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Panzera JC, Podolak OE, Master CL. Contemporary diagnosis and management of mild TBI (concussions): What you need to know. J Trauma Acute Care Surg 2024; 96:865-869. [PMID: 38696496 DOI: 10.1097/ta.0000000000004297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
ABSTRACT Concussion is a common injury in children and adolescents and is a form of mild traumatic brain injury that surgeons will see in their acute care practice. With a rapidly changing evidence base for diagnosis and management, we will focus on the importance of timely identification and diagnosis, as well as the early initiation of active management of pediatric concussion immediately after injury through recovery. This approach involves the application of targeted therapies for specific deficits identified after concussion, addressing the individual pattern of symptoms experienced by patients following concussion. We will review what is known about the underlying pathophysiology that drives the clinical manifestations of concussion, the targeted clinical assessments that can both aid in the diagnosis of concussion, as well as drive the active rehabilitation of deficits seen after concussion. The standardized approach to the return to activities will also be described, including return to learning and sports.
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Affiliation(s)
- Joseph C Panzera
- From the Sports Medicine and Performance Center, (J.C.P.); Center for Injury Research and Prevention (O.E.P.); and Sports Medicine and Performance Center, Center for Injury Research and Prevention (C.L.M.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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2
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Corwin DJ, Metzger KB, McDonald CC, Pfeiffer MR, Arbogast KB, Master CL. The Variability of Recovery From Pediatric Concussion Using Multimodal Clinical Definitions. Sports Health 2024; 16:79-88. [PMID: 36896665 PMCID: PMC10732108 DOI: 10.1177/19417381231152448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND While concussions are common pediatric injuries, a lack of agreement on a standard definition of recovery creates multiple challenges for clinicians and researchers alike. HYPOTHESIS The percentage of concussed youth deemed recovered as part of a prospective cohort study will differ depending on the recovery definition. STUDY DESIGN Descriptive epidemiologic study of a prospectively enrolled observational cohort. LEVEL OF EVIDENCE Level 3. METHODS Participants aged 11 to 18 years were enrolled from the concussion program of a tertiary care academic center. Data were collected from initial and follow-up clinical visits ≤12 weeks from injury. A total of 10 recovery definitions were assessed: (1) cleared to full return to sports; (2) return to full school; (3) self-reported return to normal; (4) self-reported full return to school; (5) self-reported full return to exercise; (6) symptom return to preinjury state; (7) complete symptom resolution; (8) symptoms below standardized threshold; (9) no abnormal visio-vestibular examination (VVE) elements; and (10) ≤1 abnormal VVE assessments. RESULTS In total, 174 participants were enrolled. By week 4, 63.8% met at least 1 recovery definition versus 78.2% by week 8 versus 88.5% by week 12. For individual measures of recovery at week 4, percent recovered ranged from 5% by self-reported full return to exercise to 45% for ≤1 VVE abnormality (similar trends at 8 and 12 weeks). CONCLUSION There is wide variability in the proportion of youth considered recovered at various points following concussion depending on the definition of recovery, with higher proportions using physiologic examination-based measures and lower proportions using patient-reported measures. CLINICAL RELEVANCE These results further emphasize the need for a multimodal assessment of recovery by clinicians as a single and standardized definition of recovery that captures the broad impact of concussion on a given patient continues to be elusive.
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Affiliation(s)
- Daniel J. Corwin
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristina B. Metzger
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa R. Pfeiffer
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, and The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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3
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Stein A, Vinh To X, Nasrallah FA, Barlow KM. Evidence of Ongoing Cerebral Microstructural Reorganization in Children With Persisting Symptoms Following Mild Traumatic Brain Injury: A NODDI DTI Analysis. J Neurotrauma 2024; 41:41-58. [PMID: 37885245 DOI: 10.1089/neu.2023.0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Approximately 300-550 children per 100,000 sustain a mild traumatic brain injury (mTBI) each year, of whom ∼25-30% have long-term cognitive problems. Following mTBI, free water (FW) accumulation occurs in white matter (WM) tracts. Diffusion tensor imaging (DTI) can be used to investigate structural integrity following mTBI. Compared with conventional DTI, neurite orientation dispersion and density imaging (NODDI) orientation dispersion index (ODI) and fraction of isolated free water (FISO) metrics may allow a more advanced insight into microstructural damage following pediatric mTBI. In this longitudinal study, we used NODDI to explore whole-brain and tract-specific differences in ODI and FISO in children with persistent symptoms after mTBI (n = 80) and in children displaying clinical recovery (n = 32) at 1 and 2-3 months post-mTBI compared with healthy controls (HCs) (n = 21). Two-way repeated measures analysis of variance (ANOVA) and voxelwise two-sample t tests were conducted to compare whole-brain and tract-specific diffusion across groups. All results were corrected at positive false discovery rate (pFDR) <0.05. We also examined the association between NODDI metrics and clinical outcomes, using logistical regression to investigate the value of NODDI metrics in predicting future recovery from mTBI. Whole-brain ODI was significantly increased in symptomatic participants compared with HCs at both 1 and 2 months post-injury, where the uncinate fasciculus (UF) and inferior fronto-occipital fasciculus (IFOF) were particularly implicated. Using region of interest (ROI) analysis in significant WM, bilateral IFOF and UF voxels, symptomatic participants had the highest ODI in all ROIs. ODI was lower in asymptomatic participants, and HCs had the lowest ODI in all ROIs. No changes in FISO were found across groups or over time. WM ODI was moderately correlated with a higher youth-reported post-concussion symptom inventory (PCSI) score. With 87% predictive power, ODI (1 month post-injury) and clinical predictors (age, sex, PCSI score, attention scores) were a more sensitive predictor of recovery at 2-3 months post-injury than fractional anisotropy (FA) and clinical predictors, or clinical predictors alone. FISO could not predict recovery at 2-3 months post-injury. Therefore, we found that ODI was significantly increased in symptomatic children following mTBI compared with HCs at 1 month post-injury, and progressively decreased over time alongside clinical recovery. We found no significant differences in FISO between groups or over time. WM ODI at 1 month was a more sensitive predictor of clinical recovery at 2-3 months post-injury than FA, FISO, or clinical measures alone. Our results show evidence of ongoing microstructural reorganization or neuroinflammation between 1 and 2-3 months post-injury, further supporting delayed return to play in children who remain symptomatic. We recommend future research examining the clinical utility of NODDI following mTBI to predict recovery or persistence of post-concussion symptoms and thereby inform management of mTBI.
