Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial.

OBJECTIVE: Investigate whether resuming physical activity (PA) at 72 hours post concussion is safe and reduces symptoms at 2 weeks, compared with resting until asymptomatic. METHODS: Real-life conditions, multicentre, single-blinded randomised clinical trial, conducted in three Canadian paediatric emergency departments (ED). Children/youth aged 10-<18 years with acute concussion were recruited between March 2017 and December 2019, and randomly assigned to a 4-week stepwise return-to-PA protocol at 72 hours post concussion even if symptomatic (experimental group (EG)) or to a return-to-PA once asymptomatic protocol (control group (CG)). The primary outcome was self-reported symptoms at 2 weeks using the Health and Behaviour Inventory. Adherence was measured using accelerometers worn 24 hours/day for 14 days post injury. Adverse events (AE) (worsening of symptoms requiring unscheduled ED or primary care visit) were monitored. Multivariable intention-to-treat (ITT) and per-protocol analyses adjusting for prognostically important covariates were examined. Missing data were imputed for the ITT analysis. RESULTS: 456 randomised participants (EG: N=227; mean (SD) age=13.3 (2.1) years; 44.5% women; CG: N=229; mean (SD) age=13.3 (2.2) years; 43.7% women) were analysed. No AE were identified. ITT analysis showed no strong evidence of a group difference at 2 weeks (adjusted mean difference=-1.3 (95% CI:-3.6 to 1.1)). In adherent participants, initiating PA 72 hours post injury significantly reduced symptoms 2 weeks post injury, compared with rest (adjusted mean difference=-4.3 (95% CI:-8.4 to -0.2)). CONCLUSION: Symptoms at 2 weeks did not differ significantly between children/youth randomised to initiate PA 72 hours post injury versus resting until asymptomatic; however, many were non-adherent to the intervention. Among adherent participants, early PA was associated with reduced symptoms at 2 weeks. Resumption of PA is safe and may be associated with milder symptoms at 2 weeks. LEVEL OF EVIDENCE: 1b. TRIAL REGISTRATION NUMBER: NCT02893969. REGISTRY NAME: Pediatric Concussion Assessment of Rest and Exertion (PedCARE).

Evaluating Adherence to Return to School and Activity Protocols in Children After Concussion.

OBJECTIVE: The need to have a pediatric-specific concussion management protocol on Return to School (RTS) and Return to Activity (RTA) after concussion has been recognized internationally. The first step to evaluate the protocol effectiveness is to establish whether children and youth are adhering to these recommendations. The objective of this study was to explore the prevalence and predictors of adherence to RTS and RTA concussion management protocols for children/youth. DESIGN: A prospective cohort of children/youth with concussion. SETTING: Childhood Disability Research Centre. PARTICIPANTS: One hundred thirty-nine children/youth aged 5 to 18 years, diagnosed with concussion and symptomatic upon enrollment, were followed for up to 6 months. Primary recruitment occurred from a Children's Hospital Emergency Department. INTERVENTION: Provision of RTS/RTA guidelines. MAIN OUTCOME MEASURES: Measurement of adherence came from multiple sources, including the child's and parent's knowledge of protocols, research personnel evaluations, and self-reported stages of RTS/RTA and Post-Concussion Symptom Scale (PCSS) scores. RESULTS: Spearman correlations and logistic regression were used, investigating the relationship between PCSS and progression of protocols and determining predictors of adherence. Significant negative associations between total PCSS score and stage of RTS/RTA protocols were found. Fifty-three percent and 56% of the participants adhered to the RTS and RTA protocols, respectively. CONCLUSIONS: Children's knowledge of protocols and total PCSS scores significantly predicted adherence to RTS/RTA and may be the most important factors in predicting adherence during recovery from concussion.

The Diagnosis of Concussion in Pediatric Emergency Departments: A Prospective Multicenter Study.

