Examining the association between psychosocial functioning and concussion symptom severity in youth.

OBJECTIVE: Guidelines recommend examining psychosocial variables as contributors to postconcussive symptoms. However, few studies examined this relation in a clinic-referred sample and fewer accounted for parent perspective, limiting practitioners implementation of this guidance. Therefore, this longitudinal study examined youth and parent-reported psychosocial variables and their association with concussion symptom severity in a clinic-referred sample of youth receiving treatment for concussion. METHODS: Youth (n = 121; mean age = 15.3 years) with a recent concussion and their parents completed measures assessing youth depression, anxiety, academic stress, quality of life and concussion symptom severity at the initial treatment appointment and again approximately three-months later or at discharge, whichever came first. RESULTS: Differences were observed in psychosocial functioning across parent and youth report. Youth-reported depression was strongly associated with concussion symptom severity whereas parent-reported depression, academic stress, and quality of life were significantly related to concussion symptom severity. Exploratory findings of the relation between psychosocial variables at initial evaluation and concussion symptom severity at follow-up are offered. CONCLUSION: Results offer guidance on the underlying psychosocial variables that may be useful to consider when developing interventions for youth recovering from concussion, especially those with a prolonged recovery.

Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists.

PURPOSE OF REVIEW: Concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another. This review summarizes the medical management of patients with concussion and persistent post-concussive symptoms (PPCS). RECENT FINDINGS: Management of concussion and PPCS relies on identifying underlying symptom generators. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments. Evidence-based treatments have emerged to treat post-concussion symptom generators for sport-related concussion and for patients with PPCS.

Clinical Assessment of Concussion and Persistent Post-Concussive Symptoms for Neurologists.

PURPOSE OF REVIEW: Concussion produces a variety of signs and symptoms. Most patients recover within 2-4 weeks, but a significant minority experiences persistent post-concussive symptoms (PPCS), some of which may be from associated cervical or persistent neurologic sub-system (e.g., vestibular) dysfunction. This review provides evidence-based information for a pertinent history and physical examination of patients with concussion. RECENT FINDINGS: The differential diagnosis of PPCS is based on the mechanism of injury, a thorough medical history and concussion-pertinent neurological and cervical physical examinations. The concussion physical examination focuses on elements of autonomic function, oculomotor and vestibular function, and the cervical spine. Abnormalities identified on physical examination can inform specific forms of rehabilitation to help speed recovery. Emerging data show that there are specific symptom generators after concussion that can be identified by a thorough history, a pertinent physical examination, and adjunct tests when indicated.

Effects of Concussion in Adolescent Students: Perceptions and Performance.

OBJECTIVE: The purpose of this study was to compare adolescent students with and without concussion on a battery of academic, neurocognitive, and socioemotional measures and assess the aftereffects of concussion across domains of functioning. METHODS: Twenty-four adolescents (ages 13-17) reporting postconcussion symptoms were compared to 24 controls matched for age and gender across a battery of tests and surveys. RESULTS: After correcting for multiple comparisons, there were no significant differences on any neuropsychological measures. Similarly, there were no significant group differences on academic measures of vocabulary, word recognition, or reading comprehension. Self-reported concussion symptoms were much greater for students with concussion, as were self-reports of anxiety, depression, and somatization symptoms. Parents also rated those with concussion as having greater depression and somatization symptoms, but not to a degree that survived Bonferroni correction. Lastly, those with concussion reported a significantly greater number of school problems and academic concerns. CONCLUSIONS: Results indicated that adolescents who reported postconcussion symptoms do not perform differently from peers on most neurocognitive and academic tasks, yet they showed considerably more worry, somatization, academic concerns, and feelings of inadequacy than matched controls. The findings suggest that interventions to address psychological and academic stress may be indicated for adolescents symptomatic from concussion.

Impaired auditory processing and neural representation of speech in noise among symptomatic post-concussion adults.

