Comparación de la efectividad entre distintas intervenciones en los síntomas posconmoción en adolescentes y jóvenes: una revisión bibliográfica / Comparison of effectiveness between different interventions in postconcussive symptoms in adolescents and young people: A literature review

Introducción: Actualmente la conmoción cerebral se considera un problema de gran magnitud, siendo los adolescentes y jóvenes la población de riesgo, ya que se encuentran en proceso de maduración. Nuestro objetivo ha sido comparar la eficacia de diferentes intervenciones (ejercicio físico terapéutico, terapia vestibular y descanso) en adolescentes y jóvenes con conmoción cerebral.Desarrollo: Se realizó una búsqueda bibliográfica en las principales bases de datos. Una vez aplicados los criterios de inclusión/exclusión y la escala metodológica Physiotherapy Evidence Database PEDro, fueron revisados seis artículos. Los resultados apoyan la utilización del ejercicio y la terapia vestibular en las etapas iniciales para disminuir los síntomas posconmoción. Según la mayoría de los autores, el ejercicio físico terapéutico y la terapia vestibular reportan mayores beneficios, aunque se necesitaría un protocolo que unificara escalas de valoración, variables de estudio y parámetros de análisis para poder realizar la inferencia en la población diana.Conclusión: Desde el momento del alta hospitalaria del paciente, la aplicación combinada de ejercicio físico y terapia vestibular, podría considerarse como la mejor opción para disminuir los síntomas posconmoción.(AU)

Introduction: Currently, concussion considers a problem of great magnitude, adolescents and young people being the population at risk, since it is in the process of maturation. Our goal has been to compare the effectiveness of different interventions (exercise therapy, vestibular rehabilitation and rest) in adolescents and young people with concussion. Development: A bibliographic search was carried out in the main databases. Once the inclusion / exclusion criteria and the PEDro methodological scale were applied, 6 articles were reviewed. The results support the use of exercise and vestibular rehabilitation in the initial stages to reduce post-concussion symptoms. According to most authors, therapeutic physical exercise and vestibular rehabilitation report greater benefits, although a protocol that unifies assessment scales, study variables and analysis parameters would be needed to be able to make the inference in the target population. Conclusión: From the moment of hospital discharge, the combined application of exercise and vestibular rehabilitation could be the best option to reduce post-concussion symptoms.(AU)

Associations of Nightmares and Sleep Disturbance With Neurobehavioral Symptoms Postconcussion.

OBJECTIVE: This study investigates the association of nightmares beyond general sleep disturbance on neurobehavioral symptoms in adults with mild traumatic brain injury (mTBI). DESIGN: Secondary analysis of a concussion cohort study. PARTICIPANTS: One hundred and eleven adults older than 20 years with mTBI were recruited from a specialized concussion treatment center. MAIN MEASURES: Behavioral Assessment Screening Tool, Pittsburgh Sleep Quality Index, and self-report of nightmare frequency in the past 2 weeks. RESULTS: Among adults with mTBI, nightmares accounted for the greatest amount of variability in negative affect (ß = .362, P < .001), anxiety (ß = .332, P < .001), and impulsivity (ß = .270, P < .001) after adjusting for age and sex. Overall sleep disturbance had the strongest association with depression (ß = .493, P < .001), fatigue (ß = .449, P < .001), self-reported executive dysfunction (ß = .376, P < .001), and overall burden from concussive symptoms (ß = .477, P < .001). CONCLUSIONS: Nightmares and sleep disturbance are differentially associated with variance in neurobehavioral symptoms. Nightmares were independently associated with neurobehavioral symptoms representing an excess of normal functioning (eg, anxiety, impulsivity), while general sleep disturbance was associated with neurobehavioral symptoms representing functioning below normal levels (eg, depression, fatigue, self-reported executive dysfunction). Clinical and research implications are discussed.

The diagnosing and treatment of concussions.

