Postconcussion Syndrome: A Review

The effects of adrenal insufficiency and its treatment on cognition in an athlete with post-concussion syndrome

Post-concussion Syndrome (PCS) describes persistent nonspecific neurological, cognitive and emotional symptoms following concussion. A young male presented to a sports concussion clinic with persistent symptoms post-injury. Neurocognitive testing found unexpected severe memory impairment. Blood tests for pituitary function returned low cortisol levels secondary to adrenal insufficiency (AI), which was immediately treated. Post-treatment and improvement of cortisol levels, repeat neuropsychology testing demonstrated reliable improvement in memory and processing speed test scores, commensurate with premorbid expectations. This case highlights the importance of a broad diagnostic approach to formulating unexpected persistent PCS symptoms, screening for AI in PCS cases, and completing neurocognitive testing.

Intranasal Administration of Human Neural Crest-Derived Nasal Turbinate Stem Cells Attenuates Microglia Activity in Mild Head Trauma Models

BACKGROUND

Mild head trauma often leads to long-term cognitive and neurological deficits. PLX3397, an inhibitor of colony-stimulating factor 1 receptor (CSF1R), offers promise as a therapeutic agent for traumatic brain injury (TBI) by targeting neuro-inflammation. Stem cell-based approaches are widely studied for neurological disorders. The objective of this study was to investigate therapeutic effect of intranasal administration of human neural crest-derived nasal turbinate stem cells (hNTSCs) on mild TBI in comparison with that of PLX3397.

METHODS

We developed a model of mice with repetitive and mild TBI following a weight-drop once a day for 5 days. PLX3397 (50 mg/kg, p. o.) was administered for 21 days. Intranasal administration of hNTSCs (1 × 106) was performed once.

RESULTS

Iba1 + and GFAP + cells were increased in the cortex and hippocampus of TBI models. Iba1 + cells and GFAP + cells were remarkably decreased in PLX3397 or hNTSC-treated TBI models. Administration of PLX3397 attenuated the decrease in neurobehavioral activity. Similar effects were observed in a TBI model with a single dose of hNTSC.

CONCLUSION

Intranasal administration of hNTSCs had a microglia-depleting effect. Administered hNTSCs were found around the cortex and hippocampus of TBI brains. This investigation may provide a promising path for therapeutic initiatives for repetitive and mild TBI.

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.

Physiological outcomes of physical activity interventions in persistent postconcussive symptoms: a scoping review protocol

There are limited therapeutic options for patients with persistent postconcussive symptoms (PPCSs). Most PPCS assessments focus on subjective measures of progression and symptom monitoring. While early exercise interventions for rehabilitation are now considered best practice for acute concussion, no comprehensive review exists on how physical activity objectively and physiologically affects outcomes in PPCS. This scoping review protocol outlines the methods to identify the efficacy of therapeutic exercise interventions for PPCS, emphasising their impact on physiological parameters, including cardiovascular autonomic responses and cerebral autoregulation. Using the Patient, Intervention, Comparison and Outcome (PICO) framework, we will include all studies presenting original data. Narrative summaries will provide clinicians. An initial search in Medline/EMBASE/PubMed, Cochrane Library, PsycINFO, Web of Science and Scopus will be completed. Key parameters from each study will be extracted, tabulated and discussed in a narrative inquiry. The study references will be reviewed for additional studies meeting the inclusion criteria. Future research applications from the findings will be emphasised. After completion of the review, the results will be stratified by type of physical activity as the intervention, emphasising the physiological outcomes. Mapping these findings will allow us to identify the key research priorities for future studies. Findings will be shared with PPCS practitioners and local/national committees and submitted for conferences and publications.

Shorter Telomere Length Is Associated With Older Age, Poor Sleep Hygiene, and Orthopedic Injury, but Not Mild Traumatic Brain Injury, in a Cohort of Canadian Children

BACKGROUND

Predicting recovery following pediatric mild traumatic brain injury (mTBI) remains challenging. The identification of objective biomarkers for prognostic purposes could improve clinical outcomes. Telomere length (TL) has previously been used as a prognostic marker of cellular health in the context of mTBI and other neurobiological conditions. While psychosocial and environmental factors are associated with recovery outcomes following pediatric mTBI, the relationship between these factors and TL has not been investigated. This study sought to examine the relationships between TL and psychosocial and environmental factors, in a cohort of Canadian children with mTBI or orthopedic injury (OI).

METHODS

Saliva was collected at a postacute (median 7 days) timepoint following injury to assess TL from a prospective longitudinal cohort of children aged 8 to 17 years with either mTBI (n = 202) or OI (n = 90), recruited from 3 Canadian sites. Questionnaires regarding psychosocial and environmental factors were obtained at a postacute follow-up visit and injury outcomes were assessed at a 3-month visit. Univariable associations between TL and psychosocial, environmental, and outcome variables were assessed using Spearman's correlation. Further adjusted analyses of these associations were performed by including injury group, age, sex, and site as covariates in multivariable generalized linear models with a Poisson family, log link function, and robust variance estimates.

RESULTS

After adjusting for age, sex, and site, TL in participants with OI was 7% shorter than those with mTBI (adjusted mean ratio = 0.93; 95% confidence interval, 0.89-0.98; P = .003). As expected, increasing age was negatively associated with TL (Spearman's r = -0.14, P = .016). Sleep hygiene at 3 months was positively associated with TL (adjusted mean ratio = 1.010; 95% confidence interval, 1.001-1.020; P = .039).

CONCLUSION

The relationships between TL and psychosocial and environmental factors in pediatric mTBI and OI are complex. TL may provide information regarding sleep quality in children recovering from mTBI or OI; however, further investigation into TL biomarker validity should employ a noninjured comparison group.

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 role of concussion history and biological sex on baseline concussion clinical profile symptoms in adolescent rugby players

BACKGROUND

Accurate concussion monitoring requires access to preinjury baseline data. This is particularly important in adolescent athletes who have a high risk of concussion and are prone to prolonged recovery. As Rugby Union is governed by similar laws for men and women, it is also an ideal population to rigorously examine the impact of biological sex on concussion symptoms.

AIMS

To evaluate self-reported concussion symptoms at baseline in adolescent rugby union players, and examine if subtype-specific symptoms are affected by concussion history and biological sex.

METHODS

Adolescent rugby union players aged 16-18 years were recruited during the 2022-2023 playing season. Participants completed a series of questionnaires covering post-concussion symptoms, concussion clinical profiles, anxiety, depression and fear avoidance behaviours. Independent variables of interest in analysis were biological sex and concussion history.

RESULTS

149 participants (75% male) were included. 42% (63/149) reported at least one previous concussion (average time since concussion: 18.7 months, range 1-72). Adolescents with a concussion history reported significantly higher scores than those with no history, across two clinical profiles (ocular and sleep), concussion symptom severity, and depression, all based on medium effect sizes (SMD 0.3-0.5). Females had significantly higher scores across cognitive/fatigue, ocular and sleep clinical profiles, concussion symptoms, anxiety and depression, each with large effect sizes (SMD > 0.5).

CONCLUSIONS

Concussion history and sex are associated with higher baseline scores on specific concussion clinical profile, concussion symptom severity, and anxiety symptoms. These findings highlight the importance of considering baseline differences when interpreting post-injury clinical profile symptoms in adolescent rugby players. (Trial registration: ACTRN12622000931774).

