Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review.

STUDY OBJECTIVE: Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. METHODS: We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS: We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. CONCLUSIONS: We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Current Management of Neuroendocrine Tumour Liver Metastases.

PURPOSE OF REVIEW: This article aims to illustrate the current state of investigations and management of liver metastases in patients with Neuroendocrine Neoplasms. Neuroendocrine tumours (NETs) are rising in incidence globally and have become the second most prevalent gastrointestinal malignancy in UK and USA. Frequently, patients have metastatic disease at time of presentation. The liver is the most common site of metastases for gastro-enteropancreatic NETs. Characterisation of liver metastases with imaging is important to ensure disease is not under-staged. RECENT FINDINGS: Magnetic resonance imaging and positron emission tomography are now becoming standard of care for imaging liver metastases. There is an increasing armamentarium of therapies available for management of NETs and loco-regional therapy for liver metastases. The data supporting surgical and loco-regional therapy is reviewed with focus on role of liver transplantation. It is important to use appropriate imaging and classification of NET liver metastases. It is key that decisions regarding approach to treatment is undertaken in a multidisciplinary team and that individualised approaches are considered for management of patients with metastatic NETs.

The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury.

OBJECTIVE: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings. DESIGN: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus. PARTICIPANTS: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations. RESULTS: The first 2 Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.' CONCLUSIONS: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Online youth concussion resources for Canadian teachers and school staff: A systematic search strategy.

INTRODUCTION: Teachers and school staff (i.e., principals, coaches, trainers, educational assistants, guidance counselors, school healthcare professionals, etc.) are well positioned to support students' return-to-school post-concussion. Teachers and school staff may access concussion resources online as they are readily available; however, their quality and accuracy are unknown. OBJECTIVE: To identify accurate online concussion resources suitable for Canadian teachers and school staff. METHODS: A five-phased systematic search strategy was conducted: 1) initial identification of resources; 2) consultation of pediatric concussion experts; 3) inclusion and exclusion criteria; 4) content review; and, 5) material evaluation. RESULTS: A total of 837 resources were identified initially and 40 resources were included in the final list. Across all resources, 310 (37%) resources were excluded as they were not designed primarily for teachers and school staff. Thirty-four (43%) of 80 resources reviewed for content accuracy were excluded. Among resources reviewed for readability, usability and suitability, six (13%) were excluded. CONCLUSIONS: The 40 resources identified in this study can enable teachers and school staff to educate themselves about concussion and how to optimally support a student's return-to-school post-concussion.

Youth intentions to provide social support to a peer with a concussion.

OBJECTIVES: 1) To describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if demographic factors and concussion knowledge are associated with components of the Theory of Planned Behavior. METHODS: The survey was completed between October 2018 and February 2019 by 200 youth (M = 15.30 years, SD = 1.52). Questions were designed for athletes and non-athletes and inquired about various types of social support. Data analysis included descriptive statistics, Wilcoxon Rank Sum Tests and Spearman's Rank-Order Correlation Coefficients. RESULTS: More favorable attitudes and intentions to provide social support were observed among females (W = 2576, p ≤ 0.001; W = 2411, p ≤ 0.001), older youth (rho = 0.32, p ≤ 0.001; rho = 0.41, p ≤ 0.001) and those with higher concussion knowledge (rho = 0.29, p ≤ 0.001; rho = 0.22; p ≤ 0.001). Participating in sports with a high-risk of concussion was associated with lower attitudes and intentions to provide social support (W = 6677; p ≤ 0.001; W = 6721; p ≤ 0.001). Self-reported concussion history or knowing someone with a concussion history was not significantly associated with social support intentions. CONCLUSION: This study identified characteristics of youth who had positive intentions to provide social support. These findings identify individuals who may model providing social support to a peer, as well as opportunities for future concussion education.

Unravelling the web: Experiences of adolescents returning to school following a concussion.

One in five adolescents will sustain a concussion in their lifetime. A concussion may result in symptoms that affect an adolescent's ability to attend school and engage in learning tasks. This study was guided by interpretivism. We conducted one-on-one semi-structured interviews to explore the perspectives of 20 adolescents (ages 14-18) returning to school after a concussion. Interviews were coded inductively and analyzed using reflexive thematic analysis. Five interconnected themes emerged with returning to school and accessing school supports: (1) concussion symptoms affected adolescents' schoolwork; (2) access to academic accommodations eased adolescents' return to school; (3) having supportive and understanding friends, family, and teachers facilitated adolescents' return to school; (4) communication amongst school stakeholders was desired, but often lacking; and (5) feeling anxious, frustrated, and sad with the return to school process. Adolescents' experiences were multifaceted and many factors contributed to their return to school experiences. Our findings can inform our understanding of the experiences of adolescents returning to school following concussion and can inform the development of concussion management supports at schools.

