Menstrual Cycle Patterns After Concussion in Adolescent Patients.

OBJECTIVE: To describe menstrual cycle patterns in adolescents with concussion and investigate whether menstrual cycle phase at injury influenced postconcussion cycle pattern changes or concussion symptoms. STUDY DESIGN: Data were collected prospectively from patients aged 13-18 years presenting to a specialty care concussion clinic for an initial visit (≤28 days postconcussion) and, if clinically indicated, at a follow-up visit 3-4 months postinjury. Primary outcomes included menstrual cycle pattern change since injury (change/no change), menstrual cycle phase at time of injury (calculated using date of last period before injury), and symptom endorsement and severity, measured by Post-Concussion Symptom Inventory (PCSI). Fisher exact tests were used to determine the association between menstrual phase at injury and change in cycle pattern. Multiple linear regression was used to determine whether menstrual phase at injury was associated with PCSI endorsement and symptom severity, adjusting for age. RESULTS: Five hundred twelve postmenarchal adolescents were enrolled (age 15.2 ± 1.4 years), with 111 (21.7%) returning for follow-up at 3-4 months. Menstrual pattern change was reported by 4% of patients at initial visit and 10.8% of patients at follow-up. At 3-4 months, menstrual phase at injury was not associated with menstrual cycle changes (P = .40) but was associated with endorsement of concussion symptoms on the PCSI (P = .01). CONCLUSIONS: At 3-4 months' postconcussion, 1 in 10 adolescents experienced a change in menses. Menstrual cycle phase at injury was associated with postconcussion symptom endorsement. Leveraging a large sample of postconcussion menstrual patterns, this study represents foundational data regarding potential menstrual cycle effects of concussion in female adolescents.

Association of Multidomain Assessment Outcomes With Referral for Vestibular Therapy After Concussion.

CONTEXT: Multiple aspects of a multidomain assessment have been validated for identifying concussion; however, researchers have yet to determine which components are related to referral for vestibular therapy. OBJECTIVE: To identify which variables from a multidomain assessment were associated with receiving a referral for vestibular therapy after a concussion. DESIGN: Retrospective chart review, level of evidence 3. PATIENTS OR OTHER PARTICIPANTS: Participants (n = 331; age = 16.9 ± 7.2 years; 39.3% female) were diagnosed with a concussion per international consensus criteria by a clinical neuropsychologist after presenting to a concussion specialty clinic. MAIN OUTCOME MEASURE(S): Medical chart data were extracted from the first clinical visit regarding preinjury medical history, computerized neurocognition, Post-Concussion Symptom Scale, Concussion Clinical Profiles Screen, and Vestibular Ocular Motor Screening within 16.2 ± 46.7 days of injury. We built 5 backwards logistic regression models to associate the outcomes from each of the 5 assessments with referral for vestibular therapy. A final logistic regression model was generated using variables retained in the previous 5 models as potential predictors of referral for vestibular therapy. RESULTS: The 5 models built from individual components of the multidomain assessment predicted referral for vestibular therapy (R2 = 0.01-0.28) with 1 to 6 statistically significant variables. The final multivariate model (R2 = 0.40) retained 9 significant variables, represented by each of the 5 multidomain assessments except neurocognition. Variables that had the strongest association with vestibular therapy referral were motor vehicle accident mechanism of injury (odds ratio [OR] = 15.45), migraine history (OR = 3.25), increased headache when concentrating (OR = 1.81), and horizontal vestibular ocular reflex (OR = 1.63). CONCLUSIONS: We demonstrated the utility of a multidomain assessment and identified outcomes associated with a referral for vestibular therapy after a concussion.

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.

Temporal Differences in Concussion Symptom Factors in Adolescents following Sports-Related Concussion.

