Prognosticators of Persistent Symptoms Following Pediatric Concussion

Zemek, Roger; Farion, Ken; Sampson, Margaret; McGahern, Candice

doi:10.1001/2013.jamapediatrics.216

Cited by 200 publications

(137 citation statements)

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“…Unfortunately, heterogeneity in study populations, definitions, follow-up, and clinical end points make it difficult to facilitate direct comparisons between studies. 48 Together, these studies suggest that 21%-59% of pediatric patients presenting with acute concussion or mTBI develop symptoms lasting longer than 1 month. 4,5,19,35,46 Clinical variables associated with development of PCS and prolonged recovery in these studies include adolescent age (11-18 years), presence of headache, hospital admission, 4 and initial symptom severity score.…”

Section: Discussionmentioning

confidence: 90%

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Ellis

Cordingley

Vis

et al. 2015

PED

145

130

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OBJECT The objective of this study was 2-fold: 1) to examine the prevalence of vestibulo-ocular dysfunction (VOD) among children and adolescents with acute sports-related concussion (SRC) and postconcussion syndrome (PCS) who were referred to a multidisciplinary pediatric concussion program; and 2) to determine if VOD is associated with the development of PCS in this cohort. METHODS The authors conducted a retrospective review of all patients with acute SRC (presenting 30 days or less postinjury) and PCS (3 or more symptoms for at least 1 month) referred to a multidisciplinary pediatric concussion program between September 2013 and July 2014. Initial assessment included clinical history, physical examination, and Post-Concussion Symptom Scale assessment. Patients were also assessed for VOD, which was defined as more than one subjective vestibular and oculomotor complaint (dizziness, blurred vision, and so on) and more than one objective physical examination finding (abnormal smooth pursuits, saccades, vestibulo-ocular reflex, and so on). This study was approved by the local institutional ethics review board. RESULTS A total of 101 patients (mean age 14.2 years, SD 2.3 years; 63 male and 38 female patients) participated, including 77 (76.2%) with acute SRC and 24 (23.8%) with PCS. Twenty-two of the 77 patients (28.6%) with acute SRC and 15 of the 24 (62.5%) with PCS met the clinical criteria for VOD. The median duration of symptoms was 40 days (interquartile range [IQR] 28.5–54 days) for patients with acute SRC who had VOD compared with 21 days (IQR 13–32 days) for those without VOD (p = 0.0001). There was a statistically significant increase in the adjusted odds of developing PCS among patients with acute SRC who had VOD compared with those without VOD (adjusted OR 4.10; 95% CI 1.04–16.16). CONCLUSIONS Evidence of VOD was detected in a significant proportion of children and adolescents with acute SRC and PCS who were referred to a multidisciplinary pediatric concussion program. This clinical feature was a significant risk factor for the subsequent development of PCS in this pediatric acute SRC cohort.

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Section: Discussionmentioning

confidence: 90%

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Ellis

Cordingley

Vis

et al. 2015

PED

145

130

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“…These data may suggest that PCS was more severe in females because they had more symptoms than males, but females reported fewer previous concussions, which are associated with prolonged recovery and an increased risk of PCS. 6,7,19,27,44 Thus, it is possible females are more susceptible to PCS as fewer concussions can trigger PCS. Females also were more likely to have prior migraine headaches, which have previously been linked to an increased risk of PCS.…”

Section: Discussionmentioning

confidence: 99%

“…Other predictors include learning disabilities, 44 migraine headaches, 19 females, 1,[4][5][6]10,12,13,26,32,39 older age, 18,21,39 and children and adolescents. 15,27 Lastly, those with previous concussions are believed to have an increased risk of PCS, 3,7,13,19,27,32,44 although the exact number required to increase the risk is unknown.…”

Section: 39mentioning

confidence: 99%

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Postconcussion syndrome: demographics and predictors in 221 patients

