Psychometric characteristics of the postconcussion symptom inventory in children and adolescents

Endophenotype presentation of athletes with concussion contingent on sex and time since injury

INTRODUCTION

Athletes with concussions experience heterogeneous symptoms and clinical trajectories. Subclassification provides diagnostic clarity that may improve prognostication and individualized treatments.

METHODS

We hypothesized that endophenotypes of adolescent athletes with concussions differ based on sex and time since injury. Post-concussive testing was performed for athletes (n = 1385) in the North Texas Concussion Registry (ConTex) at four timepoints: acute [0-3 days post-injury (DPI)], subacute-early (4-7DPI), subacute-late (8-28DPI), and persistent (29+DPI). Six endophenotypes (cognitive, headache, ocular-motor, vestibular, affective, sleep) were constructed by allocating post-concussion testing data elements described by the Concussion Subtype Workgroup.

RESULTS

Endophenotypes were defined using correlations between data elements and compared based on sex or time since injury. Correlograms revealed endophenotypes differed based on sex and time since injury. The affective endophenotype was dependent on the interaction between sex and time since injury and was more prevalent at the subacute-late and persistent timepoints. The sleep endophenotype became more prevalent at the persistent timepoint. Affective and sleep endophenotypes were interrelated with cognitive, vestibular, and headache endophenotypes at the persistent timepoint suggesting that dysregulated mood and sleep influence lingering symptoms.

CONCLUSIONS

Adolescent symptom-based concussion endophenotypes differ based on sex and time since injury. Clinical consideration may improve identification of separate trajectories following sport-related concussion and provide targeted care.

Mechanism of Injury and Clinical Recovery Outcomes Following Pediatric Concussion

Children with concussion are injured through a variety of mechanisms, but the relationship between mechanism of injury (MOI) and recovery outcomes is unclear due to small sample sizes and varied methodological designs. Our objective was to examine the association of MOI and clinical recovery in youth with concussion using a large dataset collated from a single, multisite study. We hypothesized that sport-related concussion would be related to better clinical presentation and faster recovery trajectories compared to other mechanisms of concussion. This study was a secondary analysis of data collected during the Predicting and Preventing Postconcussive Problems in Pediatrics study. Children and adolescents with concussion (n = 3056) completed the Child Sport Concussion Assessment Tool 3rd Edition and Postconcussion Symptom Inventory (PCSI) within 48 h following injury. Follow-up sessions at 1-, 2-, 4-, 8-, and 12-weeks post injury were completed using the PCSI and Pediatric Quality of Life Scale (PedsQL) scales. Acute clinical outcomes were analyzed using analysis of variances or chi-square analyses, while recovery trajectories were evaluated using linear and logistic regression. No MOI-based differences in acute clinical presentation were observed, except for balance outcomes in 13-17 year old (F[2,1001] = 5.69, p = 0.003). Symptoms improved over time regardless of age (p < 0.05). In 8-12 and 3-17 year olds, quality of life improved over time and was significantly higher in the sports group (p < 0.05). The "other" mechanism group had higher odds of persistent symptoms at 4-week than the sports group in 8-12 year olds (OR = 2.01, 95% CI = 1.20, 3.40, p = 0.008), while this finding was reversed in the 13-17 group (OR = 0.61, 95% CI = 0.38, 0.99, p = 0.045). Sport-related concussions were generally associated with better symptom and quality of life scores in older children, but these differences were modest and unlikely to be clinically significant. Regardless of MOI, most children experienced clinical improvements across the first three months following concussion.

Sex Differences in Response to Low- Versus High-Volume Aerobic Exercise for Sport-Related Concussion: A Pilot Randomized Controlled Trial

OBJECTIVE

To assess sex differences in behavior and motivation of adolescent athletes with sport-related concussion (SRC) versus controls during a 2-week individualized aerobic exercise intervention.

SETTING

Academic center research laboratory.

PARTICIPANTS

Participants were enrolled within 10 days of SRC (n = 32; 15.6 ± 1.4 years, 33% female, 6.18 ± 2.21 days from injury). Twenty-eight control participants (16.0 ± 1.6 years, 33% female) were recruited.

DESIGN

Randomized control trial with a 1:1 block randomization scheme stratified by participant sex.

MAIN MEASURES

Clinical recovery time as determined by the study physician, heart rate threshold (HRt) on the Buffalo Concussion Treadmill Test, adherence rates (calculated as exercise volume completed/exercise volume prescribed), and behavioral assessments including the perceived competence scale (PCS) and the treatment self-regulation questionnaire (TSRQ).

RESULTS

Females achieved higher initial HRts (P = .007), ie, the maximum HR during exercise testing. Males and females with a concussion showed minimal differences in motivation and perceived competence. Although it did not reach statistical significance (P = .058), females in the low-volume group appeared to recover faster than the high-volume group. This trend was not seen in males. Seven (88%) of exercise-intolerant females had to stop an exercise bout early on 1 or more days due to more-than-mild symptom exacerbation versus 3 (17%) of exercise-intolerant males (P = .002).

CONCLUSION

Females with a concussion prescribed a high volume of aerobic exercise treatment appeared to take longer to recover than females with a concussion who were prescribed a lower volume, which was not seen in males. Increased training heart rate prescriptions due to higher initial HRts and symptom exacerbation during at-home exercise may have affected female exercise behavior. Although aerobic exercise benefits SRC recovery, this study highlights the need for future research to optimize exercise treatment prescriptions for females after SRC.

Clinical Cut Point for the Pittsburgh Sleep Quality Index After Adolescent Concussion

Background

Concussions can have negative implications for sleep quality. Self-report measures, such as the Pittsburgh Sleep Quality Index (PSQI), have been used in clinical and research settings to identify individuals with sleep impairments. However, the accuracy/applicability of historically established PSQI scoring criteria for differentiating good versus poor sleep quality has not been critically examined in adolescents with concussion.

Purpose

To establish a relevant PSQI clinical cut point for adolescents with a recent concussion.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Adolescents within 16 days of concussion and uninjured controls completed the PSQI, and a global score of 0 to 21 was calculated. Independent-samples t tests were used to compare PSQI global scores, and logistic regression was used to calculate odds ratios (outcome = group; predictors = PSQI, covariates). A receiver operating characteristic curve was used to evaluate the area under the curve (AUC) and determine the optimal cut point to distinguish between adolescents with and without a concussion.

Results

A total of 110 adolescents with a concussion (mean age, 14.9 ± 1.6 years; 53% female; 9.8 ± 3.6 days since injury) and 129 uninjured controls (mean age, 15.6 ± 1.1 years; 86% female) were included for analysis. The concussion group had significantly worse (higher) PSQI scores than controls (mean, 7.41 ± 3.62 vs 2.26 ± 1.97; P < .001; Cohen d = 1.8). Both the univariable model and multivariable model (controlling for age, sex, concussion history, history of anxiety and/or depression, and self-reported use of sleep medication) had excellent diagnostic accuracy (univariable AUC, 0.90; multivariable AUC, 0.99). Within the multivariable model, a cut point of 4 correctly classified 81% of participants as concussed or control (sensitivity, 87%; specificity, 74%).

Conclusion

Adolescents with a concussion demonstrated worse sleep quality than uninjured controls. The results suggest that sleep quality, as measured by the PSQI, can distinguish between adolescents with and without a concussion, using a cut point of 4.

Anxiety, pain, and fear of pain: predictors of postural stability after a concussion

A concussion can lead to anxiety, pain, kinesiophobia, and/or postural control deficits. We conducted a cross-sectional study evaluating adolescents with a recent concussion. We hypothesized that those reporting higher levels of anxiety, pain-interference, and kinesiophobia would perform worse on postural control tests. Participants completed anxiety, pain-interference, and kinesiophobia ratings and postural control tests (single/dual-task tandem gait and a modified balance error scoring system). Using a multivariable linear regression model, we evaluated the relationship among anxiety, pain-interference, and kinesiophobia (predictors) with postural control measures (tandem gait and a modified balance error scoring system, outcomes), adjusting for sex and anxiety history. We enrolled 128 participants (53% female, age=15.4±1.7 y, and 9.3±4.0 d post-concussion). Higher anxiety was weakly correlated with slower dual-task tandem gait times (r=0.31; p=0.001) and more modified balance error scoring system errors (r=0.22; p=0.01). Multivariable modeling indicated that a higher post-concussion anxiety rating was associated with a slower dual-task tandem gait time (β=0.21, 95% confidence interval=0.01-0.41; p=0.04). The female sex was associated with slower single-task tandem gait (β=-3.01, 95% confidence interval=-6.01, -0.01; p=0.049). Adolescents with a higher anxiety post-concussion performed worse on dual-task tandem gait assessments, while pain-interference and kinesiophobia were not associated with postural control. Anxiety and impaired postural control are independently associated with poor concussion outcomes; thus, this association may inform individualized concussion care strategies.

The path from trait anxiety to post-concussion symptoms and posttraumatic stress symptoms in children with mTBI: the moderating role of alexithymia

Post-concussion symptoms (PCS) and posttraumatic stress symptoms (PTSS) are common after mild traumatic brain injuries (mTBI) in children. Psychological factors, especially pre-injury trait anxiety, are associated with the development of PCS and PTSS. However, the underlying mechanisms are understudied. The current study aimed to explore whether alexithymia (difficulty in identifying and describing emotions) moderates the associations between children's pre-injury trait anxiety and PCS, as well as PTSS in bothchildren and parents following mTBI. Participants were 53 children aged 8-16 with mTBI and their parents, recruited from the Emergency Department. Immediate mTBI symptoms were assessed by the Emergency Department physician within 24 hours post-injury. One-week post-injury, acute PTSS (children and parents), children's pre-injury trait anxiety, and alexithymia were measured using self-reported questionnaires. PCS were measured by symptom reports (including a baseline; reported by parents) and neuropsychological tests assessing cognitive functioning, including performance validity tests. PCS and cognitive functioning were assessed one-week and four-month post-injury. We found that alexithymia significantly moderated the associations between children's pre-injury trait anxiety and both PCS and PTSS in children and parents at one-week post-injury. Higher levels of alexithymia strengthened these associations. Alexithymia was found significantly associated with PCS at four-month post-injury. However, alexithymia did not moderate the association between pre-injury trait anxiety and PCS at four-month post-injury or cognitive functioning at one-week or four months. In conclusion, pre-injury trait anxiety and alexithymia are crucial in mTBI outcomes, being associated with PCS and PTSS development. Therefore, addressing emotional factors is important in TBI recovery.

Quality of life after brain injury in children and adolescents questionnaire - validation of the proxy version (QOLIBRI-KID/ADO-Proxy)

BACKGROUND

The QOLIBRI-KID/ADO-Proxy is the first disease-specific health-related quality of life (HRQoL) proxy questionnaire developed for use in the field of pediatric traumatic brain injury (TBI), when children are unable to report their HRQoL themselves.

METHODS

Its psychometric properties in a German-speaking context are examined in two samples (development and validation). Dyads of 600 parents and their children (aged 8-17 years) were included.

