Erin Selci

Psychiatric outcomes after pediatric sports-related concussion

OBJECT The objectives of this study were twofold: (1) to examine the prevalence of emotional symptoms among children and adolescents with a sports-related concussion (SRC) who were referred to a multidisciplinary pediatric concussion program and (2) to examine the prevalence, clinical features, risk factors, and management of postinjury psychiatric outcomes among those in this clinical population. METHODS The authors conducted a retrospective chart review of all patients with SRC referred to a multidisciplinary pediatric concussion program between September 2013 and October 2014. Clinical assessments carried out by a single neurosurgeon included clinical history, physical examination, and Post-Concussion Symptom Scale (PCSS) scoring. Postinjury psychiatric outcomes were defined as a subjective worsening of symptoms of a preinjury psychiatric disorder or new and isolated suicidal ideation or diagnosis of a novel psychiatric disorder (NPD). An NPD was defined as a newly diagnosed psychiatric disorder that occurred in a patient with or without a lifetime preinjury psychiatric disorder after a concussion. Clinical resources, therapeutic interventions, and clinical and return-to-play outcomes are summarized. RESULTS One hundred seventy-four patients (mean age 14.2 years, 61.5% male) were included in the study. At least 1 emotional symptom was reported in 49.4% of the patients, and the median emotional PCSS subscore was 4 (interquartile range 1-8) among those who reported at least 1 emotional symptom. Overall, 20 (11.5%) of the patients met the study criteria for a postinjury psychiatric outcome, including 14 patients with an NPD, 2 patients with isolated suicidal ideation, and 4 patients with worsening symptoms of a preinjury psychiatric disorder. Female sex, a higher initial PCSS score, a higher emotional PCSS subscore, presence of a preinjury psychiatric history, and presence of a family history of psychiatric illness were significantly associated with postinjury psychiatric outcomes. Interventions for patients with postinjury psychiatric outcomes included pharmacological therapy alone in 2 patients (10%), cognitive behavioral therapy alone in 4 (20%), multimodal therapy in 9 (45%), and no treatment in 5 (25%). Overall, 5 (25%) of the patients with postinjury psychiatric disorders were medically cleared to return to full sports participation, whereas 5 (25%) were lost to follow-up and 9 (45%) remained in treatment by the multidisciplinary concussion program at the end of the study period. One patient who was asymptomatic at the time of initial consultation committed suicide. CONCLUSIONS Emotional symptoms were commonly reported among pediatric patients with SRC referred to a multidisciplinary pediatric concussion program. In some cases, these symptoms contributed to the development of an NPD, isolated suicidal ideation, and worsening symptoms of a preexisting psychiatric disorder. Future research is needed to clarify the prevalence, pathophysiology, risk factors, and evidence-based management of postinjury psychiatric outcomes after pediatric SRC. Successful management of these patients requires prompt recognition and multidisciplinary care by experts with clinical training and experience in concussion and psychiatry.

Health-Related Quality of Life after Pediatric Mild Traumatic Brain Injury/Concussion: A Systematic Review.

Health-related quality of life (HRQOL) is an emerging method to quantify the consequences of pediatric mild traumatic brain injury (mTBI)/concussion in both clinical practice and research. However, to utilize HRQOL measurements to their full potential in the context of mTBI/concussion recovery, a better understanding of the typical course of HRQOL after these injuries is needed. The objective of this study was to summarize current knowledge on HRQOL after pediatric mTBI/concussion and identify areas in need of further research. The following databases from their earliest date of coverage through June 1, 2015 were used: MEDLINE(®), PubMed, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SPORTDiscus, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), and Child Development and Adolescent Studies (CDAS). Studies must have examined and reported HRQOL in a pediatric population after mTBI/concussion, using a validated HRQOL measurement tool. Eight of 1660 records identified ultimately met inclusion criteria. Comprehensive data were extracted and checked by a second reviewer for accuracy and completeness. There appears to be a small but important subgroup of patients who experience poor HRQOL outcomes up to a year or longer post-injury. Potential predictors of poor HRQOL include older age, lower socioeconomic status, or a history of headaches or trouble sleeping. Differing definitions of mTBI precluded meta-analysis. HRQOL represents an important outcome measure in mTBI/concussion clinical practice and research. The evidence shows that a small but important proportion of patients have diminished HRQOL up to a year or longer post-injury. Further study on this topic is warranted to determine the typical longitudinal progression of HRQOL after pediatric concussion.

