brain concussion

Importance: Concussion is a mild traumatic brain injury with associated abnormalities in brain function, rather than structural injury. An estimated 1.1 million to 1.9 million pediatric concussions occur annually in the US.

Objective: To determine the accuracy of clinical history and physical examination findings for identifying concussion in children and adolescents who have had a plausible mechanism of injury.

Data sources and study selection: PubMed, Embase, ClinicalTrials.gov, Cochrane Library, CINAHL, Web of Science, and Google Scholar were searched from January 2002 through December 2025 without language restrictions. Observational studies including patients aged 2 to 18 years evaluated for concussion in outpatient, emergency, or inpatient settings were included.

Data extraction and synthesis: Four reviewers independently extracted study characteristics and diagnostic accuracy data and assessed study quality with the Rational Clinical Examination levels of evidence.

Main outcomes and measures: Sensitivity, specificity, and likelihood ratios (LRs) for symptoms and physical signs associated with concussion were calculated using random-effects meta-analysis when summary measures were appropriate.

Results: Of 7110 screened abstracts, 23 studies (level 4 evidence; case-control design) met inclusion criteria. The presence of mental fog (LR, 11.8-12.0; specificity, 0.96), noise sensitivity (LR, 6.9; 95% CI, 3.6-13.1; specificity, 0.94), nausea (LR, 6.7; 95% CI, 3.1-14.6; specificity, 0.93), and light sensitivity (LR, 6.4; 95% CI, 2.1-19.7; specificity, 0.93) were most useful for increasing the likelihood of a concussion diagnosis. The absence of headache was the most useful symptom for decreasing the likelihood of concussion (LR, 0.20; 95% CI, 0.10-0.39; sensitivity, 0.74). Signs that increased the likelihood of concussion were abnormal near-point convergence, which is the inability to maintain ocular convergence on a near target (LR, 7.0; 95% CI, 2.0-24.9; specificity, 0.97); abnormal smooth pursuits, which are jerky, irregular eye movements when tracking a target (LR, 6.5; 95% CI, 2.4-17.5; specificity, 0.96); and saccades, which are inaccurate or slow eye movements with overshooting or undershooting when looking between 2 or more targets (LR, 4.8; 95% CI, 1.8-13.1; specificity, 0.92); however, none of these findings had a sensitivity of more than 0.40. A consensus statement by the International Conference on Concussion in Sport recommends the Sport Concussion Assessment Tool to systematize the comprehensive evaluation of patients with symptoms concerning for concussion.

Conclusions and relevance: While no single finding was sufficient to confirm or exclude concussion, the presence of mental fog, noise and light sensitivity, nausea, or ocular abnormalities were most useful to identify patients more likely to have had a concussion, while absence of a headache made a concussion less likely. These symptoms and signs are integrated into structured clinical assessments to support the clinical diagnosis and management of pediatric concussion.

Author/s:

Sonal N. Shah, Haley M. Chizuk, Hiu-Fai Fong

A Battery of Easily Accessible, Simple Tools for the Assessment of Concussion in Children

Devin Evans — Wed, 27 Jan 2021 06:00:00 +0000

Date Added:

January 27, 2021

Journal/Publication:

The Journal of Pediatrics

Volume:

229

Pages:

232-239

URL:

A Battery of Easily Accessible, Simple Tools for the Assessment of Concussion in Children

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/j.jpeds.2020.10.012

Keywords

PMID (1):

33068568

MeSH

Neurologic Examination

Athletic Injuries

Simple, accurate tests to monitor children post-concussion. James W. Mold, MD, MPH

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Objective: To determine whether a non-proprietary, novel testing battery can identify recently concussed children within 8 weeks of injury.

Study design: In total, 568 clinic outpatients aged 10-18 years were sorted into 3 groups: 316 had never been concussed, 162 had ever been concussed before 8 weeks earlier, and 90 had been recently concussed within 8 weeks. At initial and any subsequent visits, a neurologic examination and 4 procedures were performed: Stick Drop, Wall Ball, Sharpened Modified Romberg (SMR), and Animal Naming. Analysis included inter-group and intra-person performance differences using a series of t tests on the Stick Drop, Wall Ball, SMR, and Animal Naming.

