Prolonged Post-concussion Symptoms Research Articles

Nature-Based Therapeutic Intervention for Individuals with Post-Concussion Symptoms.

This study investigated the efficacy of a 10-session nature-based therapeutic intervention for people with post-concussion symptoms. The intervention involved physical and vestibular exercises, sensory training, relaxation, and psychoeducation, all of which were integrated with the natural environment in a forest therapy garden. This study was designed with a passive control period followed by the intervention (n = 30). The Mental Fatigue Scale (MFS) was the primary outcome measure. The secondary outcome measures were the Warwick-Edinburg Mental Wellbeing Scale and the short version of the Quality of Life after Brain Injury. A Likert scale was used to examine the mental strain of the sessions themselves. The MFS (primary outcome) exhibited a significant decrease with a medium-sized effect from before to after the intervention. The secondary outcomes exhibited significant increases from the beginning to the end of the intervention. All outcomes were sustained at follow-up ten weeks later. No significant difference was found from the control period. This study indicates that the described nature-based intervention is a feasible treatment for reducing prolonged post-concussion symptoms. However, it should be studied more in-depth to understand the impact of the natural environment and to validate the results on a larger representative population.

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

Concussion in children and adolescents is a significant public health concern, with 30% to 35% of patients at risk for prolonged emotional, cognitive, sleep, or physical symptoms. These symptoms negatively impact a child's quality of life while interfering with their participation in important neurodevelopmental activities such as schoolwork, socializing, and sports. Early psychological intervention following a concussion may improve the ability to regulate emotions and adapt to postinjury symptoms, resulting in the greater acceptance of change; reduced stress; and recovery of somatic, emotional, and cognitive symptoms. The primary objective of this study is to assess the feasibility of conducting a parallel-group (1:1) randomized controlled trial (RCT) to evaluate a digital therapeutics (DTx) mindfulness-based intervention (MBI) in adolescents aged 12 to <18 years. The attention-matched comparator intervention (a math game also used in previous RCTs) will be delivered on the same DTx platform. Both groups will be provided with the standard of care guidelines. The secondary objective is to examine intervention trends for quality of life; resilience; self-efficacy; cognition such as attention, working memory, and executive functioning; symptom burden; and anxiety and depression scores at 4 weeks after concussion, which will inform a more definitive RCT. A subsample will be used to examine whether those randomized to the experimental intervention group have different brain-based imaging patterns compared with those randomized to the control group. This study is a double-blind Health Canada-regulated trial. A total of 70 participants will be enrolled within 7 days of concussion and randomly assigned to receive the 4-week DTx MBI (experimental group) or comparator intervention. Feasibility will be assessed based on the recruitment rate, treatment adherence to both interventions, and retention. All outcome measures will be evaluated before the intervention (within 7 days after injury) and at 1, 2, and 4 weeks after the injury. A subset of 60 participants will undergo magnetic resonance imaging within 72 hours and at 4 weeks after recruitment to identify the neurophysiological mechanisms underlying the potential benefits from MBI training in adolescents following a concussion. The recruitment began in October 2022, and the data collection is expected to be completed by September 2024. Data collection and management is still in progress; therefore, data analysis is yet to be conducted. This trial will confirm the feasibility and resolve uncertainties to inform a future definitive multicenter efficacy RCT. If proven effective, a smartphone-based MBI has the potential to be an accessible and low-risk preventive treatment for youth at risk of experiencing prolonged postconcussion symptoms and complications. ClinicalTrials.gov NCT05105802; https://classic.clinicaltrials.gov/ct2/show/NCT05105802. DERR1-10.2196/57226.

Characterizing the profiles of patients with acute concussion versus prolonged post-concussion symptoms in Ontario

Identifying vulnerability factors for developing persisting concussion symptoms is imperative for determining which patients may require specialized treatment. Using cross-sectional questionnaire data from an Ontario-wide observational concussion study, we compared patients with acute concussion (≤ 14 days) and prolonged post-concussion symptoms (PPCS) (≥ 90 days) on four factors of interest: sex, history of mental health disorders, history of headaches/migraines, and past concussions. Differences in profile between the two groups were also explored. 110 patients with acute concussion and 96 patients with PPCS were included in our study. The groups did not differ on the four factors of interest. Interestingly, both groups had greater proportions of females (acute concussion: 61.1% F; PPCS: 66.3% F). Patient profiles, however, differed wherein patients with PPCS were significantly older, more symptomatic, more likely to have been injured in a transportation-related incident, and more likely to live outside a Metropolitan city. These novel risk factors for persisting concussion symptoms require replication and highlight the need to re-evaluate previously identified risk factors as more and more concussions occur in non-athletes and different risk factors may be at play.

