Characteristics of Pediatric Concussion across Different Mechanisms of Injury in 5 through 12-Year-Olds.

OBJECTIVE: To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and nonsport or recreation-related concussion (non-SRRC) in patients 5 through 12 years old, an understudied population in youth concussion. STUDY DESIGN: This observational study included patients aged 5 through 12 years presenting to a specialty care concussion setting at ≤28 days postinjury from 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Posthoc pairwise comparisons were employed for all analyses (α = 0.017). RESULTS: One thousand one hundred forty-one patients reported at ≤28 days of injury (female = 42.9%, median age = 11, interquartile range (IQR) = 9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (P < .001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 2 and 3 days later than SRC (P < .001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (P < .001) compared with RRC and SRC (P < .001). CONCLUSIONS: In concussion patients 5 through 12 years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury.

Epidemiology of the Injuries Sustained by Elite Spanish under-18 and under-20 Rugby Players.

This study examines the injuries suffered by players (n=166) of the Spanish national men's under-18 and under-20 rugby teams between 2015 and 2017, and identifies the actions involved in their occurrence. All injuries (total n=78) sustained during matches and training were recorded as recommended by World Rugby, and injury incidence rates per 1000 player-hours (ph) calculated for both types of activity. Injuries occurred more commonly during matches than during training (incidence 105.3 [95% CI: 78.7-131.9] per 1000 [ph] of match play, vs 1.16 [95% CI: 0.69-1.62] per 1000 ph of training), and most days absent per 1000 ph during matches with<3 days rest since the previous match (4209.2 [95% CI: 3516.2-4902.1] per 1000 ph of match play, vs 1947.4 [95% CI: 1511.8-2382.9] per 1000 ph of match play in matches with>3 days rest). These results provide information that may be useful in the development of strategies aimed at reducing the incidence of injuries.

Classification Criteria and Rates of Persistent Postconcussive Symptoms in Children: A Systematic Review and Meta-Analysis.

OBJECTIVE: To provide a systematic review of studies examining the proportion of children with persistent postconcussive symptoms (PPCS) and to examine potential moderators of prevalence. STUDY DESIGN: Searches were conducted in MEDLINE, Embase, PsycINFO, Scopus, and Cochrane Central Register of Controlled Trials on April 16, 2020. Criteria for study inclusion were children aged <18 years with concussion or mild traumatic brain injury, operational definition of PPCS, assessment of postconcussive symptoms at least 4 weeks postinjury, sample sizes and proportion with PPCS available, and study published in English. Definition of PPCS, sample size, proportion of participants identified with PPCS, child sex and age at injury, time postinjury, premorbid symptoms, diagnosis (concussion or mild traumatic brain injury), and study publication year were extracted from each article. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: Thirteen studies, with a total of 5307 participants, were included in our analysis. The proportion of children identified with PPCS was 35.1% (weighted average; 95% CI, 26.3%-45.0%). The prevalence of PPCS was higher in older and female children who presented for care at concussion clinics, and in more recent publications. CONCLUSIONS: Approximately one-third of children with concussion/mild traumatic brain injury will experience PPCS. Age, sex, and point of care could help identify children at high risk for PPCS.

Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury.

OBJECTIVE: To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT). STUDY DESIGN: We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits. RESULTS: There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS. CONCLUSIONS: Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.

Head injury and neuropsychiatric sequelae in asylum seekers.

OBJECTIVE: Asylum seekers experience a high burden of physical and psychological trauma, yet there is a scarcity of literature regarding the epidemiology and sequelae of head injury (HI) in asylum seekers. We examined HI prevalence and association with neuropsychiatric comorbidities in asylum seekers. METHODS: A retrospective cross-sectional study was performed through review of 139 medical affidavits from an affidavit database. Affidavits written from 2010 to 2018 were included. Demographic and case-related data were collected and classified based on the presence of HI. For neuropsychiatric sequelae, the primary study outcome was headache and the secondary outcomes were depression, posttraumatic stress disorder, and anxiety. Multivariable logistic regression was performed to examine the association between HI and neuropsychiatric sequelae, adjusted for demographic and clinical characteristics. RESULTS: A total of 139 medical affidavits of asylum seekers were included. The mean age was 27.4 ± 12.1 years, 56.8% were female, and 38.8% were <19 years. Almost half (42.5%) explicitly self-reported history of HI. Compared to clients who did not report HI, clients with HI were older and more likely to report a history of headache, physical abuse, physical trauma, concussion, and loss of consciousness. After adjustment for demographic and clinical characteristics, clients with HI had greater odds for neuropsychological sequelae such as headache (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.0-8.7) and depression (OR 2.5, 95% CI 1.1-5.7). CONCLUSIONS: We observed a high prevalence of HI in asylum seekers. Comprehensive screening for HI and neuropsychiatric comorbidities is encouraged when evaluating asylum seekers.

