Optimizing Concussion Care

The Minds Matter Concussion Program at Children's Hospital of Philadelphia has demonstrated a fundamentally forward-thinking mindset with its comprehensive approach to optimizing concussion care. Researchers have been hard at work phenotyping concussion with clinical and objective measures and the adoption of an active therapeutic approach to treatment. In contrast, international experts and other practitioners in the region still recommend rest with minimal guidance about active therapies.

We reject the notion that all concussions are the same and should be treated with the same, passive approach. Our research continues to use novel methods to quantify recovery and enroll concussed patients in randomized clinical trials to further investigate promising active therapies.

By implementing a personalized approach to concussion care, we can target specific deficits through emerging novel treatments to accelerate recovery and improve quality of life for these children.

Optimizing Concussion Care Research

Identifying Links between Concussion and Mitochondrial Disease Provides Insight to Treatment

The Minds Matter Concussion Program is collaborating with a range of CHOP experts on a Mitochondrial Medicine Program study. This project aims to study the link between bioenergetics (a field of biochemistry that focuses on how cells transform energy) and autonomic nervous system dysfunction seen in concussion. Minds Matter researchers are deploying pupillometry, exercise testing, and cerebral oxygenation measurement via functional near-infrared spectroscopy (fNIRS) to study this relationship in concussed youth and those with primary mitochondrial disease. Our work supports the overall study goal to develop quantitative biomarkers and objective outcome measures that measure bioenergetic dysfunction and provide insight into paths of treatment for both conditions. The goal of this cross-CHOP team is to develop tools to monitor outcomes from therapeutic interventions in patients with primary mitochondrial disease as well as secondary mitochondrial disruption, such as is seen in concussion. 

Principal Investigators: Marni Falk, MDCo-Investigators: Kristy Arbogast, PhD Christina L Master, MD, CAQSMDaniel Corwin, MD, MSCE

Funding: United States Department of Defense

Vestibular Rehabilitation

This study sought to determine whether active vestibular rehabilitation was associated with improvement in visio-vestibular deficits in children with concussion. In a sample of over 100 children with concussion who were referred to vestibular rehabilitation, symptoms decreased and performance on visio-vestibular tasks and the Balance Error Scoring System improved, after the course of therapy. Future work should determine the optimal post-injury timing of this rehabilitation.

Principal Investigator: Christina L Master, MD, CAQSM

Funding: Children's Hospital of Philadelphia

Remote Patient Monitoring for ED Concussion Care Continuity

This 5-year research project aims to improve the accuracy of concussion risk using physiologic markers of injury and assess the feasibility of a remote patient monitoring mobile eHealth tool to facilitate specialist access and care continuity. The objective is to match novel therapies to pediatric concussion patients experiencing persistent post-concussion symptoms (PPCS) by incorporating objective visio-vestibular deficits into risk models and utilizing a remote patient monitoring (RPM) tool to improve specialist access and care continuity.

Principal Investigator: Daniel Corwin, MD, MSCE

Funding: National Institutes of Health: National Institute of Neurological Disorders and Stroke

Concussion Recovery App: Use of Ecological Momentary Assessment (EMA) to Track Symptoms

As a research strategy, EMA can capture objective measures of physical activity, reports of cognitive activity, and symptomatology in real time in pediatric patients. With EMA, we can understand the time-varying nature of concussion recovery in youth. As a clinical tool, EMA can help clinicians monitor their patients’ recovery in real-time and adjust care plans accordingly. 

Research Team (CHOP): Christina L Master, MD, CAQSMMatthew Grady, MD, Michael L. Nance, MDEileen Houseknecht, RN; Research Team (Penn): Douglas Wiebe, PhD Nicole Otto, MDDanielle Sandsmark, MD

Funding: Penn Medicine Translational Neuroscience Center

Driving after Concussion: Examination of the Adolescent Brain and Behaviors

 

This 4-year research project aims to establish the evidence base for return to drive recommendations for adolescents after a concussion. The objective is to examine the neurophysiological functioning of the recovering concussed adolescent brain while managing driving tasks, the association between their neurophysiological functioning and clinical assessments, and the nature of concussed adolescents’ engagement in risky driving behaviors. The project will employ driving simulation, fNIRS, and pupillometry as measures of neurophysiological function; examine the association of these objective measures with clinical assessments; and prospectively quantify driving behaviors of concussed adolescents with objective on-road in-vehicle monitoring and ecological momentary monitoring of concussion symptoms. Research publications include:

Changes in Driving Behaviors After Concussion in Adolescents

In this 2020 study, the Minds Matter Concussion Registry was used to characterize and compare adolescent driving behaviors after concussion. This study found that nearly half of teens who sought specialty care for a concussion had returned to driving before returning to exercise or sports. The findings from this study suggest a need for evidence-based guidance on safely returning to driving for adolescents with concussion.

An Integrative Review of Return to Driving After Concussion in Adolescents

This 2020 review summarizes the current literature on return to driving after concussion in adolescents. Based on articles published between 2016 and 2020, heathcare providers are unclear on how to determine if a patient is fit to drive. This review highlights the need for future studies to examine clinical predictors of return to driving readiness in adolescents.

Principal Investigator: Catherine McDonald, PhD, RN; Co-Investigators: Kristy Arbogast, PhD, Christina L Master, MD, CAQSM, Allison Curry, PhD, Douglas Wiebe, PhD, Kit Delgado, MD, Hasan Ayaz, PhD


Funding: National Institute of Nursing Research

AMSSM Exercise Therapy Trial 

 

This multicenter, randomized controlled trial investigates if sub-symptom threshold aerobic exercise in adolescents with a recent sport-related concussion improves time to recovery compared to non-aerobic stretching activities. The study enrolls adolescents within 10 days of sport-related concussion, who complete a randomly assigned daily activity (exercise vs. stretching), report daily symptoms in a mobile app, and return for weekly follow-up visits for up to 4 weeks post-injury, unless they recover sooner. The study is a collaborative effort between CHOP, University at Buffalo, and Boston Children’s Hospital.

Principal Investigator: Christina L Master, MD, CAQSM

Funding: American Medical Society for Sports Medicine (AMSSM)

Practice Patterns in Pharmacological and Non-Pharmacological Therapies

In a survey of multiple clinical sites in North America, we explored common practice variation in the management of pediatric concussion, with a focus on understanding the frequency at which providers prescribed medications (e.g. non-steroidal anti-inflammatories) and other therapies (e.g. rest or exercise therapy). Journal of Neurotrauma. 2019.

CHOP Lead Author: Christina L Master, MD, CAQSM

Funding: Children's Hospital of Philadelphia

HIT HEADS Trial of Dietary Supplements 

 

HIT HEADS stands for “Head Injury Treatment with Healthy and Advanced Dietary Supplements.” Clinician-researchers have worked to increase therapeutic options for treating concussions. One line of inquiry concerns the potential role for dietary supplements. The HIT HEADS study is a randomized, placebo-controlled, double-blinded, therapeutic exploratory clinical trial of dietary supplements in the treatment of sports-related concussion.

Principal Investigators: Akiva Cohen, PhDSage Myers, MD

Funding: Dana Foundation

Watch Dr. Christina Master explain the importance of seeking medical attention for children with any type of head injury: