Effect of Video Discharge Instructions for Patients With Mild Traumatic Brain Injury in the Emergency Department: A Randomized Controlled Trial.

STUDY OBJECTIVE: We measure the effect of video discharge instructions on postconcussion symptoms in patients with mild traumatic brain injury in the emergency department. METHODS: A multicenter randomized controlled trial was conducted in which patients with mild traumatic brain injury were randomly assigned to either intervention (verbal, written, and video discharge information) or control (verbal and written discharge information only). All patients were interviewed 1 week and 3 months from randomization. Primary outcome measure was the Rivermead Post-Concussion Symptoms Questionnaire at 3 months. Secondary outcomes were correct recall, Hospital Anxiety and Depression Scale score, health-related quality of life (12-Item Short Form Health Survey), return visits, and patient satisfaction. RESULTS: A total of 2,883 patients were assessed for eligibility, of whom 381 were included in the control group and 390 in the video intervention group. Difference in mean total Rivermead Post-Concussion Symptoms Questionnaire score between the 2 groups was 0.2 at 1 week and 0.3 at 3 months after traumatic brain injury (estimated effect -0.7; 95% confidence interval -2.1 to 0.7). There was also no difference in Hospital Anxiety and Depression Scale score, recall, 12-Item Short Form Health Survey score, return visits, and patient satisfaction between the control and intervention group. CONCLUSION: Severity of postconcussion symptoms in patients with mild traumatic brain injury did not improve by adding video information to standard care. Also, there was no difference in recall, health-related quality of life, return visits, and patient satisfaction between the control and intervention groups.

A randomized cohort study of the efficacy of PO magnesium in the treatment of acute concussions in adolescents.

INTRODUCTION/STUDY OBJECTIVE: Concussions are becoming a growing concern in society today with one out of every five adolescents being affected. This accounts for 1.6 to 3.8 million emergency department visits annually. The current standard of care involves an initial period of mental rest with symptomatic care and symptom-based return to daily activities/sports. High dose IV magnesium has been proven to be neuroprotective in severe TBI. We hypothesized that oral magnesium replacement following a concussion will decrease the overall symptomatic period allowing a quicker return to functional baseline. METHODS: We used a randomized cohort study involving patients aged 12-18 who presented within 48 h after a concussion. Our study design had a treatment arm including acetaminophen, ondansetron, and magnesium PO and a placebo arm of acetaminophen and ondansetron. We then utilized the Post- Concussion Severity Score (PCSS) to evaluate the extent of the patient's symptoms. This score was collected immediately prior to obtaining medications, 1 h, 48 h, and 120 h after starting the study. The study relied on outpatient follow up through phone conversations, and a Sports Medicine clinic locally. RESULTS: Our data shows that there was a statistically significant decrease in the PCSS at 48 h (p = 0.016) in the magnesium group relative to the placebo treatment arm. This study does imply that magnesium supplementation has potential benefit in treatment of concussions acutely. CONCLUSION: Oral magnesium replacement decreases symptoms acutely following a concussion and should be provided with symptomatic management following a concussion in the emergency setting.

Effect of Cognitive and Physical Rest on Persistent Postconcussive Symptoms following a Pediatric Head Injury.

OBJECTIVE: To evaluate the effect of cognitive and physical rest on persistent postconcussive symptoms in a pediatric population. STUDY DESIGN: A prospective cohort study of 5- to 18-year-olds diagnosed with an acute concussion in a tertiary care pediatric emergency department was conducted from December 2016 to May 2019. Participants (n = 119) were followed over 1 month to track days off from school and sports and the development of persistent postconcussive symptoms (residual concussion symptoms beyond 1 month). Participants were dichotomized into minimal (≤2) and moderate (>2) rest, based on days off from school and sports after a concussion. Univariate and multivariable logistic regression analyses were completed to examine associations with persistent postconcussive symptoms. RESULTS: Of the participants in our study, 24% had persistent postconcussive symptoms. Adolescent age, history of prolonged concussion recovery, and headache at presentation were associated with higher odds of persistent postconcussive symptoms in univariate analyses. In a multivariable logistic regression model, only adolescent age was associated with increased odds of persistent postconcussive symptoms. Compared with the minimal cognitive rest group, moderate cognitive rest did not decrease the odds of persistent postconcussive symptoms (aOR, 1.15; 95% CI, 0.44-2.99). Compared with the minimal physical rest group, moderate physical rest also did not decrease the odds of persistent postconcussive symptoms (aOR, 3.17; 95% CI, 0.35-28.78). CONCLUSIONS: Emerging evidence supports early return to light activity for recovery of acute pediatric concussion. Our study adds to this management approach as we did not find that rest from school and sports resulted in a decreased odds of persistent postconcussive symptoms.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population.