Mild traumatic brain injury, such as concussion, was once considered self-resolving. However, over the past decade, increased understanding of the short- and long-term impact has led to new guidelines for active management. In this review, we summarise recent findings, covering diagnostic criteria, and management for early and persistent symptoms. Many of the postconcussive symptoms can be treated and an individualised approach from a biopsychosocial perspective is recommended. Overall, the new knowledge will significantly impact patient care and future research.

Applicability and clinical utility of the German rivermead post-concussion symptoms questionnaire in proxies of children after traumatic brain injury: an instrument validation study.

BACKGROUND: The German Rivermead Post-Concussion Symptoms Questionnaire (RPQ) can be used to assess post-concussion symptoms (PCS) after traumatic brain injury (TBI) in adults, adolescents, and children. METHODS: In this study, we examined the psychometric properties of the German RPQ proxy version (N = 146) for children (8-12 years) after TBI at the item, total and scale score level. Construct validity was analyzed using rank correlations with the proxy-assessed Post-Concussion Symptoms Inventory (PCSI-P), the Patient Health Questionnaire 9 (PHQ-9), and the Generalized Anxiety Disorder Scale 7 (GAD-7). Furthermore, sensitivity testing was performed concerning subjects' sociodemographic and injury-related characteristics. Differential item functioning (DIF) was analyzed to assess the comparability of RPQ proxy ratings for children with those for adolescents. RESULTS: Good internal consistency was demonstrated regarding Cronbach's α (0.81-0.90) and McDonald's ω (0.84-0.92). The factorial validity of a three-factor model was superior to the original one-factor model. Proxy ratings of the RPQ total and scale scores were strongly correlated with the PCSI-P (ϱ = 0.50-0.69), as well as moderately to strongly correlated with the PHQ-9 (ϱ = 0.49-0.65) and the GAD-7 (ϱ = 0.44-0.64). The DIF analysis revealed no relevant differences between the child and adolescent proxy versions. CONCLUSIONS: The German RPQ proxy is a psychometrically reliable and valid instrument for assessing PCS in children after TBI. Therefore, RPQ self- and proxy-ratings can be used to assess PCS in childhood as well as along the lifespan of an individual after TBI.

White Matter Alterations in Military Service Members With Remote Mild Traumatic Brain Injury.

Importance: Mild traumatic brain injury (mTBI) is the signature injury experienced by military service members and is associated with poor neuropsychiatric outcomes. Yet, there is a lack of reliable clinical tools for mTBI diagnosis and prognosis. Objective: To examine the white matter microstructure and neuropsychiatric outcomes of service members with a remote history of mTBI (ie, mTBI that occurred over 2 years ago) using diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI). Design, Setting, and Participants: This case-control study examined 98 male service members enrolled in a study at the National Intrepid Center of Excellence. Eligible participants were active duty status or able to enroll in the Defense Enrollment Eligibility Reporting system, ages 18 to 60 years, and had a remote history of mTBI; controls were matched by age. Exposures: Remote history of mTBI. Main Outcomes and Measures: White matter microstructure was assessed using a region-of-interest approach of skeletonized diffusion images, including DTI (fractional anisotropy, mean diffusivity, radial diffusivity and axial diffusivity) and NODDI (orientation dispersion index [ODI], isotropic volume fraction, intra-cellular volume fraction). Neuropsychiatric outcomes associated with posttraumatic stress disorder (PTSD) and postconcussion syndrome were assessed. Results: A total of 65 male patients with a remote history of mTBI (mean [SD] age, 40.5 [5.0] years) and 33 age-matched male controls (mean [SD] age, 38.9 [5.6] years) were included in analysis. Compared with the control cohort, the 65 service members with mTBI presented with significantly more severe PTSD-like symptoms (mean [SD] PTSD CheckList-Civilian [PCL-C] version scores: control, 19.0 [3.8] vs mTBI, 41.2 [11.6]; P < .001). DTI and NODDI metrics were altered in the mTBI group compared with the control, including intra-cellular volume fraction of the right cortico-spinal tract (ß = -0.029, Cohen d = 0.66; P < .001), ODI of the left posterior thalamic radiation (ß = -0.006, Cohen d = 0.55; P < .001), and ODI of the left uncinate fasciculus (ß = 0.013, Cohen d = 0.61; P < .001). In service members with mTBI, fractional anisotropy of the left uncinate fasciculus was associated with postconcussion syndrome (ß = 5.4 × 10-3; P = .003), isotropic volume fraction of the genu of the corpus callosum with PCL-C (ß = 4.3 × 10-4; P = .01), and ODI of the left fornix and stria terminalis with PCL-C avoidance scores (ß = 1.2 × 10-3; P = .02). Conclusions and Relevance: In this case-control study of military-related mTBI, the results suggest that advanced magnetic resonance imaging techniques using NODDI can reveal white matter microstructural alterations associated with neuropsychiatric symptoms in the chronic phase of mTBI. Diffusion trends observed throughout widespread white matter regions-of-interest may reflect mechanisms of neurodegeneration as well as postinjury tissue scarring and reorganization.