A study protocol for risk stratification in children with concussion (RSiCC): Theoretical framework, design, and methods

Research shows that one in five children will experience a concussion by age 16. Compared to adults, children experience longer and more severe postconcussive symptoms (PCS), with severity and duration varying considerably among children and complicating management of these patients. Persistent PCS can result in increased school absenteeism, social isolation, and psychological distress. Although early PCS diagnosis and access to evidence-based interventions are strongly linked to positive health and academic outcomes, symptom severity and duration are not fully explained by acute post-injury symptoms. Prior research has focused on the role of neuroinflammation in mediating PCS and associated fatigue; however relationship between inflammatory biomarkers and PCS severity, has not examined longitudinally. To identify which children are at high risk for persistent PCS and poor health, academic, and social outcomes, research tracking PCS trajectories and describing school-based impacts across the entire first year postinjury is critically needed. This study will 1) define novel PCS trajectory typologies in a racially/ethnically diverse population of 500 children with concussion (11-17 years, near equal distribution by sex), 2) identify associations between these typologies and patterns of inflammatory biomarkers and genetic variants, 3) develop a risk stratification model to identify children at risk for persistent PCS; and 4) gain unique insights and describe PCS impact, including fatigue, on longer-term academic and social outcomes. We will be the first to use NIH's symptom science model and patient-reported outcomes to explore the patterns of fatigue and other physical, cognitive, psychological, emotional and academic responses to concussion in children over a full year. Our model will enable clinicians and educators to identify children most at risk for poor long-term health, social, and academic outcomes after concussion. This work is critical to meeting our long-term goal of developing personalized concussion symptom-management strategies to improve outcomes and reduce disparities in the health and quality of life of children.

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.

New Insights Into Accelerometer-Measured Habitual Physical Activity and Sedentary Time During Early Recovery in Pediatric Concussion

PURPOSE

Concussion management is shifting away from a rest-is-best approach, as data now suggest that exercise-is-medicine for this mild brain injury. Despite this, we have limited data on habitual physical activity following concussion. Therefore, our objective was to quantify accelerometer-measured physical activity and sedentary time in children with concussion (within the first month of injury) and healthy controls. We hypothesized that children with concussion would be less active than their healthy peers.

METHODS

We performed a secondary analysis of prospectively collected accelerometer data. Our sample included children with concussion (n = 60, 31 females) and historical controls (n = 60) matched for age, sex, and season of accelerometer wear.

RESULTS

Children with concussion were significantly more sedentary than controls (mean difference [MD], 38.3 min/d, P = .006), and spent less time performing light physical activity (MD, -19.5 min/d, P = .008), moderate physical activity (MD, -9.8 min/d, P < .001), and vigorous physical activity (MD, -12.0 min/d, P < .001); these differences were observed from 8:00 AM to 9:00 PM. Sex-specific analyses identified that girls with concussion were less active and more sedentary than both boys with concussion (P = .010) and healthy girls (P < .010).

CONCLUSION

There is an activity deficit observed within the first month of pediatric concussion. Physical activity guidelines should address this while considering sex effects.

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.

The Role of Puberty and Sex on Brain Structure in Adolescents With Anxiety Following Concussion

BACKGROUND

Adolescence represents a window of vulnerability for developing psychological symptoms following concussion, especially in girls. Concussion-related lesions in emotion regulation circuits may help explain these symptoms. However, the contribution of sex and pubertal maturation remains unclear. Using the neurite density index (NDI) in emotion regulation tracts (left/right cingulum bundle [CB], forceps minor [FMIN], and left/right uncinate fasciculus), we sought to elucidate these relationships.

METHODS

No adolescent had a history of anxiety and/or depression. The Screen for Child Anxiety Related Emotional Disorders and Children's Depression Rating Scale were used at scan to assess anxiety and depressive symptoms in 55 concussed adolescents (41.8% girls) and 50 control adolescents with no current/history of concussion (44% girls). We evaluated if a mediation-moderation model including the NDI (mediation) and sex or pubertal status (moderation) could help explain this relationship.

RESULTS

Relative to control adolescents, concussed adolescents showed higher anxiety (p = .003) and lower NDI, with those at more advanced pubertal maturation showing greater abnormalities in 4 clusters: the left CB frontal (p = .002), right CB frontal (p = .011), FMIN left-sided (p = .003), and FMIN right-sided (p = .003). Across all concussed adolescents, lower NDI in the left CB frontal and FMIN left-sided clusters partially mediated the association between concussion and anxiety, with the CB being specific to female adolescents. These effects did not explain depressive symptoms.

CONCLUSIONS

Our findings indicate that lower NDI in the CB and FMIN may help explain anxiety following concussion and that adolescents at more advanced (vs less advanced) status of pubertal maturation may be more vulnerable to concussion-related injuries, especially in girls.

Longitudinal changes in brain metabolites following pediatric concussion

Concussion is commonly characterized by a cascade of neurometabolic changes following injury. Magnetic Resonance Spectroscopy (MRS) can be used to quantify neurometabolites non-invasively. Longitudinal changes in neurometabolites have rarely been studied in pediatric concussion, and fewer studies consider symptoms. This study examines longitudinal changes of neurometabolites in pediatric concussion and associations between neurometabolites and symptom burden. Participants who presented with concussion or orthopedic injury (OI, comparison group) were recruited. The first timepoint for MRS data collection was at a mean of 12 days post-injury (n = 545). Participants were then randomized to 3 (n = 243) or 6 (n = 215) months for MRS follow-up. Parents completed symptom questionnaires to quantify somatic and cognitive symptoms at multiple timepoints following injury. There were no significant changes in neurometabolites over time in the concussion group and neurometabolite trajectories did not differ between asymptomatic concussion, symptomatic concussion, and OI groups. Cross-sectionally, Choline was significantly lower in those with persistent somatic symptoms compared to OI controls at 3 months post-injury. Lower Choline was also significantly associated with higher somatic symptoms. Although overall neurometabolites do not change over time, choline differences that appear at 3 months and is related to somatic symptoms.

Early Life Stress Negatively Impacts Spatial Learning Acquisition and Increases Hippocampal CA1 Microglial Activation After a Mild Traumatic Brain Injury in Adult Male Rats

Early life stress (ELS) affects neurogenesis and spatial learning, and increases neuroinflammation after a pediatric mild traumatic brain injury (mTBI). Previous studies have shown that ELS has minimal effects in juveniles but shows age-dependent effects in adults. Hence, we aimed to evaluate the effects of ELS in adult male rats after an mTBI. Maternal separation for 180 min per day (MS180) during the first 21 post-natal (P) days was used as the ELS model. At P110, the rats were subjected to a mild controlled cortical impact injury (2.6 mm) or sham surgery. Spatial learning was evaluated in the Morris water maze (MWM) 14 days after surgery and both microglial activation and neurogenesis were quantified. The results indicate that MS180 + mTBI, but not control (CONT) + mTBI, rats show deficiencies in the acquisition of spatial learning. mTBI led to comparable increases in microglial activation in both the hilus and cortical regions for both groups. However, MS180 + mTBI rats exhibited a greater increase in microglial activation in the ipsilateral CA1 hippocampus subfield compared with CONT + mTBI. Interestingly, for the contralateral CA1 region, this effect was observed exclusively in MS180 + mTBI. ELS and mTBI independently caused a decrease in hippocampal neurogenesis and this effect was not increased further in MS180 + mTBI rats. The findings demonstrate that ELS and mTBI synergistically affect cognitive performance and neuroinflammation, thus supporting the hypothesis that increased inflammation resulting from the combination of ELS and mTBI could underlie the observed effects on learning.

