Background
Most concussion studies have focused on the perspectives and expertise of health‐care providers and caregivers. Very little qualitative research has been done, engaging the adolescents who ...have suffered concussion and continue to experience the consequences in their everyday life.
Objective
To understand the experiences of recovery from the perspective of adolescent patients of concussion and to present the findings through their voices.
Methods
Two semi‐structured focus groups and two narrative interviews were conducted with a small group of 7 adolescents. Grounded theory was used to analyse the data.
Results
Participants experience continuing difficulty 1‐5 years after treatment with cognitive, emotional, social and mental well‐being. The overriding experience among older adolescents (17‐20) is a sense of irreversibility of the impact of concussion in all these areas.
Conclusion
There is a significant gap between the medical determination of recovery and what patients understand as recovery. Adolescents do not feel ‘recovered’ more than a year after they are clinically assessed as ‘good to go’. Systematic follow‐up and support from a multi‐disciplinary health‐care team would strengthen youths' coping and resilience.
For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of ...the 6th International Conference on Concussion in Sport held in Amsterdam on 27–30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete’s perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.
ObjectiveTo determine whether differences in post-concussive symptoms (PCS) between children with concussion or orthopedic injuries (OI) are moderated by injury setting (i.e., sport-related versus ...non-sport-related).Design/Setting/ParticipantsProspective cohort study including children ages 8–16 with concussion (n=529; sport-related=81.9%) or OI (n=264; sport-related=82.3%) recruited in Emergency Departments at five hospitals across Canada.AssessmentPCS were measured using the Health and Behaviour Inventory, a reliable and validated rating scale, at 2 weeks, 3 months, and 6 months post-injury.OutcomesLinear mixed model analyses examined group (concussion vs. OI), injury setting, and time post-injury as predictors of cognitive and somatic PCS.Main ResultsMixed models revealed a significant group by setting by time interaction for cognitive (p =.032), but not somatic symptoms (p =.710). Cognitive symptoms were significantly worse in the concussion group compared to the OI group at 2 weeks post-injury for both sport-related (p < .001, d =.090) and non-sport-related settings (p < .001, d =.495), and for non-sport-related settings at both 3 (p =.020, d =.188) and 6 months (p =.004, d =.236) post-injury, but not for sport-related settings at 3 (p =.138, d =.106) or 6 months (p =.824, d =.018) post-injury. Group differences in cognitive PCS declined over time for both settings, but less rapidly for non-sport-related settings.ConclusionsCognitive PCS appear to be more pronounced and longer lasting when concussions are sustained in non-sport-related settings compared to sport-related settings. This moderating effect was not seen for somatic PCS, suggesting that trajectories of somatic and cognitive PCS are related to different predictors.
IMPORTANCE: Although concussion treatment guidelines advocate rest in the immediate postinjury period until symptoms resolve, no clear evidence has determined that avoiding physical activity ...expedites recovery. OBJECTIVE: To investigate the association between participation in physical activity within 7 days postinjury and incidence of persistent postconcussive symptoms (PPCS). DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study (August 2013-June 2015) of 3063 children and adolescents aged 5.00-17.99 years with acute concussion from 9 Pediatric Emergency Research Canada network emergency departments (EDs). EXPOSURES: Early physical activity participation within 7 days postinjury. MAIN OUTCOMES AND MEASURES: Physical activity participation and postconcussive symptom severity were rated using standardized questionnaires in the ED and at days 7 and 28 postinjury. PPCS (≥3 new or worsening symptoms on the Post-Concussion Symptom Inventory) was assessed at 28 days postenrollment. Early physical activity and PPCS relationships were examined by unadjusted analysis, 1:1 propensity score matching, and inverse probability of treatment weighting (IPTW). Sensitivity analyses examined patients (≥3 symptoms) at day 7. RESULTS: Among 2413 participants who completed the primary outcome and exposure, (mean SD age, 11.77 3.35 years; 1205 39.3% females), PPCS at 28 days occurred in 733 (30.4%); 1677 (69.5%) participated in early physical activity including light aerobic exercise (n = 795 32.9%), sport-specific exercise (n = 214 8.9%), noncontact drills (n = 143 5.9%), full-contact practice (n = 106 4.4%), or full competition (n = 419 17.4%), whereas 736 (30.5%) had no physical activity. On unadjusted analysis, early physical activity participants had lower risk of PPCS than those with no physical activity (24.6% vs 43.5%; Absolute risk difference ARD, 18.9% 95% CI,14.7%-23.0%). Early physical activity was associated with lower PPCS risk on propensity score matching (n = 1108 28.7% for early physical activity vs 40.1% for no physical activity; ARD, 11.4% 95% CI, 5.8%-16.9%) and on inverse probability of treatment weighting analysis (n = 2099; relative risk RR, 0.74 95% CI, 0.65-0.84; ARD, 9.7% 95% CI, 5.7%-13.7%). Among only patients symptomatic at day 7 (n = 803) compared with those who reported no physical activity (n = 584; PPCS, 52.9%), PPCS rates were lower for participants of light aerobic activity (n = 494 46.4%; ARD, 6.5% 95% CI, 5.7%-12.5%), moderate activity (n = 176 38.6%; ARD, 14.3% 95% CI, 5.9%-22.2%), and full-contact activity (n = 133 36.1%; ARD, 16.8% 95% CI, 7.5%-25.5%). No significant group difference was observed on propensity-matched analysis of this subgroup (n = 776 47.2% vs 51.5%; ARD, 4.4% 95% CI, −2.6% to 11.3%). CONCLUSIONS AND RELEVANCE: Among participants aged 5 to 18 years with acute concussion, physical activity within 7 days of acute injury compared with no physical activity was associated with reduced risk of PPCS at 28 days. A well-designed randomized clinical trial is needed to determine the benefits of early physical activity following concussion.