Epidemiology of Boys' Club Lacrosse Injuries During the 2018 Summer Lacrosse Season.

CONTEXT: In the past 10 years, participation in boys' youth and high school lacrosse has increased by 33%. Among many club teams and tournaments, athletes may not have access to medical coverage. Additionally, these athletes face a higher volume of play than in traditional scholastic sport settings. OBJECTIVE: To describe the injury characteristics of boys' nonscholastic youth and high school club lacrosse athletes over the course of a summer season. DESIGN: Descriptive epidemiology study. PATIENTS OR OTHER PARTICIPANTS: Boys' nonscholastic youth and high school lacrosse athletes, aged 8 to 18 years, who competed in tournaments. MAIN OUTCOME MEASURE(S): Athletic trainers at tournaments were given standardized injury report forms to document patient encounters. These reports were then entered into the Datalys Injury Surveillance Tool. RESULTS: Over the summer tournament season, 233 injuries were reported in 109 342 athlete-exposures (AEs) for an injury rate of 2.13 per 1000 AEs (95% confidence interval = 1.87, 2.42). The most frequently injured body parts were the head and/or face (n = 51, 22%), arm and/or elbow (n = 34, 15%), and hand and/or wrist (n = 29, 12%). The most common diagnoses were contusions (n = 63, 27%), concussions (n = 44, 19%), fractures (n = 39, 17%), and sprains (n = 35, 15%). The most often injured position was midfielder (n = 65, 41%), followed by defense (n = 48, 30%), attack (n = 36, 23%), and goalkeeper (n = 9, 6%). The concussion rate was 0.4 per 1000 AEs (95% confidence interval = 0.28, 0.52). CONCLUSIONS: The injury rate experienced by boys' nonscholastic club lacrosse athletes was similar to the rates of their high school counterparts as well as school-sponsored football and wrestling athletes. Because of the risk of injury, athletic training services should be available for youth and high school club lacrosse tournaments.

Brain Concussion: New Classifications and Current Physiopathological Knowledge of the Disease

The present review paper aims to update the definition and classification of cerebral concussion, highlighting its pathophysiological mechanisms. The high prevalence of cerebral concussion in emergency rooms around the world makes it necessary to know its proper management to avoid its late sequelae, which traditionally compromise cognitive aspects of behavior. New evidence on potential neuroprotective treatments is being investigated.

Risk of Repeat Concussion Among Patients Diagnosed at a Pediatric Care Network.

OBJECTIVE: To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury. STUDY DESIGN: For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion. RESULTS: Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]). CONCLUSIONS: We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts.

Initial Emergency Department Visit and Follow-Up Care for Concussions among Children with Medicaid.

OBJECTIVE: To describe the rates and patterns of initial emergency department (ED) encounters and follow-up care for concussions among Medicaid-insured children before and after the 2013 enactment of Ohio concussion law. STUDY DESIGN: Using a time-series design, this study analyzed concussion claim data obtained from Partners for Kids, a pediatric accountable-care organization in Ohio. A total of 12 512 concussions and 48 238 associated claims for services between January 1, 2008, and June 30, 2017, with an initial ED encounter among Medicaid-insured children (ages 0-18 years) were analyzed. The effect of the law on the odds of follow-up care were assessed using generalized estimating equations models, adjusted for sex, age group, and residence location. RESULTS: Of the total 12 512 concussions, 63.9% occurred in male patients, 70.1% in patients ages 10-18 years, and 65.2% in patients from urban areas. The rate of initial ED encounters for concussions increased from 2008 to 2014 (2.8 to 4.9 per 10 000 members), followed by a decrease in 2016 (4.2 per 10 000 members). A significant increase in follow-up care after the initial ED encounter was observed from pre-law to post-law (OR 1.73, 95% CI 1.61, 1.86). A shift in follow-up care was observed from radiology and ambulance services in pre-law to primary care providers in post-law. CONCLUSIONS: The Ohio concussion law may have influenced the patterns of initial ED visit and follow-up care for concussions among Medicaid-insured children. Future studies evaluating the impact of the law should analyze the utilization patterns among children with various insurance/payment types.

