Assessment of sleep parameters in adults with persistent post-concussive symptoms.

OBJECTIVES: The primary aim of this study was to characterize sleep in adults with persistent post-concussive symptoms (PPCS). Secondary aims explored relationships between sleep parameters, injury characteristics, and symptom questionnaires. METHODS: This case-controlled, cross-sectional study recruited adults (18-65yrs) diagnosed with PPCS and age and sex-matched controls. Participants wore a wrist-worn actigraph for 3-7 nights and completed daily sleep diaries. Participants completed questionnaires examining daytime sleepiness, fatigue, anxiety/depressive symptoms, and sedentariness. Sleep parameters were compared between groups using Mann-Whitney U tests. Secondary analyses used two-way ANOVA and Spearman's rank correlations. RESULTS: Fifty adults with PPCS (43.7 ± 10.6yrs, 78 % female) and 50 controls (43.6 ± 11.0yrs) were included in this study. Adults with PPCS had significantly longer sleep onset latency (PPCS 16.99 ± 14.51min, Controls 8.87 ± 6.44min, p < 0.001) and total sleep time (PPCS 8.3 ± 1.0hrs, Control 7.6 ± 0.9hrs, p = 0.030) compared to controls, but woke up later (PPCS 7:57:27 ± 1:36:40, Control 7:17:16 ± 0:50:08, p = 0.026) and had poorer sleep efficiency (PPCS 77.9 ± 7.5 %, Control 80.8 ± 6.0 %, p = 0.019) than controls. Adults with PPCS reported more daytime sleepiness (Epworth Sleepiness Scale: PPCS 8.70 ± 4.61, Control 4.28 ± 2.79, p < 0.001) and fatigue (Fatigue Severity Scale: PPCS 56.54 ± 12.92, Control 21.90 ± 10.38, p < 0.001). Injury characteristics did not significantly affect sleep parameters in adults with PPCS. Actigraphy parameters were not significantly correlated to questionnaire measures. CONCLUSION: Several actigraphy sleep parameters were significantly altered in adults with PPCS compared to controls, but did not correlate with sleep questionnaires, suggesting both are useful tools in characterizing sleep in PPCS. Further, this study provides potential treatment targets to improve sleep difficulties in adults with PPCS.

Quantitative Multimodal Assessment of Concussion Recovery in Youth Athletes.

OBJECTIVE: To evaluate recovery trajectories among youth athletes with a concussion and healthy controls across different domains using a quantitative and multifaceted protocol. STUDY DESIGN: Prospective repeated measures. PARTICIPANTS: Youth athletes diagnosed with a concussion between the ages of 8 and 18 years were evaluated (1) within 10 days after injury, (2) approximately 3 weeks after injury, and (3) after return-to-play clearance. Control participants completed the same protocol. SETTING: Sport concussion clinic. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Participants underwent a multifaceted protocol that assessed symptoms (postconcussion symptom scale [PCSS]), dual-task gait, event-related potentials (ERPs), and eye tracking. RESULTS: Sixty-seven athletes participated: 36 after concussion (age = 14.0 ± 2.6 years; 44% female) and 31 controls (age = 14.6 ± 2.2 years; 39% female). Concussion symptoms were higher for the concussion group compared with controls at the first (PCSS = 31.7 ± 18.8 vs 1.9 ± 2.9; P < 0.001) and second time points (PCSS = 10.8 ± 11.2 vs 1.8 ± 3.6; P = 0.001) but resolved by the final assessment (PCSS = 1.7 ± 3.6 vs 2.0 ± 3.8; P = 0.46). The concussion group walked slower during dual-task gait than controls at all 3 tests including after return-to-play clearance (0.83 ± 0.19 vs 0.95 ± 0.15 m/s; P = 0.049). There were no between-group differences for ERP connectivity or eye tracking. Those with concussions had a decrease in ERP connectivity recovery over the 3 time points, whereas control participants' scores increased (concussion Δ = -8.7 ± 28.0; control Δ = 13.9 ± 32.2; χ2 = 14.1, P = 0.001). CONCLUSIONS: Concussion is associated with altered dual-task gait speeds after resolution of concussion symptoms, but ERP and eye tracking measures did not demonstrate between-group differences across time. Some objective approaches to concussion monitoring may support with identifying deficits after concussion, but further work is required to delineate the role of gait, electrophysiological, and eye tracking methods for clinical decision-making.

