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Original Investigation
November 5, 2018

Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population

Author Affiliations
  • 1Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  • 2Department of Psychology, University of Calgary, Calgary, Alberta, Canada
  • 3Department of Pediatrics, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
  • 4Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  • 5Department of Emergency Medicine, New York University School of Medicine, New York
  • 6Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
  • 7Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada
  • 8Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
  • 9Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
  • 10Children’s National Health System, George Washington University School of Medicine, Rockville, Maryland
  • 11Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
JAMA Pediatr. Published online November 5, 2018. doi:10.1001/jamapediatrics.2018.3820
Key Points

Question  What is the natural progression of symptom change and recovery in children after concussion?

Findings  In this multicenter cohort study that included 2716 children aged 5 to 18 years, symptom improvement primarily occurred in the first 2 weeks after injury in children and in the first 4 weeks after injury in preadolescents and male adolescents. Female adolescents had protracted recovery.

Meaning  It may be that between-sex differences in adolescents should be taken into consideration for recovery management; the derived recovery curves may be useful for evidence-based anticipatory guidance.

Abstract

Importance  The natural progression of symptom change and recovery remains poorly defined in children after concussion.

Objectives  To describe the natural progression of symptom change by age group (5-7, 8-12, and 13-18 years) and sex, as well as to develop centile curves to inform families about children after injury recovery.

Design, Setting, and Participants  Planned secondary analysis of a prospective multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics). The setting was 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Participants were aged 5 to 18 years with acute concussion, enrolled from August 1, 2013, to May 31, 2015, and data analyses were performed between January 2018 and March 2018.

Exposures  Participants had a concussion consistent with the Zurich Consensus Statement on Concussion in Sport diagnostic criteria and 85% completeness of the Postconcussion Symptom Inventory (PCSI) at each time point.

Main Outcomes and Measures  The primary outcome was symptom change, defined as current rating minus preinjury rating (delta score), at presentation and 1, 2, 4, 8, and 12 weeks after injury, measured using the PCSI. Symptoms were self-rated for ages 8 to 18 years and rated by the child and parent for ages 5 to 7 years. The secondary outcome was recovery, defined as no change in symptoms relative to current preinjury PCSI ratings (delta score = 0). Mixed-effects models incorporated the total score, adjusting for random effects (site and participant variability), fixed-effects indicators (age, sex, time, age by time interaction, and sex by time interaction), and variables associated with recovery. Recovery centile curves by age and sex were computed.

Results  A total of 3063 children (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 60.7% male) completed the primary outcome; 2716 were included in the primary outcome analysis. For the group aged 5 to 7 years, symptom change primarily occurred the first week after injury; by 2 weeks, 75.6% of symptoms had improved (PCSI change between 0 and 2 weeks, −5.3; 95% CI, −5.5 to −5.0). For the groups aged 8 to 12 years and 13 to 18 years, symptom change was prominent the first 2 weeks but flattened between 2 and 4 weeks. By 4 weeks, 83.6% and 86.2% of symptoms, respectively, had improved for the groups aged 8 to 12 years (PCSI change between 0 and 4 weeks, −9.0; 95% CI, −9.6 to −8.4) and 13 to 18 years (PCSI change between 0 and 4 weeks, −28.6; 95% CI, −30.8 to −26.3). Sex by time interaction was significant only for the adolescent group (β = 0.32; 95% CI, 0.21-0.43; P < .001). Most adolescent girls had not recovered by week 12.

Conclusions and Relevance  Symptom improvement primarily occurs in the first 2 weeks after concussion in children and in the first 4 weeks after concussion in preadolescents and male adolescents. Female adolescents appear to have protracted recovery. The derived recovery curves may be useful for evidence-based anticipatory guidance.

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