OBJECTIVES: To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education. DESIGN: Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit. SETTING: Three military treatment facilities. PARTICIPANTS: Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury. RESULTS: Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time. CONCLUSIONS: Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider's use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Graded Combined Aerobic Resistance Exercise (CARE) to Prevent or Treat the Persistent Post-concussion Syndrome.

PURPOSE OF REVIEW: To review the growing body of indirect and direct evidence that suggests that exercise can be helpful for children, adolescents, and adults with persistent symptoms following a mild traumatic brain injury (mTBI). RECENT FINDINGS: The direct evidence shows that graded exercise assessments are safe, and that aerobic exercise interventions are associated with improvement of multiple symptoms and other benefits, including earlier return-to-sport. The indirect evidence supports this approach via studies that reveal the potential mechanisms, and show benefits for related presentations and individual symptoms, including headaches, neck pain, vestibular problems, sleep, stress, anxiety, and depression. We document the forms of exercise used for the post-acute management of mTBI, highlight the knowledge gaps, and provide future research directions. We recommend trialing a new approach that utilizes a graduated program of individually prescribed combined aerobic resistance exercises (CARE) if mTBI symptoms persist. This program has the potential to improve patient outcomes and add to the management options for providers.

Age, Gender and Mechanism of Injury Interactions in Post-Concussion Syndrome.

BACKGROUND: Certain factors such as age and gender seem to affect the risk of developing post-concussion syndrome (PCS). We assessed the interactions between age, gender, concussion history and mechanism of injury in PCS patients so that a better understanding could guide the development of targeted prevention strategies. METHODS: Demographic data including age, gender, concussion mechanism of injury and concussion history were collected from (1) a prospective study evaluating PCS biomarkers and (2) a retrospective chart review of PCS patients. A total of 437 PCS patients who were assessed at the Canadian Concussion Centre or Toronto Western Hospital, Toronto, ON, were included. RESULTS: Overall, there were more men with PCS; however, a greater percentage of women had PCS after a single concussion. The results showed that age, gender and concussion history are conditionally dependent on the mechanism of injury, and independent of one another. The relative frequency of having PCS was greater in the following instances: (1) being a woman and having had concussion from a fall or motor vehicle collision (MVC), (2) being older and having had concussion from a fall or MVC or (3) having a single concussion with cause being MVC or fall. CONCLUSION: In patients with PCS, age and gender interact with the mechanism of injury to influence the risk of concussion. Targeted prevention strategies may be essential to prevent injuries leading to PCS.

Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury: Generalization of Prolonged-Exposure PTSD Treatment Outcomes to Postconcussive Symptoms, Cognition, and Self-Efficacy in Veterans and Active Duty Service Members.

OBJECTIVES: To examine (a) generalization of the effectiveness of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) in improving postconcussive symptoms (PCSs) and other outcomes in military service members and Veterans (VA) with histories of mild to severe traumatic brain injury (TBI), and (b) factors associated with PCS reduction. SETTING: VA polytrauma medical center. PARTICIPANTS: Consecutive referrals for PTSD treatment of Active Duty (n = 17) or Veterans (n = 27) diagnosed with PTSD and TBI (N = 44). MAIN OUTCOME MEASURES: Neurobehavioral Symptom Inventory, Key Behaviors Change Inventory, Self-Efficacy for Symptom Management, Posttraumatic Stress Disorder Checklist, and Beck Depression Inventory, 2nd edition. DESIGN: Post hoc analysis of archival clinical effectiveness program evaluation data. INTERVENTIONS: PE for PTSD. RESULTS: There were significant improvements on all outcome measures with large effect sizes (Cohen's d ranging from 0.68 to 2.02). Improvement on PCS (Cohen's d = 1.21) was associated with lower levels of VA service-connected disability and PE treatment completion. CONCLUSION: PE treatment-related improvements for participants with comorbid PTSD and TBI generalize from PTSD outcomes to PCS and other TBI-related outcomes. Positive outcomes were independent of TBI severity, treatment setting, or Veteran status, but dependent upon PE treatment completion and lower levels of VA service-connected disability.

Key ingredients to an active rehabilitation programme post-concussion: perspectives of youth and parents.

