Pediatric Concussion Research Articles

Case Study: Neuropsychology-Informed Brief Intervention for Persisting Symptoms after Pediatric Concussion in a Multi-Disciplinary Clinic Setting

Case Study: Neuropsychology-Informed Brief Intervention for Persisting Symptoms after Pediatric Concussion in a Multi-Disciplinary Clinic Setting

Return to Play Guidelines in Pediatric Concussion: A Systematic Review of Current Literature.

Pediatric concussions, particularly in youth sports, are a significant public health concern, with up to 18% of children experiencing one by age 17. Return-to-play (RTP) guidelines aim to protect athletes from the adverse effects of repeated injuries, but these protocols vary widely based on factors such as age, sport, and geography. This review synthesizes current literature on RTP guidelines for pediatric concussions to provide evidence-based recommendations. A systematic search of PubMed was conducted using Medical Subject Headings (MeSH) terms "return to play," "pediatric concussion," and "mild traumatic brain injury." Studies published between January 2000 and December 2023 were included if they focused on RTP protocols for children aged 5 to 17. After screening 60 articles, 45 were selected for review. Study quality was assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. RTP protocols showed significant variability influenced by age, gender, and sport type. Common themes included initial rest followed by a gradual return to activity. Female athletes generally required longer recovery periods. Multidisciplinary care and early therapeutic interventions, such as vestibular therapy, were associated with better outcomes and faster recovery. There is a need for standardized, evidence-based RTP guidelines to address inconsistencies in concussion management. Future research should focus on creating universally applicable protocols, with attention to gender, sport-specific factors, and early intervention to improve recovery outcomes for young athletes.

The Role of Body Mass Index on Physical Activity, Symptoms, and Related Outcomes Following Pediatric Concussion

To determine the step count and self-reported activity levels for obese and non-obese pediatric patients following concussion and predict self-reported symptoms, quality of life, and psychological health over time. Participants completed the Post-Concussion Symptom Scale (PCSS), Pediatric Quality of Life (PedsQL), and Behavioral Symptom Inventory-18 (BSI-18) at an initial visit (<72 hours), 3-5 days post-injury, 10-18 days post-injury, and 1 and 2 months post-injury. Physical activity data (eg, step count) were collected via a commercial actigraph. Participants were categorized into obese and non-obese body mass index (BMI) groups based on age- and sex-adjusted growth standards. Mann Whitney U tests compared groups while nonparametric series regression models examined the effect of obese BMI and average daily step count on PCSS, PedsQL, and BSI-18 outcomes at 1- and 2-months post-injury. 194 participants were included: 153 (78.9%; M=14.6 ± 2.4 years; 50% female) in the non-obese group and 41 (21.1%; M=14.2 ± 2.0 years; 44% female) in the obese group. The obese group had a 22.8% lower average daily step count in the week post-injury (p=0.02). At 2-months, there was a significant association between obese BMI and worse PCSS total score (p=0.042), PedsQL (p=0.017), and BSI-18 anxiety (p=0.046). Average daily step count in the first week post-injury was associated with a higher PCSS total score at 2 months (p=0.031). Pediatric patients following concussion with an obese BMI had a lower daily average step count in the week after injury and exhibited worse concussion symptoms, quality of life, and anxiety at 2 months compared with those with a non-obese BMI.

Loss to follow-up at pediatric concussion clinic, an important area of study

Loss to follow-up at pediatric concussion clinic, an important area of study

Role of nonpharmacological concussion management in children: systematic review of randomized controlled trials.

