Pediatric Concussion Research Articles

Effect of Cognitive and Physical Rest on Persistent Postconcussive Symptoms following a Pediatric Head Injury

To evaluate the effect of cognitive and physical rest on persistent postconcussive symptoms in a pediatric population. A prospective cohort study of 5- to 18-year-olds diagnosed with an acute concussion in a tertiary care pediatric emergency department was conducted from December 2016 to May 2019. Participants (n=119) were followed over 1month to track days off from school and sports and the development of persistent postconcussive symptoms (residual concussion symptoms beyond 1month). Participants were dichotomized into minimal (≤2) and moderate (>2) rest, based on days off from school and sports after a concussion. Univariate and multivariable logistic regression analyses were completed to examine associations with persistent postconcussive symptoms. Of the participants in our study, 24% had persistent postconcussive symptoms. Adolescent age, history of prolonged concussion recovery, and headache at presentation were associated with higher odds of persistent postconcussive symptoms in univariate analyses. In a multivariable logistic regression model, only adolescent age was associated with increased odds of persistent postconcussive symptoms. Compared with the minimal cognitive rest group, moderate cognitive rest did not decrease the odds of persistent postconcussive symptoms (aOR, 1.15; 95% CI, 0.44-2.99). Compared with the minimal physical rest group, moderate physical rest also did not decrease the odds of persistent postconcussive symptoms (aOR, 3.17; 95% CI, 0.35-28.78). Emerging evidence supports early return to light activity for recovery of acute pediatric concussion. Our study adds to this management approach as we did not find that rest from school and sports resulted in a decreased odds of persistent postconcussive symptoms.

Concussion Symptoms by Mechanism of Injury in Elementary School–Aged Children

Research in pediatric concussion has investigated mechanism of injury and symptom reporting separately, but there is no study that examines differences in symptom reporting across multiple mechanisms of injury in elementary school–aged children. The purpose of the study was to examine symptom presentation and determine if symptoms of concussed children in middle childhood differ based upon mechanism of injury. Participants included 104 children between the ages of 6 and 10 years enrolled from area concussion clinics within 30 days of injury. All participants completed an initial clinic visit that collected demographic and injury characteristics as well as measures of post-concussion symptoms, anxiety, and depression based on parent report. We grouped the participants based on mechanism of injury (sports related, fall, hit by object, and motor vehicle accident). There was a significant group difference for age (p = 0.02) and history of previous concussion. Headache, fatigue, and trouble concentrating were the most commonly reported symptoms (> 50% of sample). We found no significant group differences in reported symptoms, although sleep disturbance approached significance. We also found no significant differences for total post-concussion symptom counts or total scores on a screener for anxiety or depression. Overall, there were no symptom differences by mechanism of injury in this young age group; however, research with larger samples is needed to enhance knowledge of the physical and emotional sequelae of concussion in younger children and inform best practices for timely interventions.

Examining the effects of atopic disease on concussion recovery: a preliminary investigation to inform personalized care

Background: Predicting time-to-recovery in pediatric concussion patients is key to advancing the treatment paradigm of pediatric concussion from a reactive to proactive precision and personalized medicine approach. Recent epidemiologic research indicates a possible mechanistic overlap between concussion and atopic disease (i.e., allergic rhinitis, asthma, and eczema) via pathways implicated in the inflammatory response. The purpose of this study was to examine patients with concussion and atopic disease comorbidity to better elucidate mechanisms that underlie protracted recovery and better predict return to play (RTP) timelines following concussion injury. Method: Data from …

The Diagnostic And Prognostic Utility Of Dual-task Tandem Gait For Pediatric Concussion