Serum neurofilament light chain, inflammatory markers, and kynurenine metabolites in patients with persistent post-concussion symptoms: A cohort study.

BACKGROUND: Concussion leads to persistent post-concussion symptoms (PPCS) in up to one-third of those affected. While previous research has linked the initial trauma to elevated serum levels of neurofilament light chain (NFL), inflammatory markers, and neurotoxic metabolites within the kynurenine pathway, few studies have explored their relevance in PPCS. This study aims to investigate these biomarkers in PPCS patients, elucidating their relevance in the prolonged phase of concussion. METHODS: Serum samples from 86 PPCS individuals aged 18-30 years, 2-6 months post-trauma were analyzed, with 54 providing follow-up samples after seven months. NFL was measured using single-molecule array (Simoa) technology, 13 inflammatory markers via a Luminex immunoassay, and five kynurenine metabolites using liquid chromatography-mass spectrometry. A control group of 120 healthy anonymous blood donors was recruited for comparison. RESULTS: No significant NFL differences were found in PPCS participants compared with healthy individuals (p = 0.22). Intriguingly, a subset (9.3%) of PPCS participants initially exhibited abnormally high NFL levels (>9.7 pg/mL), which normalized upon follow-up (p = 0.032). Additionally, serum levels of the inflammatory markers, monocyte chemoattractant protein-1 (MCP-1/CCL2), and eotaxin-1/CCL11 were 25-40% lower than in healthy individuals (p ≤ 0.001). As hypothesized, PPCS participants exhibited a 22% reduction in the ratio of kynurenic acid to quinolinic acid (neuroprotective index) (p < 0.0001), indicating a shift towards the formation of neurotoxic metabolites. CONCLUSION: NFL may serve as a biomarker to monitor recovery, and future studies should investigate the potential therapeutic benefits of modulating the kynurenine pathway to improve PPCS.

Relationship between severity of concussion's symptoms and functional performance in children.

INTRODUCTION: Concussion is a common brain injury that has significant effects on multiple functional domains in children. However, limited research exists on the relationship between concussion severity and functional performance in this population. This study aimed to examine the relationship between the severity of concussion symptoms and children's balance and functional performance. METHODS: This cross-sectional study recruited 23 children (9 males and 14 females; mean age 13.9 ± 2.2 years) with clinically diagnosed concussions from a tertiary balance center in 2016. Participants underwent clinical and functional evaluations by specialized physical therapists. Symptom severity was assessed using the Post-Concussion Symptom Scale (PCSS), while functional performance was measured using the Functional Gait Assessment (FGA). RESULTS: There was a trend suggesting a negative correlation between symptom severity (PCSS) and functional performance (FGA), indicating potentially better performance in individuals with milder symptoms. However, this trend was not significant (rs (21) = -.072, p = 0.744). Furthermore, no significant correlation was found between FGA scores and the severity of individual symptoms. CONCLUSION: The findings suggest that concussion symptom severity may not be directly related to functional performance in children. Therefore, it is crucial to incorporate functional performance measures alongside symptom assessment for comprehensive concussion management.