Background: The purpose of the study was to examine auditory event-related potential (AERP) evidence of changes in earlier and later stages of auditory processing in individuals with long-term post-concussion problems compared to healthy controls, with a secondary aim of comparing AERPs by functional auditory behavioral outcomes. Methods: P1-N1-P2 complex and P300 components recorded to speech in quiet and background noise conditions were completed in individuals with ongoing post-concussion symptoms following mTBI and healthy controls. AERPs were also examined between sub-groups with normal or impaired auditory processing by behavioral tests. Results: Group differences were present for later stages of auditory processing (P300). Earlier components did not significantly differ by group overall but were more affected by noise in the mTBI group. P2 amplitude in noise differed between mTBI sub-groups with normal or impaired auditory processing. Conclusion: AERPs revealed differences between healthy controls and those with chronic post-concussion symptoms following mTBI at a later stage of auditory processing (P300). Neural processing at the earlier stage (P1-N1-P2) was more affected by noise in the mTBI group. Preliminary evidence suggested that it may be only the proportion of individuals with functional evidence of central auditory dysfunction with changes in AERPs at earlier stages of processing.

Development and initial validation of a digital divided-attention neurocognitive test for use in concussion assessment.

Objective: Computerized neurocognitive tests are commonly used after a concussion injury. The use of reliable and valid tests that utilize a divided-attention task may improve assessment. Therefore, the purpose of this study is to test a digital divided-attention neurocognitive test for test-retest reliability, practise effects, and initial validity. Methods and procedures: One hundred ninety-two subjects (159 healthy, 33 concussed) were assessed utilizing the neurocognitive test. Group comparisons were made between subjects with concussions and matched controls to determine the initial sensitivity of the test. Results: Intraclass correlation coefficients remained high (greater than 0.50) across all time points tested, and practise effects were largest in first retest session but we correlated (single task: R2 = 0.89, divided-attention: R2 = 0.85). Subjects who had experienced concussions performed significantly worse than matched controls on both the maths computation task and shape matching task during the divided-attention test. Conclusion: The mathematical computation component of the divided-attention test yielded high reliability. Practise effects were seen between the first and second testing sessions with smaller, insignificant improvements seen thereafter. Sensitivity to injury was comparable to other digital neurocognitive tests suggesting ongoing testing is warranted.

Brainstem Evoked Potential Indices of Subcortical Auditory Processing After Mild Traumatic Brain Injury.

OBJECTIVES: The primary aim of this study was to assess subcortical auditory processing in individuals with chronic symptoms after mild traumatic brain injury (mTBI) by measuring auditory brainstem responses (ABRs) to standard click and complex speech stimuli. Consistent with reports in the literature of auditory problems after mTBI (despite normal-hearing thresholds), it was hypothesized that individuals with mTBI would have evidence of impaired neural encoding in the auditory brainstem compared to noninjured controls, as evidenced by delayed latencies and reduced amplitudes of ABR components. We further hypothesized that the speech-evoked ABR would be more sensitive than the click-evoked ABR to group differences because of its complex nature, particularly when recorded in a background noise condition. DESIGN: Click- and speech-ABRs were collected in 32 individuals diagnosed with mTBI in the past 3 to 18 months. All mTBI participants were experiencing ongoing injury symptoms for which they were seeking rehabilitation through a brain injury rehabilitation management program. The same data were collected in a group of 32 age- and gender-matched controls with no history of head injury. ABRs were recorded in both left and right ears for all participants in all conditions. Speech-ABRs were collected in both quiet and in a background of continuous 20-talker babble ipsilateral noise. Peak latencies and amplitudes were compared between groups and across subgroups of mTBI participants categorized by their behavioral auditory test performance. RESULTS: Click-ABR results were not significantly different between the mTBI and control groups. However, when comparing the control group to only those mTBI subjects with measurably decreased performance on auditory behavioral tests, small differences emerged, including delayed latencies for waves I, III, and V. Similarly, few significant group differences were observed for peak amplitudes and latencies of the speech-ABR when comparing at the whole group level but were again observed between controls and those mTBI subjects with abnormal behavioral auditory test performance. These differences were seen for the onset portions of the speech-ABR waveforms in quiet and were close to significant for the onset wave. Across groups, quiet versus noise comparisons were significant for most speech-ABR measures but the noise condition did not reveal more group differences than speech-ABR in quiet, likely because of variability and overall small amplitudes in this condition for both groups. CONCLUSIONS: The outcomes of this study indicate that subcortical neural encoding of auditory information is affected in a significant portion of individuals with long-term problems after mTBI. These subcortical differences appear to relate to performance on tests of auditory processing and perception, even in the absence of significant hearing loss on the audiogram. While confounds of age and slight differences in audiometric thresholds cannot be ruled out, these preliminary results are consistent with the idea that mTBI can result in neuronal changes within the subcortical auditory pathway that appear to relate to functional auditory outcomes. Although further research is needed, clinical audiological evaluation of individuals with ongoing post-mTBI symptoms is warranted for identification of individuals who may benefit from auditory rehabilitation as part of their overall treatment plan.

