A Randomized, Double-Blind, Placebo-Controlled Clinical Trial Evaluating Transcranial Photobiomodulation as Treatment for Concussion.

INTRODUCTION: Literature indicating that transcranial photobiomodulation (tPBM) may enable the brain to recover normal function after concussion, resulting in symptoms reduction, and improved cognitive function after concussion is limited by small sample sizes and lack of controls. METHODS: We conducted a randomized, double-blind, placebo-controlled trial examining the effect of 6 wk of tPBM in patients 11 yr or older who received care for persistent postconcussion symptoms between September 2012 and December 2015. Our primary outcome measure was the mean difference in Postconcussion Symptom Scale total score and the raw Immediate Postconcussion Assessment and Cognitive Testing composite scores between study entry and treatment completion. Participants received two, 10-min sessions either with tPBM units or via two placebo units, three times per week. We screened for potential confounding variables using univariable analyses. We entered covariables that differed between the two groups on univariable screening into a regression analysis. We considered adjusted odds ratio that did not cross one statistically significant. RESULTS: Forty-eight participants completed the study. Most were female (63%), and a majority sustained their injury during sports or exercise (71%). Despite randomization, those that received tPBM therapy reported a greater number of previous concussions. After adjusting for the effect of previous concussions and multiple comparisons, there were no significant differences between tPBM and placebo groups at 3 or 6 wk of treatment. CONCLUSIONS: Despite showing promise in previous investigations, our study did not show benefit to tPBM over placebo therapy in patients experiencing persistent postconcussion symptoms. Further investigation is needed to determine if varying the dose or timing alters the efficacy of tPBM after concussion.

Neurological and Psychological Sequelae Associated With Multisystem Inflammatory Syndrome in Children.

Importance: Acute neurological involvement occurs in some patients with multisystem inflammatory syndrome in children (MIS-C), but few data report neurological and psychological sequelae, and no investigations include direct assessments of cognitive function 6 to 12 months after discharge. Objective: To characterize neurological, psychological, and quality of life sequelae after MIS-C. Design, Setting, and Participants: This cross-sectional cohort study was conducted in the US and Canada. Participants included children with MIS-C diagnosed from November 2020 through November 2021, 6 to 12 months after hospital discharge, and their sibling or community controls, when available. Data analysis was performed from August 2022 to May 2023. Exposure: Diagnosis of MIS-C. Main Outcomes and Measures: A central study site remotely administered a onetime neurological examination and in-depth neuropsychological assessment including measures of cognition, behavior, quality of life, and daily function. Generalized estimating equations, accounting for matching, assessed for group differences. Results: Sixty-four patients with MIS-C (mean [SD] age, 11.5 [3.9] years; 20 girls [31%]) and 44 control participants (mean [SD] age, 12.6 [3.7] years; 20 girls [45%]) were enrolled. The MIS-C group exhibited abnormalities on neurological examination more frequently than controls (15 of 61 children [25%] vs 3 of 43 children [7%]; odds ratio, 4.7; 95% CI, 1.3-16.7). Although the 2 groups performed similarly on most cognitive measures, the MIS-C group scored lower on the National Institutes of Health Cognition Toolbox List Sort Working Memory Test, a measure of executive functioning (mean [SD] scores, 96.1 [14.3] vs 103.1 [10.5]). Parents reported worse psychological outcomes in cases compared with controls, particularly higher scores for depression symptoms (mean [SD] scores, 52.6 [13.1] vs 47.8 [9.4]) and somatization (mean [SD] scores, 55.5 [15.5] vs 47.0 [7.6]). Self-reported (mean [SD] scores, 79.6 [13.1] vs 85.5 [12.3]) and parent-reported (mean [SD] scores, 80.3 [15.5] vs 88.6 [13.0]) quality of life scores were also lower in cases than controls. Conclusions and Relevance: In this cohort study, compared with contemporaneous sibling or community controls, patients with MIS-C had more abnormal neurologic examinations, worse working memory scores, more somatization and depression symptoms, and lower quality of life 6 to 12 months after hospital discharge. Although these findings need to be confirmed in larger studies, enhanced monitoring may be warranted for early identification and treatment of neurological and psychological symptoms.

Neuropsychological Assessment of Sport-Related Concussion.

