Sean C. Rose

The Diagnosis and Management of Concussion in Children and Adolescents

BACKGROUND Concussion is a complex brain injury that results in more than 100,000 emergency department visits for school-aged children each year in the United States. All 50 US states have passed concussion legislation designed to promote safety in youth sports. Most of these laws require medical clearance by a licensed health care provider before returning to sport, which may have contributed to an increase in pediatric subspecialty referrals, particularly referrals to the child neurologist. METHODS We reviewed the literature on pediatric concussion. RESULTS This review summarizes the current knowledge and recommendations for concussion diagnosis and management in children and adolescents, athletes and nonathletes. It highlights concussion epidemiology, pathophysiology, advances in neuroimaging, and potential health risks including second impact syndrome and chronic traumatic encephalopathy. It also underscores clinical areas where evidence is lacking. CONCLUSIONS The diagnosis and management of concussion requires specific considerations in children. Further concussion research must be done to minimize injury risk and to optimize medical care for this common problem.

How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis

Abstract Background/aim: A standard definition of Post-concussion Syndrome (PCS) does not exist. The objective was to determine consensus regarding the definition of PCS among physician members of the American College of Sports Medicine (ACSM). Methods: Physician members of the ACSM were sent an electronic survey to determine opinions regarding the PCS diagnosis. Results: Five hundred and ninety-seven physicians completed the survey. When asked the minimum duration of symptoms required to diagnose PCS, respondents answered: <2 weeks (26.6%), 2 weeks to 1 month (20.4%), 1–3 months (33%) and >3 months (11.1%). Physicians who see ≥10% concussion patients in their practise, as well as physicians whose concussion population consists of >50% paediatric patients, were more likely to require >1 month of symptoms (p < 0.001). When asked the minimum number of symptoms required to diagnose PCS, responses varied: one symptom (55.9%), two symptoms (17.6%), three symptoms (14.6%) and four or more symptoms (3.2%). Respondents from the US were more likely than non-US respondents to require only one symptom for the PCS diagnosis (p = 0.01). Conclusions: There is a lack of consensus regarding the definition of PCS among physician members of the ACSM. A standard definition would improve consistency in concussion research and in clinical practise.

Comparing patient and parent recall of 90-day and 30-day migraine disability using elements of the PedMIDAS and an Internet headache diary

Aim The aim of this article is to compare 90-day and 30-day recall of Pediatric Migraine Disability Assessment (PedMIDAS) elements and headache frequency against daily entries from an Internet headache diary among pediatric patients and their parents. Methods In a prospective cohort study, patients aged 10–18 years with episodic migraine or probable migraine completed a 90-day Internet-based headache diary that incorporated PedMIDAS questions. Following the 90-day diary period, patients and parents completed modified PedMIDAS instruments to assess 90-day and 30-day recall. Intraclass correlation coefficients (ICC) were calculated to measure recall reliability. The Kruskal-Wallis and Jonckheere-Terpstra tests were used to explore recall accuracy as it relates to each participant’s self-reported confidence in recall and to patient age. Results Fifty-two subjects completed 90 consecutive diary entries. Comparing 30-day to 90-day recall of PedMIDAS elements, ICC scores improved by 26.2% (patients) and 17.5% (parents). Patients had better recall than their parents for all study measures. Self-reported confidence in recall and patient age had limited and inconsistent effects on recall accuracy. Conclusion The optimal recall interval to assess migraine disability must balance recall accuracy with generalizability across a range of headache frequencies. When compared to daily diary entries, recall accuracy of PedMIDAS elements and headache frequency improves at 30 days compared to 90 days. Parent report of migraine disability should not be used as a replacement for patient report.