OBJECTIVE: To evaluate temporal differences in concussion symptoms up to 30 days following a sports-related concussion. STUDY DESIGN: Adolescent and young adult athletes (n = 782) were separated based on time since injury at presentation as Early (0-7 days; n = 321, age: 15.4 ± 1.9 years, 51.7% female), Middle (8-14 days; n = 281, age: 15.8 ± 2.2 years, 54.8% female), and Late (15-30 days; n = 180, age: 15.6 ± 1.8 years, 52.8% female). All participants completed the 22-item Post-Concussion Symptom Scale at first visit. A confirmatory factor analysis was completed separately for each time since injury cohort using a 4-component model reported previously. RESULTS: The confirmatory factor analysis model fit was acceptable for Early, Middle, and Late (using cognitive-migraine-fatigue, affective, sleep, and somatic factors). Both affective (change = 0.30; P = .01; Cohen d = 0.30) and sleep (change = 0.51; P ≤ .001; Cohen d = 0.47) factors were significantly greater in the Late group compared with the Early, but not Middle, groups. The previously reported 4-factor symptom model, including cognitive-migraine-fatigue, affective, somatic, and sleep factors, was appropriate for adolescents up to 30 days' postinjury. However, adolescents who presented between 15 and 30 days' postinjury reported greater affective and sleep symptoms than those who presented within 1 week. CONCLUSIONS: Clinicians should consider these temporal differences when evaluating concussion symptoms in adolescents, as greater affective and sleep symptoms can be predictive of prolonged recovery/persistent complications.

A Longitudinal Investigation of Symptom Recovery following Concussion in Youth Soccer.

OBJECTIVE: To prospectively evaluate symptom outcomes after youth soccer-related concussion. STUDY DESIGN: Using a prospective cohort design, we enrolled male and female competitive soccer players age 8-17 years into 3 groups: concussed (n = 23), matched control (n = 23), and orthopedic injury (n = 24). Postconcussive symptoms were monitored serially via both athlete and parent report at days 1-2, 4, 7, 10, 30, and 90. RESULTS: Repeated-measures analyses revealed a significant time by group interaction (F [12, 402] = 19.91, P < .001). In the initial days postinjury, the concussed group reported greater symptoms than the comparison groups, with more symptoms reported by athletes on average than parents. By 10 days, concussed athletes did not differ from the matched controls by either rater's report, but they did differ from the orthopedic injury group by parent report. At 30 days, no differences were apparent among groups. At 30 days, 100% of concussed youth and 91% of parents rated symptoms as back to preinjury levels using reliable change indices. At 30 days, 86% of athletes had been cleared to return to full game play. CONCLUSIONS: The natural clinical history of concussion symptoms in youth competitive soccer players was similar to that seen in older athletes, with resolution in days to a few weeks. Additional study will be required to investigate which factors best predict symptom outcomes for individual athletes and how symptom report relates to performance-based outcome measures and underlying neurophysiologic recovery.

Factor structure models for the Post-Concussion Syndrome Scale with monolingual Spanish-speaking adults from Colombia.

PRIMARY OBJECTIVE: The Post-Concussion Syndrome Scale (PCSS) is a self-report questionnaire that measures post-concussive symptom severity and has been primarily normed on young Caucasian samples. This study aims to explore the factor structure models of a Spanish translation of the PCSS at a chronic post-traumatic brain injury (TBI) time point. RESEARCH DESIGN: Descriptive and exploratory research designs were utilized. METHODS AND PROCEDURES: The study consisted of a monolingual sample of Spanish-speaking adults from Colombia, with 100 subjects in the control group and 70 subjects in the TBI group. A t-test, chi-square, and MANOVA were calculated to compare group differences. Cronbach's alpha was calculated to investigate reliability. Confirmatory factor analysis compared item loadings onto an existing four-factor model. Exploratory factor analysis sought to identify a new factor model if the loadings did not fit. MAIN OUTCOMES AND RESULTS: There were no group differences in demographic variables. Internal consistency was acceptable. Model fit indices revealed a poor fit with the original four factors. Item loadings revealed a novel six-structure model. CONCLUSIONS: While the PCSS appears to capture general post-TBI sequelae, the underlying factors may differ due to cultural and linguistic differences in Spanish-speaking individuals. Clinical implications and future directions are further discussed.

Do Sideline Concussion Assessments Predict Subsequent Neurocognitive Impairment After Sport-Related Concussion?

