Persistent Post-concussion Symptoms Research Articles

Individual Symptom Report Prevalence in Children and Adolescents With One, Two, and Three or More Persistent Symptoms After Concussion: A Brief Report.

To examine differences in individual symptom report prevalence between children and adolescents experiencing 1 to 2 versus ≥3 persistent postconcussion symptoms. A prospective cohort study. Three community practice concussion clinics within a family practice network. Children and adolescents aged 8 to 18 years presenting to clinics within 72 hours of a sport-related or recreation-related concussion. Those with complete symptom data from a 1-month follow-up time point (n = 236) were included in analyses. One hundred thirty-six patients (n = 136) reported 0 symptoms as worse than preinjury at the 1-month time point. Participants reporting 1+ symptoms as worse than preinjury at 1 month were assigned to groups based on the number of symptoms endorsed: those with 1 to 2 (n = 38) compared with those experiencing ≥3 (n = 62). Fisher exact tests were used to compare symptom report prevalence for each item of the Rivermead Postconcussion Symptoms Questionnaire. This research question was formulated and examined after completion of data collection. Across both groups, headache and fatigue were the most commonly reported persistent postconcussion symptoms. Several emotional symptoms (eg, irritability, depression) were primarily or only present in those reporting ≥3 persistent symptoms. Findings provide detail regarding the clinical manifestation of experiencing fewer versus more persistent postconcussion symptoms, underscoring the importance of developing individualized, multifaceted rehabilitation programs.

Preoperative Pulmonary Rehabilitation to Prevent Postoperative Pulmonary Complications following Open Heart Surgery: A Narrative Review

Background: Numerous medical disciplines have recognized the preoperative period as a crucial phase to enhance patient recovery and outcomes. Patients perform preoperative pulmonary rehabilitation with inspiratory or expiratory muscle training to enhance lung protection. Despite the variety of breathing techniques in the clinical setting, the literature lacks a conclusive evidence regarding which technique is more effective. Research question: In adult patients undergoing open heart surgeries, is preoperative pulmonary rehabilitation of benefit in preventing postoperative pulmonary complications, shorten length of stay in the intensive care unit (ICU) or hospital? Methods: The authors conducted a search in electronic databases regarding the current evidence of preoperative pulmonary rehabilitation. Subjects: Patients undergoing Coronary Artery Bypass Grafts (CABG) and/or valvular surgery. Intervention: Any pulmonary intervention, such as incentive spirometer, inspiratory muscle training, exercise training or relaxation, delivered prior to surgery, single or combined. Outcome measures: The incidence of persistent post-concussion symptoms (PPCSs), pulmonary function test (PFT), ventilation period, length of stay in ICU and hospital Results: The authors conducted an initial search in the systematic reviews, which yielded 16 published articles. Furthermore, the authors search in the randomized controlled trials and this yielded 72 articles. The relevancy of the selected publications was determined by reviewing their titles, keyword, and abstracts. Overall a total of eight randomized controlled trials (RCTs) and six systematic reviews involving 3908 participants were included in this review. Conclusion: Preoperative pulmonary rehabilitation utilizing various breathing techniques reduces the incidence of postoperative pulmonary complications. Keywords Preoperative Care, Breathing Exercises, Postoperative Complications, Coronary Artery Bypass, Cardiac Surgery.

Responsiveness of the Post-Concussion Symptom Scale to Monitor Clinical Recovery After Concussion or Mild Traumatic Brain Injury.