Effects of Pediatric Traumatic Brain Injury on Verbal IQ: A Systematic Review and Meta-Analysis.

OBJECTIVES: To examine the effects of pediatric traumatic brain injury (TBI) on verbal IQ by severity and over time. METHODS: A systematic review and subsequent meta-analysis of verbal IQ by TBI severity were conducted using a random effects model. Subgroup analysis included two epochs of time (e.g., <12 months postinjury and ≥12 months postinjury). RESULTS: Nineteen articles met inclusion criteria after an extensive literature search in MEDLINE, PsycInfo, Embase, and CINAHL. Meta-analysis revealed negative effects of injury across severities for verbal IQ and at both time epochs except for mild TBI < 12 months postinjury. Statistical heterogeneity (i.e., between-study variability) stemmed from studies with inconsistent classification of mild TBI, small sample sizes, and in studies of mixed TBI severities, although not significant. Risk of bias on estimated effects was generally low (k = 15) except for studies with confounding bias (e.g., lack of group matching by socio-demographics; k = 2) and measurement bias (e.g., outdated measure at time of original study, translated measure; k = 2). CONCLUSIONS: Children with TBI demonstrate long-term impairment in verbal IQ, regardless of severity. Future studies are encouraged to include scores from subtests within verbal IQ (e.g., vocabulary, similarities, comprehension) in addition to functional language measures (e.g., narrative discourse, reading comprehension, verbal reasoning) to elucidate higher-level language difficulties experienced in this population.

Adolescent and parent experiences with Tele-Active Rehabilitation for concussion: an exploratory qualitative study.

PURPOSE: To explore the experiences of adolescents with concussion and their parents who participated in a novel remotely delivered Tele-Active Rehabilitation (Tele-AR) intervention involving sub-symptom threshold exercise, education, and support. Specifically, we aimed to elicit perspectives regarding the remote delivery approach, valued aspects of the program, and perceived benefits of the intervention. METHODS: This qualitative study took place within the context of a larger mixed-methods project exploring the feasibility of the Tele-AR intervention. A descriptive qualitative design was utilized. Semi-structured interviews were conducted with adolescents (n = 3; ages 14-17 years) with concussion and one of their parents (n = 3) within one week of completing the six-week Tele-AR intervention. Data were analyzed using thematic analysis. RESULTS: Four themes were identified that capture participant experiences in the intervention: (1) Enabling access to active rehabilitation; (2) Focusing on individual needs; (3) Learning to take responsibility for recovery; and (4) Convenience and comfort of engaging in rehabilitation from home. CONCLUSIONS: A small sample of 3 adolescents with concussion and their parents were satisfied with the Tele-AR intervention and appreciated the convenience and comfort of engaging in rehabilitation from home, which facilitated adolescents taking responsibility for their own recovery. Findings support continued study of Tele-AR, which may be an accessible intervention to facilitate recovery in adolescents with concussion.

The effect of transcranial direct current stimulation on cognitive performance in youth with persistent cognitive symptoms following concussion: a controlled pilot study.

OBJECTIVE: Explore the feasibility, tolerability, and early efficacy of transcranial direct current stimulation (tDCS) as a therapeutic intervention for youth with cognitive persistent post-concussion symptoms (PPCS). HYPOTHESIS: tDCS improves performance on a dual task working memory (WM) paradigm in youth with cognitive PPCS. PARTICIPANTS: Twelve youth experiencing cognitive PPCS. DESIGN: A quasi-randomized pilot trial was used to explore the tolerability of, and performance differences on, a dual N-Back WM task paired with active or sham tDCS over 3 sessions. MEASURES: Accuracy and reaction time on WM task and self-report of tDCS tolerability. RESULTS: Trends toward increases in accuracy from Day 1 to 3 seen in both groups. Active tDCS group performed better than sham on Day 2 in N-Back level N2 (p = .019), and marginally better than the sham group on Day 3 in level N3 (p = .26). Participants reported tDCS as tolerable; compared to the active tDCS group, the sham group reported more "considerable" (p = .078) and "strong" symptoms (p = .097). CONCLUSION: tDCS is a promising tool for enhancing WM performance and is a feasible and tolerable adjunct to behavioral interventions in youth with cognitive PPCS. A clinical trial to demonstrate efficacy is warranted.

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).