Specific Headache Factors Predict Sleep Disturbances Among Youth With Migraine

BACKGROUND There is a paucity of pediatric data addressing the complex relationship between primary headaches and sleep disturbances. Our study objective was to explore headache-related factors that predict sleep disturbance and to compare sleep complaints with other forms of headache-related disability among youth with migraines. METHODS A prospective cohort study was conducted in patients 10-18 years old with migraine or probable migraine and without daily sleep complaints. The patients completed a 90-day internet-based headache diary. On headache days, patients rated headache intensity, answered Pediatric Migraine Disability Assessment-based questions modified for daily scoring, and reported sleep disturbances that resulted as a direct effect of proximate headaches. RESULTS Fifty-two patients generated 4680 diary entries, 984 patients (21%) involved headaches. Headache intensity (P = 0.009) and timing of headache onset (P < 0.001) were predictive of sleep disturbances. Three Pediatric Migraine Disability Assessment-based items were also associated with sleep disturbances: partial school-day absence (P = 0.04), recreational activities prevented (P < 0.001), and decreased functioning during recreational activities (P < 0.001). Sleep disturbances correlated positively and significantly with daily headache disability scores (rpb = 0.35; P < 0.01). CONCLUSION We conclude that specific headache factors predict sleep disturbances among youth with primary headaches.

Post-traumatic headaches correlate with migraine symptoms in youth with concussion

Objective The term “post-traumatic migraine” (PTM) has been used to describe post-traumatic headaches (PTHs) that have associated migraine features, but studies of this relationship are lacking. The objective of the present study was to determine whether PTH correlates strongly with migraine symptoms among youth with concussion. Methods Twenty-three symptoms were analyzed from a retrospective cohort of 1953 pediatric patients with concussion. A principal component analysis (PCA) with oblique Promax rotation was conducted to explore underlying symptom relationships in the full cohort and in subcohorts stratified by the presence (n = 414) or absence (n = 1526) of premorbid headache. Results The mean patient age was 14.1 years; 63% were male. Headache was the most common postconcussion symptom, acknowledged by 69.4% of patients. When considering the full cohort, the PCA demonstrated clustering of headache with photophobia, phonophobia, nausea, dizziness, and neck pain. Similar clustering was present among patients without premorbid headaches. Repeating the analysis in the patients with preconcussion headaches led to elimination of neck pain from the cluster. Conclusions PTH correlates strongly with other migraine symptoms among youth with concussion, regardless of premorbid headaches. This clustering of migraine symptoms supports the existence of PTM as a distinct clinical entity in some patients.

PedMIDAS-Based Scoring Underestimates Migraine Disability on Non-School Days

The aim of this study is to compare daily Pediatric Migraine Disability Assessment (PedMIDAS)‐based scores for headaches occurring on school days vs non‐school days and during the school year vs the summer holiday.

Which Factors Affect Daily Compliance With an Internet Headache Diary Among Youth With Migraine

Objective:To determine the specific factors that affect Internet headache diary compliance among youth with primary headaches. Materials and Methods:Patients aged 10 to 18 years completed a 90-day Internet-based headache diary with date-stamping and time-stamping features that allowed compliance monitoring. Eight potential predictors were assessed in a multilevel statistical model of headache diary compliance: age, sex, diary entries during the school year versus summer, entries on evenings preceding weekends (Friday or Saturday) versus evenings preceding weekdays (Sunday through Thursday), headache days versus nonheadache days, headache intensity ratings, use of an abortive headache medicine, and the first 2 weeks of diary use versus the latter 76 days. Results:Fifty-two patients generated 4680 diary entries; 3215 (68.7%) entries were compliant (completed via same-day diary entries). Compliance for each diary participant ranged from 39% to 97% (mean, 68.7%; median, 70%; SD=0.15%). Three specific factors were associated with diary compliance in the multilevel model. Compliance was better on days when an abortive headache medicine was used (P<0.001; odds ratio [OR], 33.7 [95% confidence interval [CI], 13.1-86.6]) and during the first 2 weeks of the diary period versus the remaining 76 days (P=0.05; OR, 1.3 [95% CI, 1.03-1.68]). Compliance was worse on evenings proceeding weekends versus evenings preceding weekdays (P<0.001; OR, 0.55 [95% CI, 0.46-0.66]). Patients who did not start the diary protocol (n=12) or did not complete the 90 days (n=14) were excluded from the analysis. Discussion:Specific factors predict Internet-based headache diary compliance. Further research about the factors related to diary compliance and the optimization of diary-based data collection is warranted.

