Symptom improvement after concussion in pediatrics expected within four weeks

Originally Published By 2 Minute Medicine®. Reused on MPR with permission.

1. In this pre-planned secondary analysis of a large prospective study, symptom improvement after concussion occurred primarily in the first 2 weeks in children (age 5-7) and in the first 4 weeks in older patients (age 8-18).

2. Adolescent girls (Age 13-18) had a protracted recovery with less than half recovering by 12 weeks.

Evidence Rating Level: 2 (Good)

Study Rundown: The natural history and expected recovery after a concussion have not been well studied in the pediatric population. In this large, pre-planned secondary analysis of a prospective multi-center cohort study, the majority of symptom improvement was consistently seen in the first week after concussion, across all ages and genders. In children (age 5-7), symptom improvement plateaued after 2 weeks, while older patients' (age 8-18) recovery plateaued after 4 weeks. Female patients reported more severe symptoms with slower recovery compared with male patients across all age groups. Adolescent patients (age 13-18) had longer recovery trajectories, however adolescent females specifically had protracted recovery with less than half reporting recovery by 12 weeks. The majority of male patients and female patients age 5-12 had recovery by 12 weeks.

Although the large sample size (2716 patients) and age-specific symptom assessment scales support this study's conclusions, there are some limitations. Firstly, only patients presenting to emergency rooms were included, which may limit generalizability only to patients with severe symptoms. Secondly, more subtle neuropsychological symptoms may be challenging to decipher using self-reported symptom scales.

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Click to read the study in JAMA Pediatric

Relevant Reading: Association of Persistent Postconcussion Symptoms With Pediatric Quality of Life

In-Depth [prospective cohort]: This was a pre-planned secondary analysis of a prospective multi-center cohort study performed across nine pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Recruitment was from 2013 – 2015, and 2716 patients were included in the primary analysis. Inclusion criteria included patients age 5-18 with acute head injury in the last 48 hours meeting the concussion diagnosis criteria according to the Zurich Consensus Statement on Concussion in Sport. Exclusion criteria included Glasgow Coma Scale score < 14, trauma-related abnormality on neuroimaging, need for hospital admission, severe preexisting neurological developmental delay resulting in communication difficulties, intoxication, absence of trauma as primary event, previous enrollment, language barrier, inability to complete follow-up, neurosurgical intervention, intubation, or intensive care unit admission.

Primary outcome was symptom change over time using the Postconcussion Symptom Inventory (PCSI), a valid and reliable age-specific self-reported symptom scale. Maximum PCSI score was 20 for age 5-7, 36 for age 8-12, and 120 for age 13-18. Secondary outcome was recovery, defined as no change in symptoms relative to age-specific preinjury predicted PCSI scores. Results were stratified by age group (5-7, 8-12 or 13-18) and gender (female vs male). Data was collected at presentation and week 1, 2, 4, 8, and 12 post-presentation.

The greatest improvement in symptom severity occurred in the first week for all age groups and genders. Age 5-7 showed PCSI change of -4.4 (95%CI -4.7 to -4.2), age 8-12 showed PCSI change of -6.2 (95% CI -6.5 to -5.8), age 13-18 showed PCSI change of -18.8 (95% CI -19.8 to -17.7). This represented a relative PCSI score decrease of 63.8%, 56.9%, and 56.6% respectively. Female gender was associated with higher symptom burden in all age groups at time points. Male gender was associated with higher recovery rate by 4 weeks in all age groups.

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