Individual differences in long-term psychosocial functioning after concussions in children and adolescents are poorly understood. The aim of the study was to investigate potential predictors of ...long-term psychosocial functioning and health-related quality of life in youth after prior concussion.
Participants (N=75; mean age=14.3 years old; 52% girls) with one prior concussion (n=24), multiple prior concussions (n=24), or a prior orthopedic injury and no concussion (n=27) were seen on average 2.7 years after their most recent injury. Psychosocial functioning was assessed using the self-report versions of the Behavior Assessment System for Children (BASC-2; Anxiety and Depression scales only), the Strengths and Difficulties Questionnaire, and the Pediatric Quality of Life Inventory TM 4.0. Pre-existing conditions (attention problems, learning difficulties, mood concerns, anxiety concerns, and migraines) were reported by parents using a checklist and examined as predictors of long-term functioning. Other potential predictors included age at testing, sex, time between most recent injury and testing, and number of prior concussions.
The groups did not differ significantly on long-term psychosocial functioning. Moreover, only pre-existing mood concerns or attention problems significantly predicted psychosocial adjustment.
Children's functioning before a concussion is critical to understanding outcome. Pre-injury attention and mood concerns should be assessed in clinical settings to prevent and treat long-term psychosocial problems after concussion. (JINS, 2018, 24, 540-548).
The authors propose a heuristic model of the social outcomes of childhood brain disorder that draws on models and methods from both the emerging field of social cognitive neuroscience and the study ...of social competence in developmental psychology/psychopathology. The heuristic model characterizes the relationships between social adjustment, peer interactions and relationships, social problem solving and communication, social-affective and cognitive-executive processes, and their neural substrates. The model is illustrated by research on a specific form of childhood brain disorder, traumatic brain injury. The heuristic model may promote research regarding the neural and cognitive-affective substrates of children's social development. It also may engender more precise methods of measuring impairments and disabilities in children with brain disorder and suggest ways to promote their social adaptation.
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CEKLJ, FFLJ, NUK, ODKLJ, PEFLJ
ObjectiveTo explore high school student needs informing a peer support program following concussion.DesignQualitative case-study design.SettingHigh school.Participants53 high school students (16 ...male, 36 female, 1 prefers-not-to-disclose; median 16 (range 15–18)) enrolled in a sports medicine course at a Calgary, Alberta, Canada high school who had sustained a concussion (n=20) or were interested in supporting peers following concussion (n=33).Interventions (or Assessment of Risk Factors)Semi-structured group interviews (N=7 groups) were conducted in-person at the high school. Interviews aimed to understand what factors should be considered in the development of a peer support program for students following a concussion at their school.Outcome MeasuresInterviews were analysed using conventional content analysis.Main ResultsParticipants preferred a one-on-one buddy-program for their school, rather than a formal peer support group. The buddy-program could facilitate concussion education, advocacy for school supports, social support, and academic or tutoring support in a more confidential manner. Teachers would be tasked with facilitating pairings between trusting peers. Buddies would meet on an as needed basis, as decided by the pairing. Barriers to program uptake identified included stigma, lack of interest, decreased awareness, and failure to report a concussion. Participants highlighted a need for schoolwide concussion education and consistency in return-to-school processes.ConclusionsOne-on-one peer support is perceived by high school students to be more beneficial for students upon return-to-school following a concussion as it would provide confidentiality and trust. A multifaceted peer support buddy-program should be developed and piloted in high schools.
