Thursday, June 26, 2014

Acute Concussion Symptom Severity and Delayed Symptom Resolution

Pediatrics Editorial Board Member, Stephen Harris MD, MS, shares his expert perspective on a new article from our July issue. To learn more about Dr. Harris and his work in pediatric medicine, check out our Contributors page.

By: Stephen Harris, MD, MS

child wearing helmet
Photo by Abhisek Sarda via Flickr
During pediatric residency, I used to wear a button that said “I could’a been a brain surgeon,” just to tick off the neurosurgeons. Had I only rested my brain after getting my “bell rung” during my high school hockey days, who knows? Emergency department physicians and those who provide medical care for children now have a variety of practice guidelines, management tools and questionnaires readily available to determine the severity of a concussion, track a patient’s recovery and titrate a slow and safe return to physical and cognitive activities.

Grubenhoff and colleagues, writing in the July issue of Pediatrics (doi: 10.1542/peds.2013-2988), note that 630,000 children 0 to 19 years old visit US emergency departments (ED) for concussion. Citing the evidence that the risk of persistent symptoms may be modifiable, they hypothesized that an elevated symptom score on standardized evaluation at presentation would predict an increased risk of delayed symptom resolution.

Despite careful analysis of a well conducted study, Grubenhoff’s group did not find a target score that was statistically significantly associated with delayed symptom resolution. The authors explain that other studies have shown initial acuity predicts early symptoms, but complex, pre-existing psychological factors come into play to help explain who suffers from prolonged symptoms.

In a secondary analysis, Grubenhoff’s group did find a target score that predicted a higher risk of post-concussive syndrome as defined in the new ICD-10 system. They highlight some similarities between ICD-10 and the clinical criteria they used for delayed symptom resolution, but point out that the diagnostic accuracy of the ICD-10 criteria “is a topic of scientific debate as it is both subjective and imprecise.”

The authors’ call for those working in this research area to refine the definition of post-concussive syndrome should be heeded.

Grubenhoff and colleague’s work supports a continued conservative trajectory in the management of concussion. We now have a more full awareness of the increased risk of cerebral hemorrhage following a “second hit” to the head before one has completely recovered from a concussion—for children or adolescents. We also have an enormous and growing literature on the long-term neurologic and psychiatric consequences that may face those who participate in professional sports where one objective is to savage your opponent.

At the end of the day, any patient suffering a concussion should have close outpatient follow-up and serial symptom assessment following ED discharge.

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