Electrophysiological trajectories of concussion recovery: From acute to prolonged stages in late teenagers.

Numerous studies have reported electrophysiological differences between concussed and non-concussed groups, but few studies have systematically explored recovery trajectories from acute concussion to symptom recovery and the transition from acute concussion to prolonged phases. Questions remain about recovery prognosis and the extent to which symptom resolution coincides with injury resolution. This study therefore investigated the electrophysiological differences in recoveries between simple and complex concussion. Student athletes with acute concussion from a previous study (19(2) years old) were tracked from pre-injury baseline, 24-48 hours after concussion, and through in-season recovery. The electroencephalography (EEG) with P300 evoked response trajectories from this acute study were compared to an age-matched population of 71 patients (18(2) years old) with prolonged post-concussive symptoms (PPCS), 61 (SD 31) days after concussion. Acute, return-to-play, and PPCS groups all experienced a significant deficit in P300 amplitude compared to the pre-injury baseline group. The PPCS group, however, had significantly different EEG spectral and coherence patterns from every other group. These data suggest that while the evoked response potentials deficits of simple concussion may persist in more prolonged stages, there are certain EEG measures unique to PPCS. These metrics are readily accessible to clinicians and may provide useful parameters to help predict trajectories, characterize injury (phenotype), and track the course of injury.

Agglomerative Hierarchical Clustering of Long-Lasting Post-Concussive Symptoms: Symptom-Centric Association with Functional Impairments (P8-1.001)

<h3>Objective:</h3> The aim of this study was to characterize the underlying clusters of prolonged post-concussive symptoms lasting more than 12 months, and to investigate their association with functional impairments. <h3>Background:</h3> Following a concussion, approximately 15% of individuals experience persistent symptoms that can lead to functional deficits. However, underlying symptom-clusters that persist beyond 12 months have not been adequately characterized, and their relevance to functional deficits are unclear. <h3>Design/Methods:</h3> Although hierarchical clustering is ideally suited in evaluating subjective symptom severities, it has not been applied to post-concussive symptoms or the Rivermead Post-Concussion Questionnaire (RPQ). The RPQ and functional impairments questions were administered via a smartphone application to 445 individuals who self-reported prolonged post-concussive symptoms. Symptom-clusters were obtained using agglomerative hierarchical clustering, and their association with functional deficits were investigated with sensitivity analyses, and corrected for multiple comparisons. <h3>Results:</h3> Five symptom-clusters were identified: headache-related, sensitivity to light and sound, cognitive, mood-related, and sleep-fatigue. Individuals with more severe RPQ symptoms were more likely to report functional deficits (p&lt;0.0001). Whereas the headache and sensitivity clusters were associated with at most one impairment, at-least-mild sleeping difficulties and fatigue were associated with four, and moderate-to-severe cognitive difficulties with five functional impairments (all p&lt;0.01). <h3>Conclusions:</h3> Symptom-clusters may be clinically useful for functional outcome stratification and for targeted rehabilitation therapies, for example directed towards mild trouble sleeping. Further studies are required to replicate these findings in other cohorts and questionnaires, and to ascertain the effects of symptomatic intervention on functional outcomes. <b>Disclosure:</b> Mr. Kuleindiren has nothing to disclose. Mr. Tiersen has received personal compensation for serving as an employee of Mindstep. Mr. Tiersen has stock in Mindstep. Mr. Tiersen has received research support from Imperial College London. Dr. Johal has nothing to disclose. Dr. Lin has nothing to disclose. Mr. Selim has received personal compensation in the range of $500-$4,999 for serving as an officer or member of the Board of Directors for Mindstep . Mr. Selim has stock in Mindstep. Dr. Rifkin-Zybutz has received personal compensation for serving as an employee of Mindset Technologies Ltd. Dr. Rifkin-Zybutz has received research support from National Institute for Health and Care Research. Mr. Mahmud has received personal compensation for serving as an employee of Mindset Technologies Ltd .