Concussion symptom presentation and clinical recovery among pediatric athletes: comparing concussions sustained during school and summer months.

OBJECTIVE: We examined post-concussion symptom presentation, exercise, and sleep among pediatric athletes who sustained concussion during the school year vs. summer months. METHODS: We evaluated athletes 6-18 years old within 21-days of concussion. They reported symptoms (Health and Behavior Inventory), with cognitive/somatic domain sub-scores calculated, and indicated if they had exercised or experienced sleep problems since injury. We grouped patients by injury season: summer months (June-August) vs. school year (September-May). RESULTS: 350 patients (14.4 ± 2.4 years old; 37% female; initial visit 8.8 ± 5.3 days post-concussion) were seen for care: 24% sustained a concussion during summer months, 76% during the school year. Lower cognitive (median = 7 [IQR = 1, 15] vs. 9.5 [4, 17]; p = 0.01), but not somatic (7 [2.5, 11] vs. 8 [4, 13]; p = 0.06), HBI scores were observed for patients injured during the summer. Groups were similar in proportion exercising (16% vs 17%) and endorsing sleep problems (29% vs 31%). After adjustments, sustaining a concussion during the summer predicted total (ß=-3.43; 95%CI = -6.50, -0.36; p = 0.029) and cognitive (ß = -2.29; 95%CI = -4.22, -0.36; p = 0.02), but not somatic (ß=-1.46; 95%CI = -2.84, -0.08; p = 0.04), symptom severity. CONCLUSION: Pediatric patients with concussion may present with greater cognitive symptoms during the school year, compared to summer months.

Sex Differences in Postinjury Health Profiles Among U.S. Military Personnel Following Deployment-Related Concussion.

Background: Women in the U.S. military are now authorized to serve in direct combat occupations. This may increase their risk of combat injuries, such as concussion, in future conflicts. Knowledge of sex differences in health profiles after concussion is paramount for military medical planning efforts. The purpose of this study was to assess sex-related differences in health profiles among U.S. military personnel following deployment-related concussion. Materials and Methods: We conducted a retrospective study of service members who sustained a concussion during combat deployment between 2004 and 2013. Postinjury diagnoses were abstracted from outpatient encounters in electronic health records for 24 months after concussion. We used hierarchical clustering to identify clusters, termed "health profiles," and logistic regression to determine whether sex predicted membership in the health profiles. Results: The study sample included 346 women and 4536 men with deployment-related concussion. Five postinjury health profiles were identified and classified as no morbidity, back pain, tinnitus/memory loss, posttraumatic stress disorder/postconcussion syndrome, and multimorbidity. Women relative to men had higher odds of membership in the back pain (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.05-1.67) and multimorbidity profiles (OR = 1.44; 95% CI = 1.03-2.00) and lower odds than men in the tinnitus/memory loss profile (OR = 0.62; 95% CI = 0.42-0.91). Conclusions: Postinjury health profiles among U.S. service members differ by sex following deployment-related concussion, particularly with a higher burden of multimorbidity among women than men, which may require interdisciplinary care. Women also had higher odds of membership in the back pain profile and lower odds in the tinnitus/memory loss profile than men. To prepare for future military operations where women may have greater exposure to combat, continued research elucidating health-related sex differences after deployment-related concussion is imperative.

Do preinjury life events moderate the outcomes of mild traumatic brain injuries in children? An A-CAP Study.

