Monday, March 14, 2016

A clinical risk score for persisting concussion symptoms

A 12-point clinical score for children with concussion has been developed and shown in a new study to identify those who are more likely to have prolonged symptoms and therefore need closer follow-up.
The study, published in the March 8 issue of JAMA, was conducted by a team led by Roger Zemek, MD, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.
"We have developed an easy-to-calculate clinical score which could potentially individualize concussion care in children, identifying those with high risk of prolonged symptoms who will need closer follow-up," Dr Zemek told Medscape Medical News.
He added that the score will also be useful in advancing research on treatments for concussion as these higher-risk individuals will be the most suitable patients to include in trials of interventions that may prevent or shorten long-term concussion symptoms.
Dr Zemek noted that concussion has received a fair amount of media attention recently, which has resulted in rising numbers of visits to the emergency department and primary care doctors. "The first question parents ask is, 'When is my child going to be better?' But prior to this work we didn't have any scientific basis to answer this question," he said.
He explained that concussion symptoms are prolonged for more than a month in about one third of cases. Such symptoms can include headache, dizziness, and difficulty concentrating, symptoms that have an adverse effect on quality of life and can affect school attendance and exam performance.
"Currently we cannot tell which patients are more likely to have prolonged symptoms," he said. "It is important to be able to provide the family with some realistic guidance on when the child is likely to recover and to be able to target specialist care to the higher-risk patients."
Although there have been a few small studies in selected groups of competitive athletes, the current study included a large diverse population of children aged between 5 and 18 years for factors that are associated with persistent symptoms of concussion beyond 1 month, known as persistent post-concussion symptoms (PPCS)....
The researchers looked at more than 70 possible variables and found 9 that seemed to be particularly independently associated with long-term symptoms: female sex, age 13 years or older, migraine history, previous concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and difficulty standing on a balance beam (4 or more errors on the Balance Error Scoring System).
"Interestingly, some of the traditional risks factors that have caused concern, such as vomiting and loss of consciousness, didn't make the final round when we assessed all the risk factors together," Dr Zemek noted.
The researchers developed a scoring system; most of these factors were assigned 1 point, but age 13 or older , female sex, and fatigue were given 2 points because they were more strongly associated with long-term symptoms. This resulted in a 12-point scale, and the researchers designated a score of 9 to 12 as high risk, 0 to 3 as low risk, and 4 to 8 as intermediate risk.
"Our results suggest that a score of 9 to 12 on this scale signifies a high risk of prolonged symptoms of concussion, with a 93% certainty: ie, the test has a 93% specificity," Dr Zemek said. "We can also say that a score of 9 to 12 means that a child is three times more likely to have persistent symptoms than the standard score. And a score of 0 to 3 means they are three times less likely than a standard score to have prolonged issues."
In an accompanying editorial, Lynn Babcock, MD, and Brad G. Kurowski, MD, University of Cincinnati, Ohio, agree that the new score generates risk estimates for PPCS superior to clinician prediction, which they say was "no better than a coin toss."
They write: "Considering the variation in individual symptom profiles and trajectories, personalized patient-oriented approaches to ongoing assessments and delivery of postinjury interventions are needed to facilitate recovery in these vulnerable children and adolescents."
They caution that inclusion of patients and clinicians only from specialized pediatric emergency departments raises concerns about the generalizability of this study, and the findings need to be validated in other settings.
They also call for assessment of the score in other populations, including those with multiple trauma, younger children, and those with lower Glasgow Coma Scale scores.

Roger Zemek, Nick Barrowman, Stephen B. Freedman, Jocelyn Gravel,  Isabelle Gagnon, Candice McGahern, Mary Aglipay, Gurinder Sangha, Kathy Boutis, Darcy Beer, MD8; William Craig, Emma Burns, Ken J. Farion, Angelo Mikrogianakis,  Karen Barlow, Alexander S. Dubrovsky, Willem Meeuwisse,  Gerard Gioia, William P. Meehan III, Miriam H. Beauchamp, Yael Kamil, Anne M. Grool, Blaine Hoshizaki, Peter Anderson,  Brian L. Brooks,  Keith Owen Yeates, Michael Vassilyadi, Terry Klassen, Michelle Keightley, Lawrence Richer, Carol DeMatteo, Martin H. Osmond, for the Pediatric Emergency Research Canada (PERC) Concussion Team.    Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.    JAMA. 2016;315(10):1014-1025.    