BACKGROUND: The accurate identification of children with a concussion by emergency physicians is important to initiate appropriate anticipatory guidance and management. OBJECTIVES: We compared the frequency of persistent concussion symptoms in children who were provided the diagnosis of concussion by an emergency physician versus those who met Berlin/Zurich international criteria for this diagnosis. We also determined the clinical variables independently associated with a physician-diagnosed concussion. METHODS: This was a planned secondary analysis of a prospective, multicenter cohort study. Participants were 5-17 years of age and met the Zurich/Berlin International Consensus Statement criteria for concussion. RESULTS: There were 2946 enrolled children. In those with physician-diagnosed concussion vs. no concussion, the frequency of persistent symptoms was 62.5% vs. 38.8% (p < 0.0001) at 1 week, 46.3% vs. 25.8% (p < 0.0001) at 2 weeks, and 33.0% vs. 23.0% (p < 0.0001) at 4 weeks. Of those meeting international criteria, 2340 (79.4%) were diagnosed with a concussion by an emergency physician and 12 variables were associated with this diagnosis. Five had an odds ratio (OR) > 1.5: older age (13-17 vs. 5-7 years, OR 2.9), longer time to presentation (≥16 vs. <16 h, OR 2.1), nausea (OR 1.7), sport mechanism (OR 1.7), and amnesia (OR 1.6). CONCLUSIONS: Relative to international criteria, the more selective assignment of concussion by emergency physicians was associated with a greater frequency of persistent concussion symptoms. In addition, while most children meeting international criteria for concussion were also provided this diagnosis for concussion by an emergency physician, the presence of 5 specific variables made this diagnosis more likely.

Quality-of-life after brain injury in childhood: time, not severity, is the significant factor.

OBJECTIVE: Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI. METHODS: The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL. RESULTS: The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS. CONCLUSIONS: QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.

A review of brain regions and associated post-concussion symptoms.

The human brain is an exceptionally complex organ that is comprised of billions of neurons. Therefore, when a traumatic event such as a concussion occurs, somatic, cognitive, behavioral, and sleep impairments are the common outcome. Each concussion is unique in the sense that the magnitude of biomechanical forces and the direction, rotation, and source of those forces are different for each concussive event. This helps to explain the unpredictable nature of post-concussion symptoms that can arise and resolve. The purpose of this narrative review is to connect the anatomical location, healthy function, and associated post-concussion symptoms of some major cerebral gray and white matter brain regions and the cerebellum. As a non-exhaustive description of post-concussion symptoms nor comprehensive inclusion of all brain regions, we have aimed to amalgamate the research performed for specific brain regions into a single article to clarify and enhance clinical and research concussion assessment. The current status of concussion diagnosis is highly subjective and primarily based on self-report of symptoms, so this review may be able to provide a connection between brain anatomy and the clinical presentation of concussions to enhance medical imaging assessments. By explaining anatomical relevance in terms of clinical concussion symptom presentation, an increased understanding of concussions may also be achieved to improve concussion recognition and diagnosis.

School performance in youth after a concussion.

Objective: This study aimed to identify school problems and levels of cognitive activity in youths aged 5-18 years with a concussion during the recovery stages of return to school (RTS). Study Design: In a prospective cohort, participants completed in-person assessments at three time points: First Visit Post-injury, Symptom Resolution Visit, and Follow-Up Visit. These time points varied based on the participants' recovery progress. The post-concussion symptom scale (PCSS) and a cognitive activity scale were completed every 2 days until symptom resolution was achieved. Participants and their parents completed a school questionnaire detailing how their concussion had impacted their school learning/performance and their level of concern about their injury as well as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Results: Sixty-three percent (N = 44/70) of participants returned to school by the First Visit Post-injury (average 7.7 days following injury), and of these, 50% (N = 22) were experiencing school problems. Sixty-five participants (out of 70) returned to school at the Follow-Up Visit, and of these, 18% reported school problems. There was a significant difference in the school problems reported by parents and youth. At the First Visit Post-injury, the youth reported more problems (p = 0.02), and the In-Person Symptom Resolution Visit with parents reported more problems (p = 0.01). The cognitive activity score increased, while the PCSS score decreased from RTS Stage 1 to Stage 5. Conclusions: This study identified that 50% of youth experienced school problems at the First Visit Post-injury, whereas only 18% reported school problems at the Follow-Up Visit. There is a significant difference in the perception of school problems reported by youth and their parents at different stages of recovery. The amount and complexity of cognitive activity increased with decreasing symptoms and increasing RTS stage. Findings can guide youth with a concussion and their parents in supporting a cautious return to school with accommodations. Healthcare providers and researchers can use this knowledge to better support youth in their return to school and understand the importance of gathering information from youth and their parents to gain the best insight into recovery.

What Comes First: Return to School or Return to Activity for Youth After Concussion? Maybe We Don't Have to Choose.