Academic Outcomes in High-School Students after a Concussion: A Retrospective Population-Based Analysis

Background Many concussion symptoms, such as headaches, vision problems, or difficulty remembering or concentrating may deleteriously affect school functioning. Our objective was to determine if academic performance was lower in the academic calendar year that students sustain a concussion compared to the previous year when they did not sustain a concussion. Methods Using Manitoba Health and Manitoba Education data, we conducted a population-based, controlled before-after study from 2005–2006 to 2010–2011 academic years. Grade 9–12 students with an ICD9/10 code for concussion were matched to non-concussed controls. Overall changes in grade point average (GPA) were compared for the academic year prior to the concussion to the academic year the concussion occurred (or could have occurred among non-concussed matched students). Results Overall, 8240 students (1709 concussed, 6531 non-concussed students) were included. Both concussed and non-concussed students exhibited a lower overall GPA from one year to the next. Having sustained a concussion resulted in a -0.90% (95% CI: -1.88, 0.08) reduction in GPA. Over the same period, non-concussed matched students’ GPA reduced by -0.57% (95% CI: -1.32, 0.19). Students who sustained a concussion during high school were just as likely to graduate within four years as their non-concussed peers (ORadj: 0.84; 95% CI: 0.73, 1.02). Conclusions We found that, at a population level, a concussion had minimal long-term effects on academic performance during high school. While academic accommodations and Return-to-Learn programs are an important component of pediatric concussion management, research is needed to identify risk factors for poor academic performance after a concussion and who should receive these programs.

Multidisciplinary management of pediatric sports-related concussion

OBJECTIVES To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. METHODS We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. RESULTS 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. CONCLUSION Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.

Googling concussion care: a critical appraisal of online concussion healthcare providers and practices in Canada

Background: Concussion is an emerging public health concern, but care of patients with a concussion is presently unregulated in Canada. Methods: Independent, blinded Google Internet searches were conducted for the terms “concussion” and “concussion clinic” and each of the Canadian provinces and territories. The first 10 to 15 concussion healthcare providers per province were identified. A critical appraisal of healthcare personnel and services offered on the providers Web site was conducted. Results: Fifty-eight concussion healthcare providers were identified using this search methodology. Only 40% listed the presence of an on-site medical doctor (M.D.) as a member of the clinical team. Forty-seven percent of concussion healthcare providers advertised access to a concussion clinic, program, or center on their Web site. Professionals designated as team leaders, directors, or presidents among concussion clinics, programs, and centers included a neuropsychologist (15%), sports medicine physician (7%), neurologist (4%), and neurosurgeon (4%). Services offered by providers included baseline testing (67%), physiotherapy (50%), and hyperbaric oxygen therapy (2%). Conclusions: This study indicates that there are numerous concussion healthcare providers in Canada offering diverse services with clinics operated by professionals with varying levels of training in traumatic brain injury. In some cases, the practices of these concussion clinics do not conform to current expert consensus guidelines.

The effect of concussion or mild traumatic brain injury on academic outcomes: a systematic review

Concussion often results in symptoms, including difficulty concentrating, focusing, and remembering, that are typically managed with cognitive and physical rest. Often, the school environment is not conducive to cognitive rest and may lead to worsening or prolonged symptoms that can contribute to impaired academic performance. The objective of the review was to identify and summarize literature concerning the effects of concussion or mild traumatic brain injury (mTBI) on academic outcomes. MEDLINE, Embase, Scopus, and CINAHL were searched until June 1, 2016. Studies must have been primary literature examining students enrolled in primary, secondary, or post-secondary education, have received a physician diagnosis of concussion or mTBI, and have post-injury academic outcomes assessed in numeric or alphabet grade/grade point average (GPA), school attendance records, or national examination scores. Data were extracted and checked by a second reviewer for accuracy and completeness. Nine studies were included. Among four studies that examined grades, one found a significant difference in pre- and post-grades only in the subject Afrikaans. Three examined national test scores and no significant differences were found between cases and controls. Four examined school absenteeism and found that students who developed post-concussion syndrome missed significantly more school days and took longer to return to school than students with extremity injuries. Although mTBI or concussion is associated with missed school, the results demonstrate minimal impact on school grades and national examination scores at a group level. Further research is needed to identify risk factors for impaired school functioning following mTBI and concussion in individual patients.