Tator

Davis

Dufort

et al. 2016

JNS

109

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abbreviations ADD = attention-deficit disorder; ADHD = attention-deficit hyperactivity disorder; CTE = chronic traumatic encephalopathy; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; GCS = Glasgow Coma Scale; ICD-10 = International Classification of Diseases, 10th Revision; LOC = loss of consciousness; PCS = postconcussion syndrome; PTSD = posttraumatic stress disorder; TBI = traumatic brain injury. obJective The objective of this study was to determine the demographics and predictors of postconcussion syndrome (PCS) in a large series of patients using a novel definition of PCS. methods The authors conducted a retrospective cohort study of 284 consecutive concussed patients, 221 of whom had PCS on the basis of at least 3 symptoms persisting at least 1 month. This definition of PCS was uniformly employed and is unique in accepting an expanded list of symptoms, in shortening the postconcussion interval to 1 month from 3 months, and in excluding those with focal injuries such as hemorrhages and contusions. resUlts The 221 cases showed considerable heterogeneity in clinical features of PCS. They averaged 3.3 concussions, with a range of 0 to 12 or more concussions, and 62.4% occurred during sports and recreation. The median duration of PCS was 7 months at the time of examination, with 11.8% lasting more than 2 years, and 23.1% with PCS had only 1 concussion. The average patient age was 27 years (range 10-74 years). The average number of persistent symptoms was 8.1; 26.2% had a previous psychiatric condition, attention-deficit disorder/attention-deficit hyperactivity disorder, a learning disability, or previous migraine headaches. The prevalence of arachnoid cysts and Chiari malformation in PCS exceeded the general population. Additionally, involvement in litigation, presence of extracranial injuries, amnesia and/or loss of consciousness, and female sex were predictive of reporting a high number of symptoms. A prior history of psychiatric conditions or migraines, cause of injury, number of previous concussions, and age did not significantly predict symptom number. Only the number of symptoms reported predicted the duration of PCS. To predict the number of symptoms for those who fulfilled PCS criteria according to the International Classification of Diseases, and the Diagnostic and Statistical Manual of Mental Disorders,, the number of previous concussions was significant. conclUsions PCS is commonly associated with multiple concussions, but 23.1% in the present series occurred after only 1 concussion. Most patients with PCS had multiple symptoms persisting for months or years. The median duration of PCS was 7 months, with a range up to 26 years. In only 11.3%, the PCS had ended at the time of consultation. Not all predictors commonly cited in the literature align with the findings in this study. This is likely due to differences in the definitions of PCS used in research. These results suggest that the use of ICD-10 and DSM-IV to diagnose PCS may be biased toward those who are vulnerabl...

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“…2,8,11,16,40 Previous studies have identified important clinical variables associated with an elevated risk of prolonged recovery and PCS de-velopment following SRC. 8,18,21,26,27,29,35 While early identification of these risk factors may be important to help provide anticipatory guidance for patients and parents regarding expected length of recovery, 26,27,41 understanding the relationship between these clinical variables and the pathophysiology of SRC may provide insight into how these variables contribute to the development of PCS.…”

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confidence: 99%

Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion

Ellis

Cordingley²,

Vis³

et al. 2017

PED

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OBJECTIVE There were 2 objectives of this study. The first objective was to identify clinical variables associated with vestibulo-ocular dysfunction (VOD) detected at initial consultation among pediatric patients with acute sports-related concussion (SRC) and postconcussion syndrome (PCS). The second objective was to reexamine the prevalence of VOD in this clinical cohort and evaluate the effect of VOD on length of recovery and the development of PCS. METHODS A retrospective review was conducted for all patients with acute SRC and PCS who were evaluated at a pediatric multidisciplinary concussion program from September 2013 to May 2015. Acute SRS was defined as presenting < 30 days postinjury, and PCS was defined according to the International Classification of Diseases, 10th Revision criteria and included being symptomatic 30 days or longer postinjury. The initial assessment included clinical history and physical examination performed by 1 neurosurgeon. Patients were assessed for VOD, defined as the presence of more than 1 subjective vestibular and oculomotor complaint (dizziness, diplopia, blurred vision, etc.) and more than 1 objective physical examination finding (abnormal near point of convergence, smooth pursuits, saccades, or vestibulo-ocular reflex testing). Poisson regression analysis was used to identify factors that increased the risk of VOD at initial presentation and the development of PCS. RESULTS Three hundred ninety-nine children, including 306 patients with acute SRC and 93 with PCS, were included. Of these patients, 30.1% of those with acute SRC (65.0% male, mean age 13.9 years) and 43.0% of those with PCS (41.9% male, mean age 15.4 years) met the criteria for VOD at initial consultation. Independent predictors of VOD at initial consultation included female sex, preinjury history of depression, posttraumatic amnesia, and presence of dizziness, blurred vision, or difficulty focusing at the time of injury. Independent predictors of PCS among patients with acute SRC included the presence of VOD at initial consultation, preinjury history of depression, and posttraumatic amnesia at the time of injury. CONCLUSIONS This study identified important potential risk factors for the development of VOD following pediatric SRC. These results provide confirmatory evidence that VOD at initial consultation is associated with prolonged recovery and is an independent predictor for the development of PCS. Future studies examining clinical prediction rules in pediatric concussion should include VOD. Additional research is needed to elucidate the natural history of VOD following SRC and establish evidence-based indications for targeted vestibular rehabilitation.

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Prognosticators of Persistent Symptoms Following Pediatric Concussion

Cited by 200 publications

References 50 publications

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Postconcussion syndrome: demographics and predictors in 221 patients

Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion

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