Background: Despite the increased awareness and education to the public, concussions in children continue to ensue without proper concussion education and management in school systems. Whether the child suffers a concussion in school or at home, it is essential for school nurses to have proper concussion education and evidence based management strategies to further monitor post-concussive symptoms in the school setting. Concussion symptoms can affect the student up to 7-10 days following the injury. Concussions can range from mild to severe, with symptoms lasting hours, days, months or longer. Children who experience a concussion can experience academic challenges that will affect them in the classroom. Without proper concussion education for school nurses, concussed youth may experience post-concussive symptoms. School nurses have a significant role, collaborating with the parents, providers, and the student in providing accommodations and support while transitioning back into the classroom. Purpose: To assess the knowledge of Utah school nurses regarding concussion education and management of the concussed student. In addition evaluating the educational intervention, which changed the knowledge base of the participants. Methods: A one group pre-test and post-test design was used. Study materials were emailed via the Utah School Nurse Association listserv to all Utah school nurses. A concussion educational power point was provided to these nurses before having them complete the post-test. Results: The results of the paired sample t-test revealed that there was a significant difference (p= .000) in comparison of the pre-test and post-test results after viewing the concussion educational power point. Conclusion: The results of this study showed that there was a significant difference between pre-test and post-test results after viewing the concussion educational power point. Therefore it can be concluded that providing education and awareness regarding concussion and its management will increase the knowledge and ultimately may change practice which in turn may improve patient outcomes.

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Abstract Head injury is the leading cause of death and disability in trauma patients, and alcohol misuse is often associated with such injuries. Despite modern diagnostic facilities, the extent of traumatic brain injury (TBI) is difficult to assess and supplementary diagnostic tools are warranted. The contribution of alcohol misuse to traumas also needs to be elucidated, as the role of different patterns of alcohol drinking in particular has received less attention. We investigated the clinical utility of a novel serum marker of brain damage, protein S100B, as a tool for assessing TBI in patients with trauma. We also investigated the patterns of alcohol drinking among trauma patients and the trauma mechanisms in relation to blood alcohol concentration (BAC), with special emphasis on head traumas. Finally, we studied the early identification of hazardous drinkers among trauma patients. Serum protein S100B was found to be a feasible supplementary method for assessing TBI, as the latter was shown to elevate its levels significantly, the highest values being found in patients with severe injuries. S100B was also found to be elevated in patients with mild head injury, where it was associated with an increased risk of developing post-concussion symptoms (PCSs). Extracranial injuries also increased S100B values in patients with multitrauma. Accordingly, S100B was not specific to TBI. The more severe the extracranial injury, the higher the S100B value that was found. Binge drinking was found to be the predominant pattern in trauma patients. Alcohol intoxication on admission and hazardous drinking patterns were more often present in patients with head injury than in those with other types of trauma. The risk of sustaining a head trauma significantly increased with increasing BAC. The results also demonstrated that BAC on admission is the best marker of alcohol misuse in trauma patients. The BAC test depicts hazardous alcohol drinking better than conventional biochemical markers of alcohol misuse such as gamma-glutamyl transpeptidase (GGT), aspartate aminotransferase (AST), carbohydrate-deficient transferrin (CDT), or mean corpuscular volume (MCV) of erythrocytes. The findings support the use of S100B as a supplementary method for assessing TBI and the use of BAC as a marker of alcohol misuse in trauma patients.

Tradition measures of recovery, such as patient-reported symptoms, objective measures such as balance, specific dimensions such as depression, fatigue, cognitive status, and exercise tolerance do not fully capture the impact of the concussion on performing individual activities and participating in life situations as experienced by the patient. No concussion-specific measure of functional status currently exists. Objectives The overarching purpose of this dissertation was to develop a concussion-specific measure of functional status. There were two specific objectives: 1. To examine the concept of functioning post-concussion; 2. To generate questionnaire items based on a conceptual model of functioning. Methods This dissertation follows the recommendations of the Association for Medical Education in Europe as a framework with which to meet the objectives. The first objective was addressed by (1) generating a list of concussion-specific concepts through a systematic review (Chapter 3), and (2) qualitative interviews with individuals with persistent post-concussion symptoms and clinicians with concussion expertise (Chapter 4). The relationships between the concepts that emerged from those studies are presented graphically in a conceptual model to meet the second objective. The concepts were then transformed into questionnaire items and pretested through cognitive interviews with individuals with PPCS and clinicians with concussion expertise. Finally, the questionnaire items were critically evaluated for proportion of shared content against existing measures used in concussion clinical trials by coding all items to the International Classification of Functioning, Disability and Health. Results Objective 1 Three main themes emerged from the qualitative findings: (1) functioning at the level of the individual and society; (2) environmental barriers and facilitators; and (3) capacity, defined as the length of time one could perform a task before the onset of symptoms, and the length of time it took to recovery from those symptoms. Objective 2 The final questionnaire is presented as the CORE-Q, which is comprised of 53 items over three complimentary subscales, namely the Post-Concussion Functional Scale, the Concussion Modifiers Scale, and the Global Functional Recovery Scale. Each subscale corresponds to one of the three main themes. No existing outcome measure contained more than 40% of the content within the CORE-Q, or 55% of any subscale. Conclusions The CORE-Q is a unique measure of functional status post-concussion that considers functioning from a biopsychosocial perspective. Further studies are needed to assess the psychometric properties of the CORE-Q before it is adopted into clinical practice and intervention trials.