Concussion is a global public health problem that affects many children worldwide. Most patients present with postconcussion syndrome and normal brain imaging find- ings. Despite the high incidence of concussion in children, published research on nonpharmacological management is lacking and much more often concerns pharmacological interventions. This systematic review aimed to evaluate the role of nonpharmacological interventions in managing concussion based on randomized controlled trials. The PubMed, Scopus, Web of Science, and Cochrane data- bases were extensively searched for articles published between January 2013 and July 2023. A modified patient intervention, comparison, and outcome framework was used to construct the search strategy and eligibility criteria. Risk of bias was assessed using the Risk of Bias-2 tool. A total of 16 studies conducted between January 2013 and July 2023 were analyzed. Three studies were conducted in an acute care setting (<24-hour postinjury) involving rest, computer time, and doing nothing, while the other 13 studies were conducted in a chronic care setting (>24-hour postinjury) and included aerobic exercise, collaborative care intervention, cervical spine rehabilitation, education by physiotherapists, a hyperbaric oxygen therapy protocol, family intervention therapy, virtual reality, traditional occupational therapy, virtual rehabilitation, oculomotor control exercises, vestibular rehabilitation, coordination exercises, and balance exercises. This systematic review highlights the importance of nonpharmacological therapy in pediatric concussion cases. Active rehabilitation may yield promising outcomes. Another interesting approach may be useful in pediatric concussion management. How- ever, this systematic review shows a lack of high-quality literature supporting nonpharmacological pediatric con- cussion treatments.

Factors Associated with Loss to Follow-Up in Pediatric Concussion Patients after Initial Visit: A Retrospective Study at a Concussion Clinic

ObjectiveThe objective of this retrospective study is to identify factors associated with loss to follow-up for post-concussion clearance in pediatric patients by comparing loss to follow-up and full clearance patients. MethodsThis retrospective single-center cohort study analyzed 140 consecutive patients at a pediatric concussion clinic of a safety-net hospital for loss to follow-up, defined as not achieving clearance at last appointment. Univariate and multivariate regression models were fit on variables of interest, including demographic, mechanism and severity of concussion, and characteristics of the first evaluation post-concussion and follow-up management. ResultsOf the sample, 40% (n=56) achieved clearance and 60% (n=84) were lost to follow-up. Median age was 15 (IQR 11-17), with male predominance (60.7%). Living with a biological parent (OR =0.145, 95% CI =0.028-0.760) and sports involvement (OR =0.256, 95% CI =0.092-0.764) were protective factors, while being 10 years old or older (OR = 13.466, 95% CI = 2.792-64.958) and attending 2 or fewer follow-up appointments (OR = 19.027, 95% CI = 4.991-72.533) were risk factors for loss to follow-up. No significant differences were found between sex, race, driving distance, type of insurance, and mechanism of injury. ConclusionLiving with a biological parent and involvement in sports showed to be protective factors for loss to follow-up. Age at time of concussion and number of appointments were risk factors. A “golden window” of two appointments was identified, highlighting the need of a strong rapport and engagement in shared decision making. Future directions include prospective studies implementing strategies targeting adolescents and building a strong patient-provider relationship.

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

Concussion, or mild traumatic brain injury, is a growing public health concern, affecting approximately 1.2% of the population annually. Among children aged 1-17 years, concussion had the highest weighted prevalence compared to other injury types, highlighting the importance of addressing this issue among the youth population. This study aimed to assess adherence to Return to Activity (RTA) protocols among youth with concussion and to determine if better adherence affected time to recovery and the rate of reinjury. Children and youth (N=139) aged 5-18 years with concussion were recruited. Self-reported symptoms and protocol stage of recovery were monitored every 48 hours until symptom resolution was achieved. Daily accelerometry was assessed with the ActiGraph. Data were collected to evaluate adherence to the RTA protocol based on physical activity cutoff points corresponding to RTA stages. Participants were evaluated using a battery of physical, cognitive, and behavioral measures at recruitment, upon symptom resolution, and 3 months post symptom resolution. For RTA stage 1, a total of 13% of participants were adherent based on accelerometry, whereas 11% and 34% of participants were adherent for stage 2 and 3, respectively. The median time to symptom resolution was 13 days for participants who were subjectively reported adherent to the RTA protocol and 20 days for those who were subjectively reported as nonadherent (P=.03). No significant agreement was found between self-report of adherence and objective actigraphy adherence to the RTA protocol as well as to other clinical outcomes, such as depression, quality of life, and balance. The rate of reinjury among the entire cohort was 2% (n=3). Overall, adherence to staged protocols post concussion was minimal when assessed with accelerometers, but adherence was higher by self-report. More physical activity restrictions, as specified in the RTA protocol, resulted in lower adherence. Although objective adherence was low, reinjury rate was lower than expected, suggesting a protective effect of being monitored and increased youth awareness of protocols. The results of this study support the move to less restrictive protocols and earlier resumption of daily activities that have since been implemented in more recent protocols.