Background:The Post-Concussion Symptom Scale (PCSS) is used to assess the number and intensity of symptoms after a concussion/mild traumatic brain injury. However, its responsiveness to monitor clinical recovery has yet to be determined.Purpose:To evaluate the responsiveness of the PCSS to change and longitudinal validity in patients with persistent postconcussive symptoms as well as to explore the responsiveness of other clinical outcome measures to monitor recovery of physical symptoms in patients with persistent postconcussive symptoms.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Patients with persistent symptoms after a concussion (N = 109) were evaluated using self-reported questionnaires at baseline and after a 6-week rehabilitation program. The program consisted of an individualized symptom-limited aerobic exercise program combined with education. Questionnaires included the PCSS, Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), and Numeric Pain Rating Scale (NPRS) related to 1) neck pain and 2) headache. Internal responsiveness was evaluated using the effect size (ES) and standardized response mean (SRM), and external responsiveness was determined with the minimal clinically important difference (MCID) calculated using a receiver operating characteristic curve. The global rating of change was used as the external criterion. Pearson correlations were used to determine the longitudinal validity.Results:The PCSS was highly responsive (ES and SRM, >1.3) and had an MCID of 26.5 points (of 132) for the total score and 5.5 (of 22) for the number of symptoms. For longitudinal validity, low to moderate correlations were found between changes in PCSS and changes in NDI, HDI, and DHI. The NDI, HDI, DHI, and NPRS were also highly responsive (ES and SRM, >0.8).Conclusion:All questionnaires including the PCSS were highly responsive and can be used with confidence by clinicians and researchers to evaluate change over time in a concussion population with persistent symptoms.

Persisting symptoms after concussion: Time for a paradigm shift.

Persisting symptoms after concussion: Time for a paradigm shift.

Long-term postural control in elite athletes following mild traumatic brain injury.

BackgroundTraumas to the head and neck are common in sports and often affects otherwise healthy young individuals. Sports-related concussions (SRC), defined as a mild traumatic brain injury (mTBI), may inflict persistent neck and shoulder pain, and headache, but also more complex symptoms, such as imbalance, dizziness, and visual disturbances. These more complex symptoms are difficult to identify with standard health care diagnostic procedures.ObjectiveTo investigate postural control in a group of former elite athletes with persistent post-concussive symptoms (PPCS) at least 6 months after the incident.MethodPostural control was examined using posturography during quiet stance and randomized balance perturbations with eyes open and eyes closed. Randomized balance perturbations were used to examine motor learning through sensorimotor adaptation. Force platform recordings were converted to reflect the energy used to maintain balance and spectrally categorized into total energy used, energy used for smooth corrective changes of posture (i.e., <0.1 Hz), and energy used for fast corrective movements to maintain balance (i.e., >0.1 Hz).ResultsThe mTBI group included 20 (13 males, mean age 26.6 years) elite athletes with PPCS and the control group included 12 athletes (9 males, mean age 26.4 years) with no history of SRC. The mTBI group used significantly more energy during balance perturbations than controls: +143% total energy, p = 0.004; +122% low frequency energy, p = 0.007; and +162% high frequency energy, p = 0.004. The mTBI subjects also adapted less to the balance perturbations than controls in total (18% mTBI vs. 37% controls, p = 0.042), low frequency (24% mTBI vs. 42% controls, p = 0.046), and high frequency (6% mTBI vs. 28% controls, p = 0.040). The mTBI subjects used significantly more energy during quiet stance than controls: +128% total energy, p = 0.034; +136% low-frequency energy, p = 0.048; and +109% high-frequency energy, p = 0.015.ConclusionAthletes with previous mTBI and PPCS used more energy to stand compared to controls during balance perturbations and quiet stance and had diminished sensorimotor adaptation. Sports-related concussions are able to affect postural control and motor learning.

Post-Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms after a Mild Traumatic Brain Injury.

Mild traumatic brain injury (mTBI) is a common problem. Depending on diagnostic criteria, 13 to 62% of those patients develop persistent post-concussion symptoms (PPCS). The main objective of this prospective multi-center study is to derive and validate a clinical decision rule (CDR) for the early prediction of PPCS. Patients aged ≥14 years were included if they presented to one of our seven participating emergency departments (EDs) within 24 h of an mTBI. Clinical data were collected in the ED, and symptom evolution was assessed at 7, 30 and 90 days post-injury using the Rivermead Post-Concussion Questionnaire (RPQ). The primary outcome was PPCS at 90 days after mTBI. A predictive model called the Post-Concussion Symptoms Rule (PoCS Rule) was developed using the methodological standards for CDR. Of the 1083 analyzed patients (471 and 612 for the derivation and validation cohorts, respectively), 15.6% had PPCS. The final model included the following factors assessed in the ED: age, sex, history of prior TBI or mental health disorder, headache in ED, cervical sprain and hemorrhage on computed tomography. The 7-day follow-up identified additional risk factors: headaches, sleep disturbance, fatigue, sensitivity to light, and RPQ ≥21. The PoCS Rule had a sensitivity of 91.4% and 89.6%, a specificity of 53.8% and 44.7% and a negative predictive value of 97.2% and 95.8% in the derivation and validation cohorts, respectively. The PoCS Rule will help emergency physicians quickly stratify the risk of PPCS in mTBI patients and better plan post-discharge resources.

