Background: While concussions among youth occur both inside and outside of the sports realm, emerging research is predominantly from the sports perspective. The 6th International Conference on Concussion in Sport prompted widespread updating of concussion training and resources. Notably, the roles of rest and aerobic physical activity supporting recovery have been considerably refined.

Objective: The Concussion Awareness Training Tool (CATT) provides free, evidence-based, concussion education and resources tailored to diverse audiences, including parents and caregivers, youth, school professionals, and medical professionals. This presentation outlines the integrated knowledge translation practices employed to update CATT, and highlights new information and features of the 2024 relaunch of CATT.

Programme Description: Recently launched on its new online platform, CATT offers up-to-date educational eLearning modules and downloadable resources, each created using an integrated knowledge translation (iKT) approach. Content for the updated website, eLearning modules, and other resources was informed by research, content experts, and target audiences from across Canada.

Date: Since 2018, approximately 170,000 people worldwide have completed CATT training. On average, www.cattonline.com receives 100,000 visits per year from over 185 countries, including: Canada, United States, Australia, United Kingdom, New Zealand, South Africa, Ireland, Russia, Germany, India, France, Lebanon, China, and elsewhere. From October 1, 2023 to July 1, 2024, organic search was used to find CATT by >52K visitors, >26K had a direct link, and >10K arrived at CATT by referral. The SCAT-5 tool was accessed by 53,285 users. Other than the landing page and the SCAT5 landing page, the most popular pages are: CATT for Coach course page (>45K pageviews), Coach persona page (>34K pageviews), CATT for Athletes course page (>18K pageviews), and the CATT for Medical Professionals course page (>14K pageviews). Top CATT resources downloaded were Return to Sport (>975), Return to School (>700), the Incident Report (>675), Return to Work (>575), and Return to Activity (>300). With all eLearning modules available in English and French, work is underway to make modules for medical professionals, coaches, and educators available in Arabic at the request of the American University of Beirut to educate school nurses and administrators. CATT training has been mandated by >100 sporting associations, universities, schools, and other organizations across Canada and the United States. Furthermore, the University of British Columbia is the first medical school in Canada to incorporate concussion education into its 4th year curriculum including the completion of CATT for Medical Professionals.

Implications: Ensuring proper support and management is available to youth during concussion recovery is dependent on access to current, evidence-based education and resources.

Conclusion: CATT is a trusted resource to educate users on concussion recognition, treatment, management, and recovery. Recent updates provide users with current and relevant information in an accessible, no-cost format.

Introduction: Hits to the head are a common occurrence in early childhood. Yet, most epidemiological studies have grouped children into broad age categories, such as 0 to 5 years, assuming similar trends in mechanisms or diagnoses. Early childhood is a period of rapid change, suggesting that such groupings might hide actual trends, which could be targets for injury prevention initiatives. The purpose of this study was to describe the patterns of all injuries in children aged 0 to 59 months presenting to Emergency Departments (ED), with a focus on the different diagnostic outcomes for those presenting with a hit to the head.

Methods: Data were obtained from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), a surveillance system based on EDs in Canada. Patients who consulted between 1994 and 2024 were selected. For those who consulted following a hit to the head, diagnoses were categorized into five groups: a) no head injury (noHI) (i.e., bruises, lacerations to the head/face, or no injury), b) minor head injury (MHI), c) concussion, d) fractured skull (FS), and e) moderate to severe traumatic brain injury (msTBI) (positive scan). As this was historical data, we maintained the original diagnostic nomenclature, thereby separating MHI from concussions.

Results: Over 1.1 million injury-related ED visits were analyzed. All injuries varied according to age and gender. For example, the number of poisonings increased up to the age of 25 months and then decreased until the age of 59 months. For burns, numbers increased until the age of 15 months, decreased until the age of 32 months, and remained stable thereafter. Interestingly, between the ages of 11 and 16 months, boys had nearly twice as many burns as girls. When considering those who consulted for a hit to the head, final diagnoses also varied by age and gender. The noHI and MHI categories followed exact opposite trends, with younger children having the highest percentage of noHI and older children having the highest percentage of MHI. The age at which the percentages for both diagnoses were the same was 16 months for boys and 23 months for girls. Concussions remained stable across ages, at around 6% for both girls and boys, as did msTBIs, which were at 1%. FS were highest immediately following birth and peaked at 3 months (15%) for boys and 2 months (10%) for girls, then rapidly decreased, stabilizing at 1% by the age of 12 months.

