children’s Hospital’s (NCH) concussion clinic at least once between 7/1/2012 and 12/31/2017. We evaluated the trends and patterns of initial concussion visits across the study period using regression analyses.

Results

Of 4955 unique concussion visits included, 60.1% were males, 80.5% were white, and 69.5% were paid by private insurance. Patients’ average age was 13.9 years (SD = 3.7). The rate of the initial concussion visits per 10,000 NCH visits was consistently higher in privately insured than publicly insured youth throughout the study period (P < .0001). Privately insured youth had greater odds of initial concussion visits to sports medicine clinics (AOR = 1.45, 95% CI = 1.20, 1.76) but lower odds of initial concussion visits to the ED/urgent care (AOR = 0.74, 95% CI = 0.60, 0.90) than publicly insured youth. Days from injury to initial concussion visit significantly decreased among both insurance types throughout the study (P < .0001), with a greater decrease observed in publicly insured than privately insured youth (P = .011).

Conclusions

Results on the differences in the rate, type, and time of initial concussion-related visits may help inform more efficient care of concussion among youth with different types of insurance.

Epidemiology of Chronic Effects of Traumatic Brain Injury

Although many patients diagnosed with traumatic brain injury (TBI), particularly mild TBI, recover from their symptoms within a few weeks, a small but meaningful subset experience symptoms that persist for months or years after injury and significantly impact quality of life for the person and their family. Factors associated with an increased likelihood of negative TBI outcomes include not only characteristics of the injury and injury mechanism, but also the person’s age, pre-injury status, comorbid conditions, environment, and propensity for resilience. In this article, as part of the Brain Trauma Blueprint: TBI State of the Science framework, we examine the epidemiology of long-term outcomes of TBI, including incidence, prevalence, and risk factors. We identify the need for increased longitudinal, global, standardized, and validated assessments on incidence, recovery, and treatments, as well as standardized assessments of the influence of genetics, race, ethnicity, sex, and environment on TBI outcomes. By identifying how epidemiological factors contribute to TBI outcomes in different groups of persons and potentially impact differential disease progression, we can guide investigators and clinicians toward more-precise patient diagnosis, along with tailored management, and improve clinical trial designs, data evaluation, and patient selection criteria.

Evaluation and Management of Pediatric Concussion in the Acute Setting

ABSTRACT

Concussion, a type of mild traumatic brain injury, is a common injury encountered by providers caring for pediatric patients in the emergency department (ED) setting. Our understanding of the pathophysiologic basis for symptom and recovery trajectories for pediatric concussion continues to rapidly evolve. As this understanding changes, so do recommendations for optimal management of concussed youth. As more and more children present to EDs across the country for concussion, it is imperative that providers caring for children in these settings remain up-to-date with diagnostic recommendations and management techniques. This article will review the definition, epidemiology, pathophysiology, diagnosis, and management of pediatric concussion in the ED setting.

Clinical Outcomes of Pediatric Acute Sport- and Non-Sport-Related Concussions

OBJECTIVES

The objectives were to examine clinical characteristics, length of recovery, and the prevalence of delayed physician-documented recovery, compare clinical outcomes among those with sport-related concussion (SRC) and non-sport-related concussion (nSRC), and identify risk factors for delayed recovery.

METHODS

Included patients (8-18 years) were assessed ≤14 days post-injury at a multidisciplinary concussion program and diagnosed with an acute SRC or nSRC. Physician-documented clinical recovery was defined as returning to pre-injury symptom status, attending full-time school without symptoms, completing Return-to-Sport strategy as needed, and normal physical examination. Delayed physician-documented recovery was defined as >28 days post-injury.

