Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study
Morgan CD, Zuckerman SL, Lee YM, King L, Beaird S, Sills AK, Solomon GS. Journal of Neurosurgery: Pediatrics. 2015. Doi: 10.3171/2014.10.PEDS14356 [Epub]
Take Home Message: Delayed onset of symptoms after sport-related concussion puts young athletes at a 20.7 times greater risk for postconcussion syndrome.
The majority of sports-related concussion (SRC) symptoms resolve within 1 week of the initial injury; however, there is a group of individuals that remain symptomatic for longer periods of time. These individuals are classified as having postconcussion syndrome (PCS) with somatic, cognitive, sleep, and emotional symptoms. Risk factors such as previous concussion, loss of consciousness, and migraine headache have been identified as predictors of PCS; however, some of these predictors have been disputed when high school and young adult populations were studied. In this case-control study, the authors set-out to identify which risk factors in young athletes (9-18 years) predicted those who would experience PCS and those who would not, after SRC. They retrospectively identified young athletes that sustained a SRC, diagnosed by an athletic trainer or team physician. Individuals that reported symptoms for greater than 3 months were classified as having PCS (40 patients), and control subjects were those who sustained a concussion but had resolution of symptoms in 3 weeks or less (80 patients who were age- and sex-matched). Variables of interest included demographics; past medical, psychiatric and family history; and acute (0-24 hours) and subacute (0-3 weeks) postconcussion symptoms. The patient or health care provider also identified additional life stressors or major life events that might interfere with concussion recovery. No difference was found between those with PCS and controls for age, sex, sport of concussion, race, body mass index, and type of health insurance. Loss of consciousness, amnesia, learning disability, or use of a helmet was not predictive of PCS in this young population. The authors found that patients with PCS were more likely to have a previous concussion, history of mood disorders, history of psychiatric illness, family history of mood disorders, or delayed symptom onset compared with controls. However, a history of mood disorders (Relative Risk 17.9) and delayed onset of symptoms (Relative Risk 20.7) were the key variables related with an increased risk for PCS.
The results of this study bring to light potential risk factors for PCS in a young athletic population. History of mood disorders or psychiatric illness among the athlete or family members, as well as a history of concussion confirms what has been reported in older athletic populations. What is concerning is the delayed onset of concussive symptoms (> 3 hrs) within the PCS group. These individuals have a 20.7 times greater risk for developing PCS. Young athletes that experience a significant hit during athletic competition and do not display concussive symptoms may be cleared to return to the game. This puts the player at risk for a second hit within a short period of time, which is a known risk factor for delayed recovery. This is particularly concerning since we recently saw evidence that 29% of young athletes return to play on the same day as their injury. This study reinforces position statements and guidelines that advocate that athletes should not return to play the same day of a suspected concussion because we may need to monitor the patient for an onset of symptoms several hours after a suspected injury. Furthermore, this study should remind clinicians that they need to know the psychiatric status of an athlete and his/her family because it could affect performance on neurocognitive testing and risk for PCS.
Questions for Discussion: Do you think our criteria to allow athletes to return to the game after a suspected concussion should be more stringent? Do you think more strict criteria would help identify those with delayed symptoms? Do you think we should have different criteria for younger athletes (< 18 y/o)?
Written by: Kathleen Cummer
Reviewed by: Jeffrey Driban