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.
Abstract
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.
Abstract
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.
http://jama.jamanetwork.com/article.aspx?articleid=2499274
The accompanying editorial: Lynn Babcock, Brad G. Kurowski. Identifying Children and Adolescents at Risk for Persistent Postconcussion Symptoms. JAMA. 2016;315(10):987-988.
ReplyDeleteThe 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.
http://jama.jamanetwork.com/article.aspx?articleid=2499258
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]
ReplyDeleteAbstract
OBJECTIVE:
To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic.
STUDY DESIGN:
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.
RESULTS:
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).
CONCLUSIONS:
Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic.
Courtesy of: http://www.mdlinx.com/neurology/medical-news-article/2016/04/14/traumatic-brain-injury-tbi-mtbi-pediatric/6616020/?category=sub-specialty&page_id=1&subspec_id=317