Conclusions: This study highlights that injuries in the early stages of life, especially those following a hit to the head, vary greatly from one month to the next. Using broad age categories may be misleading and could obscure trends that might serve as targets for injury prevention initiatives.

Background: Anxiety and depression symptoms are common after concussion and undermine recovery. Mindfulness-based interventions (MBI) are efficacious in managing distress and may facilitate concussion recovery. In-person MBI are resource-intensive and unable to meet the high demand for services. This barrier could be addressed through a scalable digital therapeutics (DTx) model, such as a DTx-MBI. Objectives: We assessed the feasibility of a larger randomized control trial (RCT) to evaluate a DTx-MBI targeted to youth with a concussion by evaluating recruitment efficiency, adherence, credibility, and retention.

Methods: This parallel-group RCT includes patients aged 12-17.99 years who presented to a tertiary emergency department or concussion clinic within 7 days of diagnosed concussion and were deemed at risk for slower recovery per the 5P risk score. Eligible participants were randomized to the experimental (early introduction of DTx-MBI) or control (cognitive sham DTx) group. The DTx-MBI is a 4-to-8-week, 8-module custom-made program for youth with concussion. Each standardized psychoeducation or meditation practice is unlocked as participants progress. Participants were encouraged to engage for 10 min/day for > 4 days/week. The sham DTx uses the same main interface but excludes MBI training, offering only the simple math game 2048. Outcomes: Feasibility was assessed using predefined, adapted thresholds from previous feasibility studies, categorized by a traffic light system (green, amber, red) to guide full-scale trial progression. The green zone thresholds were: a) Eligibility: > 40% of participants screened were eligible; b) Recruitment: > 50% of eligible participants were randomized; c) Credibility: > 70% of participants scored above the midpoint on the Credibility and Expectancy Questionnaire at 1-week; d) Retention: > 75% of participants randomized completed the 4-week follow-up assessment; e) Adherence: > 70% of participants completed the requirement of 10 min for > 4 days/week.

Results: Between mid-November 2022 and mid-June 2024, 124/149 (83.2%) youth were eligible, 99/124 (79.8%) were recruited and randomized to either MBI group (n=49, mean±SD age=15.08±1.60 years, female sex=38.8%) or control group (n=50, mean±SD age=14.97±1.82 years, female sex=40.0%). 62/83 (74.7%) scored above the scale mid-point for credibility, with similar results across groups (MBI group: 75.0%; control group: 74.4%). Retention rates were also comparable, with 89.8% in the MBI group and 90.0% in the control group. Adherence over the 4 weeks was met by 54/99 (54.5%) participants, with 59.2% (amber zone) in the MBI group and 50.0% in the control group (amber zone limit). Adherence was higher in patients who completed the outcome measures (MBI group: 63.6%; control group: 55.6%).

Conclusions: Eligibility, recruitment, credibility and retention have met the green zone thresholds. However, adherence fell within the amber zone, indicating the need for some adjustments. Further analyses will explore factors contributing to lower adherence, aiming to improve it in preparation for the full-scale RCT.

The American Congress of Rehabilitation Medicine (ACRM) has recently suggested that mild traumatic brain injury (mTBI) can be classified into separate diagnostic criteria. This investigation aimed to evaluate the association between cerebral blood flow and clinical signs and whether it is moderated by diagnostic criteria.