RESULTS

The 35-item questionnaire covers six dimensions (Cognition, Self, Daily Life and Autonomy, Social Relationships, Emotions, and Physical Problems). Results showed good to excellent internal consistencies, acceptable test-retest reliability, and low to fair parent-child agreement. Confirmatory factor analyses supported the one-level six-factor structure. In terms of construct validity, there was an overlap between the disease-specific and the generic HRQoL. Lower parent-reported HRQoL in children was associated with lower parental education, lower functional recovery (Study I), more recent TBI, and more severe depressive, anxiety, and post-concussion symptoms. Findings differed between the two studies in terms of age, gender, and TBI severity. Study I found more severe TBI linked to lower HRQoL in adolescents, while Study II indicated lower HRQoL ratings in girls.

CONCLUSION

The QOLIBRI-KID/ADO-Proxy is recommended when individuals are unable to self-report their HRQoL.

Early Resumption of Physical Activity and Cognitive Outcomes at 4 Week Following Pediatric Concussion

BACKGROUND

Early physical activity (PA) after concussion may aid in symptom recovery, though its impact on other recovery domains, such as cognitive functioning, remains less explored.

OBJECTIVES

(1) Examine the association between early PA (within 7 days post-injury) and cognitive inefficiency and impairment 4 weeks after pediatric concussion; (2) investigate the association between early PA and cognitive outcomes (memory and executive functioning, information processing speed, attention, visual-motor processing, and vocabulary) 4-week post-concussion.

SETTING

Emergency departments (EDs) of four Canadian pediatric hospitals within the Pediatric Emergency Research Canada (PERC) Network.

PARTICIPANTS

Children aged 8-18 years presenting to the ED within 48 hours of a head injury and diagnosed with a concussion.

DESIGN

Planned secondary analysis of data from a prospective multicenter cohort study.

MAIN MEASURES

Participants' PA level was assessed at 1-week post-concussion through a self-report questionnaire in which they had to indicate their current level of recovery in terms of return to physical activities and sports. Early PA participation was defined as any level of PA other than "no activity" at the 1-week follow-up. Participants underwent comprehensive neuropsychological testing at 4-week post-concussion. Primary outcome measures included cognitive inefficiency and impairment (≥2 outcomes with z < -1.0 SD or <-1.5 SD below the normative mean, respectively). Secondary and tertiary outcome measures include t-scores and scaled scores from the 10 neuropsychological tasks, transformed to z-scores.

RESULTS

Early PA was not significantly associated with the likelihood of cognitive inefficiency or impairment (Ps ≥ .38). The early PA*sex interaction was related to verbal cognitive flexibility (P = .02), with females engaging in early PA having better scores. Moreover, the early PA*age interaction was associated with attention (P = .03), with younger children engaged in early PA performing worse.

CONCLUSIONS

Early PA has no overall association with cognitive inefficiency or impairment but may be differentially associated with certain cognitive outcomes by age and sex.

Factors Influencing Length of Care in Physical Therapy After Pediatric and Adolescent Concussion

CONTEXT

Social determinants of health including insurance type, income, race, and ethnicity have been shown to influence the utilization of physical therapy and recovery after an orthopedic injury. The influence of social determinants of health on the utilization of physical therapy and recovery from concussion is not well understood.

DESIGN

Prospective observational registry study in a specialty concussion program.

METHODS

Patients diagnosed with a concussion using the Postconcussion Symptom Inventory and the visio-vestibular examination (VVE) who were also referred to physical therapy were included. The main outcomes of interest were the number of days from referral to initial physical therapy evaluation and the number of physical therapy visits completed. Information related to patients' age, race, ethnicity, sex, insurance type, and Child Opportunity Index was extracted from the registry. Multivariate and univariate regressions were used to assess the associations of each sociodemographic characteristic with the outcomes.

RESULTS

A total of 341 patients diagnosed with concussion between January 2017 and December 2023 met inclusion criteria. The average age was 14.77, and 64% were female. Patients' age, race, ethnicity, insurance type, and Child Opportunity Index were not associated with days to evaluation or length of care in physical therapy. Higher PCSI scores in children under 12 years (coefficient: 0.17, 95% CI, 0.06-0.29) and female sex (coefficient: 1.2, 95% CI, 0.26-2.1) were associated with a longer course of care in physical therapy. Patients with an abnormal VVE score had on average 2.1 more physical therapy visits than those with a normal VVE score (coefficient: 2.1, 95% CI, 0.73-3.5).

CONCLUSIONS

Higher PCSI scores in children, female sex, and higher VVE scores in general predicted a longer course of care in physical therapy. Implementation of a clinical care pathway for concussion care using the PCSI and the VVE may be one strategy to help mitigate systemic factors that might otherwise negatively influence access to physical therapy.

Pediatric Emergency Medicine Physicians' Perspectives of Concussion in Young Children

OBJECTIVE

Traumatic brain injury (TBI) during early childhood (before 6 years) is prevalent, accounting for rising rates of emergency department visits. These injuries may lead to postconcussive symptoms, which may be subtle and difficult to diagnose in young children. Inadequate discharge counseling may lead to prolonged duration of symptoms and possible developmental delays. We aimed to explore pediatric emergency medicine (PEM) physicians' perspectives on "concussion" terminology, diagnosis, and management, specifically in a young child with mild TBI.

METHODS

We conducted semistructured interviews using open-ended questions involving a hypothetical scenario. We recruited currently practicing PEM physicians by a snowball sampling method. A research team recorded, transcribed, and analyzed the interviews. Using social constructionism as the philosophical framework, we developed and refined codes and derived themes until reaching thematic saturation. Peer debriefing with an expert collaborator aided with revisions of themes.

RESULTS

A single PEM researcher interviewed 13 participants. Three primary themes emerged. Our first theme identified the role of guidelines and tools in the diagnostic workup. Most participants utilized a clinical prediction tool for neuroimaging but no clinical symptom scales. Our second theme described the difficulties and inconsistencies in the approach to diagnosis of concussion, largely due to young age, lack of verbal skills and unreliable examinations. Our last theme focused on the difficulty in providing clear discharge instructions to parents. Many participants described difficulty providing activity restrictions, instead allowing self-modulation, and lack of counseling for educational tasks.

CONCLUSIONS

Variability exists among PEM physicians in diagnosis and management of concussions in young children. Discomfort with lack of reliability of symptoms and underappreciation of typical early childhood characteristics may account for findings. Educational initiatives, age-appropriate clinical tools and treatment-guided outcomes research are needed to guide PEM physicians in the care of young children with head injuries.

A Concussion Management Policy Change Promoted Earlier Initiation of Rehabilitation Services and Improved Clinical Recovery Outcomes in Concussion

CONTEXT

In line with emerging research, an interprofessional specialty concussion clinic instituted a policy change permitting earlier physiotherapy-based treatment entry. Our objective was to determine the effect of this policy change on concussion recovery outcomes.

DESIGN

Secondary analysis of prospectively collected clinical data.

METHODS

600 youth with concussion were included. Active rehabilitation was initiated ≥4 weeks (prepolicy) or ≥2 weeks (postpolicy) postconcussion based on institutional policy. Cox proportional hazard models, linear mixed models, and chi-square analyses were conducted.

RESULTS

The postpolicy group (median = 22 d [interquartile range: 17-27]) started treatment earlier than the prepolicy group (median = 26 d [interquartile range: 24-30], P < .001). Length of episode of care (χ2(1) = 11.55, P < .001, odds ratios = 1.49; 95% confidence interval, 1.19-1.88); rehabilitation (χ2(1) = 9.47, P = .002, odds ratios = 1.73, 95% confidence interval, 1.22-2.45]); and total recovery (χ2(1) = 11.53, P < .001, odds ratios = 1.49; 95% confidence interval, 1.18-1.88) were reduced in patients postpolicy change. A significant interaction effect was found for total postinjury symptom (F2,320 = 3.59, P = .03) and symptom change scores (F2,315 = 5.17, P = .006), with the postpolicy group having faster symptom resolution over time. No group differences were observed for persisting symptoms.

CONCLUSIONS

Earlier rehabilitation initiation occurred as intended following an institutional policy change, which had small, but significant, effects on recovery outcomes in youth with concussion. Health care providers should adopt policies to encourage early active rehabilitation services after concussion.

Return-to-Play With R2Play: Protocol for Evaluating Cross-Site Feasibility, Face Validity, and Content Validity of a Multidomain Concussion Assessment Tool for Youth

CONTEXT

Clinical concussion assessments do not typically simulate the speed or complexity of sport. Performance changes arising from combined physical, cognitive, and sensory demands of sport may thus remain undetected during rehabilitation. We developed R2Play, a multidomain return-to-play assessment tool for youth with concussions. R2Play involves levels and conditions that vary in physical, cognitive, and sensory load to simulate the multidomain demands of sport.

OBJECTIVES

To explore cross-site feasibility, face validity, and content validity of R2Play by integrating quantitative and qualitative data.

METHODS

Convergent mixed-methods feasibility study. Five sites will each recruit 5 clinicians (total nc = 25) and 10 youth sport participants (ages 10-25 y) with a history of concussion in the previous year (total ny = 50). Feasibility will be evaluated using quantitative criteria for acceptability, demand, implementation, practicality, and integration, and qualitative investigated data from content analysis of postassessment interviews with youth and clinician participants. Face validity will be investigated in postassessment interviews. Content validity will be established through (1) changes in performance metrics (time to completion, errors, and heart rate) across R2Play levels, (2) youth-perceived physical and cognitive exertion for each level, and (3) overall clinician perceptions determined through postassessment interviews. Qualitative and quantitative data will be merged through joint display to identify areas of convergence, divergence, and complementarity, and to establish meta-inferences about feasibility, face validity, and content validity.

DISCUSSION

This study aims to demonstrate the face and content validity of R2Play, and its feasibility for cross-site implementation. Findings will guide further iteration of R2Play and establish the foundation for a larger multicenter validation study to establish the psychometric properties of R2Play. This work represents an important first step toward the implementation of an ecologically valid multidomain assessment tool designed to support a safe and efficient return-to-play after concussion, ultimately reducing the risk of recurrent concussion and subsequent injury.

Association of Cognitive Symptoms and Abnormal Oculomotor Signs With Recovery in Adolescents After Sport-Related Concussion

OBJECTIVE

Sport-related concussion (SRC) affects cognitive and oculomotor function. We evaluated recovery from SRC in athletes with cognitive symptoms and/or oculomotor impairments who were prescribed early aerobic exercise treatment.

DESIGN

Secondary exploratory analysis of a randomized controlled trial.

SETTING

Outpatient sports medicine clinics.

PARTICIPANTS

Male and female adolescents (13-18 years) within 10 days of SRC who were prescribed aerobic exercise and who reported either a low (<12 points) or high (≥12 points) burden of cognitive symptom scores on the Post-Concussion Symptom Inventory at initial assessment.