Predictors of Sleep Outcomes Following Mild Traumatic Brain Injury in Preschoolers: Subjective and Objective Assessment of Outcome.

OBJECTIVES: To investigate sleep and its predictors in preschoolers with mild traumatic brain injury (mTBI). PARTICIPANTS AND PROCEDURE: The sample included 225 children, aged 18 to 60 months, divided into 3 groups: children with accidental mTBI (n = 85), children with orthopedic injury (n = 58), and typically developing children (n = 82). Retrospective reports of preinjury sleep and family functioning were obtained as part of a baseline assessment at the time of recruitment. Parental ratings of sleep problems were collected 6 months postinjury on the full sample, and actigraphy data were collected on a subset of children. Demographic, preinjury, and periinjury factors were examined as potential predictors of sleep outcomes. RESULTS: No group differences were found in ratings of sleep problems or for nighttime sleep duration and sleep efficiency, as measured by actigraphy. Besides, preexisting sleep disturbances and brain injury resulting in alteration of consciousness were identified as predictors of poorer sleep in the mTBI group. CONCLUSION: Although mTBI did not result in group-level sleep disturbances 6 months postinjury, the findings suggest that premorbid and injury-related factors place some children at risk for poorer sleep after mTBI. These factors should be documented so clinicians can intervene early.

Assessment of Oculomotor Function in Patients With Postconcussion Syndrome: A Systematic Review.

BACKGROUND: Concussion and its associated sequel, postconcussion syndrome (PCS), have a debilitating impact on the lives of concussed patients. However, a diagnostic biomarker for this condition is lacking. Recently, there has been a surge of interest in using oculomotor function testing as an objective assessment of patients with PCS. OBJECTIVES: To systematically synthesize, appraise, and summarize all published empirical studies that have assessed alteration of oculomotor functions in patients with PCS. METHODS: Medline, Embase, PsychINFO, and CINAHL databases searched up to July 2016 for studies that used oculomotor function assessment in patients with postconcussion symptoms. RESULTS: The search identified 1637 citations, and finally 8 case-control studies were included. Of these, 5 studies used a similar task with a target moving in a circular trajectory. Three other studies measured conventional oculomotor tasks such as saccade, vergence, and smooth pursuit eye movements. CONCLUSIONS: Currently, there is limited support for the recommendation of oculomotor function assessments for diagnosis and identification of patients with PCS following head trauma. Therefore, more rigorous studies assessing oculomotor function changes in patients with PCS are warranted.

Applying an Evidence-Based Assessment Model to Identify Students at Risk for Perceived Academic Problems following Concussion.

OBJECTIVES: The aim of this study was to demonstrate the utility of an evidence-based assessment (EBA) model to establish a multimodal set of tools for identifying students at risk for perceived post-injury academic problems. METHODS: Participants included 142 students diagnosed with concussion (age: M=14.95; SD=1.80; 59% male), evaluated within 4 weeks of injury (median=16 days). Demographics, pre-injury history, self- and parent-report measures assessing symptom severity and executive functions, and cognitive test performance were examined as predictors of self-reported post-injury academic problems. RESULTS: Latent class analysis categorized participants into "high" (44%) and "low" (56%) levels of self-reported academic problems. Receiver operating characteristic analyses revealed significant discriminative validity for self- and parent-reported symptom severity and executive dysfunction and self-reported exertional response for identifying students reporting low versus high academic problems. Parent-reported symptom ratings [area under the receiver operating characteristic curve (AUC)=.79] and executive dysfunction (AUC=.74), and self-reported ratings of executive dysfunction (AUC=.84), symptoms (AUC=.80), and exertional response (AUC=.70) each classified students significantly better than chance (ps<.001). Hierarchical logistic regression indicated that, of the above, self-reported symptoms and executive dysfunction accounted for the most variance in the prediction of self-reported academic problems. CONCLUSIONS: Post-concussion symptom severity and executive dysfunction significantly predict perceived post-injury academic problems. EBA modeling identified the strongest set of predictors of academic challenges, offering an important perspective in the management of concussion by applying traditional strengths of neuropsychological assessment to clinical decision making. (JINS, 2016, 22, 1038-1049).

Method of symptom assessment influences cognitive, affective and somatic post-concussion-like symptom base rates.