Methods: This is a substudy of a randomized clinical trial called PedCARE+MRI. Adolescents aged 10-17.99 years presenting to the emergency department within 48h of a diagnosed concussion were recruited. Participants underwent arterial spin-labelling MRI at 72±48h post-concussion to quantify brain perfusion. Perfusion maps were generated for each participant and subject-specific abnormalities variables were calculated, including numbers of clusters exhibiting abnormal hypo- and hyperfusion and the corresponding volumes. Our sample was split into mTBI criterion based on the definition provided by the ACRM. However, since all participants in our sample had at least 1 clinical sign, it was not used as a criteria. Group 1 had one of the following: loss of consciousness, Glascow Coma scale of 13 or 14 or alteration of mental status. Group 2 had ≥ 2 acute symptoms (e.g., headache, mental fog, dizziness, sensitivity to noise) along with either being physically unable to complete the Balance Error Scoring System test or having ≥ 4 errors on the test. Group 3 had ≥ 2 acute symptoms, but no clinical signs, and Group 4 had neuroimaging abnormalities on computed tomography or structural magnetic resonance imaging (if obtained). 

A linear mixed effect model was used to evaluate the association of clinical signs and perfusion moderated by mTBI criterion. The model included both sex and age as random effects. 

Results: 46 adolescents (46% female, mean age (SD) = 13.16(2.16) years) were part of Group 1, while 26 adolescents were included in Group 2 (50% female, mean age (SD) = 12.78(1.72) years). No participants met criteria for Groups 3 and 4. Mean time from recruitment to MRI was [Group 1= 3.09(1.36) days; Group 2= 3.21(1.2) days].

We observed a significant interaction between mTBI criterion group and clinical signs on the number of abnormal hyperfusion clusters (beta=13.30, 95% CI [4.87,21.73], t(133)=3.12, p=0.002; Std. beta=0.63, 95% CI [0.23,1.03]). Specifically, individuals within Criterion 1 saw a decrease in clinical signs as the number of abnormal hyperperfusion clusters increased. While those in Criterion 2 saw the opposing trend. 

Using abnormal hypoperfusion clusters, no interaction was noted, however a significant positive effect was noted by the number of clinical signs (beta=2.02, 95% CI [0.45,3.59], t(133)=2.55, p=0.012; Std. beta=0.28, 95% CI [0.06,0.49]). 

No associations were noted using volume with both abnormal hypo and hyperperfusion data. 

Discussion: Within our sample, we were able to utilize perfusion data to differentiate diagnostic criteria groups, as provided by the ACRM.

Introduction: Placebo effects are therapeutic benefits in symptoms or overall health generated from the context of receiving treatment rather than the intervention itself. Clinical trials using repetitive transcranial magnetic stimulation (rTMS), a non-invasive neuromodulation technique, have demonstrated substantial placebo responses in participants with depression, obsessive-compulsive disorder, and migraines. This may be related to the intensive procedures and perceived innovation of rTMS driving high therapeutic expectations.
It is postulated that symptoms related to traumatic brain injury (TBI) may be particularly placebo responsive. Small randomized-controlled trials of rTMS as a potential treatment for persisting post-concussion symptoms (PPCS) have offered mixed results. However, there has been limited investigation of placebo response in this patient population and therapeutic context. A greater understanding of placebo response has the potential to improve study design and treatment efficacy in rTMS clinical trials. AIM: To investigate potential factors influencing placebo response as determined by changes in the Rivermead Post-Concussion Questionnaire (RPQ), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9,) following sham rTMS in patients with PPCS. We hypothesize that participants with higher baseline anxiety, successfully blinded to condition, and expecting treatment effects will experience greater placebo response following sham rTMS.

Methods: This analysis used a control cohort nested within a double-blinded randomized controlled trial (NCT04568369). Adults with clinician diagnosed mild TBI and PPCS received 20-sessions of sham rTMS to the left dorsolateral prefrontal cortex. Expectation and blinding questionnaires were administered post-intervention. Outcome measures included PPCS severity, depression, and anxiety. Independent t-tests and Pearson’s correlations were used to compare post-intervention outcome changes in those who guessed blinding correctly/incorrectly, had high treatment expectations, or higher baseline anxiety.

