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PubMed1977

Experimental head injury in the rat. Part 1: Mechanics, pathophysiology, and morphology in an impact acceleration trauma model.

Impact acceleration was used to elicit cerebral concussion in the albino rat. The pathophysiological response and morphological damage from the concussion were studied in groups of animals. The animals were grouped according to impact velocity (6-11 m/sec), and the threshold and different degrees of the concussive response were established. The concept of concussion as primarily a neuronal, functional disturbance was confirmed. However, this reaction was readily influenced by respiratory and circulatory changes, and morphological damage. Defined reactions could be elicited in groups of animals according to impact velocity. Thus, the model appeared well standardized for further studies of concussion pathophysiology, expressed in terms of cerebral energy metabolism and blood flow.

Acceleration↗
PubMed2006

The effect of visors on head and facial injury in National Hockey League players.

There has been an increase in the number of concussions sustained by players in the National Hockey League (NHL). While wearing a helmet is now required by the NHL, the face visor remains optional. It is unknown to what degree face visors influence concussion, other head injury and eye-injury rates at the professional level. Data from the 2001-2002 NHL season were examined. It was found that wearing a face visor did not significantly influence the prevalence of concussion. Visor protection did, however, minimise eye-injuries and other, non-concussion head injuries. These data suggest that, while a visor may prevent some head and eye-injuries, other measures may be necessary to reduce the number of concussions.

Craniocerebral Trauma↗
PubMed2007

Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage.

BACKGROUND: Trauma patients without intracranial hemorrhage or focal neurologic deficits are typically considered low risk for lasting neuropsychological and emotional deficits, and such sequela may be overlooked, especially in those with skull fractures and concussions. We undertook this study to determine the prevalence of and risk factors for persistent cognitive impairment and emotional and functional difficulties in a sample of adult trauma intensive care unit survivors without intracranial hemorrhage. METHODS: We queried the Vanderbilt University Trauma Registry for all patients admitted during 2003 with an Injury Severity Score >25 and a head computed tomography scan showing no intracranial hemorrhage. Of the 97 patients identified, 58 were evaluated, in person between 12 to 24 months after hospital discharge, with a comprehensive battery of cognitive, emotional, and functional instruments. The Informant Questionnaire of Cognitive Decline in the Elderly-Short Form (IQCODE-SF) was used to evaluate for pre-existing cognitive deficits in patients suspected of having cognitive impairment before their trauma. RESULTS: A total of 33 (57%) patients were determined to have cognitive impairment, which was most pronounced in the domains of attention and executive functioning/verbal fluency. Of these patients, one (3%) was determined by the IQCODE-SF to be cognitively impaired before trauma intensive care unit hospitalization. Of the 58 patients studied, 21 (36.2%) had a concussion or skull fracture and 37 (63.8%) had neither. Cognitive impairment was significantly more likely to occur in patients who sustained a concussion or skull fracture than in trauma patients who did not (81% versus 43%; p = 0.006). Patients reported significant depressive symptoms (56%), significant symptoms of posttraumatic stress disorder (38%), and significant symptoms of anxiety (29%). Quality of life scores were lower than in the general United States population and employment difficulties were widespread. A total of 34% of patients reported being unemployed at follow-up, and cognitive impairment was more common among these patients compared with patients in the workforce (p = 0.03). Neither cognitive impairment nor emotional dysfunction was associated with age, sex, race, Injury Severity Score, blood loss, ventilatory days, or intramedullary nailing of long-bone fractures. CONCLUSIONS: The majority of trauma survivors without intracranial hemorrhage display persistent cognitive impairment, which is nearly twice as likely in those with skull fractures or concussions. This cognitive impairment was associated with functional defects, poor quality of life, and an inability to return to work. Future research must delineate modifiable risk factors for these poor outcomes, especially in patients with skull fractures and concussions, to help improve long-term cognitive and functional status.

Activities of Daily Living↗
PubMed2003

Cognitive dysfunction in young men following head injury in childhood and adolescence: a population study.

