Sports-related Concussions In Children Research Articles

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023.

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5–12 years) and adolescents (13–18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8–12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Association Between First Attempt Buffalo Concussion Treadmill Test and Days to Recovery in 855 Children With Sport-Related Concussion: A Historical Cohort Study and Prognostic Factors Analysis.

Little is known about the prognostic value of the Buffalo Concussion Treadmill Test (BCTT) after the acute phase of sport-related concussion (SRC). We examined the added prognostic value of the BCTT performed 10 to 21 days after SRC in children, in addition to participant, injury, and clinical process characteristics on days to recovery. Historical clinical cohort study. Network of approximately 150 Canadian multidisciplinary primary-care clinics. 855 children (mean age 14 years, range 6-17 years, 44% female) who presented between January 2016, and April 2019 with SRC. Participant, injury, and clinical process characteristics, with focus on BCTT exercise intolerance assessed 10 to 21 days after injury. Days to clinical recovery. Children who were exercise intolerant experienced an increase of 13 days to recovery (95% CI, 9-18 days). Each additional day between SRC and first BCTT was associated with a recovery delay of 1 day (95% CI, 1-2 days), and prior history of concussion was associated with a recovery delay of 3 days (95% CI, 1-5 days). Participant, injury, and clinical process characteristics, and the first attempt BCTT result explained 11% of the variation in recovery time, with 4% accounted for by the BCTT. Exercise-intolerance assessed 10 to 21 days after SRC was associated with delayed recovery. However, this was not a strong prognostic factor for days to recovery.

Evaluation of Sports-Related Concussion in Children (5–12) and Adolescents (13–18)

The objective of this study was to examine the association between sport/non-sport concussions as well as age and time to recovery after concussion diagnosis in children and adolescents. There is an ongoing debate between policy makers and medical specialists on when is the appropriate time to allow children to begin playing contact sports. This dilemma is important because sports are incredibly prevalent in our child and adolescent population today. There is still significant debate if age at time of concussion diagnosis is associated with long term affects and time to recovery. Of the 725 patients who received a diagnosis of concussion at Children's of Alabama (COA) from 2018 to 2019, 350 patients were included for retrospective cohort review based on documented recovery data defined as follow up appointment PRN (as needed) or begin return to play protocol. 221 patients were lost to follow up while 7 were excluded for concomitant skull fracture. Recovery time, patient demographic data, symptoms severity score, and injury characteristics were then analyzed for each patient. Overall, the mean time of recovery after new diagnosis of any concussion was 87.2 days. The mean time to documented recovery in sports-related concussion was 82.6 days compared to 98.5 days in non-sports related concussion. Of note, both the 5-12 and 13-18 age groups had the same mean time to recovery at 87 days. Sports related concussion showed decreased mean time to recovery compared to non-sports related concussion. Also, age did not play a factor in time to recovery as there was no difference in the 2 age groups. This data, along with the NCAA-DOD Care Consortium showing repetitive head injury during early adolescence is unrelated to brain health as measured by specific outcome measures, has the potential to provide valuable information for future policy on child and adolescent sports.

THE UTILITY OF A MULTIDIRECTIONAL SUBMAXIMAL EXERTIONAL STEP AS PART OF AN EXERTIONAL REHABILITATION PROTOCOL AFTER CONCUSSION

Background:This study aimed to identify whether a 5 Step Exertional Rehabilitation Protocol including a submaximal multi-directional stage (Step 5) has clinical utility for functional activity and sport clearance. Exertional Rehabilitation (EP) is a graded protocol of aerobic exercise ranging from light linear exertion (Step 1) to submaximal linear exertion (Step 4)1,2. In our 5 Step Protocol, Step 4 is followed by standardized multi-directional functional movements at high intensity intervals (Step 5) to rule out ongoing exertional intolerance.Hypothesis/Purpose:We aim to investigate if Step 5 testing demonstrates statistical evidence for its use in determining concussion recovery timelines and its diagnostic usefulness.Methods:This retrospective-chart review analyzed 60 Step 5 EP test attempts in post-concussion patients, ages 21 or younger, between Jun2019-Jun2020. Tolerance was determined by a concussion specialist who evaluated for the onset of signs/symptoms by surveying the patient throughout exercise and autonomic assessment with cardiac monitoring and pre/post orthostatic testing. Pre/Post exertion King-Devic (K-D) and vestibular testing on Force Plate were completed following Balance Error Scoring System positions. A positive change in K-D was defined as a ≥2 second delay in score on two of three reading cards from the pre-exertion testing. A positive change in vestibular testing was defined as a ≥0.2deg/sec change in the composite balance score from the pre-exertion testing.Results:The total number of failed Step 5 attempts was 21.7%. Of the failed attempts, 38.5% demonstrated dysautonomia, 92.35% had symptoms, and 30.8% demonstrated both dysautonomia and symptoms. Force Plate balance scores significantly worsened in failed attempts 15.4% of the time while passed attempts only 2.1% of the time. K-D scores did not show a statistically significant difference although failed attempts did have slightly worsened scores.Conclusion:Formal Step 5 testing is a useful diagnostic tool for understanding recovery stage, activity tolerance, and sport clearance. Autonomic, visual, and vestibular testing can be useful as objective markers of test tolerance.Tables/Figures:Figure 1.1.Figure 1.2.Citations:1) Leddy JJ, Haider MN, Ellis MJ, Mannix R, Darling SR, Freitas MS, Suffoletto HN, Leiter J, Cordingley DM, Willer B. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019 Apr 1;173(4):319-325.2) Gagnon etal. Another look at active rehabilitation for slow-to-recover sport-related concussion in children and adolescents: further evidence to support its effectiveness. BJSM, 2013.

