Debbie Friedman

Active rehabilitation for children who are slow to recover following sport-related concussion

Primary objective: To present an innovative approach to the management of children who are slow to recover after a sport-related concussion. Research design: The article describes the underlying principles and the development of specific interventions for a new rehabilitation programme as well as preliminary data on pre- and post-rehabilitation changes in outcome measures. Methods and procedures: Development of the intervention was done using multiple perspectives including that of the literature, of experts in the field of traumatic brain injury and of experienced clinicians involved with the paediatric and adolescent MTBI clientele. A logic model was developed providing sound theoretical background to the intervention. The intervention was implemented and evaluated with a sample of 16 children and adolescents. Main outcomes and results: The presented cases suggest that involvement in controlled and closely monitored rehabilitation in the post-acute period may promote recovery in children and adolescents who present with atypical recovery following a concussion. All 16 of the children and adolescents who participated in the programme experienced a relatively rapid recovery and returned to their normal lifestyles and sport participation. Conclusions: A gradual, closely-supervised active rehabilitation programme in the post-acute period (i.e. after 1 month post-injury) appears promising to improve the care provided to children who are slow to recover.

Motor performance following a mild traumatic brain injury in children: an exploratory study

Mild Traumatic Brain Injury (TBI) is a common occurrence in the paediatric population and, as the concept of motor performance has not been assessed specifically in this population, the purpose of this study was to determine if motor performance deficits are present and can be objectively identified in a sample of children having sustained a mild TBI (Glasgow Coma Scale score 13-15). Twenty-eight children aged between 5 and 15 years were recruited immediately post-trauma. Subjects were considered normal on standard neurological exam at the time of discharge. They were assessed 13-18 days post-trauma using the Bruininks-Oseretsky Test of Motor Proficiency, a norm referenced clinical standardized assessment tool. Compared to published norms, motor performance was significantly lower in domains of balance, response speed and running speed an agility (t-test p < 0.01), and significantly higher in domains of upper extremity coordination and visual motor control (t-test p < 0.01). Although excellent performance can be observed in domains requiring upper limb coordination, motor planning and execution of motor tasks, deficits in balance and response speed can be identified in a significant number of children even after mild TBI. More specific and sensitive evaluations are necessary to identify the exact nature of the problems and evaluate their functional impact on daily activities.

Exploring children's self-efficacy related to physical activity performance after a mild traumatic brain injury.

ObjectiveTo evaluate childrens self-efficacy related to their practice of physical activities prior to and after a mild traumatic brain injury (mTBI), and compare these to those of noninjured children matched for age, sex, and premorbid level of physical activity. Participants and MethodsThirty-four children (mean age: 12 ± 3 years) in each group. Children with mTBI were assessed 1 day postinjury (to document preinjury status) and at 12 weeks post-mTBI using a self-efficacy questionnaire, the Physical Activity Questionnaire, the Athletic Competence subscale of the Self-Perception Profile for Children or Adolescents, and the Rivermead Post-Concussion Symptoms Questionnaire. Noninjured children underwent the same assessments at a corresponding time interval. ResultsAt 12 weeks postinjury, self-efficacy scores of children with mTBI were significantly lower than initial (ie, pretraumatic) values and those of noninjured children. The children with mTBI had, however, returned to their preinjury level of participation in physical activities and maintained their athletic competence. ConclusionsAfter mTBI, children appear to lack confidence in their ability to perform during physical activities as compared to before their injury. Intervention strategies such as information or counseling sessions targeting children and their parents may minimize the impact of the mTBI on childrens confidence in their performance in physical activities.

Visuomotor response time in children with a mild traumatic brain injury.

