Jennifer Niskala Apps

Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial

OBJECTIVES: To determine if recommending strict rest improved concussion recovery and outcome after discharge from the pediatric emergency department (ED). METHODS: Patients aged 11 to 22 years presenting to a pediatric ED within 24 hours of concussion were recruited. Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to strict rest for 5 days versus usual care (1–2 days rest, followed by stepwise return to activity). Patients completed a diary used to record physical and mental activity level, calculate energy exertion, and record daily postconcussive symptoms. Neurocognitive and balance assessments were performed at 3 and 10 days postinjury. Sample size calculations were powered to detect clinically meaningful differences in postconcussive symptom, neurocognitive, and balance scores between treatment groups. Linear mixed modeling was used to detect contributions of group assignment to individual recovery trajectory. RESULTS: Ninety-nine patients were enrolled; 88 completed all study procedures (45 intervention, 43 control). Postdischarge, both groups reported a 20% decrease in energy exertion and physical activity levels. As expected, the intervention group reported less school and after-school attendance for days 2 to 5 postconcussion (3.8 vs 6.7 hours total, P < .05). There was no clinically significant difference in neurocognitive or balance outcomes. However, the intervention group reported more daily postconcussive symptoms (total symptom score over 10 days, 187.9 vs 131.9, P < .03) and slower symptom resolution. CONCLUSIONS: Recommending strict rest for adolescents immediately after concussion offered no added benefit over the usual care. Adolescents’ symptom reporting was influenced by recommending strict rest.

Activity-Related Symptom Exacerbations After Pediatric Concussion

Importance Recovery from concussion generally follows a trajectory of gradual improvement, but symptoms can abruptly worsen with exertion. This phenomenon is poorly understood. Objectives To characterize the incidence, course, and clinical significance of symptom exacerbations (spikes) in children after concussion. Design, Setting, and Participants This secondary analysis of clinical trial data analyzes 63 eligible participants prospectively recruited from an emergency department who were asked to complete a postconcussion symptom scale and record their activities in a structured diary for the next 10 days. They completed standardized assessments of symptoms (postconcussion symptom scale), cognition (Immediate Post-Concussion Assessment and Cognitive Testing), and balance (Balance Error Scoring System) 10 days following the injury. Eligible participants were aged 11 to 18 years and sustained a concussion (according to the Centers for Disease Control and Prevention criteria) that did not result in an abnormal computed tomography scan or require hospital admission. The trial was conducted from May 2010 to December 2012, and the analysis was conducted from November 2015 to February 2016. Main Outcome and Measure The occurrence of symptom spikes, defined as an increase of 10 or more points on the postconcussion symptom scale over consecutive days. Results Of the 63 participants, there were 41 boys (65.1%) and 22 girls (34.9%), and the mean (SD) age was 13.8 (1.8) years. Symptom spikes occurred in one-third of the sample (20 participants [31.7%]). Symptom spikes tended to partially resolve within 24 hours. An abrupt increase in mental activity (ie, returning to school and extracurricular activities) from one day to the next increased the risk of a symptom spike (relative risk, 0.81; 95% CI, 0.21-3.21), but most symptom spikes were not preceded by a documented increase in physical or mental activity. Patients with symptom spikes were initially more symptomatic in the emergency department and throughout the observation period but did not differ from the group without symptom spikes on cognition or balance 10 days following injury. Conclusions and Relevance Certain patients appeared susceptible to high and variable symptom reporting. Symptom spikes may not themselves be detrimental to recovery. The present findings support clinical guidelines for adolescents to return to school and activities gradually after concussion. Trial Registration clinicaltrials.gov Identifier: NCT01101724.

