Children and adolescents with a history of concussion take significantly longer to recover, and those that have sustained two or more previous concussions or a single concussion within the past year are at even greater risk of prolonged symptoms, finds an important new study. (1)
Relatively little is known about risk factors for prolonged postconcussive symptoms in children. Researchers at Boston Children's Hospital studied 280 patients between the ages of 11 and 22 with a mean age of 14 who were treated in the emergency department (ED) for concussion symptoms [1]. The most common symptoms were headache (85%), fatigue (65%) and dizziness [2] (63%). The majority (63.8%) were injured playing sports, the most common being hockey (14%), soccer (9.4%), football (8.5%) and basketball (8.1%).
On discharge, two thirds (65.9%) were prescribed a period of cognitive rest. [3] Nearly all (92.4%) were advised to take time off from sports; two-thirds (63.8%) were asked to follow up with their primary care doctor, nearly half (45.5%) in a sports concussion clinic, and 6.2% with another specialist.
The researchers found that concussion symptoms lasted twice as long for patients with a history of previous concussion as those without such a history (24 versus 12 days); that the median symptom duration for those with a multiple concussion history and who had sustained a concussion within the past year was 2 and 1/2 times longer (28 days) and nearly three times (33 days) longer respectively, compared with patients without such risk factors.
The finding linking multiple previous concussion history and prolonged symptom duration is consistent with a 2005 study [4] (7) led by MomsTEAM's expert sport concussion neuropsychologist, Rosemarie Scolaro Moser, PhD, [5] that showed that high school athletes with two or more concussions performed more poorly on cognitive measures than those athletes with one or no previous concussions, and a 2011 study (8) that revealed that youth athletes with multiple concussions reported more cognitive, emotional, physical and sleep complaints than their less concussed peers,
Based on studies in mice which had suggested that the effect of multiple concussions was cumulative, and that there was a time period after a concussion during which the brain was more vulnerable to the effect of additional trauma, the researchers hypothesized that symptoms for those with a previous concussion would take longer to clear than those without such a history, and that those who sustained a concussion within the previous year would have a longer time to symptom resolution than those whose injuries were more remote in time.
That is exactly what they found.
"Our study demonstrates this temporary sensitive effect of previous concussion for the first time in humans," wrote lead author Matthew A. Eisenberg, MD, of the Division of Emergency Medicine, Boston Children's Hospital. "This has direct implications on the management of athletes and other at-risk individuals who sustain concussions, supporting the concept that sufficient time to recover from a concussion may improve long-term outcomes."
The findings should help reduce "uncertainty among patients, families, and health care providers as to which patients would benefit from specialist follow-up, extended academic accommodations [6], prolonged abstinence from athletic participation, and even permanent cessation of high-risk activity," Eisenberg said.
Our study provides "support for the concept that sufficient time to recover from a concussion may improve long-term outcomes," said co-author, William P. Meehan, III, M.D., Director of the Sports Concussion Clinic and the Micheli Center for Sports Injury Prevention in the Division of Sports Medicine at Boston Children's Hospital and a MomsTEAM expert [7]. "Some have argued that a symptom-free waiting period after a concussion is unnecessary, as their studies did not find an increased risk of concussion for athletes who returned without waiting until their symptoms cleared. Our study suggests that there may be long-term benefits [to waiting longer before returning to sports]."
"Thes other findings will need further research and clarification due to confounding variables that may have influenced the statistical analysis," said Moser. "For example, that adolescents seemed to have more difficulties with recovery than pre-adolescents suggests that younger athletes may bounce back sooner, but, as the authors noted, it is possible that older athletes who came to the Emergency Department in this study may have had more significant injuries and been exposed to greater contact risk in their sports, than was the case for the younger athletes. Also, there may have been other factors that resulted in the finding that female athletes did not seem to experience longer recovery times compared to male athletes. Clearly, further research on how age and gender affect concussion recovery is needed."
"The beauty of this research study," says Moser, "is that it supports what sports concussion clinicians already intuitively know: youth athletes experience longer recovery periods and greater symptoms when concussions are close in time proximity or when there is a history of multiple concussions. The study is to be commended for its prospective approach, as previous studies in this area have been retrospective, studying a limited population of participants after the fact."
1. Eisenberg M, Andrea J, Meehan W, Mannix R. Time Interval Between Concussions and Symptom Duration. Pediatrics 2013;132(1):1-10.
2. Meehan W, Mannix R, Straccoilini A, Elbin R, Collins M. Symptom Severity Predicts Prolonged Recovery after Sport-Related Concussion, But Age and Amnesia Do Not. J Pediatrics 2013 DOI 10.1016/j.jpeds.2013.03.012 (published online ahead of print April 25, 2013).
3. Babcock L, et al. Predicting post-concussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr. 2013;167(2):156-161.
4. Baillargeon A, Lassonde M, Leclerc S, Ellemberg D. Neuropsychological and neurophysiological assessment of sport concussion in children, adolescents and adults. Brain Injury 2012;26(3):211-220.
5. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.
6. Child-SCAT3. Br J Sports Med 2013;47:263.
7. Moser RS, Schatz P, Jordan BD. Prolonged Effects of Concussion in High School Athletes. Neurosurgery 2005; 57(2):300-306.
8. Schatz P, Moser RS, Covassin T, Karpf R. Early Indicators of Enduring Symptoms in High School Athletes with Multiple Previous Concussions. Neurosurgery 2011;68:1562-1567.
Posted June 10, 2013; revised June 11, 2013 to reflect Dr. Moser's comments; further revised June 17, 2013 to include Dr. Meehan's comments
Links:
[1] https://www.momsteam.com/node/149
[2] https://www.momsteam.com/node/4029
[3] https://www.momsteam.com/node/4173
[4] https://www.momsteam.com/node/3550
[5] https://www.momsteam.com/node/3468
[6] https://www.momsteam.com/node/3549
[7] https://www.momsteam.com/node/3526
[8] https://www.momsteam.com/node/6037
[9] https://www.momsteam.com/node/150
[10] https://www.momsteam.com/node/3385
[11] https://www.momsteam.com/node/6026
[12] https://www.momsteam.com/high-initial-concussion-symptom-score-suggests-longer-recovery
[13] https://www.momsteam.com/health-safety/effects-concussion-suble-yet-prolonged-those-with-multiple-concussion-history
[14] https://www.momsteam.com/health-safety/are-teens-more-vulnerable-lingering-effects-concussion-on-working-memory
[15] https://www.momsteam.com/pcss/teens-with-multiple-concussion-history-much-more-likely-report-continuing-symptoms
[16] https://www.momsteam.com/health-safety/concussion-safety/multiple-concussion-history-important-factor-in-concussion-management
[17] https://www.momsteam.com/health-safety/concussion-safety/more-conservative-approach-concussions-in-children-teens-recommended
[18] https://www.momsteam.com/cerebral-blood-flow/new-study-supports-more-conservative-management-concussions-in-children-teens
[19] https://www.momsteam.com/health-safety/dizziness-at-time-concussion-linked-to-longer-recovery
[20] https://www.momsteam.com/cognitive-rest/cognitive-rest-after-concussion-critical