OBJECTIVE: To examine preinjury life events as moderators of postconcussive symptoms (PCS) and quality of life (QoL) in children with pediatric mild traumatic brain injury (mTBI) versus orthopedic injury (OI). METHODS: Participants were 633 children with mTBI and 334 with OI, ages 8-16.99, recruited from 5 pediatric emergency departments and followed for 6 months postinjury as part of a prospective cohort study. Preinjury life events were measured retrospectively using the Child and Adolescent Survey of Experiences, PCS using the Health and Behavior Inventory (HBI) and Post-Concussion Symptom Interview (PCS-I), and QoL using the Pediatric Quality of Life Inventory (PedsQL). Analyses involved longitudinal regression using restricted cubic splines, with group, positive and negative life events, and time as primary predictors. Covariates included age, sex, race, socioeconomic status, preinjury history (i.e., headache, migraine, previous concussion), and parent-rated retrospective PCS-I, HBI, and PedsQL scores. RESULTS: PCS and QoL were worse after mTBI than OI, but group differences declined with time (all p < .001). Group differences in PCS were larger at higher levels of positive life events, which predicted lower PCS (p= .03 to p < .001) and higher QoL (p = .048) after OI but not after mTBI. Negative life events predicted worse PCS and QoL in both groups (p = .002 to p < .001). CONCLUSIONS: Preinjury positive life events moderate outcomes after pediatric injury, with a protective effect seen in OI but not in mTBI. Negative life events are consistently associated with worse outcomes regardless of injury type.

Prefrontal Cortex Activity During Gait in People With Persistent Symptoms After Concussion.

BACKGROUND: Concussions result in transient symptoms stemming from a cortical metabolic energy crisis. Though this metabolic energy crisis typically resolves in a month, symptoms can persist for years. The symptomatic period is associated with gait dysfunction, the cortical underpinnings of which are poorly understood. Quantifying prefrontal cortex (PFC) activity during gait may provide insight into post-concussion gait dysfunction. The purpose of this study was to explore the effects of persisting concussion symptoms on PFC activity during gait. We hypothesized that adults with persisting concussion symptoms would have greater PFC activity during gait than controls. Within the concussed group, we hypothesized that worse symptoms would relate to increased PFC activity during gait, and that increased PFC activity would relate to worse gait characteristics. METHODS: The Neurobehavior Symptom Inventory (NSI) characterized concussion symptoms. Functional near-infrared spectroscopy quantified PFC activity (relative concentration changes of oxygenated hemoglobin [HbO2]) in 14 people with a concussion and 25 controls. Gait was assessed using six inertial sensors in the concussion group. RESULTS: Average NSI total score was 26.4 (13.2). HbO2 was significantly higher (P = .007) for the concussed group (0.058 [0.108]) compared to the control group (-0.016 [0.057]). Within the concussion group, HbO2 correlated with NSI total symptom score (ρ = .62; P = .02), sagittal range of motion (r = .79; P = .001), and stride time variability (r = -.54; P = .046). CONCLUSION: These data suggest PFC activity relates to symptom severity and some gait characteristics in people with persistent concussion symptoms. Identifying the neurophysiological underpinnings to gait deficits post-concussion expands our knowledge of motor behavior deficits in people with persistent concussion symptoms.

Patient-centered mild traumatic brain injury interventions in the emergency department.

INTRODUCTION: Traumatic brain injury (TBI) results in 2.5 million emergency department (ED) visits per year in the US, with mild traumatic brain injury (mTBI) accounting for 90% of cases. There is considerable evidence that many experience chronic symptoms months to years later. This population is rarely represented in interventional studies. Management of adult mTBI in the ED has remained unchanged, without consensus of therapeutic options. The aim of this review was to synthesize existing literature of patient-centered ED treatments for adults who sustain an mTBI, and to identify practices that may offer promise. METHODS: A systematic review was conducted using the PubMed and Cochrane databases, while following PRISMA guidelines. Studies describing pediatric patients, moderate to severe TBI, or interventions outside the ED were excluded. Two reviewers independently performed title and abstract screening. A third blinded reviewer resolved discrepancies. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the methodological quality of the studies. RESULTS: Our search strategy generated 1002 unique titles. 95 articles were selected for full-text screening. The 26 articles chosen for full analysis were grouped into one of the following intervention categories: (1) predictive models for Post-Concussion Syndrome (PCS), (2) discharge instructions, (3) pharmaceutical treatment, (4) clinical protocols, and (5) functional assessment. Studies that implemented a predictive PCS model successfully identified patients at highest risk for PCS. Trials implementing discharge related interventions found the use of video discharge instructions, encouragement of daily light exercise or bed rest, and text messaging did not significantly reduce mTBI symptoms. The use of electronic clinical practice guidelines (eCPG) and longer leaves of absence from work following injury reduced symptoms. Ondansetron was shown to reduce nausea in mTBI patients. Studies implementing ED Observation Units found significant declines in inpatient admissions and length of hospital stay. The use of tablet-based tasks was found to be superior to many standard cognitive assessments. CONCLUSION: Validated instruments are available to aid clinicians in identifying patients at risk for PCS or serious cognitive impairment. EDOU management and evidence-based modifications to discharge instructions may improve mTBI outcomes. Additional research is needed to establish the therapeutic value of medications and lifestyle changes for the treatment of mTBI in the ED.