Frequency and Outcomes of a Symptom-Free Waiting Period After Sport-Related Concussion

Background: Guidelines and practices for the management of sport-related concussion (SRC) have evolved swiftly over the past 2 decades. Despite common recommendations for a symptom-free waiting period (SFWP) before returning to sport, past reports have suggested poor utilization rates for this intervention. Purpose: To obtain current estimates of the utilization and characterization of SFWPs with high school and collegiate athletes. Study Design: Descriptive epidemiology study. Methods: Data were extracted from a larger prospective study that followed athletes with SRC across 13 institutions in southeastern Wisconsin from 2012 to 2014. Participants included 143 contact and collision sport athletes who were followed serially through their recoveries after SRCs. Results: In the current study sample, 99.3% of athletes used an SFWP. The mean self-reported symptom duration was 6.35 days (median, 5 days), with 72.7% reporting symptom recovery within 1 week of injury, 93.7% within 2 weeks, and 99.3% within 30 days. Rate of same-season repeat concussion was low (3.8%) and was similar to or lower than the overall rate of concussion (4.3%). Five same-season repeat concussions occurred at a range of 8 to 42 days after initial injuries. Conclusion: In comparison with prior published data collected from 1999 to 2004, utilization and duration of SFWPs were higher in the current study samples (99.3% vs 60.3% of athletes reported an SFWP; mean duration, 6.1 vs 3.2 days), and athletes were withheld from sports for more days than previously reported (12.3 vs 7.4 days). Rate of same-season repeat concussion was equivalent to that of prior published data. The findings support improved adherence to clinical management guidelines through increased utilization of SFWPs after SRC.

Pediatric and adolescent concussion

Pediatric and adolescent concussion : , Pediatric and adolescent concussion : , کتابخانه دیجیتال جندی شاپور اهواز

The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion

Objective To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only. Study design Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11‐18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow‐up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2 × 2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, χ2 with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1‐9 days after injury. Results A 2 × 2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F = 6.31, P = .01, &eegr;2 = 0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1‐6 and 8 (P < .05) for the symptoms group. Rest was beneficial for patients in the signs group on verbal memory performance (t = −2.28, P = .029), but not for the symptoms group. Conclusion Compared with patients with signs of injury, patients with predominantly symptoms were more likely to remain symptomatic after injury if prescribed rest, whereas patients with signs of injury benefited from rest after a concussion. Individualized treatment planning after concussion should start in the emergency department. Trial registration ClinicalTrials.gov: NCT01101724.

Postinjury Issues and Ethics of Return to Play in Pediatric Concussion

Concussion management is an individualized process and therefore can be confusing to patients, parents, and other caregivers. There are guidelines to assist in identifying concussion symptoms and suggest return-to-play plans, but each patient deserves a unique approach to their injury. This chapter reviews the potential long-term complications of concussion, including chronic traumatic encephalopathy, chronic headaches, and neurocognitive dysfunction. It also explores the possible management options for concussed children and adolescents, many of which are emerging and somewhat experimental. Long-term psychosocial concerns are addressed. The ethics of return-to-play are also discussed.

“He is not Working up to Potential”: Atypical Attention Deficit Hyperactivity Disorder with Executive Weaknesses

Robert was referred for neuropsychological evaluation because of concerns regarding his academic achievement. In fact, he had reportedly demonstrated inconsistent motivation in school for quite some time. In early elementary school, he had not shown any difficulty acquiring basic academic skills. However, he was occasionally distractible or inattentive. In fifth grade, his parents become concerned about his relationship with his teacher. They said Robert clashed with his teacher, developed more negative emotions about school, and struggled with classroom performance. He began therapy with a social worker, which appeared to enhance his coping skills, and he showed some improvement in the classroom, but his academic performances continued to be variable. He would “freeze” on certain tests, and his mother described him as learning faster when things were presented in a song or pattern.

Pediatric neuropsychology case studies

Pediatric neuropsychology case studies : , Pediatric neuropsychology case studies : , کتابخانه الکترونیک و دیجیتال - آذرسا

On Eggshells: Pediatric Bipolar Disorder

Jeff was referred for a neuropsychological evaluation because of longstanding concerns regarding his cognitive and emotional development. In fact, Jeffs family had been searching for diagnostic clarification and treatment since he was an infant.

Dog Attack: Physical Trauma with Associated Brain Injury

Anna was a spunky and energetic young girl who enjoyed being “mommy s little helper.” She had been to her mother s friend s house many times and was familiar with her dogs. When the women stepped outside during one visit, 8-year-old Anna thought the two dogs might like to play together, so she took down the gate that separated them from each other. She remembers reaching for the rope toy, thinking she would play with them. She remembers the sounds as first the male full-grown dog attacked her and then the adult female joined in, biting her severely, mauling her head and neck. She remembers being dragged across the room and calling out for help.