Parent-Reported Academic Outcomes After a Mild Traumatic Brain Injury in the Pediatric Population.

BACKGROUND: Millions of children are diagnosed with a traumatic brain injury (TBI) each year, most being mild TBI (mTBI). The effect of mTBIs on academic performance is of significant importance. We investigate mTBI's impact on parent-reported academic outcomes in school-aged pediatric participants. METHODS: This cross-sectional survey study queried parents (N = 285) regarding letter grade performance and the presence or absence of academic accommodations before and after an mTBI, including complicated mTBI (c-mTBI, or mTBI with radiographic abnormality). RESULTS: We found a parent-reported decline in letter grades following c-mTBI (p < .001), with no significant change following uncomplicated mTBIs. Degree and length of recovery were also associated with grade changes (p < .05). Those with no academic accommodations prior to the injury showed significant decreases in grades after injury regardless of post-injury accommodation status (p < .05). IMPLICATIONS OF SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: This study underscores the need for an improved framework of support to maximize academic performance of children following mTBI, especially in those with a c-mTBI and still recovering from their injury. CONCLUSION: Our study identifies children who are at risk for adverse academic outcomes following mTBI. We encourage efforts to better support school nurses in this effort, including improved communication between health care teams and school teams.

Talking while Walking After Concussion: Acute effects of concussion on speech pauses and gait speed.

Background: Deficits in dual-tasks (DT) are frequently observed post-concussion (i.e., mild Traumatic Brain Injury). However, traditional DT may not be relevant to daily life. Walking while talking elicits DT costs in healthy adults and is part of daily life. Objective: We investigated the effect of concussion on walking with extemporaneous speech and explored relationships between DT and acute symptoms. Methods: Participants with recent concussion (<14 days post-injury) and controls completed three tasks: single-task gait without speaking (ST G ), single-task speaking without walking (ST S ) and walking while speaking (DT). Silent pauses in speech audio reflected cognitive performance, and gait was quantified using inertial sensors. We used linear mixed models to compare groups and conditions and explored associations with self-reported symptoms. Results: Both concussion (n=19) and control (n=18) groups exhibited longer speech pauses ( p < 0.001), slower walking speeds ( p < 0.001), and slower cadence ( p < 0.001) during the DT compared to ST conditions. There were no group differences or interactions for speech pauses ( p > 0.424). The concussion group walked slower ( p = 0.010) and slowed down more during DT than the control group (group*task p = 0.032). Vestibular symptoms strongly associated with ST speech pause duration ( ρ = 0.72), ST gait speed ( ρ = -0.75), and DT gait speed ( ρ = -0.78). Conclusions: Extemporaneous speech is well-practiced, but challenging to complete while walking post-concussion. Strong associations between DT outcomes and vestibular-related symptoms suggest DT deficits vary with post-concussion symptomology. DT deficits may be deleterious to daily tasks post-concussion.

Evidence for the Validation of a Single Item Recovery Question (SIRQ) in Children With Mild and Complicated Mild Traumatic Brain Injury.

BACKGROUND: Recovery from a brain injury occurs in varying degrees. The objective of this study was to investigate the concurrent validity of a parent-reported 10-point scale for degree of recovery, Single Item Recovery Question (SIRQ), in children with mild traumatic brain injury (mTBI) or complicated mTBI (C-mTBI) compared with validated assessments of symptom burden (Post-Concussion Symptom Inventory Parent form-PCSI-P) and quality of life (Pediatric Quality of Life Inventory [PedsQL]). METHODS: A survey was sent to parents of children aged five to 18 years who presented to pediatric level I trauma center with mTBI or C-mTBI. Data included parent-reported postinjury recovery and functioning of children. Pearson correlation coefficients (r) were calculated to measure the associations of the SIRQ with the PCSI-P and the PedsQL. Hierarchical linear regression models were used to examine if covariates would increase the predictive value of the SIRQ to the PCSI-P and the PedsQL total scores. RESULTS: Of 285 responses (175 mTBI and 110 C-mTBI) analyzed, Pearson correlation coefficients for the SIRQ to the PCSI-P (r = -0.65, P < 0.001) and PedsQL total and subscale scores were all significant (P < 0.001) with mostly large-sized effects (r ≥ 0.500), regardless of mTBI classification. Covariates, including mTBI classification, age, gender, and years since injury, resulted in minimum changes in the predictive value of the SIRQ to the PCSI-P and the PedsQL total scores. CONCLUSIONS: The findings demonstrate preliminary evidence for the concurrent validity of the SIRQ in pediatric mTBI and C-mTBI.

Sport participation among children with complicated mild traumatic brain injury.