OBJECTIVES: To examine the prevalence of cognitive dysfunction among young men who had suffered a head injury during childhood or adolescence, in particular focusing upon the effects of age and the severity of the injury. METHODS: By cross linkage of Danish national registers for hospital admissions and the draft board, 3091 young men were identified who had been injured before age 18 and tested at age 18 or shortly thereafter: 970 had suffered a single concussion and were in hospital for one day only; 521 had two concussions at separate times and were in hospital for one day only on each occasion; 961 had a cranial fracture; and 639 had a cerebral lesion. For all of these, scores on the draft board's cognitive screening test were obtained, dichotomised as dysfunctional or non-dysfunctional. Prevalences of dysfunctional scores were compared with population base rates (about 20% of all Danish men appearing before the draft board had a score classified as dysfunctional). RESULTS: For young men who had suffered a single concussion, cranial fracture, or cerebral lesion before 12 years of age, resulting in less than 12 days of hospital admission (n = 376), rates of cognitive dysfunction did not exceed those in the general population (odds ratios < 1.4, NS), but the odds ratios became significant and > 1.4 where the injury occurred after age 11. For those with a cerebral lesion resulting in over 11 days of hospital admission (n = 263), all odds ratios were significant and >or= 2.0, irrespective of age at injury. For cases of two concussions, all odds ratios were > 1.4 but were not significant for all age groupings. CONCLUSIONS: For milder forms of single head injury before age 12 there is no evidence of enduring cognitive dysfunction. The apparent effect at later ages may reflect predisposing psychosocial factors. For more serious injury, and for cases with two concussions, the effect is marked and not clearly related to age. For the former, this suggests enduring neurological effects of the injury; for the latter, where the effect is unrelated to time between injuries, predisposing factors may again play a role.

Adolescent↗
PubMedDate not supplied

Head and neck injuries among ice hockey players wearing full face shields vs half face shields.

CONTEXT: Speculation exists that use of a full face shield by ice hockey players may increase their risk of concussions and neck injuries, offsetting the benefits of protection from dental, facial, and ocular injuries, but, to our knowledge, no data exist regarding this possibility. OBJECTIVE: To determine the risk of sustaining a head or neck injury among intercollegiate ice hockey players wearing full face shields compared with those wearing half shields. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study conducted during the 1997-1998 Canadian Inter-University Athletics Union hockey season of 642 male hockey players (mean age, 22 years) from 22 teams. Athletes from 11 teams wore full face shields and athletes from 11 teams wore half face shields during play. MAIN OUTCOME MEASURE: Reportable injury, defined as any event requiring assessment or treatment by a team therapist or physician or any mild traumatic brain injury or brachial plexus stretch, categorized by time lost from subsequent participation and compared by type of face shield. RESULTS: Of 319 athletes who wore full face shields, 195 (61.6%) had at least 1 injury during the study season, whereas of 323 who wore half face shields, 204 (63.2 %) were injured. The risk of sustaining a facial laceration and dental injury was 2.31 (95% confidence interval [CI], 1.53-3.48; P<.001) and 9.90 (95% CI, 1.88-52.1; P = .007) times greater, respectively, for players wearing half vs full face shields. No statistically significant risk differences were found for neck injuries, concussion, or other injuries, although time lost from participation because of concussion was significantly greater in the half shield group (P<.001), than in the group wearing full shields. CONCLUSIONS: These data provide evidence that the use of full face shields is associated with significantly reduced risk of sustaining facial and dental injuries without an increase in the risk of neck injuries, concussions, or other injuries.

Adult↗
PubMed2003

Delayed-onset deficits in verbal encoding strategies among patients with mild traumatic brain injury.

Knowledge obtained from longitudinal animal models was used to predict the course of verbal memory deficits in 19 concussed patients and 19 control patients who were given versions of the Hopkins Verbal Learning Test--Revised at 2 hr, 48 hr, and 1 week postconcussion. The physiological literature suggests that concussed patients should exhibit a decline in performance from 2 hr to 48 hr postconcussion on a measure of complex memory strategies. Consistent with this hypothesis, mixed-factor analysis of covariance revealed that concussed patients used less semantic clustering strategies than control patients at 48 hr postconcussion, whereas minimal differences were found at 2 hr postinjury. Furthermore, a chi-square analysis showed that a significant number of concussed patients experienced a decline in the number of semantic clusters they used from 2 hr to 48 hr. No differences were found between the groups at the 1-week testing session.

Adult↗
PubMed2000

Disability pensions in relation to traumatic brain injury: a population study.