BACKGROUND: Tandem gait performance is part of the Sports Concussion Assessment Tool (SCAT), but its diagnostic and prognostic value has not been fully assessed in pediatric concussion. PURPOSE: To determine the diagnostic and prognostic value of single-task and dual-task tandem gait by comparing performance of subjects with concussion relative to controls, as well as subjects who developed Persistent Post Concussion Symptoms (PPCS) and those who did not (No PPCS). METHODS: Subjects seen within 21 days of concussion and uninjured controls completed a single/dual-task tandem gait test battery and modified Balance Error Scoring System (mBESS) test. During the tandem gait test, subjects walked in a heel-toe manner along a 3m strip of fabric down and back as fast as possible. During dual-task trials, they completed a concurrent cognitive task. Outcomes included tandem gait time to completion, cognitive accuracy, and mBESS errors. Subjects with concussion were followed until symptom resolution and sub-grouped into those who developed PPCS (>28 d time to symptom resolution) vs. No PPCS. RESULTS: We evaluated 29 subjects with concussion who developed PPCS (mean age=15±2 years; 62% female; tested 12±6 days post-injury), 58 subjects with concussion who did not develop PPCS (mean age=14±3 years; 36% female; tested 8±5 days post-injury), and 58 controls (mean age= 16±1 years; 42% female). Subjects with concussion performed significantly worse than healthy controls on single-task tandem gait (24.4±12.6 vs. 14.9±3.6 s; p<0.001; area under curve [AUC]=0.85), dual-task tandem gait (33.3±14.9 vs. 20.6±7.1 s; p<0.001; AUC=0.84), dual-task cognitive accuracy (82.1±12.5 vs. 89.1±18.9 %; p=0.01; AUC=0.61), and mBESS (6.5±4.9 vs. 3.8±3.4 errors; p=0.001; AUC=0.68). The PPCS sub-group performed dual-task tandem gait significantly slower than the No PPCS group (38.8±17.7 vs. 30.6±12.7 s; p=0.016; odds ratio=1.04), but PPCS and No PPCS groups were not significantly different on other measures. CONCLUSIONS: Pediatric patients with concussion have impaired performance on balance and gait measures compared to healthy controls. Dual-task tandem gait test specifically showed diagnostic value for pediatric concussion and prognostic value in differentiating subjects who developed PPCS compared to those who did not.

The Relationship Of Subjective And Objective Sleep Measures In Pediatric Concussion

BACKGROUND: Sleep problems after concussion may impact recovery. Early research has primarily focused on subjective sleep measures; however, actigraphy data may help objectively understand sleep patterns after pediatric concussion. PURPOSE: To determine association between subjective and objective sleep measures among pediatric athletes with concussion. METHODS: Pediatric athletes evaluated within 14 days of concussion were given a wrist-worn activity tracker, to be worn full-time, including during sleep. During initial visit and follow up evaluation at clearance for return to play (RTP), athletes completed the Pittsburgh Sleep Quality Index (PSQI). PSQI measures included self-reported sleep duration, time spent in bed, and sleep quality, while activity tracker actigraphy data was used for objective sleep duration, time spent in bed and time spent in each sleep stage. RESULTS: A total of 12 individuals (mean age=15.0±1.8 yrs; 42% female) completed initial concussion evaluation (mean=7.4±3.3 days post-injury), and follow-up evaluation at RTP clearance (mean=21.7±18.9 days post-injury). There was no significant difference in amount of sleep recorded using self-reported (7.9±1.2 hrs) and actigraphy (7.3±0.7 hrs) measures (p=0.10), or for amount of time spent in bed per night (8.8±1.6 vs. 8.2±0.7 hrs; p=0.25). Self-reported and actigraphy measures were highly and significantly correlated for amount of sleep per night (r=0.73; p=0.04) but not for amount of time spent in bed (r=0.59; p=0.12). Participants spent an average of 12±3% awake, 20±4% in REM sleep, 51±4% in light sleep, and 17±2% in deep sleep per night. Those who reported very good sleep quality on PSQI at RTP clearance visit had significantly more time in deep sleep (17.9±1.2% vs. 16.0±0.8% of the night; p=0.04) and significantly less time in light sleep (48.4±1.8% vs. 52.8±2.9% of the night; p=0.04) than those who reported fairly good or fairly bad sleep quality. CONCLUSIONS: There was no difference in subjective and objective measures for sleep duration and time spent in bed. Actigraphy data was highly correlated with self-reported measures for sleep duration following concussion. Minor differences in light and deep sleep proportions were present between pediatric athletes who reported very good sleep vs fairly good/fairly bad sleep quality.

