Ledoux AA, Tang K, Yeates KO, Pusic MV, Boutis K, Craig WR, Gravel J, Freedman SB, Gagnon I, Gioia GA, Osmond MH, Zemek RL; Pediatric Emergency Research Canada (PERC) Concussion Team. Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population. JAMA Pediatr. 2018 Nov 5:e183820. doi:10.1001/jamapediatrics.2018.3820. [Epub ahead of print]
The natural progression of symptom change and recovery remains poorly defined in children after concussion.
To describe the natural progression of symptom change by age group (5-7, 8-12, and 13-18 years) and sex, as well as to develop centile curves to inform families about children after injury recovery.
DESIGN, SETTING, AND PARTICIPANTS:
Planned secondary analysis of a prospective multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics). The setting was 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Participants were aged 5 to 18 years with acute concussion, enrolled from August 1, 2013, to May 31, 2015, and data analyses were performed between January 2018 and March 2018.
Participants had a concussion consistent with the Zurich Consensus Statement on Concussion in Sport diagnostic criteria and 85% completeness of the Postconcussion Symptom Inventory (PCSI) at each time point.
MAIN OUTCOMES AND MEASURES:
The primary outcome was symptom change, defined as current rating minus preinjury rating (delta score), at presentation and 1, 2, 4, 8, and 12 weeks after injury, measured using the PCSI. Symptoms were self-rated for ages 8 to 18 years and rated by the child and parent for ages 5 to 7 years. The secondary outcome was recovery, defined as no change in symptoms relative to current preinjury PCSI ratings (delta score = 0). Mixed-effects models incorporated the total score, adjusting for random effects (site and participant variability), fixed-effects indicators (age, sex, time, age by time interaction, and sex by time interaction), and variables associated with recovery. Recovery centile curves by age and sex were computed.
A total of 3063 children (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 60.7% male) completed the primary outcome; 2716 were included in the primary outcome analysis. For the group aged 5 to 7 years, symptom change primarily occurred the first week after injury; by 2 weeks, 75.6% of symptoms had improved (PCSI change between 0 and 2 weeks, -5.3; 95% CI, -5.5 to -5.0). For the groups aged 8 to 12 years and 13 to 18 years, symptom change was prominent the first 2 weeks but flattened between 2 and 4 weeks. By 4 weeks, 83.6% and 86.2% of symptoms, respectively, had improved for the groups aged 8 to 12 years (PCSI change between 0 and 4 weeks, -9.0; 95% CI, -9.6 to -8.4) and 13 to 18 years (PCSI change between 0 and 4 weeks, -28.6; 95% CI, -30.8 to -26.3). Sex by time interaction was significant only for the adolescent group (β = 0.32; 95% CI, 0.21-0.43; P < .001). Most adolescent girls had not recovered by week 12.
CONCLUSIONS AND RELEVANCE:Symptom improvement primarily occurs in the first 2 weeks after concussion in children and in the first 4 weeks after concussion in preadolescents and male adolescents. Female adolescents appear to have protracted recovery. The derived recovery curves may be useful for evidence-based anticipatory guidance.
For adolescent girls, symptom change trajectory was often protracted, the researchers observed. Their symptoms improved predominantly in the first four weeks after injury and plateaued between weeks four and eight, with fewer than half of adolescent girls reaching full recovery by 12 weeks after injury.
"Based on the rate of symptom change over time, our results suggested that those at risk of prolonged symptoms can be identified at two weeks for younger children, at four weeks for older children and male adolescents, and at four weeks for female adolescents (despite protracted recovery)," the authors write.
"Adolescent girls may potentially benefit from individualized management protocols, with the goal of promoting faster recovery," they suggest.
The researchers note that the children with acute concussion were initially seen in pediatric emergency departments; therefore, the results may not be generalizable to children having delayed symptoms (>48 hours), those seeking care outside of an ED (such as a family medicine clinic or sports clinic), those receiving care on the sideline by an athletic trainer or those not obtaining any care. "This may have biased our sample to children with higher initial symptom burden or more severe mechanisms of injury. However, the participants were sampled from a heterogeneous population across Canada," they note.
Also, the study only included self-rated clinical symptom recovery and is, therefore, not representative of neurophysiological and neuropsychological recovery.
Despite these limitations and caveats, Dr. Ledoux told Reuters Health, "Sex and age differences exist throughout recovery processes and these should be taken into consideration when managing pediatric concussions. In our report we provide clinicians with more tools to make effective healthcare decisions for children based on the natural progression of symptom change and recovery from concussion. Health providers now have a guide to track whether a child is within expected normal range of recovery for their age group and sex. We also hope this tool can provide a better perspective to families and children on the child’s recovery status."