Concussion Incidence, Duration, and Return to School and Sport in 5- to 14-Year-Old American Football Athletes.

OBJECTIVE: To collect prospective data on concussion incidence, risk factors, duration of symptoms, and return to school and sport in 5- to 14-year-old American football participants. STUDY DESIGN: We conducted a prospective cohort study over 2 years collecting data during two 10-week fall seasons. Youth with concussion were followed to determine time to return to school, sport, and baseline level of symptoms. Logistic regression was used to estimate the risk of sustaining a concussion associated with baseline demographic factors. Time to return to school, sport, and baseline symptoms were analyzed using Kaplan-Meier survival curves. RESULTS: Of 863 youth followed (996 player-seasons), 51 sustained a football-related concussion, for an athlete-level incidence of 5.1% per season. Youth with history of concussion had a 2-fold increased risk for sustaining an incident concussion (OR, 2.2; 95% CI, 1.1-4.8). Youth with depression had a 5-fold increased risk of concussion (OR, 5.6; 95% CI, 1.7-18.8). After a concussion, 50% of athletes returned to school by 3 days, 50% returned to sport by 13 days, and 50% returned to a baseline level of symptoms by 3 weeks. CONCLUSIONS: Concussion rates in this study were slightly higher than previously reported, with 5 of every 100 youth sustaining a football-related concussion each season. One-half of youth were still symptomatic 3 weeks after injury. Further research is needed to address the risk of concussion in youth football.

Risk of Concussion During Sports Versus Physical Education Among New Mexico Middle and High School Students.

OBJECTIVES: To measure the risk of concussion among New Mexico middle and high school students during both sports and physical education. METHODS: Athletic directors or athletic trainers in 147 schools were asked to report the number of concussions occurring during sports and physical education in the 2013 to 2014 school year. We calculated 1-year cumulative incidence rates. RESULTS: Of the 147 schools, 99 responded (67%). During the school year, 598 students were removed from athletics because of a concussion, a 1-year cumulative incidence of 3.5 per 100. The concussion rate during sports was 3.0: 3.5 for boys and 2.4 for girls (relative risk [RR] = 1.5; 95% confidence interval [CI] = 1.2, 1.7). An additional 335 students experienced concussions during physical education. Concussion rates during physical education were 60% higher than during sports (RR = 1.6; 95% CI = 1.4, 1.8). CONCLUSIONS: In our data, the risk of concussion was higher in physical education than in sports. This suggests that concussions should be tracked for a wide range of youth athletic activities, not just for sports. Monitoring cumulative incidence, in addition to other measures, may allow comparisons across schools and regions. More prevention efforts are needed.

Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks.

OBJECTIVE: To examine attitudes and practices of pediatricians toward sports-related head trauma and youth participation in tackle football and ice hockey. STUDY DESIGN: A respondent-anonymous electronic survey was distributed 3 times to members of the American Academy of Pediatrics Section of Bioethics, Council on Injury, Violence, and Poison Prevention, and Council on Sports Medicine and Fitness. RESULTS: Of 791 eligible pediatricians, 227 (29%) responded. Most respondents (189/223; 85%) treat sports-related concussions, among whom 83% (137/165) reported access to an established return-to-play protocol within their practice. Virtually all (160/166; 96%) reported increased parental awareness/concern regarding concussions and 85% (139/163) reported increased visits for head trauma. Overall, 77% (140/183) would not allow their son to play tackle football and 35% (64/181) and 34% (63/184) would not allow their son or daughter, respectively, to participate in ice hockey. Most respondents endorsed limiting or eliminating tackling (143/176; 81%) and checking (144/179; 80%) from practice. Respondents were evenly divided in their support for counseling against youth participation in full-contact sports, with 48% in favor (87/180). CONCLUSIONS: Most respondents would not allow their own child to play tackle football and endorsed limiting or eliminating tackling in practice. The American Academy of Pediatrics should consider recommending restrictions on tackling in football to support the current concussion concerns of its members.