Neuropsychological assessment is a key component in a comprehensive, multidisciplinary approach to assessment of sport-related concussion (SRC). Currently computerized tests are the most commonly used modality of neurocognitive testing and involve both baseline and postinjury assessments. A comprehensive neuropsychological assessment should not only include neurocognitive testing but also incorporate symptom inventories, vestibular-ocular screening, and a psychological evaluation. Neuropsychological assessments are most effective when completed by a Clinical Neuropsychologist, given their specialized training in test interpretation and conceptualization of the psychological, cognitive, behavioral, physiologic, as well as neurologic principals when treating and managing SRC.

The Association Between Premorbid Conditions in School-Aged Children With Prolonged Concussion Recovery.

The association between preexisting anxiety, depression, and/or neurodevelopmental disorders and symptom duration among younger children who sustain concussions is not well known. The authors conducted a prospective cohort study of 569 patients presenting to a pediatric neurology clinic with the diagnosis of concussion. The authors measured associations between symptom duration and premorbid conditions, as well as gender, age, mechanism of injury, and other factors. Premorbid conditions were common in both age groups. On univariate modeling female gender, age >12 years, and premorbid conditions were associated with longer symptom duration. On multivariable modeling, females and patients ≤12 years old with a history of headaches, migraines, or a history of psychiatric conditions took significantly longer to recover than those without such conditions. Premorbid conditions are associated with a prolonged recovery from concussion among those patients ≤12 years old.

Educational Initiative to Standardize Concussion Management in Pediatric Primary Care.

Pediatric primary care providers report limited training and tools to manage concussion. We developed a learning community intervention for a large independent pediatric practice association affiliated with a university hospital to standardize concussion management and improve the use of consensus-based guidelines. The learning community included in-person and online didactics, followed by a web-based reinforcement platform to educate and train clinicians on our treatment algorithm and decision support tools. Chart reviews before and after the intervention demonstrated significant increases in the use of standardized symptom rating scales (19.6% to 69.3%; P < .001), balance assessment (2.3% to 37.6%; P < .001), and scheduled follow-up (41.8% to 61.2%; P < .001), with an increase in delivery of our entire best practice bundle from 3.5% to 28.1% ( P < .001). A multimodal educational intervention can effect change among pediatric primary care providers and help align their management practices with consensus-based guidelines.

Neurocognitive Deficits of Concussed Adolescent Athletes at Self-reported Symptom Resolution in the Zurich Guidelines Era.

BACKGROUND: Previous studies have evaluated high school and collegiate athletes in the pre-Zurich guidelines era; whether adolescent athletes demonstrate similar neurocognitive decrements in the current concussion management era remains unclear. PURPOSE: To assess for the presence of neurocognitive deficits in adolescents with a sport-related concussion at the time of self-reported symptom resolution. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We conducted a prospective cohort study of 32 patients, aged 13 to 18 years, who sustained concussions during ice hockey and who were referred to 3 sports medicine clinics between September 1, 2012, and March 31, 2015. Demographic, anthropometric, and injury data were collected at the time of the initial postconcussion evaluation. To document symptoms, patients completed the Post-Concussion Symptom Scale (PCSS) at initial and follow-up visits. Baseline and postinjury neurocognitive function were assessed using computerized neurocognitive testing (Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]), and a reliable change index was used to determine significant changes in composite scores. Statistical comparisons were conducted using the Student t test and Mann-Whitney U test. RESULTS: A total of 9 of 32 athletes (28.1%; 95% CI, 14.8%-46.9%) demonstrated continued neurocognitive impairment on ≥1 composite score when no longer reporting concussion-related symptoms, while only 2 of 32 athletes (6.3%; 95% CI, 1.4%-23.2%) demonstrated continued neurocognitive impairment on ≥2 composite scores. CONCLUSION: Neurocognitive deficits persist in adolescent athletes who no longer report concussion-related symptoms, at rates similar to those of collegiate athletes but at longer time intervals. This finding provides further evidence that adolescent athletes with a sport-related concussion demonstrate a protracted recovery and resolution of neurocognitive deficits compared with collegiate and professional athletes. Computer-based neurocognitive testing as part of a multifaceted approach continues to play an important role in return-to-play decision making after a sport-related concussion in adolescent athletes. Test-taking strategies may erroneously identify asymptomatic athletes as exhibiting neurocognitive impairment.