RESULTS

Four hundred and fifteen patients were included (77.8% SRC). There was no difference in loss of consciousness (SRC: 9.9% vs nSRC: 13.0%, p = 0.39) or post-traumatic amnesia (SRC: 24.1% vs SRC: 31.5%, p = 0.15) at the time of injury or any differences in median Post-Concussion Symptom Scale scores (SRC: 20 vs nSRC: 23, p = 0.15) at initial assessment. Among those with complete clinical follow-up, the median physician-documented clinical recovery was 20 days (SRC: 19 vs nSRC: 23; p = 0.37). There was no difference in the proportion of patients who developed delayed physician-documented recovery (SRC: 27.7% vs nSRC: 36.1%; p = 0.19). Higher initial symptom score increased the risk of delayed physician-documented recovery (IRR: 1.39; 95% CI: 1.29, 1.49). Greater material deprivation and social deprivation were associated with an increased risk of delayed physician-documented recovery.

CONCLUSIONS

Most pediatric concussion patients who undergo early medical assessment and complete follow-up appear to make a complete clinical recovery within 4 weeks, regardless of mechanism.

Factors associated with concussion-symptom knowledge and attitudes toward concussion care seeking in a national survey of parents of middle-school children in the US

BACKGROUND

Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion-symptom knowledge and care-seeking attitudes among parents of MS children (aged 10-15 years).

METHODS

A panel of 1224 randomly selected U.S. residents, aged ≥ 18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion-symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 point (range: 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range: 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) (excluding 1.00) were deemed statistically significant.

RESULTS

Median scores were 39 (interquartile range: 32-44) for symptom knowledge and 32 (interquartile range: 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71), and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99) and in older parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47).

CONCLUSION

Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion-symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention.

Comparing prevalence estimates of concussion/head injury in U.S. children and adolescents in national surveys

BACKGROUND AND OBJECTIVES

Reports on pediatric lifetime concussions/head injuries (LCHI) from national surveys have offered estimates on prevalence that range from 2.5% to 18% in the general population. The purpose of this study is to examine national surveys to compare methodologies and limitations pertaining to LCHI data collection.

METHODS

Three nationally representative surveys that measure LCHI in children, including the National Survey of Children's Health, the National Health Interview Survey, and the Monitoring the Future Survey were examined. Children were grouped by ages 3-17 years and adolescent ages 13-17 years, stratified by selected demographic characteristics. Participants in the surveys included parents (NSCH and NHIS) and adolescents (MTF survey). The primary outcome measure is an estimate of LCHI in children.

RESULTS

Estimates of prevalence of LCHI ranged from 3.6% to 7.0% for children ages 3-17 years and from 6.5% to 18.3% for adolescents 13-17 years. Survey modality, question wording, and respondent may contribute to differing estimates. Prevalence showed consistent variation by age, sex, and race/ethnicity across surveys. Associations were inconsistent between LCHI and insurance status, parental education, and household primary language.

CONCLUSIONS

Although there are methodological differences in capturing pediatric LCHI across surveys, the prevalence estimates and correlational associations generated can offer awareness about the burden of these injuries and insights to research and clinical care.

It is time to rewrite state youth sports concussion laws

Between 2009 and 2014, all 50 states and the District of Columbia passed legislation to improve the recognition and management of youth concussed in sports. These laws can include requirements for concussion training for school athletic personnel, concussion education for children and their parents, return-to-play (RTP) procedures, and medical clearance to for RTP. Concussion can impact academic learning and performance in children and adolescents. Postconcussion academic accommodations during recovery can be an important component of secondary prevention for mitigating the sequalae of head injury. Few state youth concussion laws, however, include provision of postconcussion return-to-learn (RTL) accommodations and most of those that do address RTL apply to student athletes only. Concussions may occur in youth who are not participating in organised sports (eg, falls, traffic crashes) and thus may not be subjected to RTL accommodations, even if the state mandates such procedures for athletes. Low income and students of colour may be more likely to have non-sports concussions than their more affluent and white peers, thus potentially creating demographic disparities in the benefits of RTL procedures. State youth sports concussion laws should be revised so that they include RTL provisions that apply to all students, athletes and non-athletes alike.