American pediatric surgical association journal of pediatric surgery lecture.

Every year in the United States, 1.6 to 3.8 million concussions occur secondary to injuries sustained during sports and recreational activities. Major advances have been made in terms of identifying specific clinical profiles following concussion. Nevertheless, there are continued misunderstandings regarding this injury and variable clinical management strategies being employed that may result in protracted recovery periods for youth athletes. Therefore, it is essential that individualized treatment plans target the particular clinical profile(s) present following concussion. Further progress related to management of this injury depends on medical professionals working as part of multidisciplinary teams to provide appropriate education, accurate information, and treatments based on the identified clinical profiles. It is also important for medical professionals of all disciplines to stay vigilant toward future research and practice guidelines given the evolving nature of this injury.

Annual and Seasonal Trends in Ambulatory Visits for Pediatric Concussion in Ontario between 2003 and 2013.

OBJECTIVE: To investigate annual and seasonal trends in physician office and emergency department (ED) visit rates for pediatric concussion in Ontario between 2003 and 2013. STUDY DESIGN: A retrospective, population-based study was conducted using linked health administrative data from all concussion-related visits to ED and physician office by children aged 5 through 18 years. Time series analysis was used to assess whether periodic components exist in the monthly number of concussion-related visits. RESULTS: Over the 11-year study period, there were 176 685 pediatric visits for concussion in EDs and physician offices in Ontario. Standardized concussion-related visits showed a 4.4-fold (95% CI 4.37-4.45) increase per 100 000 from 2003 to 2013, with nearly 35 000 total visits in 2013. Concussion-related visits demonstrated a steep increase from 2010 onward. The greatest increases in standardized visits were in females (6.3-fold, 95% CI 6.23-6.46 vs 3.6-fold, 95% CI 3.56-3.64 in males) and 13-18.99 year olds (5.0-fold, 95% CI 4.93-5.08 vs 4.1-fold, 95% CI 3.99-4.27 in 9-12 years and 2.3-fold, 95% CI 2.23-2.42 in 5-8 years). A strong seasonal variability (R2autoreg = 0.87, P < .01) in the number of concussion-related visits was present, with most occurring in fall and winter. CONCLUSIONS: Pediatric concussion-related ED and physician office visit rates have greatly increased in the last decade, particularly since 2010. Prevention strategies may be targeted at those most at risk and at seasonal-related activities carrying the greatest risk of concussion.

Conmoción cerebral en el karate deportivo: disminución en la frecuencia en los campeonatos mundiales de karate / Cerebral concussion in sport karate: decrease in the frequency in world karate championships

Objetivo: presentar la reducción progresiva en la frecuencia de conmociones cerebrales en los Campeonatos Mundiales de Karate, a partir de los cambios en el reglamento de la Federación Mundial de Karate (FMK). Material y Método: Estudio prospectivo de las conmociones cerebrales ocurridas en los campeonatos del mundo de Madrid (2002), Monterrey (2004), Tampere (2006), Tokio (2008), Belgrado (2010) y París (2012). Resultados: La frecuencia de conmociones cerebrales, definidas según la Conferencia Internacional de Conmoción en el Deporte (Viena 2001, Praga 2004, Zurich 2008 y 2012) ha disminuido progresivamente en los Campeonatos del Mundo de Karate: una conmoción cada 230 combates en Madrid, una cada 196 en Monterrey, una cada 99 en Tampere, una cada 612 en Tokio, una cada 512 en Belgrado, y una cada 1.140 en París. Discusión y Conclusión: El uso de protecciones, la aplicación rigurosa del reglamento del karate deportivo y la educación continua en la prevención de lesiones de los competidores, técnicos y árbitros, ha disminuido la frecuencia de conmocionescerebrales en los Campeonatos del Mundo, haciendo del karate deportivo una disciplina más segura, cumpliendo con los principios del Olimpismo.