Interdisciplinary Rehabilitation for Concussion Recovery (i-RECOveR): protocol of an investigator-blinded, randomised, case series with multiple baseline design to evaluate the feasibility and preliminary efficacy of a 12-week treatment for persistent post-concussion symptoms

BackgroundUp to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored.MethodsFifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews.DiscussionResults from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes.Trial registrationANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118

More Physical Activity Reduces Fear Of Movement For Adolescent Athletes With Persistent Post-concussion Symptoms

PURPOSE: Physical activity (PA) is recommended to improve concussion recovery time, however, fear of pain with movement (i.e., kinesiophobia) may limit activity. The relationship between PA and kinesiophobia during concussion recovery is unknown. Our purpose was to examine the correlation between PA level and kinesiophobia between initial evaluation and return to play (RTP) clearance among adolescents who did and did not experience persistent post-concussion symptoms (PPCS). METHODS: Participants rated kinesiophobia using the Tampa Scale of Kinesiophobia (TSK) at initial (≤14 days post-concussion) and RTP clearance visits. They wore activity monitors that quantified daily step count and exercise frequency and duration between initial and RTP clearance visits. Our primary outcome was TSK score change from initial to RTP visits. We analyzed participants separately based on whether they experienced PPCS (symptoms28 days) or not (symptoms28 days), and calculated correlation coefficients (Pearson r for normally distributed and Spearman rho for non-normally distributed variables) between each activity variable and TSK change scores. RESULTS: We enrolled 41 athletes ages 10-18 years diagnosed with concussion who were evaluated within 14 days post-concussion. Among our sample, 44% developed PPCS (n = 18; age = 14.5 ± 2.0 years; 50% female; symptom resolution = 57.3 ± 6.2 days, RTP = 66.8 ± 6.4 days) and 56% did not (n = 23; age = 14.9 ± 1.8 years; 48% female; symptom resolution = 15.2 ± 1.5 days; RTP = 21.7 ± 1.9 days). For the PPCS group, lower TSK change scores were significantly and moderately correlated with higher daily step count (r = -0.60, p = 0.008) and exercise frequency (r = -0.63, p = 0.005), but weakly and non-significantly correlated with exercise duration (rho = -0.12, p = 0.65). Among the no PPCS group, we found weak and non-significant correlations between activity variables and TSK change scores (step count: r = -0.18, p = 0.41; frequency: r = -0.34, p = 0.12; duration: rho = 0.10, p = 0.67). CONCLUSIONS: Higher daily step count and exercise frequency during concussion recovery are moderately correlated with greater reductions in kinesiophobia at RTP among those who experience PPCS. Regular PA during recovery, regardless of duration or intensity, may help reduce kinesiophobia for those with persistent symptoms.

A-16 More than Total Symptom Severity: Identifying Subtypes of Persistent Post-Concussion Symptoms using Normative Data

Abstract Objective: Prior factor analyses have supported the multidimensionality of post-concussion symptoms, but the symptom total score is often interpreted alone in practice. This study examined the added value of norm-referenced post-concussion symptom subscales to detect different subtypes of symptom presentations following concussion. Method: Adolescent student-athletes (N = 1008; 15.3 ± 1.4 years-old; 66.7% boys) with one or more prior concussions, at least 6 months post injury, completed the Post-Concussion Symptom Scale at preseason baseline. Severity ratings on four symptom subscales (i.e., cognitive, sleep-arousal, physical, and affective) were compared to normative data matched on gender and preexisting health conditions. The frequencies at which participants were elevated on one or more symptom subscales were calculated. Results: In the total sample, 21% of student-athletes were elevated on only one symptom subscale, 11% on two subscales, 8% on three subscales, and 6% on four subscales. Among student-athletes with a single elevated subscale, all symptom domains had similar frequencies of elevation. No differences in symptom elevations were found based on gender or number of prior concussions. Conclusion(s): A single-domain symptom elevation was the most common post-concussion symptom presentation among a cohort of adolescent student-athletes, with 26% of student-athletes elevated on a single subscale but not the total symptom score. These findings indicate that there are subtypes of post-concussion symptom presentations that would be missed through an interpretation of a total symptom severity score alone.

