Isabelle Gagnon

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.

Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED

IMPORTANCE Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist. OBJECTIVE To derive and validate a clinical risk score for PPCS among children presenting to the emergency department. DESIGN, SETTING, AND PARTICIPANTS Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury. EXPOSURES All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria. MAIN OUTCOMES AND MEASURES The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury. RESULTS In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort. CONCLUSIONS AND RELEVANCE A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.

A Functional Magnetic Resonance Imaging Study of Working Memory in Youth after Sports-Related Concussion: Is It Still Working?

Abstract In children, the importance of detecting deficits after mild traumatic brain injury (mTBI) or concussion has grown with the increasing popularity of leisure physical activities and contact sports. Whereas most postconcussive symptoms (PCS) are similar for children and adults, the breadth of consequences to children remains largely unknown. To investigate the effect of mTBI on brain function, we compared working memory performance and related brain activity using blood-oxygen-level-dependent (BOLD) functional magnetic resonance imaging (fMRI) in 15 concussed youths and 15 healthy age-matched control subjects. Neuropsychological tests, self-perceived PCS, and levels of anxiety and depression were also assessed. Our results showed that, behaviorally, concussed youths had significantly worse performances on the working memory tasks, as well as on the Rey figure delayed recall and verbal fluency. fMRI results revealed that, compared to healthy children, concussed youths had significantly reduced task-related activity in bilateral dorsolateral prefrontal cortex, left premotor cortex, supplementary motor area, and left superior parietal lobule during performance of verbal and nonverbal working memory tasks. Additionally, concussed youths also showed less activation than healthy controls in the dorsal anterior cingulate cortex, left thalamus, and left caudate nucleus during the nonverbal task. Regression analysis indicated that BOLD signal changes in bilateral dorsolateral prefrontal cortex were significantly correlated with performance such that greater activities in these regions, relative to the control condition, were associated with greater accuracy. Our findings confirmed functional alterations in brain activity after concussion in youths, a result similar to that observed in adults. However, significant differences were noted. In particular, the observation of reduced working memory accuracy suggests that youths may be unable to engage compensatory strategies to maintain cognitive performance after mTBI. This has significant implications for safe return to daily activities, including competitive sport.

Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents

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.

Mild traumatic brain injury induces prolonged visual processing deficits in children

Primary objective: To compare the sensitivity to simple and complex visual stimuli of children who have sustained a mild traumatic brain injury (mTBI) to that of matched non-injured children and to determine the evolution of visuo-perceptual performance over time. Research design: A prospective design was used to assess 18 children with mTBI and 18 matched healthy controls (8–16 years of age). Methods and procedures: Sensitivity to static and dynamic forms of simple (first-order) and complex (second-order) stimuli were assessed at 1, 4 and 12 weeks post-injury and at equivalent times for controls. Orientation and direction identification thresholds were measured for all participants for static and dynamic conditions, respectively. In addition, sensitivity to radial optic flow (inward vs outward), a complex motion stimulus, was assessed. Main outcomes and results: Thresholds measured from all complex stimuli were significantly affected for the mTBI children over time whereas no difference in threshold between groups across all testing conditions was found for simple, first-order information. Sensitivity to all complex stimuli was still affected 12 weeks after the injury. Conclusion: These findings suggest that injured children present selective processing deficits for higher-order information and that this deficit persists over relatively long periods. Such measures could be useful to assess children who have sustained mTBI and possibly contribute to identifying potential risks of returning these children to demanding physical 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.

Perspectives of adolescents and their parents regarding service needs following a mild traumatic brain injury.

Primary objective: Various guidelines have been developed to implement coherent and uniform management of persons with a mild traumatic brain injury (mTBI), but those have typically been developed for adults or children and may not address or meet the specific needs of adolescents. The purpose of this study was to explore the specific service needs of adolescents (12–18 years) after a mTBI. Study design: Qualitative phenomenological study. Methods and procedures: Individual semi-structured interviews were conducted with 15 adolescents and their parents who had received different levels of care from paediatric trauma centres within the previous 12 months. Main outcomes and results: All adolescents and parents expressed the need to receive information about the injury, its expected recovery and when to return to activities. Many adolescents reported wanting to be seen rapidly, by professionals who genuinely care about them and who acknowledge that they have specific needs that differ from those of younger children. Parents and, to a lesser degree, adolescents think that enhanced communication between the healthcare and school systems would be beneficial following a mTBI to assist in returning to demanding academic activities. Conclusions: Professionals involved in the management of adolescents with mTBI should be aware of their needs in order to provide optimal and developmentally appropriate services.

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.

Exploring the impact of osteopathic treatment on cranial asymmetries associated with nonsynostotic plagiocephaly in infants

OBJECTIVES To document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who were to undergo a course of four osteopathic treatments (in addition to the standard positioning recommendations) as well as to determine the feasibility of using this methodology to conduct a randomized clinical trial investigating the impact of osteopathic intervention for infants with NSOP. DESIGN Pilot clinical standardization project using pre-post design in which 12 infants participated. Ten infants presented an initial Oblique Diameter Difference Index (ODDI) over 104% and five of them had an initial moderate to severe Cranial Vault Asymmetry (CVA) (over 12mm). INTERVENTIONS Infants received four osteopathic treatments at 2-week intervals. MAIN OUTCOME MEASURES Anthropometric, plagiocephalometric as well as qualitative measures were administered pre-intervention (T1), during the third treatment (T2) and two weeks after the fourth treatment (T3). RESULTS Participants showed a significant decrease in CVA (p=0.02), Skull Base Asymmetry (SBA) (p=0.01), Trans-Cranial Vault Asymmetry (TCVA) (p<0.003) between the first and third evaluations. CONCLUSIONS These clinical findings support the hypothesis that osteopathic treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP characteristics.

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.