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Affiliation(s)
- Athena Stein
- Acquired Brain Injury in Children Research Group, The University of Queensland, South Brisbane, Queensland, Australia
| | - Xuan Vinh To
- Queensland Brain Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Fatima A Nasrallah
- Queensland Brain Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Karen M Barlow
- Acquired Brain Injury in Children Research Group, The University of Queensland, South Brisbane, Queensland, Australia
- Queensland Pediatric Rehabilitation Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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Beauchamp MH, Dégeilh F, Rose SC. Improving outcome after paediatric concussion: challenges and possibilities. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:728-740. [PMID: 37734775 DOI: 10.1016/s2352-4642(23)00193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 09/23/2023]
Abstract
The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.
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Affiliation(s)
- Miriam H Beauchamp
- Sainte-Justine Research Center, University of Montreal, Montréal, QC, Canada; Department of Psychology, University of Montreal, Montréal, QC, Canada.
| | - Fanny Dégeilh
- Univ Rennes, CNRS, Inria, Inserm, IRISA UMR 6074, EMPENN ERL U-1228, Rennes, France
| | - Sean C Rose
- Pediatric Neurology, Nationwide Children's Hospital, Columbus, OH, USA; Ohio State University College of Medicine, Columbus, OH, USA
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Edemann-Callesen H, Andersen HK, Ussing A, Virring A, Jennum P, Debes NM, Laursen T, Baandrup L, Gade C, Dettmann J, Holm J, Krogh C, Birkefoss K, Tarp S, Händel MN. Use of melatonin for children and adolescents with chronic insomnia attributable to disorders beyond indication: a systematic review, meta-analysis and clinical recommendation. EClinicalMedicine 2023; 61:102049. [PMID: 37457114 PMCID: PMC10339185 DOI: 10.1016/j.eclinm.2023.102049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
Background Melatonin has become a widely used sleeping aid for young individuals currently not included in existing guidelines. The aim was to develop a recommendation on the use of melatonin in children and adolescents aged 2-20 years, with chronic insomnia due to disorders beyond indication. Methods We performed a systematic search for guidelines, systematic reviews, and randomised trials (RCTs) in Medline, Embase, Cochrane Library, PsycInfo, Cinahl, Guidelines International Network, Trip Database, Canadian Agency for Drugs and Technologies in Health, American Academy of Sleep Medicine, European Sleep Research Society and Scandinavian Health Authorities databases. A separate search for adverse events was also performed. The latest search for guidelines, systematic reviews, and adverse events was performed on March 17, 2023. The latest search for RCTs was performed on to February 6, 2023. The language was restricted to English, Danish, Norwegian, and Swedish. Eligible participants were children and adolescents (2-20 years of age) with chronic insomnia due to underlying disorders, in whom sleep hygiene practices have been inadequate and melatonin was tested. Studies exclusively on autism spectrum disorders or attention deficit hyperactive disorder were excluded. There were no restrictions on dosage, duration of treatment, time of consumption or release formula. Primary outcomes were quality of sleep, daytime functioning and serious adverse events, assessed at 2-4 weeks post-treatment. Secondary outcomes included total sleep time, sleep latency, awakenings, drowsiness, quality of life, non-serious adverse events, and all-cause dropouts (assessed at 2-4 weeks post-treatment), plus quality of sleep and daytime functioning (assessed at 3-6 months post-treatment). Pooled estimates were calculated using inverse variance random effects model. Statistical heterogeneity was calculated using I2 statistics. Risk of bias was assessed using Cochrane risk of bias tool. Publication bias was assessed using funnel plots. A multidisciplinary guideline panel constructed the recommendation using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). The certainty of evidence was considered either high, moderate, low or very low depending on the extent of risk of bias, inconsistency, imprecision, indirectness, or publication bias. The evidence-to-decision framework was used to discuss the feasibility and acceptance of the constructed recommendation and its impact on resources and equity. The protocol is registered with the Danish Health Authority. Findings We identified 13 RCTs, including 403 patients with a wide range of conditions. Melatonin reduced sleep latency by 14.88 min (95% CI 23.42-6.34, 9 studies, I2 = 60%) and increased total sleep time by 18.97 min (95% CI 0.37-37.57, 10 studies, I2 = 57%). The funnel plot for total sleep time showed no apparent indication of publication bias. No other clinical benefits were found. The number of patients experiencing adverse events was not statistically increased however, safety data was scarce. Certainty of evidence was low. Interpretation Low certainty evidence supports a moderate effect of melatonin in treating sleep continuity parameters in children and adolescents with chronic insomnia due to primarily medical disorders beyond indication. The off-label use of melatonin for these patients should never be the first choice of treatment, but may be considered by medical specialists with knowledge of the underlying disorder and if non-pharmacological interventions are inadequate. If treatment with melatonin is initiated, adequate follow-up to evaluate treatment effect and adverse events is essential. Funding The Danish Health Authority. The Parker Institute, Bispebjerg and Frederiksberg Hospital, supported by the Oak Foundation.
