Paediatric post-concussive symptoms: symptom clusters and clinical phenotypes

Lyons TW, Mannix R, Tang K, Yeates KO, Sangha G, Burns EC, Beer D, Dubrovsky AS, Gagnon I, Gravel J, Freedman SB, Craig W, Boutis K, Osmond MH, Gioia G, Zemek R; Pediatric Emergency Research Canada (PERC) 5P Concussion Team. Br J Sports Med. 2022 Mar 10:bjsports-2021-105193. doi: 10.1136/bjsports-2021-105193. Epub ahead of print.

https://bjsm.bmj.com/content/early/2022/04/06/bjsports-2021-105193

Take-Home Message

A patient who reports persistent symptoms a month after a concussion often reports a headache or fatigue. Fatigue is often reported with cognitive and emotional symptoms.

Background

Most children following a concussion will recover completely within four weeks. However, many children have persistent symptoms that last longer than one month. Patients who suffer from prolonged symptoms after a concussion may have an impaired quality of life. Targeted rehabilitation may allow expedient symptom reduction or resolution if clinicians can identify clusters of symptoms that frequently co-occur in patients following concussion.

Study Goals

The authors aimed to determine the co-occurrence of patient-reported persistent symptoms after concussion. Additionally, the authors aimed to identify subsets of concussion based on symptom severity and type.

Methods

This study’s data originated from the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) study. Participants were 5-17 years old, presented within 48 hours of sustaining a concussion, and were diagnosed with a concussion based upon the Zurich 2012 Consensus Statement. Study staff contacted participants 4 weeks after a concussion. The authors used the post-concussion symptom inventory and only used the 13 items that were common across all ages. Each symptom severity score ranged from 0 to 6, regardless of age.

Results

The most commonly reported persistent symptoms were fatigue (22%) and headache (19%). Persistent physical symptoms clustered into two groups: vestibular-ocular (e.g., balance problems, dizziness, vision problems) and headache. Cognitive and emotional symptoms often occurred together, along with severe physical symptoms. Fatigue often clustered with cognitive and emotional symptoms.

Viewpoints

These results give insight into symptoms that often co-occur. This information may help clinicians identify patients with persistent symptoms and guide follow-up questions about unreported symptoms. For example, if someone reports ongoing balance problems, it may be helpful to specifically ask about dizziness or vision problems. Some limitations of this study include that patients who present to the emergency department following a concussion may have more severe concussions than those who never seek care at an emergency department. Furthermore, the authors only considered symptoms reported only at 28 days post-injury. Hence, it is unclear if these symptoms will still co-occur at other times.

Clinical Implications

Clinicians should be aware of this information and be able to target specific symptom clusters with active rehabilitation for patients following concussion.

Questions for Discussion

Which patient-reported symptoms do you have the most comfort with rehabilitating? Which of these clusters may be associated with a longer/shorter recovery period?

Females at Increased Risk of Protracted Concussion Symptoms
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Written by Mitchell Barnhart
Reviewed by Jeffrey Driban

Evidence-Based Assessment of Concussion Course - 5 EBP CEUs

1 Comment

Justin Trickett on June 17, 2022 at 1:46 am

In my clinical experience, I have become most comfortable with rehabilitating patients’ vision problems. While these exercises are not the athletes favorite exercises, working on smooth pursuits with eye-tracking, rapid eye movements with saccades, and near point of convergence with a Brock string has been effective in rehabilitating some of the eye/vision issues my patients have complained about. While I have found them to be effective and I am most comfortable with them, I also have noticed that these symptoms along with some of the other vestibulocochlear symptoms have tended to linger the longest. Dizziness/balance problems are some in particular that I have had trouble rehabbing because it is hard to get the patient to buy into doing exercises that make them feel worse in the short term. In my experience, I have found that emotional symptoms disappear quicker however I have no explanation since it is very hard to rehabilitate emotions.