INTERVENTIONS

Early aerobic exercise treatment.

MAIN OUTCOME MEASURES

Recovery time and incidence of persisting postconcussive symptoms beyond 1 month.

RESULTS

Adolescents with a high burden of cognitive symptoms (n = 24, 16.0 ± 1.3 years old, 50% male, 5.3 ± 2.4 days since injury) took longer to recover (34.4 ± 37.1 vs 15.3 ± 7.6 days) than adolescents with a low burden (n = 32, 14.9 ± 1.4 years old, 69% male, 6.1 ± 2.3 days since injury) and had 6-fold higher odds of developing persisting postconcussive symptoms (odds ratio = 6.17 [1.15-33.15]). Abnormal repetitive saccades and vestibular ocular reflex were independently associated with longer recovery after controlling for multiple comparisons ( P < 0.0125), but only abnormal smooth pursuits were a significant effect modifier for the association between cognitive symptoms and recovery (interaction term hazard ratio = 0.133 [0.035-0.504], P = 0.003).

CONCLUSIONS

Individuals with impaired ability to smoothly track a moving target and whose cognitive symptoms are a significant burden are at substantial risk for delayed recovery from SRC. Early initiation of oculomotor rehabilitation may facilitate recovery in these patients.

TRIALS REGISTRATION

Clinicaltrials.gov ID NCT02959216.

Balance Performance After Mild Traumatic Brain Injury in Children and Adolescents: Instrumented BESS in the Acute Situation and Over Time

Background: Mild traumatic brain injury (mTBI) in the pediatric population is a significant public health concern, often associated with persistent post-concussion symptoms, including postural instability. Current tools for assessing postural control, such as the Balance Error Scoring System (BESS), lack integration with objective metrics. Incorporating force plate sensors into BESS assessments may enhance diagnostic accuracy and support return-to-play or sports decisions. This study evaluates postural performance in children with mTBI compared to controls using an instrumented BESS and examines recovery trajectories after mTBI. Methods: This prospective, longitudinal study included 31 children with mTBI (12.01 ± 3.28 years, 20 females) and 31 controls (12.31 ± 3.27 years, 18 females). Postural control was assessed using an instrumented BESS protocol during standing on a ground reaction force plate at three timepoints: within 72 h post injury (T1), at two weeks (T2), and three months after trauma (T3). Posturographic parameters derived from the displacement of the center of pressure included the ellipse area, path length, and mean velocity in the anterior-posterior and medio-lateral directions. Symptom burden was monitored using the Post-Concussion Symptom Inventory (PCSI). Results: The BESS total scores did not differ significantly between the groups at any timepoint. A significant reduction in BESS errors over time was observed exclusively in the two-legged stance on a soft surface (p = 0.047). The instrumented BESS revealed higher body swaying in the mTBI group compared to controls, particularly under demanding conditions. Significant between-group differences were most frequently observed in single-leg soft surface (38% of comparisons) and two-legged soft surface stances (29%). In those cases, path length and mean velocity differed between groups, respectively. Ellipse area did not show significant differences across conditions. Conclusions: An instrumented BESS has the potential to enhance the detection of subtle postural deficits in pediatric mTBI patients. Specifically, more demanding conditions with altered sensory-proprioceptive input and path length as an outcome measure should be focused on. This study underscores the need for tailored and age-appropriate objective and quantitative balance assessments to improve diagnostic precision in pediatric mTBI populations.

5P Risk Classification Predicts Performance on Self-reported but Not Objective Clinical Outcomes at 4 Weeks Postconcussion in Children

OBJECTIVE

To determine if performance on symptom, cognitive, balance, fatigue, physical activity, and quality of life outcomes at 4 weeks postinjury in children with concussion differs based on acute Predicting and Preventing Postconcussive Problems in Pediatrics (5P) risk classification.

DESIGN

Prospective cohort.

SETTING

Laboratory.

PARTICIPANTS

Sixty-two children (age: 13.27±2.50y; 29 [46.7%] women) with diagnosed concussion.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient demographics and postinjury assessments were completed within 72 hours of concussion and used to classify patients as "high," "moderate," or "low" persistent postconcussion symptoms risk. Children then completed a multimodal assessment battery at 4 weeks postconcussion. Kruskal-Wallis assessments analyzed whether study outcomes differed between 5P risk groups.

RESULTS

Significant group differences were observed in symptom (χ2(2)=9.76, P=.008), fatigue (χ2(2)=14.60, P<.001), physical activity (χ2(2)=15.76, P<.001), and quality of life (χ2(2)=7.82, P=.02) outcomes. The low-risk group had fewer symptoms and less fatigue but increased physical activity levels and quality of life compared with the high-risk group. No significant differences in cognitive or balance outcomes were observed (P>.05).

CONCLUSIONS

The 5P rule provides clinicians with valuable prognostic information related to persistent postconcussion symptoms and self-reported outcomes 4 weeks postconcussion, but not objective cognitive or balance outcomes. This information may help clinicians prioritize treatment resources to children most at risk of prolonged concussion recovery.

Headache after pediatric traumatic brain injury: a comparison between a post-acute sample of children and adolescents and general population

BACKGROUND

Headache is one of the most common post-concussion symptoms following pediatric traumatic brain injury (TBI). To better understand its impact on young individuals, this study aims to investigate the prevalence of headache in a German-speaking post-acute pediatric TBI sample and compare it with the general population. In addition, factors associated with the development of pediatric post-TBI headache are investigated to improve the understanding of this condition.

METHODS

A post-acute sample (3 months up to 10 years post-injury) comprising N = 463 children and adolescents aged 8 to 17 years from the TBI sample and N = 463 individuals from the general population matched for gender, age, and health status were included in the study. The Postconcussion Symptom Inventory (PCSI) item assessing headache was used as the outcome variable. Logistic regression was used to examine the association between the risk of developing headache and sociodemographic and health-related factors.

RESULTS

Slightly less than half of the participants reported the presence of headache (TBI sample: 46%; matched controls: 44%). Compared with matched controls, the odds of headache in the TBI sample were not significantly different (OR = 1.09, 95% CI 0.85 to 1.4, p = 0.49). The association between PCSI symptoms was generally stronger in adolescents than in children and in the matched controls than in the TBI sample. In the TBI sample, the probability of reporting headache increased with age.

CONCLUSIONS

The results of this study suggest that the prevalence of headache in the post-acute phase of pediatric TBI is not significantly different from that in the matched non-TBI population, indicating good recovery from injury. However, due to its high prevalence, follow-up screening for this common TBI symptom, especially in adolescents, may be helpful to prevent further chronification.

TRIAL REGISTRATION

The study is retrospectively registered in German Clinical Trials Register and in International Clinical Trials Registry Platform (ID DRKS00032854).

Regionally specific resting-state beta neural power predicts brain injury and symptom recovery in adolescents with concussion: a longitudinal study

Mild traumatic brain injury (mTBI) is common in adolescents. Magnetoencephalography (MEG) studies (primarily reporting on adult males) have demonstrated abnormal resting-state (RS) brain activity in mTBI. The present study sought to identify RS abnormalities in male and female adolescents with mTBI (no previous mTBI and no previous DSM-5 diagnosis) identified from an outpatient specialty care concussion program setting as a basis for evaluating potential clinical utility. Visit 1 MEG RS data were obtained from 46 adolescents with mTBI (mean age: 15.4 years, 25 females) within 4 months of a mTBI (mTBI acute to sub-acute period) as well as from 34 typically developing (TD) controls (mean age: 14.8 years; 17 females) identified from the local community. Visit 2 RS data (follow-up ∼4.3 months after Visit 1; mTBI sub-chronic period) were obtained from 36 mTBI (19 females) and 29 TD (14 females) of those participants. Source-space RS neural activity was examined from 4 to 56 Hz. Visit 1 t-tests showed that group differences were largest in the beta range (16-30 Hz; mTBI < TD), with Visit 2 whole-brain linear mixed model (LMM) analyses examining beta-band group differences as a function of Visit. A main effect of Group indicated Visit 1 and 2 beta-band group differences in midline superior frontal gyrus, right temporal pole, and right central sulcus (all mTBI < TD). The group effects were large (Cohen's d values 0.75 to 1.31). Of clinical significance in the mTBI group, a decrease in mTBI symptoms from Visit 1 to 2 was associated with an increase in beta power in 4 other brain regions. Present findings suggest that RS beta power has potential as a measure and perhaps as a mechanism of clinical recovery in adolescents with mTBI.

Comparing peer relationship ratings among adolescents with sport and Non-sport Related Concussions

OBJECTIVE

To evaluate if peer relationship ratings differ among adolescents who sustain a sport-related concussion compared to those who sustain a non-sport-related concussion.

STUDY DESIGN

We conducted a cross-sectional investigation of 123 adolescents who sustained a concussion within 21 days before their initial post-injury evaluation (mean = 9.2 ± 3.9 days post-concussion). Participants reported whether their injury occurred during organized sport participation (sport-related concussion group) or not (non-sport-related concussion group). Participants completed the PROMIS Global Pediatric 25 assessment, as well as the Post-Concussion Symptom Inventory (PCSI) to rate concussion symptom severity and a background/demographic intake form during the evaluation. We compared PROMIS peer relationship ratings between groups using independent t-tests and evaluated the association between peer relationship ratings and sport-related concussion using multiple linear regression after adjusting for covariates including PROMIS anxiety rating, age, sex, concussion and musculoskeletal injury history, loss of consciousness at time of concussion, physical activity participation prior to study evaluation, and concussion symptom severity.

RESULTS

Most (N = 96, 78%) participants reported sustaining a concussion during sports. The group who sustained sport-related concussion reported significantly better post-concussion peer relationship ratings compared to the group who sustained a non-sport-related concussion (52.7 ± 7.7 vs. 47.7 ± 10.4; p = 0.009, Cohen's d = 0.60). After covariate adjustment, those who sustained a sport-related concussion had a significantly greater post-concussion peer relationship rating than those who sustained a non-sport-related concussion (β = 4.19, 95% CI = 0.39, 8.00; p = 0.03). Higher peer relationship ratings were also associated with lower anxiety ratings following concussion (β= -0.21, 95% CI= -0.38, -0.04; p = 0.03).

CONCLUSION

Adolescents who sustained a concussion during sports reported significantly greater post-concussion peer relationship ratings than those in non-sport settings. Better peer relationship ratings were associated with less anxiety in the post-injury period. These findings suggest the potential effects of contextual factors (e.g. peer support) to facilitate improved outcomes following adolescent concussion.

Evolution of dizziness-related disability in children following concussion: a group-based trajectory analysis

OBJECTIVE

This study aimed to identify Dizziness-Related Disability (DRD) recovery trajectories in pediatric concussion and assess clinical predictors of disability groups.