Evidence of Ongoing Cerebral Microstructural Reorganization in Children With Persisting Symptoms Following Mild Traumatic Brain Injury: A NODDI DTI Analysis

Approximately 300-550 children per 100,000 sustain a mild traumatic brain injury (mTBI) each year, of whom ∼25-30% have long-term cognitive problems. Following mTBI, free water (FW) accumulation occurs in white matter (WM) tracts. Diffusion tensor imaging (DTI) can be used to investigate structural integrity following mTBI. Compared with conventional DTI, neurite orientation dispersion and density imaging (NODDI) orientation dispersion index (ODI) and fraction of isolated free water (FISO) metrics may allow a more advanced insight into microstructural damage following pediatric mTBI. In this longitudinal study, we used NODDI to explore whole-brain and tract-specific differences in ODI and FISO in children with persistent symptoms after mTBI (n = 80) and in children displaying clinical recovery (n = 32) at 1 and 2-3 months post-mTBI compared with healthy controls (HCs) (n = 21). Two-way repeated measures analysis of variance (ANOVA) and voxelwise two-sample t tests were conducted to compare whole-brain and tract-specific diffusion across groups. All results were corrected at positive false discovery rate (pFDR) <0.05. We also examined the association between NODDI metrics and clinical outcomes, using logistical regression to investigate the value of NODDI metrics in predicting future recovery from mTBI. Whole-brain ODI was significantly increased in symptomatic participants compared with HCs at both 1 and 2 months post-injury, where the uncinate fasciculus (UF) and inferior fronto-occipital fasciculus (IFOF) were particularly implicated. Using region of interest (ROI) analysis in significant WM, bilateral IFOF and UF voxels, symptomatic participants had the highest ODI in all ROIs. ODI was lower in asymptomatic participants, and HCs had the lowest ODI in all ROIs. No changes in FISO were found across groups or over time. WM ODI was moderately correlated with a higher youth-reported post-concussion symptom inventory (PCSI) score. With 87% predictive power, ODI (1 month post-injury) and clinical predictors (age, sex, PCSI score, attention scores) were a more sensitive predictor of recovery at 2-3 months post-injury than fractional anisotropy (FA) and clinical predictors, or clinical predictors alone. FISO could not predict recovery at 2-3 months post-injury. Therefore, we found that ODI was significantly increased in symptomatic children following mTBI compared with HCs at 1 month post-injury, and progressively decreased over time alongside clinical recovery. We found no significant differences in FISO between groups or over time. WM ODI at 1 month was a more sensitive predictor of clinical recovery at 2-3 months post-injury than FA, FISO, or clinical measures alone. Our results show evidence of ongoing microstructural reorganization or neuroinflammation between 1 and 2-3 months post-injury, further supporting delayed return to play in children who remain symptomatic. We recommend future research examining the clinical utility of NODDI following mTBI to predict recovery or persistence of post-concussion symptoms and thereby inform management of mTBI.

Early vs. delayed evaluation and persisting concussion symptoms during recovery in adults

Objective: Persisting concussion symptoms may adversely affect return to work and functioning in daily activities. This study compared adults who were initially evaluated < 30 days versus those evaluated ≥ 30 days following a concussion at a specialty concussion clinic to determine if delayed initial evaluation is associated with persisting symptoms during recovery. Method: Participants (N = 205) 18 years of age and older who sustained a concussion and presented to a North Texas Concussion Registry (ConTex) clinic were evaluated at two time points: initial clinical visit and three-month follow-up. Participants provided medical history, injury related information, and completed the Sport Concussion Assessment Tool-5 Symptom Evaluation, Generalized Anxiety Disorder 7-item scale (GAD-7), and Patient Health Questionnaire (PHQ-8). Participants were divided into two groups: early and delayed evaluation (±30 days post injury). Results: Number and severity of concussion symptoms were similar between both groups at their initial clinical visit. However, linear regression models showed that a delayed clinical evaluation was associated with a greater number and severity of concussion symptoms along with greater aggravation of symptoms from physical and cognitive activity at three-month follow-up. Conclusions: Individuals who sought care at specialty concussion clinics regardless of previous care 30 or more days following their injury reported more serious persisting concussion symptoms at three month follow-up than those who sought care sooner. Education to improve adults' recognition of concussions when they occur and obtaining earlier clinical evaluation may represent important opportunities in promoting better recovery and reducing persisting concussion symptoms.

From acute stress to persistent post-concussion symptoms: The role of parental accommodation and child's coping strategies

Background: Acute stress following mild Traumatic Brain Injury (mTBI) is highly prevalent and associated with Persistent Post-Concussion symptoms (PPCS). However, the mechanism mediating this relationship is understudied. Objective: To examine whether parental accommodation (i.e. parents' attempts to adjust the environment to the child's difficulties) and child's coping strategies mediate the association between acute stress and PPCS in children following mTBI. Method: Participants were 58 children aged 8-16 who sustained a mTBI and their parents. Children's acute stress (one-week post-injury) and coping strategies (three weeks post-injury), and parental accommodation (three weeks and four months post-injury) were assessed. Outcome measures included PPCS (four months post-injury) and neuropsychological tests of cognitive functioning (attention and memory). A baseline for PPCS was obtained by a retrospective report of pre-injury symptoms immediately after the injury. Results: Children's acute stress and negative coping strategies (escape-oriented coping strategies) and four-months parental accommodation were significantly related to PPCS. Acute stress predicted PPCS and attention and memory performance. Parental accommodation significantly mediated the association between acute stress and PPCS. Conclusions: Stress plays an important role in children's recovery from mTBI and PPCS. Parental accommodation mediates this relationship, and thus, clinical attention to parental reactions during recovery is needed.

Characteristics of Associated Injuries in Children and Teenagers With Craniofacial Fractures

The incidence of pediatric craniofacial fractures and heterogeneity of fractures is known to increase with age. This study aimed to determine the occurrence of associated injuries (AIs) to craniofacial fractures and identify differences in patterns of and predictors for AIs in children and teenagers. A 6-year retrospective cross-sectional cohort study was designed and implemented. The study population included 397 patients aged 19 years or less diagnosed with craniofacial fracture at Helsinki University Hospital from 2013 to 2018. Boys (71.0%) and teenagers (64.7%) were predominated. Associated injuries were more common in teenagers than children. Teenagers had more often AI in 2 or more organ systems. Assault and intoxication by alcohol were observed only in teenagers and predominantly boys. A total of 27.0% of all patients sustained AIs. In 18.1%, brain injury was reported. In children, motor vehicle accident (MVA) was an independent predictor for AI. In teenagers, independent predictors for AI were female sex, isolated cranial fracture, combined cranial fracture, and high-energy trauma mechanism. Injury patterns and AI related to craniofacial fractures in the pediatric population are age-specific, requiring multidisciplinary collaboration in the diagnosis, treatment, and follow-up of such trauma. Predictors for AIs increase in complexity with age, and the role of sex as a predictor is evident in teenagers.

Premature white matter microstructure in female children with a history of concussion

Childhood concussion may interfere with neurodevelopment and influence cognition. Females are more likely to experience persistent symptoms after concussion, yet the sex-specific impact of concussion on brain microstructure in children is understudied. This study examined white matter and cortical microstructure, based on neurite density (ND) from diffusion-weighted MRI, in 9-to-10-year-old children in the Adolescent Brain Cognitive Development Study with (n = 336) and without (n = 7368) a history of concussion, and its relationship with cognitive performance. Multivariate regression was used to investigate relationships between ND and group, sex, and age in deep and superficial white matter, subcortical structures, and cortex. Partial least square correlation was performed to identify associations between ND and performance on NIH Toolbox tasks in children with concussion. All tissue types demonstrated higher ND with age, reflecting brain maturation. Group comparisons revealed higher ND in deep and superficial white matter in females with concussion. In female but not male children with concussion, there were significant associations between ND and performance on cognitive tests. These results demonstrate a greater long-term impact of childhood concussion on white matter microstructure in females compared to males that is associated with cognitive function. The increase in ND in females may reflect premature white matter maturation.