Symptom severity and duration of recovery in pediatric patients with concussion

Purpose: We aimed to identify clinically meaningful Post-Concussion Symptom Scale (PCSS) scores in pediatric concussion patients relative to patients with referral orders and prolonged recovery. Prolonged recovery is defined as greater than 30 days to return-to-learn (RTL) and return-to-play (RTP). Methods: Patients aged 8-17 years reporting to a tertiary care concussion clinic were invited to participate from August 2014 through February 2018 in a prospective cohort study. Participant data collected through electronic medical records included PCSS at initial visit, ordered referrals (ophthalmology, physical therapy, occupational therapy, neuropsychology, child psychology, neurology, or other …

Benign Paroxysmal Positional Vertigo After Pediatric Sports-Related Concussion.

Report the clinical findings and outcomes among pediatric patients diagnosed with benign paroxysmal positional vertigo (BPPV) after sports-related concussion (SRC). Retrospective case series. Multidisciplinary pediatric concussion program. Patients younger than 19 years with a sport or recreation activity-related concussion referred for comprehensive vestibular physiotherapy assessment. Symptom resolution after targeted particle repositioning (PR). During the study period, 115 pediatric SRC patients underwent vestibular physiotherapy assessment including 12 (10.4%) who were diagnosed with BPPV. Unilateral posterior semicircular canal (SCC) BPPV was diagnosed in 8/12 (75%) patients, and unilateral anterior SCC BPPV diagnosed in 4/12 (25%) patients. Benign paroxysmal positional vertigo was successfully treated in all patients with a mean of 1.58 targeted PR maneuvers (range = 1-4). Comprehensive management of pediatric SRC requires a multidisciplinary approach to address the heterogeneous pathophysiology of persistent postconcussion symptoms. Pediatric SRC patients with coexisting BPPV should be considered for targeted PR.

Parental Beliefs and Expectations in Pediatric Concussion Assessment

Parental Beliefs and Expectations in Pediatric Concussion Assessment

A-18 Utility of the Child SCAT-5: Performance Differences Across Assessments in Pediatric Concussion

Abstract Objective In 2017, the Sport Concussion Assessment Tool-5 Child (Child SCAT-5) was introduced as a tool for clinicians to assess cognitive function and symptoms in children following a concussion (Davis, 2017; Echmendia, 2017); however, there are limited data supporting its use. The purpose of this study was to assess performance on the Child SCAT-5 among concussed pediatric patients (i.e., 5–9 years) across two clinic visits. Method Participants included 95 children (42.15% female) aged 5–9 years (7.42 +/− 1.12) who were diagnosed with a concussion within 30 days of injury (8.75 +/− 5.65 days). Patients underwent clinical interview and Child SCAT-5. Paired t-tests were used to compare measures on symptomatology, neurocognitive function, and balance performance between their first two clinical encounters (18.07 +/− 16.05 days). Results Analyses revealed significant improvements for immediate memory (p &amp;lt; 0.001) and delayed recall (p = 0.035), as well as improvements in symptom count (p &amp;lt; 0.001), symptom severity (p &amp;lt; 0.001), and back-to-normal rating (p = 0.004). Headaches (85.6%), feeling tired a lot (65.9%), getting tired easily (59.3%), difficulty concentrating (57.1%), and being distracted (54.9%) were the most commonly reported symptoms at patients’ initial clinic visit. Conclusions The findings from this study indicate that the Child SCAT-5 is useful for identifying common symptoms in pediatric patients tracking symptom improvement across clinic visits. The measure was also useful in identifying improvements in neurocognitive functioning in this population, particularly memory performance. Further research should focus on how the Child SCAT-5 and other pediatric-specific measures can assess and track improvement in clinical outcomes for this at-risk population.

Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department

BackgroundVisio-vestibular examination (VVE) deficits are common following pediatric concussion. Guidelines recommend assessing these deficits on all potentially concussed youth given their diagnostic and prognostic value, however test psychometrics of the VVE in the emergency department (ED) setting are unknown. Our objective was to determine the inter-rater (IRR) and test-retest reliability (TRR) of the VVE in a pediatric ED. MethodsWe enrolled 155 patients (112 IRR; 43 TRR) age 6–18 years with head injury presenting to the ED of a tertiary care children's hospital. Exams were performed by a group of 65 attending/fellow physicians, pediatricians, and advanced practice providers. The VVE consisted of 9 maneuvers (smooth pursuits, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, complex tandem gait). Cohen's kappa was calculated for IRR and TRR for each element. ResultsFor IRR, 5/9 kappas (saccades, gaze stability, monocular accommodation) were in the moderate agreement range (0.40 to 0.60); remaining kappas showed fair agreement. For TRR, 6/9 maneuvers (saccades, horizontal gaze stability, monocular accommodation, tandem gait) showed substantial agreement (0.60 to 0.80). Kappas of 7/9 elements for subjects age 15–18 showed improved IRR and TRR. ConclusionsThe individual elements of the VVE show fair to moderate agreement between providers and moderate to substantial agreement among the same provider in the ED setting. These findings suggest a role in the VVE in evaluating concussion acutely, particularly given its previously demonstrated ability to assist in risk stratification of concussed youth and the importance of early diagnosis for improved outcomes.

Improving subacute management of post concussion symptoms: a pilot study of the Melbourne Paediatric Concussion Scale parent report.

Aim:To pilot a modification of the Post Concussion Symptom Inventory, the Melbourne Paediatric Concussion Scale (MPCS) and examine its clinical utility.Materials & methods:A total of 40 families of concussed children, aged 8–18 years, were recruited from the emergency department. Parent responses to the MPCS in the emergency department and 2-weeks post injury determined child symptomatic status. Association between MPCS symptom endorsement and symptomatic group status was examined.Results:All additional MPCS items were endorsed by at least 25% of the parents of symptomatic children at 2 weeks. MPCS items were classified into nine symptom domains, with most falling in mood, neurological, autonomic and vestibular domains.Conclusion:The additional items and domain classifications in the MPCS have the potential to improve subacute diagnostic precision, monitoring of clinical recovery and identification of appropriate interventions post pediatric concussion.

Early Aerobic Exercise for the Treatment of Acute Pediatric Concussions

Sport-related concussion is a common injury that has garnered the attention of the media and general public because of the potential for prolonged acute symptoms and increased risk for long-term impairment. Currently, a growing body of evidence supports the use of various therapies to improve recovery after a concussion. A contemporary approach to managing concussion symptoms is to use aerobic exercise as treatment. To date, several studies on both pediatric and adult patients have established that controlled aerobic exercise is a safe and effective way to rehabilitate patients experiencing delayed recovery after concussion. However, less is known about the utility of an early exercise protocol for optimizing recovery after acute concussion and reducing the risk for persistent postconcussive symptoms, particularly in pediatric populations. Thus, the purpose of our paper was to review and evaluate the available literature on the implementation of aerobic exercise for the treatment of acute pediatric concussion.

Symptom Presentation After Concussion and Pre-existing Anxiety Among Youth Athletes.

Our purpose was to evaluate the effect of self-reported pre-injury anxiety diagnosis on persistent symptom development, vestibular symptom severity, and balance control among youth who sustained a concussion. We performed a retrospective study of patients seen at a specialty pediatric concussion clinic. Patients were 18 years of age or younger, examined within 10 days of concussion, and received care until full recovery. A questionnaire was used to assess pre-existing medical and psychiatric conditions, including anxiety. Our main outcomes were prolonged symptom recovery defined as persistent symptoms for > 28 days after concussion) and severity of vestibular symptoms. Patients who reported pre-injury anxiety (n=43; median age=14.9 years; 37% female) were more likely to experience symptoms>28 days post-injury (76 vs. 54%; p=0.04) than those without pre-existing anxiety (n=241; median age=14.9 years; 53% female). After adjusting for sex, history of migraine, depression and ADHD, however, there was no independent association between pre-existing anxiety and prolonged symptom duration (adjusted odds ratio=2.34; 95% CI=0.083-6.63; p=0.11). Pre-existing anxiety was independently associated with self-reported nausea/vomiting severity (β coefficient=0.59, 95% CI=0.07-1.11). A pre-existing anxiety diagnosis does not appear to be associated with persistent symptoms after concussion, although it may be associated with post-injury nausea.