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

This study aimed to identify Dizziness-Related Disability (DRD) recovery trajectories in pediatric concussion and assess clinical predictors of disability groups. In this prospective cohort study, 81 children (8-17 years) diagnosed with an acute concussion took part in 3 evaluation sessions (baseline, 3-month, and 6-month). All sessions included the primary disability outcome, the Dizziness Handicap Inventory (DHI) to create the DRD recovery trajectories using group-based multi-trajectory modeling analysis. Each independent variable included general patients' characteristics, premorbid conditions, function and symptoms questionnaires, and clinical physical measures; and were compared between the trajectories with logistic regression models. Low DRD (LD) trajectory (n = 64, 79%), and a High DRD (HD) trajectory (n = 17, 21%) were identified. The Predicting and Preventing Postconcussive Problems in Pediatrics (5P) total score (Odds Ratio (OR):1.50, 95% Confidence Interval (CI): 1.01-2.22), self-reported neck pain (OR:7.25, 95%CI: 1.24-42.36), and premorbid anxiety (OR:7.25, 95%CI: 1.24-42.36) were the strongest predictors of belonging to HD group. Neck pain, premorbid anxiety, and the 5P score should be considered initially in clinical practice as to predict DRD at 3 and 6-month. Further research is needed to refine predictions and enhance personalized treatment strategies for pediatric concussion.

Associations Between Changes in Psychological Resilience and Resting-State Functional Connectivity Throughout Pediatric Concussion Recovery.

Purpose: This study investigated the association between psychological resilience and resting-state network functional connectivity of three major brain networks in pediatric concussion. Methods: This was a substudy of a randomized controlled trial, recruiting children with concussion and orthopedic injury. Participants completed the Connor-Davidson Resilience 10 Scale and underwent magnetic resonance imaging at 72 h and 4-weeks postinjury. We explored associations between resilience and connectivity with the default mode network (DMN), central executive network (CEN), and salience network (SN) at both timepoints and also any change that occurred over time. We also explored associations between resilience and connectivity within each network. Results: A total of 67 children with a concussion (median age = 12.87 [IQR: 11.79-14.36]; 46% female) and 30 with orthopedic injury (median age = 12.27 [IQR: 11.19-13.94]; 40% female) were included. Seed-to-voxel analyses detected a positive correlation between 72-h resilience and CEN connectivity in the concussion group. Group moderated associations between resilience and SN connectivity at 72 h, as well as resilience and DMN connectivity over time. Regions-of-interest analyses identified group as a moderator of longitudinal resilience and within-DMN connectivity. Conclusions: These results suggest that neural recovery from concussion could be reliant on resilience. Resilience was related to functional connectivity with three of the main networks in the brain that are often impacted by concussion. Improving resilience might be investigated as a modifiable variable in children as both a protective and restorative in the context of concussion. Clinical Trial Registration Identifier: NCT05105802. PedCARE+MRI team (see Supplementary Appendix S1).

Follow-up visits after pediatric concussion and the factors associated with early follow-up: a population-based study in British Columbia.

To explore the rates and timing of a first follow-up visit for children and adolescents with a concussive injury and to identify factors associated with follow-up timing. A descriptive, correlational design drawing on linked, population-based administrative data of concussed children and adolescents (ages 5-18 years) from the province of British Columbia (BC), Canada. Data were accessed through Population Data BC. Descriptive statistics and binary logistic regression were used to analyze the data. From January 1, 2016 to December 31, 2017, we retrieved 22,601 cases of concussion, of which 19% had an early follow-up visit (N = 4,294), 4.9% had later follow-up (N = 1,107), and 76.1% had no follow-up (N = 17,200). The factors of older age, living in a rural area, higher socioeconomic status, and seeing a specialist physician at an initial concussion diagnosis were more likely to have an early follow-up visit. Early follow-up is important for recovery, but most children and adolescents with a concussion do not receive follow-up in BC.

