Youth with repeat concussion have worse outcomes and more delays returning to normal life.
A majority of youth are symptom-free and fully recovered 1 year after concussion.
Still, those with repeat concussion had worse outcomes and delays in returning to normal school routines and sports.
The findings suggested the need for education strategies to potentially reduce parental anxiety following a pediatric concussion. Such strategies should be implemented into standardized care at the time of initial assessment to normalize outcome expectations. Further, clinicians, parents, and youth should consider the overall risks and benefits of resuming at-risk activities before medical clearance is granted.
Jacquie van Ierssel, PT, PhD, and a team of investigators included youth aged 5-18 years old who presented to the emergency department within 48-hours of sustaining a head injury and met the diagnostic criteria for concussion based on the Zurich Consensus Statement on Concussion in Sport.
Parents gave information on injury characteristics, concussion history, and developmental and psychiatric conditions using the Acute Concussion Evaluation (ACE). They rated symptoms using elements of the validated parent version of the Post-Concussion Symptom Inventory and completed a standardized electronic questionnaire between 12-18 months after the concussion to rate their child’s current symptoms, perceived level of recovery, concussion treatment, school functioning, physical activity, and if they sustained a repeat concussion.
Primary outcomes were the total number of symptoms parents rated as worse on the one-year questionnaire than pre-injury based on 25 symptom questions across 4 domains, physical, cognitive, sleep, and emotional. Additional outcomes were assessed to better understand recovery, school function, and physical activity. Children were considered to have returned to their normal school routine if they no longer needed academic support, modifications to class schedule, or academic accommodations.
Among eligible youth, 432 responded to a post-hoc request and completed the one-year follow-up survey at a median of 14 months following the index concussion. Those who responded were younger (11.5 years old vs 12.1 years old; P=.003) and had a personal history of migraine (9% vs 14%; P=.015) compared to those who did not respond.
A majority of youth experiences a significant reduction in all symptoms one-year post-concussion (P <.001). Headache was the most common residual symptom at one-year (26% in the repeat concussion subgroup vs 13% in those without; difference, 14% [95% CI, 1-34]; P=.024). Following headache, the most common symptoms were fatigue, difficulty remembering, irritability, and feeling more emotional.
Repeat concussion led to the odds of having a higher number of symptoms worse than baseline (OR, 2.54; 95% CI, 1.33-4.86; P=.005). Only 50% of youth with repeat concussion were symptom-free following 1 year compared with 75% of youth with only acute concussion (difference, 25%; 95% CI, 8-41; P=.002).
Parents reported concern about the effect of concussion on school function one-year post concussion with (53%) and without repeat concussion (36%) (difference, 17%; 95% CI, 0-33; P=.207). They were also concerned about their child’s school performance (44% vs 20%; difference, 24%; 95% CI, 3-47; P=.06) and ability to learn (39% vs 44%; difference, -5%; 95% CI, 19-25; P=.06).
Investigators found at one-year post-concussion, 98% of youth without repeat concussion and 85% of those with repeat concussion resumed physical activity (difference, 13%; 95% CI, 4-28; P <.0001), and 95% of youth without repeated concussion and 82% of youth with repeat concussion returned to organized sports (difference, 13%; 95% CI, 3-29; P=.009). Fear of re-injury, generalized anxiety, and medical advisement to discontinue collision sports were common reasons why youth had not resumed their previous sports.
Additional research is needed to characterize the risk of repeat concussion to inform pediatric concussion clinical guidelines and decision-making.
The study, “Symptom Burden, School Function, and Physical Activity One-Year Following Pediatric Concussion,” was published online in The Journal of Pediatrics.