A prospective study of symptoms and neurocognitive outcomes in youth with concussion vs orthopaedic injuries.

BACKGROUND: This study examined symptom reports and neurocognitive outcomes in children (8-17 years) with mild traumatic brain injury (mTBI) or orthopaedic injury (OI). METHOD: Children and parents were initially assessed upon presentation in the Emergency Department of a local hospital and again at 3 months. Children completed the Immediate Post-Concussion Assessment and Cognitive Testing battery (ImPACT) and parents completed the Behavior Rating Inventory of Executive Function (BRIEF). The Peabody Picture Vocabulary Test, 3rd edition (PPVT-III) was completed by the children at the 3-month assessment. RESULTS: Children with mTBI reported more symptoms than the OI group initially, but did not differ from the OI group at 3 months. Both groups reported a higher than expected number of symptoms at 3 months. On the ImPACT, children with mTBI performed significantly worse than the OI on a visual memory test at both assessments. The OI group had higher levels of parent-reported executive dysfunction on the BRIEF at initial and 3-month assessments. DISCUSSION: As expected, more post-concussion symptoms were initially reported by children and adolescents with mTBI vs orthopaedic injury, but there was no difference at 3 months. The BRIEF and ImPACT cognitive measures did not differentiate concussed subjects from controls, with the exception of concussed subjects' lower performance on a visual memory test at both initial assessment and at 3 months.

Subacute to chronic mild traumatic brain injury.

Although a universally accepted definition is lacking, mild traumatic brain injury and concussion are classified by transient loss of consciousness, amnesia, altered mental status, a Glasgow Coma Score of 13 to 15, and focal neurologic deficits following an acute closed head injury. Most patients recover quickly, with a predictable clinical course of recovery within the first one to two weeks following traumatic brain injury. Persistent physical, cognitive, or behavioral postconcussive symptoms may be noted in 5 to 20 percent of persons who have mild traumatic brain injury. Physical symptoms include headaches, dizziness, and nausea, and changes in coordination, balance, appetite, sleep, vision, and hearing. Cognitive and behavioral symptoms include fatigue, anxiety, depression, and irritability, and problems with memory, concentration and decision making. Women, older adults, less educated persons, and those with a previous mental health diagnosis are more likely to have persistent symptoms. The diagnostic workup for subacute to chronic mild traumatic brain injury focuses on the history and physical examination, with continuing observation for the development of red flags such as the progression of physical, cognitive, and behavioral symptoms, seizure, progressive vomiting, and altered mental status. Early patient and family education should include information on diagnosis and prognosis, symptoms, and further injury prevention. Symptom-specific treatment, gradual return to activity, and multidisciplinary coordination of care lead to the best outcomes. Psychiatric and medical comorbidities, psychosocial issues, and legal or compensatory incentives should be explored in patients resistant to treatment.

Auditory and Cognitive Behavioral Performance Deficits and Symptom Reporting in Postconcussion Syndrome Following Mild Traumatic Brain Injury.

Purpose This study examined auditory deficits and symptom reporting in individuals with long-term postconcussion symptoms following a single mild traumatic brain injury (mTBI) compared to age- and gender-matched controls without a history of mTBI. Method Case history interviews, symptom questionnaires, and a battery of central auditory and neuropsychological tests were administered to 2 groups. The mTBI group was a civilian population recruited from a local concussion management program who were seeking rehabilitation for postconcussion-related problems in a postacute period between 3 and 18 months following injury. Symptom validity testing was included to assess the rate of possible insufficient test effort and its influence on scores for all outcome measures. Analyses of group differences in test scores were performed both with and without the participants who showed insufficient test effort. Rates of symptom reporting, correlations among symptoms and behavioral test outcomes, and the relationships between auditory and cognitive test performance were analyzed. Results The mTBI group reported a high rate of auditory symptoms and general postconcussion symptoms. Performance on neuropsychological tests of cognitive function showed some differences in raw scores between groups, but when effort was considered, there were no significant differences in the rate of abnormal performance between groups. In contrast, there were significant differences in both raw scores and the rate of abnormal performance between groups for some auditory tests when only considering participants with sufficient effort. Auditory symptoms were strongly correlated with other general postconcussion symptoms. Conclusions Significant auditory symptoms and evidence of long-term central auditory dysfunction were found in a subset of individuals who had chronic postconcussion symptoms after a single mTBI unrelated to blast trauma. The rate of abnormal performance on auditory behavioral tests exceeded the rate of abnormal performance on tests of cognitive function. Supplemental Material https://doi.org/10.23641/asha.8329955.