Objectives: Return to School (RTS) and Return to Activity/Play (RTA) protocols are important in concussion management. Minimal evidence exists as to sequence and whether progression can occur simultaneously. Experts recommend that children/youth fully return to school before beginning RTA protocols. This study investigates recovery trajectories of children/youth while following RTA and RTS protocols simultaneously, with the following objectives: (1) to compare rates and patterns of progression through the stages of both protocols; (2) to evaluate symptom trajectories of youth post-concussion while progressing through stages of RTS and RTA; and (3) to propose a new model for concussion management in youth that involves the integration of Return to Activity and Return to School protocols. Methods: In a 3-year prospective-cohort study of 139 children/youth aged 5-18 years with concussive injury, self-reported symptoms using PCSS and stage of protocols were evaluated every 48 h using electronic surveys until full return to school and activity/sport were attained. Information regarding school accommodation and achievement was collected. Results: Sample mean age is 13 years, 46% male. Youth are returning to school with accommodations significantly quicker than RTA (p = 0.001). Significant negative correlations between total PCSS score and stage of RTS protocol were found at: 1-week (r = -0.376, p < 0.0001; r = -0.317, p = 0.0003), 1-month (r = -0.483, p < 0.0001; r = -0.555, p < 0.0001), and 3-months (r = -0.598, p < 0.0001; r = -0.617, p < 0.0001); indicating lower symptom scores correlated with higher guideline stages. Median full return to school time is 35 days with 21% of youth symptomatic at full return. Median return time to full sport competition is 38 days with 15% still symptomatic. Sixty-four percent of youth reported experiencing school problems during recovery and 30% at symptom resolution, with 31% reporting a drop in their grades during recovery and 18% at study completion. Conclusions: Children/youth return to school faster than they return to play in spite of the self-reported, school-related symptoms they experience while moving through the protocols. Youth can progress simultaneously through the RTS and RTA protocols during stages 1-3. Considering the numbers of youth having school difficulties post-concussion, full contact sport, stage 6, of RTA, should be delayed until full and successful reintegration back to school has been achieved. In light of the huge variability in recovery, determining how to resume participation in activities despite ongoing symptoms is still the challenge for each individual child. There is much to be learned with further research needed in this area.

Exploring postinjury living environments for children and youth with acquired brain injury.

OBJECTIVES: To explore and describe the extent to which children and youth (10-18y) with acquired brain injury in Ontario are living in environments considered inappropriate, to describe the nature of services and supports in those environments, and to determine appropriate living environments for children and youth with acquired brain injury. DESIGN: A mixed-methods approach with a case-study design was used in which the living environment represented the case. This article reports on the qualitative component. SETTING: Community agencies and service providers. PARTICIPANTS: Forty-four service providers across a wide range of profit and nonprofit services for children and youth with acquired brain injury throughout the province of Ontario. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Semistructured in-depth interviews with participants. RESULTS: Seven major themes emerged from the data: kids go home, a continuum of appropriateness, show me the way home, same chapter different story, cracking the acquired brain injury code, who said care was fair, and coping, and managing and advocating: new dimensions for families. Important service recommendations were also reported. CONCLUSIONS: Most children and youth with acquired brain injury are living at home. The level of appropriateness of the environment for children and youth after acquired brain injury can depend on multiple interrelated factors including type and severity of acquired brain injury, existing services and service delivery, acquired brain injury knowledge, and family's ability to cope and manage.

"My child doesn't have a brain injury, he only has a concussion".

OBJECTIVE: The term "concussion" is frequently used in clinical records to describe a traumatic head injury; however, there are no standard definitions of this term, particularly in how it is used with children. The goals of this study were to examine the clinical correlates of the concussion diagnosis and to identify the factors that lead to the use of this term in a regional pediatric center. METHODS: Medical data were prospectively collected from 434 children with traumatic brain injury who were admitted to a Canadian children's hospital. A proportional hazards regression was used to examine the association of the concussion diagnosis and the times until discharge and school return. A classification-tree analysis modeled the clinical correlates of patients who received a concussion diagnosis. RESULTS: The concussion label was significantly more likely to be applied to children with mild Glasgow Coma Scale scores of 13 to 15 (P = .03). The concussion label was strongly predictive of earlier hospital discharge (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.2-1.9; P = .003) and earlier return to school (OR: 2.4 [95% CI: 1.6-3.7]; P < .001). A diagnosis of a concussion was significantly more likely when the computed-tomography results were normal and the child had lost consciousness. CONCLUSIONS: Children with mild traumatic brain injuries have an increased frequency of receiving the concussion label, although the label may also be applied to children with more-severe injuries. The concussion diagnosis is associated with important clinical outcomes. Its typical use in hospital settings likely refers to an impact-related mild brain injury, in the absence of indicators other than a loss of consciousness. Clinicians may use the concussion label because it is less alarming to parents than the term mild brain injury, with the intent of implying that the injury is transient with no significant long-term health consequences.