Objective: to present the progressive reduction of the frequency of cerebral concussion in the World Karate Championships, due to the changes in the Rules and Regulations of the World Karate Federation (WKF). Material and Method: Prospective study of the brain concussions occurred in the World Championships of Madrid (2002), Monterrey (2004), Tampere (2006), Tokyo (2008), Belgrade (2010) and Paris (2012). Results: The frequency of brain concussion, defined by the International Conference of Sports Concussion (Vienne 2001, Prague 2004, Zurich 2008 and 2012) has progressively diminished in the World Karate Championships: one concussion each 230 bouts in Madrid, one each 196 in Monterrey, one each 99 in Tampere, one each 612 in Tokyo, one each 512 in Belgrade, and one each 1,140 in Paris. Discussion and Conclusion: The use of protections, the rigorous enforcement of the Rules and Regulations of the Sports Karate and the continuous education inthe prevention of injury of athletes, technicians and referees, has diminished the frequency of brain concussion in the World Championships, making Karate a much safer sport, achieving Olympic principles.

Trends in Ambulatory Care for Children with Concussion and Minor Head Injury from Eastern Massachusetts between 2007 and 2013.

OBJECTIVE: To characterize trends in health care utilization and costs for children diagnosed with concussion or minor head injury within a large pediatric primary-care association. STUDY DESIGN: We conducted a retrospective cohort analysis from 2007 through 2013 examining all outpatient medical claims related to concussion and minor head injury from 4 commercial insurance companies for children 6-21 years of age who were patients within a large pediatric independent practice association located throughout eastern Massachusetts. RESULTS: Health care visits for concussion and minor head injury increased more than 4-fold during the study period, with primary-care and specialty clinics experiencing the greatest increases in the rate of visits while emergency department visits increased comparatively less. These increases were accounted for by both the proportion of children diagnosed with concussion or minor head injury (1.3% of all children in 2007 vs 3.3% in 2013) and the number of encounters per diagnosed patient (1.0 encounters per patient in 2007 vs 1.7 in 2013). Although the overall population costs devoted to care for concussion or minor head injury increased 34%, the cost per individual diagnosed child decreased 31%. CONCLUSIONS: Over the past 7 years, health care encounters for children diagnosed with concussion or minor head injury increased substantially in eastern Massachusetts. Care for these injuries increasingly shifted from the emergency department to primary-care and specialty providers.

Football injuries during the 2014 FIFA World Cup.

BACKGROUND: FIFA has surveyed match injuries in its tournaments since 1998. AIM: To analyse the incidence and characteristics of match injuries incurred during the 2014 FIFA World Cup in comparison to previous FIFA World Cups. METHODS: The chief physicians of the participating teams reported all newly incurred injuries of their players after the match on a standardised report form. 124 (97%) forms were returned. RESULTS: A total of 104 injuries were reported, equivalent to an incidence of 1.68 injuries per match (95% CI 1.36 to 2.00). 64 (63.4%) injuries were caused by contact with another player. Thigh (26; 25%) and head (19; 18%) were the most frequently injured body parts. The most frequent diagnosis was thigh strain (n=18). Five concussions and three fractures to the head were reported. While most thigh strains (15/17; 88.2%) occurred without contact, almost all head injuries (18/19; 94.7%) were caused by contact. 0.97 injuries per match (95% CI 0.72 to 1.22) were expected to result in absence from training or match. Eight injuries were classified as severe. The incidence of match injuries in the 2014 FIFA World Cup was significantly lower than the average of the four preceding FIFA World Cups, both for all injuries (2.34; 95% CI 2.15 to 2.53) and time-loss injuries (1.51; 95% CI 1.37 to 1.65). CONCLUSIONS: The overall incidence of injury during the FIFA World Cups decreased from 2002 to 2014 by 37%. A detailed analysis of the injury mechanism is recommended to further improve prevention strategies.