Do concussed and non-concussed head trauma individuals have similar symptoms? A retrospective chart review of chronic post-concussive symptomatology

Many head trauma patients who present with prolonged post-concussion symptoms do not meet the American Congress of Rehabilitation Medicine (ACRM) diagnostic criteria for mild traumatic brain injuries (mTBI). This population has not been extensively studied and its clinical characteristics are currently uncertain. A retrospective chart review was conducted to explore the symptomatic differences between mTBI and non-mTBI head trauma patients presenting at a concussion clinic with chronic post-concussion symptoms (PCSx). Patient information was extracted from 161 charts, of which 128 subjects met the ACRM criteria for mTBI (ACRM + PCSx), while 33 did not (non-ACRM + PCSx). These two groups were compared for demographic variables and symptomology. This study found that 20.5% of subjects presenting with chronic post-concussion symptoms do not meet ACRM criteria. No symptom-specific differences were found between the two populations in any of the categories tested. These results show that chronic post-concussion symptoms are similar in both mTBI and non-mTBI head trauma patients in the general population, suggesting a need for further research focusing on this group.

Hierarchical clustering of prolonged post-concussive symptoms after 12 months: symptom-centric analysis and association with functional impairments

ABSTRACT Background Following a concussion, approximately 15% of individuals experience persistent symptoms that can lead to functional deficits. However, underlying symptom-clusters that persist beyond 12 months have not been adequately characterized, and their relevance to functional deficits are unclear. The aim of this study was to characterize the underlying clusters of prolonged post-concussive symptoms lasting more than 12 months, and to investigate their association with functional impairments. Methods Although hierarchical clustering is ideally suited in evaluating subjective symptom severities, it has not been applied to the Rivermead Post-Concussion Questionnaire (RPQ). The RPQ and functional impairments questions were administered via a smartphone application to 445 individuals who self-reported prolonged post-concussive symptoms. Symptom-clusters were obtained using agglomerative hierarchical clustering, and their association with functional deficits were investigated with sensitivity analyses, and corrected for multiple comparisons. Results Five symptom-clusters were identified: headache-related, sensitivity to light and sound, cognitive, mood-related, and sleep-fatigue. Individuals with more severe RPQ symptoms were more likely to report functional deficits (p < 0.0001). Whereas the headache and sensitivity clusters were associated with at most one impairment, at-least-mild sleeping difficulties and fatigue were associated with four, and moderate-to-severe cognitive difficulties with five (all p < 0.01). Conclusions Symptom-clusters may be clinically useful for functional outcome stratification for targeted rehabilitation therapies. Further studies are required to replicate these findings in other cohorts and questionnaires, and to ascertain the effects of symptomatic intervention on functional outcomes.

Exploring the experiences of youth with persistent post-concussion symptoms and their families with an interprofessional team-based assessment

ABSTRACT A proportion of youth who experience concussion develop persistent or prolonged post-concussion symptoms (PPCS). Owing to the complex clinical presentation of PPCS, an interprofessional approach to care is increasingly recommended. Despite increased research in this area, there remains a dearth of evidence from the perspective of the recipients of interprofessional concussion care. The objective of this qualitative descriptive study was to explore the experiences of youth with PPCS and their parents who participated in an interdisciplinary team-based assessment (ITA) at a children’s rehabilitation hospital in Ontario, Canada. Semi-structured interviews were conducted with fifteen individuals (eight youth [8–17 years] and seven parents). Results suggest that the ITA serves as a context for meaningful therapeutic interactions whereby youth, their parents, and the interprofessional team establish and build therapeutic relationships, engage in dialogue emphasizing collaboration, prioritize the young person rather than the injury, and co-create an individualized treatment plan. Results are discussed within the broader literature in the areas of client and family-centered care, interdisciplinary assessment, and concussion management.

Sleep Dysfunction in Adolescents With Prolonged Postconcussion Symptoms: A Reciprocal Coupling of Traumatic Brain Injury and Sleep-Related Problems.