MATERIALS AND METHODS

In this prospective cohort study, 81 children (8-17 years) diagnosed with an acute concussion took part in 3 evaluation sessions (baseline, 3-month, and 6-month). All sessions included the primary disability outcome, the Dizziness Handicap Inventory (DHI) to create the DRD recovery trajectories using group-based multi-trajectory modeling analysis. Each independent variable included general patients' characteristics, premorbid conditions, function and symptoms questionnaires, and clinical physical measures; and were compared between the trajectories with logistic regression models.

RESULTS

Low DRD (LD) trajectory (n = 64, 79%), and a High DRD (HD) trajectory (n = 17, 21%) were identified. The Predicting and Preventing Postconcussive Problems in Pediatrics (5P) total score (Odds Ratio (OR):1.50, 95% Confidence Interval (CI): 1.01-2.22), self-reported neck pain (OR:7.25, 95%CI: 1.24-42.36), and premorbid anxiety (OR:7.25, 95%CI: 1.24-42.36) were the strongest predictors of belonging to HD group.

CONCLUSIONS

Neck pain, premorbid anxiety, and the 5P score should be considered initially in clinical practice as to predict DRD at 3 and 6-month. Further research is needed to refine predictions and enhance personalized treatment strategies for pediatric concussion.

Adolescents With a High Burden of New-Onset Mood Symptoms After Sport-Related Concussion Benefit From Prescribed Aerobic Exercise, a Secondary Analysis of 2 Randomized Controlled Trials

OBJECTIVE

Approximately 20% of students with sport-related concussion (SRC) report new symptoms of anxiety and depression which may be associated with delayed recovery and increased risk for developing a mood disorder. Early prescribed aerobic exercise facilitates recovery in athletes with concussion-related exercise intolerance. We studied the effect of aerobic exercise treatment on new mood symptoms early after SRC.

DESIGN

Exploratory secondary analysis of 2 randomized controlled trials (RCT).

SETTING

Sports medicine clinics associated with UB (Buffalo, NY), CHOP (Philadelphia, PA), and Boston Children's Hospital (Boston, MA).

PARTICIPANTS

Male and female adolescents (aged 13-18 years) diagnosed with SRC (2-10 days since injury).

INTERVENTIONS

Participants were randomized to individualized targeted heart rate aerobic exercise (n = 102) or to a placebo intervention designed to mimic relative rest (n = 96).

MAIN OUTCOME MEASURES

Incidence of Persisting Post-Concussive Symptoms (PPCS, symptoms ≥28 days).

RESULTS

First RCT recruited from 2016 to 2018 and the second from 2018 to 2020. Of 198 adolescents, 156 (79%) reported a low burden (mean 1.2 ± 1.65/24) while 42 (21%) reported a high burden (mean 9.74 ± 3.70/24) of emotional symptoms before randomization. Intervention hazard ratio for developing PPCS for low burden was 0.767 (95% CI, 0.546-1.079; P = 0.128; β = 0.085) and for high burden was 0.290 (95% CI, 0.123-0.683; P = 0.005; β = 0.732).

CONCLUSIONS

High burden of mood symptoms early after injury increases risk for PPCS, but the sports medicine model of providing early targeted aerobic exercise treatment reduces it. Nonsports medicine clinicians who treat patients with a high burden of new mood symptoms after concussion should consider prescribing aerobic exercise treatment to reduce the risk of PPCS and a mood disorder.

The Diagnostic Utility of Cervical Spine Proprioception for Adolescent Concussion

OBJECTIVE

Cervical spine proprioception may be impaired after concussion. Our objective was to determine the diagnostic utility of cervical spine proprioception for adolescent concussion.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

Adolescents ≤18 days of concussion and uninjured controls.

INTERVENTIONS

N/A.

MAIN OUTCOMES

Head repositioning accuracy (HRA) testing, a measure of cervical spine proprioception. The HRA test involved patients relocating their head back to a neutral starting position with eyes closed after maximal cervical spine flexion, extension, and right and left rotations. The overall HRA error score was the mean error (distance from the starting point to self-reported return to neutral) across 12 trials: 3 trials in each direction. We used t -tests to compare group means and logistic regression (outcome = group, predictor = HRA, covariates) to calculate odds ratios. We used a receiver operator characteristic curve to evaluate area under the curve (AUC) and calculate the optimal HRA cutpoint to distinguish concussion from controls.

RESULTS

We enrolled and tested 46 participants with concussion (age = 15.8 ± 1.3 years, 59% female, mean = 11.3 ± 3.3 days postconcussion) and 83 uninjured controls (age = 16.1 ± 1.4 years, 88% female). The concussion group had significantly worse HRA than controls (4.3 ± 1.6 vs 2.9 ± 0.7 degrees, P < 0.001, Cohen d = 1.19). The univariable HRA model AUC was 0.81 (95% CI = 0.73, 0.90). After adjusting for age, sex, and concussion history, the multivariable model AUC improved to 0.85 (95% CI = 0.77, 0.92). The model correctly classified 80% of participants as concussion/control at a 3.5-degree cutpoint.

CONCLUSIONS

Adolescents with concussion demonstrated worse cervical spine proprioception than uninjured controls. Head repositioning accuracy may offer diagnostic utility for subacute concussion.

Measuring Self-Efficacy for Concussion Recovery: Psychometric Characteristics of the Progressive Activities of Controlled Exertion-Self-Efficacy Scale

Control over symptoms postconcussion is central to an active self-directed recovery process. Therefore, assessing a patient's confidence in controlling their symptoms and facilitating their concussion recovery is an important component of treatment. Previously, no measures existed to assess symptom-specific self-efficacy (SE) in pediatric concussion recovery. SE is an individual's belief or confidence in their capabilities to execute action plans necessary to perform certain behaviors. Based on this definition, we developed the Progressive Activities of Controlled Exertion-Self-Efficacy (PACE-SE) scale to measure a patient's SE related to pediatric concussion recovery-specific activities. The aim of this article is to present the psychometric characteristics (evidence of reliability, validity) of the PACE-SE scale. The 17-item PACE-SE was administered to children and adolescents, 10-18 years of age, recovering from a diagnosed concussion as part of a standard clinical evaluation. Results revealed a four-factor structure producing the following scales: Managing My Stress, Managing My Activity, Seeking Adult Assistance, and Maintaining Positive Outlook. The PACE-SE scores indicated excellent internal consistency reliability with reasonable test-retest reliability over time. Evidence for the association between recovery status and greater confidence and control over recovery-related activities as measured by the PACE-SE was supported by: (1) an inverse association with symptom status reflecting lower confidence for managing recovery with higher symptom load, (2) greater reported problems with school performance associated with lower SE, (3) positive change in SE ratings across two clinic visits associated with symptom improvement, and (4) a significant difference in SE ratings evident between recovered and nonrecovered patients. The psychometric evidence supporting the PACE-SE scale provides the clinician with a measure to understand the child/adolescent patient's self-confidence in facilitating their concussion recovery.

Feasibility of at-Home Sleep Monitoring in Adolescents with and without Concussion

Background

Poor sleep is associated with longer recovery following adolescent concussion, making the longitudinal assessment of sleep important for monitoring recovery and identifying sleep disruptions. An important consideration for successful monitoring of sleep following concussion is the feasibility and adherence of a given sleep monitoring tool when used in an at-home environment. Understanding the usability of different sleep monitoring tools is essential for determining their applicability for longitudinal assessment in an ecologically valid environment.

Purpose

The purpose of this study was to: (1) report on the adherence and feasibility of at-home sleep monitoring in adolescents following concussion, and (2) compare outcomes of subjective and wearable measures of sleep between adolescents with and without a concussion.

Patients and Methods

Participants included adolescents within 21 days of a concussion and uninjured controls that participated in four separate, prospective and longitudinal investigations of sleep following concussion. Sleep data was measured with: (1) Dreem Headband; (2) Philips Actiwatch; (3) Fitbit; and (4) subjective sleep diary. Sleep data was collected nightly, and adherence was defined as percentage of nights the participant used the sleep-monitoring tool over the study duration. Independent t-tests and effect sizes were calculated for the following sleep data outcomes as measured by each of the monitoring tools: duration, efficiency, latency, wake after sleep onset.

Results

Sleep data for a total of 183 adolescents (104 with concussion, 79 uninjured controls) was assessed. Adherence rates across all devices ranged from 53% to 98%, with the subjective sleep diary showing the highest adherence rate for both groups (concussion: 91%, control: 94%). Across the four different monitoring tools, adolescents with a concussion demonstrated longer duration, latency, wake after sleep onset, and lower (worse) efficiency, with medium to large effect sizes.

Conclusion

The results indicate that at-home sleep monitoring is a feasible approach for tracking sleep in adolescents following concussion.

Reference values for the adolescent post version of the Postconcussion Symptom Inventory from the German general population

The present study aims at providing reference values from the general pediatric population for the German version of the 21-item self-report post version of the Postconcussion Symptom Inventory for adolescents aged 13-17 years (PCSI-SR13) following pediatric traumatic brain injury (pTBI). A total of N = 950 adolescents completed an adapted version of the PCSI-SR13. Prior to establishing reference values using percentiles, psychometric properties (i.e., reliability and factorial validity) and regression analyses were examined to identify factors contributing to PCSI-SR13 scores. In addition, construct assessment in the general population sample was compared to that in the pTBI sample (N = 234) using measurement invariance analyses and direct comparisons at the score levels. The results indicate good reliability (Cronbach's α and McDonald's ω of 0.97 each). The four-factor structure covering physical, emotional, cognitive, and fatigue symptom groups could be replicated with χ2(183) = 995.96, p < 0.001, χ2/df = 5.44, CFI = 0.99, TLI = 0.98, RMSEA (90% CI) = 0.068 (0.064, 0.073), SRMR = 0.03. With minor restrictions, the assessment of symptoms was comparable between the general population and the pTBI samples. Participants in the pTBI sample reported a significantly higher symptom burden than those in the general population sample. Reference values were provided using the total sample without further stratification. Conclusion: For the German post version of the PCSI-SR13, reference values are now available for direct score comparisons and for drawing conclusions about the clinical relevance of the reported symptoms, while considering the prevalence in a comparable general population without a history of pTBI.Trial registration: The study is retrospectively registered in the German Clinical Trials Register and in the International Clinical Trials Registry Platform (ID DRKS00032854).

Symptom Recovery in Children Aged 5 to 12 Years With Sport-Related and Non-Sport-Related Concussion

Importance

There is limited research on clinical features and symptom recovery from sport-related concussion (SRC) and non-SRC in younger children.

Objective

To investigate the trajectory of symptom recovery in children aged 5 to 7 years and 8 to 12 years with SRC and non-SRC at 1, 2, 4, 8, and 12 weeks postinjury.

Design, Setting, and Participants

This secondary analysis of a prospective multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics) included participants aged 5 to 12 years with acute concussion who presented to 9 pediatric emergency departments within the Pediatric Emergency Research Canada network between August 2013 and June 2015. Analyses were conducted from September 2023 to May 2024.

Exposure

Participants had a concussion consistent with the Zurich consensus diagnostic criteria and 85% completeness of the Post-Concussion Symptom Inventory (PCSI) at each time point.

