Detailed concussion symptom analysis in a paediatric ED population

Article (PDF Available)inBrain Injury 25(10):943-9 · September 2011with27 Reads
DOI: 10.3109/02699052.2011.597043 · Source: PubMed
Abstract
To examine the frequency of acute mild traumatic brain injury (mTBI) symptoms in children using a concussion symptom inventory and to identify which symptoms are most useful in identifying mTBI. It was hypothesized that symptoms associated with mTBI are more common in children with head injury than orthopaedic injury and certain symptoms are more useful than others in identifying mTBI. Research design: Prospective case-control study conducted in a paediatric trauma centre emergency department. Children of 6-18 years old with head injury or a minor extremity injury were enrolled. Symptoms were assessed using a graded symptom checklist. Symptom frequency was compared using a chi-square test. The association between individual symptoms with AMS was evaluated with logistic regression analysis. Children with head injury displayed more frequent symptoms than controls. Head-injured cases with altered mental status (AMS) demonstrated the most frequent and severe symptoms (median symptom scores: control = 1, cases without AMS = 5, cases with AMS = 10; p < 0.001). Headache, nausea, dizziness, blurred/double vision and not feeling 'sharp' were associated with AMS. Symptoms associated with mTBI are more frequent in children with head injury. AMS magnifies this effect. A symptom inventory is integral to the evaluation of mTBI in children; a smaller set of dichotomized symptoms may be as useful as and more easily administered than lengthier symptom scales.