Concussions are often neglected injuries that affect children and adolescents. Two physiological responses to a concussion are an ionic flux and an increased indiscriminate release of glutamate, which leads to an increase of intracellular calcium and extracellular potassium. This can ultimately result in sleep dysfunction, which often occurs after concussion and has long been thought of as simply another concussion symptom. Does the likelihood of prolonged postconcussion symptoms increase with reported sleep-related problems (SRPs) in young athletes (8-18y) compared to concussed young athletes without SRPs and healthy controls? Four cohort studies with level 2/3 evidence measured subjective and objective sleep dysregulations in concussed and healthy populations. Overall, there was a difference in subjective SRPs between concussed and healthy patients. This correlated with other studies where worse sleep scores during the acute phase of concussion and increased SRPs led to worse ImPACT scores in patients 3 to 12 months postconcussion and longer overall recovery. Objective sleep dysfunction measures were significantly worse in concussed patients than in healthy controls, but no significant difference existed in melatonin measures. There is strong evidence that sleep dysfunction is both a symptom of concussion as well as a causal factor of prolonged postconcussion symptoms. These studies show that sleep dysregulation is not always evident in objective measurements, leading to the strong possibility of a functional dysregulation of the sleep-wake cycle that is evident solely from subjective reports. While there are strong cohort studies researching the role of sleep in those with postconcussion symptoms, the nature of sleep studies prevents the production of strong, high-level evidence studies such as randomized control trials. Thus, there is level B evidence that the likelihood of prolonged postconcussion symptoms is increased by a higher amount of SRPs.

Prolonged Post Traumatic Headache after Repetitive Sports Related Concussions

Background: Human and animal studies have shown evidence of pathological brain changes as well as increased cognitive dysfunction with repetitive injury. Case Presentation: We present a case of prolonged persistent post concussive symptoms after a mild concussion, in the setting of multiple prior concussions. In this case a 29-year-old man presented for a moderate persistent daily headache for one month after a minor injury due to a branch hitting his helmet while mountain biking. He had previously sustained one non-sports related concussion with loss of consciousness as well as at least two other sports related concussions in the past five years which caused one-to-two-week intervals of headaches and dizziness. At initial evaluation he reported persistent photosensitivity, difficulty working on screens, as well as intermittent lightheadedness, insomnia, irritability, anxiety, and anhedonia. Symptoms of headache completely resolved over the course of three months with serotonin norepinephrine reuptake inhibitors (SSRI) management, but he reported some persistent anxiety and depressive symptoms. Conclusion: This case report highlights the long-term impact as well as the need for more specific return to activity guidelines for patients with multiple prior concussions.

Neuromodulation Treatments for Mild Traumatic Brain Injury and Post-concussive Symptoms.

Mild traumatic brain injury (mTBI) can result in prolonged post-concussive symptoms (e.g., depression, headaches, cognitive impairment) that are debilitating and difficult to treat. This article reviews recent research on neuromodulation for mTBI. Transcranial magnetic stimulation (TMS) is the most studied neuromodulation approach for mTBI (four studies for depression, four for headache, one for cognitive impairment, and two for global post-concussive symptoms) with promising results for post-concussive depression and headache. Transcranial direct current stimulation (tDCS) has also been evaluated (one study for post-traumatic headache, and three for cognitive impairment), with more mixed results overall. TMS appears to be a potentially promising neuromodulation treatment strategy for post-concussive symptoms; however, integration into clinical practice will require larger sham-controlled randomized trials with longer and more consistent follow-up periods. Future studies should also explore new stimulation protocols, personalized approaches, and the role of placebo effects.

Emotional Modulation of Frontal Alpha Asymmetry - a Novel Biomarker of Mild Traumatic Brain Injury.