Optimizing the Combination of Common Clinical Concussion Batteries to Predict Persistent Postconcussion Symptoms in a Prospective Cohort of Concussed Youth.

BACKGROUND: Studies have evaluated individual factors associated with persistent postconcussion symptoms (PPCS) in youth concussion, but no study has combined individual elements of common concussion batteries with patient characteristics, comorbidities, and visio-vestibular deficits in assessing an optimal model to predict PPCS. PURPOSE: To determine the combination of elements from 4 commonly used clinical concussion batteries and known patient characteristics and comorbid risk factors that maximize the ability to predict PPCS. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: We enrolled 198 concussed participants-87 developed PPCS and 111 did not-aged 8 to 19 years assessed within 14 days of injury from a suburban high school and the concussion program of a tertiary care academic medical center. We defined PPCS as a Post-Concussion Symptom Inventory (PCSI) score at 28 days from injury of ≥3 points compared with the preinjury PCSI score-scaled for younger children. Predictors included the individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, 5th Edition (SCAT-5), King-Devick test, and PCSI, in addition to age, sex, concussion history, and migraine headache history. The individual elements of these tests were grouped into interpretable factors using sparse principal component analysis. The 12 resultant factors were combined into a logistic regression and ranked by frequency of inclusion into the combined optimal model, whose predictive performance was compared with the VVE, initial PCSI, and the current existing predictive model (the Predicting and Prevention Postconcussive Problems in Pediatrics (5P) prediction rule) using the area under the receiver operating characteristic curve (AUC). RESULTS: A cluster of 2 factors (SCAT-5/PCSI symptoms and VVE near point of convergence/accommodation) emerged. A model fit with these factors had an AUC of 0.805 (95% CI, 0.661-0.929). This was a higher AUC point estimate, with overlapping 95% CIs, compared with the PCSI (AUC, 0.773 [95% CI, 0.617-0.912]), VVE (AUC, 0.736 [95% CI, 0.569-0.878]), and 5P Prediction Rule (AUC, 0.728 [95% CI, 0.554-0.870]). CONCLUSION: Among commonly used clinical assessments for youth concussion, a combination of symptom burden and the vision component of the VVE has the potential to augment predictive power for PPCS over either current risk models or individual batteries.

Dose-Response Effect of Mental Health Diagnoses on Concussion Recovery in Children and Adolescents.