Objectives: To explore the prevalence and structure of self-reported disability after mild traumatic brain injury and the impact of traumatic brain pathology on such outcome. Material and methods: In study 1-3, symptoms data were collected by use of Rivermead Post-concussion Symptoms Questionnaire (RPQ) and data on global function by use of Glasgow Outcome Scale Extended (GOSE) from 2602 patients at 3 months after MTBI. RPQ data were subject to factor and Rasch-analyses Head CT data from 1262 patients were used in a prediction analysis that also included age and gender. In study 4, MRI and symptoms data were collected at 2-3 days and at 3-7 months follow-up after MTBI in 19 patients. Global function was assessed at follow-up by use of the Rivermead Head Injury Follow-Up Questionnaire (RHIFUQ) and GOSE. Results: I. Most respondents reported no remaining symptoms but 24% reported ≥3 and 10% ≥7 remaining symptoms. The factor analysis demonstrated that all symptoms are correlated but also identified subgroups of symptoms. II. Rasch-analysis of RPQ showed disordered category function, local dependency of items, poor targeting of persons to items and indications of 3 or more dimensions. There was no differential item functioning. III. Head CT pathology with no need for acute intervention was observed in 52 patients (4%) but was not associated with either frequency of remaining symptoms or global outcome at 3 months post injury. Female gender and age over 30 years were associated with less favourable outcome with respect to symptoms and GOSE. IV. Post-acute MRI indicated trauma-related pathology in one patient and follow-up MRI indicated loss of brain volume in 4 patients. Conclusions: A substantial proportion of patients with MTBI report remaining problems at three months after MTBI. RPQ is useful but not optimal to assess symptoms outcome after MTBI and calculation of a total sum score is not recommended. Female gender and older age are negative prognostic factors while brain pathology according to CT has no effect on self-reported outcome. Loss of brain volume after MTBI according to MRI may be a sensitive marker of traumatic brain pathology and deserves further studies.

Objectives: After mild traumatic brain injury (mTBI), psychological factors can contribute to persisting post-concussion symptoms (PCS). Consistent with constructive theories of memory, negative expectations for increased symptoms after mTBI may contribute to misattributing symptoms to the mTBI and underestimating pre-injury symptoms, called the “good old days’ bias” (Gunstad & Suhr, 2001). The good old days’ bias is not thought to be a general retrospective recall bias but studies to date have largely not controlled for normative memory processes including those that lead to a biased, more positive recall of the past. Therefore, the current study examines whether there is a good old days’ bias after mTBI above and beyond normal memory biases. This study also examines how soon after mTBI the good old days’ bias affects recall of pre-injury symptoms in the first month after mTBI in adolescents as well as whether the good old days’ bias causes pre-injury symptom severity to be underestimated or if symptoms are entirely forgotten. Finally, the clinical significance of symptom recall biases is investigated. Method: The sample is 42 adolescents who sustained an mTBI (ages 13-18 years; 24 males) and 42 uninjured adolescents (ages 13-18 years; 24 males, ). The mTBI group rated current and retrospective post-concussion symptom ratings within one week and again, at one month, post-injury. The control group rated current and retrospective post-concussion symptoms at baseline and one month later. Cross-sectional and longitudinal comparisons using non-parametric statistical tests were used. Results: Wilcoxon signed-rank tests showed that, by one month post-mTBI, adolescents report fewer total, physical, and emotional pre-injury symptoms than they had reported within one week of their concussion. The control group did not demonstrate this good old days’ bias. There were no between-group differences in retrospective PCS ratings at either time point. Chi-square analyses found that the mTBI group was as likely as the control group to recall “no” pre-injury/past symptoms one month post-injury after having initially reported some pre-injury symptoms. Only four more adolescents were classified as “recovered” if their one-month PCS ratings were compared with pre-injury PCS ratings made within 1-week post-concussion rather than pre-injury ratings from 1-month post-injury. Discussion: There was mixed evidence for a good old days’ bias by one month post-concussion. This bias was not demonstrated in healthy adolescents, suggesting that the good old days’ bias is found specifically after concussion. During the acute post-injury period, the good old days’ bias may only be apparent by studying changes in concussed individuals’ own PCS ratings. The good old days’ bias leads to underestimating the severity of pre-injury symptoms rather than forgetting them entirely. The good old days’ bias does not greatly affect symptom recovery tracking by one month post-concussion. Future studies should directly examine expectations about concussion and their effect on current and retrospective symptom reporting. / Graduate / 2019-07-10