Interdisciplinary intervention (GAIN) for adults with post-concussion symptoms: a study protocol for a stepped-wedge cluster randomised trial

BackgroundPersistent post-concussion symptoms (PCS) are associated with prolonged disability, reduced health-related quality of life and reduced workability. At present, no strong evidence for treatments for people with persistent PCS exists. Our research group developed a novel intervention, “Get going After concussIoN (GAIN)”, that incorporates multiple evidence-based strategies including prescribed exercise, cognitive behavioural therapy, and gradual return to activity advice. In a previous randomised trial, GAIN provided in a hospital setting was effective in reducing symptoms in 15–30-year-olds with PCS 2–6 months post-injury. In the current study, we describe the protocol for a trial designed to test the effectiveness of GAIN in a larger municipality setting. Additionally, we test the intervention within a broader age group and evaluate a broader range of outcomes. The primary hypothesis is that participants allocated to enhanced usual care plus GAIN report a higher reduction in PCS 3 months post-intervention compared to participants allocated to enhanced usual care only.MethodsThe study is a stepped-wedge cluster-randomised trial with five clusters. The 8-week interdisciplinary GAIN program will be rolled out to clusters in 3-month intervals. Power calculation yield at least 180 participants to be enrolled. Primary outcome is mean change in PCS measured by the Rivermead Post-Concussion Symptoms Questionnaire from enrolment to 3 months after end of treatment. Secondary outcomes include participation in and satisfaction with everyday activities, labour market attachment and other behavioural measures. Self-reported outcomes are measured at baseline, by end of treatment and at 3, 6, and 18 months after end of treatment. Registry-based outcomes are measured up to 36 months after concussion.DiscussionThe trial will provide important information concerning the effectiveness of the GAIN intervention in a municipality setting. Furthermore, it will provide knowledge of possible barriers and facilitators that may be relevant for future implementation of GAIN in different settings.Trial registrationThe current GAIN trial is registered in ClinicalTrials.gov (study identifier: NCT04798885) on 20 October 2020.

The impact of the COVID‐19 pandemic on the well‐being of individuals with persistent postconcussive symptoms: A qualitative study

BackgroundIn response to the COVID‐19 pandemic, public health measures were implemented that closed essential businesses, mandated social distancing, and imposed substantial changes to the routine care experienced by patients with mild traumatic brain injury (mTBI) and persistent postconcussive symptoms (PPCS). Patients with PPCS often rely on a comprehensive care team, requiring in‐person treatments and consistent care. Little information exists regarding how access to these services have been affected by public health measures and what outcome the measures have had on the recovery of patients with PPCS.ObjectiveTo explore the impact of the restriction of in‐person treatments, shifts to virtual care, and global public health measures on the recovery and psychological well‐being of patients with PPCS.DesignQualitative interviews were recorded, transcribed, and analyzed using a reflexive thematic analysis approach to identify the main impacts of the public health measures on participants with PPCS.SettingParticipant interviews were completed remotely via telephone or video‐calling software during province‐wide shutdowns.Participants20 individuals with PPCS who attended the institution's Brain Injury Program consented to participate.InterventionsNot applicable.ResultsThe impacts of the public health measures emerged most prominently in three main categories: (1) day‐to‐day lived experiences, (2) personal health status, and (3) health service experiences and barriers.ConclusionsThis in‐depth investigation of the lived experiences of patients with PPCS outlines how the COVID‐19 public health measures negatively affected their care and well‐being. The analysis identified that through increasing social support systems, providing better access to standard or remote treatment, and developing more effective telehealth strategies, this population could be better supported in the event of future public health measures.