CONTEXT: Comprehensive, multidomain assessment is the standard of care after sport-related concussion. However, the relationship between performance on sideline concussion-assessment tools and in-office computerized neurocognitive testing has received little attention, and the prognostic utility of sideline measures is unknown. OBJECTIVE: To evaluate concurrent impairment on commonly used concussion measures 24 to 48 hours postinjury while also determining the predictive utility of sideline measures on computerized neurocognitive testing in the acute to subacute recovery periods postinjury. DESIGN: Case-control study. SETTING: High school and collegiate athletics. PATIENTS OR OTHER PARTICIPANTS: A total of 125 high school and college-aged athletes (85 males, 40 females) 14 to 23 (16.8 ± 2.21) years old. MAIN OUTCOME MEASURE(S): Participants were administered sideline concussion-assessment measures (ie, Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT], Standardized Assessment of Concussion [SAC], and Balance Error Scoring System [BESS]) 24 to 48 hours postinjury and completed ImPACT and the Post-Concussion Symptom Scale 5 to 7 and 10 to 14 days postinjury. Outcome measures were the ImPACT composite (verbal memory, visual memory, reaction time, visual-motor speed), SAC, and BESS scores and total symptom score on the Post-Concussion Symptom Scale. RESULTS: Participants demonstrated heterogeneous patterns of impairment on measures 24 to 48 hours postinjury, with the most common pattern being impairment on ImPACT and the SAC. Performance on the SAC and BESS at 24 to 48 hours after injury did not distinguish between those with and those without impairment on ImPACT at 5 to 7 days postinjury (χ2 = 5.076, P = .079) or 10 to 14 days postinjury (χ2 = 2.04, P = .361). CONCLUSIONS: More than 90% of athletes were impaired on at least 1 sideline or neurocognitive measure 24 to 48 hours after sport-related concussion. Although sideline measures are useful for concussion diagnosis, they are not suitable for prognostication of impairment or the presence of symptoms 1 to 2 weeks postinjury.

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?

Physical Maturity and Concussion Symptom Duration among Adolescent Ice Hockey Players.

OBJECTIVE: To investigate the association between physical maturity and risk of prolonged concussion symptoms in adolescent ice hockey players. STUDY DESIGN: Prospective cohort study of 145 patients ages 13-18 years with concussion referred to 3 hospital-affiliated sports medicine clinics between September 1, 2012 and March 31, 2015. Concussion evaluations included Post Concussive Symptom Score, neurologic examination, and postinjury computerized neurocognitive testing. Pubertal development at initial visit was assessed by the Pubertal Developmental Scale. Duration of concussion symptoms (days) was the main outcome. Statistical comparisons were conducted using Student t test, Wilcoxon rank sum, and logistic regression. RESULTS: Mean symptom duration was 44.5 ± 48.7 days. Nearly one-half (48.3%) of all players enrolled had prolonged concussion symptoms (≥ 28 days); most (86.9%) had symptom resolution by 90 days. Among males, less physically mature adolescents took longer to recover than more physically mature players (54.5 days vs 33.4 days; P = .004). "Early" Pubertal Category Score was the strongest predictor of prolonged symptoms (OR = 4.29, 95% CI 1.24-14.85; P = .021) among males. Among females, heavier weight increased the odds of experiencing prolonged symptoms (OR 1.07, 95% CI 1.00-1.14; P = .039). CONCLUSIONS: Among adolescent ice hockey players, early-pubertal stage is independently associated with longer recovery from concussion in males, and heavier weight is associated with longer concussion recovery in females. Until further studies determine valid physical maturity indicators, peripubertal collision sport athletes should compete in leagues grouped by relative age and be discouraged from "playing up" on varsity teams.

A Pilot Study Investigating Neuropsychological Consultation as an Intervention for Persistent Postconcussive Symptoms in a Pediatric Sample.