Pediatric and adolescent injury in snowboarding

ABSTRACT To systematically review published literature on pediatric snowboard injuries, a literature search was performed in PubMed for “snowboard*”. Studies must 1) have been primary research; 2) included at least 10 snowboarders; 3) included children and/or adolescents 4) reported specific injury outcomes, risk factors, or injury prevention program effectiveness. The overall injury rates ranged from 0.5 per 1,000 runs to 420 per 1,000 snowboarders. The most common injuries types were fractures, sprains and strains. Most injuries occurred to an upper extremity or the head. Falls and collisions were the most common mechanisms. Snowboarders who were younger, female, had less snowboard experience, or had a previous injury were at greater risk for injury. Wearing wrist guards had a protective effect. Injury rates varied by injury denominator and source of data. Injury prevention efforts should evaluate modifiable extrinsic risk factors, such as strategies to increase use of protective equipment.

The Effect of Concussion or Mild Traumatic Brain Injury on School Grades, National Examination Scores, and School Attendance: A Systematic Review

Concussion often results in symptoms, including difficulty concentrating, focusing, and remembering, that are typically managed with cognitive and physical rest. Often, the school environment is not conducive to cognitive rest and may lead to worsening or prolonged symptoms that can contribute to impaired academic performance. The objective of the review was to identify and summarize literature concerning the effects of concussion or mild traumatic brain injury (mTBI) on academic outcomes. MEDLINE, Embase, Scopus, and CINAHL were searched until June 1, 2016. Studies must have been primary literature examining students enrolled in primary, secondary, or post-secondary education, have received a physician diagnosis of concussion or mTBI, and have post-injury academic outcomes assessed in numeric or alphabet grade/grade point average (GPA), school attendance records, or national examination scores. Data were extracted and checked by a second reviewer for accuracy and completeness. Nine studies were included. Among four studies that examined grades, one found a significant difference in pre- and post-grades only in the subject Afrikaans. Three examined national test scores and no significant differences were found between cases and controls. Four examined school absenteeism and found that students who developed post-concussion syndrome missed significantly more school days and took longer to return to school than students with extremity injuries. Although mTBI or concussion is associated with missed school, the results demonstrate minimal impact on school grades and national examination scores at a group level. Further research is needed to identify risk factors for impaired school functioning following mTBI and concussion in individual patients.

Googling concussion care in the USA: a critical appraisal of online concussion healthcare providers

Aim: To examine the online personnel and practice profiles of concussion healthcare providers in the USA. Methods: We conducted independent, blinded, Google Internet searches for concussion healthcare providers using the terms ‘concussion clinic’ and ‘concussion program’ and each American state and completed a critical appraisal of healthcare personnel and services at these websites. Results: A total of 184 concussion healthcare providers were identified. Despite offering care to traumatic brain injury (TBI) patients, access to professionals with expertise in TBI including neuropsychologists (40.8%), neurologists (33.7%) and neurosurgeons (21.7%) was variable across sites. Conclusion: Concussion healthcare in the USA is presently delivered by a range of healthcare professionals with varying levels of training in TBI offering a variety of services.

Academic outcomes and accommodations following adolescent sport-related concussion: a pilot study

Aim: The purpose of this study was to examine academic achievement, absenteeism and school accommodations following adolescent sport-related concussion (SRC). Methods: A case-series was conducted among grade 8–12 students who suffered an SRC. The primary outcomes were change in pre- and post-concussion overall, core report card grade point average (GPA) and absenteeism due to concussion. The most helpful school accommodations were tabulated. Results: Pre- and post-concussion GPA was obtained from 33 students – 16 (48%) developed persistent post-concussion symptoms (symptoms lasting >4 weeks). There was no significant difference in pre- and post-concussion grades among students with a SRC for overall (p = 0.75) or core (p = 0.56) GPA. The median number of missed school days was 4 (interquartile range [IQR]: 2–8). Allowing for physical and cognitive rest was identified as the most helpful accommodation (30%). Conclusion: Larger studies should investigate the role that school accommodations and development of persistent post-concussion symptoms have on academic outcomes.