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Mild traumatic brain injury (mTBI), or concussion, is the most common type of traumatic brain injury. With mTBI comes symptoms that include headaches, fatigue, depression, anxiety and irritability, as well as impaired cognitive function. Symptom resolution is thought to occur within 3 months post-injury, with the exception of a small percentage of individuals who are said to experience persistent post-concussion syndrome. The number of individuals who experience persistent symptoms appears to be low despite clear evidence of longer-term pathophysiological changes resulting from mTBI. In light of the incongruency between these longer-term changes in brain pathology and the number of individuals with longer-term mTBI-related symptoms, particularly impaired cognitive function, we performed a scoping review of the literature that behaviourally assessed short- and long-term cognitive function in individuals with a single mTBI, with the goal of identifying the impact of a single concussion on cognitive function in the chronic stage post-injury. CINAHL, Embase, and Medline/Ovid were searched July 2015 for studies related to concussion and cognitive impairment. Data relating to the presence/absence of cognitive impairment were extracted from 45 studies meeting our inclusion criteria. Results indicate that, in contrast to the prevailing view that most symptoms of concussion are resolved within 3 months post-injury, approximately half of individuals with a single mTBI demonstrate long-term cognitive impairment. Study limitations notwithstanding, these findings highlight the need to carefully examine the long-term implications of a single mTBI.

ABSTRACT BACKGROUND: Previous research estimates that the majority of athletes with sport-related concussion (SRC) will recover between 7 and 10 days after injury. This short temporal window of recovery is based predominately on symptom resolution and cognitive improvement and does not accurately reflect recent advances in the clinical assessment model. OBJECTIVE: To characterize SRC recovery at 1-week postinjury time intervals on symptom, neurocognitive, and vestibular-oculomotor outcomes and to examine sex differences in SRC recovery time. METHODS: A prospective, repeated-measures design was used to examine the temporal resolution of neurocognitive, symptom, and vestibular-oculomotor impairment in 66 subjects (age, 16.5 ± 1.9 years; range, 14-23 years; 64% male) with SRC. RESULTS: Recovery time across all outcomes was between 21 and 28 days after SRC for most athletes. Symptoms demonstrated the greatest improvement in the first 2 weeks, although neurocognitive impairment lingered across various domains up to 28 days after SRC. Vestibular-oculomotor decrements also resolved between 1 and 3 weeks after injury. There were no sex differences in neurocognitive recovery. Male subjects were more likely to be asymptomatic by the fourth week and reported less vestibular-oculomotor impairment than female subjects at weeks 1 and 2. CONCLUSION: When the recommended “comprehensive” approach is used for concussion assessment, recovery time for SRC is approximately 3 to 4 weeks, which is longer than the commonly reported 7 to 14 days. Sports medicine clinicians should use a variety of complementing assessment tools to capture the heterogeneity of SRC.

ObjectiveInvestigate whether resuming physical activity (PA) at 72 hours post concussion is safe and reduces symptoms at 2 weeks, compared with resting until asymptomatic.MethodsReal-life conditions, multicentre, single-blinded randomised clinical trial, conducted in three Canadian paediatric emergency departments (ED). Children/youth aged 10–<18 years with acute concussion were recruited between March 2017 and December 2019, and randomly assigned to a 4-week stepwise return-to-PA protocol at 72 hours post concussion even if symptomatic (experimental group (EG)) or to a return-to-PA once asymptomatic protocol (control group (CG)). The primary outcome was self-reported symptoms at 2 weeks using the Health and Behaviour Inventory. Adherence was measured using accelerometers worn 24 hours/day for 14 days post injury. Adverse events (AE) (worsening of symptoms requiring unscheduled ED or primary care visit) were monitored. Multivariable intention-to-treat (ITT) and per-protocol analyses adjusting for prognostically important covariates were examined. Missing data were imputed for the ITT analysis.Results456 randomised participants (EG: N=227; mean (SD) age=13.3 (2.1) years; 44.5% women; CG: N=229; mean (SD) age=13.3 (2.2) years; 43.7% women) were analysed. No AE were identified. ITT analysis showed no strong evidence of a group difference at 2 weeks (adjusted mean difference=−1.3 (95% CI:−3.6 to 1.1)). In adherent participants, initiating PA 72 hours post injury significantly reduced symptoms 2 weeks post injury, compared with rest (adjusted mean difference=−4.3 (95% CI:−8.4 to –0.2)).ConclusionSymptoms at 2 weeks did not differ significantly between children/youth randomised to initiate PA 72 hours post injury versus resting until asymptomatic; however, many were non-adherent to the intervention. Among adherent participants, early PA was associated with reduced symptoms at 2 weeks. Resumption of PA is safe and may be associated with milder symptoms at 2 weeks.Level of evidence1b.Trial registration number NCT02893969.Registry namePediatric Concussion Assessment of Rest and Exertion (PedCARE).