From a Danish national register of hospitalizations, all patients were identified who had a discharge diagnosis of traumatic brain injury between the years 1979-1993 inclusive, at ages 18-66 years inclusive. These were classified as having suffered either a concussion (n = 74,398), a cranial fracture (n = 4,452) or a cerebral contusion (n = 8,141). Patients in each of these groups were then checked in annual registers of disability pension awards between 1979-1995. Disability pensions had been awarded to 16% of the concussion group, 18% of the fracture group, and 33% of the contusion group. Date of application, grounds for the application, and the pension level awarded were noted. Analysis of the date of application for the disability pension revealed that in all groups a high proportion of the pension applications had been made prior to the injury. Among the concussion group, the pension award appeared to be independent of the injury itself. Rather, being awarded a disability pension appeared to be related to conditions which themselves are risk factors for a traumatic brain injury, e.g. chronic skeletomuscular disease and psychiatric disorders including alcoholism. Comparison with population statistics revealed that the relative risk of being assigned a low or intermediate disability pension is markedly elevated among the concussion group, especially at younger ages and among males. For the fracture and contusion groups, a clear post-injury elevation in rate was detectable, especially for highest level pensions.

Adolescent↗
PubMed2000

The clinical value of serum S-100 protein measurements in minor head injury: a Scandinavian multicentre study.

PURPOSE: This study of patients with minor head injury was designed to investigate the relation of S-100 protein measurements to computed tomograpy (CT) findings and patients outcomes. Increased serum levels of this protein were hypothetized to predict intracranial pathology and increased frequency of post-concussion symptoms. METHODS: One hundred and eighty-two patients were studied with Glasgow Coma Scale scores of 13-15. The study recruited patients from three Scandinavian neurotrauma centres. Serum levels of S-100 protein were measured at admittance and CT scans of the brain were obtained within 24 hours postinjury in all patients. Outcome was evaluated with the Rivermead Postconcussion Symptoms Questionnaire (RPQ) 3 months after the injury. RESULTS: Increased serum level of S-100 protein was detected in 69 (38%) patients, and CT scan demonstrated intracranial pathology in 10 (5%) (brain contusion in seven, epidural haematoma in two, traumatic subarachnoid haemorrhage in one). The proportion of patients with detectable serum level was significantly (p < 0.01) higher among those with intracranial pathology (90%) compared to those without (35%). The negative predictive value of an undetectable S-100 level was 0.99. Sixty-two per cent reported one or more post-concussion symptoms at follow-up. A trend was observed towards an increased frequency of post-concussion symptoms among patients with detectable serum levels. CONCLUSIONS: Undetectable serum level of S-100 protein predicts normal intracranial findings on CT scan. Determination of S-100 protein in serum may be used to select patients for CT scanning. Increased S-100 serum levels may be more related to post-concussion symptoms caused by mild traumatic brain injury than to symptoms of psychological origin.

Adolescent↗
PubMed2001

Focal cerebral hyperemia in postconcussive amnesia.

Transient amnesia caused by minor head injury is commonly encountered in daily neurosurgical practice, but the mechanism of such amnesia has not been extensively studied. We measured the regional cerebral blood flow (rCBF) of patients with postconcussive amnesia with Xe/CT CBF to examine whether a focal disturbance of CBF exists. The Xe/CT CBF study was performed in eight patients with closed head injury without organic cerebral lesion while they were suffering from posttraumatic amnesia (concussion group). The time interval between accident and CBF measurement was less than 2 h in three patients, 5-6 h in two, 8-9 h in two, and 18 in one. The results were compared with those of nine normal volunteers and eight other age-matched patients who recovered without any neurological deficit despite the presence of hemorrhagic regions (mild hemorrhage group). The rCBF of the concussion group was significantly elevated in the bilateral mesial temporal cortex in comparison to the normal group. The rCBF in the mild hemorrhage group was lower than that of normal controls in all regions. The analysis of right-left difference in CBF indicated that there was significant asymmetry (right > left) in the frontal and temporal cortex in the concussion group, but not in the normal and mild hemorrhage group. This Xe/CT CBF study in acute stages of cerebral concussion, in which patients were amnestic, detected focal cerebral hyperemia. Such hyperemia in regions closely related to human memory function may be the result of vasoparalysis or the compensatory activation of memory circuits after denervation injury.