Results: The recently concussed group performed worse (P < .01 for all) on Stick Drop, total Wall Ball bounces and drops, and SMR compared with never-concussed and ever-concussed groups. This effect for Stick Drop, SMR, and Wall Ball but not Animal Naming persisted beyond the 4 weeks commonly stated to define recovery. Of 59 recently concussed subjects who returned for ≥1 visit, there were improvements in Stick Drop average (P = .004) and maxima (P = .02) as well as SMR (P = .01) but not Animal Naming between initial and subsequent visits.

Conclusions: This novel, rapid testing battery distinguished groups of children ages 10-18 years who had and had not experienced a recent concussion. A view that physical concussion symptoms resolve within a month of injury may be incomplete. Deployment of this readily available, inexpensive and non-proprietary battery should be compared with other tools and studied further in serial assessments.

Author/s:

Brown, William D., Baird, Janette, Kriz, Peter K.

Return to Sport Following Adolescent Concussion: Epidemiologic Findings From a High School Population

Brian Desmarais — Thu, 18 Jun 2020 18:52:31 +0000

Date Added:

June 18, 2020

Journal/Publication:

Orthopedics

Publication Date:

June 4, 2020

URL:

Return to Sport Following Adolescent Concussion: Epidemiologic Findings From a High School Population

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.3928/01477447-20200521-03

MeSH

Adolescent athletes with concussion require an average of 1 month recovery time before they are ready to return to their sport. James W. Mold, MD, MPH

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Abstract

High school athletes sustaining a concussion require careful attention when determining return-to-sport (RTS) readiness. The purpose of this study was to determine epidemiological and RTS data of a large cohort of high school athletes who sustained 1 or more concussions. Records of 357 consecutive youth patients who sustained concussions and presented to a single health care system between September 2013 and December 2016 were reviewed. Demographic data, RTS, and concussion-related variables were obtained via chart review. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores at baseline and following concussions were performed by neuropsychologists. The average age at injury was 15.5 years (range, 14-18 years), 61.9% of patients were male, 6.7% reported a loss of consciousness, and 14.3% reported amnesia, requiring 30.4±23.3 days of recovery prior to RTS. The most common sport of injury was football (27.7%). There was a high incidence of previous concussion (33.1%), and 32 athletes sustained a recurrent concussion. A multivariate model demonstrated that females, players with a history of concussion, and those diagnosed in-clinic rather than in-game required increased time to RTS. Memory ImPACT scores were found to increase as players had recurrent concussions. Visual motor speed and reaction time scores decreased with recurrent concussions. [Orthopedics. 2020;43(x):xx-xx.].

Author/s:

Jildeh, T.R., Okoroha, K.R., Denha, E., Eyers, C., Johnson, A., Shehab, R.

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management

Brian Desmarais — Fri, 05 Jun 2020 18:53:50 +0000

Date Added:

June 5, 2020

Journal/Publication:

The Journal of Pediatrics

Publication Date:

June 4, 2020

URL:

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management

Type:

Clinical Research Results

Format:

Article

DOI (1):

https://doi.org/10.1016/j.jpeds.2020.04.001

Keywords

concussion

vision

vestibular

traumatic brain injury

school-aged

MeSH

brain concussion

This article provides information on the typical presentation and course of concussion in elementary school-age children and focuses on the elements of the visuo-vestibular exam recommended for evaluation of these children. James W. Mold, MD, MPH

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Objective

To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes.

Study design

A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients.

Results

Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations.

Conclusions

Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

Author/s:

Master, C.L., Curry, A.E., Pfeiffer, M.R., Metzger, K.B., Kessler, R.S., Haarbauer-Krupa, J., DePadilla, L., Greenspan, A., Breiding, M.J., Arbogast, K.B.

Subconcussive Football Hits May Leave a Telltale Signature of Brain Damage

John Bayhi — Fri, 04 Oct 2019 13:19:44 +0000

Date Added:

October 4, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

October 3, 2019

URL:

Subconcussive Football Hits May Leave a Telltale Signature of Brain Damage

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2019.15361

Keywords

PMID (1):

31580382

MeSH

Humans

male

football

Chronic Traumatic Encephalopathy

Diffuse Axonal Injury

White Matter

Diffusion Magnetic Resonance Imaging

Head Protective Devices

brain concussion

brain

Craniocerebral Trauma

Soccer

retrospective studies

cohort studies

Even sub-concussive head injuries can injure the brains of football players. James W. Mold, MD, MPH

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College football players in the United States endure over 1000 head hits every season. Although many don’t produce symptoms such as dizziness or blurred vision that often accompany frank concussion, these “clinically silent” hits are associated with the same type of brain damage as concussion, according to a recent Science Advances study.

