Neurocognitive Evaluation of Mild Traumatic Brain Injury in the Hospitalized Pediatric Population
Condition: Mild Traumatic Brain Injury; Concussion
MeSH terms: Brain Injuries; Brain Injuries, Traumatic; Brain Concussion; Wounds and Injuries
Study type: Observational

Summary: 
      Brain injuries from trauma are common in children, often resulting in death and disability.
      Most brain injuries are minor, yet their treatment can be challenging. Because there are many
      different scales used to characterize the severity of brain injury, there is no consensus
      regarding how to manage patients with minor brain injuries. Specifically, there is no
      agreement on recommendations regarding the safety of return to activities following injury.
      In young athletes with minor brain injuries (i.e. concussions) there is strong data
      suggesting that return to baseline neurologic function is often delayed by days or weeks.
      Children allowed to return to activities too soon may be at a higher risk for a second
      concussion, may delay recovery or, in rare cases, die. Researchers have designed a
      computer-based testing system (ImPACT©) to objectively test for neurologic deficits following
      injury. This test has been used primarily in athletes following a concussion but is also
      applicable to children with brain injuries from non-sports related traumas. We propose to
      utilize this testing in pediatric patients admitted to the hospital with minor brain injury.
      The test would be administered at the time of the hospitalization as well as in the
      outpatient trauma clinic at the time of routine follow up. The test would allow us to
      determine if there are neurologic deficits, potentially subclinical, in these brain injured
      patients and how quickly they recover from their injuries. If successful, the testing will
      likely be useful in other clinical settings such as the primary care office (e.g.
      pediatrician), specialty care office (e.g. sports medicine), or emergency room to determine
      if an injured child requires additional intervention.
    

Detailed description: 
      BACKGROUND

      Head injuries are a frequent source of morbidity and the most common source of mortality in
      the pediatric trauma population. [1] It is estimated that head injuries result in more than
      500,000 emergency department visits, 95,000 hospital admissions and 7,000 deaths in the
      pediatric age-groups. [1] Despite the magnitude of these numbers, they likely underestimate
      the problem, as many injured children are not brought to medical attention. Fortunately, most
      head injuries (75%) are classified as minor. [2] While major head injuries obviously pose a
      greater threat to life for the individual, the sheer volume of minor head injuries, as well
      as the potential for enduring neurologic sequelae, makes them a significant public health
      problem. Management of this large group of patients can be most challenging due to a lack of
      consensus in the health care community regarding the definition of minor traumatic brain
      injury, the ideal assessment modality for the injured child and recommendations for return to
      activity following a brain injury. Return to play recommendations have traditionally been
      based on the grade of concussion and the clinical exam. However given the large number of
      concussion grading scales in existence and the subtle nature of many of the neurologic
      deficits, standard recommendations have been lacking. Further still, the tremendous
      variability in time to full recovery exhibited by brain-injured children make generic
      guidelines naïve.

      While the recovery from head injury in children is variable and difficult to predict, the
      desire to return to activity however, is near constant. Determining when it is safe to return
      to play is thus important. Recent literature has highlighted the perils of premature return
      to activities (most notably contact sports) for children with traumatic brain injury. [3-6]
      Dangers include prolongation of post-concussive symptoms, increased risk of recurrence of
      injury and death.[3-6] Further, these dangers may be more common in the younger athletes.[7]
      However, there is evidence that even non-contact, exertional activities may be detrimental if
      initiated too quickly. It was the observation of the First International Conference on
      Concussion in Sport that no previously published guidelines for management of concussion was
      adequate for assessment of all concussions. Further, they recognized the utility of
      neuropsychological testing in understanding the injury and determining management for the
      concussed patient. [8] Unfortunately, the majority of treating clinicians have few tools
      available to help determine when it is appropriate for the individual to return to
      activities. One such tool that has been used extensively and effectively in the head injured
      athlete is the Immediate Post concussion Assessment and Cognitive Testing (ImPACT©) program.
      This is an interactive software program originally designed to assess subjective and
      objective cognitive abilities of the head injured athlete. The program has been validated for
      use in sports-related concussion. [9, 10] Studies of concussed athletes have demonstrated a
      much slower return to baseline than previously had been appreciated. [11] Further, the
      younger athletes (high school vs. college or professional) were the slowest to return to the
      baseline. [7] This program has proven quite useful in determining the optimal time to return
      to activities in the population of head injured athletes by providing objective data upon
      which to base recommendations.

      The same decisions facing clinicians treating children with sports related head injuries also
      exist for other non-sports related mechanisms (e.g. motor vehicle collisions, falls). Motor
      vehicle related causes and falls are the most common sources of traumatic brain injury in
      children. [12] Sports and recreation account for less than 10% of hospitalized minor
      traumatic brain injuries. Non-sports related traumatic brain injuries are often more severe
      but can be equally as difficult to assess. Anecdotal evidence collected by the researchers
      with the ImPACT© team suggests that the neurocognitive testing would be similarly efficacious
      in the assessment of non-sports related brain injured patients.

      Utilizing a treatment algorithm that involves neurocognitive testing at the level of the
      individual is most likely to effectively determine the suitability to return to activities
      and the need for specialty intervention.

      SPECIFIC AIMS

        1. To assess the feasibility of inpatient bedside neurocognitive testing of pediatric
           patients with minor traumatic brain injury.

        2. To establish if neurocognitive deficits exist, and to what extent, in the cohort of
           hospitalized pediatric patients with minor traumatic brain injury.

        3. To document the timing and extent of recovery for pediatric traumatic brain injury
           through follow-up neurocognitive testing.
    

Intervention name(s): Immediate Post-concussion Assessment and Cognitive Testing
Intervention type(s): Other
Intervention description(s): ImPACT© utilizes a battery of neurocognitive tests to assess neurologic deficits.
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Pediatric blunt trauma patients (age 11-19 years) admitted to The Children's Hospital of
        Philadelphia for treatment of mild traumatic brain injury
      
Keywords: traumatic brain injury; pediatric; neurocognitive; concussion