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Affiliation(s)
- Henriette Edemann-Callesen
- The Danish Health Authority, 2300, Copenhagen, Denmark
- Center for Evidence-Based Psychiatry, Psychiatric Research Unit, Psychiatry Region Zealand, 4200, Slagelse, Denmark
| | | | - Anja Ussing
- The Danish Health Authority, 2300, Copenhagen, Denmark
| | - Anne Virring
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Nanette Mol Debes
- Department of Pediatrics, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Torben Laursen
- Department of Clinical Pharmacology, Aarhus University Hospital, Denmark
| | - Lone Baandrup
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Bispebjerg and Gentofte Departments, Mental Health Centre Copenhagen, Copenhagen University Hospital – the Mental Health Services of the Capital Region in Denmark, Denmark
| | - Christina Gade
- Department of Clinical Pharmacology and Clinical Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, University of Copenhagen, Denmark
| | - Jette Dettmann
- Department of Pediatrics, Copenhagen University Hospital – NOH, Hillerød, Denmark
| | - Jonas Holm
- The Occupational Therapist Association, Denmark
| | - Camilla Krogh
- The Danish Health Authority, 2300, Copenhagen, Denmark
| | | | - Simon Tarp
- The Danish Health Authority, 2300, Copenhagen, Denmark
| | - Mina Nicole Händel
- The Danish Health Authority, 2300, Copenhagen, Denmark
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
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Grigg-Damberger MM. Sleep/Wake Disorders After Sports Concussion: Risks, Revelations, and Interventions. J Clin Neurophysiol 2023; 40:417-425. [PMID: 36930200 DOI: 10.1097/wnp.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
SUMMARY Sleep-wake disturbances (SWDs) are among the most prevalent, persistent, and often disregarded sequelae of traumatic brain injury. Identification and treatment of SWDs in patients with traumatic brain injury is important and can complement other efforts to promote maximum functional recovery. SWDs can accentuate other consequences of traumatic brain injury, negatively affect mood, exacerbate pain, heighten irritability, and diminish cognitive abilities and the potential for recovery. The risk for sports injuries increases when athletes are sleep deprived. Sleep deprivation increases risk-taking behaviors, predisposing to injuries. SWDs are an independent risk factor for prolonged recovery after sports-related concussion. SWDs following sports-related concussion have been shown to impede recovery, rehabilitation, and return to preinjury activities.
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Händel MN, Andersen HK, Ussing A, Virring A, Jennum P, Debes NM, Laursen T, Baandrup L, Gade C, Dettmann J, Holm J, Krogh C, Birkefoss K, Tarp S, Bliddal M, Edemann-Callesen H. The short-term and long-term adverse effects of melatonin treatment in children and adolescents: a systematic review and GRADE assessment. EClinicalMedicine 2023; 61:102083. [PMID: 37483551 PMCID: PMC10359736 DOI: 10.1016/j.eclinm.2023.102083] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Background Currently, melatonin is used to treat children and adolescents with insomnia without knowing the full extent of the short-term and long-term consequences. Our aim was to provide clinicians and guideline panels with a systematic assessment of serious-and non-serious adverse events seen in continuation of melatonin treatment and the impact on pubertal development and bone health following long-term administration in children and adolescents with chronic insomnia. Methods We searched PubMed, Embase, Cinahl and PsycINFO via Ovid, up to March 17, 2023, for studies on melatonin treatment among children and adolescents (aged 5-20 years) with chronic insomnia. The language was restricted to English, Danish, Norwegian, and Swedish. Outcomes were non-serious adverse events and serious adverse events assessed 2-4 weeks after initiating treatment and pubertal development and bone health, with no restriction on definition or time of measurement. Observational studies were included for the assessment of long-term outcomes, and serious and non-serious adverse events were assessed via randomised studies. The certainty of the evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). The protocol is registered with the Danish Health Authority. Findings We identified 22 randomised studies with 1350 patients reporting on serious-and non-serious adverse events and four observational studies with a total of 105 patients reporting on pubertal development. Melatonin was not associated with serious adverse events, yet the number of patients experiencing non-serious adverse events was increased (Relative risk 1.56, 95% CI 1.01-2.43, 17 studies, I2 = 47%). Three studies reported little or no influence on pubertal development following 2-4 years of treatment, whereas one study registered a potential delay following longer treatment durations (>7 years). These findings need further evaluation due to several methodological limitations. Interpretation Children who use melatonin are likely to experience non-serious adverse events, yet the actual extent to which melatonin leads to non-serious adverse events and the long-term consequences remain uncertain. This major gap of knowledge on safety calls for caution against complacent use of melatonin in children and adolescents with chronic insomnia and for more research to inform clinicians and guideline panels on this key issue. Funding The Danish Health Authority. The Parker Institute, Bispebjerg and Frederiksberg Hospital, supported by the Oak Foundation.
