Wednesday, August 17, 2016

Factors predictive of slow recovery from concussion

Several factors, including continued physical activity following a concussion, worsening symptoms from the time of injury to the time a patient seeks care, and a previous history of headaches, help predict which children are likely to have a protracted concussion recovery, physician-researchers at Nationwide Children's Hospital have found.

Their study comes as the number of children seeking medical help for concussions has risen over the last decade, resulting now in 174,000 or more visits to emergency departments in the United States annually.

Despite the increase, recovery remains poorly understood. Compared to adults, who usually recover in 7 to 10 days, children may be more vulnerable and have longer-lasting post-concussion symptoms. Previous studies have found some youth continue to report post-concussion symptoms after three months, but evidence linking clinical factors to protracted symptoms is inconsistent and sometimes contradictory.

"Concussion research is still evolving," says Anastasia Fischer, MD, a physician in the Division of Sports Medicine at Nationwide Children's and an author of the study. "Learning which symptoms seem to prolong recovery from concussion can help direct research towards etiology and management of those symptoms and concussion injuries in general."

To identify which factors are consistently predictive, the researchers used a multivariate analysis of symptom, demographic and other information in the records of more than 1,900 minors aged 10 to 19. The patients were referred to the Nationwide Children's Sports Concussion Clinic from 2012 through 2014. The records included answers to questions about the concussions from the patients and their parents. The analysis showed the following factors were predictive of prolonged recovery:

Female sex
Continued participation in physical activity
Loss of consciousness
Anterograde amnesia
Premorbid headaches
Worsening of symptoms between injury and first physician visit
Overall symptom burden
Emotional symptoms, such as sadness and irritability on the day of concussion
Emotional, cognitive-fatigue, cephalagic and arousal-stimulation symptoms the day of clinical evaluation

"Even tools as simple as a concussion symptom questionnaire and detailed history can help guide treatment and management of concussions," says Dr. Fischer, who is also a clinical associate professor of Pediatrics at The Ohio State University College of Medicine.

Dr. Fischer and her colleagues are applying what they learned from the study.

Concussions tend to last about two to three weeks in adolescents, she says.  "Setting reasonable expectations for time out of sport and duration of symptoms at a first physician visit can prepare athletes and families for appropriate care —especially if some of the factors that prolong recovery are present."

For example, she talks with families of athletes who continued to play football, soccer or another sport after suffering head injuries but before evaluation.

"Now that we know this can ultimately keep them out of sports longer, I hope that it will encourage athletes to seek evaluation sooner after a head injury, helping to prevent further injury and hopefully optimize their recovery," Dr. Fischer says.

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 Jul;174:33-38.e2.

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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