Evaluation of a follow-up program for mild traumatic brain injury in schoolchildren

Introduction

Mild traumatic brain injury is a common condition in childhood. Although classified as mild, post-concussive symptoms may persist and interfere with daily activities. Because no established guidelines exist with respect to follow-up medical care for these children, there may be a delay in receiving appropriate care. We developed a follow up program to screen for persistent symptoms and if necessary, refer patients for further medical assistance.

A prospective, population-based, follow-up study of mild traumatic brain injury in children

OBJECTIVE: Outline the annual incidence of mild traumatic brain injury in children, aged 0-17 years, using the American Congress of Rehabilitation Medicine classification and record the presence of new symptoms up to six months after injury. SETTINGS AND METHODS: The study population comprised all the children in the age group of 0-17 years (a total of 40,984) in an administrative district in south-western Sweden. All the individuals registered in the Brain Injury Register, during the periods 1 January to 30 June 1999 and 1 April to 30 September 2000, fulfilling the inclusion criteria defined by American Congress of Rehabilitation Medicine, were included. New symptoms occurring three to six months after the injury were recorded using a mailed 21-item questionnaire. RESULTS: 192 children fulfilled the criteria, yielding an annual incidence of 468/100,000 (95% CI 402-535/100,000). Boys accounted for 57 per cent and fall injuries accounted for 61 per cent of the external causes. New symptoms were reported by 24 per cent of those who answered the questionnaire. CONCLUSION: This study revealed that the annual incidence of mild traumatic brain injury in children was almost as high as that among adults in the same area and population.     

Effect of depression on cognition after mild traumatic brain injury in adults

Objective: The current study examined the effect of depression on cognitive test performance in a sample of adults seeking treatment for a mild traumatic brain injury (MTBI). We hypothesized that patients with greater depressive symptoms would perform worse on tasks of fluid cognition compared to those without depression, after controlling for potential confounds.

Method: Patients (N = 76) completed a brief cognitive test battery (NIH Toolbox Cognition Battery; NIHTB-CB) and a depression screening questionnaire (PHQ-9) at 11.7-weeks post injury (SD = 6.3 range 2–26). Cognitive scores were adjusted for age, education, gender, and race/ethnicity. Depressive symptoms were examined continuously and dichotomized as: (1) total PHQ-9 score of ≥ 10, the optimal cut-off for Major Depressive Disorder caseness from prior research, and (2) five or more symptoms of depression, including either depressed mood or anhedonia (i.e. DSM-5-based definition).

Results: Twenty-seven patients (35.5%) met DSM-5-based criteria for depression and 42 (55.3%) met criteria based on PHQ-9 > 10. Depression symptom severity correlated with lower fluid cognition composite scores [r = ?.22, p = .05] and contributed to the prediction of fluid cognition performance in a model that controlled for time since injury and crystallized cognitive abilities [F(3, 72) = 7.49, p < .001; R² = 20.6%]. Examining specific NIHTB-CB fluid subtests, the largest group differences were seen on processing speed (d = .40–.49), cognitive flexibility (d = .32–.36), and episodic memory (d = .20–.34). Depression severity was strongly associated with overall post-concussion symptom burden (r = .77, p < .001).

Conclusion: Depression is a common comorbidity and an important factor to consider when interpreting neurocognitive test performance in adults with concussion in a clinical setting.     

Assessment of subtle cognitive-communication deficits following acquired brain injury: A normative study of the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)

Primary objective: To present a new measure, the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES), with evidence for its reliability and validity in a normative study. The FAVRES is designed to evaluate the subtle cognitive-communication deficits of individuals with ABI. Methods and procedures: The FAVRES consists of four complex, contextually rich, verbal reasoning tasks that simulate everyday situations and require processing of text and discourse. Scoring considers the time, accuracy and justification of reasoning responses. The FAVRES scores of 52 adults with ABI were compared to those of 101 adults without ABI. Outcomes: FAVRES scores clearly differentiated the performances of individuals with and without ABI. Individuals with ABI were slower and less accurate in reasoning and presented fewer adequate rationales for their decisions. Inter-rater reliability for scoring was acceptable. Conclusions: The FAVRES provides a reliable, functional and quantifiable measure of the cognitive-communication difficulties of individuals with ABI.     

The Utility of Post-Concussion Neuropsychological Data in Identifying Cognitive Change Following Sports-Related MTBI in the Absence of Baseline Data

Neuropsychological tests have become commonplace in the assessment of sports-related concussion. Typically, post-injury test data are compared to pre-injury “baselines.” Baseline testing can be expensive and logistically challenging, yet the usefulness of neuropsychological baseline testing has not been tested empirically. This paper examines the extent to which baseline testing is useful for detecting neurocognitive deficits following sports concussion in a college-age population. A total of 223 collegiate athletes from multiple sports who sustained concussions and had both baseline and post-injury testing using Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) were included in the study. Reliable change (RC) in scores was determined by two approaches, the Jacobson and Truax (JT) and the Gulliksen-Lord-Novick (GLN) methods. The 90% confidence interval was used for both. Classification using these methods was compared to standard normative methods that compared post-concussion performance to baseline population means. Agreement between reliable change and normative methods was examined using Cohen's Kappa scores to determine whether post-injury scores alone could identify reliable cognitive decline. Mean time from concussion to post-injury testing was 3.40 days. The percentage of athletes who declined when using the JT method was similar to the percentage that would be expected to decline due to chance alone. Although the GLN and JT methods demonstrated moderate to substantial agreement, the GLN method consistently identified more cognitively compromised athletes than the JT method. Post-injury scores alone identified a significant majority of athletes with a reliable decline on ImPACT. Although preliminary and in need of replication across age groups and instruments, these findings suggest that the majority of collegiate athletes who experience clinically meaningful post-concussion cognitive decline can be identified without baseline data.     

Diagnosis clinical criteria of sport related concussion: Toward an operational criteria definition in France

ObjectiveAn expert working group was set up at the initiative of the French Ministry of Sports with the objective of harmonising the management of sport related concussion (SRC) in France, starting with its definition and diagnosis criteria.ResultsDefinition: A clinical definition in 4 points have been established as follows: Concussion is a brain injury: 1) caused by a direct or indirect transmission of kinetic energy to the head; 2) resulting in an immediate and transient dysfunction of the brain characterised by at least one of the following disorders: a) Loss of consciousness, b) loss of memory, c) altered mental status, d) neurological signs; 3) possibly followed by one or more functional complaints (concussion syndrome); 4) the signs and symptoms are not explained by another cause. Diagnosis criteria: In the context of the direct or indirect transmission of kinetic energy to the head, the diagnosis of concussion may be asserted if at least one of the following signs or symptoms, observed or reported, is present within the first 24 hours and not explained by another cause: 1) loss of consciousness; 2) convulsions, tonic posturing; 3) ataxia; 4) visual trouble; 5) neurological deficit; 6) confusion; 7) disorientation; 8) unusual behaviour; 9) amnesia; 10) headaches; 11) dizziness; 12) fatigue, low energy; 13) feeling slowed down, drowsiness; 14) nausea; 15) sensitivity to light/noise; 16) not feeling right, in a fog; 17) difficulty concentrating.ConclusionSharing the same definition and the same clinical diagnostic criteria for concussion is the prerequisite for common rules of management for all sports and should allow the pooling of results to improve our knowledge of this pathology.