Adolescent↗
PubMed1986

Metabolic and neurophysiologic sequelae of brain injury: a cholinergic hypothesis.

This paper reviews a number of lines of evidence developed in our laboratories indicating that at least some components of neurologic disturbances following concussion may be attributable to increased functional activity of cholinergic systems located within specific brain regions. These lines of evidence include EEG studies indicating that disruption of the reticular activating system is not necessary for production of a reversible, flaccid, comatose state following low levels of concussion, systematic transection studies indicating that regions bounded by collicular and midpontine transections may contribute to at least motor components of the behavioral suppression associated with concussion, local rates of glucose utilization following fluid percussion injury increase in restricted areas bounded by collicular and midpontine transections; microinjection of carbachol (but not tetracaine) into these hypermetabolic regions produced behavioral suppression and electroencephalographic changes resembling those following concussion, systemic administration or microinjections of atropine, but not mecamylamine, antagonized the behavioral effects of carbachol, and data indicating that pharmacologic blockage of muscarinic cholinergic systems can attenuate neurologic deficits. Taken in conjunction with data from earlier clinical and laboratory studies, our research also indicates that anticholinergic therapy may potentially benefit head-injured patients.

Animals↗
PubMed2001

Case report of sudden death after a blow to the back of the neck.

A 13-year-old girl experienced a fall during gym class that caused immediate unresponsiveness and death. The lone witness reported that the decedent lost her balance as she approached a hurdle and fell, striking her head on a crossbar of the hurdle near the ground. Autopsy revealed no external injury. Internal injury that could be demonstrated anatomically was confined to a contusion within the right semicapitis muscle at the base of the skull. In the absence of an anatomic cause of death, possible explanations of the death include a cardiac dysrhythmia, a vasovagal stimulus, and diffuse axonal injury caused by a concussive force to the junction of the medulla and spinal cord. Animal studies have shown that severe concussion can cause death via profound autonomic dysfunction without leaving anatomic evidence of injury, and that the essential component of concussion is an element of rotational injury to the brain. The authors believe that the blow to the neck caused this death by the transmission of a concussive force through the reticular activating system. The prompt work of police in distinguishing the lone witness from several people in the area who thought they knew what had happened was essential for diagnosis. On reaching our conclusions, the authors notified first the family, then the superintendent of the school system, and finally the news media. The authors told each party in turn that they would be contacting the others.

Accidental Falls↗
PubMed2003

Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention.

OBJECTIVE: To identify the prevalence of head injuries and related symptoms among college athletes and examine knowledge of head injury consequences and behavioral tendencies of athletes in the presence of symptoms. DESIGN: Retrospective survey. PARTICIPANTS: A total of 461 male and female athletes beginning competitive play at the University of Akron (Akron, OH) during the years 1995 to 2001. MAIN OUTCOME MEASURES: Responses to survey questions were analyzed to determine the frequency of concussions and injury-related symptoms (eg, dizziness, headache, nausea or vomiting) in addition to behavioral responses in the presence of certain symptoms (eg, playing with headache, failure to report symptoms while playing). Written responses to queries regarding symptom knowledge were analyzed for thematic content and were used to identify deficiencies in signs and symptoms of concussion. RESULTS: Nearly 32% of all athletes had experienced a blow to the head causing dizziness, with over 1/4 confirming various somatic symptoms following a blow to the head (eg, seeing stars, nausea or vomiting, head pain). Continuing to play despite symptom presence was noted (eg, dizziness, 28.2%; headache, 30.4%), with 19.5% reporting a concussion diagnosis. Knowledge of head injury consequences was found to be deficient, with 56% indicating no knowledge of the possible consequences following a head injury. Of those providing responses, the majority reflected awareness of cognitive (eg, memory problems) and physical (eg, brain damage) consequences. CONCLUSIONS: A sizable number of athletes may enter collegiate play with a previous concussion diagnosis, and many more are likely to have experienced symptoms suggestive of a mild head injury. Of considerable concern is the tendency to play while symptomatic (eg, headache, dizziness) and the failure to report symptoms while playing--especially among football players (25.2%). The apparent deficiency in athlete knowledge of head injury consequences raises concern regarding athlete recognition of potentially problematic symptoms and represents an important area for educational intervention.

