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

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 (%).

Variable	Concussion (n=22)	Control (n=22)	P value
Female sex	12 (55%)	12 (55%)	1.00
Age (years)	13.5 (3.4)	14.8 (1.7)	0.11
Assessment 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].

Domain	Concussion	Control	P value
Mobility	8 [2-9]	0 [0-0]	< 0.001
Anxiety	2 [0-8]	2 [0-6]	0.63
Depressive	2.5 [1-5]	1 [0-2]	0.05
Fatigue	8 [6-12]	1 [0-3]	< 0.001
Peer relationships	16 [12-16]	15 [12-16]	0.55
Pain interference	9 [5-12]	0 [0-2]	< 0.001
Pain VAS rating	5 [3-6]	0 [0-1]	< 0.001

Table 3.

School-related difficulties reported by concussion patients on the CLASS survey.

Factor	Response	% (n)
Concern about injury affecting school performance	Very concerned Moderately concerned Mildly concerned Not concerned	19% (4) 33% (7) 29% (6) 19% (4)
School factor most concerned about	Grades dropping Ability to learn, remember, concentrate Amount of work/falling behind Other	52% (10) 21% (4) 16% (3) 11% (2)
Types of problems experienced after concussion	Headaches interfering Can’t pay attention in class Too tired Homework is taking longer Difficulty studying for tests Difficulty taking notes Difficulty understanding material	50% (11) 45% (10) 41% (9) 27% (6) 27% (6) 23% (5) 14% (3)
Classes/subjects producing the most trouble after concussion	Reading/English Math Science Social Studies/History Foreign Language Physical Education Art Music	55% (12) 32% (7) 18% (4) 14% (3) 9% (2) 9% (2) 5% (1) 5% (1)
Grades affected since injury?	Yes Not yet, but worried they might No	39% (7) 33% (6) 28% (5)
Kind of help needed in returning to school	Rest breaks Extra time to complete work I don’t know Reduced homework Shortened day No tests Shorter classes	55% (12) 45% (10) 32% (7) 27% (6) 23% (5) 14% (3) 5% (1)
Best person at school to coordinate support	Guidance counselor Homeroom teacher Athletic trainer Principal/Assistant Principal School nurse Coach School psychologist Special education teacher	27% (6) 27% (6) 18% (4) 18% (4) 14% (3) 14% (3) 5% (1) 5% (1)