The term “repetitive head impacts” (RHI) refers to the cumulative exposure to concussive and subconcussive events. Although RHI are believed to increase risk for later-life neurological consequences (including chronic traumatic encephalopathy), quantitative analysis of this relationship has not yet been examined because of the lack of validated tools to quantify lifetime RHI exposure. The objectives of this study were: 1) to develop a metric to quantify cumulative RHI exposure from football, which we term the “cumulative head impact index” (CHII); 2) to use the CHII to examine the association between RHI exposure and long-term clinical outcomes; and 3) to evaluate its predictive properties relative to other exposure metrics (i.e., duration of play, age of first exposure, concussion history). Participants included 93 former high school and collegiate football players who completed objective cognitive and self-reported behavioral/mood tests as part of a larger ongoing longitudinal study. Using established cutoff scores, we transformed continuous outcomes into dichotomous variables (normal vs. impaired). The CHII was computed for each participant and derived from a combination of self-reported athletic history (i.e., number of seasons, position[s], levels played), and impact frequencies reported in helmet accelerometer studies. A bivariate probit, instrumental variable model revealed a threshold dose-response relationship between the CHII and risk for later-life cognitive impairment (p < 0.0001), self-reported executive dysfunction (p < 0.0001), depression (p < 0.0001), apathy (p = 0.0161), and behavioral dysregulation (p < 0.0001). Ultimately, the CHII demonstrated greater predictive validity than other individual exposure metrics.

Vestibular and oculomotor impairment and symptoms may be associated with worse outcomes after sport-related concussion (SRC), including prolonged recovery. In this review, we evaluate current findings on vestibular and oculomotor impairments as well as treatment approaches after SRC, and we highlight areas in which investigation is needed. Clinical researchers have intimated that recovery from SRC may follow certain clinical profiles that affect the vestibular and oculomotor pathways. Identifying clinical profiles may help to inform better treatment and earlier intervention to reduce recovery time after SRC. As such, screening for and subsequent monitoring of vestibular and oculomotor impairment and symptoms are critical to assessing and informing subsequent referral, treatment, and return to play. However, until recently, no brief-screening vestibular and oculomotor tools were available to evaluate this injury. In response, researchers and clinicians partnered to develop the Vestibular/Ocular-Motor Screening, which assesses pursuits, saccades, vestibular ocular reflex, visual motion sensitivity, and convergence via symptom provocation and measurement of near-point convergence. Other specialized tools, such as the King-Devick test for saccadic eye movements and the Dizziness Handicap Inventory for dizziness, may provide additional information regarding specific impairments and symptoms. Tools such as the Vestibular/Ocular-Motor Screening provide information to guide specialized referrals for additional assessment and targeted rehabilitation. Vestibular rehabilitation and visual-oculomotor therapies involve an active, expose-recover approach to reduce impairment and symptoms. Initial results support the effectiveness of both vestibular and visual-oculomotor therapies, especially those that target specific impairments. However, the evidence supporting rehabilitation strategies for both vestibular and oculomotor impairment and symptoms is limited and involves small sample sizes, combined therapies, nonrandomized treatment groups, and lack of controls. Additional studies on the effectiveness of screening tools and rehabilitation strategies for both vestibular and oculomotor impairment and symptoms after SRC are warranted.

Mild traumatic brain injury (TBI) is defined as a head trauma resulting in a brief loss of consciousness and/or alteration of mental state. Diagnostic methods to determine the extent of injury to the brain and potential long-term damage in patients are lacking. In this Review, the authors discuss the need for fluid biomarkers of mild TBI, and the potential validation of biomarkers before clinical implementation. Mild traumatic brain injury (TBI), which is defined as a head trauma resulting in a brief loss of consciousness and/or alteration of mental state, is usually benign, but occasionally causes persistent and sometimes progressive symptoms. Whether a threshold for the amount of brain injury and/or individual vulnerability might contribute to the development of these long-term consequences is unknown. Furthermore, reliable diagnostic methods that can establish whether a blow to the head has affected the brain (and in what way) are lacking. In this Review, we discuss potential biomarkers of injury to different structures and cell types in the CNS that can be detected in body fluids. We present arguments in support of the need for further development and validation of such biomarkers, and for their use in assessing patients with head trauma in whom the brain might have been affected. Specifically, we focus on the need for such biomarkers in the management of sports-related concussion, the most common cause of mild TBI in young individuals, to prevent long-term neurological sequelae due to concussive or subconcussive blows to the head. Key Points Biomarkers of neuronal, axonal and astroglial damage could be used to diagnose mild traumatic brain injury (TBI) and predict clinical outcomes of patients with head trauma Such biomarkers could provide important information for medical counselling of at-risk individuals, such as military personnel and concussed athletes Cerebrospinal fluid markers are preferred over peripheral blood markers, owing to their increased proximity to the brain and decreased susceptibility to the confounding effects of various extracerebral factors Ultrasensitive assays are needed for reliable quantification of CNS-specific biomarkers in blood, as their concentrations are below the lower limit of detection by most standard immunoassays Clinical studies of serial biomarker measurements in conjunction with advanced brain imaging during the acute and subacute phases of mild TBI are warranted Longitudinal studies of biomarkers in patients with chronic or progressive symptoms after TBI might help to clarify the pathogenesis and clinical course of chronic traumatic encephalopathy