Main Outcomes and Measures

The primary outcome was symptom change, defined as current minus preinjury ratings 1, 2, 4, 8, and 12 weeks postinjury, measured using the PCSI. Symptoms were self-rated for children aged 8 to 12 years and child- and parent-rated for children aged 5 to 7 years. Mixed-effect models were conducted using total PCSI score adjusting for random effects; fixed-effect indicators included injury setting (SRC and non-SRC), time, injury setting × time, and other variables associated with recovery.

Results

A total of 1747 children, including 513 aged 5 to 7 years (mean [SD] age, 6.57 [0.85] years; 320 male [62.4%]) and 1234 aged 8 to 12 years (mean [SD] age, 10.68 [1.40] years; 806 male [65.3%]) were recruited, of whom 477 aged 5 to 7 years and 1157 aged 8 to 12 years were included in the analysis. Of those included in the analysis, 207 aged 5 to 7 years (43.4%; mean [SD] age, 6.68 [0.84] years; 142 male [68.6%]) and 790 aged 8 to 12 years (67.2%; mean [SD] age, 10.77 [1.40] years; 547 male [69.2%]) sustained an SRC. No significant differences in recovery curves across time postinjury were found between those with SRC and non-SRC (5-7 years: β = -0.09; 95% CI, -1.10 to 0.92; 8-12 years: β = 0.11; 95%CI, -1.50 to 1.70).

Conclusions and Relevance

In this cohort study of children aged 5 to 12 years with an acute SRC or non-SRC, symptom recovery trajectories over time were similar in both groups. This finding suggests similar management protocols can be used for sport and nonsport mechanisms of injury (excluding assault and motor vehicle crash) in the younger population.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

A short scale to measure health-related quality of life after traumatic brain injury in children and adolescents (QOLIBRI-OS-KID/ADO): psychometric properties and German reference values

PURPOSE

The impact of pediatric traumatic brain injury (pTBI) on health-related quality of life (HRQoL) in children and adolescents remains understudied. Short scales have some advantages in terms of economy and administration over longer scales, especially in younger children. The aim of the present study is to psychometrically evaluate the six-item German version of the QOLIBRI-OS-KID/ADO scale for children and adolescents. In addition, reference values from a general German pediatric population are obtained to assist clinicians and researchers in the interpretation of HRQoL after pTBI.

METHODS

A total of 297 individuals after TBI and 1997 from a general population sample completed the questionnaire. Reliability, validity, and comparability of the assessed construct were examined.

RESULTS

The questionnaire showed satisfactory reliability (α = 0.75 and ω = 0.81 and α = 0.85 and ω = 0.86 for the TBI and general population samples, respectively). The QOLIBRI-OS-KID/ADO was highly correlated with its long version (R2 = 67%) and showed an overlap with disease-specific HRQoL (R2 = 55%) in the TBI sample. The one-dimensional factorial structure could be replicated and tested for measurement invariance between samples, indicating a comparable HRQoL construct assessment. Therefore, reference values and cut-offs indicating clinically relevant impairment could be provided using percentiles stratified by factors significantly associated with the total score in the regression analyses (i.e., age group and gender).

CONCLUSION

In combination with the cut-offs, the QOLIBRI-OS-KID/ADO provides a cost-effective screening tool, complemented by interpretation guidelines, which may help to draw clinical conclusions and indications such as further administration of a longer version of the instrument to gain more detailed insight into impaired HRQoL domains or omission of further steps in the absence of an indication.

Reduced Cortical Excitability is Associated with Cognitive Symptoms in Concussed Adolescent Football Players

Background

American tackle football is associated with high rates of concussion, leading to neurophysiological disturbances and debilitating clinical symptoms. Previous investigations of the neurophysiological effects of concussion have largely ignored aperiodic neurophysiological activity, which is a marker of cortical excitability.

Purpose

We examined whether concussion during a season of high school football is related to changes in aperiodic and periodic neurophysiological activity and whether any such changes are associated with clinical outcomes.

Materials and Methods

Pre- and post-season resting-state magnetoencephalography (MEG) data were collected from 91 high school football players over as many as four seasons of play, for a total of 278 data collections. During these seasons of football play, a cohort of 10 individuals were diagnosed with concussion. MEG data were source-imaged, frequency-transformed and parameterized, and linear mixed models were used to examine effects of concussion on pre-to-post-season changes in neurophysiological activity. Scores on the Post-Concussive Symptom Inventory were correlated with pre-to-post-season neurophysiological changes to determine their clinical relevance.

Results

Concussion was associated with increased aperiodic exponents in superior frontal cortices, indicating a relative reduction in cortical excitability. This slowing of aperiodic neurophysiology mediated concussion effects on raw delta and gamma power and was associated with worse cognitive concerns across participants. Pre-to-post-season changes in aperiodic-corrected alpha and theta rhythmic activity were also decreased in posterior cortices in concussed players.

Conclusion

These findings indicate that concussion alters both the excitability and rhythmic signaling of the cortex, with differing spatial topographies and implications for clinical symptoms.

Characteristics of Pediatric Concussion across Different Mechanisms of Injury in 5 through 12-Year-Olds

OBJECTIVE

To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and nonsport or recreation-related concussion (non-SRRC) in patients 5 through 12 years old, an understudied population in youth concussion.

STUDY DESIGN

This observational study included patients aged 5 through 12 years presenting to a specialty care concussion setting at ≤28 days postinjury from 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Posthoc pairwise comparisons were employed for all analyses (α = 0.017).

RESULTS

One thousand one hundred forty-one patients reported at ≤28 days of injury (female = 42.9%, median age = 11, interquartile range (IQR) = 9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (P < .001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 2 and 3 days later than SRC (P < .001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (P < .001) compared with RRC and SRC (P < .001).

CONCLUSIONS

In concussion patients 5 through 12 years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury.

Fact or Fiction-Accelerometry Versus Self-Report in Adherence to Pediatric Concussion Protocols: Prospective Longitudinal Cohort Study

Background

Concussion, or mild traumatic brain injury, is a growing public health concern, affecting approximately 1.2% of the population annually. Among children aged 1-17 years, concussion had the highest weighted prevalence compared to other injury types, highlighting the importance of addressing this issue among the youth population.

Objective

This study aimed to assess adherence to Return to Activity (RTA) protocols among youth with concussion and to determine if better adherence affected time to recovery and the rate of reinjury.

Methods

Children and youth (N=139) aged 5-18 years with concussion were recruited. Self-reported symptoms and protocol stage of recovery were monitored every 48 hours until symptom resolution was achieved. Daily accelerometry was assessed with the ActiGraph. Data were collected to evaluate adherence to the RTA protocol based on physical activity cutoff points corresponding to RTA stages. Participants were evaluated using a battery of physical, cognitive, and behavioral measures at recruitment, upon symptom resolution, and 3 months post symptom resolution.

Results

For RTA stage 1, a total of 13% of participants were adherent based on accelerometry, whereas 11% and 34% of participants were adherent for stage 2 and 3, respectively. The median time to symptom resolution was 13 days for participants who were subjectively reported adherent to the RTA protocol and 20 days for those who were subjectively reported as nonadherent (P=.03). No significant agreement was found between self-report of adherence and objective actigraphy adherence to the RTA protocol as well as to other clinical outcomes, such as depression, quality of life, and balance. The rate of reinjury among the entire cohort was 2% (n=3).

Conclusions

Overall, adherence to staged protocols post concussion was minimal when assessed with accelerometers, but adherence was higher by self-report. More physical activity restrictions, as specified in the RTA protocol, resulted in lower adherence. Although objective adherence was low, reinjury rate was lower than expected, suggesting a protective effect of being monitored and increased youth awareness of protocols. The results of this study support the move to less restrictive protocols and earlier resumption of daily activities that have since been implemented in more recent protocols.

Age-Related Variations in Clinical Profiles for Children with Sports- and Recreation-Related Concussions

OBJECTIVE

The purpose was to examine clinical profiles in concussed children aged 5-9 and 10-12 years and compare them with those of adolescents >12 years.

METHODS

This study included patients aged 5-18 years presenting to a specialty care concussion program with a sports- and recreation-related (SRR) concussion ≤28 days postinjury. Demographics, injury mechanisms, symptoms, and clinical features were assessed. Chi-squared tests, one-way ANOVA, and Kruskal-Wallis were used for comparisons across age groups.

RESULTS

A total of 3280 patients with SRR concussion were included: 5.0% were 5-9 years, 18.4% were 10-12 years, and 76.6% were 13-18 years. Younger age groups had more males than females (5-9 years: 70.7% vs. 29.3%) and more commonly sustained their injury during limited- (28.7%), and non-contact (7.9%) activities compared to other age groups (p < 0.01). Younger children presented less symptoms frequently (p ≤ 0.042), but higher symptom severity in somatic and emotional domains (p ≤ 0.016). Fewer 5-9-year-olds reported changes in school (25.6%), sleep (46.3%), and daily habits (40.9%) than adolescents (p < 0.001).

CONCLUSIONS

Among SRR-concussed children and adolescents, we found significant age-related variations in demographics, injury mechanism, symptoms, and clinical features. Recognizing these unique features in younger children may facilitate targeted management and treatment.

An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion

OBJECTIVE

Pediatric athletes with concussion present with a variety of impairments on clinical assessment and require individualized treatment. The Buffalo Concussion Physical Examination is a brief, pertinent clinical assessment for individuals with concussion. The purpose of this study was to identify physical examination subtypes in pediatric athletes with concussion within 2 weeks of injury that are relevant to diagnosis and treatment.

DESIGN

Secondary analysis of a published cohort study and clinician consensus.

SETTING

Three university-affiliated sports medicine centers.

PARTICIPANTS

Two hundred seventy children (14.9 ± 1.9 years).

INDEPENDENT VARIABLES

Orthostatic intolerance, horizontal and vertical saccades, smooth pursuits, vestibulo-ocular reflex, near-point convergence, complex tandem gait, neck range of motion, neck tenderness, and neck spasm.

MAIN OUTCOME MEASURES

Correlations between independent variables were calculated, and network graphs were made. k -means and hierarchical clustering were used to identify clusters of impairments. Optimal number of clusters was assessed. Results were reviewed by experienced clinicians and consensus was reached on proposed subtypes.

RESULTS

Physical examination clusters overlapped with each other, and no optimal number of clusters was identified. Clinician consensus suggested 3 possible subtypes: (1) visio-vestibular (horizontal and vertical saccades, smooth pursuits, and vestibulo-ocular reflex), (2) cervicogenic (neck range of motion and spasm), and (3) autonomic/balance (orthostatic intolerance and complex tandem gait).

CONCLUSIONS

Although we identified 3 physical examination subtypes, it seemed that physical examination findings alone are not enough to define subtypes that are both statistically supported and clinically relevant, likely because they do not include symptoms, assessment of mood or cognitive problems, or graded exertion testing.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The association between symptom burden and processing speed and executive functioning at 4 and 12 weeks following pediatric concussion

OBJECTIVES

Symptoms and cognition are both utilized as indicators of recovery following pediatric concussion, yet their interrelationship is not well understood. This study aimed to investigate: 1) the association of post-concussion symptom burden and cognitive outcomes (processing speed and executive functioning [EF]) at 4 and 12 weeks after pediatric concussion, and 2) the moderating effect of sex on this association.