Objective findings of brain injury or dysfunction are typically lacking in mild traumatic brain injury (MTBI) despite prolonged post-concussion symptoms in some patients. Thus, there is a need for objective biomarkers of MTBI that reflect altered brain physiology underlying subjective symptoms. We have previously reported increased attention to threat-related stimuli in subjects with MTBI, suggesting a physiological vulnerability to depression. Vulnerability to depression has been linked with relatively greater activity of the right than left frontal cortex reflected in inverse pattern in frontal alpha with greater power on the left than right. We investigated whether patients with previous MTBI show this pattern of frontal activity reflected in more negative frontal alpha asymmetry (FAA) scores. Furthermore, in search for potential biomarkers of MTBI, we created a novel index, emotional modulation of FAA (eFAA) and investigated whether it correlates with subjective symptoms. EEG was recorded while subjects with previous MTBI and controls performed a computer-based reaction time task integrating different cognitive executive functions and containing either threat-related or emotionally neutral visual stimuli. Post-concussion symptoms and depression were assessed using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and Beck’s depression inventory (BDI). Task-induced FAA was assessed and eFAA calculated by subtracting FAA in the context of neutral stimuli from FAA in the context of emotional stimuli. The MTBI group showed FAA scores reflecting relatively greater right-sided frontal activity compared to healthy controls. eFAA differentiated the symptomatic MTBI from non-symptomatic MTBI group and from healthy controls. eFAA also correlated with RPQ and BDI scores. In conclusion, FAA pattern previously linked with vulnerability to depression, was observed in patients with previous MTBI. Furthermore, eFAA has potential as a biomarker of altered affective brain functions in MTBI.

Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score.

Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion. Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years ([Formula: see text] = 0.54), bipolar disorder ([Formula: see text] = 0.52), high pre-injury primary care visits per year ([Formula: see text] = 0.46), personality disorders ([Formula: see text] = 0.45), and anxiety and depression ([Formula: see text] = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis. In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual's risk of requiring treatment more than 6 months post-concussion.

Neurofeedback Impact on Chronic Headache, Sleep, and Attention Disorders Experienced by Veterans with Mild Traumatic Brain Injury: A Pilot Study

A good number of veterans while serving in recent combat zones experienced blast injuries resulting in traumatic brain injuries (TBIs), 80% of which were mild (m) with 25%–50% having prolonged postconcussive symptoms (PCSs). Neurofeedback (NFB) has demonstrated a decent degree of efficacy with mTBI PCSs in civilian and veteran populations. Using infra-low frequency NFB, the authors conducted a pilot study to determine the feasibility and initial efficacy with veterans. Because these results were promising, funding for a full clinical trial was subsequently applied for and acquired.

Incidence and Patterns of Menstrual Irregularities in Pediatric Patients After Concussion

Determine the incidence and patterns of menstrual irregularities in pediatric patients after a concussion and whether this is associated with prolonged recovery time. Abnormal menstrual patterns have been observed in women following a traumatic brain injury, which may be the result of disruption in the hypothalamic-pituitary-ovarian axis. The incidence and clinical significance of menstrual irregularities (MI) in pediatric patients after concussion is not well understood. A retrospective cohort chart review of female pediatric (11-20 years of age) concussion patients (n = 97). Questionnaire survey provided at each visit. The survey asked for number of years since first menses, hormonal contraceptive use, if any MI since the concussion, and type of MI if applicable. Data collected from 11/1/2018 to 5/30/2019. Patients with menarche less than 2 years and/or had experienced irregularities prior to concussion were excluded from study. MI was reported in 26.8% of pediatric patients. The majority of pediatric cases with MI were between the ages of 16 and 20 (73.1%). 84.6% of pediatric patients with reported MI had prolonged post concussive symptoms (PPCS). Other self-reported irregularities included painful dysmenorrhea, more frequent cycles in a short amount of time, or menstruation after prolonged period of amenorrhea due to hormonal contraceptive use. Recovered pediatric patients with reported MI had an average recovery time of 142 days, while recovered pediatric patients without reported MI had an average of 133 days of recovery time, which was not statistically significant (p = 0.825). Menstrual irregularities are common after pediatric concussions and most common in the PPCS population with the highest rates in the older adolescent (16-20) age group. MI may be an important predictor of PPCS and should be reviewed by clinicians in the setting of head trauma. Recovery time after pediatric concussion was longer in the recovered menstrual irregularity group but was not statistically significant.