OBJECTIVE: To identify key ingredients in a six-week active rehabilitation intervention from the perspectives of youth recovering from concussion and their parents. METHODS: Surveys with open- and closed-ended questions were administered to youth (N = 38) ages 10-18 years (average = 14.5 years) and their parents (n = 36) immediately post intervention. Descriptive statistics and thematic analysis were used to analyse data. RESULTS: One hundred percent (N = 38) of youth and 100% (N = 36) of parents reported that the active rehabilitation intervention was helpful. The most helpful ingredients according to youth were: energy management strategies (47.4%, N = 18), aerobic exercise (31.6%, N = 12) and sport coordination drills (21.1%, N = 8). Qualitative analysis of youth survey questions resulted in three themes: (1) learning energy management; (2) engaging in physical activity and (3) seeking help. Themes emerging from the parent survey were: (1) encouraging recovery and confidence through structured activity; (2) recognizing youth's accountability and (3) learning to be patient and to accept uncertain timelines. CONCLUSIONS: Education about energy management is an important ingredient of the active rehabilitation intervention for youth with concussion. Parents benefit from learning how their child can be more accountable for their own rehabilitation and to be more accepting of unclear recovery timelines.

The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion.

OBJECTIVE: To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only. STUDY DESIGN: Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11-18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow-up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2?×?2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, ?2 with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1-9 days after injury. RESULTS: A 2?×?2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F?=?6.31, P?=?.01, ?2?=?0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1-6 and 8 (P?

Ambulatory or inpatient management of mild TBI in children: a post-concussion analysis.

BACKGROUND: Diagnosis and treatment of children with mild traumatic brain injury (mTBI) remain a challenge since initial signs and symptoms do not always indicate the severity of the trauma. Therefore, guidelines regarding the decision upon imaging methods and ambulatory or hospitalized treatment are needed. The goal of our study was to investigate if the standard that was allied from the PECARN rules and is applied in this study can ensure that patients with clinically important brain injury are recognized and leads to outcomes with a low complication rate, a high patient satisfaction and minimal post-concussion syndrome incidence. METHODS: We enrolled 478 children with mTBI and contacted their families with a questionnaire. Out of these, 267 valid questionnaires were received. Patient records and questionnaires were analyzed yielding a number of 140 ambulatory and 127 hospitalized patients. RESULTS: Patients with mild TBI were admitted according to the above-mentioned guidelines or sent home for observation through their parents after thorough patient examination and information. Among ambulatory patients only 13 children (9%) underwent any imaging procedure; however, none of those showed any pathological findings. Next, in 41 of 127 hospitalized patients (32.2%) an imaging study was performed and of these only 3 according to 2.4% of hospitalized patients showed pathological findings, namely a skull fracture, two of them in combination with an intracranial hemorrhage. The duration of inpatient observation was 48 h in most cases (55.3%). Moreover, a majority of all patients (72.4%) did not seek any follow-up visit and did not need any further treatment. Of all patients in the study, only 10 patients according to 3.7% developed a post-concussion syndrome. Patient satisfaction was very high in both, the ambulatory and hospitalized patient group. CONCLUSION: This study confirms that PECARN rules as administered in this study can ensure safe decision-making regarding ambulatory or inpatient treatment.

A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion.

The purpose of this study was to examine the effectiveness of an active rehabilitation intervention for adolescents who are slow-to-recover after a sport-related concussion. Ten adolescents (three girls and seven boys) seen at the Montreal Children's Hospital Concussion Clinic participated in this case series. Adolescents who were symptomatic more than 4 weeks after the injury were provided with an active rehabilitation intervention (M = 7.9 weeks following injury; range = 3.7 to 26.2 weeks). The rehabilitation program includes gradual, closely monitored light aerobic exercise, general coordination exercises, mental imagery, as well as reassurance, normalization of recovery, and stress/anxiety reduction strategies. The program continued until complete symptom resolution and readiness to begin stepwise return to activities. The primary outcome of the study was evolution of post-concussion symptoms. Secondary outcomes included mood, energy, balance, and cognition. After the intervention, post-concussion symptoms significantly decreased for the group of participants. They also had decreased fatigue and improved mood after 6 weeks of initiating the rehabilitation intervention. This case series shows that postconcussive symptoms and functioning in adolescents following sports-related concussion can be improved after participation in an active rehabilitation intervention. The introduction of graded light intensity exercise in the post-acute period following concussion is safe, feasible and appears to have a positive impact on adolescents' functioning.