Results: Thirty-nine participants (aged 40.3 ± 12.2 years, 67% female) received sham rTMS stimulation and completed the outcome measures. 21/33 (64%) expected treatment to be efficacious and 21/36 (58%) incorrectly guessed they received active rTMS. RPQ (t(76)=3.051, p=0.003) and GAD-7 (t(76)=0.283, p=0.025) significantly improved post-sham stimulation, however PHQ-9 did not (p=0.165). Participants guessing they received active rTMS had significantly higher baseline PHQ-9 (t(34)=1.233, p=0.020). Changes in outcome measures were not significantly different between those correctly/incorrectly guessing intervention. Treatment expectations, categorized as no, some, moderate, or high, were correlated with post-intervention change in GAD-7 (r=0.365, p=0.037) suggesting that participants with no or lower expectations had a greater anxiety placebo response. When dichotomized to minimal (GAD-7 score 0-4), mild (5-9), moderate (10-14), or severe (15-21) anxiety, higher baseline anxiety was correlated with greater improvements in RPQ (r=-0.332, p=0.039) and PHQ-9 (r=-0.421, p=0.008).

Conclusion: Our results demonstrate a significant relationship between higher baseline anxiety and lower treatment expectations and placebo response. Larger sample sizes and more sensitive measures are required to further explore relationships between expectancy, blinding, and rTMS placebo response in adults with PPCS.

Background: Persistent post-concussion symptoms (PPCS) affect between 34 and 46% of patients following mild traumatic brain injury (mTBI), and many experience exercise intolerance. Sub-symptom threshold aerobic exercise, SSTAE, characterized by exercise intensity below symptom-exacerbating levels, has been proposed as a treatment to reduce the symptom burden and increase exercise tolerance. However, its effectiveness in the persistent phase after mTBI remains unclear. This study aimed to compare the effectiveness of SSTAE to treatment as usual, including standard physical activity advice, tailored to symptom levels.

Methods: Randomized, controlled, single-blind parallel-group study with follow-up at 12 weeks and 6 months. Patients from outpatient TBI clinic at Oslo University Hospital (OUH) aged 18 - 60 with PPCS lasting 3-24 months and exercise intolerance were recruited and randomized into intervention or control group. All patients received the BCTT and follow-ups at the outpatient clinic. The intervention group received in addition a 12-week SSTAE-program consisting of two sessions with PT, retests every 3rd week and exercise diaries to optimize dosage and progression. Primary outcome: Symptom burden, measured with the Rivermead Post-Concussive Symptom Questionnaire (RPQ). Secondary outcome: Symptom threshold (% of HRmax at test cessation) measured with the Buffalo Concussion Treadmill Test (BCTT). The analysis was performed using mixed-effect model in the intention-to-treat population.

Results: Eighty-one patients (58% females) with exercise intolerance were included. The average age was 35.8 (SD: 10.6) years. Mean days since injury was 212 (SD 113). Primary endpoint: At baseline mean RPQ-score was 29.7 (95%CI: 25.6 – 32.1). Mixed-effect model repeated measure for RPQ, T1: -5.75 (SE: 1.6, p<0.001), T2: -11.1 (SE: 1.6, p<0.001), T1 x Group: 0.61 (SE: 2.53, p = 0.48), T2 x Group: 3.98 (SE: 2.5, p=0.12). Secondary endpoint: At baseline the symptom threshold was 69.2% of HRmax (95%CI: 65.9 – 72.55), T1: 8.8 (SE: 23, p<0.001), T2: 13.4 (SE: 2.4, p=0.001), T1 x Group: 4.98 (SE: 2.4, p=0.068), T2x Group: 2.6 (SE: 2.4, p=0.373). DISCUSSION AND

Conclusions: All patients had a significant improvement on the RPQ of 11 points from baseline to T2. However, there was no significant interaction effect between group and time for symptom burden, and the observed difference between the groups change was smaller than the minimal clinical important difference of 5 points. The symptom threshold on BCTT improved with 13.4% HRmax from baseline to T2. However, further post hoc analysis is needed to establish the interaction effect between time and group. To conclude, SSTAE did not demonstrate additional benefits over treatment as usual with tailored physical activity advice in terms of RPQ scores at 12 weeks and 6 months, and its effect of symptom threshold on the BCTT is inconclusive. Further investigation of the secondary endpoint is warranted and will be presented at the congress.

Background: There is a scarcity of multi-country data about employment following mild traumatic brain injury (mTBI). Therefore, this study aimed to investigate the absence from work in the 12 months after mTBI in Europe.

