Objective
To identify pre-existing characteristics associated with prolonged
recovery from concussion in a sample of patients referred to a pediatric
sports medicine clinic.
Study design
This was a retrospective, exploratory cohort study of 247 patients
age 5-18 years old with concussion referred to a tertiary pediatric
hospital-affiliated sports medicine clinic from July 1, 2010, through
December 31, 2011. A random sample of all eligible patient visits (3740) was
chosen for further review and abstraction. Statistical comparisons between
subsets of patients were conducted using exact chi-square tests, logistic
regression, quantile regression, and Kaplan Meier survival curves.
Results
The median time until returning to school part-time was 12 days
(interquartile range (IQR) 6-21); until returning to school full-time
without accommodations was 35 days (IQR 11-105); until becoming symptom-free
was 64 days (IQR 18-119); and until being fully cleared to return to sports
was 75 days (IQR 30-153). 73% of all patients were symptomatic for >4
weeks, 73% were prescribed some form of school accommodation, and 61%
reported a decline in grades. Characteristics associated with a prolonged
recovery included a history of depression or anxiety; an initial complaint
of dizziness; abnormal convergence or symptom provocation following
oculomotor examination on physical examination; and history of prior
concussion.
Conclusion
Pediatric and adolescent patients with concussion may experience
cognitive and emotional morbidity that can last for several months following
injury. Clinicians should consider specific pre-existing characteristics and
presenting symptoms that may be associated with a more complicated recovery
for concussion patients.
A high prevalence of vision diagnoses (accommodative, binocular convergence, and saccadic eye movement disorders) was found in this sample of adolescents with concussion, with some manifesting more than one vision diagnosis. These data indicate that a comprehensive visual examination may be helpful in the evaluation of a subset of adolescents with concussion. Academic accommodations for students with concussion returning to the classroom setting should account for these vision diagnoses.
CME Educational Objectives
1.
Prescribe physical and cognitive rest for pediatric and adolescent concussion.
2.
Implement a gradual “return-to-learn” plan for student-athletes after concussion.
3.
Communicate specific school-based accommodations to facilitate a gradual reintegration to full school activities.
The concept of “return-to-play” after concussion is familiar to pediatricians who routinely care for injured student-athletes. Premature return-to-play of a student-athlete who is still injured from a concussion may result in more severe and potentially long-lasting deficits.
1
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