ObjectiveCompare the visuomotor response times of children after a mild traumatic brain injury (mTBI) with those of noninjured children matched for age, sex, and premorbid level of physical activity. DesignProspective cohort study. SettingPediatric trauma center. ParticipantsThirty-eight children aged 7 to 16 years in each group. Children with mTBI had a mean Glasgow Coma Scale score of 14.8 and were considered normal on a neurological assessment carried out at the time of hospital discharge. Noninjured children were friends of those with mTBI. InterventionAssessments of response time were conducted at 1, 4, and 12 weeks after mTBI and at corresponding time intervals for the control children. Main Outcome MeasuresThe response speed subtest of the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP); reaction and movement time for upper and lower extremities, for simple, choice, and reversed choice response time paradigms. ResultsOver the assessment period, children with mTBI performed worse than the control group only on the response speed subtest of the BOTMP. The mTBI children however tended to have slower movement times 1 week postinjury for the reversed choice response time paradigm for the lower extremities. ConclusionsSome children with mTBI may have some problems in response time persisting until 12 weeks postinjury. Further research is required to better identify and understand the severity of these problems and determine their impact, if any, on participation in physical activities.

Balance findings in a child before and after a mild head injury.

Objective:This case study reviews the preinjury and postinjury balance performance of an 11-year-old child who sustained a mild head injury. Design:A prospective design was used to document balance 5 days before injury and 1, 4, and 12 weeks after injury. Outcome Measures:The assessments used were the balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency, the Pediatric Clinical Test of Sensory Interaction for Balance, and the Postural Stress Test. Results:One week after the trauma, balance deficits were observed in the three tests. The deficits improved 4 weeks after the injury, and performance remained stable over the following 2 months for two of the evaluations except for the Postural Stress Test performance, which failed to improve in the 3-month period after trauma. Conclusions:The good recovery of balance skills observed over the first month after injury seems to validate the current activity restrictions imposed on children after a mild head injury. However, the persistence of poor performance in the area of reactions to external perturbations indicates that some deficits may persist beyond what is expected with this population.

Identifying the specific needs of adolescents after a mild traumatic brain injury: A service provider perspective

Primary objective: To identify the specific service needs of adolescents with mild traumatic brain injury (MTBI) and those of their parents through the perspective of expert service providers as well as to compare it to the perspective of adolescents and their parents obtained in a prior study. Study design: Qualitative design including a focus group held with experts in the field of adolescent TBI and a validation survey of other professionals. Methods and procedures: Eight experts from a variety of disciplines participated in a focus group where important needs of adolescents were discussed. Results were then validated through a questionnaire to 33 professionals. Main outcomes and results: Experts questioned through both methods are generally in agreement and acknowledge that adolescents are unique, but they often find them challenging. Like adolescents themselves, experts identify the need for information as the most important but are wary of offering too much detail and fear that this could encourage malingering of symptoms and problems. Service providers also recognize the importance of supporting adolescents and parents when returning to activities (school and physical activities). Conclusions: The notion that teens represent a specific group of consumers of healthcare services is supported by findings in this study. These results provide important information to those involved in the structuring of service provision to adolescents following MTBI.

Evaluation of an active rehabilitation program for concussion management in children and adolescents

ABSTRACT Objective: To estimate the extent to which post-concussion symptoms were influenced by participation in an Active Rehabilitation (AR) program (aerobic exercise, coordination drills, visualization and education) for children and adolescents who are slow to recover from concussion. A secondary exploratory objective included examining the influence of sex on symptom evolution. Methods: Analysis of prospectively collected data was performed on 277 youth who initiated an AR program, between three and four weeks post-injury at a Concussion Clinic in a tertiary care paediatric teaching hospital. Main outcome measure: Post-concussion symptom scale (PCSS) from Sport Concussion Assessment Tool-3 (SCAT 3). Results: Children and adolescents participating in an active rehabilitation program displayed improved post-concussion symptom severity at follow-up (median = 9.5) compared to pre-intervention (median = 18) (p < .05). Patients demonstrated improved physical, cognitive, emotional and sleep-related post-concussion symptoms (p < .05). Female sex was associated with an increased post-concussion symptom severity at follow-up. Conclusions: Youth experiencing persisting symptoms three to four weeks post-concussion demonstrated improved post-concussion symptoms scores (physical, cognitive, emotional and sleep related) with participation in an active rehabilitation program.

