In this newsletter: Opportunities, Education, Sports, Pathophysiology, Therapies Currently Available, Therapies & Diagnostic Tools Under Research, Veterans & Service Members, Youth, Women’s Health, and Culture.

The lead article this week, Study supports efficacy of new Return to School resource for educators, parents, & students, is in the Education category.

We appreciate the Concussion Alliance Volunteers who created this edition:

Writers: Minhong Kim, Josh Wu, Ming Shen, Shelly Seth, Conor Gormally & Malayka Gormally

Editors: Conor Gormally and Malayka Gormally

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Opportunities

Thursday, April 7, 4 pm EST: free webinar with speaker Robert A. Stern, PhD, CTE and the Long-Term Consequences of Sport-Related Repetitive Head Impact Exposure: What We Know and What We Need to Know Next. Presented by the University of Michigan Concussion Center. Register here.

Tuesday, April 12, 6 pm EST: free webinar, Prevention of Subsequent Concussions with Stephanie Cowle of Parachute Canada and Dr. Firas Al Rawi: produced by the Canadian Concussion Centre. Sign up here.

Wednesday, April 13, 11 am PST: free online class, Strength-Based and Person-Centered Goal Setting with Anita Chin, Certified Life Coach. Presented by the Brain Injury Alliance of WA State. You don’t need to be a resident of WA state to attend. Register in advance.

Education

Study supports efficacy of new Return to School resource for educators, parents, & students

A research article published in Canadian Family Physician discussed findings of a “usability and satisfaction” survey about SCHOOLFirst, “an evidence-based resource to enable educators to support students returning to school after concussion.” Christine F. Provvidenza et al. found that “Educators were satisfied with the resource and saw opportunities to use it to support their students.” While return-to-school (or learn) protocols often exist in school settings and outline when to begin to return to school, the protocols often miss the “support to foster how to return to school.” To this end, SCHOOLFirst provides educators, parents, and healthcare providers information and resources divided into three areas; “Build Your Knowledge, Create a Supportive Culture, and Know your Role.”

While SCHOOLFirst was created for a Canadian audience (also available in French), Concussion Alliance highly recommends this resource for educators and parents in the U.S. as well. Watch the 2-minute introductory video to get oriented, and check out the Downloads & Other Resources section for direct links to pdf resources and videos. One of our favorite resources is Examples of classroom supports for students with concussion, which has 34 potential accommodations to support students with a concussion, divided into ‘environment,’ ‘instruction,’ and ‘assessment & evaluation’ categories. In addition to educators, parents and teenage students can use this list to advocate for concussion-specific accommodations.

Also, look at the Concussion Alliance summary of Return to School Guidelines, written for parents, and check out the CDC resource HEADS UP to Schools, which includes sections for various school professionals and parents. As the Provvidenza et al. article emphasizes, the return to learn process is crucial, as “concussion symptoms can result in declines in academic performance and in school attendance. Symptoms (e.g., difficulty concentrating, fatigue, headache) can reduce a youth’s ability to learn, complete memory-related tasks, or focus in the classroom.”

Sports

Duration of continued athletic participation after sport-related concussion impacts recovery outcomes

See our blog post to read this synopsis.

Pathophysiology

Sex, race, psychiatric history, intracranial injury associated with increased prevalence of insomnia after a TBI

See our blog post to read this synopsis.

Therapies Currently Available

Pediatric guidelines: very early aerobic assessment and prescribed exercise treatment recommended for a broad swath of patients

Guidelines concerning physical activity after concussion have been updated in the PedsConcussion Living Guidelines for Pediatric Concussion Care. What’s new is the recommendation for very early exercise tolerance assessment and referral for prescribed exercise treatment for “select patients.” Considering all the updates, the group of select patients is quite broad.

“Select patients” should be referred following acute (recent onset) injury “to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment.” The guideline says the aerobic exercise assessment can be as early as 48 hours after a concussion, not just a referral.

This group of select patients includes “highly-active or competitive athletes,” for whom an exercise tolerance assessment “can be as early as 48 hours following acute injury.” Also included in this group of “select patients” are “those who are not tolerating a graduated return to physical activity, or those who are slow to recover.” These recommendations are based on this 2021 study by Leddy et al.; Concussion Alliance explains how to implement the Leddy study on our page on Graduated Exercise Therapy, which was approved for accuracy by one of the study authors. Included is an explanation of how to implement the program yourself when you don’t have a physical therapist.

