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Paediatric post-concussive symptoms: symptom clusters and clinical phenotypes
  1. Todd W Lyons1,2,
  2. Rebekah Mannix1,2,
  3. Ken Tang3,
  4. Keith Owen Yeates4,5,
  5. Gurinder Sangha6,7,
  6. Emma CM Burns8,9,
  7. Darcy Beer10,
  8. Alexander S Dubrovsky11,12,
  9. Isabelle Gagnon13,
  10. Jocelyn Gravel14,
  11. Stephen B Freedman15,
  12. William Craig16,
  13. Kathy Boutis17,
  14. Martin H Osmond3,18,
  15. Gerard Gioia19,
  16. Roger Zemek3,18
  17. The Pediatric Emergency Research Canada (PERC) 5P Concussion Team
  1. 1Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  3. 3Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  4. 4Department of Psychology, Hotchkiss Brain Institute, Calgary, Alberta, Canada
  5. 5Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
  6. 6Department of Pediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada
  7. 7Department of Pediatrics, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
  8. 8Department of Emergency Medicine, IWK Health Centre, Halifax, Nova Scotia, Canada
  9. 9Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
  10. 10Department of Pediatrics, Children's Hospital Foundation of Manitoba, Winnipeg, Manitoba, Canada
  11. 11UP Centre for Pediatric Emergencies, Montreal, Quebec, Canada
  12. 12Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
  13. 13Division of Physical and Occupational Therapy, McGill University Health Centre, Montreal, Quebec, Canada
  14. 14Department of Pediatrics, Saint Justine Hospital, Montreal, Quebec, Canada
  15. 15Department of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  16. 16Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
  17. 17Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
  18. 18Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
  19. 19Division of Neuropsychology, Children's National Hospital, Washington, District of Columbia, USA
  20. 20Pediatric Emergency Research Canada, Calgary, Alberta, Canada
  1. Correspondence to Dr Todd W Lyons, Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, USA; Todd.Lyons{at}childrens.harvard.edu

Abstract

Objective To assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity.

Methods We performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5–17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings.

Results 3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2–14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%–72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity.

Conclusion Post-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes.

  • brain concussion
  • fatigue
  • head

Data availability statement

Data are available upon reasonable request. Data for this manuscript are stored and available online in BrainCode and are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request. Data for this manuscript are stored and available online in BrainCode and are available upon reasonable request.

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Footnotes

  • Correction notice This article has been corrected since it published Online First. The abstract has been amended.

  • Collaborators For the Pediatric Emergency Research Canada 5P Concussion Team.

  • Contributors TWL, RM, KT and RZ designed the study and performed and interpreted data analyses. KY, GS, EB, DB, AD, WC, KB, MO, GG and RZ supervised data collection at the participating sites. TWL, RM and RZ drafted the manuscript. All authors critically reviewed and revised the manuscript and contributed to the final submission. TWL is responsible for the overall content as guarantor.

  • Funding This study was supported by operating grant (126197) and planning grant (MRP: #119829) from the Canadian Institutes of Health Research and grant (TM1:#127047) from the Canadian Institutes of Health Research–Ontario Neurotrauma Foundation Mild Traumatic Brain Injury Team. The funders played no role in the design and conduct of the study; collection, management, analysis or interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

  • Competing interests GG is an author of the Post-Concussion Symptom Inventory (PCSI) used in this study. The PCSI is freely available and he receives no financial benefit from its use.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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