METHODS

This prospective, multicenter cohort study included participants aged 5.00-17.99 years with acute concussion presenting to four Emergency Departments of the Pediatric Emergency Research Canada network. Five processing speed and EF tasks and the Post-Concussion Symptom Inventory (PCSI; symptom burden, defined as the difference between post-injury and retrospective [pre-injury] scores) were administered at 4 and 12 weeks post-concussion. Generalized least squares models were conducted with task performances as dependent variables and PCSI and PCSI*sex interaction as the main predictors, with important pre-injury demographic and injury characteristics as covariates.

RESULTS

311 children (65.0% males; median age = 11.92 [IQR = 9.14-14.21 years]) were included in the analysis. After adjusting for covariates, higher symptom burden was associated with lower Backward Digit Span (χ2 = 9.85, p = .043) and Verbal Fluency scores (χ2 = 10.48, p = .033) across time points; these associations were not moderated by sex, ps ≥ .20. Symptom burden was not associated with performance on the Coding, Continuous Performance Test, and Color-Word Interference scores, ps ≥ .17.

CONCLUSIONS

Higher symptom burden is associated with lower working memory and cognitive flexibility following pediatric concussion, yet these associations were not moderated by sex. Findings may inform concussion management by emphasizing the importance of multifaceted assessments of EF.

Neurovascular Coupling in Acutely Concussed Adolescent Patients

Neurovascular coupling (NVC) uniquely describes cerebrovascular response to neural activation and has demonstrated impairments following concussion in adult patients. It is currently unclear how adolescent patients experience impaired NVC acutely following concussion during this dynamic phase of physiological development. The purpose of this study was to investigate NVC in acutely concussed adolescent patients relative to controls. We recruited patients presenting to a sports medicine practice within 28 days of a concussion or a musculoskeletal injury (controls). Transcranial Doppler ultrasound was used to measure changes in patients' posterior cerebral artery (PCA) velocity in response to two progressively challenging visual tasks: (1) reading and (2) visual search. Each task was presented in five 1-min trials (20 sec eyes closed/40 sec eyes open). Resting PCA velocity data were derived by averaging PCA velocity across a 2-min baseline period that preceded the visual tasks. Filtered task data were converted to time-series curves representing 40 consecutive 1-sec averages for each trial. Curves were then averaged across the five trials and time-aligned to stimulus onset (eyes open) to generate a single ensemble-averaged 40-sec curve representing NVC response for each participant for each task. Independent t tests were used to assess group differences (concussion vs. control) in resting PCA velocity. Separate linear mixed-effects models were used to evaluate group differences (concussion vs. control) in NVC response profiles for both visual tasks and group-by-task interaction. Twenty-one concussion patients (female = 8 [38.1%]; age = 14.4 ± 1.9 years) and 20 controls (female = 7 [35.0%]; age = 14.4 ± 1.9 years) were included in our analysis. Average resting PCA velocity did not significantly differ between concussion patients (36.6 ± 8.0 cm/sec) and controls (39.3 ± 8.5 cm/sec) (t39 = 1.06; p = 0.30). There were no significant group differences in relative NVC response curves during the reading task (F1,1560 = 2.23; p = 0.14) or the visual search task (F1,1521 = 2.04; p = 0.15). In contrast, the differential response to task (e.g., increase from reading task to visual search task) was significantly greater in concussion patients than in controls (p < 0.0001). The NVC response to the visual search task was 7.1% higher than the response to reading in concussion patients relative to being 5.5% higher in controls. Our data indicate that concussed patients present with a significantly greater response to more difficult tasks than do controls, suggesting that concussed adolescents require increased neural resource allocation as task difficulty increases. The study provides insight into the neurophysiological consequences of concussion in adolescent patients.

Psychological Predictors of Mental Health Difficulties After Pediatric Concussion

Children often experience mental health difficulties after a concussion. Yet, the extent to which a concussion precipitates or exacerbates mental health difficulties remains unclear. This study aimed to examine psychological predictors of mental health difficulties after pediatric concussion. Children (5 to <18 years of age, M = 11.7, SD = 3.3) with concussion were recruited in a single-site longitudinal prospective cohort study conducted at a tertiary children's hospital (n = 115, 73.9% male). The primary outcomes included internalizing (anxious, depressed, withdrawn behaviors), externalizing (risk-taking, aggression, attention difficulties), and total mental health problems, as measured by the Child Behavior Checklist at 2 weeks (acute) and 3 months (post-acute) after concussion. Predictors included parents' retrospective reports of premorbid concussive symptoms (Post-Concussion Symptom Inventory; PCSI), the child and their family's psychiatric history, child-rated perfectionism (Adaptive-Maladaptive Perfectionism Scale), and child-rated resilience (Youth Resilience Measure). Higher premorbid PCSI ratings consistently predicted acute and post-acute mental health difficulties. This relationship was significantly moderated by child psychiatric history. Furthermore, pre-injury learning difficulties, child psychiatric diagnoses, family psychiatric history, lower resilience, previous concussions, female sex, and older age at injury were associated with greater mental health difficulties after concussion. Pre-injury factors accounted for 23.4-39.9% of acute mental health outcomes, and 32.3-37.8% of post-acute mental health outcomes. When acute mental health was factored into the model, a total of 47.0-68.8% of variance was explained by the model. Overall, in this sample of children, several pre-injury demographic and psychological factors were observed to predict mental health difficulties after a concussion. These findings need to be validated in future research involving larger, multi-site studies that include a broader cohort of children after concussion.

Different trajectories of post-concussive symptom subscales after pediatric mild traumatic brain injury: Data from a prospective longitudinal study

PURPOSE

The aim of this study was to investigate the trajectory of parent-rated post-concussive symptoms (PCS), attentional performance and participation within 6 months in children after mild traumatic brain injury (mTBI).

METHODS

For this prospective longitudinal study, we included data on 64 children after mTBI and 57 healthy control children (age 8-16 years). Parents rated PCS using the Post-Concussion Symptom Inventory (PCSI) immediately (T0), 1 week (T1), and 3-6 months after injury (T2). Attentional performance (alertness, selective and divided attention) was measured using the Test of Attentional Performance (TAP) at T1 and T2 and participation was measured using the Child and Adolescent Scale of Participation (CASP) at T2.

RESULTS

Friedman tests showed different trajectories of PCS subscales over time: Compared to pre-injury level, the amount of somatic and cognitive PCS was still elevated at T1, while emotional PCS at T1 were already comparable to pre-injury level. The rating of sleep-related PCS at T2 was significantly elevated compared to the pre-injury rating. Quade ANCOVAs indicated group differences in PCS subscales between patients and controls at T1, but not at T2. Patients and controls showed a similar performance in tests of attention at T1 and T2, but parental rating of participation at school was significantly reduced. Although cognitive PCS and attention were not correlated, there were significantly negative Spearman correlations between participation at home and pre-injury and concurrent PCS at T2.

CONCLUSIONS

Our data imply that sleep-related PCS are still elevated weeks after injury and are thus a target for interventions after mTBI.

Altered Oculomotor and Vestibulo-ocular Function in Children and Adolescents Postconcussion

OBJECTIVE

To document (1) oculomotor (OM) and vestibulo-ocular (VO) function in children with concussion who were symptomatic at the time of assessment and to compare it with that in children with concussion who were clinically recovered (asymptomatic) and in children with no concussive injury, and (2) the extent to which OM and VO function relates to postconcussion symptom severity in injured children.

SETTING

Participants were recruited from a concussion clinic or the community.

PARTICIPANTS

A total of 108 youth with concussion (72 symptomatic; 36 recovered) and 79 healthy youth (aged 9-18 years). Youth with concussion were included if aged 9 to 18 years, had no previous concussion within the last 12 months, less than 90 days since injury, and no known existing visual disorders or learning disabilities.

STUDY DESIGN

A prospective cross-sectional study.

MAIN MEASURES

All participants were tested for OM and VO function with a commercial virtual reality (VR) eye-tracking system (Neuroflex ® , Montreal,Québec, Canada). Participants in the concussion group who completed the postconcussion symptoms were scored with the Post-Concussion Symptom Inventory.

RESULTS

There was a significant group effect for vergence during smooth pursuit ( F2,176 = 10.90; P < .05), mean latency during saccades ( F2,171 = 5.99; P = .003), and mean response delay during antisaccades ( F2,177 = 9.07; P < .05), where children with symptomatic concussion showed poorer performance than clinically recovered and healthy children. Similar results were found in VO for average vestibular ocular reflex gain in the horizontal leftward ( F2,168 = 7; P = .001) and rightward directions ( F2,163 = 13.08; P < .05) and vertical upward ( F2,147 = 7.60; P = .001) and downward directions ( F2,144 = 13.70; P < .05). Mean saccade error was positively correlated to total Post-Concussion Symptom Inventory scores in younger clinically recovered children.

CONCLUSION

VR eye tracking may be an effective tool for identifying OM and VO deficits in the subacute phase (<90 days) postconcussion.

Using mobile health to expedite access to specialty care for youth presenting to the emergency department with concussion at highest risk of developing persisting symptoms: a protocol paper for a non-randomised hybrid implementation-effectiveness trial

INTRODUCTION

Paediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the benefit of early, active, targeted therapeutic strategies. However, these are primarily prescribed from the specialty setting. Early access to concussion specialty care has been shown to improve recovery times for those at risk for persisting symptoms, but there are disparities in which youth are able to access such care. Mobile health (mHealth) technology has the potential to improve access to concussion specialists. This trial will evaluate the feasibility of a mHealth remote patient monitoring (RPM)-based care handoff model to facilitate access to specialty care, and the effectiveness of the handoff model in reducing the incidence of PPCS.

METHODS AND ANALYSIS

This study is a non-randomised type I, hybrid implementation-effectiveness trial. Youth with concussion ages 13-18 will be enrolled from the emergency department of a large paediatric healthcare network. Patients deemed a moderate-to-high risk for PPCS using the predicting and preventing postconcussive problems in paediatrics (5P) stratification tool will be registered for a web-based chat platform that uses RPM to collect information on symptoms and activity. Those patients with escalating or plateauing symptoms will be contacted for a specialty visit using data collected from RPM to guide management. The primary effectiveness outcome will be the incidence of PPCS, defined as at least three concussion-related symptoms above baseline at 28 days following injury. Secondary effectiveness outcomes will include the number of days until return to preinjury symptom score, clearance for full activity and return to school without accommodations. The primary implementation outcome will be fidelity, defined as the per cent of patients meeting specialty care referral criteria who are ultimately seen in concussion specialty care. Secondary implementation outcomes will include patient-defined and clinician-defined appropriateness and acceptability.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of the Children's Hospital of Philadelphia (IRB 22-019755). Study findings will be published in peer-reviewed journals and disseminated at national and international meetings.