4043 Saliva microRNA for pediatric concussion assessment

OBJECTIVES/GOALS: There is no objective, biologic tool to detect concussion or guide clinical management. We previously showed that saliva microRNA (miRNA) levels differ in children with concussion and may predict symptom duration. The purpose of this study was to validate the utility of saliva miRNA and define longitudinal trends during the recovery period. METHODS/STUDY POPULATION: We collected concussion symptom burden (SCAT-5), cognitive performance (DANA), balance measures (ClearEdge), and saliva from 150 children (7-21 years) with concussion over 5 time-points: 0-2, 3-6, 7-14, 15-29, and 30-60 days post-injury. Saliva miRNA levels within the 443 concussion samples were quantified with RNA sequencing and compared to 218 samples from age- and sex-matched controls (healthy and post-exercise participants). Non-parametric ANOVA assessed RNA levels across time-points, and between concussions/controls. Machine learning was used to build logistic regression algorithms differentiating concussions/controls, and symptomatic/recovered concussion participants. Relationships between miRNAs and concussion phenotypes were explored with Spearman’s Rank correlations. RESULTS/ANTICIPATED RESULTS: Fifteen miRNAs differed across control and concussion participants (FDR &lt; 0.05). Within concussion participants, all 15 miRNAs trended back toward control levels by 30-60 days post injury. A regression algorithm employing 6 of the 15 miRNAs differentiated control and concussion participants with an area under the curve (AUC) of 0.78 in a training set (n = 244) and 0.84 in a naïve test set (n = 24). Similarly, 6 miRNAs were able to differentiate symptomatic (SCAT-5 symptom score &gt; 7) and asymptomatic concussion participants with an AUC of 0.73 in a training set (n = 219) and 0.76 in a naïve test set (n = 44). Furthermore, 5 miRNAs showed significant (R &gt; 0.3; FDR &lt; 0.05) associations with subjective and/or objective measures of concussion-related symptoms. DISCUSSION/SIGNIFICANCE OF IMPACT: Saliva miRNAs levels are altered in children with concussion, and display predictable longitudinal trends following injury. Saliva miRNA measurement represents a non-invasive, objective tool that could be rapidly assessed to provide biologic evidence for clinicians managing pediatric concussion. CONFLICT OF INTEREST DESCRIPTION: I serve as a paid consultant and scientific advisory board member for Quadrant Biosciences, who has funded a portion of this work and licensed the findings from the Penn State College of Medicine.

Use of the sport concussion assessment tools in the emergency department to predict persistent post-concussive symptoms in children.

The Sport Concussion Assessment Tool v3 (SCAT3) and its child version (ChildSCAT3) are composite tools including a symptom scale, a rapid cognitive assessment (standardised assessment of concussion (SAC)) and the modified Balance Error Scoring System (mBESS). It is unclear whether their use for the acute assessment of paediatric concussion in the emergency department (ED) may help predict persistent post-concussive symptoms (PPCS). We aim to assess the predictive value of the main SCAT3/ChildSCAT3 components for PPCS when applied in the ED. A single-site, prospective longitudinal cohort study of children aged 5-18 years assessed within 48 h of their concussion at the ED of a state-wide tertiary paediatric hospital and followed up at the affiliated concussion clinic, between November 2013 and August 2017. PPCS was defined as ≥2 new or worsening symptoms at 1 month post-injury using the Post-Concussive Symptom Inventory. Of the 370 children enrolled, 213 (57.7% <13 years old) provided complete data. Of these, 34.7% had PPCS at 1 month post-injury (38.2% of children <13 years and 30.0% ≥13 years of age, P = 0.272). The adjusted ORs from multiple logistic regression models, for number and severity of symptoms, and for the SAC and mBESS performance in both the ChildSCAT3/SCAT3, were all not significant. The area under the curve of receiver operator characteristic curves for all analysed ChildSCAT3/SCAT3 components was below 0.6. Although SCAT3 and ChildSCAT3 are recommended tools to assist with concussion diagnosis and monitoring of patient recovery, their use in the ED does not seem to help predict PPCS.