Eye Tracking Metrics Differences among Uninjured Adolescents and Those with Acute or Persistent Post-Concussion Symptoms.

Eye tracking assessments that include pupil metrics can supplement current clinical assessments of vision and autonomic dysfunction in concussed adolescents. This study aimed to explore the utility of a 220-second eye tracking assessment in distinguishing eye position, saccadic movement, and pupillary dynamics among uninjured adolescents, those with acute post-concussion symptoms (≤28 days since concussion), or those with persistent post-concussion symptoms (>28 days since concussion). Two hundred fifty-six eye tracking metrics across a prospective observational cohort of 180 uninjured adolescents recruited from a private suburban high school and 224 concussed adolescents, with acute or persistent symptoms, recruited from a tertiary care subspecialty concussion care program, 13 to 17 years old, from August 2017 to June 2021 were compared. Kruskal-Wallis tests were used, and Bonferroni corrections were applied to account for multiple comparisons and constructed receiver operating characteristic curves. Principal components analysis and regression models were applied to determine whether eye tracking metrics can augment clinical and demographic information in differentiating uninjured controls from concussed adolescents. Two metrics of eye position were worse in those with concussion than uninjured adolescents, and only one metric was significantly different between acute cases and persistent cases. Concussed adolescents had larger left and right mean, median, minimum, and maximum pupil size than uninjured controls. Concussed adolescents had greater differences in mean, median, and variance of left and right pupil size. Twelve metrics distinguished female concussed participants from uninjured; only four were associated with concussion status in males. A logistic regression model including clinical and demographics data and transformed eye tracking metrics performed better in predicting concussion status than clinical and demographics data alone. Objective eye tracking technology is capable of quickly identifying vision and pupillary disturbances after concussion, augmenting traditional clinical concussion assessments. These metrics may add to existing clinical practice for monitoring recovery in a heterogeneous adolescent concussion population.

A-24 Neurorehabilitation Improves Neuropsychological Symptoms in Active and Retired NFL Players

Abstract Purpose: The prevalence of concussions in the NFL have decreased since 2017, however, they still occur frequently with about 177 concussions occurring per season. Neuropsychological symptoms continue to persist long after these players are cleared to return to play. This could be because the underlying cause of these symptoms may have not fully been addressed through neurorehabilitation. Methods: A neurorehabilitation clinic treated 4 active or retired NFL players with symptoms relating to head injury obtained during participation in their sport. A 5-day, multi-modal neurorehabilitation program was administered in 10 one-hour treatment sessions. Each session consisted of a combination of photobiomodulation, repetitive peripheral somatosensory stimulation, neuromuscular reeducation, vestibular rehabilitation, orthoptic exercises, cognitive exercises, and/or off-vertical axis rotation utilizing a multi-axis rotational chair. Results: On intake, a SCAT5 graded symptom checklist was performed with symptoms falling into four domains: somatic, emotional, cognitive, and sleep. The average overall symptom severity score was 57.75, and the average severity of emotional domain symptoms (Nervousness/Anxiety, Irritability, Sadness, More Emotional) was 14.5. On average, emotional domain symptom severity score decreased by 82.76% compared to the 72.73% decrease in total symptom severity. Conclusions: This neurorehabilitation program has shown to be beneficial at decreasing the severity in both overall symptoms and emotional domain symptoms in NFL players with persistent post-concussion symptoms. The authors suggest further research be performed over larger player populations and in other contact sports.

A Remotely Delivered Progressive Walking Intervention for Adults With Persistent Symptoms of a Mild Traumatic Brain Injury: Feasibility and Exploration of Its Impact.

IntroductionPersistent post-concussion symptoms following a mild traumatic brain injury (mTBI) can impact function and participation of adults. Physical activity is recommended to reduce symptoms and foster return to normal activities. Adults with a mTBI may have personal factors or experience accessibility issues restricting physical activity. Walking is a physical activity accessible to most that could be delivered remotely.ObjectivesDetermine the feasibility, safety, and acceptability of a remotely delivered progressive walking intervention designed for adults with persistent mTBI symptoms and explore its effects on health-related outcomes.MethodologyThis feasibility study using a single-group pre-post mixed methods convergent parallel design was conducted remotely. Adults aged 18–65 years with a mTBI reporting persistent symptoms for ≥3 months were recruited. The 8-week remote progressive walking intervention aimed to increase the weekly number of steps walked by 40% based on a 1-week baseline measured by a Fitbit Inspire 2 activity monitor. Feasibility measures were about the intervention, its remote delivery, safety, and acceptability. Health-related outcomes were post-concussion symptoms, kinesiophobia, mood, sleep, fatigue, and quality of life. Semi-structured exit interviews were recorded and transcribed verbatim. Quantitative and qualitative data were analyzed separately, and results merged, compared, and contrasted. Descriptive statistics and paired samples t-tests were used. The qualitative analyses followed an iterative content analysis approach using reflexivity and triangulation of sources.ResultsTwenty adults (16 women) aged 42.5 ± 11.51 years with persisting symptoms for 9.25 ± 6.43 months participated, adhered to 94.38% of sessions, completed the intervention, and found it to be feasible, safe and acceptable. Participants increased weekly total number of steps walked (change = 14,886 ± 18,283; t = 3.55, p = 0.002). Severity of post-concussion symptoms (change = −6.42 ± 10.69; t = −2.62, p = 0.018), kinesiophobia (change = −5 ± 6.86; t = 3.18, p = 0.005), anxiety (change = −1.53 ± 3.01; t = −2.21, p = 0.04), and fatigue (change = −10.21 ± 10.20; t = −4.37, p < 0.001) were reduced, whilst quality of life improved (change = 10.58 ± 13.35; t = 3.46, p = 0.003). Participants' perceptions corroborate most quantitative results; they felt improved self-efficacy about physical activity and provided five key recommendations.DiscussionThis study demonstrates the feasibility, safety, and acceptability of the remote 8-week progressive walking intervention, a promising approach to reduce persisting symptoms, improve physical activity level health-related outcomes and quality of life of adults with persistent post-concussion symptoms following a mTBI.

Dysfunction of the stress response in individuals with persistent post-concussion symptoms: a scoping review

Background Preliminary evidence suggests that individuals with persistent post-concussion symptoms (PPCS) have a dysfunctional stress response, consisting of the autonomic nervous system (ANS) and hypothalamic pituitary adrenal-axis (HPA-axis). Objectives This review aims to explore the extent of evidence for dysfunction of the stress response in individuals with PPCS by individually mapping the literature surrounding quantifiable changes of the (1) ANS and (2) HPA-axis using non-invasive and clinical tools, and highlighting any (3) knowledge gaps. Methods Nine electronic databases and grey literature were searched on the 1st of June 2021 and 4th of October 2021. Studies were included if their population was classified with PPCS, and their study stated at least one quantifiable marker of the ANS or HPA-axis using non-invasive and clinical tools. Relevant studies were screened, and data extracted. Results A total of 37 articles were included in this scoping review. The majority of studies assessed quantifiable markers of the ANS (n = 34), in comparison to the HPA-axis (n = 2), and ANS and HPA-axis (n = 1). The most common quantifiable markers of the ANS included heart rate (n = 20), blood pressure (n = 16), and heart rate variability (n = 10). Cortisol was the only included quantifiable marker of the HPA-axis (n = 2). Conclusions Most of the evidence in this review supports quantifiable dysfunction of the ANS in those with PPCS. Further research is required investigating quantifiable dysfunction of the HPA-axis, and subsequently ANS and HPA-axis in unison, in those with PPCS.

Moving on from Concussion?

