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November 7, 2014
Letter to the Editor

Early symptom burden predicts recovery after sport-related concussion

December 9, 2014 issue
83 (24) 2204-2210

Abstract

Objective:

To identify independent predictors of and use recursive partitioning to develop a multivariate regression tree predicting symptom duration greater than 28 days after a sport-related concussion.

Methods:

We conducted a prospective cohort study of patients in a sports concussion clinic. Participants completed questionnaires that included the Post-Concussion Symptom Scale (PCSS). Participants were asked to record the date on which they last experienced symptoms. Potential predictor variables included age, sex, score on symptom inventories, history of prior concussions, performance on computerized neurocognitive assessments, loss of consciousness and amnesia at the time of injury, history of prior medical treatment for headaches, history of migraines, and family history of concussion. We used recursive partitioning analysis to develop a multivariate prediction model for identifying athletes at risk for a prolonged recovery from concussion.

Results:

A total of 531 patients ranged in age from 7 to 26 years (mean 14.6 ± 2.9 years). The mean PCSS score at the initial visit was 26 ± 26; mean time to presentation was 12 ± 5 days. Only total score on symptom inventory was independently associated with symptoms lasting longer than 28 days (adjusted odds ratio 1.044; 95% confidence interval [CI] 1.034, 1.054 for PCSS). No other potential predictor variables were independently associated with symptom duration or useful in developing the optimal regression decision tree. Most participants (86%; 95% CI 80%, 90%) with an initial PCSS score of <13 had resolution of their symptoms within 28 days of injury.

Conclusions:

The only independent predictor of prolonged symptoms after sport-related concussion is overall symptom burden.

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REFERENCES

1.
McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290:2556–2563.
2.
Meehan WP, d'Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med 2010;38:2405–2409.
3.
Meehan WP, d'Hemecourt PA, Collins CL, Comstock RD. Assessment and management of sport-related concussions in United States high schools. Am J Sports Med 2011;39:2304–2310.
4.
Chrisman SP, Rivara FP, Schiff MA, Zhou C, Comstock RD. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Inj 2013;27:1–9.
5.
Babcock L, Byczkowski T, Wade SL, Ho M, Mookerjee S, Bazarian JJ. Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr 2013;167:156–161.
6.
Dischinger PC, Ryb GE, Kufera JA, Auman KM. Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. J Trauma 2009;66:289–296; discussion 296–287.
7.
Eisenberg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics 2013;132:8–17.
8.
Faux S, Sheedy J, Delaney R, Riopelle R. Emergency department prediction of post-concussive syndrome following mild traumatic brain injury: an international cross-validation study. Brain Inj 2011;25:14–22.
9.
McCrea M, Guskiewicz K, Randolph C, et al. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J Int Neuropsychol Soc 2013;19:22–33.
10.
Lau B, Lovell MR, Collins MW, Pardini J. Neurocognitive and symptom predictors of recovery in high school athletes. Clin J Sport Med 2009;19:216–221.
11.
Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med 2011;39:1209–1216.
12.
Lau BC, Collins MW, Lovell MR. Cutoff scores in neurocognitive testing and symptom clusters that predict protracted recovery from concussions in high school athletes. Neurosurgery 2012;70:371–379.
13.
Meehan WP, Mannix RC, Stracciolini A, Elbin RJ, Collins MW. Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. J Pediatr 2013;163:721–725.
14.
McCrory P, Meeuwisse W, Johnston K, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009;43(suppl 1):i76–i90.
15.
Collins MW, Field M, Lovell MR, et al. Relationship between postconcussion headache and neuropsychological test performance in high school athletes. Am J Sports Med 2003;31:168–173.
16.
Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med 2003;13:222–229.
17.
Iverson GL, Lovell MR, Collins MW. Interpreting change on ImPACT following sport concussion. Clin Neuropsychol 2003;17:460–467.
18.
Iverson GL, Gaetz M, Lovell MR, Collins MW. Relation between subjective fogginess and neuropsychological testing following concussion. J Int Neuropsychol Soc 2004;10:904–906.
19.
Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med 2006;34:1630–1635.
20.
Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290:2549–2555.
21.
Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR. Natural history of concussion in sport: markers of severity and implications for management. Am J Sports Med 2010;38:464–471.
22.
Erlanger D, Kaushik T, Cantu R, et al. Symptom-based assessment of the severity of a concussion. J Neurosurg 2003;98:477–484.
23.
Gronwall D, Wrightson P. Cumulative effect of concussion. Lancet 1975;2:995–997.
24.
Lovell MR, Collins MW, Iverson GL, et al. Recovery from mild concussion in high school athletes. J Neurosurg 2003;98:296–301.
25.
Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 2003;142:546–553.
26.
Gordon KE, Dooley JM, Wood EP. Is migraine a risk factor for the development of concussion? Br J Sports Med 2006;40:184–185.
27.
Sperandi S. Understanding logistic regression analysis. Biochem Med 2013;24:12–18.
28.
Dawson B, Trapp RG. Statistical Methods for Multiple Variables: Basic and Clinical Biostatistics, 4th ed. New York: McGraw-Hill; 2004.
29.
Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med 2011;39:2311–2318.
30.
Zemek RL, Farion KJ, Sampson M, McGahern C. Prognosticators of persistent symptoms following pediatric concussion: a systematic review. JAMA Pediatr 2013;167:259–265.
Letters to the Editor
14 January 2015
omitted references
Ira R. Casson, neurologist

