Quality of Life Differences in Children and Adolescents With 0, 1 to 2, or 3+ Persistent Postconcussion Symptoms.

CONTEXT: Persistent postconcussion symptoms (PPCSs) are associated with lower health-related quality of life (HRQoL) in children and adolescents. Despite commonly cited criteria for PPCSs involving 3 or more complaints, many individuals experience just 1 or 2 symptoms that may still negatively affect HRQoL. OBJECTIVE: To determine differences in HRQoL between children and adolescents with 0, 1 to 2, or 3+ parent-reported persistent symptoms at 1 month postconcussion. DESIGN: Prospective cohort study. SETTING: Community practice clinics. PATIENTS OR OTHER PARTICIPANTS: Individuals aged 8 to 18 years presented for the initial visit within 3 days of a sport- or recreation-related concussion. One month later, parents or guardians reported persistent symptoms using the Rivermead Post Concussion Symptoms Questionnaire (RPQ). Individuals with complete symptom data were analyzed (n = 236/245, n = 97 females, age = 14.3 ± 2.1 years). Participants were grouped by the number of discrete RPQ symptoms reported as worse than preinjury (0, 1-2, or 3+). MAIN OUTCOME MEASURE(S): Total summary and subscale scores on the Pediatric Quality of Life Inventory (PedsQL) 23-item HRQoL inventory and 18-item Multidimensional Fatigue Scale (MDFS). RESULTS: Kruskal-Wallis rank sum tests highlighted differences in PedsQL HRQoL and MDFS total scores across symptom groups (PedsQL HRQoL: χ22 = 85.53, P < .001; MDFS: χ22 = 93.15, P < .001). Dunn post hoc analyses indicated all 3 groups were statistically significantly different from each other (P < .001). The median (interquartile range) values for the Peds QL Inventory HRQoL totals were 93.5 (84.2-98.8) for those with 0 symptoms; 84.8 (73.9-92.4) for those with 1 to 2 symptoms; and 70.7 (58.7-78.0) for those with 3+ symptoms. The median (interquartile range) values for the MDFS totals were 92.4 (76.4-98.6) for those with 0 symptoms; 78.5 (65.6-88.9) for those with 1 to 2 symptoms; and 54.2 (46.2-65.3) for those with 3+ symptoms. Similar group differences were observed for each PedsQL HRQoL and MDFS subscale score. CONCLUSIONS: Children and adolescents whose parents reported 1 to 2 PPCSs had lower HRQoL and more fatigue than those with 0 symptoms. Across all 3 groups, those with 3+ persistent symptoms had the lowest HRQoL and most fatigue. These findings indicate the continued need for intervention in this age group to prevent and address PPCSs.

Individual Symptom Report Prevalence in Children and Adolescents With One, Two, and Three or More Persistent Symptoms After Concussion: A Brief Report.

OBJECTIVE: To examine differences in individual symptom report prevalence between children and adolescents experiencing 1 to 2 versus ≥3 persistent postconcussion symptoms. DESIGN: A prospective cohort study. SETTING: Three community practice concussion clinics within a family practice network. PATIENTS: Children and adolescents aged 8 to 18 years presenting to clinics within 72 hours of a sport-related or recreation-related concussion. Those with complete symptom data from a 1-month follow-up time point (n = 236) were included in analyses. INDEPENDENT VARIABLES: One hundred thirty-six patients (n = 136) reported 0 symptoms as worse than preinjury at the 1-month time point. Participants reporting 1+ symptoms as worse than preinjury at 1 month were assigned to groups based on the number of symptoms endorsed: those with 1 to 2 (n = 38) compared with those experiencing ≥3 (n = 62). MAIN OUTCOME MEASURES: Fisher exact tests were used to compare symptom report prevalence for each item of the Rivermead Postconcussion Symptoms Questionnaire. This research question was formulated and examined after completion of data collection. RESULTS: Across both groups, headache and fatigue were the most commonly reported persistent postconcussion symptoms. Several emotional symptoms (eg, irritability, depression) were primarily or only present in those reporting ≥3 persistent symptoms. CONCLUSIONS: Findings provide detail regarding the clinical manifestation of experiencing fewer versus more persistent postconcussion symptoms, underscoring the importance of developing individualized, multifaceted rehabilitation programs.

Presence of Persistent Parent Reported Emotional and Behavioral-Related Concussion Symptoms Is Associated with Lower Health-Related Quality of Life in Adolescent Athletes.

Persistent concussion symptoms in adolescents are associated with lower health-related quality of life (HRQOL). The association between persistent emotional and behavioral-related concussion symptoms (EBS) and HRQOL is unknown, however. This study was a prospective cohort of adolescent athletes presenting to a concussion clinic within three days post-concussion and completing a one-month follow-up. The independent variable in these analyses was parent reported EBS symptom presence grouped as: (1) no EBS; (2) EBS present at pre-concussion levels; and (3) EBS worse than pre-concussion. The EBS included the following concussion symptoms: feeling irritable, depressed, frustrated/impatient, restless, reduced tolerance to stress/emotion, poor concentration, and fear of permanent symptoms. Dependent variables were parent reported psychosocial, physical, and total HRQOL. Separate multi-variable linear regression models controlling for age, sex, and concussion history were used to assess the association between EBS and HRQOL. Estimated adjusted mean differences (MD) and 95% confidence intervals (CI) were used to assess associations; MDs with a 95%CI excluding 0.0 were considered statistically significant. Overall, n = 245 presented to the study clinic three days post-concussion and completed the one-month follow-up (Mage = 14.28 ± 2.09 years, 59.02% male, 90.64% Caucasian, 31.84% with concussion history). At one-month post-concussion, adolescents with pre-concussion EBS levels had significantly lower psychosocial, physical, and total HRQOL than those with no EBS. In addition, those with EBS worse than pre-concussion had significantly lower psychosocial, physical, and total HRQOL than those with no EBS and EBS at pre-concussion levels. These findings highlight the importance of HRQOL assessments and that targeted interventions may be needed for those with EBS at one-month post-concussion to improve HRQOL.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.

BACKGROUND: Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE: To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS: On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS: A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION: Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS: ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.