Pediatric Concussions in Contact Sports: A 10-Year Retrospective Analysis of Mechanisms and Associated Symptoms.

Concussions make up a significant proportion of sports injuries. This study aimed to describe the mechanisms of injury and associated symptoms of pediatric patients diagnosed with concussions (age range, 4-17 years) from contact sports. Mechanisms of injury would differ based on sex and age, with female athletes and younger athletes aged 4 to 11 years sustaining fewer concussions from player-to-player contact. Descriptive epidemiology study. The National Electronic Injury Surveillance System was queried for all contact sport concussions presented to United States emergency departments. The sports analyzed included basketball, football, soccer, hockey, rugby, and lacrosse. Descriptive data, mechanisms of injury, and associated symptoms were analyzed for each sport. Differences in the number of concussions sustained by year and sport, the severity of the injury, and associated symptoms were compared using chi-square test, and differences in proportion were calculated for mechanisms of injury stratified by sex and age. A total of 12,602 youth athletes sustained concussions between 2012 and 2021. Most patients were male (78.5%), with a mean age of 13.48 years. Football concussions were the most common, with 45.32% of the concussions. The mechanism of injury was largely sport-specific, with player-to-player contact the most common overall. Older male athletes were more likely to have concussions from player-to-player contact, whereas younger athletes were more impacted by head-to-ground mechanisms. Symptom presentation was not sport-specific, and headache and dizziness were the most common presentation at 41.2% and 26.2%, respectively. The most important overall mechanism of injury was player-to-player contact, especially in older male youth athletes, whereas younger athletes were more likely to be concussed due to head-to-ground injuries.

Pediatric Snowboarding-Related Concussions and Musculoskeletal Injuries Decreased From 2012 to 2022

Pediatric Snowboarding-Related Concussions and Musculoskeletal Injuries Decreased From 2012 to 2022

Shared Decision-Making About Returning to Sport After Recovery From Pediatric Concussion: Clinician Perspectives.

Describe how sports medicine clinicians support decision making about sport participation after concussion recovery with adolescent patients and their parents. Specific areas of inquiry related to how clinicians framed the decision, what factors they considered in how they approached the decision process, and how they navigated discordance within families. Qualitative study. Tertiary care sports medicine clinics at 4 children's hospitals in the United States. Individual interviews were conducted with 17 clinicians practicing in sports medicine settings. N/A. Semi-structured interviews explored clinician approaches to supporting decision making, with the question guide informed by components of the Ottawa Decision Support Framework. Clinicians routinely incorporated aspects of shared decision making (SDM) into their conversations with families. This included ensuring all parties were informed about risk and aligned behind a shared value of adolescent well-being. Mediation strategies were used to manage discordance between adolescents and their parents, and between parents. These strategies aimed to facilitate a decision that was adolescent centered. When clinicians believed that there was a medical benefit to modifying the adolescent's sport participation practices, or when they did not believe the athlete was psychologically ready to return to the sport in which they were injured, they initiated conversations about alternative activities. In such situations, they used persuasive communication practices to encourage families to strongly consider this option. The strengths and strategies used by sports medicine clinicians in this study provide a foundation for guidance or intervention development aimed at supporting SDM after concussion with adolescents and their families.

