Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population

Abstract

; for the Pediatric Emergency Research Canada (PERC) Concussion Team IMPORTANCE The natural progression of symptom change and recovery remains poorly defined in children after concussion. OBJECTIVES To describe the natural progression of symptom change by age group (5-7, 8-12, and 13-18 years) and sex, as well as to develop centile curves to inform families about children after injury recovery. DESIGN, SETTING, AND PARTICIPANTS Planned secondary analysis of a prospective multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics). The setting was 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Participants were aged 5 to 18 years with acute concussion, enrolled from August 1, 2013, to May 31, 2015, and data analyses were performed between January 2018 and March 2018. EXPOSURES Participants had a concussion consistent with the Zurich Consensus Statement on Concussion in Sport diagnostic criteria and 85% completeness of the Postconcussion Symptom Inventory (PCSI) at each time point. MAIN OUTCOMES AND MEASURES The primary outcome was symptom change, defined as current rating minus preinjury rating (delta score), at presentation and 1, 2, 4, 8, and 12 weeks after injury, measured using the PCSI. Symptoms were self-rated for ages 8 to 18 years and rated by the child and parent for ages 5 to 7 years. The secondary outcome was recovery, defined as no change in symptoms relative to current preinjury PCSI ratings (delta score = 0). Mixed-effects models incorporated the total score, adjusting for random effects (site and participant variability), fixed-effects indicators (age, sex, time, age by time interaction, and sex by time interaction), and variables associated with recovery. Recovery centile curves by age and sex were computed. RESULTS A total of 3063 children (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 60.7% male) completed the primary outcome; 2716 were included in the primary outcome analysis. For the group aged 5 to 7 years, symptom change primarily occurred the first week after injury; by 2 weeks, 75.6% of symptoms had improved (PCSI change between 0 and 2 weeks, −5.3; 95% CI, −5.5 to −5.0). For the groups aged 8 to 12 years and 13 to 18 years, symptom change was prominent the first 2 weeks but flattened between 2 and 4 weeks. By 4 weeks, 83.6% and 86.2% of symptoms, respectively, had improved for the groups aged 8 to 12 years (PCSI change between 0 and 4 weeks, −9.0; 95% CI, −9.6 to −8.4) and 13 to 18 years (PCSI change between 0 and 4 weeks, −28.6; 95% CI, −30.8 to −26.3). Sex by time interaction was significant only for the adolescent group (β = 0.32; 95% CI, 0.21-0.43; P < .001). Most adolescent girls had not recovered by week 12. CONCLUSIONS AND RELEVANCE Symptom improvement primarily occurs in the first 2 weeks after concussion in children and in the first 4 weeks after concussion in preadolescents and male adolescents. Female adolescents appear to have protracted recovery. The derived recovery curves may be usef...

Default mode network anatomy and function is linked to pediatric concussion recovery

“…Although grey matter and intra-regional connectivity values did not indicate gender-specific associations, the negative association between inter-regional FC and sleep disturbances was driven by females. This association, along with the fact that females reported higher levels of sleep-related symptoms compared to males, is in line with the suggestion that concussed females are more sensitive to sleep difficulties and have protracted recovery patterns 8,51 .…”

“…Predicting the recovery trajectory of a child with PPCS is encumbered by the high interindividual variability in symptoms, age, gender, and pre-morbid characteristics 8 . Our findings showed that the inter-individual variability of PPCS recovery in children is linked to variations in brain indices that are indexed by relatively simple clinical scores of sleep disturbance and fatigue.…”

“…There are several PPCS phenotypes with the commonest symptoms being headaches, fatigue, sleep disturbances and cognitive difficulties 6 . These symptoms have a detrimental impact on health-related quality of life and long-term outcomes [7][8][9] .…”

“…Moreover, the association between brain changes linked to mTBI, PPCS, and clinical outcomes remains to be proven. On the basis of existing evidence, individual prediction of PPCS recovery may be achievable by examining changes in brain anatomy and function of the DMN following mTBI/concussion 8 .…”

The symptom experience of adolescents with concussion

“…For example, adolescents are more likely to report symptoms for longer periods of time after their concussion than adults (Purcell, Harvey, & Seabrook, 2016). Most adults recover within 10-14 days compared to adolescents who take an average of 1 month to recover (Henry, Elbin, Collins, Marchetti, & Kontos, 2016;Ledoux et al, 2019). In addition to an extended recovery period, the management of their concussion symptoms is somewhat different.…”