THE CLINICAL UTILITY OF THE VESTIBULAR AND OCULAR MOTOR SCREENING FOR PROTRACTED RECOVERY IN PEDIATRIC CONCUSSION PATIENTS

Background:Sports-related concussions (SRCs) are a concern for youth athletes and their subsequent healthy development into adulthood. Protracted recovery (>28 days) from a SRC may lead to long-term complications resultant of persistent symptoms. There is a current lack in understanding of the factors contributing to protracted recovery from SRC in children, and in particular no tools exist to identify those SRC patients that may be more likely have a protracted recovery in an acute clinical setting.Hypothesis/Purpose:To examine the relationship between initial Vestibular and Ocular Motor Screening (VOMS) and protracted recovery from concussion in youth.Methods:Children aged 8-12 years old, who were diagnosed with a SRC and seen in a concussion specialty clinic within 7-days of injury were included in the analysis. VOMS was administered during the initial visit. A positive VOMS score was defined as any 2-point increase from baseline in patient reported symptom severity on dizziness, fogginess, headache, and nausea, or any convergence measure greater than 6 centimeters. Recovery time (days) was the interval between date of injury and date of medical clearance. Multivariable logistic regressions were used to determine the odds of protracted recovery based on an initial positive VOMS.Results:A total of 108 males (mean age=10.8, sd=1.3) and 66 females (mean age=10.8, sd=1.4), took a median (IQR) 20.0 (15.0-28.5) and 22.0 (15.0-34.0) days to recover, respectively. After controlling for age and days since injury, those with a positive VOMS were 3.92 (95% CI = 1.58-9.71, p=0.003) times more likely to have a protracted recovery compared to those with a negative VOMS. When stratified by sex, observed effects were more amplified among males (OR=5.92, 95% CI=1.59-21.96, p=0.008), than among females (OR=2.44, 95% CI=0.61-9.71, p=0.21).Conclusion:There is a need to determine the relationship between SRC assessment measures and recovery time to improve clinical management and outcomes. In this sample of pediatric concussion patients aged 8-12 years, the VOMS displayed potential as a tool to screen for delayed recovery among males. Future studies should confirm these findings in other, larger samples, while taking into consideration other factors that may influence recovery time.

Concussion Education in Children and Youth: A Scoping Review.

IntroductionSports-related concussions in children and youth are a significant health concern. There is increasing literature pertaining to levels of knowledge about concussion and the effects of educational interventions, but the literature has not yet been synthesized for the subpopulation of children and youth. Therefore, the purpose of this review was to identify and summarize the current state of the literature on concussion knowledge, and the effect of concussion education on the knowledge, attitudes, and behaviors of children and youth who engage in sports.MethodsA scoping review was conducted, guided by Joanna Briggs Institute methodology. Two databases, MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature), and reference lists were searched to identify relevant studies that focused on children and youth less than 19 years of age who engage in sports. We also searched Google Scholar for gray literature.ResultsOf the 21 articles that met inclusion criteria, 15 focused on levels of concussion knowledge, and 6 examined the effects of educational interventions. Children and youths’ level of knowledge and exposure to prior concussion education varied, although more of the studies found a lack of concussion knowledge. Educational interventions of various types have been associated with short-term increases in knowledge and intention to report, but few of the studies found sustained effects.ConclusionsFindings highlight the need for improved concussion education for children and youth engaged in sports. Findings also indicate a need for further research using more rigorous methods, and studies that examine subgroup differences in knowledge and factors that may moderate the effects of educational interventions.