Exploring the value of the SCHOOLFirst return-to-school resource: Evaluating usability and satisfaction.

OBJECTIVE: To cocreate an evidence-based resource to enable educators to support students returning to school after concussion; evaluate the usability of and users' satisfaction with the resource; understand the role of the resource in supporting students' return to school; and describe changes in concussion knowledge following a concussion education and training workshop. DESIGN: Survey during a concussion education and training workshop. SETTING: Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ont, and York Region District School Board in Richmond Hill, Ont. PARTICIPANTS: Fifty-six educators, of whom 64% were teachers, 11% were school administrators, 23% fulfilled other roles (eg, child and youth worker), and 2% fulfilled unspecified roles. MAIN OUTCOME MEASURES: The survey collected demographic information, usability data via the System Usability Scale, and satisfaction data. Thematic analysis was used for open-ended questions. RESULTS: Participants reported the resource to be easy to use (69.6%), not complex (62.5%), and most felt confident using this resource (83.9%). Participants indicated they were satisfied with the resource (73.2%) and would use it in the future (87.5%). Some found the resource overwhelming and recommended it be summarized in a reference guide. Participants found the links, videos, and classroom accommodations or academic supports to be helpful. CONCLUSION: SCHOOLFirst is an evidence-based, user-driven resource that was created for educators to support students returning to school following concussion. Educators, health care providers, youth, and families collaborated on developing SCHOOLFirst to improve students' successful return to school following concussion. Educators were satisfied with the resource and saw opportunities to use it to support their students.

Interactive effects of task load and music tempo on psychological, psychophysiological, and behavioural outcomes during simulated driving.

We examined the interactive effects of task load and music tempo on cognition, affect, cardiac response, and safety-relevant behaviour during simulated driving. Using a counterbalanced, within-subjects design, participants (N = 46) were exposed to fast-, slow-, and no-music conditions at high and low loads in a high-grade simulator. Task load had the most salient effect across a broad swath of variables. For core affect, the Load × Music Condition interaction showed that, under high load, affective arousal scores were higher in the fast-tempo condition vs. slow. A main effect of tempo emerged for the HRV index of SDNN, with fast-tempo music eliciting lower scores than both slow- and no-music conditions. Behavioural data showed a main effect of tempo for risk ratings, with fast-tempo music eliciting the highest scores for a traffic-light trigger. Our findings indicate that drivers in high-load, urban environments should exercise caution in their use of fast-tempo music. Practitioner summary: We examined the interactive effects of task load and music tempo in simulated driving (urban and highway). Cognition, mood, cardiac response, and driving behaviour were assessed. Participants exhibited more risky behaviours in response to fast-tempo music. Drivers should exercise caution in their use of up-tempo music in urban settings.

Pediatric concussion working memory outcomes: a scoping review.

Objective: Characterize the working memory (WM) profile of children and youth who have experienced concussion by systematically synthesizing existing literature on the neuropsychological outcomes of these injuries.Methods: Implemented a peer-reviewed search strategy combining key concepts of concussion/mild traumatic brain injury (mTBI), WM, and pediatrics across MedLine, Embase, PsycINFO, and CINAHL. Included studies written in English with extractable results on a WM outcome measure in individuals aged 21 and under who experienced concussion. Applied narrative synthesis to identify trends in the literature. Assessed risk of bias and quality using the NHLBI's Quality Assessment of Observational Cohort and Cross-Sectional Studies.Results: 40 articles met inclusion criteria. 34/40 studies compared WM performance in children or youth with concussion to healthy controls, pre-injury performance, or normative values, of which 15 reported significantly lower WM performance in the concussion sample. Visual/spatial WM was more consistently impacted than verbal WM. Cognitive demanding dual-task conditions were also reliably impacted.Conclusion: Literature indicated that WM is vulnerable to negative outcomes following pediatric concussion, yet the nature of outcomes is variable. Clinicians and researchers should implement comprehensive and theoretically motivated WM assessments to better understand the WM components impacted by injury.

Diagnosing and managing paediatric concussion: Key recommendations for general paediatricians and family doctors.

Concussion in children and adolescents is an important health concern. Most paediatric patients fully recover in 1 month or less following an acute concussion. However, some experience prolonged or persistent concussion symptoms for months. Those with prolonged post-concussion-related symptoms may have impaired quality of life, and limited involvement in social, academic, and physical activities with associated mental health implications. In this review, we share key updated clinical recommendations from the Living Guideline for Diagnosing and Managing Pediatric Concussion that will improve the way general paediatricians and family doctors diagnose and manage paediatric patients with suspected concussion.

