Peer-reviewed article

QUALITY-OF-LIFE OUTCOMES AND ACADEMIC CONCERNS FOLLOWING PEDIATRIC CONCUSSION: INITIAL FINDINGS FROM THE PRISM CONCUSSION RIG

Howell D, Fazekas M, Grady M, Halstead M, Master C et al. · 1 Apr 2020

Abstract

Background: Concussion is a complicated injury that affects many facets of life in children and adolescents. Neurocognitive and self-reported symptom outcomes are commonly used to understand post-concussion effects. The degree to which concussion affects quality-of-life (QoL) and school performance remains difficult to determine among this age group. Purposes and Hypotheses: Our first purpose was to compare QoL domains using the Patient-Reported Outcomes Measurement Information System (PROMIS) among concussed children to healthy children. We hypothesized that concussed children would report worse QoL than controls. Our second purpose was to identify school-related difficulties that children encounter post-concussion. We hypothesized that the majority of patients would report moderate-to-high academic concerns. Methods: We conducted a multi-site study of patients evaluated at pediatric sports medicine centers and healthy controls undergoing pre-participation physical examinations. All participants were less than 19 years of age and those with a concussion were evaluated <14 days post-injury. Our primary outcomes were derived from PROMIS and Concussion Learning Assessment and School Survey (CLASS) questionnaires. The CLASS was completed only among the concussed group. We compared PROMIS outcomes using Mann Whitney U tests and constructed linear regression models to control for the effect of age and sex. Results: Forty-four individuals participated: 22 with concussion and 22 controls. No significant differences were noted between groups in regard to sex or age. On average, the concussion group missed 2.8 days of school, required 25 days for symptom resolution, and 40 days until return to sports clearance (Table 1). The concussion group reported significantly worse mobility, fatigue, pain interference, and pain visual analog scale (VAS) ratings than the control group (Table 2). After adjusting for age and sex, the concussion group still had significantly worse mobility (β=6.6; 95% CI=4.8,8.4), fatigue (β=6.8; 95% CI=4.5,9.2), pain interference (β=6.1; 95% CI=3.5,8.7), and pain VAS ratings (β=4.5; 95% CI=3.7,5.3) than healthy controls. Among the concussed cohort, 52% reported a moderate or very high overall concern related to the perceived effect their concussion had on school performance with 50% reporting that headaches interfered with their schoolwork and 55% reporting that reading/English were the most troubling classes (Table 3). Conclusion: Within 14 days of injury, concussed children reported significantly worse mobility, fatigue and pain outcomes relative to healthy controls, and reported troubling academic concerns related to their injury. Assessment of patient-reported outcomes following concussion may provide valuable insights to direct management plans beyond typical assessments of concussion symptoms or neurocognitive function. Table 1. Characteristics of concussion and control groups. Continuous variables are presented as means (sd) and categorical variables are presented as n (%).VariableConcussion(n=22)Control(n=22)P valueFemale sex12 (55%)12 (55%)1.00Age (years)13.5 (3.4)14.8 (1.7)0.11Assessment time (days post-injury)7.6 (3.6)--Number of school days missed (days)2.8 (1.7)--Symptom resolution time (days)25.1 (16.4)--Return to play time (days)40.1 (26.5)--Table 2. Comparison between concussion and control groups on PROMIS outcome measures. Data are presented as median [interquartile range].DomainConcussionControlP valueMobility8 [2-9]0 [0-0]< 0.001Anxiety2 [0-8]2 [0-6]0.63Depressive2.5 [1-5]1 [0-2]0.05Fatigue8 [6-12]1 [0-3]< 0.001Peer relationships16 [12-16]15 [12-16]0.55Pain interference9 [5-12]0 [0-2]< 0.001Pain VAS rating5 [3-6]0 [0-1]< 0.001Table 3. School-related difficulties reported by concussion patients on the CLASS survey.FactorResponse% (n)Concern about injury affecting school performanceVery concernedModerately concernedMildly concernedNot concerned19% (4)33% (7)29% (6)19% (4)School factor most concerned aboutGrades droppingAbility to learn, remember, concentrateAmount of work/falling behindOther52% (10)21% (4)16% (3)11% (2)Types of problems experienced after concussionHeadaches interferingCan’t pay attention in classToo tiredHomework is taking longerDifficulty studying for testsDifficulty taking notesDifficulty understanding material50% (11)45% (10)41% (9)27% (6)27% (6)23% (5)14% (3)Classes/subjects producing the most trouble after concussionReading/EnglishMathScienceSocial Studies/HistoryForeign LanguagePhysical EducationArtMusic55% (12)32% (7)18% (4)14% (3)9% (2)9% (2)5% (1)5% (1)Grades affected since injury?YesNot yet, but worried they mightNo39% (7)33% (6)28% (5)Kind of help needed in returning to schoolRest breaksExtra time to complete workI don’t knowReduced homeworkShortened dayNo testsShorter classes55% (12)45% (10)32% (7)27% (6)23% (5)14% (3)5% (1)Best person at school to coordinate supportGuidance counselorHomeroom teacherAthletic trainerPrincipal/Assistant PrincipalSchool nurseCoachSchool psychologistSpecial education teacher27% (6)27% (6)18% (4)18% (4)14% (3)14% (3)5% (1)5% (1)