Author/s:

Sancar, F

Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial

Tracy Ashby — Mon, 08 Apr 2019 05:00:00 +0000

Date Added:

April 8, 2019

Journal/Publication:

JAMA Pediatrics

Publisher:

American Medical Association

Publication Date:

February 4, 2019

URL:

Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial.

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamapediatrics.2018.4397

Keywords

PMID (1):

30715132

MeSH

Sub-symptomatic aerobic exercise is good for adolescents recovering from concussion. Makes sense. James W. Mold, MD, MPH

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IMPORTANCE:

Sport-related concussion (SRC) is a significant public health problem without an effective treatment.

OBJECTIVE:

To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC.

DESIGN, SETTING, AND PARTICIPANTS:

This multicenter prospective randomized clinical trialwas conducted at university concussion centers. Male and female adolescent athletes (age 13-18 years) presenting within 10 days of SRC were randomly assigned to aerobic exercise or a placebo-like stretching regimen.

INTERVENTIONS:

After systematic determination of treadmill exercise tolerance on the first visit, participants were randomly assigned to a progressive subsymptom threshold aerobicexercise or a progressive placebo-like stretching program (that would not substantially elevate heart rate). Both forms of exercise were performed approximately 20 minutes per day, and participants reported daily symptoms and compliance with exercise prescription via a website.

MAIN OUTCOMES AND MEASURES:

Days from injury to recovery; recovery was defined as being asymptomatic, having recovery confirmed through an assessment by a physician blinded to treatment group, and returning to normal exercise tolerance on treadmill testing. Participants were also classified as having normal (<30 days) or delayed (≥30 days) recovery.

RESULTS:

A total of 103 participants were included (aerobic exercise: n = 52; 24 female [46%]; stretching, n = 51; 24 female [47%]). Participants in the aerobic exercise group were seen a mean (SD) of 4.9 (2.2) days after the SRC, and those in the stretching group were seen a mean (SD) of 4.8 (2.4) days after the SRC. There were no differences in age, sex, previous concussions, time from injury, initial symptom severity score, or initial exercise treadmill test and physical examination results. Aerobic exercise participants recovered in a median of 13 (interquartile range [IQR], 10-18.5) days, whereas stretching participants recovered in 17 (IQR, 13-23) days (P = .009 by Mann-Whitney test). There was a nonsignificant lower incidence of delayed recovery in the aerobic exercise group (2 participants [4%] in the aerobic group vs 7 [14%] in the placebo group; P = .08).

CONCLUSIONS AND RELEVANCE:

This is, to our knowledge, the first RCT to show that individualized subsymptom threshold aerobic exercise treatment prescribed to adolescents with concussion symptoms during the first week after SRC speeds recovery and may reduce the incidence of delayed recovery.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT02710123.

Author/s:

Leddy, John J., Haider, Mohammad N., Ellis, Michael J., Mannix, Rebekah, Darling, Scott R., Freitas, Michael S., Suffoletto, Heidi N., Leiter, Jeff, Cordingley, Dean M., Willer, Barry

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

Jeffrey Wilson — Wed, 03 Apr 2019 14:35:11 +0000

Date Added:

April 3, 2019

Journal/Publication:

The Journal of Pediatrics

Publisher:

Elsevier

Publication Date:

April 1, 2019

Volume:

207

Pages:

176-184

URL:

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

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/j.jpeds.2018.11.003

Keywords

child

brain trauma

PMID (1):

30554790

MeSH

brain concussion

football

adolescent

In this cohort of 863 U.S. children 5 – 14 years old who played football, the incidence of concussions was 5%/year. Children with a prior concussion were twice as likely to have another concussion, and children who were depressed were 5 times more likely to have a concussion. James W. Mold, MD, MPH

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.

Author/s:

Chrisman, Sara P. D., Lowry, Sara, Herring, Stanley A., Kroshus, Emily, Hoopes, Teah R., Higgins, Shannon K., Rivara, Frederick P.