A Scoping Review of Registered Clinical Studies on Mild Traumatic Brain Injury and Concussion (2000 to 2019)

While many patients with mild traumatic brain injury (mTBI) or concussion recover completely, prolonged postconcussion symptoms remain a challenge for patients and an opportunity for clinical research. This has led to numerous research initiatives over the last 2 decades. To review the characteristics of clinical studies on management of mTBI/concussion; and to examine their definitions of mTBI/concussion. This scoping review included all clinical studies on diagnosis and management of patients with mTBI/concussion registered at www.clinicaltrials.gov from 2000 to June/2019. The terms "mild TBI/concussion" were used for the primary search. Definitions of mTBI/concussion were obtained from the protocols. When a definition was missing in the website, the study's investigators were contacted for clarification. There were 225 interventional and 95 observational studies. Most of the studies are focused on treatment (54.7%) or diagnosis (37.5%), while 3.4% examined preventive measures, 2.8% evaluated prognostic instruments, and 1.6% developed registries. Most of the studies in this American database were single-center initiatives led by American and Canadian institutions. The definitions of mTBI/concussion differed widely among 109 studies. The results of this review suggest that most of the clinical studies are focused on diagnosis and non-pharmacological therapies for patients with mTBI/concussion. The large number of differing definitions of mTBI/concussion among the studies creates significant limitations when comparing studies. The requirements for registering research protocols on mTBI/concussion should include the necessity to state the definition being used. There is a need for consensus on a uniform definition of concussion.

FUNCTIONAL NEUROCOGNITIVE DEFICITS AND CORTICAL EVOKED POTENTIALS IN PEDIATRIC PATIENTS WITH PROLONGED POST CONCUSSIVE SYMPTOMS

Background: Prolonged neurophysiological impairments have been demonstrated after brain injury utilizing tools such as auditory evoked response potentials. The objectivity and sensitivity of such tools can provide clinicians a unique perspective on patients with prolonged post concussive symptoms (PPCS), and help determine optimal management strategies. Limited research currently exists on evoked potentials and pediatric PPCS. Purpose: Illustrate the clinical utility of abnormal evoked potentials in adolescents with PPCS. Methods and Study Design: The study is a retrospective cross-sectional analysis of pediatric PPCS cases from 7/2018 to 7/2019 at a private concussion clinic in Tucson AZ. Patients were included if they had prolonged symptoms beyond 30 days from date of injury date, were 13-16 years old, and diagnosed with PPCS based on SCAT5 assessment and clinical evaluation. All patients with PPCS had moderate to severe clinical symptoms with limited academic and exertional tolerance. Patients were excluded if they had a history of learning disorders, seizure disorder, or complex concussions with a skull fracture or intracranial hemorrhage. Patients were tested using the standard oddball audio P300 EEG protocol. Measures extracted included P300 latency, P300 amplitude, and coherence frequency on mapping. The PPCS cohort (n=71) was then compared to age-matched references (n=73) obtained during baseline testing of non-injured athletes using the same protocol (and hardware) from a multitude of sites. Results: There was a significant correlation between PPCS and reduced P300 amplitude along with an increased coherence. The PPCS group had an average P300 amplitude of 13.7uV compared to 16.9uV in the reference group (p&lt;0.001, CohD=.51). Increased coherence (in the alpha frequency) was observed where the average PPCS patient had 9.1 connected pairs (scalp sites) with coherences that were &gt;2σ, compared to the expected 3.1 connections in reference group &gt;2 σ (p&lt;0.001, CohD=.86). There was no significant difference in P300 latency between the groups. Conclusions: Pediatric patients with PPCS showed decreased P300 amplitude and increased coherence on average compared to the reference group. Reduced voltages and/or increased coherence likely represent ongoing primary brain dysfunction, adaptability, and recovery. These findings suggest the need for ongoing care, and should guide a conservative care approach towards return to high-risk activities. Evoked potentials may be a critical tool to help identify primary neurologic dysfunction in PPCS and help guide management strategies. This tool may also aide in differentiating ongoing neurophysiologic recovery from commonly reported secondary psychosocial symptoms after PPCS. [Figure: see text]

The Effects of Including Aerobic Exercise in the Treatment Protocol of Concussions: A Systemic Review and Meta-analysis