Epidemiology of Injuries in Ultimate (Frisbee): A Systematic Review

Ultimate is a high-intensity, non-contact team sport played with a flying disc (e.g., frisbee). Despite the growing popularity of ultimate worldwide, there is limited information about the epidemiology of injury in the sport. The purpose of this review is to provide a comprehensive overview and synthesis of the literature on the epidemiology of injury in ultimate. A comprehensive search of the literature was conducted in five electronic databases (i.e., MEDLINE, Embase, AMED, SPORTDiscus, and AusportMed). All databases were searched from inception to 1 July 2020. A total of eleven studies were included and qualitatively synthesized. Injury incidence rate estimates ranged from 0.4 to 84.9 injuries per 1000 athlete-exposures. The lifetime prevalence of any injury and concussion were 100% and 26%, respectively. The most commonly injured body region was the lower limb, with the knee and thigh being the most frequently injured anatomical locations. The most frequent injury types were muscle injuries and superficial contusions. The most common injury situation was direct contact with another player. There is a substantial risk of injury in ultimate, in particular muscle strains and joint sprains to the knee and shoulder areas. Development and implementation of effective, sport-specific injury prevention initiatives, including improved injury risk management and sport safety culture, should be a priority to reduce the burden of injury in ultimate.

Persistent alterations in cerebrovascular reactivity in response to hypercapnia following pediatric mild traumatic brain injury

Much attention has been paid to the effects of mild traumatic brain injury (mTBI) on cerebrovascular reactivity in adult populations, yet it remains understudied in pediatric injury. In this study, 30 adolescents (12-18 years old) with pediatric mTBI (pmTBI) and 35 age- and sex-matched healthy controls (HC) underwent clinical and neuroimaging assessments during sub-acute (6.9 ± 2.2 days) and early chronic (120.4 ± 11.7 days) phases of injury. Relative to controls, pmTBI reported greater initial post-concussion symptoms, headache, pain, and anxiety, resolving by four months post-injury. Patients reported increased sleep issues and exhibited deficits in processing speed and attention across both visits. In grey-white matter interface areas throughout the brain, pmTBI displayed increased maximal fit/amplitude of a time-shifted end-tidal CO2 regressor to blood oxygen-level dependent response relative to HC, as well as increased latency to maximal fit. The alterations persisted through the early chronic phase of injury, with maximal fit being associated with complaints of ongoing sleep disturbances during post hoc analyses but not cognitive measures of processing speed or attention. Collectively, these findings suggest that deficits in the speed and degree of cerebrovascular reactivity may persist longer than current conceptualizations about clinical recovery within 30 days.

Sports and non-sports-related concussions among Medicaid-insured children: health care utilization before and after Ohio's concussion law

Objective

To evaluate patterns of health care utilization for sports-related concussions (SRCs) and non-sports-related concussions (NSRCs) among Medicaid-insured children before and after the enactment of Ohio’s concussion law in April 2013.

Methods

We analyzed claim data from the Partners For Kids (PFK) Ohio Medicaid database. Concussion diagnoses were identified between April 1, 2008 and June 30, 2017. We compared frequency of concussions by age and sex across the law period. We evaluated type of health care utilization before and after law enactment using multinomial logistic regression.

Results

Over the 9 year study period, 6157 concussions were included, most of which (70.4%) were NSRCs. The proportion of SRCs increased with age. Among children younger than 5 years old, the majority (96.1%) of concussions were NSRCs. During the post-law period, greater odds of primary care visits than emergency department (ED) visits were observed for both SRCs (OR = 1.53; 95% CI 1.34, 1.75) and NSRCs (OR = 1.73; 95% CI 1.58, 1.90) compared to the pre-law period.

Conclusions

We observed higher proportions of health care utilization for NSRCs than SRCs in Medicaid insured children and a shift in health care utilization from the ED to primary care in the post-law period. SRCs and NSRCs are likely to have different patterns of health care utilization before and after the enactment of Ohio’s concussion law. Our results demonstrate that Ohio’s youth concussion law had a quantifiable impact on health care utilization.

