Clinical Risk Score for Persistent Postconcusison Symptoms Among Children with Acute Concussion in ED
Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, Aglipay M, Sangha G, Boutis K, Beer D, Craig W, Burns E, Farion KJ, Mikrogianakis A, Barlow K, Dubrovsky AS, Meeuwisse W, Gioia G, Meehan WP, Beauchamp MH, Kamil Y, Grool AM, Hoshizaki B, Anderson P, Brooks BL, Yeates KO, Vassilyadi M, Klassen T, Keightley M, Richer L, DeMatteo C, Osmond MH; Pediatric Emergency Research Canada (PERC) Concussion Team. JAMA. 2016 Mar 8;315(10):1014-25.
Take Home Message: A novel clinical risk score developed for the acutely concussed pediatric population has a modest ability to discriminate between those at low, medium, or high risk for persistent postconcussion symptoms at 28 days.
After a concussion, nearly a third of pediatric patients experience somatic, cognitive, psychological, and behavioral symptoms for longer than 28 days, which is often referred to as persistent postconcussion symptoms (PPCS). Unfortunately, medical professionals lack a validated tool to identify a young athlete at risk for PPCS. Therefore, the authors of this multi-center prospective cohort study aimed to derive and validate a clinical risk score for PPCS among children presenting to an emergency department. The study included 2,584 patients (ages 5-17 [median 12 years old]) who were diagnosed with a concussion within 48 hours at 1 of 9 emergency departments (within the Pediatric Emergency Research Canada Network). All patients underwent a standardized concussion evaluation (demographic data, medical and injury history, post-concussion symptominventory, SCAT3). The authors followed the patients using electronic surveys (post-concussion symptom inventory) at 7, 14, and 28 days after injury. Patients recruited during August 2013 to September 2014 were placed in the derivation group, and those recruited during October 2014 to June 2015 were included in the validation cohort. Thirty-one percent (801 patients) of the derivation and 30% (501 patients) of the validation reported PPCS. The authors developed a 9-factor PPCS risk score model using the clinical variables from initial evaluation and follow up survey (female sex, age of 13 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 tandem stance during the Balance Error Scoring System Test). A score of 0-3 determined low risk, 6-9 medium risk, and 10-12 was high risk for PPCS. The discrimination of this model to detect PCSS risk was modest compared with physician judgment in predicting PCSS. For the low-risk patients the sensitivity was 94% and the specificity was 18%. For the high-risk patients the sensitivity was 20% and the specificity was 93%.
The authors assessed a large, diverse cohort of pediatric patients presenting at an emergency department with an acute concussion, and determined a PPCS risk score with a modest ability to discriminate between those at low, medium, or high risk for PPCS compared to physician judgment. This is the first survey of its kind to determine a risk score for PPCS. The survey is affordable, and easy for the patient and parent to answer. Additionally, it provides the medical professional with an easy to interpret score for PPCS risk (low, middle, high). Many of these factors are already collected during a standard concussion assessment. The authors acknowledged that more research needs to be done to refine this score before it is ready for clinical use. It is reassuring however that these robust findings complement previous research, which found several of these factors to be associated with prolonged recovery, such as, migraine history, or symptoms lasting more than 1 week. Therefore, it seems intuitive that this would be a valid way of assessing risk. The pediatric population takes longer to recovery than the adult population, which puts these patients at risk for returning to physical activity sooner than they should. Knowing the risk of PCSS would be helpful for medical professionals to monitor and manage a concussion more efficiently. While it may take time to optimize this risk scores clinicians should be aware of the factors identified in this study as increasing the risk of PPCS. When a patient has more than one of these risk factors it may be important to discuss with the patient the risk of PPCS.
Questions for Discussion: Would you use a clinical risk score survey? Do the factors included in the clinical risk score align with what you see in your concussed patients with prolong recovery?
Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban
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