Returning the student to school after concussion: what do clinicians need to know?

Participation in school is vital to a child’s academic and social development. Following concussion, returning the student to school can pose several challenges for families, healthcare providers and school personnel. The complex constellation of postconcussion symptoms can impair learning and can make the school environment intolerable. Research evidence to guide the return to school process is lacking, but protocols have been proposed that outline a gradual reintroduction to school with academic accommodations tailored to the student’s specific symptoms. Key medical and school personnel must understand their respective roles to optimize the process. This review of the current literature examines the available data and expert recommendations that can support a student’s successful return to school following concussion.

Utilization of conventional neuroimaging following youth concussion.

ABSTRACT Background/objective: Conventional neuroimaging is not recommended for the routine diagnosis of concussion, but some patients with concussion undergo computed tomography (CT) or magnetic resonance imaging (MRI). The objective of this study was to explore the clinical factors that predict neuroimaging utilization in concussion. Methods: Concussion-related CT and MRI data were analysed from 1953 patients, aged 10–19 years, who presented to a sports concussion clinic within 30 days of injury. Results: The majority of CT scans (n = 193) were obtained during the acute concussion period (mean = 2.7 days post-concussion), whereas MRI scans (n = 134) were ordered later during recovery (mean = 39.4 days post-concussion). Predictors of CT utilization included loss of consciousness, amnesia and vomiting (all p < 0.001). Prior concussion (p = 0.002) and continued participation in activity after injury (p = 0.03) predicted greater MRI utilization. Neuroimaging with either CT (p = 0.024, hazard ratio = 1.2) or MRI (p < 0.001, hazard ratio = 2.75) was associated with prolonged symptoms. Only 3.1% of CTs and 1.5% of MRIs demonstrated signs of traumatic brain injury. Conclusion: Several clinical factors predict neuroimaging utilization in patients with concussion. CT is generally used acutely, while MRI is used in the sub-acute and chronic post-concussion periods. In a sports concussion clinic, delayed neuroimaging has limited clinical yield.

Physicians’ Management Practices and Perceived Health Risks When Postconcussion Symptoms Persist

Background: Concussion guidelines recommend physical and cognitive rest until all postconcussion symptoms resolve, in part because of potential health risks, including catastrophic injury related to a second impact. However, when postconcussion symptoms persist for weeks or months, these risks are poorly characterized. Hypothesis: Physicians’ perceived health risks and management strategies for patients with persistent postconcussion symptoms will vary. Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: A survey of the physician members of the American College of Sports Medicine assessed the perceived health risks related to advancing activity, the indications for neuroimaging, and the referral patterns for patients with persistent postconcussion symptoms. Results: A total of 572 physicians completed the survey (response rate, 27.2%). The majority of physicians recommended physical rest (97.4%) and cognitive rest (93.8%) within the first week of injury. Perceived health risks related to advancing activity in the symptomatic patient differed at 2 weeks versus 3 months after injury (P < 0.001 for all comparisons). Respondents from the United States were more likely to list second impact syndrome as a potential health risk at 2 weeks compared with respondents from other countries (P = 0.04). The majority (56%) responded that the risk of second impact syndrome remains until all symptoms resolve. When postconcussion symptoms persist beyond 1 month, 61.9% of physicians responded that neuroimaging is indicated. Approximately 60% of respondents had access to a multidisciplinary concussion clinic within 60 miles of their practice. Conclusion: When postconcussion symptoms persist, the perceived health risks, management practices, and access to multidisciplinary care vary among physicians.