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Affiliation(s)
- Mina Nicole Händel
- The Danish Health Authority, 2300, Copenhagen, Denmark
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | | | - Anja Ussing
- The Danish Health Authority, 2300, Copenhagen, Denmark
| | - Anne Virring
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Poul Jennum
- Danish Centre for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Nanette Mol Debes
- Department of Pediatrics, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Torben Laursen
- Department of Clinical Pharmacology, Aarhus University Hospital, Denmark
| | - Lone Baandrup
- Bispebjerg and Gentofte Departments, Mental Health Centre Copenhagen, Copenhagen University Hospital – the Mental Health Services of the Capital Region in Denmark & Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christina Gade
- Departments of Clinical Pharmacology and Clinical Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, University of Copenhagen, Denmark
| | - Jette Dettmann
- Department of Pediatrics, Copenhagen University Hospital – NOH, Hillerød, Denmark
| | - Jonas Holm
- The Occupational Therapist Association, Denmark
| | - Camilla Krogh
- The Danish Health Authority, 2300, Copenhagen, Denmark
| | | | - Simon Tarp
- The Danish Health Authority, 2300, Copenhagen, Denmark
| | - Mette Bliddal
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henriette Edemann-Callesen
- The Danish Health Authority, 2300, Copenhagen, Denmark
- Centre for Evidence-Based Psychiatry, Psychiatric Research Unit, Psychiatry Region Zealand, 4200, Slagelse, Denmark
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Hanalioglu D, Hanalioglu S, Arango JI, Adelson PD. Current evidence for pharmacological management of pediatric concussion: a systematic review. Childs Nerv Syst 2023; 39:1831-1849. [PMID: 37208486 DOI: 10.1007/s00381-023-05960-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 04/13/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE Mild traumatic brain injury (mTBI) is a global public health problem and its current management is limited to rest and symptom management. Despite frequent use of drugs for symptom control, there is a lack of consensus on the optimal pharmacological management of post-concussive symptoms. We reviewed the relevant literature to compile the evidence about the pharmaceutical management of pediatric mTBI. METHODS We performed a systematic review of the literature available in PubMed, Cochrane CENTRAL, and ClinicalTrials.Gov as well as through citation tracing. A modified PICO framework was used for the construction of search strategy and eligibility criteria. Risk of bias was assessed using RoB-2 tool for randomized and ROBINS-I for non-randomized studies. RESULTS A total of 6260 articles were screened for eligibility. After exclusions, a total of 88 articles received full text review. A total of 15 reports representing 13 studies (5 randomized clinical trials, 1 prospective randomized cohort study, 1 prospective cohort study, and 6 retrospective cohort studies) met the eligibility criteria and were included in the review. We identified 16 pharmacological interventions in a total of 931 pediatric patients with mTBI. Amytriptiline (n = 4), ondansetron (n = 3), melatonin (n = 3), metoclopramide (n = 2), magnesium (n = 2), and topiramate (n = 2) were investigated in multiple studies. All RCTs were relatively of small size (n ≤ 33/group). CONCLUSION The available evidence supporting pharmacological intervention in pediatric mild traumatic brain injury is scarce. We propose a framework to facilitate future collaborative research efforts to test and validate various pharmacological interventions for acute and persistent post-concussive symptoms in children.
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Affiliation(s)
- Damla Hanalioglu
- Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
- Division of Pediatric Emergency Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sahin Hanalioglu
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Jorge I Arango
- Division of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - P David Adelson
- Department of Neurosurgery, Rockefeller Neuroscience Institute at WVU Medicine, Morgantown, WV, USA.