Importance  Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist.
Objective  To derive and validate a clinical risk score for PPCS among children presenting to the emergency department. 
Design, Setting, and Participants  Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury.
Exposures  All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria.
Main Outcomes and Measures  The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury.
Results  In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort.
Conclusions and Relevance  A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.              


  1. The accompanying editorial: Lynn Babcock, Brad G. Kurowski. Identifying Children and Adolescents at Risk for Persistent Postconcussion Symptoms. JAMA. 2016;315(10):987-988.

    The risk score derived by Zemek et al should be validated in other settings in which children and adolescents with acute concussion are evaluated, including general EDs, urgent care centers, and some office settings, including primary care, orthopedics, and sports medicine. Assessment of the PPCS risk score in other mild TBI populations is also needed, including those with multiple trauma, younger children, those with lower Glasgow Coma Scale scores (<14), and those with structural abnormality of neuroimaging (eg, complicated mild TBI). The performance of the model should be evaluated with the addition of other bedside vestibular ocular measures, serum biomarkers, genetic factors, and advanced neuroimaging measures associated with acute TBI.

    Because rigorous systematic clinical trials are lacking, postinjury management is based primarily on consensus guidelines and there is considerable variation in management approaches. Anticipatory guidance, psychoeducation, and cognitive behavioral techniques are some of the currently used therapeutic interventions. Guidelines recommend cognitive and physical rest followed by gradual return to cognitive and physical activities as tolerated by symptom burden,yet effectiveness and dosing of rest to enhance recovery remain unclear.

    The clinical risk score developed by Zemek et al, if validated in other settings, may facilitate selection of patients who may be at highest risk of impairments as the optimal target population for much-needed interventional trials. Considering the variation in individual symptom profiles and trajectories, personalized patient-oriented approaches to ongoing assessments and delivery of postinjury interventions are needed to facilitate recovery in these vulnerable children and adolescents.

  2. Heyer GL, Schaffer CE, Rose SC, Young JA, McNally KA, Fischer AN. Specific Factors Influence Postconcussion Symptom Duration among Youth Referred to a Sports Concussion Clinic. J Pediatr. 2016 Apr 4. pii: S0022-3476(16)00317-6. doi:10.1016/j.jpeds.2016.03.014. [Epub ahead of print]

    To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic.
    A retrospective cohort study was conducted to evaluate several potential predictors of symptom duration via a Cox proportional hazards analyses. The individual postconcussion symptom scores were highly correlated, so these symptoms were analyzed in the statistical model as coefficients derived from principal component analyses.
    Among 1953 youth with concussion, 1755 (89.9%) had dates of reported symptom resolution. The remainder (10.1%) were lost to follow-up and censored. The median time to recovery was 18 days (range 1-353 days). By 30 days, 72.6% had recovered; by 60 days, 91.4% had recovered; and by 90 days, 96.8% had recovered. Several variables in a multivariate Cox model predicted postconcussion symptom duration: female sex (P < .001, hazard ratio [HR] = 1.28), continued activity participation (P = .02, HR = 1.13), loss of consciousness (P = .03, HR = 1.18), anterograde amnesia (P = .04, HR = 1.15), premorbid headaches (P = .03, HR = 1.15), symptom components from the day of concussion (emotion, P = .03, HR = 1.08), and the day of clinic evaluation (cognitive-fatigue, P < .001, HR = 1.22; cephalalgic, P < .001, HR = 1.27; emotional, P = .05, HR = 1.08; arousal-stimulation, P = .003, HR = 1.1). In univariate analyses, greater symptom scores generally predicted longer symptom durations. Worsening of symptoms from the day of concussion to the day of clinic evaluation also predicted longer recovery (P < .001, HR = 1.59).
    Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic.

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