BACKGROUND: Pre-existing mental health diagnoses may contribute to greater emotional symptom burden and prolonged recovery after concussion. HYPOTHESIS: Youth with pre-existing mental health diagnoses will have greater emotional symptom burden, greater risk for delayed return to exercise, and more prolonged recovery from concussion than those without those diagnoses. STUDY DESIGN: Prospective cohort. LEVEL OF EVIDENCE: Level 3. METHODS: A prospective registry of youth concussion was examined for differences in emotional symptom burden after injury to develop a predictive risk model for prolonged recovery. The impact of individual and total number of pre-existing mental health diagnoses (0, 1, 2, and 3+) was assessed, and multivariable logistic regression was performed to identify factors associated with prolonged recovery. RESULTS: Among a cohort of 3105 youth with concussion, those with a history of mental health diagnoses, in a dose-response fashion, had greater postinjury emotional symptom burden (7 emotional symptoms vs 4; P < 0.01), visio-vestibular dysfunction (65% abnormal vs 56% abnormal; P < 0.01), later return to symptom-limited exercise (23 vs 21 days; P < 0.01), and overall longer concussion recovery (38 days, interquartile range [IQR] 18, 80) versus 25 days (IQR 13, 54; P < 0.01). Boys with prolonged recovery after concussion had greater emotional symptom burden than girls (5 emotional symptoms vs 3; P < 0.01). CONCLUSION: Pre-existing mental health diagnoses are associated with greater postinjury emotional symptom burden and longer concussion recovery in a dose-response fashion. Visiovestibular deficits and delayed return to exercise are also associated with pre-existing mental health diagnoses and prolonged recovery. Boys with prolonged recovery from concussion experience greater emotional symptom burden than girls. CLINICAL RELEVANCE: Addressing pre-existing mental health diagnoses is essential to concussion management. Boys with prolonged recovery from concussion may particularly benefit from interventions to address their higher emotional symptom burden. Interventions, including a home visio-vestibular exercise program and symptom-limited exercise, may contribute to improving time to concussion recovery.

Exploring the association between cognitive activity and symptom resolution following concussion in adolescents aged 11-17 years.

OBJECTIVE: As opposed to postconcussion physical activity, the potential influence of cognitive activity on concussion recovery is not well characterised. This study evaluated the intensity and duration of daily cognitive activity reported by adolescents following concussion and examined the associations between these daily cognitive activities and postconcussion symptom duration. METHODS: This study prospectively enrolled adolescents aged 11-17 years with a physician-confirmed concussion diagnosis within 72 hours of injury from the emergency department and affiliated concussion clinics. Participants were followed daily until symptom resolution or a maximum of 45 days postinjury to record their daily cognitive activity (intensity and duration) and postconcussion symptom scores. RESULTS: Participants (n=83) sustained their concussion mostly during sports (84%), had a mean age of 14.2 years, and were primarily male (65%) and white (72%). Participants reported an average of 191 (SD=148), 166 (SD=151) and 38 (SD=61) minutes of low-intensity, moderate-intensity and high-intensity daily cognitive activity postconcussion while still being symptomatic. Every 10 standardised minutes per hour increase in moderate-intensity or high-intensity cognitive activities postconcussion was associated with a 22% greater rate of symptom resolution (adjusted hazard ratio (aHR) 1.22, 95% CI 1.01 to 1.47). Additionally, each extra day's delay in returning to school postconcussion was associated with an 8% lower rate of symptom resolution (aHR 0.92, 95% CI 0.85 to 0.99). CONCLUSION: In adolescents with concussion, more moderate-high intensity cognitive activity is associated with faster symptom resolution, and a delayed return to school is associated with slower symptom resolution. However, these relationships may be bidirectional and do not necessarily imply causality. Randomised controlled trials are needed to determine if exposure to early cognitive activity can promote concussion recovery in adolescents.

Treatment of chronic symptoms following mild traumatic brain injury with transcranial LED: a sham run-in pilot study of photobiomodulation therapy.

PRIMARY OBJECTIVE: We evaluated whether photobiomodulation with red/near infrared light applied transcranially via light emitting diodes (LED) was associated with reduced symptoms and improved cognitive functioning in patients with chronic symptoms following mild traumatic brain injury. RESEARCH DESIGN: Participants (3 men, 6 women; 22-61 years-old) underwent a 6-week intervention involving 18 40-minute transcranial LED treatment sessions. METHODS AND PROCEDURES: Reliable change indices were calculated for 10 neuropsychological test scores and 3 self-report questionnaires of subjective cognition, post-concussion symptoms, and depression at baseline and following treatment. Questionnaires were also administered after 2-week sham and at 1-month and 2-month follow-ups. MAIN OUTCOME AND RESULTS: Only 2 participants improved on neuropsychological testing. On questionnaires, 4 reported improved cognition, 5 reported improved post-concussion symptoms, and 3 reported improved depression. Significant improvement in 2 or more domains was reported by 4 participants and mostly maintained at both follow-ups. CONCLUSIONS: Most participants did not improve on neuropsychological testing. A minority self-reported improvement in symptoms, potentially explained by the intervention, psychiatric medication changes, placebo effects, or other factors. Selecting participants with different clinical characteristics, and dosing and delivery system changes, may produce different results. A study design accounting for placebo effects appears warranted in future trials.