Sport-Related Concussion in Children and Adolescents.

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

Sports-Related Concussions in Children: Differences in Care and Expectations When Seen in an Emergency Department Versus a Sports Medicine Clinic.

Patient and parent expectations can potentially influence management of care. We compared expectations in the diagnosis of concussion between patients who presented to a pediatric emergency department (ED) and those who presented to a sports medicine clinic, and if there was a difference in computed tomography (CT) scans performed. Head-injured athletes aged 8 to 18 years presenting to a pediatric ED and a sports medicine clinic were enrolled. Both groups completed questionnaires on their understanding of concussion and expectations of care. Charts were then reviewed. Forty patients were enrolled in the study: 23 from a pediatric ED and 17 from a sports medicine clinic. Forty-one percent of athletes received a head CT in the pediatric ED versus 12% of those in the clinic population with no abnormal findings (P = 0.04). Forty-one percent of athletes and 48% of parents in the pediatric ED setting reported that a CT was "necessary" to diagnose concussion versus 18% in both groups from the clinic (P = 0.12, P = 0.07). Athletes presenting to the clinic were more likely to have been evaluated by an athletic trainer after the injury than those presenting to the pediatric ED (80% vs 23%, P = 0.004). Patients and parents who presented to a pediatric ED for sports-related head injury had a trend toward higher expectations of a CT scan being necessary to diagnose concussion and did have a higher rate of CT scans performed. Education of athletes and parents engaging in organized sports may be worthwhile to assist in setting expectations in diagnosis of concussion.

BET 2: Should children with sport-related concussion observe strict physical rest until symptom-free?

A short cut review was carried out to establish whether strict physical rest following sports related concussion in children is better than normal activity in reducing post-concussional symptoms. two recent...

Sports-related Concussion in Children and Adolescents.

Concussions are becoming increasingly important to manage properly as sports participation continues to rise. Repeated injuries occurring before the brain has had a chance to recover from an initial insult are particularly dangerous and must be prevented. Although much national media attention has been devoted to concussions in professional sports, it is important to appreciate that athletes in any age group, children and adolescents in particular, are at risk of sports-related concussion. It is crucial to remove an athlete from play any time concussion is suspected. Once removed from play, recovery then begins with a period of cognitive and physical rest, followed by a gradual return to cognitive and athletic activities as symptoms resolve. Children and adolescents pose a unique challenge to the clinician managing their recovery, as the physical and cognitive rest periods required often involve time away from school and sports, which can be academically detrimental and socially isolating. Recently developed sideline assessment tools have greatly aided the urgent sideline assessment of an athlete suspected of having a concussion. In this article, a brief review of current guidelines is presented in tandem with the authors' preferred treatment of concussion.

Sport-Related Concussion in Youth: A Curriculum for Advanced Practice Nurses

Sports-related concussions are a major public health concern for children, parents, and health care providers. Effective management of sports-related concussions in children and adolescents requires timely and accurate diagnosis and appropriate management. Advance practice nursing textbooks often do not address sport-related concussions. Although nurse practitioners routinely care for these patients, they may not have adequate education or training to diagnose and manage them. It is essential to close the gap in education by providing up-to-date recommendations and guidelines for diagnosis and management. Current research and recommendations are presented to facilitate nurse practitioner education about sport-related concussion.

Patterns of Recovery Following Sport-Related Concussion in Children and Adolescents.

Time to symptom resolution, return to school, and return to play after a sport-related concussion in children and adolescents (8-17 years of age) was examined using a retrospective cohort design. A total of 198 patients aged 8 to 17 years were included, with a mean age of 13.5 years (SD = 2.2). Patients aged 8 to 12 years were symptom-free in a median of 12.0 (range 1-60) days whereas 13- to 17-year olds were symptom-free in a median of 14.0 (range 1-300) days (P = .04). Patients aged 8 to 12 years returned to learn in a median of 4.0 (range 0-30) days compared with 2.5 (range 0-55.0) days in 13- to 17-year-olds (P = .86). Patients aged 8 to 12 years returned to play in a median of 14.0 (range 4-75) days compared with a median of 19.5 (range 5-75) days in 13- to 17-year-olds (P = .06). These results indicate that children and adolescents generally take 2 to 4 weeks to recover from a sport-related concussion.

On-field management and return-to-play in sports-related concussion in children: Are children managed appropriately?