The effect of recommending cognitive rest on recovery from sport-related concussion.

OBJECTIVE: To determine whether recommending cognitive rest to athletes after a sport-related concussion affects time to symptom resolution. METHODS: A retrospective cohort study was conducted of 184 patients who presented to a sports concussion clinic in an academic medical centre between 1 November 2007 and 31 July 2009. The effect of recommending cognitive rest on symptom duration (days) was measured after adjusting for age, gender, initial PCSS score, history of amnesia, history of loss of consciousness and number of previous concussions. Using multivariate logistic regression, independent predictors of prolonged symptoms were identified, defined as >30 days. RESULTS: Of the 135 study patients with complete medical records, 85 (63%) had cognitive rest recommended. Of those, 79 (59%) had prolonged symptoms. In the multivariate analysis, only initial PCSS score was associated with the duration of concussion symptoms (adjusted odds ratio (AOR) = 1.03; 95% CI = 1.01-1.05). The recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution (AOR = 0.5; 95% CI = 0.18-1.37). CONCLUSIONS: Given the limited evidence regarding the effects of cognitive rest on recovery from concussion, recommendations of prolonged periods of cognitive rest, particularly absences from school, should be approached cautiously.

Early intervention for patients at risk for persisting disability after mild traumatic brain injury: a randomized, controlled study.

STUDY OBJECTIVE: To investigate the effect of an early intervention visit in addition to written information and treatment as usual for patients with an estimated high risk for persisting disability after a mild traumatic brain injury (MTBI). RESEARCH DESIGN: Randomized controlled trial. METHODS: One hundred and seventy-three patients, aged 15-70 years with a Glasgow coma scale of 14-15 were included. All received written information about MTBI. Ninety-seven patients who reported three or more symptoms according to the rivermead post-concussion symptoms questionnaire (RPQ) at 10 days after the injury were considered as high-risk patients and were randomized to either early visit to a doctor or to treatment as usual (TAU); all patients including the 76 low-risk patients were followed-up at 3 months. Completion rate was 83%. Outcome measures included RPQ and the hospital anxiety and depression scale. RESULTS: RPQ symptoms decreased significantly in both randomized groups, but were not significantly different in the groups at 3 months. At 3 months, anxiety and depression scores did not differ between groups. CONCLUSIONS: An early intervention, offered to patients with an estimated high risk for persisting disability, had no additional effect on symptom level at 3 months after MTBI as compared to TAU.

Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial.

Importance: There are limited data to guide screen time recommendations after concussion. Objective: To determine whether screen time in the first 48 hours after concussion has an effect on the duration of concussive symptoms. Design, Setting, and Participants: This randomized clinical trial was conducted in the pediatric and adult emergency departments of a tertiary medical center between June 2018 and February 2020. Participants included a convenience sample of patients aged 12 to 25 years presenting to the emergency department within 24 hours of sustaining a concussion. A total of 162 patients were approached, 22 patients met exclusion criteria, and 15 patients declined participation; 125 participants were enrolled and randomized. Interventions: Patients were either permitted to engage in screen time (screen time permitted group) or asked to abstain from screen time (screen time abstinent group) for 48 hours after injury. Main Outcomes and Measures: The primary outcome was days to resolution of symptoms, defined as a total Post-Concussive Symptom Scale (PCSS) score of 3 points or lower. Patients completed the PCSS, a 22-symptom scale that grades each symptom from 0 (not present) to 6 (severe), each day for 10 days. Kaplan-Meier curves and Cox regression modeling were used to compare the 2 groups. A Wilcoxon rank sum test was also performed among participants who completed the PCSS each day through recovery or conclusion of the study period. Results: Among 125 patients with concussion, the mean (SD) age was 17.0 (3.4) years; 64 participants (51.2%) were male. A total of 66 patients were randomized to the screen time permitted group, and 59 patients were randomized to the screen time abstinent group. The Cox regression model including the intervention group and the patient's self-identified sex demonstrated a significant effect of screen time (hazard ratio [HR], 0.51; 95% CI, 0.29-0.90), indicating that participants who engaged in screen time were less likely to recover during the study period. In total, 91 patients were included in the Wilcoxon rank sum test (47 patients from the screen time permitted group, and 44 patients from the screen time abstinent group). The screen time permitted group had a significantly longer median recovery time of 8.0 days (interquartile range [IQR], 3.0 to >10.0 days) compared with 3.5 days (IQR, 2.0 to >10.0 days; P = .03) in the screen time abstinent group. The screen time permitted group reported a median screen time of 630 minutes (IQR, 415-995 minutes) during the intervention period compared with 130 minutes (IQR, 61-275 minutes) in the screen time abstinent group. Conclusions and Relevance: The findings of this study indicated that avoiding screen time during acute concussion recovery may shorten the duration of symptoms. A multicenter study would help to further assess the effect of screen time exposure. Trial Registration: ClinicalTrials.gov Identifier: NCT03564210.

Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms.

CONTEXT: Emerging research supports the use of mild to moderate aerobic exercise for treating sport-related concussion (SRC) and persistent postconcussive symptoms (PPCS), yet the current standard of care remains to be strict rest. The purpose of this review is to summarize the existing literature on physical activity and prescribed exercise for SRC and PPCS. EVIDENCE ACQUISITION: PubMed and Embase were searched in April of 2019 for studies assessing rest or prescribed exercise for SRC and PPCS. No specific search syntax was used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: A majority of studies show that spontaneous physical activity is safe after SRC and that subsymptom threshold aerobic exercise safely speeds up recovery after SRC and reduces symptoms in those with PPCS. Exercise tolerance can safely be assessed using graded exertion test protocols within days of injury, and the degree of early exercise tolerance has diagnostic and prognostic value. CONCLUSION: Subsymptom threshold aerobic exercise is safe and effective for the treatment of SRC as well as in athletes with PPCS. Further research is warranted to establish the most effective method and dose of aerobic exercise for the active treatment of SRC and whether early exercise treatment can prevent PPCS in athletes. STRENGTH OF RECOMMENDATION TAXONOMY: 2.

Early Aerobic Exercise for the Treatment of Acute Pediatric Concussions.

Sport-related concussion is a common injury that has garnered the attention of the media and general public because of the potential for prolonged acute symptoms and increased risk for long-term impairment. Currently, a growing body of evidence supports the use of various therapies to improve recovery after a concussion. A contemporary approach to managing concussion symptoms is to use aerobic exercise as treatment. To date, several studies on both pediatric and adult patients have established that controlled aerobic exercise is a safe and effective way to rehabilitate patients experiencing delayed recovery after concussion. However, less is known about the utility of an early exercise protocol for optimizing recovery after acute concussion and reducing the risk for persistent postconcussive symptoms, particularly in pediatric populations. Thus, the purpose of our paper was to review and evaluate the available literature on the implementation of aerobic exercise for the treatment of acute pediatric concussion.

Factors Associated With Delayed Concussion Reporting by United States Service Academy Cadets.

CONTEXT: Approximately half of individuals who sustain a concussion do not immediately report their injuries. Motivators for not reporting include thinking the suspected concussion was not a serious injury and wanting to continue participating in activity. Additionally, military personnel have concerns about how concussions may affect their careers. However, delayed reporting can prolong neurobehavioral recovery. Understanding the frequency of delayed reporting and contributing factors will aid in identifying individuals who may be more likely to delay reporting. OBJECTIVE: To describe the frequency of delayed concussion reporting by service academy cadets and determine if sex, injury setting, sport level, or medical history is capable of predicting delayed reporting. DESIGN: Cohort study. SETTING: Service academies. PATIENTS OR OTHER PARTICIPANTS: A total of 316 patients with concussions were observed from January 2014 to August 2016. MAIN OUTCOME MEASURE(S): All cadets completed an annual concussion baseline collection of demographic, medical history, and sports participation information. Delayed concussion reporting served as the outcome variable. Predictor variables were sex, injury setting, and sport level, as well as concussion, headache, and learning disorder history. Frequencies were calculated to describe the proportion of participants who delayed reporting. Univariable and multivariable logistic regression models were used to assess if the predictor variables were associated with delayed concussion reporting. Odds ratios (ORs) and 95% confidence intervals were calculated for all variables included in the final model. RESULTS: Of the patients with concussion, 51% were classified as delayed reporting. In univariable models, females (OR = 1.70) and National Collegiate Athletic Association cadet-athletes (OR = 1.98) were more likely to delay reporting than males and intramural cadet-athletes, respectively. The multivariable model yielded similar findings. CONCLUSIONS: Roughly half of the cadets who sustained a concussion failed to immediately report their injury. Specifically, our data suggested that female cadets, cadets injured outside of competition, and highly competitive cadet-athletes were almost twice as likely to delay reporting as others.