Identification and
validation of prognostic criteria for persistence of mild traumatic brain
injury-related impairment in the pediatric patient

DJ., Collins MW., Nance Ml. Pediatric Emergency Care, 2012; 28: 498-502.

Athletes returning to play before
their concussions fully resolve are more prone to a second concussion, which is
usually associated with more severe signs and symptoms (s/s). However, there
are no prognostic tests to identify athletes who are going to suffer from a
concussion for longer periods of time to ensure a safe return to play. Therefore,
the purpose of this study was to develop and validate prognostic criteria to
identify children at risk for persistent concussion impairment. This 2-year study recruited patients ages 11 to 17 years that were admitted to the hospital
due to an acute concussion (only excluding patients with a penetrating
mechanism). All patients were evaluated using neurocognitive testing (ImPACT) at
time of hospitalization and again at their clinic follow-up (typically after 2
weeks). The patients were split randomly into 2 groups: 42 participants were
placed into a group to develop the predictive criteria and 21 participants were
placed into a group to verify the predictive criteria. The authors categorized
symptom severity outcomes into “any impairment” or “severe impairment” using
previously established definitions. Any impairment (n = 62) was defined as a
total ImPACT symptom score higher than 8 (normal is 0 to 8) or scoring less
than 25th percentile on at least 1 of the neurocognitive modules at
baseline or during the 2-week follow-up. Severe impairment (n = 44) was defined
as a total ImPACT symptoms score higher than 12 or scoring less than 25th
percentile in at least 2 of the neurocognitive modules. In the development subcohort,
100% of the patients had any impairment and 79% were categorized as severe
impairment at baseline and at follow-up 88% had any impairment and 71% had
severe impairment. In the validation group at baseline 95% had any impairment
and 52% had severe impairment, and at follow-up 95% had any impairment and 81%
had severe impairment. Researchers found that using the average of the
patients’ 4 neurocognitive modules scores at baseline with a cut point of 26 percentile
could correctly predict 62 to 67% of the time whether a patient would have
severe impairment at 2 weeks. This corresponded to a 91% chance that when it
predicts the person to have a severe impairment at follow-up it will be correct
but when it predicts a resolution of severe symptoms it is likely wrong (30%
chance of correctly predicting symptom resolution).

There is a tremendous amount of variability
in how athletes present and recover from concussions making it difficult for
medical personal to safely estimate when athletes may be able to return an
athlete to play. This study recognized the need for a prognostic test to help
predict how long s/s may linger. These findings demonstrate that neurocognitive
testing, like ImPACT testing, may have some potential as prognostic criteria.
Using the mean score from the 4 neurocognitive modules at baseline medical personnel
can correctly predict about 90% of those who will likely continue to have
severe symptoms at 2-weeks (but it may be less accurate at predicting
resolution of symptoms). Having objective variables instead of relying on
subjective s/s may greatly benefit medical personnel on estimating returning
athletes to play. This prognostic tool still needs some additional research
especially among a larger more variable population that includes more patients
with less severe symptoms. Furthermore, it will be interesting to see if other
neurocognitive exams would have these results. It should be noted that this type of
predictive rule can only be used as a guide. At the end of the day, the most
important thing will be how the patient presents at follow-up. If you do not
have a neurocognitive baseline testing do these results prompt you to want to
start? Do you think it would be helpful to have a score that could help
estimate how long the patient may continue to have s/s or neurocognitive

by: Jane McDevitt MS, ATC, CSCS
by: Jeffrey Driban

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Electrophysiological Recovery After Sport-Related Concussion

Wiebe DJ, Collins MW, & Nance ML (2012). Identification and validation of prognostic criteria for persistence of mild traumatic brain injury-related impairment in the pediatric patient. Pediatric Emergency Care, 28 (6), 498-502 PMID: 22653462