BACKGROUND: Complicated mild traumatic brain injury (C-mTBI) represents mTBI with positive trauma-related radiographic findings, such as hematoma. It is estimated that 7.5% of all pediatric mTBIs meet these criteria. There is a paucity of research on return to sports in children with C-mTBI. OBJECTIVE: To examine children with C-mTBI, mTBI with skull fracture (mTBI-SF) only and mTBI in relation to sport participation and factors associated with repeated injury. DESIGN: Cross-sectional survey. SETTING: Level I pediatric trauma center. PARTICIPANTS: Parents of children who were 5-18 years of age at the time of injury who sustained C-mTBI or mTBI from 2010 to 2013. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sports participation characteristics before and after injury in children with C-mTBI and mTBI as a function of degree and length of recovery. Repeat mTBI after the index injury was also examined. RESULTS: Of 247 children who participated in sports preinjury (27.5% with C-mTBI and 9.7% with mTBI-SF), 95.1% returned to sports. There was no significant difference by mTBI type regarding participation in any sports (p = .811) nor with high-risk sports (p = .128). C-mTBI but not mTBI-SF (versus mTBI) was associated with lower odds of sustaining a repeat mTBI (odds ratio = 0.30, p = .045). Waiting longer (>3 months compared to <1 month) to return to contact sports was associated with lower odds of sustaining a repeat mTBI (odds ratio = 0.23, p < .05). CONCLUSIONS: Children with C-mTBI and mTBI-SF resume similar sports as children with mTBI. Those with C-mTBI and those who take longer to return to play may have lower risk of repeat mTBIs. Prospective research is needed to inform the development of evidence-based guidelines for children with C-mTBI and mTBI-SF.

Outcomes after minimally invasive and surgical management of suprascapular nerve entrapment: A systematic review.

Background: The prevalence of suprascapular neuropathy is higher than previously estimated. Recent literature highlights a myriad of treatment options for patients ranging from conservative treatment and minimally invasive options to surgical management. However, there are no comprehensive review articles comparing these treatment modalities. Objective: The purpose of this review article is to summarize the current state of knowledge on suprascapular nerve entrapment and to compare minimally invasive treatments to surgical treatments. Methods: The literature search was performed in Mendeley. Search fields were varied redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. A full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by 3 authors until an agreement was reached. Results: Recent studies have further elucidated the pathoanatomy and described several risk factors for entrapment ranging. Four studies met our inclusion criteria regarding peripheral nerve stimulation with good pain and clinical outcomes. Two studies met our inclusion criteria regarding pulsed radiofrequency and showed promising pain and clinical outcomes. One study met our inclusion criteria regarding transcutaneous electrical nerve stimulation and showed good results that were equivalent to pulsed radiofrequency. Surgical treatment has shifted to become nearly all arthroscopic and surgical outcomes remain higher than minimally invasive treatments. Conclusions: Many recently elucidated anatomical factors predispose to entrapment. A history of overhead sports or known rotator cuff disease can heighten a clinician's suspicion. Entrapment at the suprascapular notch is more common overall, yet young athletes may be predisposed to isolated spinoglenoid notch entrapment. Pulsed radiofrequency, peripheral nerve stimulation, and transcutaneous electrical nerve stimulation may be effective in treating patients with suprascapular nerve entrapment. Arthroscopic treatment remains the gold-standard in patients with refractory entrapment symptoms.

Sensory Phenotypes for Balance Dysfunction After Mild Traumatic Brain Injury.

BACKGROUND AND OBJECTIVES: Recent team-based models of care use symptom subtypes to guide treatments for individuals with chronic effects of mild traumatic brain injury (mTBI). However, these subtypes, or phenotypes, may be too broad, particularly for balance (e.g., 'vestibular subtype'). To gain insight into mTBI-related imbalance we 1) explored whether a dominant sensory phenotype (e.g., vestibular impaired) exists in the chronic mTBI population, 2) determined the clinical characteristics, symptomatic clusters, functional measures, and injury mechanisms that associate with sensory phenotypes for balance control in this population, and 3) compared the presentations of sensory phenotypes between individuals with and without previous mTBI. METHODS: A secondary analysis was conducted on the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium. Sensory ratios were calculated from the Sensory Organization Test, and individuals were categorized into one of eight possible sensory phenotypes. Demographic, clinical, and injury characteristics were compared across phenotypes. Symptoms, cognition, and physical function were compared across phenotypes, groups, and their interaction. RESULTS: Data from 758 Service Members and Veterans with mTBI and 172 with no lifetime history of mTBI were included. Abnormal visual, vestibular, and proprioception ratios were observed in 29%, 36%, and 38% of people with mTBI, respectively, with 32% exhibiting more than one abnormal sensory ratio. Within the mTBI group, global outcomes (p<0.001), self-reported symptom severity (p<0.027), and nearly all physical and cognitive functioning tests (p<0.027) differed across sensory phenotypes. Individuals with mTBI generally reported worse symptoms than their non-mTBI counterparts within the same phenotype (p=0.026), but participants with mTBI in the Vestibular-Deficient phenotype reported lower symptom burdens than their non-mTBI counterparts [e.g., mean(SD) Dizziness Handicap Inventory = 4.9(8.1) for mTBI vs. 12.8(12.4) for non-mTBI, group*phenotype interaction p<0.001]. Physical and cognitive functioning did not differ between groups after accounting for phenotype. DISCUSSION: Individuals with mTBI exhibit a variety of chronic balance deficits involving heterogeneous sensory integration problems. While imbalance when relying on vestibular information is common, it is inaccurate to label all mTBI-related balance dysfunction under the 'vestibular' umbrella. Future work should consider specific classification of balance deficits, including specific sensory phenotypes for balance control.