Functional magnetic resonance imaging study of working memory several years after pediatric concussion

ABSTRACT Primary objective: The neurophysiological effects of pediatric concussion several years after injury remain inadequately characterized. The objective of this study was to determine if a history of concussion was associated with BOLD response differences during an n-back working memory task in youth. Research Design: Observational, cross-sectional. Methods and Procedures: Participants include 52 children and adolescents (M = 15.1 years, 95%CI = 14.4–15.8, range = 9–19) with past concussion (n = 33) or orthopedic injury (OI; n = 19). Mean time since injury was 2.5 years (95%CI = 2.0–3.0). Measures included postconcussion symptom ratings, neuropsychological testing, and blood-oxygen-dependent-level (BOLD) functional magnetic resonance imaging (fMRI) during an n-back working memory task. Main Outcomes and Results: Groups did not differ on accuracy or speed during the three n-back conditions. They also did not differ in BOLD signal change for the 1- vs. 0-back or 2- vs. 0-back contrasts (controlling for task performance). Conclusions: This study does not support group differences in BOLD response during an n-back working memory task in youth who are on average 2.5 years post-concussion. The findings are encouraging from the perspective of understanding recovery after pediatric concussion.

Child concussion recognition and recovery: a community delivered, evidenced-based solution.

Pediatric concussion is a growing health concern. Concussion is generally poorly understood within the community. Many parents are unaware of the signs and varying symptoms of concussion. Despite the existence of concussion management and return to play guidelines, few parents are aware of how to manage their child’s recovery and return to activities. Digital health technology can improve the way this information is communicated to the community. A multidisciplinary team of pediatric concussion researchers and clinicians translated evidence-based, gold-standard guidelines and tools into a smartphone application with recognition and recovery components. HeadCheck is a community facing digital health application developed in Australia (not associated with HeadCheck Health) for management of concussion in children aged 5–18 years. The application consists of (I) a sideline concussion check and (II) symptom monitoring and symptom-targeted psychoeducation to assist the parent manage their child’s safe return to school, exercise and sport. The application was tested with target end users as part of the development process. HeadCheck provides an accessible platform for disseminating best practice evidence. It provides feedback to help recognize a concussion and symptoms of more serious injuries and assists parents guide their child’s recovery.

P076: Assessment of a newly integrated and standardized approach for pediatric concussions aimed to improve the concussion recovery process

Introduction: Children with concussions presenting to emergency departments often receive very different recommendations for how to recover. In addition, there are no instructions for teachers to how children should return to learn and play after a concussion. Therefore, some children take too long to return to learn and play at school while others return too soon, thereby risking long-term problems because their brain injury is not fully healed. The purpose of this project is to determine the impact of a new integrated, standardized approach aimed to help a concussed child recover faster and whether the recovery experience for all involved has improved. Methods: Structured interviews were conducted with 11 parents of children treated for concussion at the Emergency Department of Pasqua Hospital in Regina, SK, four of whom received care after a change in practice whereby parents were provided with a return-to-school protocol form prior to discharge. Data were analyzed using an inductive qualitative content analysis approach using NVivo 12 software. Results: Three main categories were noted in the data: Parental response to the child's concussion, satisfaction with health services, and the communication amongst parents, physicians, and teachers. It was with regard to the last theme in particular that the impact of the return to school protocol was noted, helping to at least indirectly address the issue of the parent as the “middleman” in the communication triad. Most parents whose children received care prior to the introduction of the protocol suggested that providing written information at discharge to guide parents through the concussion recovery process would be helpful. Conclusion: Our initial results show a positive impact in regards to the process of children returning to learn and play after a concussion. Specifically, the increased communication between physician, teacher, and parent seems to benefit and improve the child's recovery process.

Sleep Symptoms Predict School Attendance After Pediatric Concussion.

This study examined the relationship between postconcussive symptom domain and school attendance. Retrospective chart review was completed for 88 children aged 6 to 18 years who were evaluated within 30 days postinjury. Hierarchical multiple regression was used to assess the association of physical, cognitive, emotional, and sleep symptoms with extent of school attendance. A subgroup multiple regression analysis was conducted to evaluate whether age affected the relationship of symptoms to school attendance. After controlling for demographic variables and total number of symptoms, a higher number of postconcussive sleep symptoms strongly predicted less school attendance. Specifically, older children (≥14 years old) with more sleep symptoms demonstrated less school attendance. For children presenting for specialty care after concussion, sleep symptoms are unfavorably associated with return to school. Future work aimed at optimizing sleep regulation following concussion may assist with early reengagement in school as recommended by current concussion management guidelines.

The prevalence of concentration deficits in pediatric concussion patients (2503)

The prevalence of concentration deficits in pediatric concussion patients (2503)