New Concussion Score for Children Flags Higher-Risk Cases

March 09, 2016

A 12-point clinical score for children with concussion has been developed and shown in a new study to identify those who are more likely to have prolonged symptoms and therefore need closer follow-up.

The study, published in the March 8 issue of JAMA, was conducted by a team led by Roger Zemek, MD, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.

"We have developed an easy-to-calculate clinical score which could potentially individualize concussion care in children, identifying those with high risk of prolonged symptoms who will need closer follow-up," Dr Zemek told Medscape Medical News.

He added that the score will also be useful in advancing research on treatments for concussion as these higher-risk individuals will be the most suitable patients to include in trials of interventions that may prevent or shorten long-term concussion symptoms.

Dr Zemek noted that concussion has received a fair amount of media attention recently, which has resulted in rising numbers of visits to the emergency department and primary care doctors. "The first question parents ask is, 'When is my child going to be better?' But prior to this work we didn't have any scientific basis to answer this question," he said.

He explained that concussion symptoms are prolonged for more than a month in about one third of cases. Such symptoms can include headache, dizziness, and difficulty concentrating, symptoms that have an adverse effect on quality of life and can affect school attendance and exam performance.

"Currently we cannot tell which patients are more likely to have prolonged symptoms," he said. "It is important to be able to provide the family with some realistic guidance on when the child is likely to recover and to be able to target specialist care to the higher-risk patients."

Although there have been a few small studies in selected groups of competitive athletes, the current study included a large diverse population of children aged between 5 and 18 years for factors that are associated with persistent symptoms of concussion beyond 1 month, known as persistent post-concussion symptoms (PPCS).

Nine Factors for Concern

The researchers looked at more than 70 possible variables and found 9 that seemed to be particularly independently associated with long-term symptoms: female sex, age 13 years or older, migraine history, previous concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and difficulty standing on a balance beam (4 or more errors on the Balance Error Scoring System).

"Interestingly, some of the traditional risks factors that have caused concern, such as vomiting and loss of consciousness, didn't make the final round when we assessed all the risk factors together," Dr Zemek noted.

The researchers developed a scoring system; most of these factors were assigned 1 point, but age 13 or older , female sex, and fatigue were given 2 points because they were more strongly associated with long-term symptoms. This resulted in a 12-point scale, and the researchers designated a score of 9 to 12 as high risk, 0 to 3 as low risk, and 4 to 8 as intermediate risk.

"Our results suggest that a score of 9 to 12 on this scale signifies a high risk of prolonged symptoms of concussion, with a 93% certainty: ie, the test has a 93% specificity," Dr Zemek said. "We can also say that a score of 9 to 12 means that a child is three times more likely to have persistent symptoms than the standard score. And a score of 0 to 3 means they are three times less likely than a standard score to have prolonged issues."

The study involved 3063 children aged 5 to 18 presenting at one of nine pediatric emergency departments across Canada with one or more symptoms associated with concussion and a Glasgow Coma Scale score of 14 or 15.

The primary outcome was patient-reported presence of three or more new or worsening symptoms compared with before the injury occurred, documented on questionnaires administered 28 days after injury via email or telephone.

Results showed that a low-risk score of 0 to 3 on the 12-point scale was associated with a probability of PPCS of 4.1% to 11.8%. The high-risk scores of 9 to 12 were associated with a probability of PPCS of 57.1% to 80.8%. The medium-risk scores of 4 to 8 showed a probability of long-term symptoms of 16.4% to 47.6%.

The test had "modest discrimination" when compared with other methods of assessing risk, with a C statistic of 0.71. Dr Zemek commented: "A C statistic of 1.0 means that the test is 100% accurate.

"A value of 0.5 means it is right half the time — so just the play of chance. There really isn't anything else to use to gauge who will have long-term symptoms at present. The clinical judgment of a doctor showed a C statistic of 0.57, not much better than the play of chance. Our test represents a significant improvement on that."

Clinician Prediction "No Better Than a Coin Toss"

In an accompanying editorial, Lynn Babcock, MD, and Brad G. Kurowski, MD, University of Cincinnati, Ohio, agree that the new score generates risk estimates for PPCS superior to clinician prediction, which they say was "no better than a coin toss."

They write: "Considering the variation in individual symptom profiles and trajectories, personalized patient-oriented approaches to ongoing assessments and delivery of postinjury interventions are needed to facilitate recovery in these vulnerable children and adolescents."

They caution that inclusion of patients and clinicians only from specialized pediatric emergency departments raises concerns about the generalizability of this study, and the findings need to be validated in other settings.

They also call for assessment of the score in other populations, including those with multiple trauma, younger children, and those with lower Glasgow Coma Scale scores.

This study was supported by the Canadian Institutes of Health Research, the Canadian Institutes of Health Research–Ontario Neurotrauma Foundation Mild Traumatic Brain Injury Team, and a planning grant from the Canadian Institutes of Health Research. Dr Zemek has disclosed no relevant financial relationships; disclosures for coauthors appear in the paper. Dr Kurowski reported receiving grants from the National Institutes of Health and the US Centers for Disease Control and Prevention. Dr Babcock has disclosed no relevant financial relationships.

JAMA. Published online March 8, 2016. Full text Editorial

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