I agree with Meehan et al's conclusion that " the best predictor of prolonged symptoms after sport-related concussion is simply total symptom burden at the time of presentation". [1] This confirms our similar findings [2] These two papers were not cited by Meehan et al. and I respectfully request that the authors correct this oversight.

1. Pellman EJ, Viano D, Casson IR, Arfken C, Powell J. Concussion in Professional Football: InjuriesInvolving 7 or more Days Out - Part 5. Neurosurgery 2004; 55: 1100 - 1119.

2. Pellman EJ, Viano D, Casson IR, Arfken C, Feuer H. Concussion in Professional Football: Players Returning to the Same Game - Part 7. Neurosurgery 2005; 56: 79 - 92.

For disclosures, please contact the editorial office at [email protected].
14 January 2015
Reply to Dr. Casson
William P. Meehan III, MD

We thank Dr. Casson for his interest in our work [1] and are pleased that he agreed with the conclusions. Although we are familiar with his studies, we did not cite them in our article for several reasons. We conducted an original study versus a literature review, meta-analysis, or systematic review. Thus, our discussion section was focused on the interpretation of our results and described how our results fit into the overall body of literature on this topic. [2] As our population consisted of all patients with a concussion who presented to an outpatient clinic at an academic medical center, it would substantially differ from the population of professional football players on which Dr. Casson reported. Given the substantial difference between the study populations and methodologies used, we did not believe comparisons between our studies were appropriate.

1. Meehan III WP, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology 2014; 83: 2204-2210.

2. Browner WS. Discussion. In Publishing and Presenting Clinical Research. Philadelphia: Lipincott, Williams & Wilkins; 2006.

For disclosures, contact the editorial office at [email protected].

14 January 2015
Response to Dr. Sethi
William P. Meehan

We thank Dr. Sethi for his interest in our work. [1] His observations that the acute findings do not reliably predict either the symptom burden or duration of symptoms after a concussion appear accurate and are corroborated by previous investigations. These findings, in part, led to the change away from grading systems that used the acute clinical parameters to grade concussions. His hypotheses regarding the reasons for the variability of symptom burden between patients that sustain concussions all seem plausible. In addition, we note that the symptoms of concussion are non-specific and therefore, particularly as time goes by, some symptoms may be due to the treatment of concussion, namely the restrictions placed on cognitive and physical activity, as opposed to the pathophysiology of concussion itself.

1. Meehan III WP, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology 2014; 83: 2204-2210.

For disclosures, contact the editorial office at [email protected].

8 January 2015
Prolonged recovery after concussion
Nitin K. Sethi, Assistant Professor of Neurology
Nitin K Sethi, New York, NY

The authors [1] and the editorialists [2] assessed the prediction of recovery after sports-related concussion. Overall subjective symptom burden was the only independent predictor of prolonged recovery in Meehan et al.???s cohort. I would like to know the reason why some athletes report a greater subjective symptom burden after a concussion than others. I see athletes and non-athletes with "mild" concussion if graded on the basis of mechanism of injury, presence or absence of loss of consciousness (LOC), duration of LOC and duration of post traumatic amnesia (PTA) but who report an increased subjective symptom burden (high scores on the Post-Concussion Symptom Scale) and have a prolonged and at times incomplete recovery from their reported subjective symptoms. This is contrary to some athletes and non-athletes who seem to have had a "moderate" or "severe" concussion but report few subjective symptoms. It may be that some brains are inherently more vulnerable to concussion due to yet unidentified genetic, structural and functional brain connectivity causes. Pre-morbid (concussion) factors such as baseline IQ, personality and psychosocial factors: family support, presence or absence of underlying anxiety-depressive disorder, primary or secondary gain, may alter the reported subjective symptom burden.