Parent Knowledge and Perceptions of Concussion Related to Youth Football.

Introduction There is increased concern about concussion in youth athletes, yet there is little research on parent knowledge of concussion. Purpose  The purpose of the current study was to investigate attitudes to and knowledge of concussion among parents of youth football players. Methods We surveyed 180 parents/guardians of youth football players, ages 5-12, regarding their knowledge and beliefs concerning concussion. Results We found that the vast majority of respondents (86%) had confidence in their ability to recognize concussions. Yet, a significant number also held misconceptions about concussions, such as 'too much sleep' (48%) or 'eating certain foods' (26%) make concussion symptoms worse. Most (82%) had not heard of the Zurich guidelines, and less than half (44%) were aware that sustained mental activity could worsen symptoms. Parents were concerned about their child sustaining a concussion, but a substantial minority also reported 'serious concern' about their children losing playing time or their position.  Discussion Results are somewhat positive in terms of parents' general knowledge of concussions; yet, response variability and misconceptions point to a continued need for concussion education for parents. Medical professionals can play an important role in informing families about concussion symptoms, management, and recovery.

Measuring postural stability with an inertial sensor: validity and sensitivity.

INTRODUCTION/PURPOSE: To examine the concurrent validity, and sensitivity, of an inertial sensor for use in the assessment of postural sway. METHODS: This was a laboratory-based, repeated-measures design with ten healthy participants. Concurrent validity was tested between an inertial sensor, forceplate, and rigid-body kinematics across three commonly used balance tests. Further, the inertial sensor measures were compared across eight commonly used tests of balance. Variables manipulated include stance position, surface condition, and eyes-open versus eyes-closed. RESULTS: The inertial sensor was correlated to both the forceplate-derived measures (r=0.793) and rigid-body kinematics (r=0.887). Significant differences between the balance tests were observed when tested with the inertial sensor. In general, there was a three-way interactions between the three balance factors (surface, stance, and vision) leading to pairwise comparisons between each balance test. The root-mean-square showed an increase across tasks of greater difficulty ranging from an average of 0.0368 with two legs, eyes-open to 0.911 when tested during tandem stance, eyes-closed tested on a foam pad. CONCLUSION: The new inertial sensor shows promise for use in the assessment of postural sway. Additionally, the inertial sensor appears sensitive to differences in balance tasks of varying degrees of difficulty when tested in a healthy sample of young adults. This inertial sensor may provide new opportunities for further research in the assessment of balance changes in the mild traumatic brain injury population.

Factors Associated With Problems for Adolescents Returning to the Classroom After Sport-Related Concussion.

The primary objective of this study was to determine factors in the clinic setting associated with concussion-related problems in the school setting. A total of 91 student athletes, 13 to 19 years old, completed the SCAT2 and computerized testing during their initial visit to the clinic. During a follow-up telephone interview, one-third reported problems with return to school. The presence of problems reported in school was associated with severity of concussion as represented by recovery time and the overall number of symptoms at the first clinic visit. Gender, age, and previous concussions were not associated with school problems. Athletes with computerized test scores below the ninth percentile were more likely to report school problems. The current study offers some descriptive information for clinicians and ideas for future research related to adolescent athletes with concussion and problems with return to the classroom.

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.

Teaching teachers about childhood cancer: the effects of a web-based training program.

The purpose of this study was to examine the utility and acceptability of a modular computer-based training program on childhood cancer (eg, acute and late effects of treatment, intervention strategies) for teachers. A within-subjects design was implemented with 41 teachers and teachers in training. Participants completed tests of childhood cancer knowledge and application skills both before and after completing the web-based training. An acceptability questionnaire was completed after the training. Results indicated significant gains in knowledge and in case application, as well as high levels of acceptability of the training. It seems that a web-based training program can be accessed by teachers and in 2 to 4 hours can significantly increase cancer knowledge in an acceptable manner.