Background of Study: More research studies are being completed advocating for the use of exercise as an intervention and form of treatment for concussions. However, exercise can include many forms of physical activity, intensities, and durations. This systemic review and meta-analysis focused on the use of aerobic exercise, such as cycling or walking, as an intervention and form of treatment for children and young adults suffering from a concussion. Objective: The purpose of this systematic review and meta-analysis was to determine if the addition of aerobic exercise to an individual concussion treatment makes a significant difference when compared to treatments using flexibility as a form of physical activity or traditional methods of treatment following guidelines from the 2016 Berlin Consensus Statement on Concussion in Sport. Method: The search conducted for articles generated 472 studies. Out of these, 5 studies were selected based from the inclusion criteria. Results: Aerobic exercise was shown to significantly decrease the absolute risk difference for the development of prolonged post-concussion symptoms in children and adolescents with concussions when compared to those who reported no physical activity. The mean risk difference for the independent variable (IV) was -0.12 with a 95% confidence interval was reported to be -0.17 to -0.07 and an effect size of Z = 4.94 (P &lt; 0.00001). Aerobic exercise was also shown to have an effect on the change in post-concussion symptom scale scores. The mean IV difference was 8.7 with a 95% confidence interval of 2.05 to 14.35 and an effect size of Z=3.02 (p=0.003). Conclusion: In conclusion, while there is evidence that aerobic exercise is beneficial for children and adolescents with a concussion, more studies need to be completed focusing on this age group and the effects of aerobic exercise on concussion recovery.

Diffusion kurtosis imaging in patients with prolonged post-concussion symptoms

Risk of infections is elevated in patients with schizophrenia. Predicting their occurrence is essential, as infections in this group of patients are associated with prolonged hospital admission and increased mortality. The objective of the current investigation was to identify the potential risk factors of major infection after diagnosis with schizophrenia.This national prospective observational cohort study included 7788 people with schizophrenia born in Denmark between 1975 and 1990. Socio-demographic, psychiatric and health related data were obtained from Danish national registers. The Cox regression model was used for data analyses. Crude and adjusted hazard ratios (HRs) with 95% confidence intervals (95%CIs) are presented.The most significant risk factors associated with the development of major infections included young age, female gender, medical comorbidity and substance abuse. A history of treatment with antipsychotics preceding the diagnosis was negatively associated with such morbidity.This study reports several factors that might increase the risk of infections in individuals with schizophrenia. Early intervention towards infections should be considered in the subpopulation of schizophrenia patients who are at increased risk of infections.

The association of reported cognitive symptoms and objective cognitive performance in patients with prolonged post-concussion symptoms

ObjectiveWithin a sample of patients with prolonged post-concussion symptoms, the current study evaluated the etiology of patients reported cognitive symptoms.BackgroundApproximately 20% of individuals who sustain a concussion will go on to have prolonged post-concussion symptoms. There has been little research examining how patients' perceived symptoms relate to objective markers, especially in regard to perceived cognitive symptoms (e.g., difficulty concentrating). It is important to understand what contributes to patients' reported complaints in order inform prognosis as well as identify areas for intervention. We hypothesize that patients reported cognitive complaints are better accounted for by other concussion symptoms (e.g., somatic, affective, sleep) than by difficulties in their underlying cognitive abilities.MethodsThirty-seven patients between the ages of 12–23 were retrospectively included in the study based on the following: reported post-concussion symptoms, evaluated between 1 month and 1 year post-injury. Hierarchical linear regression analysis was used to test if objective cognitive performance, as measured by a verbal learning/memory task (RAVLT Total) and an attention/working memory task (WAIS-IV Digit Span Total), significantly predicted reported cognitive symptoms above and beyond somatic, sleep, and affective symptoms.ResultsResults of the regression analyses indicated somatic, sleep, and affective symptoms significantly explained 50.3% of the variance in reported cognitive symptoms. Objective cognitive performance did not significantly predict reported cognitive symptoms above and beyond the 3 other symptom factors (R2 Change = 0.04, F [2,31] = 1.45, p = 0.25). Additionally, objective cognitive performance was not a significant predictor of reported cognitive symptoms, explaining only 2.4% of the variance.ConclusionsResults suggest cognitive difficulties are unlikely related to underlying neurocognitive pathology, but instead are related to functional challenges in the face of other symptoms (e.g., headache). Treatment of patients with cognitive complaints should focus on their entire symptom set, likely leading to a reduction in cognitive complaints.