On-field management and return-to-play guidelines aim to ensure the identification and appropriate management of the concussed athlete. Compliance with current guidelines in many settings is unknown. We assessed whether key components of current concussion guidelines are being followed in child athletes. Prospective observational study. Data were collected from children (5-18 years) presenting to a paediatric emergency department with sport-related concussion via researcher-administered surveys in the emergency department and during a follow up phone call. On hospital discharge all patients received a return to sports fact sheet based on the International Concussion in Sports Group. Ninety-three had sustained a concussion (mean age 12.7 (±0.27) years, 83% male). Sports played included Australian Football (47%), soccer (12%), rugby (9%) basketball (8%), other (25%). 82% participated in organised sports. Concussive signs or symptoms included loss of consciousness (41%), disorientation (36%), vomiting (23%), amnesia (30%), headache (60%). For concussive injury in organised sports (n=76), overall 42% were not managed according to recommended guidelines: 19% were not immediately removed from play, 29% were allowed to return to play on the same day and 27% were not assessed by qualified personnel. 93% of parents and 96% of patients were unaware of concussion or return-to-play guidelines from their organisations. Overall, 72% were compliant with provided return-to-play guidelines. Many children with sports related-concussion are not formally assessed on-field and continue to play. On-field concussion management and return to play practices are often suboptimal. Awareness and education of coaches, teachers, parents and children need to be improved.

Exploring parent and youth perspectives of the influence of concussion on school, sport and life: a qualitative study

ObjectiveThe purpose of this qualitative study was to describe the perceived impact of sports-related concussion by youth and their parents on home, school and sport functioning.DesignSemi-structured interviews were used to...

Another look at active rehabilitation for slow-to-recover sport-related concussion in children and adolescents: further evidence to support its effectiveness

ObjectiveTo explore and impact of a previously developed active rehabilitation intervention for children who are slow-to-recover after concussion.DesignProspective repeated measures design.SettingThe Montreal Children's Hospital Concussion Clinic.ParticipantsTen children (three girls and...

Clinical Report—Sport-Related Concussion in Children and Adolescents

Clinical Report—Sport-Related Concussion in Children and Adolescents

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is a "hot topic" in the media and in medicine. It is a common injury that is likely underreported by pediatric and adolescent athletes. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports. A clear understanding of the definition, signs, and symptoms of concussion is necessary to recognize it and rule out more severe intracranial injury. Concussion can cause symptoms that interfere with school, social and family relationships, and participation in sports. Recognition and education are paramount, because although proper equipment, sport technique, and adherence to rules of the sport may decrease the incidence or severity of concussions, nothing has been shown to prevent them. Appropriate management is essential for reducing the risk of long-term symptoms and complications. Cognitive and physical rest is the mainstay of management after diagnosis, and neuropsychological testing is a helpful tool in the management of concussion. Return to sport should be accomplished by using a progressive exercise program while evaluating for any return of signs or symptoms. This report serves as a basis for understanding the diagnosis and management of concussion in children and adolescent athletes.

Neuropsychological And Neurophysiological Deficits Following A Sport-related Concussion In Children And Adults

Neuropsychological And Neurophysiological Deficits Following A Sport-related Concussion In Children And Adults

Management of Sports-Related Concussion in Children and Adolescents

Management of Sports-Related Concussion in Children and Adolescents

Sports-related concussions in pediatrics

Mild traumatic brain injury (mTBI) accompanied by concussion is a common presenting complaint among children presenting to emergency departments (EDs). There is wide practice variation regarding diagnosis and management of sports-related concussions in children. Our aim is to review the most recent evidence and expert recommendations regarding initial diagnosis and management of sports-related concussions in children. Previous classifications and return-to-play guidelines for sports-related concussions in children were inadequate and have been abandoned. The most recent recommendations, from the Third International Conference on Concussion in Sport (CIS), reinforce an individualized evaluation of the athlete's neurocognitive functioning, symptoms and balance. They further reinforce a step-wise approach in the return-to-play process once neurocognitive function has returned to baseline and all symptoms have resolved. The need for a standardized and objective tool to aid in the initial evaluation and diagnosis of mTBI in the clinical setting led to the development of the Acute Concussion Evaluation (ACE) protocol, which is currently being modified for specific use in the ED. Computed tomography (CT) in the acute setting is not likely to be useful for children with mTBI. Newer functional imaging techniques may prove relevant in the future. Further research on both the incidence of sports-related concussions in children and management paradigms is needed. The role of novel imaging modalities in clinical assessment also needs to be elucidated. An individualized approach to evaluation and management of sports-related concussions is recommended. It should incorporate standard symptom assessment, neuropsychological testing and postural stability testing.