Athletic Injuries↗
PubMed2004

Head injuries presenting to emergency departments in the United States from 1990 to 1999 for ice hockey, soccer, and football.

STUDY OBJECTIVE: To examine the number and rates of head injuries occurring in the community as a whole for the team sports of ice hockey, soccer, and football by analyzing data from patients presenting to US emergency departments (EDs) from 1990 to 1999. DESIGN: Retrospective analysis. MAIN OUTCOME MEASURES: Data compiled for the US Consumer Product Safety Commission using the National Electronic Injury Surveillance System were used to generate estimates for the total number of head injuries, concussions, internal head injuries, and skull fractures occurring on a national level from the years 1990 to 1999. These data were combined with yearly participation figures to generate rates of injuries presenting to the ED for each sport. RESULTS: There were an estimated 17,008 head injuries from ice hockey, 86,697 from soccer, and 204,802 from football that presented to US EDs from 1990 to 1999. The total number of concussions presenting to EDs in the United States over the same period was estimated to be 4820 from ice hockey, 21,715 from soccer, and 68,861 from football. While the rates of head injuries, concussions, and combined concussions/internal head injuries/skull fractures presenting to EDs per 10,000 players were not always statistically similar for all 3 sports in each year data were available, they were usually comparable. CONCLUSION: While the total numbers of head injuries, concussions, and combined concussions/skull fractures/internal head injuries presenting to EDs in the United States are different for ice hockey, soccer, and football for the years studied, the yearly rates for these injuries are comparable among all 3 sports.

Athletic Injuries↗
PubMed2006

A latent class analysis of injury patterns among rear-seated, seat-belted children.

BACKGROUND: The objective of the study was to determine the constellation of injury patterns in rear-seated, seat-belt-restrained children using data-driven latent class methodology novel to injury prevention research. METHODS: A cross-sectional probability sample of rear-seated, belt-restrained children aged 5 to 15 years in crashes was obtained via insurance claims records and a telephone survey. Eight body regions of AIS 2 or greater injury (concussion, nonconcussive head injury, face, chest, abdomen, neck/spine/back, upper extremity, lower extremity) were determined, and a latent class model was fit to determine whether underlying "injury clusters" were present. RESULTS: A three-class model appears to best fit to observed data: an "abdominal/spine" cluster that contained 11% of the population, a "concussion" cluster that contained 56% of the population, and a residual "mixture" cluster that contained the remaining 33% of the population. When compared with the mixture cluster, the abdomen/spine cluster was associated with 4 to 8 year old children, lap-only belt restraint, frontal impacts, and minivans. The concussion cluster was also more common among 4 to 8 and 9 to 12 year olds, with side or rear impact crashes, and with pickup trucks. CONCLUSIONS: Latent class analysis allows injury clusters to be estimated from the data, not predetermined by the investigator, and suggests that distinct mechanisms of abdominal injury and concussive head injury exist in a population-based sample of children in motor vehicle crashes.

Abdominal Injuries↗
PubMed1992

Early and late outcome in head injury patients with radiological evidence of brain damage.

This study examined the early and late outcome in head injury patients with focal or multifocal (unilateral or bilateral) brain contusions revealed by computerized tomography (CT) scanning. The outcome was also evaluated in patients hospitalized due to brain concussion. Three months after the injury (the early outcome) 43% of the 86 cases with multifocal contusions on the CT scan were dead. As evaluated by the Glasgow Outcome Scale, all the 57 patients with a focal brain contusion, as well as the 117 cases with brain concussion, made a good recovery or were moderately disabled. The late outcome (1 to 5 years after injury) was evaluated in 78 cases with brain contusion and in 85 cases with brain concussion, and revealed that complaints and impaired adaptive functioning were frequent in both the contusion and concussion group. The occurrence of headache, dizziness and sleep problems did not significantly differ among the various head injury groups. However, focal or multifocal brain contusions on the CT scan increased the frequency of impaired memory, impaired concentration, speech problems, weakness in arms or legs and seizures with loss of consciousness. Cognitive deficits and speech problems were particularly common in patients with a focal contusion in the temporal lobe. The late adaptive and social functioning were most markedly impaired in cases with multifocal bilateral contusions.

Adolescent↗
PubMed2005

Biomechanical investigation of head impacts in football.