TRIAL REGISTRATION NUMBER

NCT05741411.

Head Injury Treatment With Healthy and Advanced Dietary Supplements: A Pilot Randomized Controlled Trial of the Tolerability, Safety, and Efficacy of Branched Chain Amino Acids in the Treatment of Concussion in Adolescents and Young Adults

Concussion is a common injury in the adolescent and young adult populations. Although branched chain amino acid (BCAA) supplementation has shown improvements in neurocognitive and sleep function in pre-clinical animal models of mild-to-moderate traumatic brain injury (TBI), to date, no studies have been performed evaluating the efficacy of BCAAs in concussed adolescents and young adults. The goal of this pilot trial was to determine the efficacy, tolerability, and safety of varied doses of oral BCAA supplementation in a group of concussed adolescents and young adults. The study was conducted as a pilot, double-blind, randomized controlled trial of participants ages 11-34 presenting with concussion to outpatient clinics (sports medicine and primary care), urgent care, and emergency departments of a tertiary care pediatric children's hospital and an urban tertiary care adult hospital, between June 24, 2014 and December 5, 2020. Participants were randomized to one of five study arms (placebo and 15 g, 30 g, 45 g, and 54 g BCAA treatment daily) and followed for 21 days after enrollment. Outcome measures included daily computerized neurocognitive tests (processing speed, the a priori primary outcome; and attention, visual learning, and working memory), symptom score, physical and cognitive activity, sleep/wake alterations, treatment compliance, and adverse events. In total, 42 participants were randomized, 38 of whom provided analyzable data. We found no difference in our primary outcome of processing speed between the arms; however, there was a significant reduction in total symptom score (decrease of 4.4 points on a 0-54 scale for every 500 g of study drug consumed, p value for trend = 0.0036, [uncorrected]) and return to physical activity (increase of 0.503 points on a 0-5 scale for every 500 g of study drug consumed, p value for trend = 0.005 [uncorrected]). There were no serious adverse events. Eight of 38 participants reported a mild (not interfering with daily activity) or moderate (limitation of daily activity) adverse event; there were no differences in adverse events by arm, with only two reported mild adverse events (both gastrointestinal) in the highest (45 g and 54 g) BCAA arms. Although limited by slow enrollment, small sample size, and missing data, this study provides the first demonstration of efficacy, as well as safety and tolerability, of BCAAs in concussed adolescents and young adults; specifically, a dose-response effect in reducing concussion symptoms and a return to baseline physical activity in those treated with higher total doses of BCAAs. These findings provide important preliminary data to inform a larger trial of BCAA therapy to expedite concussion recovery.

Response Rate Patterns in Adolescents With Concussion Using Mobile Health and Remote Patient Monitoring: Observational Study

Background

A concussion is a common adolescent injury that can result in a constellation of symptoms, negatively affecting academic performance, neurobiological development, and quality of life. Mobile health (mHealth) technologies, such as apps for patients to report symptoms or wearables to measure physiological metrics like heart rate, have been shown to be promising in health maintenance. However, there is limited evidence about mHealth engagement in adolescents with a concussion during their recovery course.

Objective

This study aims to determine the response rate and response rate patterns in concussed adolescents reporting their daily symptoms through mHealth technology. It will also examine the effect of time-, demographic-, and injury-related characteristics on response rate patterns.

Methods

Participants aged between 11-18 years (median days since injury at enrollment: 11 days) were recruited from the concussion program of a tertiary care academic medical center and a suburban school's athletic teams. They were asked to report their daily symptoms using a mobile app. Participants were prompted to complete the Post-Concussion Symptom Inventory (PCSI) 3 times (ie, morning, afternoon, and evening) per day for 4 weeks following enrollment. The primary outcome was the response rate pattern over time (by day since initial app use and the day since injury). Time-, demographic-, and injury-related differences in reporting behaviors were compared using Mann Whitney U tests.

Results

A total of 56 participants were enrolled (mean age 15.3, SD 1.9 years; n=32, 57% female). The median response rate across all days of app use in the evening was 37.0% (IQR 27.2%-46.4%), which was significantly higher than the morning (21.2%, IQR 15.6%-30.5%) or afternoon (26.4%, IQR 21.1%-31.5%; P<.001). The median daily response was significantly different by sex (female: 53.8%, IQR 46.2%-64.2% vs male: 42.0%, IQR 28.6%-51.1%; P=.003), days since injury to app use (participants starting to use the app >7 days since injury: 54.1%, IQR 47.4%-62.2% vs starting to use the app ≤7 days since injury: 38.0%, IQR 26.0%-53.3%; P=.002), and concussion history (participants with a history of at least one prior concussion: 57.4%, IQR 44.5%-70.5% vs participants without concussion history: 42.3%, IQR 36.8%-53.5%; P=.03). There were no significant differences by age. Differences by injury mechanism (sports- and recreation-related injury: 39.6%, IQR 36.1%-50.4% vs non-sports- or recreation-related injury: 30.6%, IQR 20.0%-42.9%; P=.04) and initial symptom burden (PCSI scores greater than the median score of 47: 40.9%, IQR 35.2%-53.8% vs PCSI scores less than or equal to the median score: 31.9%, IQR 24.6%-40.6%; P=.04) were evident in the evening response rates; however, daily rates were not statistically different.

Conclusions

Evening may be the optimal time to prompt for daily concussion symptom assessment among concussed adolescents compared with morning or afternoon. Multiple demographic- and injury-related characteristics were associated with higher daily response rates, including for female participants, those with more than 1 week from injury to beginning mHealth monitoring, and those with a history of at least one previous concussion. Future studies may consider incentive strategies or adaptive digital concussion assessments to increase response rates in populations with low engagement.

A systematic review of pre-injury anxiety disorder and post-concussion outcomes in youth and young adult athletes

Pre-injury anxiety disorder may be a risk factor for poor outcomes following sportsrelated concussion. A systematic review was performed to characterize the relationship between pre-injury anxiety disorder and post-concussion symptom presentation and recovery time after sports-related concussions among children, adolescents, and young adults. A PRISMA-compliant literature search was conducted in Ovid MEDLINE, PsycINFO, EMBASE, and Scopus for articles published up to 25 January 2024. The initial query yielded 1358 unique articles. Articles that analyzed the relationship between pre-injury anxiety disorder and post-concussion symptoms and recovery time were included. A final cohort of 11 articles was extracted, comprising a total of 8390 study participants, of whom 921 had a history of pre-injury anxiety disorder. Pre-injury anxiety disorder was associated with prolonged time to return to sports activity and an increased incidence of physical, emotional, cognitive, and sleep-related symptoms. While the results of this review suggest an association between pre-injury anxiety disorder and post-concussion symptoms and recovery time, future studies should be more stringent regarding standardized anxiety disorder definitions, longitudinal assessment of post-concussion symptoms, anxiety disorder subtypes, and anxiety treatment history.

Factors Associated with Symptom Resolution after Aerobic Exercise Intervention in Adolescent and Young Adults with Concussion

BACKGROUND

Aerobic exercise facilitates postconcussion symptom resolution at the group level, but patient-level characteristics may affect the likelihood of treatment efficacy.

PURPOSE

This study aimed to investigate demographic and clinical characteristics, which differentiate postconcussion aerobic exercise treatment efficacy from nonefficacy in the intervention arm of a randomized clinical trial.

METHODS

Adolescent and young adult participants initiated a standardized aerobic exercise intervention within 14 d of concussion, consisting of self-selected exercise for 100 min·wk -1 at an individualized heart rate (80% of heart rate induced symptom exacerbation during graded exercise testing). Treatment efficacy was defined as symptom resolution within 28-d postconcussion. Treatment efficacy and nonefficacy groups were compared on demographics, clinical characteristics, intervention adherence, and persistent symptom risk using the Predicting Persistent Postconcussive Problems in Pediatrics (5P) clinical risk score.

RESULTS

A total of 27 participants (16.1 ± 2.3 yr old; range, 11-21 yr; 52% female) began the intervention, with a mean of 9.5 ± 3.7 d after concussion; half ( n = 13; 48%) demonstrated treatment efficacy (symptom resolution within 28 d postconcussion). Those whose symptoms resolved within 28 d had significantly lower preintervention postconcussion symptom inventory scores (21.2 ± 13.2 vs 41.4 ± 22.2; P < 0.01), greater adherence to the intervention (77% vs 36%; P = 0.05), and longer average exercise duration (median [interquartile range], 49.7 [36.8-68.6] vs 30.4 [20.7-34.7] min; P < 0.01) than those whose symptoms lasted more than 28 d. Groups were similar in age, sex, timing of intervention, and preintervention 5P risk score.

CONCLUSIONS

A standardized aerobic exercise intervention initiated within 14 d of concussion demonstrated efficacy for approximately half of participants, according to our definition of treatment efficacy. This multisite aerobic exercise intervention suggests that lower symptom severity, higher intervention adherence, and greater exercise duration are factors that increase the likelihood of symptoms resolving within 28 d of concussion.

Postconcussion Moderate to Vigorous Physical Activity Predicts Anxiety Severity among Adolescent Athletes

PURPOSE

This study aimed to examine how moderate-to-vigorous physical activity (MVPA) during concussion recovery influences self-reported anxiety symptoms at follow-up assessment. We hypothesized that more MVPA after concussion would be associated with lower anxiety rating at follow-up.

METHODS

We performed a prospective study of participants aged 13-18 yr initially assessed within 14 d of diagnosed concussion. Participants rated concussion symptoms using the Post-Concussion Symptom Inventory and were provided a wrist-worn actigraphy device to track activity for 1 wk after assessment. At follow-up assessment, participants rated anxiety symptoms using the four-question Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety subscale. Each question ranged from 1 (never) to 5 (almost always), with an overall score range of 4-20. For univariable analysis, we calculated correlation coefficients between MVPA and PROMIS anxiety subscale scores. We then created a multiple linear regression model with follow-up PROMIS anxiety subscale score as the outcome and MVPA, sex, initial symptom severity, and preconcussion anxiety as predictors.

RESULTS

We enrolled and initially tested 55 participants, and 48 were included in the final analysis (age, 14.6±2.7 yr; 56% female; initial assessment, 7.3± 3.1 d; follow-up assessment, 42.0±29.7 d). We observed an inverse and low correlation between MVPA and follow-up PROMIS anxiety subscale T-scores ( r = -0.30, P = 0.04). Multivariable regression results indicated that MVPA ( β = -5.30; 95% confidence interval (CI), -10.58 to -0.01), initial Post-Concussion Symptom Inventory score ( β = 0.11; 95% CI, 0.03 to 0.19), and preconcussion anxiety ( β = 5.56; 95% CI, 0.12 to 11.0), but not sex ( β = -2.60; 95% CI, -7.14, to 1.94), were associated with follow-up PROMIS anxiety subscale T-scores.

