What is the risk of recurrent concussion in children and adolescents aged 5–18 years? A systematic review and meta-analysis

Abstract

ObjectiveWe aimed to examine the risk of concussion in children with a previous history of concussion.DesignSystematic review and meta-analysis. The primary outcome was number of children with and without a previous lifetime history of concussion who sustained a diagnosed concussion within each study period. Risk of bias was assessed using the Newcastle-Ottawa Scale. A random effects model was used to estimate a pooled risk ratio (RR) with corresponding 95% CIs; results were summarised in forest plots.Data sourcesFour electronic databases (MEDLINE, Embase, CINAHL, SPORTDiscus) and selected reference lists were searched (PROSPERO registration No CRD42019135462).Eligibility criteriaOriginal English language peer-reviewed publications that compared concussion risk in children aged 5–18 years with and without a previous concussion history in which risk estimates were reported or able to be calculated.ResultsOf 732 identified studies, 7 studies representing 23 411 children (risk of bias range, 7–9; maximum possible score=9) were included for meta-analysis. Pooled risk of sustaining a concussion was more than three times greater in children with a previous concussion compared with those with no previous concussion (RR=3.64; 95% CI: 2.68 to 4.96; p<0.0001; I2=90.55%). Unreported sex-stratified data precluded direct comparison of concussion risk in male versus female athletes.ConclusionPreviously concussed children have four times the risk of sustaining a concussion compared with those with no previous concussion history. This should be a consideration for clinicians in return to sport decision-making. Future studies examining subsequent recurrent concussion in youth sports must consider sex differences.

Risk of Mental Health Problems in Children and Youths Following Concussion

“…Because the risk of subsequent concussions may be high 55 and may increase the risk of mental health issues, we conducted a sensitivity analysis to assess whether number of concussions occurring after the index concussion would affect the main results. We introduced a time-dependent variable representing concussions during the follow-up period; any emergency or primary care practitioner visit resulting in a concussion diagnosis at 4 weeks or more after the index event for cohort entry was defined as a new concussion.…”

“…Youth who have incurred a concussion are at 3 times higher risk of sustaining a subsequent concussion. 55 Multiple concussions may increase the likelihood of MHPs. However, even when concussions after the index concussion were taken into account, mental health disorders, psychiatric hospitalization, and self-harm remained significantly associated with concussion, and the magnitude of risk of developing one of these outcomes did not change.…”

Which psychosocial factors are associated with return to sport following concussion? A systematic review

“…However, growing evidence suggests that psychosocial factors are an important predictor of recurrent injury and determinant of return to preinjury level of performance among athletes with orthopedic injuries. 3 , 4 , 5 , 6 , 7 , 8 , 9 Athletes with a previous history of concussion are nearly 4 times more likely to sustain a recurrent concussion than those without, 10 yet clinicians have received little guidance on how to measure or mitigate the impact of psychosocial factors on RTS medical clearance following a concussion despite the known existence of psychosocial sequelae. 11 …”

“… 7 , 16 , 17 , 18 Injury-related biases in this area limit generalizability, 19 and a concussion-specific understanding of psychosocial factors associated with RTS is critical due to key differences in recovery from concussion compared with orthopedic injuries including the fact that: (a) objective diagnostic and recovery biomarkers are lacking for concussion; (b) symptoms are multidimensional with wide-ranging functional impacts; (c) prognosis and recovery trajectories are unclear; (d) treatment options are poorly understood; (e) few concussion studies use clearly defined RTS criteria despite recommendations for a multimodal evaluation; 2 , 20 and (f) RTS before recovery is complete is a risk factor for recurrent concussion with possible serious consequences, including death. 10 , 21 …”

Concussion Among Children in the United States General Population: Incidence and Risk Factors

“…A few potential risk factors for pediatric sport-related concussion have been identified. Systematic reviews have identified strong evidence that history of a previous concussion is a risk factor for sustaining a future concussion (8,9), with previously concussed youth athletes having more than 3 times greater risk of sustaining a future concussion (pooled risk ratio = 3.64; 95% CI: 2.68-4.96) (8). In addition, several retrospective studies of youth athletes report that boys have a greater lifetime history of concussion than girls (10)(11)(12).…”