OBJECTIVES: This study sought to measure the head accelerations induced from upper extremity to head and head to head impact during the game of football and relate this to the risk of mild traumatic brain injury using the Head Impact Power (HIP) index. Furthermore, measurement of upper neck forces and torques will indicate the potential for serious neck injury. More stringent rules or punitive sanctions may be warranted for intentional impact by the upper extremity or head during game play. METHODS: Game video of 62 cases of head impact (38% caused by the upper extremity and 30% by the head of the opposing player) was provided by F-MARC. Video analysis revealed the typical impact configurations and representative impact speeds. Upper extremity impacts of elbow strike and lateral hand strike were re-enacted in the laboratory by five volunteer football players striking an instrumented Hybrid III pedestrian model crash test manikin. Head to head impacts were re-enacted using two instrumented test manikins. RESULTS: Elbow to head impacts (1.7-4.6 m/s) and lateral hand strikes (5.2-9.3 m/s) resulted in low risk of concussion (<5%) and severe neck injury (<5%). Head to head impacts (1.5-3.0 m/s) resulted in high concussion risk (up to 67%) but low risk of severe neck injury (<5%). CONCLUSION: The laboratory simulations suggest little risk of concussion based on head accelerations and maximum HIP. There is no biomechanical justification for harsher penalties in this regard. However, deliberate use of the head to impact another player's head poses a high risk of concussion, and justifies a harsher position by regulatory bodies. In either case the risk of serious neck injury is very low.

Acceleration↗
PubMed2001

Effectiveness of headgear in a pilot study of under 15 rugby union football.

OBJECTIVE: To determine whether protective headgear reduced the incidence of concussion in a pilot study of under 15 rugby union. METHODS: Sixteen under 15 rugby union teams were recruited from three interschool competitions in metropolitan Sydney and the adjacent country region. A prospective study was undertaken over a single competitive season. The study had two arms: a headgear arm and a control arm. Headgear wearing rates and injury data were reported to the investigators and verified using spot checks. RESULTS: A total of 294 players participated in the study. There were 1179 player exposures with headgear and 357 without headgear. In the study time frame, there were nine incidences of concussion; seven of the players involved wore headgear and two did not. There was no significant difference between concussion rates between the two study arms. CONCLUSIONS: Although there is some controversy about the desirability of wearing protective headgear in football, this pilot study strongly suggests that current headgear does not provide significant protection against concussion in rugby union at a junior level.

Adolescent↗
PubMed1998

Routine follow up after head injury: a second randomised controlled trial.

OBJECTIVE: To confirm that patients admitted to hospital with a head injury benefit from a routinely offered early intervention service. PATIENTS AND METHODS: A mixed rural and urban Health District of 560000 people with two accident and emergency departments provided the setting. Existing routine services for most patients with head injury are minimal. All patients aged 16-65 years admitted to hospital after a head injury of any severity, with or without other injuries entered the trial. Prospective randomisation, with a block randomisation procedure was used to allocate all eligible patients to either: a group offered an additional service by a specialist team; or a group receiving existing standard services. Patients were assessed at follow up six months after injury. The primary outcome measure was the Rivermead head injury follow up questionnaire, a validated and reliable measure of social disability. The Rivermead post-concussion symptoms questionnaire was used to estimate severity of post-concussion symptoms. Each patient in the trial group was contacted 7-10 days after injury, and offered assessment and interventions as needed. These initially focused on the provision of information, support, and advice. Forty six per cent of patients in the trial group also received further outpatient intervention or additional support by telephone. RESULTS: 314 patients were registered: 184 were randomised into the trial group, 130 into the control group. For prognostic data, the groups were comparable at randomisation, and remained comparable when assessed at six months. 132 trial and 86 control patients were followed up at six months after injury. Patients' posttraumatic amnesia ranged from mild (n=79, 40%), and moderate (n=62, 32%), to severe (n=38, 19%) and very severe (n=17, 9%). The trial group patients had significantly less social disability (p=0.01) and significantly less severe post-concussion symptoms (p=0.02) at follow up at six months after injury than the control group patients. CONCLUSIONS: The early interventions offered by a specialist service significantly reduced social morbidity and severity of post-concussion symptoms in trial group patients at six months after head injury. Recommendations about how specialist services should be targeted are made both in the light of these results and those from a previous randomised controlled trial.

Adolescent↗