A - 17 Pre-injury Predictors of Protracted Recovery from Pediatric Concussion: a Latent Class Analysis

Abstract Purpose This person-centered study examined pre-injury psychological and neurodevelopmental risk factors in youth experiencing persistent concussion symptoms (PCS). Latent class analysis (LCA) was used to empirically define groups of children and adolescents experiencing PCS, and compare their functional outcomes. Method 126 pediatric patients (Mean age = 15.94 years; 65.1% female) experiencing PCS (Mean time since injury = 315 days) participated in a clinical neuropsychological consultation and evaluation within the Minds Matter Concussion Program at Children’s Hospital of Philadelphia. LCA models were run using pre-injury variables (mood and anxiety concerns, attention and learning challenges). Functional outcomes (neuropsychological performance, academic decline, symptom magnification) were then compared across the resulting classes. Results Statistical indicators [Akaike Information Criteria (804.59), adjusted Bayesian Information Criteria (801.01), Bootstrap Likelihood Ratio Test (p &amp;lt; 0.001)] indicated that a two-class model provided the best fit. Class 1 (n = 58) was predominately females (78.3%) with comorbid pre-injury developmental (46.6% learning challenges, 54.6% attention concerns) and psychological concerns (75.6% anxiety, 48.9% mood concerns). Class 2 (n = 68) was half females (49.8%) with fewer comorbid pre-injury developmental (14.6% learning challenges, 22.5% attention concerns) and psychological concerns (39.3% anxiety, 0% mood concerns). The two classes did not significantly differ on functional outcomes. Standardized testing scores were within the average range across the sample. Conclusions Pre-injury risk factors contribute to persistent symptom experience and functional complaints in the absence of objective cognitive impairment. Given the incidence across groups, these findings highlight the importance of understanding psychological and neurodevelopmental factors, as well as sex-based differences when directing referrals and treatment of PCS within a multidisciplinary program.

A - 05 The Relationship between Child Opportunity and Self-Efficacy Following Pediatric Concussion

A - 05 The Relationship between Child Opportunity and Self-Efficacy Following Pediatric Concussion

A - 02 Time to Physical Therapy in Pediatric Concussion Patients Influences Recovery Outcomes

A - 02 Time to Physical Therapy in Pediatric Concussion Patients Influences Recovery Outcomes

White matter fiber morphology in persisting postconcussive symptoms and posttraumatic headache after pediatric concussion: a fixel-based analysis.

Posttraumatic headache (PTH) represents the most common acute and persistent postconcussive symptom (PCS) in children after concussion, yet there remains a lack of valid and objective biomarkers to facilitate risk stratification and early intervention in this patient population. Fixel-based analysis of diffusion-weighted imaging, which overcomes constraints of traditional diffusion tensor imaging analyses, can improve the sensitivity and specificity of detecting white matter changes postconcussion. The aim of this study was to investigate whole-brain and tract-based differences in white matter morphology, including fiber density (FD) and fiber bundle cross-section (FC) area in children with PCSs and PTH at 2 weeks after concussion. This prospective longitudinal study recruited children aged 5-18 years who presented to the emergency department of a tertiary pediatric hospital with a concussion sustained within the previous 48 hours. Participants underwent diffusion-weighted MRI at 2 weeks postinjury. Whole-brain white matter statistical analysis was performed at the level of each individual fiber population within an image voxel (fixel) to compute FD, FC, and a combined metric (FD and bundle cross-section [FDC]) using connectivity-based fixel enhancement. Tract-based Bayesian analysis was performed to examine FD in 23 major white matter tracts. Comparisons of 1) recovered (n = 27) and symptomatic (n = 16) children, and those with 2) PTH (n = 13) and non-PTH (n = 30; overall mean age 12.99 ± 2.70 years, 74% male) found no fiber-specific white matter microstructural differences in FD, FC, or FDC at 2 weeks postconcussion, when adjusting for age and sex (family-wise error rate corrected p value > 0.05). Tract-based Bayesian analysis showed evidence of no effect of PTH on FD in 10 major white matter tracts, and evidence of no effect of recovery group on FD in 3 white matter tracts (Bayes factor < 1/3). Using whole-brain fixel-wise and tract-based analyses, these findings indicate that fiber-specific properties of white matter microstructure are not different between children with persisting PCSs compared with recovered children 2 weeks after concussion. These data extend the limited research on white matter fiber-specific morphology while overcoming limitations inherent to traditional diffusion models. Further validation of our findings with a large-scale cohort is warranted.