The updated PedsConcussion section explained above is rated as Level A evidence. An additional updated section of the guideline (level C evidence) has the same recommendations for “patients who are active.” This section likely has level C evidence because “patients who are active” is a significantly broader category and the Leddy study was more targeted. (Level 3 evidence means that the update is based on expert consensus, usual practice, opinion, or weaker level evidence.)

Considering both these updated sections, early assessment and prescribed exercise treatment are recommended for a broad swath of patients, including active, highly-active, competitive, slow to recover, or patients not tolerating a self-directed “graduated return to physical activity.” The PedsConcussion updates are to 2.3d and 3.3 (return to activity).

Therapies & Diagnostic Tools Under Research

New research to develop better diagnostic tools for diagnosing mTBI in the elderly

See our blog post to read this synopsis.

Veterans & Service Members

Help steer research through virtual meetings in Ohio, Texas, North Carolina, and Florida – Mind Over Matter: A Veteran-driven Roadmap to Research on Traumatic Brain Injury

The input from mTBI and their caregivers will be used to develop a M.O.M. Roadmap for Research on TBI featuring PCOR topics and CER questions that matter most to veterans which will be translated into a publicly accessible resource. Virtual meetings will be taking place in the states of Florida, Ohio, South Carolina, and Texas lasting up to one hour and will run monthly through May 2023. As a token of appreciation for participation, the veteran and/or community stakeholder will receive a $10 gift card, a $10 meal card, and a challenge coin.

If you are interested in participating in the project and would like more information, please contact the Project Manager, S. Juliana Moreno (fau_smoreno@health.fau.edu).

Youth

Study shows high rates of persistent symptoms with no diagnosis in children with mTBI

Eli Fried et al. performed a multicenter, retrospective cohort study to examine the prevalence of persistent post-concussion symptoms (PPCS) among children aged 8-15 admitted to an emergency department (ED) for mild traumatic brain injury (mTBI). Fried et al. found that 25.3% of mTBI patients (evaluated at 6-60 months post-injury) had PPCS, while only 2.4% of controls had PPCS-like symptoms. Strikingly, while the researchers determined 25.3% of mTBI study participants to have PPCS, none had received a PPCS diagnosis from their healthcare providers.

The study included 205 mTBI patients who received a CT scan and/or were hospitalized for at least a day for observation and 205 demographic-matched controls with wrist fracture injuries. The authors cite this inclusion criterion as a limitation to the study, as “the decision to perform a CT or to hospitalize after a head injury is based on clinical judgment and may represent the more significant cases of mTBI.”

The authors called parents of children admitted to 2 EDs in Israel between 2015-2020 for either mTBI or an uncomplicated wrist fracture. They then administered the Rivermead Post-Concussion Questionnaire (RPQ), which evaluates 16 symptoms in cognitive, somatic (physical), and emotional domains with a scoring range of 0-48. The authors “defined PPCS as the presence of three or more symptoms on the RPQ that were worse than before the injury.“

On average, both mTBI patients and controls were 33 months out from their injury at time of interview, though time since injury did not affect the prevalence of PPCS. Among children and adolescents with PPCS, over 50% reported problems with headaches and difficulty concentrating. In general, PPCS participants reported 65% of symptoms as mild and only 13.2% of symptoms as severe.

Among mTBI patients who were still symptomatic at evaluation, those who were 2+ years from their injury had lower somatic (physical) symptom scores–but similar behavioral and cognitive symptom scores– compared to symptomatic patients less than two years out from their injury when evaluated. Concussion Alliance would like to note that symptom scores as reported by parents could be unknowingly biased towards underreporting physical symptoms. At 2+ years post-injury, concussion patients, particularly children, may have integrated chronic pain or physical discomfort into their lives and report or complain of these problems less to their parents, whereas parents can more easily observe behavioral and cognitive symptoms.

Perhaps most critically, the authors’ found an underdiagnosis of PPCS in adolescents. According to the authors, “none of the 52 patients who had PPCS were officially categorized as such in their electronic medical records by their pediatric primary care physician or neurologist.” They argue that these findings highlight the need for better screening and diagnosis guidelines among pediatric patients “since these children are prone to deficits in attention and cognitive control, school-related problems, inferior academic achievements, and truancy. Furthermore, recent studies have shown that children with a delayed diagnosis of concussion are at a higher risk for persistent symptoms.”