Identifying Persistent Postconcussion Symptom Risk in a Pediatric Sports Medicine Clinic

Abstract

Background: Although most children report symptom resolution within a month of a concussion, some patients experience persistent postconcussion symptoms (PPCS) that continues for more than 1 month. Identifying patients at risk for PPCS soon after an injury can provide useful clinical information. Purpose: To determine if the Predicting Persistent Post-concussive Problems in Pediatrics (5P) clinical risk score, an emergency department (ED)–derived and validated tool, is associated with developing PPCS when obtained in a primary care sports concussion setting. Study Design: Cohort study; Level of evidence, 3. Methods: We conducted a study of patients seen at a pediatric sports medicine concussion clinic between May 1, 2013, and October 1, 2017, who were <19 years of age and evaluated within 10 days of a concussion. The main outcome was PPCS, defined as symptoms lasting >28 days. Nine variables were used to calculate the 5P clinical risk score, and we assessed the association between the 5P clinical risk score and PPCS occurrence. The secondary outcome was total symptom duration. Results: We examined data from 230 children (mean age, 14.8 ± 2.5 years; 50% female; mean time from injury to clinical assessment, 5.6 ± 2.7 days). In univariable analyses, a greater proportion of those who developed PPCS reported feeling slowed down (72% vs 44%, respectively; P < .001), headache (94% vs 72%, respectively; P < .001), sensitivity to noise (71% vs 43%, respectively; P < .001), and fatigue (82% vs 51%, respectively; P < .001) and committed ≥4 errors in tandem stance (33% vs 7%, respectively; P < .001) than those who did not. Higher 5P clinical risk scores were associated with increased odds of developing PPCS (adjusted odds ratio [OR], 1.62 [95% CI, 1.30-2.02]) and longer symptom resolution times (β = 8.40 [95% CI, 3.25-13.50]). Among the individual participants who received a high 5P clinical risk score (9-12), the majority (82%) went on to experience PPCS. The area under the curve for the 5P clinical risk score was 0.75 (95% CI, 0.66-0.84). After adjusting for the effect of covariates, fatigue (adjusted OR, 2.93) and ≥4 errors in tandem stance (adjusted OR, 7.40) were independently associated with PPCS. Conclusion: Our findings extend the potential use for an ED-derived clinical risk score for predicting the PPCS risk into the sports concussion clinic setting. While not all 9 predictor variables of the 5P clinical risk score were independently associated with the PPCS risk in univariable or multivariable analyses, the combination of factors used to calculate the 5P clinical risk score was significantly associated with the odds of developing PPCS. Thus, obtaining clinically pragmatic risk scores soon after a concussion may be useful for early treatments or interventions to mitigate the PPCS risk.

Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines

“…75,[81][82][83] History of prior mTBI(s) 75,76,84,85 and typical intracranial abnormalities on day-ofinjury CT (eg, subdural hematoma) 76,86 have been inconsistent predictors of clinical outcome. The more symptoms a patient has soon after mTBI, the more symptoms they tend to have weeks and months later 81,[83][84][85] In adults, preinjury mental health problems and postinjury psychological distress (symptoms of depression and anxiety) are robust predictors of prolonged recovery. 76,81,83,85,87 Treatment Early clinical management.…”

Pediatric Post‐Traumatic Headache and Implications for Return to Sport: A Narrative Review

“…According to one group, there are 9 “clinical risks” associated with persistent post‐concussive symptoms in pediatrics: being a teenage female, having a prior prolonged recovery from a previous mTBI, a higher somatic symptom score post‐injury (including headache, sensitive to noise, fatigue, and cognitive slowing) and/or >4 errors on the balance error scoring system (BESS) 14,120 . A further study suggested that it is likely a constellation of factors, including a history of mood disorders, prior mTBI, and delayed symptom onset (possibly a marker of maladaptive coping), that leads to an increased risk for both PPTH and persistent PCS 24 .…”

Clinical predictors of symptom resolution for children and adolescents with sport-related concussion

“…28 Recent work has indicated that postural instability, defined as more than three errors during the tandem stance of the BESS test, is associated with prolonged symptom duration in patients seen in both the ED and sports medicine clinic settings. 20,44 In addition to postural instability assessment, the Romberg test may also serve as a method to determine if patients are exaggerating their postinjury deficits in a manner that reflects balance dysfunction. 42 The idea that some youths may exaggerate or feign symptoms after concussion has been studied in the context of neuropsychological testing and symptom reporting, 1,7,26 but it has not received substantial attention with regard to postural stability tests.…”

“…44 In addition, recently investigators applied this approach to the sports medicine setting and were able to successfully identify those patients at risk for persistent symptoms. 20 A particularly vulnerable time in life for developing persistent symptoms after a concussion is the teenage years, during which girls may carry a higher risk than boys. 22 Several other noninjury factors that have been associated with concussion recovery time include previous concussions, attention-deficit/hyperactivity disorder (ADHD), learning disability, prior psychiatric history, and migraine history.…”