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Cassimatis M, Orr R, Fyffe A, Browne G. Association of Sleep Disturbance With Neurocognition, Symptom Severity, and Recovery in Pediatric Concussion: A 10-Year Retrospective Analysis of a Tertiary Referral Concussion Clinic. J Head Trauma Rehabil 2023; 38:231-239. [PMID: 35862900 DOI: 10.1097/htr.0000000000000804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the relationship between sleep disturbance, neurocognition, symptom severity, and recovery in children and adolescents with concussion. Sex-related comparisons were also examined. SETTING Pediatric tertiary referral concussion clinic. PARTICIPANTS Children and adolescents (aged 6-18 years; n = 554) diagnosed with concussion. DESIGN Cross-sectional retrospective study. MAIN MEASURES Assessment data were obtained from Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Applications. Sleep disturbance was quantified using the sleep-related domains of the Post-Concussion Symptom Scale (PCSS) and self-report sleep duration. Sleep duration was categorized as short (<7 hours), intermediate (7-9 hours), and long (≥9 hours). Outcome measures included neurocognition, measured via composite scores of ImPACT cognitive domains (verbal memory, visual memory, visual motor speed, reaction time); symptom severity, using the PCSS; and concussion recovery time (days). RESULTS Short sleep resulted in significantly poorer verbal memory ( P = .03), visual memory ( P = .02), and reaction time ( P = .01). Sleep disturbance was strongly associated with total symptom burden (ρ = 0.90, P < .001). Recovery time, median (interquartile range), was significantly prolonged with short sleep, 61 (30-136) days, compared with intermediate, 38 (21-72) days, and long, 34 (19-71) days, sleep ( P < .001). Overall, female participants demonstrated significantly longer recovery times than male participants (mean 91 ± 95 vs 58 ± 85 days, P < .001). Females exhibited similar concussion recovery times irrespective of reported sleep duration ( P = .95), whereas mean recovery time in males was significantly longer with short sleep (84 ± 82 days) than with intermediate (61 ± 106 days) and long (49 ± 62 days) sleep ( P < .001). CONCLUSION Sleep disturbance following concussion poses as a promising modifiable risk factor to alleviate postinjury impairments, including cognitive deficits and symptom burden. Female children were found to experience more severe concussion symptoms and protracted recovery times than their male counterparts. Investigations into the factors that may contribute to sex-related differences following concussion are warranted.
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Affiliation(s)
- Maree Cassimatis
- Discipline of Exercise and Sports Science, Faculty of Medicine and Health, Sydney School of Health Sciences (Ms Cassimatis, Dr Orr, and Mr Fyffe), and Discipline of Child and Adolescent Health, The Children's Hospital at Westmead Clinical School (Browne), The University of Sydney, Sydney, New South Wales, Australia; and Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, Children's Hospital Westmead, Sydney, New South Wales, Australia (Drs Orr and Browne and Mr Fyffe)
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10
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Deshpande SN, Simkin DR. Complementary and Integrative Approaches to Sleep Disorders in Children. Child Adolesc Psychiatr Clin N Am 2023; 32:243-272. [PMID: 37147039 DOI: 10.1016/j.chc.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Sleep problems are very common in children and adolescents. Chronic insomnia is the leading cause of sleep disorders in children and adolescents. Adjunctive interventions that address low ferritin levels and vitamin D3 deficiency are helpful in children and adolescents. The addition of l-5-hydroxytryptophan, gabadone, l-theanine, Ashwagandha, omega 3 fatty acids, probiotics in bipolar disorder, and children with colic, meditation, and changing from a high-fat diet to a Mediterranean diet are also helpful adjunctive interventions. Actigraphy data should be collected in future sleep studies because subjective data may not indicate the true effect of the intervention.
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Affiliation(s)
- Swapna N Deshpande
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University, 5310 East 31st Street, Tulsa, OK 74135, USA.
| | - Deborah R Simkin
- Department of Psychiatry, Emory University School of Medicine, 8955 Highway 98 West, Suite 204, Miramar Beach, FL 32550, USA
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11
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Herrero Babiloni A, Baril AA, Charlebois-Plante C, Jodoin M, Sanchez E, De Baets L, Arbour C, Lavigne GJ, Gosselin N, De Beaumont L. The Putative Role of Neuroinflammation in the Interaction between Traumatic Brain Injuries, Sleep, Pain and Other Neuropsychiatric Outcomes: A State-of-the-Art Review. J Clin Med 2023; 12:jcm12051793. [PMID: 36902580 PMCID: PMC10002551 DOI: 10.3390/jcm12051793] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Sleep disturbances are widely prevalent following a traumatic brain injury (TBI) and have the potential to contribute to numerous post-traumatic physiological, psychological, and cognitive difficulties developing chronically, including chronic pain. An important pathophysiological mechanism involved in the recovery of TBI is neuroinflammation, which leads to many downstream consequences. While neuroinflammation is a process that can be both beneficial and detrimental to individuals' recovery after sustaining a TBI, recent evidence suggests that neuroinflammation may worsen outcomes in traumatically injured patients, as well as exacerbate the deleterious consequences of sleep disturbances. Additionally, a bidirectional relationship between neuroinflammation and sleep has been described, where neuroinflammation plays a role in sleep regulation and, in turn, poor sleep promotes neuroinflammation. Given the complexity of this interplay, this review aims to clarify the role of neuroinflammation in the relationship between sleep and TBI, with an emphasis on long-term outcomes such as pain, mood disorders, cognitive dysfunctions, and elevated risk of Alzheimer's disease and dementia. In addition, some management strategies and novel treatment targeting sleep and neuroinflammation will be discussed in order to establish an effective approach to mitigate long-term outcomes after TBI.