Sensitivity and Specificity of a Multimodal Approach for Concussion Assessment in Youth Athletes.

CONTEXT: Current international consensus endorses a multimodal approach to concussion assessment. However, the psychometric evaluation of clinical measures used to identify postconcussion performance deficits once an athlete is asymptomatic remains limited, particularly in the pediatric population. OBJECTIVE: To describe and compare the sensitivity and specificity of a multimodal assessment battery (balance, cognition, and upper and lower body strength) versus individual clinical measures at discriminating between concussed youth athletes and noninjured controls when asymptomatic. DESIGN: Prospective cohort study. SETTING: Hospital laboratory setting. PARTICIPANTS: A total of 32 youth athletes with a concussion and 32 matched (age and sex) noninjured control participants aged 10-18 years. INTERVENTION(S): Participants were administered preinjury (baseline) assessments of cognition (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]), balance (BioSway), and upper and lower body strength (grip strength and standing long jump). Assessments were readministered when concussed participants reported symptom resolution (asymptomatic time point). Noninjured control participants were reassessed using the same time interval as their concussion matched pair. Sensitivity and specificity were calculated using standardized regression-based methods and receiver operating characteristic curves. MAIN OUTCOME MEASURES: Outcome measures included baseline and postinjury ImPACT, BioSway, grip strength, and standing long jump scores. RESULTS: When asymptomatic, declines in performance on each individual clinical measure were seen in 3% to 22% of the concussion group (sensitivity = 3%-22%) compared with 3% to 13% of the noninjured control group (specificity = 87%-97%) (90% confidence interval). The multimodal battery of all combined clinical measures yielded a sensitivity of 41% and a specificity of 77% (90% confidence interval). Based on discriminative analyses, the multimodal approach was statistically superior compared with an individual measures approach for balance and upper and lower body strength, but not for cognition. CONCLUSIONS: Results provide a foundation for understanding which domains of assessment (cognition, balance, and strength) may be sensitive and specific to deficits once symptoms resolve in youth athletes. More work is needed prior to clinical implementation of a preinjury (baseline) to postinjury multimodal approach to assessment following concussion in youth athletes.

A randomized double-blind phase II study evaluating the role of maintenance therapy with cabozantinib in high-grade uterine sarcoma after stabilization or response to doxorubicin ± ifosfamide following surgery or in metastatic first line treatment (EORTC62113).

BACKGROUND: Uterine sarcomas are a group of rare tumors that include different subtypes. Patients with histopathological high-grade diseases are at high-risk of recurrence or progression, and have a poor prognosis. We aim to explore the most appropriate management in patients with uterine high-grade sarcomas. PRIMARY OBJECTIVE: To assess the efficacy of maintenance treatment with cabozantinib in patients with high-grade uterine sarcomas who achieved clinical benefit after standard chemotherapy. STUDY HYPOTHESIS: Maintenance treatment with cabozantinib after standard chemotherapy given as an adjuvant treatment after curative surgery, or in locally advanced or metastatic disease, increases progression-free survival compared with placebo TRIAL DESIGN: This is a randomized double blinded phase II trial. MAJOR INCLUSION/EXCLUSION CRITERIA: The study is enrolling adult patients with high-grade undifferentiated uterine sarcomas, high-grade endometrial stromal sarcomas, high-grade leiomyosarcoma, and high-grade adenosarcoma, FIGO (Federation International gynecologue Obstétricien) stage II/III to IV in stable disease or who achieved complete or partial response with doxorubicin ± ifosfamide, who are assigned 1:1 to 60 mg daily cabozantinib (experimental arm) or placebo (control arm), as maintenance therapy. Exclusion criteria include low-grade sarcoma. PRIMARY ENDPOINT: Progression-free survival at 4 months. SAMPLE SIZE: The study plans to enroll 90 patients to allow the randomization of 54 patients to detect an improvement in 4-month progression-free survival from 50% to 80% with 15% significance level and 85% power. Estimated dates for accrual completion: recruitment for the trial started in February 2015, and has currently enrolled 83 patients, of whom 35 patients have been randomized. The end of recruitment is anticipated for December 2020. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, number NCT01979393.

Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines.

At least 3 million Americans sustain a mild traumatic brain injury (mTBI) each year, and 1 in 5 have symptoms that persist beyond 1 month. Standards of mTBI care have evolved rapidly, with numerous expert consensus statements and clinical practice guidelines published in the last 5 years. This Special Communication synthesizes recent expert consensus statements and evidenced-based clinical practice guidelines for civilians, athletes, military, and pediatric populations for clinicians practicing outside of specialty mTBI clinics, including primary care providers. The article offers guidance on key clinical decisions in mTBI care and highlights priority interventions that can be initiated in primary care to prevent chronicity.