Relationship Between CT Head Findings and Long-term Recovery in Children with Complicated Mild Traumatic Brain Injury.

PRIMARY OBJECTIVE: Complicated mild traumatic brain injury (C-mTBI) refers to CT positive patients with clinically mild TBI. This study investigates the association between CT head findings at time of injury and recovery of paediatric patients with C-mTBI. RESEARCH DESIGN: Retrospective survey and chart review. METHODS: For paediatric patients with C-mTBI (N = 77), CT findings associated with corresponding degree and lengths of recovery from C-mTBI using logistic regression analysis. RESULTS: There was a trend that the odds of incomplete recovery at the time of survey was higher for older children than for younger children (OR = 1.14, 95% CI = 0.98-1.32, p = 0.072). There was a trend that the odds of incomplete recovery (OR = 6.26, 95% CI = 0.97-40.57, p = 0.054) and longer duration for recovery (OR = 8.14, 95% CI = 0.78-84.46, p = 0.079) was higher for children with multiple haemorrhagic contusions than those with single haemorrhagic contusion. No other imaging patterns predicted degree or length of recovery with statistical significance (p > 0.05). CONCLUSIONS: Other than the presence of multiple haemorrhagic contusions, no other pattern of imaging abnormality in paediatric C-mTBI appears to be associated with degree or length of recovery. Further studies with larger cohorts are encouraged.

Hyperhidrosis of the residual limb: a narrative review of the measurement and treatment of excess perspiration affecting individuals with amputation.

BACKGROUND: Hyperhidrosis (HH) is a relatively common disorder involving excessive sweating, typically of the palms or axilla. HH can also frequently occur after limb amputation, where the remaining residual limb excessively perspires, leading to an increased risk of dermatological disorders and functional limitations, such as the inability to comfortably or safely wear a prosthesis. Although many treatments have been proposed to treat HH within the dermatology community, they are not widely known by healthcare providers typically involved in caring for individuals with acquired limb loss. OBJECTIVES: To appraise the current state of quantitative and qualitative assessment of HH within the residual limb and examine existing and future treatment strategies for this problem. STUDY DESIGN: Narrative Literature Review. METHODS: A literature review focused on the assessment and treatment of excessive sweating of residual limbs. RESULTS: There is currently no objective or subjective standard to assess or diagnose HH of the residual limb. Conventional therapies for HH do not always translate to the population of individuals with limb loss. Emerging modalities for treating HH show promise toward a permanent resolution of excess perspiration but require additional studies within people with amputation. CONCLUSIONS: Further research is needed to quantify standard values to objectively and subjectively assess and diagnose hyperhidrosis of the residual limb. New and developing treatments for hyperhidrosis require additional studies to assess efficacy and safety in the residual limb.

Novice vs expert inter-rater reliability of the balance error scoring system in children between the ages of 5 and 14.

BACKGROUND: The Balance Error Scoring System (BESS) is a tool to measure balance, however, no studies have shown its reliability between novice and expert raters. RESEARCH QUESTION: What is the inter-rater reliability of BESS measurements when performed by novice raters compared to experts, and does completion of a focused, online training module increase the inter-rater reliability among novice raters? METHODS: In this reliability study, 5 novice volunteers were asked to independently rate BESS tests from 50 random prerecorded BESS videos of normal healthy subjects aged 5-14. Novice raters regraded the same 50 videos after receiving a formal training. The novices' scores before and after the formal training were compared to one another and then the scores were compared to 4 expert scores. Intraclass correlation (ICC) with 95 % confidence intervals or percent agreements were calculated and compared across groups. RESULTS: For the total BESS score, novice raters showed good reliability (ICC 0.845) which did not change with a formal training (ICC 0.846). Expert raters showed excellent reliability (ICC 0.929). Poor to moderate reliability was noted in the foam stance-single leg in the untrained novice and trained novice group (ICCs 0.452 and 0.64 L respectively). SIGNIFICANCE: BESS testing by novice raters with only written instruction and no formal training yields good inter-rater reliability. In contrast, BESS testing by expert raters yields excellent reliability. A focused training for novice raters conferred a small improvement in the reliability of the scoring of the single leg stance on foam condition but not a significant difference to the overall BESS score. While novices demonstrated promising reliability for overall BESS scores, optimizing clinical research using the BESS with expert raters show the highest reliability.