Quality of Life after Brain Injury in Children and Adolescents (QOLIBRI-KID/ADO)-The First Disease-Specific Self-Report Questionnaire after Traumatic Brain Injury

The subjective impact of the consequences of pediatric traumatic brain injury (pTBI) on different life dimensions should be assessed multidimensionally and as sensitively as possible using a disease-specific health-related quality of life (HRQoL) instrument. The development and psychometrics of the first such self-report questionnaire for children and adolescents after TBI are reported here. Focus group interviews with children, adolescents, and their parents, cognitive debriefing, item pool generation and reduction using Delphi expert panels were performed. The resulting version was psychometrically tested on 300 individuals aged 8-17 years. After item reduction based on factor analyses, differential item functioning, reliability, and validity were investigated. The final 35 items were associated with six scales (Cognition, Self, Daily Life and Autonomy, Social Relationships, Emotions, Physical Problems). Internal consistency and construct validity were satisfactory. Health-related Quality of life (HRQoL) was significantly lower in older and in female participants, as well as those with cognitive disabilities, anxiety, depression and post-concussion symptoms, than in comparative groups. The new QOLIBRI-KID/ADO is a comprehensive, multidimensional, reliable, and valid instrument, comparable in content and items to the QOLIBRI adult version. Therefore, disease-specific HRQoL can now be measured across the lifespan and may support the amelioration of treatment, care, rehabilitation, and daily life of children and adolescents after TBI.

Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial

OBJECTIVES

To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs.

METHODS

Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care.

RESULTS

A total of 2878 unique patients (1164 female, 1713 male) aged 5-17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change - 23.76 min, 95% CI - 37.99, - 9.52). Total physician claims increased significantly at only 1 of 5 sites.

CONCLUSIONS

Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05095012.

Post-Concussive Symptoms in Preschool Children up to Three Months Post-Injury

BACKGROUND AND AIMS

Post-concussive symptoms (PCS) are central to the assessment and management of mild traumatic brain injury (mTBI); however, this remains poorly understood in children aged ≤5 years. The study aimed to explore individual PCS, pattern of parents' PCS report over time, proportion of symptomatic children, and variables associated with parents' report of PCS in their preschool child after a mTBI.

METHODS

Children aged 2-5 years with either a mTBI (n=13) or limb injury (n=6) were recruited from the emergency department (ED). Parent ratings of child PCS were assessed at ED presentation, at one month, and at three months post-injury. Injury (e.g. injury group, pain), child (e.g. pre-existing behavior, symptoms), and parent (e.g. parental stress, education) characteristics were considered when investigating variables that may be relevant to parent report of PCS.

RESULTS

The number of total, physical, and sleep PCS were significantly higher after mTBI, with a significant decrease in physical and sleep PCS over time. The proportion of symptomatic children was comparable between injury groups at each time point. Acute pain and pre-injury symptoms were significantly associated with parents' acute PCS report in the mTBI group. Further research is needed on variables that may be relevant to parents' PCS report at follow-up.

CONCLUSION

Preliminary findings suggest a general trauma response after a mTBI or limb injury, but acute physical and sleep PCS may help differentiate the injury groups. Injury and premorbid child variables may be relevant to parents' report of acute PCS in their child. Additional research is needed to investigate PCS in preschoolers and variables that may predict parents' PCS report.

Altered longitudinal structural connectome in paediatric mild traumatic brain injury: an Advancing Concussion Assessment in Paediatrics study

Advanced diffusion-weighted imaging techniques have increased understanding of the neuropathology of paediatric mild traumatic brain injury (i.e. concussion). Most studies have examined discrete white-matter pathways, which may not capture the characteristically subtle, diffuse and heterogenous effects of paediatric concussion on brain microstructure. This study compared the structural connectome of children with concussion to those with mild orthopaedic injury to determine whether network metrics and their trajectories across time post-injury differentiate paediatric concussion from mild traumatic injury more generally. Data were drawn from of a large study of outcomes in paediatric concussion. Children aged 8-16.99 years were recruited from five paediatric emergency departments within 48 h of sustaining a concussion (n = 360; 56% male) or mild orthopaedic injury (n = 196; 62% male). A reliable change score was used to classify children with concussion into two groups: concussion with or without persistent symptoms. Children completed 3 T MRI at post-acute (2-33 days) and/or chronic (3 or 6 months, via random assignment) post-injury follow-ups. Diffusion-weighted images were used to calculate the diffusion tensor, conduct deterministic whole-brain fibre tractography and compute connectivity matrices in native (diffusion) space for 90 supratentorial regions. Weighted adjacency matrices were constructed using average fractional anisotropy and used to calculate global and local (regional) graph theory metrics. Linear mixed effects modelling was performed to compare groups, correcting for multiple comparisons. Groups did not differ in global network metrics. However, the clustering coefficient, betweenness centrality and efficiency of the insula, cingulate, parietal, occipital and subcortical regions differed among groups, with differences moderated by time (days) post-injury, biological sex and age at time of injury. Post-acute differences were minimal, whereas more robust alterations emerged at 3 and especially 6 months in children with concussion with persistent symptoms, albeit differently by sex and age. In the largest neuroimaging study to date, post-acute regional network metrics distinguished concussion from mild orthopaedic injury and predicted symptom recovery 1-month post-injury. Regional network parameters alterations were more robust and widespread at chronic timepoints than post-acutely after concussion. Results suggest that increased regional and local subnetwork segregation (modularity) and inefficiency occurs across time after concussion, emerging after post-concussive symptom resolve in most children. These differences persist up to 6 months after concussion, especially in children who showed persistent symptoms. While prognostic, the small to modest effect size of group differences and the moderating effects of sex likely would preclude effective clinical application in individual patients.

Cognitive functions and symptoms predicting later use of psychiatric services following mild traumatic brain injury in school-age

OBJECTIVE

To investigate whether neuropsychological test performance or presence of some specific injury symptoms at 1-3 months following pediatric mild traumatic brain injury (mTBI) can help to identify the children at risk for developing post-traumatic psychiatric symptoms.

METHODS

Data from 120 children and adolescents aged 7-15 years, treated at Turku University Hospital between 2010 and 2016 due to mTBI, and who had undergone neuropsychological evaluation at 1-3 months following injury, were enrolled from the hospital records. Neuropsychological test performancesand injury symptom reports were retrospectively retrieved from the patient files.

RESULTS

Slow information processing speed (p = 0.044), emotion regulation deficit (p = 0.014), impulsivity (p = 0.013), verbal processing difficulties (p = 0.042) and headache (p = 0.026) were independent predictors for having later contact in psychiatric care.

CONCLUSIONS

Neuropsychological examination containing measure of information processing speed, injury symptom interview, and parental questionnaires on behavioural issues of the child at 1-3 months following mTBI seems to be useful in detecting children with risk for post traumatic psychiatric symptoms. Targeted support and guidance for this group of children and adolescents and their families are recommended to prevent the development of an unfavorable psychosocial outcome.

Findings from a Randomized Controlled Trial of SMART: An EHealth Intervention for Mild Traumatic Brain Injury

OBJECTIVE

The aim of this study was to examine the efficacy of the SMART (Self-Management After Recent Traumatic brain injury) program and potential moderators.

METHODS

Parallel randomized controlled trial (ClinicalTrials.gov Identifier: NCT03498495) was conducted. Eligibility criteria included treatment for mild traumatic brain injury in the emergency department and age 11-18 years. Participants were assigned equally to SMART (n = 35) or usual care (UC; n = 36). SMART included symptom monitoring and online modules supporting the return to activities and symptom management. Coping and quality of life (QoL) (primary outcomes) and post-concussive symptoms (secondary outcome) were assessed at baseline and weekly for 4 weeks.

RESULTS

Groups did not differ in coping, QoL, or return to pre-injury symptom levels at any time point. Problem-focused engagement (PFE) moderated group differences over time (p = .02). At high PFE, UC participants reported lower QoL at time 1 (effect size [ES] = 0.60); SMART participants did not report a decline at any point. At low PFE, SMART participants reported declining QoL from pre-injury to time 1 (ES = 0.68), whereas UC participants reported an increase from time 1 to 3 (ES = 0.56). PFE also moderated group differences on the Health and Behavior Inventory (HBI) cognitive (p = .02) and somatic symptom scales (p = .05). At high PFE, SMART participants reported a more rapid return to pre-injury levels than UC participants (p = .05). Resilience also moderated group differences in QoL and HBI cognitive recovery.