The long-term effects of mild TBI (mTBI) are not well understood, and there is an ongoing debate about whether there are sex differences in outcomes following mTBI. This study examined i) symptom burden and functional outcomes at 8-years post-injury in males and females following mTBI; ii) sex differences in outcomes at 8-years post-injury for those aged <45 years and ≥45 years and; iii) sex differences in outcomes for single and repetitive TBI. Adults (≥16 years at injury) identified as part of a population-based TBI incidence study (BIONIC) who experienced mTBI 8-years ago (N = 151) and a TBI-free sample (N = 151) completed self-report measures of symptoms and symptom burden (Rivermead Post-Concussion Symptom Questionnaire, Hospital Anxiety and Depression Scale, Post-traumatic Stress Disorder Checklist), and functional outcomes (Participation Assessments with Recombined Tools, Work Limitations Questionnaire). The mTBI group reported significantly greater post-concussion symptoms compared to the TBI-free group (F(1,298) = 26.84, p<.01, ηp 2 = .08). Females with mTBI were twice as likely to exceed clinical cut-offs for post-concussive (X 2 (1)>5.2, p<.05, V>.19) and PTSD symptoms (X 2 (1) = 6.10, p = .014, V = .20) compared to the other groups, and reported their health had the greatest impact on time-related work demands (F(1,171) = 4.36, p = .04, ηp 2 = .03. There was no interaction between sex and age on outcomes. The repetitive mTBI group reported significantly greater post-concussion symptoms (F(1,147) = 9.80, p<.01, ηp 2 = .06) compared to the single mTBI group. Twice the proportion of women with repetitive mTBI exceeded the clinical cut-offs for post-concussive (X 2 (1)>6.90, p<.01, V>.30), anxiety (X 2 (1)>3.95, p<.05, V>.23) and PTSD symptoms (X2(1)>5.11, p<.02, V>.26) compared with males with repetitive TBI or women with single TBI. Thus, at 8-years post-mTBI, people continued to report a high symptom burden. Women with mTBI, particularly those with a history of repetitive mTBI, had the greatest symptom burden and were most likely to have symptoms of clinical significance. When treating mTBI it is important to assess TBI history, particularly in women. This may help identify those at greatest risk of poor long-term outcomes to direct early treatment and intervention.

More than 75% of traumatic brain injuries (TBIs) seeking medical attention are mild, and outcome in that group is heterogeneous. Until sensitive and valid biomarkers are identified, methods are needed to classify mild TBI into more homogeneous subgroups. Four hundred twenty-one adults with mild TBI were divided into groups based on Glasgow Coma Scale (GCS) 13–15 without computed tomography (CT) abnormalities, GCS 15 with CT abnormalities, and GCS 13–14 with CT abnormalities, and were compared with 120 trauma controls on 1-month and 1-year outcomes. At 1 month post-injury, almost all neuropsychological variables differed significantly among the groups. Compared with trauma controls, the GCS 13–15 CT normal group showed no significant differences on any neuropsychological measure or Glasgow Outcome Scale (GOS). The GCS 15 CT abnormal group performed significantly worse on only a measure of episodic memory and learning (Selective Reminding Recall [SRCL]) and GOS, and the GCS 13–14 CT abnormal group performed significantly worse on most neuropsychological measures and GOS. At 1 year post-injury, except for an isolated difficulty on SRCL in the GCS 13–14 CT abnormal group, no differences were observed on any neuropsychological measures nor on GOS. Mean percent of total post-traumatic symptoms endorsed as new or worse and percent endorsing three or more symptoms differed significantly (p < 0.001), with each TBI subgroup reporting significantly more symptoms than the trauma controls at both 1 month and 1 year. In conclusion, this subgrouping improves granularity within mild TBI. While most neuropsychological and functional differences abate by 1 year, reporting three or more post-traumatic symptoms remain for about half of individuals.