CONCLUSIONS

After adjusting for covariates, more MVPA early after concussion predicted lower PROMIS anxiety subscale scores at follow-up. Although initial concussion symptom severity and preconcussion anxiety were also associated with follow-up PROMIS anxiety subscale score, MVPA represents a modifiable factor that may contribute to lower anxiety symptoms.

Applicability and clinical utility of the German rivermead post-concussion symptoms questionnaire in proxies of children after traumatic brain injury: an instrument validation study

BACKGROUND

The German Rivermead Post-Concussion Symptoms Questionnaire (RPQ) can be used to assess post-concussion symptoms (PCS) after traumatic brain injury (TBI) in adults, adolescents, and children.

METHODS

In this study, we examined the psychometric properties of the German RPQ proxy version (N = 146) for children (8-12 years) after TBI at the item, total and scale score level. Construct validity was analyzed using rank correlations with the proxy-assessed Post-Concussion Symptoms Inventory (PCSI-P), the Patient Health Questionnaire 9 (PHQ-9), and the Generalized Anxiety Disorder Scale 7 (GAD-7). Furthermore, sensitivity testing was performed concerning subjects' sociodemographic and injury-related characteristics. Differential item functioning (DIF) was analyzed to assess the comparability of RPQ proxy ratings for children with those for adolescents.

RESULTS

Good internal consistency was demonstrated regarding Cronbach's α (0.81-0.90) and McDonald's ω (0.84-0.92). The factorial validity of a three-factor model was superior to the original one-factor model. Proxy ratings of the RPQ total and scale scores were strongly correlated with the PCSI-P (ϱ = 0.50-0.69), as well as moderately to strongly correlated with the PHQ-9 (ϱ = 0.49-0.65) and the GAD-7 (ϱ = 0.44-0.64). The DIF analysis revealed no relevant differences between the child and adolescent proxy versions.

CONCLUSIONS

The German RPQ proxy is a psychometrically reliable and valid instrument for assessing PCS in children after TBI. Therefore, RPQ self- and proxy-ratings can be used to assess PCS in childhood as well as along the lifespan of an individual after TBI.

Smartphone App-Delivered Mindfulness-Based Intervention for Mild Traumatic Brain Injury in Adolescents: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Concussion in children and adolescents is a significant public health concern, with 30% to 35% of patients at risk for prolonged emotional, cognitive, sleep, or physical symptoms. These symptoms negatively impact a child's quality of life while interfering with their participation in important neurodevelopmental activities such as schoolwork, socializing, and sports. Early psychological intervention following a concussion may improve the ability to regulate emotions and adapt to postinjury symptoms, resulting in the greater acceptance of change; reduced stress; and recovery of somatic, emotional, and cognitive symptoms.

OBJECTIVE

The primary objective of this study is to assess the feasibility of conducting a parallel-group (1:1) randomized controlled trial (RCT) to evaluate a digital therapeutics (DTx) mindfulness-based intervention (MBI) in adolescents aged 12 to <18 years. The attention-matched comparator intervention (a math game also used in previous RCTs) will be delivered on the same DTx platform. Both groups will be provided with the standard of care guidelines. The secondary objective is to examine intervention trends for quality of life; resilience; self-efficacy; cognition such as attention, working memory, and executive functioning; symptom burden; and anxiety and depression scores at 4 weeks after concussion, which will inform a more definitive RCT. A subsample will be used to examine whether those randomized to the experimental intervention group have different brain-based imaging patterns compared with those randomized to the control group.

METHODS

This study is a double-blind Health Canada-regulated trial. A total of 70 participants will be enrolled within 7 days of concussion and randomly assigned to receive the 4-week DTx MBI (experimental group) or comparator intervention. Feasibility will be assessed based on the recruitment rate, treatment adherence to both interventions, and retention. All outcome measures will be evaluated before the intervention (within 7 days after injury) and at 1, 2, and 4 weeks after the injury. A subset of 60 participants will undergo magnetic resonance imaging within 72 hours and at 4 weeks after recruitment to identify the neurophysiological mechanisms underlying the potential benefits from MBI training in adolescents following a concussion.

RESULTS

The recruitment began in October 2022, and the data collection is expected to be completed by September 2024. Data collection and management is still in progress; therefore, data analysis is yet to be conducted.

CONCLUSIONS

This trial will confirm the feasibility and resolve uncertainties to inform a future definitive multicenter efficacy RCT. If proven effective, a smartphone-based MBI has the potential to be an accessible and low-risk preventive treatment for youth at risk of experiencing prolonged postconcussion symptoms and complications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05105802; https://classic.clinicaltrials.gov/ct2/show/NCT05105802.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57226.

Final Validation of the Quality of Life after Brain Injury for Children and Adolescents (QOLIBRI-KID/ADO) Questionnaire

Until recently, no disease-specific health-related quality of life (HRQoL) questionnaire existed for pediatric traumatic brain injuries (TBIs). In this revalidation study, the psychometric properties and the validity of the 35-item QOLIBRI-KID/ADO questionnaire in its final German version were examined in 300 children and adolescents. It is the first self-reported TBI-specific tool for measuring pediatric HRQoL in individuals aged between 8 and 17 years. The six-factor model fits the data adequately. The questionnaire's internal consistency was excellent for the total score and satisfactory to excellent for the scale scores. Intraclass correlations indicated good test-retest reliability, and the measure's construct validity was supported by the overlap between the QOLBRI-KID/ADO and the PedsQL, which measures generic HRQoL. The discriminant validity tests showed that older children and girls reported a significantly lower HRQoL than comparison groups, and this was also true of children who were anxious or depressed, or who suffered from post-concussion symptoms, replicating the results of the questionnaire's first developmental study. Our results suggest that the QOLIBRI-KID/ADO is a reliable and valid multidimensional tool that can be used together with the adult version in clinical contexts and research to measure disease-specific HRQoL after pediatric TBI throughout a person's life. This may help improve care, treatment, daily functioning, and HRQoL after TBI.

Validation of the Scandinavian guidelines for minor and moderate head trauma in children: protocol for a pragmatic, prospective, observational, multicentre cohort study

INTRODUCTION

Mild traumatic brain injury is common in children and it can be challenging to accurately identify those in need of urgent medical intervention. The Scandinavian guidelines for management of minor and moderate head trauma in children, the Scandinavian Neurotrauma Committee guideline 2016 (SNC16), were developed to aid in risk stratification and decision-making in Scandinavian emergency departments (EDs). This guideline has been validated externally with encouraging results, but internal validation in the intended healthcare system is warranted prior to broad clinical implementation.

OBJECTIVE

We aim to validate the diagnostic accuracy of the SNC16 to predict clinically important intracranial injuries (CIII) in paediatric patients suffering from blunt head trauma, assessed in EDs in Sweden and Norway.

METHODS AND ANALYSIS

This is a prospective, pragmatic, observational cohort study. Children (aged 0-17 years) with blunt head trauma, presenting with a Glasgow Coma Scale of 9-15 within 24 hours postinjury at an ED in 1 of the 16 participating hospitals, are eligible for inclusion. Included patients are assessed and managed according to the clinical management routines of each hospital. Data elements for risk stratification are collected in an electronic case report form by the examining doctor. The primary outcome is defined as CIII within 1 week of injury. Secondary outcomes of importance include traumatic CT findings, neurosurgery and 3-month outcome. Diagnostic accuracy of the SNC16 to predict endpoints will be assessed by point estimate and 95% CIs for sensitivity, specificity, likelihood ratio, negative predictive value and positive predictive value.

ETHICS AND DISSEMINATION

The study is approved by the ethical board in both Sweden and Norway. Results from this validation will be published in scientific journals, and a tailored development and implementation process will follow if the SNC16 is found safe and effective.

TRIAL REGISTRATION NUMBER

NCT05964764.

Nominal Differences in Acute Symptom Presentation and Recovery Duration of Sport-Related Concussion Between Male and Female Collegiate Athletes in the PAC-12

BACKGROUND

Sport-related concussion (SRC) is a heterogenous injury that often presents with varied symptoms and impairment. Recently, research has focused on identifying subtypes, or clinical profiles of concussion to be used in assessing and treating athletes with SRC. The purpose of this study was to investigate sex differences in clinical profiles, recovery duration, and initial symptom severity after SRC in a cohort of collegiate athletes in the Pacific-12 Conference (Pac-12).

METHODS

This prospective cohort study examined post-SRC symptoms, recovery, and return-to-play times using data from the Pac-12 CARE Affiliated Program and Pac-12 Health Analytics Program. Clinical profiles reported by student-athletes were defined by the number (> 50%) of specific symptoms frequently reported for each profile. Generalized linear mixed models were used to examine associations among sex, clinical profiles, time-to-recovery, and return-to-play times.

RESULTS

479 concussion incidents met inclusion criteria. The probabilities of initial presentation of each clinical profile, initial injury severity scores, and recovery times within a profile did not differ between sexes (p = 0.33-0.98). However, both males and females had > 0.75 probabilities of exhibiting cognitive and ocular profiles. Initial injury severity score was a strong nonlinear predictor of initial number of clinical profiles (p < 0.0001), which did not differ between sexes. The number of clinical profiles was also a nonlinear predictor of time-to-recovery (p = 0.03) and return-to-play times (p < 0.0001).

CONCLUSIONS

Initial symptom severity was strongly predictive of the number of acute clinical profiles experienced post-SRC. As the number of clinical profiles increased, time-to-recovery and time to return-to-play also increased. Factors other than sex may be better associated with acute symptom presentation post-concussion as no sex differences were found in reported clinical profiles or recovery. Understanding the number and type of clinical profiles experienced post-SRC may help inform concussion diagnostics and management.

Impaired Neuromotor Control During Gait in Concussed Adolescents-A Frequency Analysis

Disruptions in gait function are common after concussion in adolescents; however, the neuromotor control deficits driving these gait disruptions are not well known. Fifteen concussed (age mean [SD]): 17.4 [0.6], 13 females, days since injury: 26.3 [9.9]) and 17 uninjured (age: 18.0 [0.7], 10 females) adolescents completed 3 trials each of single-task gait and dual-task gait (DT). During DT, participants simultaneously walked while completing a serial subtraction task. Gait metrics and variability in instantaneous mean frequency in lower extremity muscles were captured by inertial sensors and surface electromyography, respectively. A 2-way analysis of covariance was used to compare gait metrics across groups and conditions. Functional principal components analysis was used to identify regions of variability in instantaneous mean frequency curves. Functional principal component scores were compared across groups using a Welch statistic. Both groups displayed worse performance on gait metrics during DT condition compared to single-task, with no differences between groups (P < .001). Concussed adolescents displayed significantly greater instantaneous mean frequency, indicated by functional principal component 1, in the tibialis anterior, biceps femoris, and semitendinosus (P < .05) during single-task and DT compared with uninjured adolescents. Our observations suggest that concussed adolescents display inefficient motor unit recruitment lasting longer than 2 weeks following injury, regardless of the addition of a secondary task.