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Affiliation(s)
- Alberto Herrero Babiloni
- Division of Experimental Medicine, McGill University, Montreal, QC H3A 0C7, Canada
- CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montreal, QC H4J 1C5, Canada
- Correspondence:
| | - Andrée-Ann Baril
- Douglas Mental Health University Institute, Montreal, QC H4H 1R3, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | | | - Marianne Jodoin
- CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montreal, QC H4J 1C5, Canada
- Department of Psychology, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Erlan Sanchez
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Liesbet De Baets
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Faculty of Medicine, University of Montreal, Montreal, QC H3T 1C5, Canada
- Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1050 Brussel, Belgium
| | - Caroline Arbour
- CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montreal, QC H4J 1C5, Canada
- Faculty of Nursing, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Gilles J. Lavigne
- Division of Experimental Medicine, McGill University, Montreal, QC H3A 0C7, Canada
- CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montreal, QC H4J 1C5, Canada
- Faculty of Dental Medicine, University of Montreal, Montreal, QC H3T 1C5, Canada
| | - Nadia Gosselin
- CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montreal, QC H4J 1C5, Canada
| | - Louis De Beaumont
- CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montreal, QC H4J 1C5, Canada
- Department of Surgery, University of Montreal, Montreal, QC H3T 1J4, Canada
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12
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Cassimatis M, Browne G, Orr R. The Utility of Melatonin for the Treatment of Sleep Disturbance After Traumatic Brain Injury: A Scoping Review. Arch Phys Med Rehabil 2023; 104:340-349. [PMID: 36243124 DOI: 10.1016/j.apmr.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/22/2022] [Accepted: 09/24/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the utility of melatonin supplementation as a treatment option for individuals with sleep disturbance after traumatic brain injury (TBI). DATA SOURCES A systematic search was conducted in 6 electronic databases (Medline, AMED, CINAHL, Embase, Scopus, and SPORTDiscus) from earliest records to April 2022. STUDY SELECTION Studies were eligible for inclusion if they met the following criteria: a) human participants with sleep disturbance after TBI, b) melatonin or melatonergic agent used as an intervention to treat sleep disturbance, and c) outcomes of melatonin administration reported. All TBI severity types (mild, moderate, and severe) were eligible. The initial search retrieved a total of 595 articles, with 9 studies meeting the eligibility criteria. DATA EXTRACTION Two reviewers independently extracted data from eligible studies and assessed methodological quality. Extracted data consisted of participant and injury characteristics, melatonin interventional properties, and sleep outcome. Methodological quality was assessed via the Downs and Black checklist. DATA SYNTHESIS A total of 251 participants with TBI-induced sleep disturbance (mean age range: 14.0-42.5 years) were included. Melatonin, Circadin (prolonged-release melatonin), or Ramelteon (melatonin receptor agonist) were administered. Dosages and intervention duration ranged from 2 to 10 mg and 3 to 12 weeks, respectively. Eight out of 9 studies reported positive outcomes after melatonin treatment. Significant improvements in subjective sleep quality, objective sleep efficiency, and total sleep time were found with melatonin. Reductions in self-reported fatigue, anxiety, and depressive symptoms were also observed with melatonin treatment. No serious adverse events were reported after melatonin administration. CONCLUSION Melatonin has good tolerability after short-term use and the potential to be a therapeutic agent for those with sleep disturbance after TBI. Melatonin was shown to be beneficial to sleep quality, sleep duration, and sleep efficiency. Additional clinically relevant outcomes of improved mental health suggest that melatonin use may be a promising treatment option for individuals experiencing co-occurring disorders of mood and sleep disturbance post-injury.
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Affiliation(s)
- Maree Cassimatis
- Discipline of Exercise and Sports Science, Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Gary Browne
- Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, Children's Hospital Westmead, Sydney, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Rhonda Orr
- Discipline of Exercise and Sports Science, Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia; Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, Children's Hospital Westmead, Sydney, Australia.