1. Meehan WP 3rd, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology. 2014;83:2204-2210.

2. Tsao JW, Perry BN, Kennedy CH, Beresford R. Predicting prolonged recovery after concussion. Neurology. 2014;83:2196-2197.

For disclosures, please contact the editorial office at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 83Number 24December 9, 2014
Pages: 2204-2210
PubMed: 25381296

Publication History

Received: April 24, 2014
Accepted: July 26, 2014
Published online: November 7, 2014
Published in print: December 9, 2014

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Disclosure

W. Meehan receives royalties from ABC-Clio for the sale of his book, Kids, Sports, and Concussion: A Guide for Coaches and Parents and royalties from Wolters Kluwer for working as an author for UpToDate. R. Mannix, M. Monuteaux, and C. Stein report no disclosures relevant to the manuscript. R. Bachur receives royalties from Wolters Kluwer for his work as an editor for UpToDate and from Lippincott Williams & Wilkins for his work as editor of Textbook of Pediatric Emergency Medicine. His research on biomarkers for appendicitis receives industry sponsorship from Astute Medical. Go to Neurology.org for full disclosures.

Study Funding

Funded by the NIH T32 HD040128-06A (Dr. Meehan) and the NFL Players Association (Dr. Meehan).

Authors

Affiliations & Disclosures

William P. Meehan, III, MD
From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
I receive royalties from Praeger Publishing for my book: Kids, Sports, and Concussion: A guide for coaches and parents. I also receive royalties from Wolters-Kluwer for writing for the online medical resource UpToDate: Sport-Related Concussion in Children and Adolescents: clinical manifestations and diagnosis; Sport-Related Concussion in Children and Adolescents: management; and Chronic Exertional Compartment Syndrome.
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Bauer - I was site PI on a project studying impact forces sustained by the head during youth ice hockey. The study was funded in part by Bauer, maker of ice hockey helmets.
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
I am associate director of the Football Players Health Study at Harvard, a large, long-term project investigating the medical conditions and health-related issues affecting current and former NFL players.
Research Support, Foundations and Societies:
1.
I received funding to study the effects of light emitting diodes in the red/near infrared spectrum on symptoms and cognitive assessments after concussion from the following: (1) The Center for the Integration of Medicine and Innovative Technology, (2) The American Medical Society for Sports Medicine, and (3) The American College of Sports Medicine.
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Rebekah Mannix, MD, MPH
From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
1) Boston Children's Hospital Translational Research Program
Research Support, Foundations and Societies:
1.
1) The Baby Alex Foundation 2) The Charles Hood Foundation
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Michael C. Monuteaux, ScD
From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NIH, Site PI, 2012-1014
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Cynthia J. Stein, MD, MPH
From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Summer Explo $250 to speak to grade school and high school students. Commercial organization.
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
Spinal Injuries and Conditions in Young Athletes. (2014) Edited by Micheli L, Stein C, O�Brien M, d�Hemecourt P. New York, NY: Springer. No royalties received to date.
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Richard G. Bachur, MD
From The Micheli Center for Sports Injury Prevention (W.P.M.), Waltham; and the Sports Concussion Clinic, Division of Sports Medicine (W.P.M., C.J.S.), Division of Emergency Medicine (W.P.M., R.M., M.C.M., R.G.B.), and Brain Injury Center (W.P.M., R.M.), Boston Children's Hospital, MA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
UpToDate, section editor, pediatric trauma, 2009-current
Patents:
1.
Biomarkers for pediatric appendicitis
Publishing Royalties:
1.
(1) Textbook of Pediatric Emergency Medicine, Lippincott, 2010; (2) UpToDate, UpToDate.com, 2009-current
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Astute (San Diego, CA), support of research for appendicitis biomarkers
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
biomarkers for appendicitis, Astute, 2012-current
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
Expert legal opinion - 1-2 legal firms per year for since 2007; none related to content of this paper

Notes

Correspondence to Dr. Meehan: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Dr. Meehan contributed to the concept of the study, design of the study, data collection, data analysis, interpretation, and manuscript preparation. Dr. Mannix contributed to the concept of the study, design of the study, data analysis, interpretation, and manuscript preparation. Michael Monuteaux contributed to the design of the study, data analysis, interpretation, and manuscript preparation. Dr. Stein contributed to the data collection, data analysis, interpretation, and manuscript preparation. Dr. Bachur contributed to the concept of the study, design of the study, data analysis, interpretation, and manuscript preparation.

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