Same Care, Different Populations.

The authors conducted a cross-sectional survey of Massachusetts school nurses examining return-to-learn practices for children recovering from concussion in prekindergarten through high school. Regardless of school setting, all students received academic accommodations to support learning during recovery. School nurses perceived less benefit to prolonged cognitive rest (>4 days) for high school students relative to students in elementary school, but provided academic accommodations to them for comparatively longer periods of time (10-14 days vs 6-10 days). In all settings, respondents indicated a need for improved communication among treating physicians, parents, and school personnel, as well as improved education and standardized management tools for younger children and those who sustain non-sport-related injuries. Despite serving children at different developmental stages, school return-to-learn practices are essentially the same in primary and secondary schools, highlighting the need for standardized, developmentally appropriate return-to-learn plans and additional education for the providers and school personnel who implement them.

Division III Collision Sports Are Not Associated with Neurobehavioral Quality of Life.

We sought to determine whether the exposure to the sub-concussive blows that occur during division III collegiate collision sports affect later life neurobehavioral quality-of-life measures. We conducted a cross-sectional study of alumni from four division III colleges, targeting those between the ages of 40-70 years, using several well-validated quality-of-life measures for executive function, general concerns, anxiety, depression, emotional and behavior dyscontrol, fatigue, positive affect, sleep disturbance, and negative consequences of alcohol use. We used multivariable linear regression to assess for associations between collision sport participation and quality-of-life measures while adjusting for covariates including age, gender, race, annual income, highest educational degree, college grades, exercise frequency, and common medical conditions. We obtained data from 3702 alumni, more than half of whom (2132) had participated in collegiate sports, 23% in collision sports, 23% in non-contact sports. Respondents with a history of concussion had worse self-reported health on several measures. When subjects with a history of concussion were removed from the analyses in order to assess for any potential effect of sub-concussive blows alone, negative consequences of alcohol use remained higher among collision sport athletes (ß-coefficient 1.957, 95% CI 0.827-3.086). There were, however, no other significant associations between exposure to collision sports during college and any other quality-of-life measures. Our results suggest that, in the absence of a history of concussions, participation in collision sports at the Division III collegiate level is not a risk factor for worse long-term neurobehavioral outcomes, despite exposure to repeated sub-concussive blows.

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.

Neuropsychological evaluation and management of sport-related concussion.

PURPOSE OF REVIEW: Sport-related concussion (SRC) is common in children and adolescents. Although symptoms are typically self-limiting and short-lived, some individuals suffer persistent negative outcomes. The risk of repeat injury and prolonged recovery can be reduced by accurate diagnosis and management. In the absence of reported symptoms, neuropsychological assessment has been identified as objective means of determining dysfunction following concussion. Most research to date has focused on adult populations. This review summarizes the literature regarding neuropsychological evaluation of SRC in the pediatric athlete. RECENT FINDINGS: As with adult populations, neuropsychological evaluation of children and adolescents diagnosed with SRC has documented skills and abilities that are particularly sensitive to head injury. Difficulties with attention and concentration, speed of information processing, and memory are commonly reported in the literature. There is also some evidence to suggest that younger children are particularly vulnerable to neurologic insult and are at greater risk for secondary consequences. Although such findings argue for more conservative management, the availability of diagnostic tools, including computerized neurocognitive assessment batteries, is limited. SUMMARY: The neuropsychological impact of SRC on functioning is well established. Because documented deficits have the potential to interfere with critical aspects of normal development in children and adolescents, accurate diagnosis and management of SRC are especially important. Despite some limitations, there is good evidence to support the use of neuropsychological assessment to inform treatments and return-to-play decision making.

Computerized neurocognitive testing for the management of sport-related concussions.