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13
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Mucha A, Pardini JE, Herring SA, Murphy J, Elbin RJ, Bauer RM, Schmidt JD, Resch JE, Broshek DK. Persisting symptoms after concussion: Considerations for active treatment. PM R 2022; 15:663-673. [PMID: 36507616 DOI: 10.1002/pmrj.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Anne Mucha
- UPMC Centers for Rehab Services, UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Jamie E Pardini
- Departments of Internal Medicine and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Stanley A Herring
- Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Justin Murphy
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - R J Elbin
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, Arkansas, USA
| | - Russell M Bauer
- Department of Clinical & Health Psychology, University of Florida Department of Clinical & Health Psychology, Gainesville, Florida, USA
| | - Julianne D Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, Georgia, USA
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Donna K Broshek
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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14
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Hadanny A, Catalogna M, Yaniv S, Stolar O, Rothstein L, Shabi A, Suzin G, Sasson E, Lang E, Finci S, Polak N, Fishlev G, Harpaz RT, Adler M, Goldman RE, Zemel Y, Bechor Y, Efrati S. Hyperbaric oxygen therapy in children with post-concussion syndrome improves cognitive and behavioral function: a randomized controlled trial. Sci Rep 2022; 12:15233. [PMID: 36151105 PMCID: PMC9508089 DOI: 10.1038/s41598-022-19395-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Persistent post-concussion syndrome (PPCS) is a common and significant morbidity among children following traumatic brain injury (TBI) and the evidence for effective PPCS treatments remains limited. Recent studies have shown the beneficial effects of hyperbaric oxygen therapy (HBOT) in PPCS adult patients. This randomized, sham-control, double blind trial evaluated the effect of hyperbaric oxygen therapy (HBOT) on children (age 8–15) suffering from PPCS from mild-moderate TBI events six months to 10 years prior. Twenty-five children were randomized to receive 60 daily sessions of HBOT (n = 15) or sham (n = 10) treatments. Following HBOT, there was a significant increase in cognitive function including the general cognitive score (d = 0.598, p = 0.01), memory (d = 0.480, p = 0.02), executive function (d = 0.739, p = 0.003), PPCS symptoms including emotional score (p = 0.04, d = – 0.676), behavioral symptoms including hyperactivity (d = 0.244, p = 0.03), global executive composite score (d = 0.528, p = 0.001), planning/organizing score (d = 1.09, p = 0.007). Clinical outcomes correlated with significant improvements in brain MRI microstructural changes in the insula, supramarginal, lingual, inferior frontal and fusiform gyri. The study suggests that HBOT improves both cognitive and behavioral function, PPCS symptoms, and quality of life in pediatric PPCS patients at the chronic stage, even years after injury. Additional data is needed to optimize the protocol and to characterize the children who can benefit the most.
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Affiliation(s)
- Amir Hadanny
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel. .,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Merav Catalogna
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Slava Yaniv
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Orit Stolar
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Autism Center, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Lynn Rothstein
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Adi Shabi
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Gil Suzin
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Efrat Sasson
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Erez Lang
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shachar Finci
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nir Polak
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gregory Fishlev
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ruth Tock Harpaz
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Moran Adler
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Ron-El Goldman
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yonatan Zemel
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yair Bechor
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Shai Efrati
- Sagol Center for Hyperbaric Medicine and Research, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
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15
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Sleep and Executive Functioning in Pediatric Traumatic Brain Injury Survivors after Critical Care. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9050748. [PMID: 35626925 PMCID: PMC9139390 DOI: 10.3390/children9050748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/10/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022]
Abstract
Over 50,000 children are hospitalized annually for traumatic brain injury (TBI) and face long-term cognitive morbidity. Over 50% develop sleep/wake disturbances (SWDs) that can affect brain development and healing. We hypothesized SWDs would portend worse executive function outcomes in children aged 3−18 years with TBI 1−3 months after hospital discharge. SWDs were defined using the Sleep Disturbances Scale for Children (t-scores ≥ 60). Outcomes included the Global Executive Composite (GEC, t-score) from the Behavior Rating Inventory of Executive Function, Second and Preschool Editions, and multiple objective executive function assessments combined through Principal Components Analysis into a Neurocognitive Index (NCI, z-score). Multiple linear regression evaluated associations between SWDs and executive function outcomes, controlling for covariates. Among 131 children, 68% had clinically significant SWDs, which were associated with significantly worse median scores on the GEC (56 vs. 45) and NCI (−0.02 vs. 0.42; both p < 0.05). When controlling for baseline characteristics and injury severity in multivariable analyses, SWDs were associated with worse GEC (β-coefficient = 7.8; 95% Confidence Interval = 2.5, 13.1), and worse NCI (β-coefficient = −0.4; 95% Confidence Interval = −0.8, −0.04). SWDs in children with TBI are associated with worse executive function outcomes after hospital discharge, and may serve as modifiable targets to improve outcomes.
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16
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Lima Santos JP, Kontos AP, Holland CL, Stiffler RS, Bitzer HB, Caviston K, Shaffer M, Suss Jr. SJ, Martinez L, Manelis A, Iyengar S, Brent D, Ladouceur CD, Collins MW, Phillips ML, Versace A. The role of sleep quality on white matter integrity and concussion symptom severity in adolescents. NEUROIMAGE: CLINICAL 2022; 35:103130. [PMID: 35917722 PMCID: PMC9421495 DOI: 10.1016/j.nicl.2022.103130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/29/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
Poor sleepers showed lower NDI in several tracts relative to good sleepers. The effect of sleep quality was significant after seven days between injury and scan. Good sleepers showed no differences relative to non-concussed controls. Significant relationship between low NDI, poor sleep, and higher symptom severity. Being female and low NDI significantly correlate with higher severity of symptoms.