Post-concussion symptom burden in children following motor vehicle collisions

OBJECTIVE

Motor vehicle collisions generate considerable transmitted forces resulting in traumatic brain injury in children presenting to emergency departments (EDs). To date, no large study has examined post-concussive symptoms in children sustaining concussions in motor vehicle collisions. This study aimed to compare trends in acute post-concussive symptom burden in children with concussion following motor vehicle collisions as compared to other injury mechanisms.

METHODS

The study is a secondary analysis of the Predicting Persistent Post-concussive Problems in Pediatrics study, which prospectively recruited a multicenter cohort of 3029 children 5-17 years of age presenting to the ED with concussion from 2013-2015. Post-concussive symptom ratings were obtained at pre-specified time points for 12 weeks post-injury, using the validated Post-Concussion Symptom Inventory (PCSI). Symptom severity and recovery trajectories were measured using delta scores on the PCSI (mean post-injury symptom score minus perceived pre-injury score). A multivariable, longitudinal model evaluated the adjusted effect of mechanism of injury (motor vehicle collisions vs other mechanisms) on mean symptom scores, compared to perceived pre-injury reports, and the temporal change in mean scores over during recovery.

RESULTS

Of 3029 study participants, 56 (1.8%) sustained concussion from motor vehicle collisions. Children sustaining concussion in a motor vehicle collision had lower post-concussive symptom scores upon ED presentation, measured as differences from their perceived pre-injury reports, as compared to other injury mechanisms (-0.36 [95% confidence interval (CI) = -0.58, -0.15]). However, the motor vehicle collisions group showed the smallest decline in symptom burden over 1 month following injury (-0.54 [95% CI = -0.81, -0.27]).

CONCLUSIONS

Children sustaining concussions in motor vehicle collisions may have lower initial symptom burdens but slower symptom recovery at 1 month compared to other mechanisms of injury and may represent a distinct population for prognostic counseling in the ED requiring further research.

Mental Health in the Young Athlete

PURPOSE OF REVIEW

The goal of the present paper is to provide a comprehensive overview of mental health concerns in young athletes, with a focus on common disorders, as well as population-specific risk factors.

RECENT FINDINGS

Athletes experience similar mental health concerns as non-athlete peers, such as anxiety, depression and suicidal ideation, ADHD, eating disorders, and substance abuse. However, they also experience unique stressors that put them at risk for the development or exacerbation of mental health disorders. Student athletes have to balance academics with rigorous training regimens while focusing on optimal performance and managing high expectations. Physical injuries, overtraining, concussion, sleep disorders, and social identity are some of the factors that also impact the mental health of student athletes. Existing literature highlights the need to develop proactive mental health and wellness education for young athletes, and to develop services that recognize the unique needs of this population.

Sports- or Physical Activity-Related Concussions and Feelings of Sadness or Hopelessness Among U.S. High School Students: Results From the 2017 Youth Behavior Risk Survey

For this study, we explored the association between high school students' reported history of sport- or physical activity-related concussions and persistent feelings of sadness or hopelessness. Data from the 2017 national Youth Risk Behavior Survey (YRBS; N = 14,765) was used for this analysis. YRBS is administered to high school students throughout the country every 2 years. Findings from this study demonstrate that the prevalence of persistent feelings of sadness or hopelessness was 36.4% among students who reported sustaining one or more concussions. Compared to students who did not report having sustained a concussion, the odds of persistent feelings of sadness or hopelessness were significantly higher among students who had sustained one or more concussions (AOR = 1.41). These findings support the need for continued efforts by school nurses and other health care providers to identify students with a history of concussion and assess their mental health needs.

