A novel clinical risk score better predicted postconcussive symptoms in pediatric patients than physician judgement, results from a prospective, multicenter cohort study indicate.
Nearly one-third of pediatric concussion patients experience persistent postconcussive symptoms (PPCS), including somatic, cognitive, and psychological or behavioral symptoms, however no validated tools exist to identify high-risk patients.
Using readily available clinical features, researchers led by Roger Zemek, MD, of Children’s Hospital of Eastern Ontario at the University of Ottawa in Ottawa, Canada, set out to validate the risk score, defined as 3 or more new or worsening symptoms based on patient-reported Postconcussion Symptom Inventory compared with recall of their state of being prior to injury. Out of 46 potential variables, the researchers identified 9 easily obtainable factors highly associated with PPCS that accounted for demographics, history, initial symptoms, cognitive complaints, and physical examination.
In total, 3063 patients (median age, 12 years; 39% girls) were enrolled (n=2006 in derivation cohort; n=1057 in validation cohort), of whom 2584 (n=1701 derivation; n=883 validation) completed follow-up 28 days after injury. PPCS were present in 31% of patients (n=801).
The 12-point PPCS risk score model for the derivation cohort included variables for female sex, age 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, noise sensitivity, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort. Based on the 12-point scoring system, the researchers proposed 3 levels of risk: low risk, with probability of PPCS ranging from 4.1%-11.8%; medium risk, with probability of PPCS ranging from 16.4%-47.6%; and high risk, with probability of PPCS ranging from 57.1%-80.8%.
The risk score showed modest discrimination to stratify PPCS risk at 28 days post-injury.
“Although the clinical utility of the PPCS risk score will need to be assessed in an externally validated implementation study prior to adoption into routine practice, the risk stratification score has the potential to individualize concussion care through optimal symptom management and appropriate follow-up,” the authors wrote. “Therefore, future research needs to determine if the moderate test characteristics of the PPCS risk score allow for clinicians to confidently provide reassurance, alter management plans, or both.”
Utilizing the risk score in the future may allow physicians to not only identify patients in need of further screening or evaluation, but also identify those who may benefit from emerging treatments, noted Lynn Babcock, MD, MS, and Brad G. Kurowski, MD, MS, who authored an accompanying editorial.
“Considering the variation in individual symptom profiles and trajectories, personalized patient-oriented approaches to ongoing assessments and delivery of post-injury interventions are needed to facilitate recovery in these vulnerable children and adolescents.”
- Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016;315(10):1014-1025. doi:10.1001/jama.2016.1203.
- Babcock L, Kurowski BG. Identifying Children and Adolescents at Risk for Persistent Postconcussion Symptoms.JAMA. 2016;315(10):987-988. doi:10.1001/jama.2016.1276.