CONCLUSION

Effectiveness of the SMART app varied based on preinjury coping styles and resilience, underscoring the potential need to tailor treatments to individual characteristics.

Can quantitative susceptibility mapping help diagnose and predict recovery of concussion in children? An A-CAP study

BACKGROUND

Quantitative susceptibility mapping (QSM) is an MRI technique that is a potential biomarker for concussion. We performed QSM in children following concussion or orthopaedic injury (OI), to assess QSM performance as a diagnostic and prognostic biomarker.

METHODS

Children aged 8-17 years with either concussion (N=255) or OI (N=116) were recruited from four Canadian paediatric emergency departments and underwent QSM postacutely (2-33 days postinjury) using 3 Tesla MRI. QSM Z-scores within nine regions of interest (ROI) were compared between groups. QSM Z-scores were also compared with the 5P score, the current clinical benchmark for predicting persistent postconcussion symptoms (PPCS), at 4 weeks postinjury, with PPCS defined using reliable change methods based on both participant and parent reports.

RESULTS

Concussion and OI groups did not differ significantly in QSM Z-scores for any ROI. Higher QSM Z-scores within frontal white matter (WM) independently predicted PPCS based on parent ratings of cognitive symptoms (p=0.001). The combination of frontal WM QSM Z-score and 5P score was better at predicting PPCS than 5P score alone (p=0.004). The area under the curve was 0.72 (95% CI 0.63 to 0.81) for frontal WM susceptibility, 0.69 (95% CI 0.59 to 0.79) for the 5P score and 0.74 (95% CI 0.65 to 0.83) for both.

CONCLUSION

The findings suggest that QSM is a potential MRI biomarker that can help predict PPCS in children with concussion, over and above the current clinical benchmark, and thereby aid in clinical management. They also suggest a frontal lobe substrate for PPCS, highlighting the potential for QSM to clarify the neurophysiology of paediatric concussion.

Sex-specific differences in resting-state functional brain activity in pediatric concussion

Pediatric concussion has a rising incidence and can lead to long-term symptoms in nearly 30% of children. Resting state functional magnetic resonance imaging (rs-fMRI) disturbances are a common pathological feature of pediatric concussion, though no studies have explicitly examined sex-differences with respect to this outcome, precluding a sex-specific understanding of the functional neuropathology of pediatric concussion. Therefore, we performed a secondary data analysis of rs-fMRI data collected on children with concussion (n = 29) recruited from in a pediatric hospital setting, with greater than 12:1 matched control data accessed from the open-source ABIDE-II database. Seed-based and region of interest (ROI) analyses were used to examine sex-based rs-fMRI differences; threshold-free cluster enhancement (TFCE) and a family-wise error (FWE) corrected p-values were used to identify significantly different clusters. In comparing females with concussion to healthy females, groupwise differences were observed irrespective of seed selected. Notably, we observed (in order of largest effect) hypo-connectivity between the anterior cingulate cortex of the salience network and the thalamus and precuneus (TFCE = 1473.5, p-FWE < 0.001) and the cingulate gyrus (TFCE = 769.3, p-FWE = 0.009), and the seed (posterior cingulate cortex (PCC)) of the default mode network and the paracingulate gyrus (TFCE = 1275.7, p-FWE  < 0.001), occipital pole right (TFCE = 1045.0, p-FWE = 0.001), and sub-callosal cortex (TFCE = 844.9, p-FWE = 0.005). Hyper-connectivity was observed between the salience network seed and the cerebellum (TFCE = 1719.3, p-FWE < 0.001) and the PCC and the thalamus (TFCE = 1198.3, p-FWE < 0.001), cuneal cortex (1070.9, p-FWE = 0.001), and lateral occipital cortex left (TFCE = 832.8, p-FWE = 0.006). ROI analyses showed 10 and 5 significant clusters of hypo- and hyper-connectivity in females, respectively. Only one cluster of difference was found between males with concussion and healthy males on seed-based analyses, and 3 clusters on ROI analyses. There are alterations in rs-fMRI in females with concussion at one-month post-injury that are minimally present in males, which provides further evidence that recovery timelines in pediatric concussion may differ by sex.

Parents’/guardians’ experiences with their adolescents’ prolonged recovery from a sport-related concussion

Sport-related concussions (SRCs) occur at alarming rates among adolescents and evidence suggests that adolescents experience more severe and longer-lasting symptoms compared to other age groups. Developmentally, adolescence is a time when youth become less reliant on their parents, establish their personal identity, and rely more on other social support networks (e.g., peers, teammates). However, previous studies show that parents play a prominent role in the recovery process from an SRC, especially in situations where recovery is prolonged. The purpose of this study was to examine the lived experiences of parents/guardians of teens who were recovering from a concussion and whose symptoms were persistent. Participants ( N = 12) were individually interviewed to better understand how they navigated and advocated for their teen during their prolonged recovery. An inductive content analysis revealed eight thematic categories that were interpreted with a developmental lens: (a) difficulties enforcing cognitive and physical rest, (b) concerns about depression and isolation, (c) observing struggles with athletic identity, (d) feelings of frustration, helplessness, and stress, (e) challenges of a hidden injury, (f) decisions about returning to sport, (g) being lied to about symptoms, and (h) offering strategies and practical advice. The themes illustrate how challenging and complicated the recovery process can be for parents of teenagers in particular, which is supported in previous concussion studies and the broader developmental literature. These results reinforce the idea that taking a biopsychosocial approach to care is best in order to adequately support parents/guardians and adolescents during the SRC recovery process.

Persistent post-concussion symptoms in children: pre-injury social difficulties and acute stress reaction as risk factors

Following mild traumatic brain injury (mTBI) children usually experience one or more somatic, cognitive, and/or emotional-behavioral post-concussion symptoms (PCS). PCS may be transient, however for some children, persistent post-concussion symptoms (PPCS) might linger for months or years. Identifying risk factors for PPCS may allow earlier interventions for patients at greater risk. We examined pre-injury social difficulties and acute stress reaction as risk factors to PPCS in children. Participants were 83 children (aged 8-16) with mTBI. In a prospective follow-up, pre-injury social difficulties, 24-hours post-concussion symptoms, and acute stress reactions were tested as predictors of one-week and four-months PCS reports. Parents' reports, self-reports, and neurocognitive tests were employed. One-week PCS level was associated with acute stress, and not with 24-hours post-concussion symptoms or pre-injury social difficulties. Four-months PCS level was predicted by pre-injury social difficulties and 24-hours post-concussion symptoms, with no contribution of acute stress. Interestingly, less symptoms at 24-hour from injury were associated with a higher level of PCS at four months. Cognitive functioning at four months was predicted by acute stress, with no contribution of 24-hours post-concussion symptoms or pre-injury social difficulties. Cognitive functioning did not differ between children with and without PPCS. In conclusion, non-injury, socio-emotional factors (pre-injury social difficulties, acute stress) should be considered, alongside injury-related factors, in predicting recovery from mTBI. Pre-injury social difficulties and stress reaction to the traumatic event might pose an emotional burden and limit one's social support during recovery, thus require clinical attention in children following mTBI.

Somatization in Adolescents With Persistent Symptoms After Concussion: A Retrospective Chart Review

OBJECTIVE

After concussion, approximately 30% of adolescents experience symptoms that persist beyond 1 month postinjury. For some, these symptoms affect functioning, development, and quality of life. Somatization, where psychological distress contributes to physical symptoms, may contribute to persistent symptoms after concussion in some adolescents. Understanding how clinicians identify somatization in adolescents with persistent symptoms after concussion in practice is a critical next step in improving our understanding, identification, and subsequent treatment of somatization in this patient population. To address this, the investigators assessed and compared characteristics of adolescents with persistent symptoms after concussion with and without clinician-identified somatization.