Background Sleep problems are common after concussion; yet, to date, no study has evaluated the relationship between sleep, white matter integrity, and post-concussion symptoms in adolescents. Using self-reported quality of sleep measures within the first 10 days of injury, we aimed to determine if quality of sleep exerts a main effect on white matter integrity in major tracts, as measured by diffusion Magnetic Resonance Imaging (dMRI), and further examine whether this effect can help explain the variance in post-concussion symptom severity in 12- to 17.9-year-old adolescents. Methods dMRI data were collected in 57 concussed adolescents (mean age[SD] = 15.4[1.5] years; 41.2 % female) with no history of major psychiatric diagnoses. Severity of post-concussion symptoms was assessed at study entry (mean days[SD] = 3.7[2.5] days since injury). Using the Pittsburgh Sleep Quality Index (PSQI), concussed adolescents were divided into two groups based on their quality of sleep in the days between injury and scan: good sleepers (PSQI global score ≤ 5; N = 33) and poor sleepers (PSQI global score > 5; N = 24). Neurite Orientation Dispersion and Dispersion Index (NODDI), specifically the Neurite Density Index (NDI), was used to quantify microstructural properties in major tracts, including 18 bilateral and one interhemispheric tract, and identify whether dMRI differences existed in good vs poor sleepers. Since the interval between concussion and neuroimaging acquisition varied among concussed adolescents, this interval was included in the analysis along with an interaction term with sleep groups. Regularized regression was used to identify if quality of sleep-related dMRI measures correlated with post-concussion symptom severity. Due to higher reported concussion symptom severity in females, interaction terms between dMRI and sex were included in the regularized regression model. Data collected in 33 sex- and age-matched non-concussed controls (mean age[SD] = 15.2[1.5]; 45.5 % female) served as healthy reference and sex and age were covariates in all analyses. Results Relative to good sleepers, poor sleepers demonstrated widespread lower NDI (18 of the 19 tracts; FDR corrected P < 0.048). This group effect was only significant with at least seven days between concussion and neuroimaging acquisition. Post-concussion symptoms severity was negatively correlated with NDI in four of these tracts: cingulum bundle, optic radiation, striato-fronto-orbital tract, and superior longitudinal fasciculus I. The multiple linear regression model combining sex and NDI of these four tracts was able to explain 33.2 % of the variability in symptom severity (F[7,49] = 4.9, P < 0.001, Adjusted R2 = 0.332). Relative to non-concussed controls, poor sleepers demonstrated lower NDI in the cingulum bundle, optic radiation, and superior longitudinal fasciculus I (FDR corrected P < 0.040). Conclusions Poor quality of sleep following concussion is associated with widespread lower integrity of major white matter tracts, that in turn helped to explain post-concussion symptom severity in 12–17.9-year-old adolescents. The effect of sleep on white matter integrity following concussion was significant after one week, suggesting that acute sleep interventions may need this time to begin to take effect. Our findings may suggest an important relationship between good quality of sleep in the days following concussion and integrity of major white matter tracts. Moving forward, researchers should evaluate the effectiveness of sleep interventions on white matter integrity and clinical outcomes following concussion.
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17
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Pieroth EM. Assessment and Management of Persistent Post-Concussion Symptoms. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Falco C, Barton C. Melatonin administration for sleep disorders in traumatic brain injury: A review of the literature. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2022. [DOI: 10.4103/jisprm.jisprm-000153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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19
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Leddy JJ, Haider MN, Noble JM, Rieger B, Flanagan S, McPherson JI, Shubin-Stein K, Saleem GT, Corsaro L, Willer B. Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists. Curr Neurol Neurosci Rep 2021; 21:72. [PMID: 34817719 DOI: 10.1007/s11910-021-01160-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW Concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another. This review summarizes the medical management of patients with concussion and persistent post-concussive symptoms (PPCS). RECENT FINDINGS Management of concussion and PPCS relies on identifying underlying symptom generators. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments. Evidence-based treatments have emerged to treat post-concussion symptom generators for sport-related concussion and for patients with PPCS.
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Affiliation(s)
- John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
| | - Mohammad Nadir Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.,Department of Neuroscience, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - James M Noble
- Department of Neurology, Taub Institute for Research On Alzheimer's Disease and the Aging Brain, and G.H. Sergievsky Center, Columbia University, New York, NY, USA
| | - Brian Rieger
- Department of Physical Medicine and Rehabilitation, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Steven Flanagan
- Department of Rehabilitation Medicine, Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Jacob I McPherson
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | | | - Ghazala T Saleem
- Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | - Louis Corsaro
- Northern Westchester and Southern Putnam County School Districts, New York, NY, USA
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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20
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Corwin DJ, Grady MF, Master CL, Joffe MD, Zonfrillo MR. Evaluation and Management of Pediatric Concussion in the Acute Setting. Pediatr Emerg Care 2021; 37:371-379. [PMID: 34180858 DOI: 10.1097/pec.0000000000002498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Daniel J Corwin
- From the Attending Physician, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Matthew F Grady
- Attending Physician, Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina L Master
- Attending Physician, Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark D Joffe
- From the Attending Physician, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Mark R Zonfrillo
- Attending Physician, Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
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