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Postconcussive symptoms may warrant referral to specialist

Primary care physicians caring for patients with postconcussive symptoms lasting more than 1 month should consider referring such patients to a neuropsychologist with the appropriate expertise, according to data published in the Journal of Pediatrics.

The researchers also concluded that somatization was associated with delayed symptom resolution among children with concussion.

“Although injury factors such as the severity of injury likely contribute to the persistence of symptoms, noninjury psychological components clearly influence symptomatology after concussion,” Joseph A. Grubenhoff, MD, of the University of Colorado School of Health, and colleagues wrote. “For example, pre-existing anxiety and depression are risk factors for the development of persistent postconcussive symptoms…. For practicing pediatric providers, knowing whether psychological factors contribute to delayed symptom resolution in children with concussion, similar to patterns seen in adults, is important for management.”

To determine the psychological factors associated with persistent pediatric concussion symptoms, the researchers conducted a longitudinal cohort study of 179 children aged 8 to 18 years evaluated in an ED for concussion. Patients were then followed for 1 month, with the researchers noting delayed symptom resolution, defined as three or more symptoms that were new or worse than preinjury symptoms. Preinjury traits were collected through parent survey results.

Reports of postinjury anxiety and injury perception were measured using the State-Trait Anxiety Inventory for Children and Children’s Illness Perception Questionnaire. The researchers compared psychological instrument scores between patients with and without delayed symptom resolution.

According to the researchers, delayed symptom resolution occurred in 21% of participants. In addition, score distributions were significantly worse, both for the State-Trait Anxiety Inventory for Children (38 [IQR 33-40] vs. 35 [IQR 31-39]; P = .04) and the somatization sub-scale (1 [IQR 0-3] vs. 1 [IQR 0-1]; P = .01), among those with delayed symptom resolution, compared with children with early symptom resolution. Somatization was linked with delayed symptom resolution (adjusted OR = 1.35, 95% CI, 1.08-1.69), and the percentage of participants with abnormal somatization scores in the delayed symptom resolution group was 34.2%, compared with 12.8% in the early symptom resolution group (P < .01).

“Our data indicate that noninjury factors, especially the tendency to somaticized and, to a lesser degree, anxiety, contribute significantly to delayed symptom resolution,” Grubenhoff and colleagues wrote. “Because the psychological assessments used in this study are likely to be unfamiliar to primary care pediatric providers, we do not suggest attempting to incorporate them into a busy office practice. Rather, primary care providers managing the recovery of children with concussion with persistent symptoms should consider referring patients to providers with particular expertise in behavioral health, such as pediatric psychologists or neuropsychologists.” – by Jason Laday

Disclosure: Grubenhoff reports salary support from the Thrasher Research Fund Early Career Award and the National Institutes of Health/National Center for Advancing Translational Sciences. The researchers report no other relevant financial disclosures.