ObjectiveInvestigate whether resuming physical activity (PA) at 72 hours post concussion is safe and reduces symptoms at 2 weeks, compared with resting until asymptomatic.MethodsReal-life conditions, ...multicentre, single-blinded randomised clinical trial, conducted in three Canadian paediatric emergency departments (ED). Children/youth aged 10–<18 years with acute concussion were recruited between March 2017 and December 2019, and randomly assigned to a 4-week stepwise return-to-PA protocol at 72 hours post concussion even if symptomatic (experimental group (EG)) or to a return-to-PA once asymptomatic protocol (control group (CG)). The primary outcome was self-reported symptoms at 2 weeks using the Health and Behaviour Inventory. Adherence was measured using accelerometers worn 24 hours/day for 14 days post injury. Adverse events (AE) (worsening of symptoms requiring unscheduled ED or primary care visit) were monitored. Multivariable intention-to-treat (ITT) and per-protocol analyses adjusting for prognostically important covariates were examined. Missing data were imputed for the ITT analysis.Results456 randomised participants (EG: N=227; mean (SD) age=13.3 (2.1) years; 44.5% women; CG: N=229; mean (SD) age=13.3 (2.2) years; 43.7% women) were analysed. No AE were identified. ITT analysis showed no strong evidence of a group difference at 2 weeks (adjusted mean difference=−1.3 (95% CI:−3.6 to 1.1)). In adherent participants, initiating PA 72 hours post injury significantly reduced symptoms 2 weeks post injury, compared with rest (adjusted mean difference=−4.3 (95% CI:−8.4 to –0.2)).ConclusionSymptoms at 2 weeks did not differ significantly between children/youth randomised to initiate PA 72 hours post injury versus resting until asymptomatic; however, many were non-adherent to the intervention. Among adherent participants, early PA was associated with reduced symptoms at 2 weeks. Resumption of PA is safe and may be associated with milder symptoms at 2 weeks.Level of evidence1b.Trial registration number NCT02893969.Registry namePediatric Concussion Assessment of Rest and Exertion (PedCARE).
To validate the two-factor structure (i.e., cognitive and somatic) of the Health and Behaviour Inventory (HBI), a widely used post-concussive symptom (PCS) rating scale, through factor analyses using ...bifactor and correlated factor models and by examining measurement invariance (MI).
PCS ratings were obtained from children aged 8-16.99 years, who presented to the emergency department with concussion (n = 565) or orthopedic injury (OI) (n = 289), and their parents, at 10-days, 3-months, and 6-months post-injury. Item-level HBI ratings were analyzed separately for parents and children using exploratory and confirmatory factor analyses (CFAs). Bifactor and correlated models were compared using various fit indices and tested for MI across time post-injury, raters (parent vs. child), and groups (concussion vs. OI).
CFAs showed good fit for both a three-factor bifactor model, consisting of a general factor with two subfactors (i.e., cognitive and somatic), and a correlated two-factor model with cognitive and somatic factors, at all time points for both raters. Some results suggested the possibility of a third factor involving fatigue. All models demonstrated strict invariance across raters and time. Group comparisons showed at least strong or strict invariance.
The findings support the two symptom dimensions measured by the HBI. The three-factor bifactor model showed the best fit, suggesting that ratings on the HBI also can be captured by a general factor. Both correlated and bifactor models showed substantial MI. The results provide further validation of the HBI, supporting its use in childhood concussion research and clinical practice.
•Multi-site MRS data contains sources of non-biological variance that can mask biological effects of interest.•ComBat data harmonization successfully removes variance contributed by scanner and site ...differences.•Removal of this variance revealed biological effects that were previously not detected.•ComBat harmonization can be successfully applied to MRS data in multi-site MRS studies.
Magnetic resonance spectroscopy (MRS) is a non-invasive neuroimaging technique used to measure brain chemistry in vivo and has been used to study the healthy brain as well as neuropathology in numerous neurological disorders. The number of multi-site studies using MRS are increasing; however, non-biological variability introduced during data collection across multiple sites, such as differences in scanner vendors and site-specific acquisition implementations for MRS, can obscure detection of biological effects of interest. ComBat is a data harmonization technique that can remove non-biological sources of variance in multisite studies. It has been validated for use with structural and functional MRI metrics but not for MRS measured metabolites. This study investigated the validity of using ComBat to harmonize MRS metabolites for vendor and site differences. Analyses were performed using data acquired across 20 sites and included edited MRS for GABA+ (N = 218) and macromolecule-suppressed GABA data (N = 209), as well as standard PRESS data to quantify NAA, creatine, choline, and glutamate (N = 190). ComBat harmonization successfully mitigated vendor and site differences for all metabolites of interest. Moreover, significant associations were detected between sex and choline levels and between age and glutamate and GABA+ levels that were not detectable prior to harmonization, confirming the importance of removing site and vendor effects in multi-site data. In conclusion, ComBat harmonization can be successfully applied to MRS data in multi-site MRS studies.
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