PRIMARY OBJECTIVE: To investigate whether assessment method influences the type of post-concussion-like symptoms. METHODS AND PROCEDURES: Participants were 73 Australian undergraduate students (Mage = 24.14, SD = 8.84; 75.3% female) with no history of mild traumatic brain injury (mTBI). Participants reported symptoms experienced over the previous 2 weeks in response to an open-ended question (free report), mock interview and standardized checklist (British Columbia Post-concussion Symptom Inventory; BC-PSI). MAIN OUTCOMES AND RESULTS: In the free report and checklist conditions, cognitive symptoms were reported significantly less frequently than affective (free report: p < 0.001; checklist: p < 0.001) or somatic symptoms (free report: p < 0.001; checklist: p = 0.004). However, in the mock structured interview condition, cognitive and somatic symptoms were reported significantly less frequently than affective symptoms (both p < 0.001). No participants reported at least one symptom from all three domains when assessed by free report, whereas most participants did so when symptoms were assessed by a mock structured interview (75%) or checklist (90%). CONCLUSIONS: Previous studies have shown that the method used to assess symptoms affects the number reported. This study shows that the assessment method also affects the type of reported symptoms.

Quantitative assessment of post-concussion syndrome following mild traumatic brain injury using robotic technology.

Post-Concussion Syndrome (PCS) is a common sequelae of mild Traumatic Brain Injury (mTBI). Currently, there is no reliable test to determine which patients will develop PCS following an mTBI. As a result, clinicians are challenged to identify patients at high risk for subsequent PCS. Hence, there is a need to develop an objective test that can guide clinical risk stratification and predict the likelihood of PCS at the initial point of care in an Emergency Department (ED). This paper presents the results of robotic-assisted neurologic testing completed on mTBI patients in the ED and its ability to predict PCS at 3 weeks post-injury. Preliminary results show that abnormal proprioception, as measured using robotic testing is associated with higher risk of developing PCS following mTBI. In this pilot study, proprioceptive measures obtained through robotic testing had a 77% specificity (95CI: 46%-94%) and a 64% sensitivity (95CI: 41%-82%).

Postconcussive impairment differences across a multifaceted concussion assessment protocol.

OBJECTIVE: To examine the proportion of athletes with concussion and with impairment disagreements across various clinical concussion assessment measures. DESIGN: Quasi-experimental repeated measures design. SETTING: Clinical research laboratory. PARTICIPANTS: A sample of 100 collegiate-aged athletes participated in the study (mean [SD] age, 18.5 ± 1.1 years; mean [SD] height, 180.6 ± 9.9 cm; mean [SD] weight, 84.1 ± 20.6 kg). METHODS OR INTERVENTIONS: Participants completed preseason baseline and postconcussive injury assessments on a clinical assessment battery, including a 17-item graded symptom checklist, a computerized neurocognitive assessment, and a balance performance assessment. MAIN OUTCOME MEASUREMENTS: Symptom severity total score, 8 cognitive domain scores from the Automated Neuropsychological Assessment Metrics, and the composite balance score obtained from the Sensory Organization Test served as outcome measures for the study. McNemar tests of paired proportions were then used to analyze impairment disagreements (where one measure identified impairments not identified by the other) between the study outcome measures. The α level was set to .05 a priori. RESULTS: We observed significant disagreements between symptom severity total scores, and all other measures used in the study in which symptom severity total scores identified more impairments than all other measures. In addition, we observed significant disagreements for half of the clinical measures used in the study, with disagreement proportions that ranged from 22%-52%. CONCLUSIONS: Our study underscores the importance of using a multifaceted approach for management of concussion that includes assessment of symptom severity, cognitive function, and balance. Use of this multifaceted approach also can aid clinicians in understanding other comorbidities that may complicate the management of concussion.

[Sensorineural hearing loss after dull head injury or concussion trauma]. / Innenohrschwerhörigkeit nach stumpfem Schädelhirntrauma bzw. Kopfanpralltrauma.

A dull head injury can lead to isolated damage of the inner ear (cochlear labyrinthine concussion) or damage of the otolithe organ (vestibular labyrinthine concussion) due to a bone conduction pressure . A typical sign is a high frequency SNHL in form of a c5-dip. The c5-dip can be bilateral or unilateral or different on each side - dependant on the side of injury. In case of a unilateral skull base fracture a contralateral labyrinthine concussion is also possible. Moreover a lot of cases also show an accompanying tinnitus. This knowledge is based on animal and human experiments, as well as data from clinical and medical report examinations over decades. It is important to differentiate between a SNHL caused by accident or uni- or bilateral endogenic degenerative hearing loss.

