Which kids are most likely to have prolonged concussion symptoms?

Today, more and more children are being diagnosed with concussions. We have evidence that these injuries are occurring more often. The Centers for Disease Control and Prevention reports that between 2001 and 2009, the rate of kids 19 years old and younger seen in the emergency department due to sports- or recreation-related injuries that included a diagnosis of concussion rose by 57%. And sports is only one cause of concussions—there are others including falls and car accidents. In addition, there is greater awareness among physicians, parents, and the “community.” We now have concussion laws in every state, and a much greater realization that “having your bell rung” is not a badge of honor but a significant brain injury.

Doctors in emergency departments and primary care, as well as neurologists and sport medicine specialists, have also become more and more expert at diagnosing concussions. But recognizing concussion is just a start. The ultimate goal is to get these children back to their normal lives. The tricky part is that it can be hard to tell in advance which kids are going to get better fairly quickly and which kids won’t. It is generally believed that about one third of children may experience concussion symptoms that last more than a month. Persistent post-concussive symptoms (PPCS) can impede return-to-learn and return-to-play.

One of the older concussion grading systems labeled children whose symptoms went away in 7 to 10 days as having a “simple concussion.” “Complex concussions” were those where symptoms lasted more than 10 days. By definition, these diagnoses could only be established after the fact.

An article recently published in JAMA proposed a risk scoring system that could make it easier for clinicians to guide families of children who just suffered a concussion going forward. This multicenter study was performed across pediatric emergency rooms throughout Canada. It looked at 46 separate risk factors, and determined that nine of them seemed to help predict the likelihood of PPCS, specifically:

1. being female
2. age of 13 years or older
3. physician-diagnosed migraine history
4. prior concussion with symptoms lasting longer than one week
5. headache
6. sensitivity to noise
7. fatigue
8. answering questions slowly, and
9. 4 or more errors on part of a specific test for balance.

Based on these nine risk factors, the authors created a 12-point grading scale that was able to stratify the children into low, moderate and high risk for suffering PPCS. It was reasonably accurate for kids rated as low risk for PPCS (4-11%) and high-risk kids (57-81%). However the risk for children in the moderate risk range was wide (16-48%), which makes it less useful for giving specific advice to families of these children.

It is difficult to know exactly how a child with a newly diagnosed concussion will fare. The children and their families are desperate to know if and when they’re going to get better, and clinical intuition is generally no better than random chance at determining this. If further study shows that the new grading scale works well across a wider spectrum of patients, for example, including those who go to primary care and specialty care clinics (rather than the emergency room), it will be very useful.

Concussion management has come a long way over the past 20 years. Not so long ago, it was really a black box for most clinicians and it is reassuring to think how far we have come. This newly proposed clinical risk score is another tool—one of many we’ve seen emerge—for clinicians to use going forward. It is now incumbent upon us as providers to figure out how to use them most effectively. For example, neurocognitive testing clearly has a role in concussion management, but while it was once thought to be a magic bullet, we now realize that it has to be used judiciously and within context of the overall disease process. This study is another step closer to improving the care of our young patients, and getting them back to school, learning, and a healthy life.