Continuum of Care Following Sports-Related Concussion

Purpose Although guidelines have changed regarding federally mandated concussion practices since their inception, little is known regarding the implementation of such guidelines and the resultant continuum of care for youth athletes participating in recreational or organized sports who incur concussions. Furthermore, data regarding the role of speech-language pathologists in the historic postconcussion care are lacking. Therefore, the purpose of this retrospective study was to investigate the experiences of young adults with history of sports-related concussion as it related to injury reporting and received follow-up care. Method Participants included 13 young adults with history of at least one sports-related concussion across their life span. We implemented a mixed-methods design to collect both quantitative and qualitative information through structured interviews. Participants reported experiencing 42 concussions across the life span-26 subsequent to sports injuries. Results Twenty-three concussions were reported to a parent or medical professional, 14 resulted in a formal diagnosis, and participants received initial medical care for only 10 of the incidents and treatment or services on only two occasions. Participants reported concussions to an athletic trainer least frequently and to parents most frequently. Participants commented that previous experience with concussion reduced the need for seeking treatment or that they were unaware treatments or supports existed postconcussion. Only one concussion incident resulted in the care from a speech-language pathologist. Conclusion The results of the study reported herein shed light on the fidelity of sports-related concussion care management across time. Subsequently, we suggest guidelines related to continuum of care from injury to individualized therapy.

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management

OBJECTIVE

To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes.

STUDY DESIGN

A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients.

RESULTS

Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations.

CONCLUSIONS

Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

Utilizing the Biopsychosocial Model in Concussion Treatment: Post-Traumatic Headache and beyond

PURPOSE OF REVIEW

To discuss recent literature concerning the application of the biopsychosocial model in the management of concussion and post-concussion headache.

RECENT FINDINGS

Current research suggests that the biopsychosocial model is applicable to the concussion management process, particularly management of post-concussion headache. Such application is best illustrated by current active treatment strategies such as exercise, multifaceted rehabilitation, and psychosocial interventions targeting improved patient outcomes. Overall, the biopsychosocial model has significant applications to the management of concussion, particularly post-concussion headache. Presentation and recovery following concussion and post-traumatic headache is multifaceted and includes the continuum of biological, psychological, and social considerations. In order to fully understand the widespread clinical utility and application of such models, there is a continued need for researcher, practitioner, and patient integration and collaboration to determine the most effective assessment and treatment strategies.

Radiologic common data elements rates in pediatric mild traumatic brain injury

OBJECTIVE

The nosology for classifying structural MRI findings following pediatric mild traumatic brain injury (pmTBI) remains actively debated. Radiologic common data elements (rCDE) were developed to standardize reporting in research settings. However, some rCDE are more specific to trauma (probable rCDE). Other more recently proposed rCDE have multiple etiologies (possible rCDE), and may therefore be more common in all children. Independent cohorts of patients with pmTBI and controls were therefore recruited from multiple sites (New Mexico and Ohio) to test the dual hypothesis of a higher incidence of probable rCDE (pmTBI > controls) vs similar rates of possible rCDE on structural MRI.

METHODS

Patients with subacute pmTBI (n = 287), matched healthy controls (HC; n = 106), and orthopedically injured (OI; n = 71) patients underwent imaging approximately 1 week postinjury and were followed for 3-4 months.

RESULTS

Probable rCDE were specific to pmTBI, occurring in 4%-5% of each sample, rates consistent with previous large-scale CT studies. In contrast, prevalence rates for incidental findings and possible rCDE were similar across groups (pmTBI vs OI vs HC). The prevalence of possible rCDE was also the only finding that varied as a function of site. Possible rCDE and incidental findings were not associated with postconcussive symptomatology or quality of life 3-4 months postinjury.

CONCLUSION

Collectively, current findings question the trauma-related specificity of certain rCDE, as well how these rCDE are radiologically interpreted. Refinement of rCDE in the context of pmTBI may be warranted, especially as diagnostic schema are evolving to stratify patients with structural MRI abnormalities as having a moderate injury.

