Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score

Abstract

Background Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion. Methods and findings Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years (p^ = 0.54), bipolar disorder (p^ = 0.52), high pre-injury primary care visits per year (p^ = 0.46), personality disorders (p^ = 0.45), and anxiety and depression (p^ = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis. Conclusions In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual’s risk of requiring treatment more than 6 months post-concussion.

Correlation between Mild Traumatic Brain Injury-Induced Inflammatory Cytokines and Emotional Symptom Traits: A Systematic Review

“…A minority of patients, about 15–20%, recover slowly or not at all [ 3 , 4 , 5 ]. Almost all of these have depressive or anxiety symptoms [ 6 ].…”

“…Similar to concussed patients, systemic inflammation seems to be associated with psychological conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD) in the non-concussed population [ 28 , 29 , 30 ]. This led us to question whether the same inflammatory mediators were active in concussed patients and played a role in the genesis of post-concussion emotional impairments, particularly depression, anxiety, and PTSD, that are hallmarks of persistent post-concussion symptoms (PPCS) [ 6 ].…”

“…This study focuses on mTBI/concussions as they are the most common among all TBI subtypes [ 1 , 2 ]. Additionally, emotional symptoms are more predominant in this TBI subgroup [ 6 ]. We hypothesize that the inflammatory cytokines seen in mTBI patients with emotional symptoms would coincide with those commonly seen in patients with emotional symptoms without mTBI.…”

The Role of Reported Affective Symptoms and Anxiety in Recovery Trajectories After Sport-Related Concussion

“…46 Moreover, in a study of adults with concussions seen by a primary care physician or emergency department, premorbid psychiatric conditions (eg, depression and anxiety) were a predictor of longer recovery, along with older age, comorbid personality disorders, and preinjury health care utilization. 27 Similarly, pediatric patients, aged 12 to 18 years, with preexisting emotional distress (eg, depression and anxiety) exhibited longer symptom resolution relative to patients without a history of depression or anxiety. 39 Importantly, the authors also reported that girls and women experienced longer recovery times as well as higher percentages of preexisting anxiety compared with men.…”

Post-Concussion Syndrome Latent Onset Related to Intracranial Lesion on Head Injury Patient in Dr. M. Djamil General Hospital Padang

“…Studies report that more than half of people with PCS still have symptoms more than 1 year after the injury. 10,11 PCS usually disappears within 2-4 weeks but some studies have found PCS last more than 6 months (latent onset). Another study states that PCS may be permanent if recovery has not occurred within 3 years.…”