Close to a million children are evaluated emergently each year in the United States for traumatic brain injury, and most of these injuries are mild traumatic brain injury, or concussion. Symptoms, such as headache, fatigue, and dizziness, lasting more than four weeks are termed persistent post-concussive symptoms (PPCS) and can be quite disabling for children and adolescents. What proportion of children develop PPCS? In this issue of The Journal Chadwick et al present a systematic review to address this question. This particular meta-analysis was conducted rigorously with robust statistical methods, adhered to PRISMA and MOOSE guidelines, and deployed the Newcastle-Ottawa scales to address study quality. The estimated proportion of children with PPCS was 35.1% (95% CI 26.3% to 45.0%). This finding is striking. While this meta-analysis has limitations and is subject to underlying biases from studies often derived from specialty concussion clinics, we must acknowledge that perhaps more than 300 000 children each year experience PPCS, particularly teens and females. This finding highlights the burden that PPCS is placing on our health care and educational systems. While preventing concussion is a major children's health priority, such traumatic brain injury and PPCS have likely been highly prevalent for decades, long before the recent explosion of attention to and research on concussion in children. Interventions for PPCS are clearly needed for the reintegration of affected children back to school and daily activities. No matter how we consider the data, this meta-analysis makes clear that PPCS is common, and we need to develop ways for children to move on effectively from concussion. Article page 131

Physician recommended school accommodations and student outcomes following a mild traumatic brain injury among youth with persistent post-concussive symptoms.

BACKGROUND:Post-concussion return-to-learn (RTL) guidelines include implementation of school accommodations. Yet, little is known about physician recommendations for school accommodations and their impact, particularly among youth experiencing persistent post-concussive symptoms (PPCS).OBJECTIVE:We examined the association between physician recommended school accommodations and student outcomes among youth experiencing PPCS.METHODS:Data from a randomized comparative effectiveness trial was used. Physician recommended school accommodations (≤90 days post-injury) were collected via chart abstraction. Grade point average was extracted from school records. Reports of problems at school, concussion symptoms, health-related quality of life (HRQOL), anxiety symptoms, and depressive symptoms were collected by survey (at baseline, three months, and 12 months post study entry).RESULTS:Of 200 participants (Mage = 14.7, 62% female), 86% were recommended school accommodations. Number of recommended school accommodations was positively associated with number of school problems at three months (aRR 1.18, 95% CI:1.12–1.24) and 12 months (aRR 1.11, 95% CI:1.05–1.18). No significant associations were found between recommended school accommodations and GPA, HRQOL, anxiety symptoms, or depressive symptoms.CONCLUSIONS:Physicians recommend more school accommodations for students experiencing more school problems post-concussion. Appropriate implementation of RTL recommendations made by physicians by fostering partnerships among physicians, students, and schools may be needed to achieve student-centered RTL.

B.1 Can quantitative susceptibility mapping help diagnose and predict recovery of concussion in children?

Background: Quantitative susceptibility mapping (QSM) is an MR sequence that has potential as a biomarker in concussion. We compared QSM in pediatric concussion patients versus a comparison group of children with orthopedic injuries (OI) and assessed QSM’s performance relative to the current clinical benchmark (5P risk score) for predicting persistent postconcussion symptoms (PPCS). Methods: Children (N=967) aged 8-16.99 years with either concussion or OI were prospectively recruited from 5 Canadian centers. Participants completed QSM at a post-acute assessment 2-33 days post-injury. QSM z-score metrics for 9 regions of interest (ROI) were derived from 371 children (concussion=255, OI=116). PPCS at 1-month post-injury was defined using reliable change methods. Results: The concussion and OI groups did not differ significantly in QSM across ROI. Increased frontal white matter (WM) susceptibility predicted reliable increases in parent-rated cognitive symptoms (p=0.001). Together, frontal WM susceptibility and the 5P risk score were better at predicting persistent cognitive symptoms than the 5P risk score alone (p=0.0021). AUC were 0.71 (95%CI: 0.62-0.80) for frontal WM susceptibility, 0.67 (95%CI: 0.56-0.78) for the 5P risk score, and 0.73 (95%CI: 0.64-0.82) for both. Conclusions: This is the first study to demonstrate a potential imaging biomarker that predicts persistent symptoms in children with concussion compared to the current clinical benchmark.

Salivary miRNA Expression in Children With Persistent Post-concussive Symptoms.