A 20-Year Comparison of Football-Related Injuries in American and Canadian Youth Aged 6 to 17 Years A Replication Study

Introduction. Little is known about Canadian youth football injuries. The objectives of this study were (a) to contrast the injuries in Canadian and American football players aged 6 to 17 years and (b) compare the injuries sustained during organized football with those in nonorganized football. Methods. Using a retrospective cohort design based on data from the Canadian Hospitals Injury Reporting and Prevention Program and the National Electronic Injury Surveillance System a comparison of injuries was made. Results. Trends in injuries were comparable. Proportions and odds of injuries were similar, except for a few exceptions. In Canada, more girls were injured and fractures were more prevalent. Compared with nonorganized football, organized football players were older, involved more males, and suffered more traumatic brain injuries and injuries to their lower extremities. Conclusion. Canadian and American youth football injuries were similar. The type of football, be it organized or nonorganized, has an impact on injuries.

Is There an Optimal Time to Initiate an Active Rehabilitation Protocol for Concussion Management in Children? A Case Series

Objective: To estimate the time frame during which initiating an active rehabilitation intervention (aerobic exercise, balance, and sport specific skills) after concussion contributed to improvement in symptoms at follow-up in children and adolescents who are slow to recover (symptoms persisting beyond 2 weeks) from concussion. Setting: Concussion clinic at a tertiary care pediatric teaching hospital. Participants: A total of 677 children and adolescents with concussion aged 7 to 18 years. Design: Case series of participants starting active rehabilitation less than 2, 2, 3, 4, 5, or 6 or more weeks postconcussion. Main Measure: Symptom severity measured by the 22-item Post-Concussion Scale (PCS)-revised. Results: All patients experienced significant improvement of symptoms while participating in active rehabilitation, irrespective of the start time postonset. Patients initiating active rehabilitation at 2 (P < .001) or 3 (P = .039) weeks postinjury demonstrated lower symptom severity at follow-up than those starting at 6 weeks or later. Patients starting at 2 weeks had lower symptom severity than patients starting less than 2 (P = .02), 4 (P = .20), or 5 weeks postinjury (P = .04). Lastly, patients starting less than 2 and 6 weeks or more postinjury yielded equivalent outcomes. Conclusions: The findings support the use of active rehabilitation in children and adolescents who are slow to recover from concussion. Participants starting active rehabilitation less than 2 weeks and up to 6 or more weeks postconcussion demonstrated significant symptom improvements, but improvement was observed in all groups, regardless of the time to start active rehabilitation.

Ringette-related injuries in young female players

Objective:To document the injuries sustained during organized ringette games. Design:Retrospective data. Setting:Canadian Childrens Hospital Emergency Department. Patients:Information reported by the Canadian Hospitals Injury Reporting Prevention Program on the injuries of 494 female ringette players (age, 10-17 years) between 2004 and 2010. Assessment of Risk Factors:The injuries (types, body part, and mechanisms) presenting to emergency departments were compared between the 4 levels of minor organized ringette. Main Outcome Measures:Proportions of injuries by diagnosis, body site, and mechanisms. Results:The common injuries noted were contusions and head injuries, fractures of the upper extremities, and contusions to both lower and upper extremities. Hospitalizations after injury were rare (1.0%). Body contacts, intentional or incidental, accounted for 63% of all injuries. The actual ringette (rubber ring) was not involved in any injury. Conclusions:Even though all types of contact are forbidden in ringette, our research showed that in minor leagues, a significant proportion of the injuries were caused by body contact. As with regular ice hockey, enforcing policies regarding contacts, use of proper equipment, good maintenance (ice conditions should be checked regularly), and proper skill training should help diminish these types of injuries.