Co-existence of depression and post-concussion syndrome one month after mild traumatic brain injury.

BACKGROUND: Previous studies suggest an association between Post-concussion syndrome (PCS) and depression, both highly prevalent after mTBI. OBJECTIVE: To assess the prevalence and risk-factors of depression among patients with PCS 1 month after mTBI. METHODS: We prospectively screened 372 mTBI patients admitted in two academic Emergency Departments between 2017 and 2019. One month after mTBI, we administered the Rivermead Post-concussion symptoms Questionnaire (RPQ) and the Patient Health Questionnaire (PHQ-9) questionnaires over the telephone. PCS and depression were defined by RPQ ≥ 12 and PHQ-9 ≥ 10. Multivariate multinomial regression identified baseline factors associated with PCS and depression. RESULTS: Two hundred and eight completed RPQ and PHQ-9. Forty-seven patients (22.5%) met criteria for PCS, among which 22 (46.8%) met criteria for depression (PCS+D+). Patients with PCS but without depression were less likely to present with an associated injury (Coefficient = -1.6, p = 0.047) and to report initial sadness (Coefficient = -2.5, p = 0.03). Initial sadness (Coefficient = -1.3, p = 0.047), associated injury (Coefficient = -1.9, p = 0.008), as well as initial nausea (Coefficient = -1.8, p = 0.002), and male sex (Coefficient = 1.8, p = 0.002), were associated with the absence of depression and PCS in comparison with PCS+D+ patients. CONCLUSION: Among patients with PCS 1 month after mTBI, those with depression are more likely to present with initial sadness and with an associated injury.

Serum calcitonin gene-related peptide in patients with persistent post-concussion symptoms, including headache: a cohort study.

BACKGROUND: Calcitonin gene-related peptide (CGRP) plays an important role in migraine pathophysiology, and post-traumatic headache (PTH) frequently presents with migraine-like features. Despite several clinical similarities, few studies have explored CGRP in PTH and concussion. This study investigates serum CGRP levels in patients with persistent post-concussion symptoms (PPCS), including PTH. METHODS: This cohort study was based on serum samples from individuals aged 18-30 years with PPCS who participated in a previously published randomized controlled trial of a non-pharmacological intervention. The primary outcome was serum CGRP concentrations, determined at baseline before randomization and at follow-up 7 months later, using an enzyme-linked immunosorbent assay (ELISA). CGRP levels at baseline were compared with healthy anonymous blood donors in the same age group. RESULTS: Baseline serum samples were collected from 86 participants with PPCS. The participants were most often female (78%) and migraine-like headache was the most frequent headache phenotype (74%). Serum CGRP levels were higher in participants with PPCS than in 120 healthy individuals (median: 158.5 pg/mL vs. 76.3 pg/mL, p = 0.050). A stratified analysis revealed that females with PPCS had a fivefold higher median than healthy females (166.3 pg/mL vs. 32.1 pg/mL, p = 0.0006), while no differences were observed in males (p = 0.83). At follow-up, CGRP levels decreased with a median change of - 1.3 pg/mL (95% confidence interval: - 17.6-0, p = 0.024). DISCUSSION: Elevated serum levels of CGRP in patients with PPCS and a decrease over time suggest an involvement of CGRP in PTH/PPCS. If confirmed in other studies, it could pave the way for CGRP-targeted therapies, which could have clinical significance.