OBJECTIVE: To examine the efficacy of a one-time neuropsychological consultation as an intervention for youth with persistent postconcussive symptoms following mild traumatic brain injury. STUDY DESIGN: Using a prospective interrupted time series design, we enrolled 80 patients aged 8-17 years referred consecutively for clinical neuropsychological consultation. Patients needed to have sustained injury between 2 and 12 months prior to enrollment. Parent and child postconcussive symptom ratings were used as the primary outcome measures and were collected at 6 time points, 3 before the neuropsychological consultation and 3 after. Repeated measure ANOVA was used to estimate the magnitude of change in symptom ratings before and after the neuropsychological intervention. RESULTS: The decrease in symptoms for the week prior to consultation was nonsignificant by both child (P = .63) and parent (P = .19) report. In contrast, for both reporters, the decrease in symptoms at 1 week and 3 months postconsultation was significant (P < .0001). The difference in reported change was also significant when comparing the week before the intervention to the 3 months after (child: P < .0001; parent: P = .0009). CONCLUSIONS: Postconcussive symptoms decreased significantly following the neuropsychological consultation. The primary limitation of the study is that it lacked randomization and a control group. The results warrant further research into the benefits of neuropsychological consultation after mild traumatic brain injury and provide justification for clinical providers to consider referring to neuropsychologists in the face of persistent postconcussive symptoms.

Simple Schizophrenia Remains a Complicated Diagnosis: Case Report and Literature Review.

The diagnosis of simple schizophrenia has been challenged and criticized since it was first described by Otto Diem in 1903. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), released by the American Psychiatric Association in May 2013, classified it as a condition for further study with the name "attenuated psychosis syndrome." This clinical condition has undergone several revisions with each edition of the DSM. It is characterized by oddities in conduct, inability to meet the demands of society, and decline in total performance in the absence of obvious psychotic symptoms. We discuss the case of a 35-year-old man who presented with symptoms fitting the criteria for simple schizophrenia and review the various definitions and case reports published over the years that defend the diagnosis of simple schizophrenia.

Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion.

OBJECTIVES: To evaluate the efficacy of cognitive and physical rest for the treatment of concussion. STUDY DESIGN: High school and collegiate athletes (N = 49) underwent post-concussion evaluations between April 2010 and September 2011 and were prescribed at least 1 week of cognitive and physical rest. Participants were assigned to groups on the basis of the time elapsed between sustaining a concussion and the onset of rest (1-7 days, 8-30 days, 31+ days). Main outcome measures included Concussion Symptom Scale ratings and scores on the 4 composite indices of the Immediate Post-Concussion Assessment and Cognitive Testing measure, both before and following rest. Mixed-factorial design ANOVA were used to compare changes on the dependent measures within and between groups. RESULTS: Participants showed significantly improved performance on Immediate Post-Concussion Assessment and Cognitive Testing and decreased symptom reporting following prescribed cognitive and physical rest (P < .001), regardless of the time between concussion and onset of rest (P = .44). CONCLUSION: These preliminary data suggest that a period of cognitive and physical rest may be a useful means of treating concussion-related symptoms, whether applied soon after a concussion or weeks to months later.

Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes.

OBJECTIVE: To evaluate symptoms and neurocognitive recovery patterns after sports-related concussion in high school and college athletes. STUDY DESIGN: College athletes (n = 371) and high school athletes (n = 183) underwent baseline neuropsychological evaluation between 1997 and 2000. Individuals who received a concussion during athletic competition (n = 54) underwent serial neuropsychologic evaluation after injury and were compared with a noninjured within-sample control group (n = 38). Main outcome measures included structured interview, four memory measures, and Concussion Symptom Scale ratings. Baseline to postinjury change scores and multiple analyses of variance were used to compare recovery curves within and between groups. RESULTS: High school athletes with concussion had prolonged memory dysfunction compared with college athletes with concussion. High school athletes performed significantly worse than age-matched control subjects at 7 days after injury (F = 2.90; P <.005). College athletes, despite having more severe in-season concussions, displayed commensurate performance with matched control subjects by day 3 after concussion. Self-report of postconcussion symptoms by student athletes was not predictive of poor performance on neuropsychologic testing. CONCLUSIONS: Caution and systematic evaluation should be undertaken before returning athletes with concussion to competition. Sole reliance on the self-report of the athlete may be inadequate. Preliminary data may suggest a more protracted recovery from concussion in high school athletes.