Symptom Burden and Profiles in Concussed Children with and without Prolonged Recovery

Although symptom burden and symptom profile severity are independent predictors of post-concussion symptom duration, few studies have examined their effects on prolonged recovery simultaneously. This study examined differences in symptom burden and symptom profile scores between concussed children with prolonged recovery and those with typical recovery. We conducted a retrospective case-control study of concussed children aged 10–18 years. Prolonged recovery was defined as symptom duration beyond 28 days post-injury. Symptom burden was measured as total symptom score (TSS) at injury. Symptom profiles included: (1) vestibular, (2) ocular, (3) cognitive/fatigue, (4) migraine, and (5) anxiety. A total of 4380 unique concussions sustained by 3777 patients were included; 80.3% white, 60.0% male, and 44.0% aged 13–15 years. The prolonged recovery group had a significantly higher TSS and greater number of symptoms than the typical recovery group (p < 0.001 and p < 0.001, respectively). The prolonged recovery group had significantly higher scores on all five symptom profiles, including vestibular (p < 0.001), ocular (p < 0.001), cognitive/fatigue (p < 0.001), migraine (p < 0.001) and anxiety (p < 0.001), than the typical recovery group, even after adjusting for number of symptoms and other covariates. Further studies using prospective cohort designs are needed to better understand the influence of symptom burden and profiles on pediatric concussion recovery.

Protocol for the mixed-methods development of a concussion-specific health-related quality of life outcome measure based on the international classification of functioning, disability and health

INTRODUCTION

Recovery from concussion has traditionally been evaluated by patient-reported symptoms, objective measures such as loss of consciousness, specific dimensions such as depression or fatigue, cognitive status, employment status, level of physical activity and the more complex construct of disability. Increasingly, patient-reported outcome measures of health-related quality of life (HRQOL) are being emphasised as an important end point in patient care, clinical trial and health policy decisions. Currently, no standardised concussion-specific HRQOL outcome measure exists. The process for developing a concussion-specific HRQOL outcome measure based on the international classification of functioning, disability and health is outlined.

METHODS AND ANALYSIS

A multistage, patient-centred approach to developing the outcome measure will integrate evidence from systematic reviews, qualitative research and cognitive interviewing into a self-report questionnaire to guide clinical decision-making. The psychometric properties of the questionnaire will be evaluated to assess the inter-rater reliability and construct validity of the measure in individuals with persistent post-concussion symptoms. To date, the systematic review and the clinical expert interviews within the preparatory phase have been completed and work is progressing on the subsequent phases. It is anticipated that the outcome measure will be ready for psychometric testing in September 2018.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ottawa Health Science Network Research Ethics Board (Protocol #20170720-01H) on 31 October 2017 to conduct the patient and clinical expert interviews. Ethical approval for psychometric testing of the outcome measure will be sought by the Ottawa Health Science Network Research Ethics Board in Phase II, after the development of the final HRQOL questionnaire. Results will be disseminated through peer-reviewed journals and professional conferences.

PROSPERO REGISTRATION

Phase I systematic review registration number CRD42017075588 (15 June 2017). Phase II systematic review registration number CRD42017075588 (27 September 2017).

Divergent Classification Methods of Post-Concussion Syndrome after Mild Traumatic Brain Injury: Prevalence Rates, Risk Factors, and Functional Outcome

Mild traumatic brain injury (mTBI) is a common diagnosis and approximately one third of mTBI patients experience a variety of cognitive, emotional, psychosocial, and behavioral post-concussion symptoms. When a cluster of these symptoms persists for more than 3 months they are often classified as post-concussion syndrome (PCS). The objective of this study was to determine prevalence rates, risk factors, and functional outcome associated with PCS 6 months after mTBI, applying divergent classification methods. Follow-up questionnaires at 6 months after mTBI included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and the Glasgow Outcome Scale Extended (GOSE). The RPQ was analyzed according to different classification methods: the mapped International Classification of Diseases, 10th revision (ICD-10)/Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the RPQ total score, the RPQ3 and the three-factor model using two different cutoff points (mild or worse and moderate or worse). Our results from a sample of 731 mTBI patients showed that prevalence rates of PCS ranged from 11.4% to 38.7% using divergent classification methods. According to all eight methods, 6.3% (n = 46) of mTBI patients experienced PCS. Applying the divergent classification methods resulted in a different set of predictors being statistically significantly associated with PCS, and a different percentage of overlap with functional impairment, measured with the GOSE. In conclusion, depending on the classification method and rating score used, prevalence rates of PCS deviated considerably. For future research, consensus regarding the diagnostic criteria for PCS and the analysis of the RPQ should be reached, to enhance comparability of studies regarding PCS after mTBI.

[Post-concussion syndrome is a neuro-cognitive condition]

Post-concussion syndrome (PCS) is often caused by an uncomplicated mild head injury but followed by long-lasting somatic, cognitive and psychiatric symptoms. For many years PCS has been an area of controversy between clinicians. New diagnostic techniques and clinical researches has shed light to some neurobiological aspects behind PCS. In Diagnostic and Statistical Manual of Mental Disorders V PCS is redefined as a neuro-cognitive condition emphasizing the importance of neuropsychological deficits among these patients. New clinical recommendations do not support previous concept of long-term rest, but suggest gradual training back to a daily life.

[Mild brain injuries: definition, classifications and prognosis]

Brain injuries may be graded into mild, moderate and severe depending on clinical and radiological criterions. Mild brain injuries (MBI) are usually defined by an initial unconsciousness limited to 30 minutes, a Glasgow score between 13 and 15, the absence of intra-cranial lesion on the CT scan, a post-traumatic amnesia period between one and 24 hours depending on the authors. The consequences of a MBI may be simple but the injured often suffer from a transitory post-concussive syndrome. Traumatic stress states are a well known pathology and consist in a psychological reaction against the trauma. The acute traumatic stress may or may not run its course to a chronic post-traumatic stress disorder, formerly called post-traumatic neurosis.

Postconcussional disorder: Are the DSM-IV criteria an improvement over the ICD-10?

Little is known about the characteristics and outcomes of patients diagnosed with postconcussional disorder (PCD) under the provisionally proposed criteria in the DSM-IV and how they differ from patients diagnosed with postconcussional syndrome (PCS) under the International Classification of Diseases, 10th edition clinical (ICD-10) criteria. This study investigated differences in outcome based on a diagnosis of PCD (DSM-IV) versus PCS (ICD-10 clinical criteria) as to which criteria set might be preferred for clinical practice. A consecutive series of adult patients with mild (N = 319) to moderate (N = 21) traumatic brain injury was assessed at 3 months postinjury with a brief neuropsychological battery and measures of specific outcome domains. In two separate series of analyses, patients with PCD were compared with those without PCD, and those with PCS were compared with those without PCS. Although the two criteria sets resulted in markedly different incidence rates, there was no substantial pattern of differences between the DSM-IV and ICD-10 in the outcome domains of psychiatric symptoms and disorders, social and community integration, health-related quality of life, or global outcome as measured by the Glasgow Outcome Scale-Extended. In spite of significant differences between the two diagnostic criteria sets and different incidence rates for PCD/PCS, outcome in all measured domains was very similar at 3 months postinjury. There is no compelling evidence, based on these outcome domains, to suggest which of the two diagnostic criteria sets should be clinically preferred.