Sex-Based Differences in the Incidence of Sports-Related Concussion: Systematic Review and Meta-analysis

CONTEXT

The incidence of sports-related concussion in females has been increasing in recent years.

OBJECTIVE

To conduct a meta-analysis on sex-based differences in concussion incidence in various sports and to determine the effects of study design (retrospective vs prospective), setting (competition vs practice), and population (university and above vs high school and below) via a meta-regression.

DATA SOURCES

PubMed (Medline), EMBASE, and Cochrane Library databases were searched from January 2000 to January 2018.

STUDY SELECTION

Studies reporting sports-related concussion incidence data for both males and females (age ≥10 years) were included.

STUDY DESIGN

Systematic review with meta-analysis and meta-regression.

LEVEL OF EVIDENCE

Level 4.

METHODS

The rate ratio was calculated as the concussion rate in females/males. Data were pooled using the DerSimonian-Laird random-effects model.

RESULTS

Thirty-eight studies met the eligibility criteria and were included in the meta-analysis. Soccer and basketball demonstrated significantly higher incidence of concussions in females compared with males (rate ratio [95% CI], 1.76 [1.43-2.16] and 1.99 [1.56-2.54], respectively; P < 0.01). Sex-based differences in concussion incidence rates for baseball/softball, ice hockey, lacrosse, swimming/diving, and track and field were not statistically significant. In the meta-regression analysis, there were no significant effects on the rate ratio when evaluating study design, setting, and population.

CONCLUSION

Concussion incidence rates were significantly higher in females than in males for soccer and basketball.

Factors Affecting Recovery Trajectories in Pediatric Female Concussion

OBJECTIVE

Up to one-third of children with concussion have persistent postconcussion symptoms lasting beyond 4 weeks. Females have been shown to have prolonged concussion recovery compared with males. This study examined characteristics in pediatric athletes with concussion to investigate the underlying factors that may contribute to this difference and their relation to recovery trajectories in females compared with males.

DESIGN

A retrospective cohort study of pediatric patients with sports-related concussion (SRC).

SETTING

A subspecialty pediatric concussion program.

SUBJECTS

One hundred ninety-two records were reviewed, 75 females and 117 males, ages 7 to 18 years old.

ASSESSMENT OF RISK FACTORS

Sex of patient, time to presentation to specialty care after injury, presence of vision, and vestibular deficits on initial clinical examination.

MAIN OUTCOME MEASURES

The main outcome of interest was time to clinical recovery, defined by resolution of symptoms, recovery of physical examination deficits, including vision and vestibular examination, recovery of neurocognitive function, and return to school, exercise, and sport.

RESULTS

Pediatric females, on average, presented later to specialty care for evaluation after SRC than males. Females also took longer to recover on 5 markers of recovery: time to return to school without accommodations, time to return to noncontact exercise, time to return to full sport, time to recovery of neurocognitive function on computerized testing, and time to clinical recovery of vision and vestibular deficits on examination including smooth pursuits, saccades, gaze stability, near point of convergence, and balance. These sex-based differences in recovery disappeared when controlling for time to presentation to specialty care.

CONCLUSIONS

In this cohort of pediatric patients, ages 7 to 18 years old with SRC, females took longer to recover than males. Our results indicate, however, that a modifiable extrinsic factor, time to presentation to specialty care, may contribute to this difference in recovery between the sexes.

The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Middle and High School-Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention

Purpose The Centers for Disease Control and Prevention (CDC) recently released guidelines for rehabilitation professionals regarding the care of children with mild traumatic brain injury (mTBI). Given that mTBI impacts millions of children each year and can be particularly detrimental to children in middle and high school age groups, access to universal recommendations for management of postinjury symptoms is ideal. Method This viewpoint article examines the CDC guidelines and applies these recommendations directly to speech-language pathology practices. In particular, education, assessment, treatment, team management, and ongoing monitoring are discussed. In addition, suggested timelines regarding implementation of services by speech-language pathologists (SLPs) are provided. Specific focus is placed on adolescents (i.e., middle and high school-age children). Results SLPs are critical members of the rehabilitation team working with children with mTBI and should be involved in education, symptom monitoring, and assessment early in the recovery process. SLPs can also provide unique insight into the cognitive and linguistic challenges of these students and can serve to bridge the gap among rehabilitation and school-based professionals, the adolescent with brain injury, and their parents. Conclusion The guidelines provided by the CDC, along with evidence from the field of speech pathology, can guide SLPs to advocate for involvement in the care of adolescents with mTBI. More research is needed to enhance the evidence base for direct assessment and treatment with this population; however, SLPs can use their extensive knowledge and experience working with individuals with traumatic brain injury as a starting point for post-mTBI care.

The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada

Concussion is a form of mild traumatic brain injury that affects thousands of Canadian children and adolescents annually. Despite national efforts to harmonize the recognition and management of pediatric concussion in Canada, timely access to primary and specialized care following this injury remains a challenge for many patients especially those who live in rural and remote communities. To address similar challenges facing patients with stroke and other neurological disorders, physicians have begun to leverage advances in telemedicine to improve the delivery of specialized neurological care to those living in medically underserved regions. Preliminary studies suggest that telemedicine may be a safe and cost-effective approach to assist in the medical care of select patients with acute concussion and persistent post-concussion symptoms. Here we provide an overview of telemedicine, teleneurology, the principles of concussion assessment and management, as well as the current state of concussion care in Canada. Utilizing preliminary evidence from studies of telemedicine in concussion and experience from comprehensive systems of care for stroke, we outline steps that must be taken to evaluate the potential of telemedicine-based concussion networks to improve the care of pediatric concussion patients living in underserved rural and remote communities in Canada.

Risk of Repeat Concussion Among Patients Diagnosed at a Pediatric Care Network

OBJECTIVE

To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury.

STUDY DESIGN

For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion.

RESULTS

Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]).

CONCLUSIONS

We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts.

Injuries and concussions among young children, ages 5-11, playing sports in recreational leagues in Florida

Background

The specific research aims of this study included: 1) Conduct an epidemiologic analysis of recreational sports injuries among 1500 children, ages 5–11 in Florida: and 2) Utilize the computerized pediatric concussion tool from ImPACT Applications, Inc. for baseline and follow-up testing to better understand these injuries. This research followed a prospective surveillance design utilizing a large cohort of children, ages, 5–11, who play recreational football, soccer, and baseball/softball in Florida. The study venue was a large athletic facility in Hillsborough County, Florida. The sports observed were soccer (girls’ and boys’), baseball, softball, and football. Internal and external advisory boards were consulted throughout the study.

Methods

Certified Athletic Trainers (ATCs) were hired to use High School Reporting Information Online (RIO) for injuries and the Ipad-administered pediatric concussion tool developed by ImPACT Applications, Inc for baseline/follow-up concussion data.

Results

Over the course of the project, 26 RIO-reported injuries were reported. Football and soccer produced the greatest rate of injuries. There were 12 concussions which comprised nearly half of all the RIO injuries (46%). We conducted 882 baseline concussion tests and 13 follow-up tests over the 2 years.

Conclusions

To the best of our knowledge, this is the first time data have been collected and reported on sports injuries in the study population. Future studies built on these findings will allow for the development of targeted guidelines and interventions for coaches, players, and parents so sports injury-related morbidity and mortality decrease in our youngest athletes.

Initial Emergency Department Visit and Follow-Up Care for Concussions among Children with Medicaid

OBJECTIVE

To describe the rates and patterns of initial emergency department (ED) encounters and follow-up care for concussions among Medicaid-insured children before and after the 2013 enactment of Ohio concussion law.