The primary aim of the present study was to evaluate the effectiveness of the intervention provided by Massey University Concussion Clinic for individuals following Mild Traumatic Brain Injury (MTBI). Concussion Clinics were set up across New Zealand to provide early intervention and assessment for individuals with MTBI to prevent long term complaints. Treatment outcomes at these clinics have not been empirically examined before. The current study compared the levels of post concussion symptoms, anxiety, depression, and psychosocial functioning between an intervention and a control group using a quasi-experimental design. In addition, reasons for nonattendance to the clinic, and participants’ perceptions of their recovery were also explored. The main outcome measures used were the Rivermead Postconcussion Symptoms Questionnaire, the Hospital Anxiety and Depression Scale, and the Sydney Psychosocial Reintegration Scale-2. Outcomes were initially assessed soon after injury or referral to the clinic and then three months later. Participants were recruited from the Palmerston North Hospital Emergency Department and the Massey University Concussion Clinic. With 20 participants in the intervention group and 15 in the control group, the main results showed that the Concussion Clinic intervention significantly decreased the level of anxiety and depression reported by participants in the intervention group over the control group. Greater improvements in post concussion symptoms and psychosocial functioning were also indicated in the intervention group. Additional findings suggest difficulty with transportation as a reason for nonattendance, which could be a potential barrier to recovery. Furthermore, participants highlighted the benefits of attending the service and its role in their recovery. Important issues relating to the referral processes were also identified. Findings of the current study suggest that the Concussion Clinic intervention is effective in improving recovery for those accessing the service. Nevertheless, these results must be interpreted with caution due to the small sample size. Further research is warranted to examine the effectiveness of the Concussion Clinics with larger samples, and the current study may serve as a valuable pilot for these future investigations.

Traumatic brain injuries are common (hospitalization incidence: 250-300 per 100.000 inhabitants/year) and a great majority of these injuries (80-85%) are classified as mild traumatic brain injury (MTBI/concussion). Many patients with MTBI (20-80%) suffer from subsequent persistent and often disabling symptoms. In previous studies serum levels of biochemical markers of brain tissue damage (S-100B and neuron-specific enolase, NSE) have been propounded to serve as predictors of persisting symptoms.In the present studies serum concentrations of S-100B, NSE and cortisol in acute phase and post-concussion symptoms, post-traumatic stress-related symptoms, disabilities and life satisfaction one year after the trauma, were investigated in 88 patients (53 men and 35 women) with MTBI. Serum concentrations of S-100B and NSE were also assessed in elite players (n=54) of typical contact sports (ice-hockey and soccer), which are known to be high risk activities with respect to head injury. Basketball players (n=18) were used as a control group. A majority of patients with MTBI showed higher serum concentrations of S-100B, NSE and cortisol on admission compared with a second blood sample obtained about 7 hours later (p<0.001 for all analyses). Sequelae were common one year after the injury. Postconcussion symptoms were encountered in 45 % of the patients, stress-related symptoms in 17 % and disabilities in 48 %, but only 3 patients (4 %) were on sick-leave on follow-up due to the head trauma. There was a statistically significant negative correlation between the total score of life satisfaction and the total score of disability (r= -0.514, p<0.001). Symptoms on admission (dizziness, nausea) and S-100B were statistically significantly associated with disabilities (p<0.024, multiple logistic regression analysis). Nausea on admission was also statistically significantly associated with life satisfaction (p=0.004). A statistically significant association was found only for S-100B with early (0-1 week postinjury, p=0.008) and only for cortisol with late (more than 52 weeks post-injury, p=0.022) post-traumatic stress-related symptoms. Concentrations of S-100B after game were statistically significantly increased in comparison with the levels before game (soccer, p<0.001; ice-hockey, p<0.001; basketball (p<0.001). Concentrations of NSE were only raised after soccer play (p<0.001). Increases in S-100-B (post-game minus pre-game values) were correlated to the number of jumps in basketball play (r=0.706, p=0.002). For soccer, increases in S-100B were correlated to the number of headers (r=0.428, p=0.02) and to the number of acceleration/deceleration events other than heading (r=0.453, p=0.02). The findings provide support for the idea that injury of brain tissue is involved in the genesis of persisting disabilities and long-term changes of life satisfaction in MTBI. Since S-100B increases in serum were correlated to the number of headers and since soccer play also increased serum levels of NSE (in contrast to ice hockey and basketball), it seems that heading may have an impact on brain tissue. The studies have also shown that ordinary playing of the team sports in question (i.e. soccer, ice hockey and basketball) increases S-100B serum concentrations, which has to be taken into consideration when S-100B is used for the detection of injury of brain tissue in sportsmen with acute/overt head trauma during sport practice. An analysis of the biochemical markers of brain damage (in particular S-100B) may be an additional source of valuable information in the management of patients and sportsmen with MTBI. S-100B also seems to be promising for the prediction of impairments and disabilities after MTBI.