METHODS

Participants were adolescents (N=94) referred for persistent symptoms after concussion to a specialty youth concussion clinic between January 2016 and May 2018. A retrospective chart review extracted demographic and injury characteristics, symptoms after concussion, school attendance, premorbid experiences, mental health, and medical service use. Participants with physician-identified somatization were compared with those without physician-identified somatization on these measures.

RESULTS

Adolescents with identified somatization had more severe and atypical neurological and psychiatric symptoms after concussion and more postinjury impairment in school attendance, were more likely to have a history of premorbid chronic pain or medically unexplained symptoms, and obtained more neuroimaging and health care after injury compared with those unaffected by somatization. They did not differ in mood or anxiety symptom self-reports.

CONCLUSIONS

This study identified characteristic differences and similarities in adolescents with and without clinician-identified somatization after a prolonged concussion recovery. These findings have the potential to improve clinical identification of somatization in youths following a concussion and may aid in treatment among this demographic group.

Hyperbaric oxygen therapy in children with post-concussion syndrome improves cognitive and behavioral function: a randomized controlled trial

Persistent post-concussion syndrome (PPCS) is a common and significant morbidity among children following traumatic brain injury (TBI) and the evidence for effective PPCS treatments remains limited. Recent studies have shown the beneficial effects of hyperbaric oxygen therapy (HBOT) in PPCS adult patients. This randomized, sham-control, double blind trial evaluated the effect of hyperbaric oxygen therapy (HBOT) on children (age 8–15) suffering from PPCS from mild-moderate TBI events six months to 10 years prior. Twenty-five children were randomized to receive 60 daily sessions of HBOT (n = 15) or sham (n = 10) treatments. Following HBOT, there was a significant increase in cognitive function including the general cognitive score (d = 0.598, p = 0.01), memory (d = 0.480, p = 0.02), executive function (d = 0.739, p = 0.003), PPCS symptoms including emotional score (p = 0.04, d = – 0.676), behavioral symptoms including hyperactivity (d = 0.244, p = 0.03), global executive composite score (d = 0.528, p = 0.001), planning/organizing score (d = 1.09, p = 0.007). Clinical outcomes correlated with significant improvements in brain MRI microstructural changes in the insula, supramarginal, lingual, inferior frontal and fusiform gyri. The study suggests that HBOT improves both cognitive and behavioral function, PPCS symptoms, and quality of life in pediatric PPCS patients at the chronic stage, even years after injury. Additional data is needed to optimize the protocol and to characterize the children who can benefit the most.

Exploring the relationship between resting state intra-network connectivity and accelerometer-measured physical activity in pediatric concussion: A cohort study

Our objective was to explore the association between resting state functional connectivity and accelerometer-measured physical activity in pediatric concussion. Fourteen children with concussion (aged 14.54 ± 2.39 years, 8 female) were included in this secondary data analysis of a larger study. Participants had neuroimaging at 15.3 ± 6.7 days post-injury and subsequently a mean of 11.1 ± 5.0 days of accelerometer data. Intra-network connectivity of the default mode network (DMN), sensorimotor network (SMN), salience network (SN), and fronto-parietal network (FPN) was computed using resting state functional MRI. We found that per general linear models, only intra-network connectivity of the DMN was associated with physical activity levels. More specifically, increased intra-network connectivity of the DMN was significantly associated with higher levels of subsequent accelerometer-measured light physical activity (F(2, 11) = 7.053, p = 0.011, Ra2 = 0.562; β = 0.469), moderate physical activity (F(2, 11) = 7.053, p = 0.011, Ra2 = 0.562; β = 0.725), and vigorous physical activity (F(2, 11) = 10.855, p = 0.002, Ra2 = 0.664; β = 0.79). Intra-network connectivity of the DMN did not significantly predict sedentary time. Therefore, these preliminary findings suggest that there is a positive association between the intra-network connectivity of the DMN and device-measured physical activity in children with concussion.

Family Burden in Adolescents With Refractory Postconcussion Symptoms

OBJECTIVE

A significant minority of adolescents will have persistent postconcussion symptoms after an injury, potentially having a negative impact on family functioning. However, the reasons for a family's negative impact are not clearly understood. The objective of this study was to determine whether preinjury/demographic factors, injury characteristics, and/or worse postinjury symptoms are associated with higher levels of family stress in youth with refractory postconcussion symptoms.

SETTING

Pediatric refractory concussion clinic in a tertiary care center.

PARTICIPANTS

A total of 121 adolescents (13-18 years old) who were 1 to 12 months postconcussion.

MEASURES

Primary outcome was the mean stress rating on the Family Burden of Injury Interview (FBII), a 27-item questionnaire rating the impact on a family as a result of an injury. Preinjury/demographic and injury details were collected. Youth and their parents also completed measures of postconcussion symptoms, depression, anxiety, and behavioral problems.

RESULTS

Participants had a mean age of 16.0 years (SD = 1.3), of which, 65% identified as female, and were on an average 5.2 months (SD = 2.4) postconcussion. FBII ratings were not significantly correlated with demographics, preinjury functioning, injury severity, duration of persistent postconcussion problems (ie, time since injury), or self-reported postconcussion symptoms. Greater family burden (higher FBII ratings) significantly correlated with worse parent-reported postconcussion symptoms, worse psychological functioning (self-reported depression, parent-reported anxiety, and depression), and worse behavioral functioning (parent-reported conduct problems and peer problems). A multiple linear regression model revealed that parent-perceived postconcussion cognitive symptoms (β = .292, t = 2.56, P = .012) and parent-perceived peer problems (β = .263, t = 2.59, P = .011) were significantly associated with family burden ( F8,105 = 6.53; P < .001; R2 = 0.35).

CONCLUSION

Families of youth with refractory postconcussion symptoms can experience a negative impact. The severity of reported family burden in those with slow recovery from concussion was significantly associated with parents' perception of their child's cognitive symptoms and peer problems. These results could provide support for family-based interventions in this population.

The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen

Traumatic brain injury (TBI) represents a major public health concern. Although the majority of individuals that suffer mild-moderate TBI recover relatively quickly, a substantial subset of individuals experiences prolonged and debilitating symptoms. An exacerbated response to physiological and psychological stressors after TBI may mediate poor functional recovery. Individuals with TBI can suffer from poor stress tolerance, impairments in the ability to evaluate stressors, and poor initiation (and cessation) of neuroendocrine stress responses, all of which can exacerbate TBI-mediated dysfunction. Here, we pay tribute to the pioneering neuroendocrinologist Dr. Bruce McEwen by discussing the ways in which his work on stress physiology and allostatic loading impacts the TBI patient population both before and after their injuries. Specifically, we will discuss the modulatory role of hypothalamic-pituitary-adrenal axis responses immediately after TBI and later in recovery. We will also consider the impact of stressors and stress responses in promoting post-concussive syndrome and post-traumatic stress disorders, two common sequelae of TBI. Finally, we will explore the role of early life stressors, prior to brain injuries, as modulators of injury outcomes.

Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review

Objective

Concussion is a common yet heterogenous injury. Approximately 15-30% of cases present with persistent post-concussion symptoms (PPCS), continuing 4 weeks or more post-injury in children, youth, and adolescents, and 3 months or more in adults. There are known bidirectional links between PPCS and mental health outcomes. The focus of this scoping review is to explore the literature on mental health outcomes in individuals experiencing PPCS. Research objectives were to explore: (1) the mental health outcomes of individuals with PPCS and types of assessments used to identify mental health outcomes this group, and (2) how mental health outcomes compare in terms of similarities and differences among pediatric and adult populations with PPCS.

Method

Ovid MEDLINE; EMBASE; CINAHL, and PsycInfo databases were searched. After title and abstract screening of 11,920 studies, 481 articles were reviewed. Twenty-five papers met inclusion criteria. Results were organized by mental health outcomes of pediatric and adult populations, separately.