Headache Characteristics of Pediatric Sport-Related Concussion.

Headache is among the most common symptoms following concussion, yet headache after concussion (HAC) remains poorly characterized. This study describes headache characteristics over the first four weeks following pediatric sport-related concussion. This is a retrospective case series of 87 athletes (mean: 14.9 years; range: 8.4-18.8 years; 38% female) treated in a specialty sports concussion clinic within 28 days of injury. Primary outcomes of headache consistency, frequency, duration, and associated migrainous symptoms were assessed at immediate (0 to 48 h) and weekly time points over the first 28 days post-injury. Generalized mixed linear models compared headache characteristics across time points. Secondary analyses compared each outcome by as-needed analgesic use. During the immediate post-injury period, headache was more often constant (p = 0.002) and associated with migrainous symptoms (p < 0.001). By the third week post-injury, episodic headache was more prevalent (p < 0.001). Most patients (54%) transitioned from constant, migrainous headache to episodic, non-migrainous headache. This finding was uninfluenced by as-needed analgesic medication use. These findings document the trajectory of HAC. Future studies should assess relationships between initial headache characteristics and recovery.

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

To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and nonsport or recreation-related concussion (non-SRRC) in patients 5 through 12years old, an understudied population in youth concussion. This observational study included patients aged 5 through 12years presenting to a specialty care concussion setting at ≤28days postinjury from 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Posthoc pairwise comparisons were employed for all analyses (α=0.017). One thousand one hundred forty-one patients reported at ≤28days of injury (female=42.9%, median age=11, interquartile range (IQR)=9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (P<.001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 2 and 3days later than SRC (P<.001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (P<.001) compared with RRC and SRC (P<.001). In concussion patients 5 through 12years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury.

The Concussion, Exercise, and Brain Networks (ConExNet) study: a cohort study aimed at understanding the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion

BackgroundRecent scientific evidence has challenged the traditional “rest-is-best” approach for concussion management. It is now thought that “exercise-is-medicine” for concussion, owing to dozens of studies which demonstrate that sub-maximal, graded aerobic exercise can reduce symptom burden and time to symptom resolution. However, the primary neuropathology of concussion is altered functional brain activity. To date, no studies have examined the effects of sub-maximal aerobic exercise on resting state functional brain activity in pediatric concussion. In addition, although exercise is now more widely prescribed following concussion, its cardiopulmonary response is not yet well understood in this population. Our study has two main goals. The first is to understand whether there are exercise-induced resting state functional brain activity differences in children with concussion vs. healthy controls. The second is to profile the physiological response to exercise and understand whether it differs between groups.MethodsWe will perform a single-center, controlled, prospective cohort study of pediatric concussion at a large, urban children’s hospital and academic center. Children with sport-related concussion (aged 12–17 years) will be recruited within 4-weeks of injury by our clinical study team members. Key inclusion criteria include: medical clearance to exercise, no prior concussion or neurological history, and no implants that would preclude MRI. Age- and sex-matched healthy controls will be required to meet the same inclusion criteria and will be recruited through the community. The study will be performed over two visits separated by 24–48 h. Visit 1 involves exercise testing (following the current clinical standard for concussion) and breath-by-breath gas collection using a metabolic cart. Visit 2 involves two functional MRI (fMRI) scans interspersed by 10-minutes of treadmill walking at an intensity calibrated to Visit 1 findings. To address sub-objectives, all participants will be asked to self-report symptoms daily and wear a waist-worn tri-axial accelerometer for 28-days after Visit 2.DiscussionOur study will advance the growing exercise-concussion field by helping us understand whether exercise impacts outcomes beyond symptoms in pediatric concussion. We will also be able to profile the cardiopulmonary response to exercise, which may allow for further understanding (and eventual optimization) of exercise in concussion management.Trial registrationNot applicable.