The youth concussion awareness network (You-CAN) - a school-based peer-led intervention to improve concussion reporting and social support: the protocol for a cluster randomized trial.

BACKGROUND: Concussion prevalence is increasing in the pediatric population, and is a matter of public health concern. Concussion symptoms can be physical, cognitive, emotional and behavioural, and last longer in high school aged youth than adults. Concussions are underreported in youth due to their lack of knowledge, social environment, perceived outcomes of reporting, norms, and self-efficacy. The Youth Concussion Awareness Network (You-CAN) is a school-based peer-led program designed to increase high school students' intent to report a concussion, and provide social support to a peer. This study aims to investigate whether participation in You-CAN, a program grounded in service learning principles, impacts concussion knowledge, attitudes, intent to report a suspected concussion to an adult, and intent to provide social support to a peer. Secondary aims include assessing the implementation fidelity and acceptability of the intervention. METHODS: This longitudinal study will use a cluster randomized trial design. Three high schools from six randomly selected Canadian school boards will participate and be randomized to three study arms: (1) You-CAN led by school staff; (2) You-CAN led by school staff and research team; and (3) untreated comparison group. Intervention arms 1 and 2 will deliver the You-CAN program and create a Concussion Council at their school. The Concussion Council will deliver a concussion awareness campaign and participate in an online showcase with other participating schools. In addition, arm 2 will have monthly video-calls with the research team. A survey based on the Theory of Planned Behaviour will be administered school-wide with all arms (1, 2, 3) at two time points (beginning {T0} and end {T1} of the school year). Exit interviews will be completed with the Concussion Councils and participating school staff. DISCUSSION: This study will provide evidence of the effectiveness of a school-based peer-led concussion program on increasing concussion knowledge, attitudes, subjective norms, perceived behavioural control, intent to report a concussion to an adult, and intent to provide social support to a peer amongst Canadian high school students. It will also provide important information about the implementation and acceptability of the You-CAN program for high school students and staff. TRIAL REGISTRATION: This trial is registered with the ISRCTN registry (ISRCTN64944275, 14/01/2020, retrospectively registered).

Online concussion resources for Canadian high school aged youth: A systematic search strategy.

Objective: To identify online concussion resources that are suitable for Canadian youth and accurate according to the current International Consensus Statement on Concussion in Sport.Methods: A five-phased systematic search strategy was used to identify concussion resources. This included 1. searching key Canadian stakeholder websites (sport organizations, injury prevention groups, children's hospitals, governments, public health agencies, and physical and health education associations), 2. pediatric concussion expert consultation, 3. applying inclusion and exclusion criteria, 4. reviewing content for accuracy according to the consensus statement and 5. evaluating resources for readability, usability and suitability.Results: A total of 456 resources were initially identified however, only 32 met the final criteria. Across all resources, 34.6% (n=109) were excluded as they were not designed primarily for youth. Among resources reviewed for content accuracy according to the consensus statement, 53.1% (n=51) were excluded. When evaluating resources for readability, usability and suitability, 28.5% (n=13) were excluded as they were not suitable for youth.Implications: Most concussion resources available online are not written for youth and do not contain accurate information on pediatric concussion. The identified evidence-based resources can ensure that accurate and suitable information is provided to youth in order to enhance their concussion knowledge.

Social support during youth concussion recovery.

PURPOSE: We explored the lived experience of high-school aged girls receiving social support during concussion recovery to better understand (1) how they define meaningful social support and barriers/facilitators to receiving it; (2) who provides that support; and (3) the role of peers. METHODS: In person, semi-structured interviews were conducted with 10 girls (aged 14-19 years) with a personal history of concussion. RESULTS: Close friends, youth with personal history of concussion, and parents were identified as key providers of meaningful social support during concussion recovery. Participants identified specific examples of support provided by each group. Close friends built a sense of social inclusion that mitigated feelings of social isolation. Youth with a personal history of concussion used their lived experiences to communicate empathy and validate the participant's challenges. Parents assisted with practical challenges (e.g. accessing accommodations) by leveraging their "adult power". Participants identified that lack of understanding of their lived experiences was a key barrier to receiving support. They proposed solutions focused on education initiatives highlighting personal accounts from youth with concussion, and specific examples of how peers can help. CONCLUSIONS: Fostering social support may require strategies tailored to each group of key providers as they mitigate different challenges in recovery.