Results

There was a significantly higher number of studies devoted to adult populations. Of the 25 studies, 19 (76%) focused on adults, while six (24%) focused on adolescents. In adult populations, studies focused on symptoms of: anxiety (n = 2), depression (n = 8), and anxiety and depression (n = 9). Two studies assessed other emotional outcomes (10.5%). Within pediatric populations, an equal number of studies explored symptoms of: anxiety (n = 2), depression (n = 2), and anxiety and depression (n = 2). No studies focused on other emotional outcomes. Studies ranged greatly in methods, design, and control group. Most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.

Discussion

This review contributes to the understanding of mental health outcomes in those experiencing PPCS. Mental health and PPCS requires greater attention in pediatric populations, and consider strategies for those experiencing PPCS and mental health impacts. Future studies should consider including a wider range of emotional outcomes in their design, not limited to anxiety and depression. Study results may lead to improvements and research in the identification, assessment, and management of PPCS and mental health.

Perceptions of Symptom Duration are Associated With Emotional Distress and Functioning in Adolescents With Protracted Concussion Recovery

 

Adolescents with persisting post-concussive symptoms often report high levels of emotional distress, which can impact their daily functioning. The associations between modifiable factors, such as perceptions of recovery, and emotional distress have not been investigated in this age group.

Objective

To evaluate perceptions about recovery duration (e.g., “my symptoms will last a long time”, “my symptoms will be permanent rather than temporary”) and its associations with emotional distress and functioning in children and adolescents with a slower post-concussive recovery.

Methods

Participants (N = 49, 69% girls, 11–17 years old, M = 15.8 years old, SD = 1.8) were recruited from a concussion clinic on average 7.7 months after injury (SD = 2.5). Measures included the Illness Perception Questionnaire Revised (perceived duration of symptoms only) to evaluate recovery expectations, the Health and Behavior Inventory (self and parent reports) to evaluate current post-concussive symptoms (cognitive and somatic symptoms), the emotional distress subscale of the Strengths and Difficulties Questionnaire (SDQ—self-report), and the emotional functioning subscale of the Pediatric Quality of Life Questionnaire (PedsQL—self-report).

Results

Regression analyses (linear models with all covariates entered at once) suggested that greater expectations for symptom persistence were significantly associated with higher emotional distress on both SDQ and PedsQL subscales, after controlling for post-concussive symptom severity and other confounds. Emotional distress/functioning was not associated with perceptions of symptom duration reported by parents, severity of post-concussive symptoms (self- and parent reports), age, number of concussions, time since injury, or a history of mental health concern or diagnosis (parent-reported).

Conclusions

This study suggests that pessimistic attitudes for recovery duration may be more strongly associated with emotional distress than current post-concussive symptom severity or a history of mental health concern or diagnosis.

Post-Concussive Orthostatic Tachycardia is Distinct from Postural Orthostatic Tachycardia Syndrome (POTS) in Children and Adolescents

Background: Orthostatic tachycardia (OT) affects some patients after concussion/mild traumatic brain injury (mTBI). In this study, we sought to identify the factors associated with increased risk for OT in patients with mTBI. Methods: We conducted a retrospective review of 268 patients (8-25 years) with mTBI/concussion to determine the prevalence of OT, defined as orthostatic heart rate change ≥40 bpm for those ≤19 years of age and ≥30 bpm on active standing test for those >19 years of age. Results: Among the study population, 7% (n = 19) exhibited post-concussive OT. The only significant difference between OT and non-OT groups was that history of prior concussion was more prevalent in the OT group. Conclusion: A substantial subset (7%) of concussion clinic patients exhibit OT. While POTS literature describes female and adolescent predominance, post-concussive OT had similar prevalence across age and gender groups in this study, suggesting that it may be distinct from POTS.

The effect of transcranial direct current stimulation on cognitive performance in youth with persistent cognitive symptoms following concussion: a controlled pilot study

OBJECTIVE

Explore the feasibility, tolerability, and early efficacy of transcranial direct current stimulation (tDCS) as a therapeutic intervention for youth with cognitive persistent post-concussion symptoms (PPCS).

HYPOTHESIS

tDCS improves performance on a dual task working memory (WM) paradigm in youth with cognitive PPCS.

PARTICIPANTS

Twelve youth experiencing cognitive PPCS.

DESIGN

A quasi-randomized pilot trial was used to explore the tolerability of, and performance differences on, a dual N-Back WM task paired with active or sham tDCS over 3 sessions.

MEASURES

Accuracy and reaction time on WM task and self-report of tDCS tolerability.

RESULTS

Trends toward increases in accuracy from Day 1 to 3 seen in both groups. Active tDCS group performed better than sham on Day 2 in N-Back level N2 (p = .019), and marginally better than the sham group on Day 3 in level N3 (p = .26). Participants reported tDCS as tolerable; compared to the active tDCS group, the sham group reported more "considerable" (p = .078) and "strong" symptoms (p = .097).

CONCLUSION

tDCS is a promising tool for enhancing WM performance and is a feasible and tolerable adjunct to behavioral interventions in youth with cognitive PPCS. A clinical trial to demonstrate efficacy is warranted.

Learning and Attention Deficit/Hyperactivity Disorders as Risk Factors for Prolonged Concussion Recovery in Children and Adolescents

OBJECTIVE

Examine pre-existing learning disorders (LD) and attention deficit/hyperactivity disorders (ADHD) as risk factors for prolonged recovery and increased symptomology following pediatric mild traumatic brain injury (mTBI).

METHODS

We conducted a retrospective cohort study of children/adolescents (5-17 years) with mTBI who presented to a Children's Minnesota Concussion Clinic between April 2018 and March 2019. Differences across strata of pre-existing conditions (present vs. absent) in time to recovery measures were estimated via Kaplan-Meier and Cox proportional hazards analyses and differences in symptom trajectories were examined via linear mixed-effects regression models. Regression models were adjusted for age, sex and other confounders.

RESULTS

In our cohort of 680 mTBI patients, those with LD (n = 70) or ADHD (n = 107) experienced significantly longer median durations of symptoms (58 and 68 days, respectively) than those without (43 days). Accordingly, LD was significantly associated with delayed symptom recovery (adjusted hazard ratio (aHR) = 1.63, 95% CI: 1.16-2.29), return to school (1.47, 1.08-2.00), and return to physical activity (1.50, 1.10-2.04). Likewise, ADHD was associated with delayed recovery (1.69, 1.28-2.23), return to school (1.52, 1.17-1.97) and physical activity (1.55, 1.19-2.01). Further, patients with LD or ADHD reported, on average, significantly more concussion symptoms and higher vision symptom scores throughout recovery versus those without. There was no evidence that concussion or vision symptom recovery trajectories varied over time between those with/without LD or ADHD (joint P-interactions > 0.05).

CONCLUSION

Pre-existing LD and ADHD are risk factors for prolonged and more symptomatic mTBI recovery in youth. These results can inform clinical concussion management and recovery expectations.

Cerebral Blood Flow Predicts Recovery in Children with Persistent Post-Concussion Symptoms after Mild Traumatic Brain Injury

Persistent post-concussion symptoms (PPCS) following pediatric mild traumatic brain injury (mTBI) are associated with differential changes in cerebral blood flow (CBF). Given its potential as a therapeutic target, we examined CBF changes during recovery in children with PPCS. We hypothesized that CBF would decrease and that such decreases would mirror clinical recovery. In a prospective cohort study, 61 children and adolescents (mean age 14 [standard deviation = 2.6] years; 41% male) with PPCS were imaged with three-dimensional (3D) pseudo-continuous arterial spin-labelled (pCASL) magnetic resonance imaging (MRI) at 4-6 and 8-10 weeks post-injury. Exclusion criteria included any significant past medical history and/or previous concussion within the past 3 months. Twenty-three participants had clinically recovered at the time of the second scan. We found that relative and mean absolute CBF were higher in participants with poor recovery, 44.0 (95% confidence interval [CI]: 43.32, 44.67) than in those with good recovery, 42.19 (95% CI: 41.77, 42.60) mL/min/100 g gray tissue and decreased over time (β = -1.75; p < 0.001). The decrease was greater in those with good recovery (β = 2.29; p < 0.001) and predicted outcome in 77% of children with PPCS (odds ratio [OR] 0.54, 95% CI: 0.36, 0.80; p = 0.002). Future studies are warranted to validate the utility of CBF as a useful predictive biomarker of outcome in PPCS.