Methods: European prospective and longitudinal data from the Collaborative European NeuroTrauma Effectiveness Research in TBI project (CENTER-TBI) were used. TBI occurred between December 2014 and December 2017, and mTBI was defined as an at-accident Glasgow Coma Scale (GCS) score higher or equal to 13. The sample consisted of adults working at the time of injury. Variables included sociodemographic factors, variables related to the use of psychoactive substances, pre-injury medical history, factors related to medical care, complications, and discharge, and scores collected at a two-week follow-up. Associations were assessed using generalized linear mixed-effects models.

Results: There were 729 working-age adults included in the study (median [IQR] age: 44 [23] years; 528 [72.4%] men). The median (IQR) number of pre-injury chronic physical conditions was 0.0 (1.0), while 73 (10.1%) of the sample had a pre-injury psychiatric disorder. Median (IQR) at-accident GCS score was 15.0 (1.0). The absence from work (and change of work, return to previous work at reduced levels, and special employment) at two weeks and three, six, and 12 months was 36.0% (11.6%), 30.1% (14.8%), 24.7% (12.6%), and 23.8% (12.7%) (p-value for changes in absence from work <0.001). Absence from work in the 12 months following traumatic brain injury was statistically associated with age (per one-year increase: OR=1.04, 95% CI=1.01-1.07), current tobacco use (OR=2.05, 95% CI=1.00-4.17), number of pre-injury chronic physical conditions (per one-condition increase: OR=1.44, 95% CI=1.01-2.04), pre-injury psychiatric disorder (OR=5.48, 95% CI=1.79-16.75), Injury Severity Score (per one-point increase: OR=1.09, 95% CI=1.06-1.12), and the two-week Quality of Life after Brain Injury (QOLIBRI) score (OR=0.98, 95% CI=0.96-1.00).

Conclusions: Absence from work was frequent in the year following mTBI in this European population. The study strengthened the importance of age, pre-injury health behaviors, pre-injury physical and psychiatric comorbidity, overall injury severity and the early perception of health-related quality of life in predicting absence from work after mTBI. Based on these findings, measures should be undertaken to improve post-mTBI return to work in Europe.

Background: The evolution of symptoms and quality of life (QoL) after mild traumatic brain injury (mTBI) varies between individuals. Group-based trajectory modeling (GBTM) approaches have previously highlighted this heterogeneity during the first year post-mTBI but do not appear to have been employed over a longer duration in this population.

Objectives: 1) Identify symptom and QoL trajectories over the first four years following mTBI; 2) examine patterns of symptom trajectory membership in relation to QoL trajectory membership; 3) assess relationships between sociodemographic and injury-related variables and QoL trajectory membership.

Methods: Participants were 143 adults (ages 18-65) who had sustained a mTBI and had been hospitalized for at least 24 hours after injury (not necessarily due to the mTBI). They were assessed at 4, 8, 12, 24, 36, and 48 months post-mTBI using validated questionnaires and an interview to evaluate anxiety, depression, fatigue, insomnia, subjective cognitive symptoms, headaches, and dizziness, as well as QoL. GBTM analyses were conducted to detect trajectories, while chi-square tests were performed to assess relationships between symptom and QoL trajectory membership. ANOVAs and chi-square tests assessed relationships between participant characteristics and QoL trajectory membership.

Results: The identified trajectories demonstrated a high degree of stability over time. Notable percentages of participants had clinically significant symptoms for the entirety of the study: 62% for subjective cognitive symptoms, 54% for fatigue, 44% for anxiety, 43% for insomnia, 27% for depression, 23% for headaches, and 17% for dizziness, while 66% had low QoL. Membership in a trajectory of greater symptom severity, no matter the symptom, was significantly associated with membership in a trajectory of poorer QoL. None of the sociodemographic or injury-related variables examined (i.e., sex, age, intracranial injuries, history of previous mTBI, psychiatric history, years of education, or length of inpatient hospitalization) were associated with QoL trajectory membership.

Conclusions: Clinically significant symptoms are common and persist for up to four years in a substantial minority of individuals hospitalized after mTBI. While the factors influencing symptom persistence and QoL require further investigation, the relationship between symptom and QoL trajectories suggests a need to treat symptoms in order to improve QoL.