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Original Investigation |

Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED

Roger Zemek, MD1; Nick Barrowman, PhD2; Stephen B. Freedman, MDCM, MSc3; Jocelyn Gravel, MD4; Isabelle Gagnon, PhD5; Candice McGahern, BA2; Mary Aglipay, MSc2; Gurinder Sangha, MD6; Kathy Boutis, MD7; Darcy Beer, MD8; William Craig, MDCM9; Emma Burns, MD10; Ken J. Farion, MD1; Angelo Mikrogianakis, MD11; Karen Barlow, MD12; Alexander S. Dubrovsky, MDCM, MSc5; Willem Meeuwisse, MD, PhD13; Gerard Gioia, PhD14; William P. Meehan III, MD15; Miriam H. Beauchamp, PhD16; Yael Kamil, BSc2; Anne M. Grool, MD, PhD, MSc2; Blaine Hoshizaki, PhD17; Peter Anderson, PhD18; Brian L. Brooks, PhD19; Keith Owen Yeates, PhD20; Michael Vassilyadi, MDCM, MSc21; Terry Klassen, MD8; Michelle Keightley, PhD22; Lawrence Richer, MD23; Carol DeMatteo, MSc24; Martin H. Osmond, MDCM1 ; for the Pediatric Emergency Research Canada (PERC) Concussion Team
[+] Author Affiliations
1Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
2Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
3Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
4Department of Pediatrics, Hospital Ste Justine, University of Montreal, Montreal, Quebec, Canada
5Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
6Department of Pediatrics, Children’s Hospital of Western Ontario, Western University, London, Canada
7Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
8Department of Pediatrics, Manitoba Children’s Hospital, Winnipeg, Canada
9Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada
10Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
11Department of Pediatrics, Alberta Children’s Hospital, Calgary, Canada
12Department of Pediatrics and Clinical Neurosciences, Alberta’s Children’s Hospital, University of Calgary, Calgary, Canada
13Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
14Department of Neuropsychology, Children’s National Health System, George Washington University School of Medicine, Rockville, Maryland
15Sports Concussion Clinic, Boston Children’s Hospital, Boston, Massachusetts
16Ste Justine Research Center, University of Montreal, Montreal, Quebec, Canada
17Department of Kinesiology, University of Ottawa, Ottawa, Ontario, Canada
18Department of Psychology, Children’s Hospital of Eastern Ontario, Ottawa, Canada
19Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
20Department of Psychology, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
21Department of Neurosurgery, Children’s Hospital of Eastern Ontario, Ottawa, Canada
22Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
23Department of Neurology, Stollery Children’s Hospital, Edmonton, Alberta, Canada
24School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
JAMA. 2016;315(10):1014-1025. doi:10.1001/jama.2016.1203.
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Published online

Importance  Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist.

Objective  To derive and validate a clinical risk score for PPCS among children presenting to the emergency department.

Design, Setting, and Participants  Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury.

Exposures  All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria.

Main Outcomes and Measures  The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury.

Results  In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, 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.

Conclusions and Relevance  A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.

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Figure 1.
Flow Diagram of Patients

aThe research ethics board for 1 of the 9 sites did not permit the collection of reasons for meeting exclusion criteria due to provincial regulations. Therefore, the total for “other” includes not specified along with missing.

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Figure 2.
Receiver Operating Characteristic Curves

PPCS indicates persistent postconcussive symptoms. 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.

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