OBJECTIVES: To describe the prevalence of computerized neurocognitive testing for the assessment of high school athletes who sustain concussions, and to describe associations between using computerized neurocognitive tests, timing of return-to-play, and medical provider managing the athlete. METHODS: Concussions recorded in the High School Reporting Information Online injury surveillance system during the 2009-2010 academic year were included. Measures of association between use of computerized neurocognitive testing and outcomes were analyzed. A questionnaire was sent to athletic trainers (ATs) querying the use of computerized neurocognitive testing. χ(2) analyses were conducted for categorical variables. Logistic regression analyses were used to adjust for potential confounders. Statistical significance was set at P < .05. RESULTS: High School Reporting Information Online recorded 1056 concussions. Athletes who underwent computerized neurocognitive testing were less likely to be returned to play within 10 days of injury (38.5% vs 55.7%, P < .001) and more likely to be returned to play by a physician (60.9% vs 45.6%, P < .001). We had a response rate of 97.3% for the survey. Of respondents, 39.9% used computerized neurocognitive testing; 93.0% of those used ImPACT. Tests were most often interpreted by ATs (78.9%) and/or physicians (78.8%), as opposed to neuropsychologists (16.9%). CONCLUSIONS: Approximately 40% of US high schools that employ an AT use computerized neurocognitive tests when managing sport-related concussions. Tests are most often interpreted by ATs and physicians, as opposed to neuropsychologists. Computerized neurocognitive tests are significantly associated with the timing of return-to-play.

The pediatric athlete: younger athletes with sport-related concussion.

Although much of the lay media attention surrounding sport-related concussion (SRC) focuses on professional athletes, SRC is a common injury in pediatric sports. The anatomy, biomechanics, and response to injury of the developing pediatric brain differ from those of the adult. Similarly, the neurocognitive abilities of the child are developing more rapidly than in an adult. The effects of concussive brain injury on the life of a child are different from those of an adult. This article focuses on the aspects of SRC that are specific to the younger athletes.

Examination of volunteer bias in research involving patients diagnosed with psychogenic nonepileptic seizures.

There is some evidence to suggest that the same personality and emotional features observed in patients diagnosed with psychogenic nonepileptic seizures (PNES) may be related to nonparticipation in studies aimed at determining the most effective interventions for treating this patient population. This study aimed to document the frequency with which patients referred to an epilepsy monitoring unit (EMU) for video/EEG telemetry who are diagnosed with PNES or epileptic seizures (ES) participate in survey research. Of the 139 patients approached, 16 patients declined and 23 produced invalid or incomplete surveys. There was no significant difference in participation rates between patients diagnosed with PNES and those diagnosed with ES. These findings argue against a volunteer bias in research involving PNES and suggest that the results of other studies with these patients generalize to the population as a whole.

Computerized neuropsychological profiles of South African versus US athletes: a basis for commentary on cross-cultural norming issues in the sports concussion arena.

Computerized programs are widely used as part of the overall medical management of concussion in order to monitor recovery and facilitate safe return-to-play decisions. Typically, neurocognitive profiles of concussed athletes are compared with baseline and/or normative data in the absence of baseline scores. However, the cultural equivalence of performance on neuropsychological tests cannot be assumed and has not been sufficiently researched. The purpose of this study was to investigate the neuropsychological test profiles of the ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) on age-matched South African (SA) rugby and US football players. Participants included 11 257 English-speaking, predominantly white male athletes from multiple SA and US schools and sports organizations in 3 age groups: 11 to 13 years (SA, n = 301; US, n = 775); 14 to 16 years (SA, n = 997; US, n = 4081); and 17 to 21 years (SA, n = 319; US, n = 4784). ImPACT neurocognitive composite scores (verbal and visual memory, visual motor speed, reaction time, impulse control) and the ImPACT total symptom score, derived from the initial baseline testing, were used for comparison purposes between the targeted groups. Independent t-test comparisons revealed overall equivalence between the SA and US athletes on the neurocognitive measures, but they also revealed consistently higher symptom scores for SA athletes in association with clinically relevant effect sizes. It was concluded that US neurocognitive normative data on the ImPACT test are appropriate for use on South African athletes whose first language is English, whereas culture-specific sensitivity for symptom reporting on this same population should be taken into consideration for management purposes. It is argued that neurocognitive equivalence is less likely to apply in educationally disadvantaged populations. The use of registered psychologists is deemed necessary to provide contextualized interpretations of computerized test scores, thereby protecting against misdiagnosis that may occur within the concussion management arena via actuarial approaches that fail to take sociocultural complexities into account.