STUDY DESIGN

Using a time-series design, this study analyzed concussion claim data obtained from Partners for Kids, a pediatric accountable-care organization in Ohio. A total of 12 512 concussions and 48 238 associated claims for services between January 1, 2008, and June 30, 2017, with an initial ED encounter among Medicaid-insured children (ages 0-18 years) were analyzed. The effect of the law on the odds of follow-up care were assessed using generalized estimating equations models, adjusted for sex, age group, and residence location.

RESULTS

Of the total 12 512 concussions, 63.9% occurred in male patients, 70.1% in patients ages 10-18 years, and 65.2% in patients from urban areas. The rate of initial ED encounters for concussions increased from 2008 to 2014 (2.8 to 4.9 per 10 000 members), followed by a decrease in 2016 (4.2 per 10 000 members). A significant increase in follow-up care after the initial ED encounter was observed from pre-law to post-law (OR 1.73, 95% CI 1.61, 1.86). A shift in follow-up care was observed from radiology and ambulance services in pre-law to primary care providers in post-law.

CONCLUSIONS

The Ohio concussion law may have influenced the patterns of initial ED visit and follow-up care for concussions among Medicaid-insured children. Future studies evaluating the impact of the law should analyze the utilization patterns among children with various insurance/payment types.

The Role of Speech-Language Pathology in an Interdisciplinary Care Model for Persistent Symptomatology of Mild Traumatic Brain Injury

The Marcus Institute for Brain Health (MIBH) provides interdisciplinary care for adults struggling with persistent effects of mild traumatic brain injury and accompanying changes in behavioral health, with specific emphases on Veterans and retired elite athletes. The cognitive, physical, and behavioral symptoms associated with mild traumatic brain injury are interrelated, with neurobiopsychosocial modeling encompassing the factors related to recovery from a traumatic brain injury. The diffuse impacts of chronic concussive injuries require multiple clinical providers to address the breadth of symptoms, facilitating both interdisciplinary and transdisciplinary care models. By implementing integrated practice units, patients receive advanced medical care, imaging, speech-language pathology, physical therapy, behavioral health, neuropsychology, and clinical pharmacy for a cohesive diagnostic and intervention plan. Nationally, speech-language pathologists report challenges with best-practice options for concussion, particularly in the domain of assessment practices. At the MIBH, speech-language pathologists begin their assessment with a structured clinical interview that focuses on patients' needs and concerns. Evaluation modalities focus on hearing, communication, and functional cognition to guide therapeutic treatment planning. The intensive outpatient care program at MIBH incorporates both individual sessions targeting patient-centered goals and group care, where speech-language pathologists work transdisciplinarily to generalize care from all disciplines out into the community. Care practices for concussive injuries continue to evolve rapidly; speech-language pathology at the MIBH offers one such vision for excellence in clinical care.

Using Community Detection Analysis to Elucidate Caregivers’ Mental Models of Pediatric Concussion Symptoms

Due to a culture of resistance around concussion reporting, novel methods are needed to reveal implicit beliefs that could affect symptom reporting. The goal of this study was to elucidate caregivers’ mental models of pediatric concussion symptoms using an exploratory community detection analysis (CDA). Caregivers (n = 76) of adolescents 10–15 years old participated in a survey that assessed their intentions of seeking medical treatment for 12 injury symptoms following their child’s involvement in three hypothetical injury scenarios. We used a series of analyses of variance (ANOVAs) to compare injury symptoms across these scenarios and CDA to determine if caregivers implicitly group symptoms together. We then used logistic regressions to further explore associations between the CDA-identified symptom indices and known factors of injury risk. There were no differences in the likelihood to seek treatment for symptoms across injury scenarios; however, the CDA revealed distinct symptom clusters that were characterized by the degree of risk for non-treatment and symptom type. We observed associations between injury risk factors and intentions of seeking medical treatment for the higher-risk indices. Results indicate that caregivers’ mental models of concussion symptoms are nuanced, not monolithic. Therefore, it is inaccurate to measure intentions to seek treatment for concussion without taking these nuances into consideration.