Measuring post-concussion symptoms in adolescents: feasibility of ecological momentary assessment.

Although there is a large literature examining head trauma in general, several areas remain understudied. Notably, little is known about symptom expression over the course of a day for adolescents recovering from concussion. Furthermore, intra-individual symptom variability has not been well characterized. This pilot study examined the feasibility of a momentary data-gathering method, as well as the sensitivity of the assessment to the subtle and dynamic changes in symptoms of concussion. Six adolescents, three of whom suffered a concussion and three non-injured controls, provided symptom ratings five times per day for 5 days. This ecological momentary assessment (EMA) was conducted on a personal digital assistant to capture variability in symptom reports while in the natural environment. Preliminary results indicated that the EMA method showed great promise as a research tool in natural settings (e.g., school and home). Adolescents were able to comply with all tasks with little interference in their daily activities. Students with concussion showed generally higher symptom ratings across physical, cognitive, and affective domains, and temporal and diurnal patterns for symptoms emerged. Implications for future research and patient care are discussed.

Family burden and parental distress following mild traumatic brain injury in children and its relationship to post-concussive symptoms.

OBJECTIVE: To examine the relationship of mild traumatic brain injuries (TBI) and post-concussive symptoms (PCS) to post injury family burden and parental distress, using data from a prospective, longitudinal study. METHODS: Participants included 71 children with mild TBI with loss of consciousness (LOC), 110 with mild TBI without LOC, and 97 controls with orthopedic injuries not involving the head (OI), and their parents. Shortly after injury, parents and children completed a PCS interview and questionnaire, and parents rated premorbid family functioning. Parents also rated family burden and parental distress shortly after injury and at 3 months post injury. RESULTS: Mild TBI with LOC was associated with greater family burden at 3 months than OI, independent of socioeconomic status and premorbid family functioning. Higher PCS shortly after injury was related to higher ratings of family burden and distress at 3 months. CONCLUSIONS: Mild TBI are associated with family burden and distress more than mild injuries not involving the head, although PCS may influence post injury family burden and distress more than the injury per se. Clinical implications of the current findings are noted in the Discussion section.

Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery.

Little scientific attention has been aimed at the non-acute clinical care of pediatric mild TBI. We propose a clinical management model focused on both evaluation and intervention from the time of injury through recovery. Intervention strategies are outlined using a framework encompassing four relevant domains: the individual youth, family, school, and athletics. Clinical management has primary value in its potential to speed recovery, minimize distress during the recovery process, and reduce the number of individuals who subjectively experience longer lasting postconcussive problems. With proper management, most children and adolescents sustaining an uncomplicated mild TBI can be expected to recover fully.

A validation of the post concussion symptom scale in the assessment of complex concussion using cognitive testing and functional MRI.

BACKGROUND: Clinical assessment of cerebral concussion relies on the presence and duration of post concussive symptoms (PCS). Given that these PCS are subjective reports and not always specific to concussion, their usefulness remains to be validated. OBJECTIVE: To evaluate the usefulness of self-reported PCS by means of cognitive tests and functional MRI (fMRI). METHOD: 28 male athletes with and without concussion were grouped according to their PCS score. They were then administered a computerised cognitive test battery and submitted to an fMRI session where cerebral activations associated with verbal and non-verbal working memory tasks were analysed. RESULTS: Behaviourally, response accuracy and speed on the cognitive test battery were comparable for the control and low PCS group. The moderate PCS group showed significantly slower response times than the control group on the matching (p<0.05) and one-back tasks (p<0.05). The functional MRI study showed reduced task related activation patterns in the dorsolateral prefrontal cortex for both low and moderate PCS groups. Activation peaks outside the regions of interest, not seen in the control group, were also noted for both PCS groups. Regression analyses indicated an inverse relationship between PCS scores and performances on several CogSport subtests. Severity of PCS also predicted fMRI blood oxygen level dependent signal changes in cerebral prefrontal regions. CONCLUSION: Self-reported PCS is associated with an ongoing cerebral haemodynamic abnormality as well as with mild cognitive impairment. These results support the use of the PCS scale in the assessment of cerebral concussion and in monitoring recovery.