Neurocognitive correlates of persisting concussion symptoms in youth

Many patients that experience a concussion have impairing symptoms that persist beyond typical recovery timeframes. Concussion symptoms often remit within a month, but persisting impairments are difficult to characterize and attribute to concussion given the poorly defined diagnostic criteria of post-concussion syndrome and inadequate understanding of the cognitive symptoms associated with this condition. The current study aims to clarify the cognitive profiles of school-aged concussion patients (n = 21; N = 36; 64% male) that have persisting symptoms to improve the clinical identification methods for this condition. Logistic regression was used to explore the importance of cognitive processing speed and working memory for identifying patients with persisting concussion symptoms (PCS). Additional exploratory analyses were conducted to clarify cognitive domains that may be impacted by having PCS. Findings indicate processing speed and working memory abilities alone are not adequate to identify patients with PCS. Further, measures of processing speed, fluid reasoning, working memory, and long-term retrieval together were found to be necessary to identify those who had a prior concussion with PCS. These findings indicate clinical neuropsychological batteries must include measures of these four cognitive domains when assessing school-aged patients with chronic symptoms that extend beyond three months following injury.

Post-concussive Signs and Symptoms in Preschool Children: A Systematic Review

Mild traumatic brain injury (mTBI) is common in children aged < 5 years, however, less is known about their experience of post-concussive signs and symptoms. This systematic review aims to identify post-concussive signs and symptoms experienced by preschool children up to 12 months post-injury, and to review the methods used to report this data. Relevant findings, including rates, progression, and possible predictors of post-concussive signs and symptoms were also identified. Databases (Ovid MEDLINE, EMBASE, PsycInfo, PubMed, Scopus) and reference lists were searched for relevant articles, which were screened based on specified criteria. Eleven articles met the inclusion criteria, being original studies published in English and presenting data on post-concussive signs and symptoms specific to preschool children with mTBI. Most reviewed studies investigated acute presentations of mTBI, and identified that preschool children demonstrate post-concussive symptoms (PCS) similar to other age groups. Post-traumatic amnesia duration of approximately one day was reported in preschool children following mTBI, as were changes in mood and behavior during the recovery period. Parents were the main informants, with data obtained through either interview or questionnaire. Review findings highlight the lack of empirical data regarding the presentation and progression of PCS in preschoolers following mTBI and evidence on how to best manage this group during recovery.

Neurocognitive Outcomes and Their Diffusion Tensor Imaging Correlates in Children With Mild Traumatic Brain Injury

This study aimed to assess the neurocognitive outcomes and their diffusion tensor imaging correlates in children (aged 6-16 years) with mild traumatic brain injury. This prospective analysis included 74 children with mild traumatic brain injury (52 boys; mean age: 9.5 [±2.7] years). Wechsler Intelligence Scale for Children-Indian adaptation (WISC-IV), Child Behavior Checklist, and Children's Sleep Habits Questionnaire were administered for 57 cases (at 3 months postinjury) and 51 controls of similar age. The findings of diffusion tensor imaging (done within 7 days of injury) were correlated with various WISC-IV indices. The presenting features at the time of injury were loss of consciousness (53%), confusion or disorientation (47%), and post-traumatic amnesia (10%). Other features in the acute phase included drowsiness (86%), headache (78%), balance problems (62%), nausea (47%), fatigue (45%), vomiting (35%), nasal or ear bleed (12%), sensitivity to sound and light (12%), etc. At 3 months postinjury, the children with mild traumatic brain injury performed poorly in terms of Intelligence Quotient, perceptual reasoning index, and processing speed index as compared to controls. Based on the Child Behavior Checklist, 17% of children with mild traumatic brain injury had internalizing behavioral problems in comparison with 4% of controls. Prevalence of poor sleepers in the mild traumatic brain injury cohort and controls was 12.3% and 2% respectively. Headache, reduced attention span, and fatigue were common postconcussion symptoms. There was a positive correlation between right uncinate fasciculus fractional anisotropy and verbal comprehension index (r = 0.32; P < .05).

White Matter Abnormalities Associated With Prolonged Recovery in Adolescents Following Concussion

Background: Concussion symptoms in adolescents typically resolve within 4 weeks. However, 20 - 30% of adolescents experience a prolonged recovery. Abnormalities in tracts implicated in visuospatial attention and emotional regulation (i.e., inferior longitudinal fasciculus, ILF; inferior fronto-occipital fasciculus, IFOF; uncinate fasciculus; UF) have been consistently reported in concussion; yet, to date, there are no objective markers of prolonged recovery in adolescents. Here, we evaluated the utility of diffusion MRI in outcome prediction. Forty-two adolescents (12.1 - 17.9 years; female: 44.0%) underwent a diffusion Magnetic Resonance Imaging (dMRI) protocol within the first 10 days of concussion. Based on days of injury until medical clearance, adolescents were then categorized into SHORT (<28 days; N = 21) or LONG (>28 days; N = 21) recovery time. Fractional anisotropy (FA) in the ILF, IFOF, UF, and/or concussion symptoms were used as predictors of recovery time (SHORT, LONG). Forty-two age- and sex-matched healthy controls served as reference. Higher FA in the ILF (left: adjusted odds ratio; AOR = 0.36, 95% CI = 0.15 - 0.91, P = 0.030; right: AOR = 0.28, 95% CI = 0.10 - 0.83, P = 0.021), IFOF (left: AOR = 0.21, 95% CI = 0.07 - 0.66, P = 0.008; right: AOR = 0.30, 95% CI = 0.11 - 0.83, P = 0.020), and UF (left: AOR = 0.26, 95% CI = 0.09 - 0.74, P = 0.011; right: AOR = 0.28, 95% CI = 0.10 - 0.73, P = 0.010) was associated with SHORT recovery. In additional analyses, while adolescents with SHORT recovery did not differ from HC, those with LONG recovery showed lower FA in the ILF and IFOF (P < 0.014). Notably, inclusion of dMRI findings increased the sensitivity and specificity (AUC = 0.93) of a prediction model including clinical variables only (AUC = 0.75). Our findings indicate that higher FA in long associative tracts (especially ILF) might inform a more objective and accurate prognosis for recovery time in adolescents following concussion.

Perceived Recovery and Self-Reported Functioning in Adolescents with Mild Traumatic Brain Injury: The Role of Sleep, Mood, and Physical Symptoms

Purpose: To determine the contributions of anxiety, depressive, and concussion symptoms and sleep quality to self-perceived recovery in adolescents with concussion.Method: Adolescents aged 12-20 (n = 298) completed anxiety, depression, concussion symptoms, and sleep measures at an initial concussion clinic visit and three-month follow-up. At follow-up, they reported self-perceived recovery as percent back to normal.Results: Injury-related factors alone did not predict self-perceived recovery (R²_Adj =.017, p =.074). More concurrent physical, mental health, and sleep symptoms explained 18.8% additional variance in poorer self-perceived recovery (R²_Adj Change =.188, p <.05). Physical symptoms (B_stand = -.292) and anxiety (B_stand = -.260) accounted for the most variance in self-perceived recovery.Conclusion: Post-concussive symptoms, in particular anxiety and self-reported physical symptoms, seem to characterize protracted recovery. Self-perceived recovery as an outcome measure may provide a more holistic understanding of adolescents' experiences after concussion.