BackgroundUp to one-third of concussed children develop persistent post-concussive symptoms (PPCS). The identification of biomarkers such as salivary miRNAs that detect concussed children at increased risk of PPCS has received growing attention in recent years. However, whether and how salivary miRNA expression levels differ over time between concussed children with and without PPCS is unknown.AimTo identify salivary MicroRNAs (miRNAs) whose expression levels differ over time post-concussion in children with vs. without PPCS.MethodsWe conducted a prospective cohort study with saliva collection at up to three timepoints: (1) within one week of injury; (2) one to two weeks post-injury; and (3) 4-weeks post-injury. Participants were children (ages 11 to 17 years) with a physician-diagnosed concussion from a single hospital center. We collected participants' daily post-concussion symptom ratings throughout their enrollment using the Post-concussion Symptom Scale, and defined PPCS as a total symptom score of ≥ 5 at 28 days post-concussion. We extracted salivary RNA from the saliva samples and measured expression levels of 827 salivary miRNAs. We then compared the longitudinal expression levels of salivary miRNAs in children with vs. without PPCS using linear models with repeated measures.ResultsA total of 135 saliva samples were collected from 60 children. Of the 827 miRNAs analyzed, 91 had expression levels above the calculated background threshold and were included in the differential gene expression analyses. Of these 91 miRNAs, 13 had expression levels that differed significantly across the three timepoints post-concussion between children with and without PPCS (i.e., hsa-miR-95-3p, hsa-miR-301a-5p, hsa-miR-626, hsa-miR-548y, hsa-miR-203a-5p, hsa-miR-548e-5p, hsa-miR-585-3p, hsa-miR-378h, hsa-miR-1323, hsa-miR-183-5p, hsa-miR-200a-3p, hsa-miR-888-5p, hsa-miR-199a-3p+hsa-miR-199b-3p). Among these 13 miRNAs, one (i.e., hsa-miR-203a-5p) was also identified in a prior study, with significantly different expression levels between children with and without PPCS.ConclusionOur results from the longitudinal assessment of miRNAs indicate that the expression levels of 13 salivary miRNAs differ over time post-injury in concussed children with vs. without PPCS. Salivary miRNAs may be a promising biomarker for PPCS in children, although replication studies are needed.

Use of Novel Concussion Protocol With Infralow Frequency Neuromodulation Demonstrates Significant Treatment Response in Patients With Persistent Postconcussion Symptoms, a Retrospective Study.

IntroductionConcussion is a growing public health concern. No uniformly established therapy exists; neurofeedback studies report treatment value. We use infralow frequency neuromodulation (ILF) to remediate disabling neurological symptoms caused by traumatic brain injury (TBI) and noted improved outcomes with a novel concussion protocol. Postconcussion symptoms (PCS) and persistent postconcussion symptoms (PPCS; >3 months post head injury) are designated timelines for protracted neurological complaints following TBI. We performed a retrospective study to explore effectiveness of ILF in PCS/PPCS and investigated the value of using this concussion protocol.MethodPatients with PCS/PPCS seen for their first neurology office visit or received their first neurofeedback session between 1 August 2018 and 31 January 2021 were entered. Outcomes were compared following treatment as usual (TAU) vs. TAU with ILF neurotherapy (TAU+ILF). The study cohort was limited to PPCS patients; the TAU+ILF group was restricted further to PPCS patients receiving at least 10 neurotherapy sessions. Within the TAU+ILF group, comparisons were made between those who trained at least 10 sessions using concussion protocol (TAU+ILF+CP) and those who trained for at least 10 sessions of ILF regardless of protocol (TAU+ILF-CP).ResultsAmong our resultant PPCS cohort (n = 59) leading persistent neurological complaints were headache (67.8%), memory impairment (57.6%), and brain fog (50.8%). PPCS patients in TAU+ILF+CP (n = 25) demonstrated greater net (p = 0.004) and percent (p = 0.026) improvement of symptoms compared to PPCS subjects in TAU (n = 26). PPCS patients in TAU+ILF-CP (n = 8) trended toward significant symptom improvements compared to TAU, and TAU+ILF+CP trended toward greater efficacy than TAU+ILF-CP.ConclusionPPCS patients who received TAU+ILF+CP demonstrated significantly greater improvement as a group when compared to TAU. When used as an integrative modality to treatment as usual in managing patients with PPCS, ILF neuromodulation with use of concussion protocol provided significant symptom improvements.