Figures

Brain Injury, September 2011; 25(10): 943–949
ORIGINAL ARTICLE
Detailed concussion symptom analysis in a paediatric
ED population
JOSEPH A. GRUBENHOFF
1
, MICHAEL W. KIRKWOOD
2
, SARA DEAKYNE
1
,
& JOE WATHEN
1
1
University of Colorado School of Medicine, Department of Pediatrics, Section of Emergency Medicine and
2
Physical Medicine and Rehabilitation, Children’s Hospital Colorado, Aurora, CO, USA
(Received 8 November 2010; revised 11 April 2011; accepted 17 May 2011)
Abstract
Primary objective: To examine the frequency of acute mild traumatic brain injury (mTBI) symptoms in children using a
concussion symptom inventory and to identify which symptoms are most useful in identifying mTBI. It was hypothesized
that symptoms associated with mTBI are more common in children with head injury than orthopaedic injury and certain
symptoms are more useful than others in identifying mTBI.
Research design: Prospective case-control study conducted in a paediatric trauma centre emergency department.
Methods and procedures: Children of 6–18 years old with head injury or a minor extremity injury were enrolled. Symptoms
were assessed using a graded symptom checklist. Symptom frequency was compared using a chi-square test. The association
between individual symptoms with AMS was evaluated with logistic regression analysis.
Main outcomes and results: Children with head injury displayed more frequent symptoms than controls. Head-injured cases
with altered mental status (AMS) demonstrated the most frequent and severe symptoms (median symptom scores:
control ¼ 1, cases without AMS ¼ 5, cases with AMS ¼ 10; p < 0.001). Headache, nausea, dizziness, blurred/double vision
and not feeling ‘sharp’ were associated with AMS.
Conclusions: Symptoms associated with mTBI are more frequent in children with head injury. AMS magnifies this effect.
A symptom inventory is integral to the evaluation of mTBI in children; a smaller set of dichotomized symptoms may be
as useful as and more easily administered than lengthier symptom scales.
Keywords: Brain concussion, closed head injury, traumatic brain injury
Abbreviations: ED, emergency department; GCS, Glasgow Coma Scale; LOC, loss of consciousness; mTBI, mild
traumatic brain injury; PCS, post-concussive syndrome; SAC, Standardized Assessment of Concussion
Background
Traumatic brain injury is a common occurrence in
children, leading to over 600 000 emergency depart-
ment (ED) visits annually. The majority of these
patients are diagnosed with mild traumatic brain
injury (mTBI) or concussion [1, 2]. Symptoms
following a mTBI are relatively non-specific and
can be seen in numerous other conditions or
following other types of injury [3–9]. This lack of
specificity has led to controversy regarding the utility
of symptom evaluation to monitor recovery from
mTBI or in making the diagnosis of ‘post-concussion
syndrome’ (PCS).
Nonetheless, studies of children and adults with
traumatic injuries have found significantly more
concussion symptoms following injury in mTBI
Correspondence: Joseph A. Grubenhoff, MD, 13123 E. 16th Avenue, B-251, Aurora, CO 80045, USA. Tel: (303) 724-2581. Fax: (720) 777-7317.
E-mail: grubenhoff.joe@tchden.org
ISSN 0269–9052 print/ISSN 1362–301X online ß 2011 Informa UK Ltd.
DOI: 10.3109/02699052.2011.597043
Brain Inj Downloaded from informahealthcare.com by University of Colorado on 09/07/11
For personal use only.
victims compared to orthopaedic controls [10–13].
At least among high school and collegiate athletes,
these symptoms tend to be greatest immediately
after injury, wane significantly even in the few hours
following injury and gradually resolve for most
patients [14–16]. Studies of high-school and colle-
giate athletes have shown that concussion symptom
inventories are useful for tracking recovery after
mTBI and can play a central role in the management
of patients with mTBI. Randolph et al. [17] have
also clearly demonstrated that certain symptoms are
more useful than others for this purpose. A limita-
tion of many studies that have included younger
children is a lack of data regarding the constellation
of symptoms in the hours immediately following
injury. Increased awareness and testing in athletic
venues has led to better recognition of mTBI;
however, mTBI often remains undiagnosed in the
acute care setting [18]. Over one third of patients
evaluated in an ED may not receive specific follow-
up recommendations even when they are diagnosed
with mTBI [19]. According to Barlow et al. [20], at
least 9% of all children who suffer mTBI evaluated
in an ED will have persistent symptoms at 3 months.
This study sought to examine the frequency of
mTBI symptoms in children shortly after suffering a
head injury, regardless of cause, compared to chil-
dren suffering an extremity injury. Additionally, the
aim was to determine which symptoms were most
useful in discriminating between these groups and if
any symptoms distinguished patients with and with-
out AMS. This report is a secondary analysis of data
obtained during a study investigating the utility of
the Standardized Assessment of Concussion for
evaluation of children with mTBI in the emergency
department [21]. A previous report found that
aggregate symptom scores were higher in cases
than in controls but did not explore the relative
contributions of the total number of symptoms
reported, the severity of those symptoms or which
individual symptoms best identified those with brain
injury. This analysis was undertaken to better
understand these factors. It was hypothesized that
mTBI symptoms will be more frequent in children
with head injuries than in children with minor
extremity injuries. It was expected that a select
group of a few symptoms could be found that best
discriminated the groups.
Methods
The authors prospectively enrolled 6–18 year old
children during the hours of 12 o’clock pm and 10
o’clock pm 6 days a week when research assistants
were available. Cases met inclusion criteria if they
had suffered isolated blunt head trauma in the 24
hours preceding presentation. For analysis, cases
were further sub-divided into those with and without
objective evidence of altered mental status (AMS).
Objective evidence of AMS was defined as any
witnessed loss of consciousness (LOC), post-trau-
matic amnesia or a Glasgow Coma Scale score of 13
or 14. Controls met inclusion criteria if they had
suffered minor extremity injuries in the absence of
head trauma in the 24 hours preceding presentation.
Subjects were excluded if they had received opioid
pain medications prior to enrolment, had a history
of intracranial surgery or neoplasm, developmental
delay or autism, structural brain abnormality, inborn
error of metabolism, had evidence of an open skull
fracture or appeared to be intoxicated.
The Standardized Assessment of Concussion
(SAC) includes a graded symptom checklist of 15
symptoms associated with mTBI (headache, nausea,
vomiting, dizziness, poor balance, blurred/double
vision, photophobia, phonophobia, tinnitus, poor
concentration, memory problems, not feeling
‘sharp’, fatigue/sluggish, sadness and irritability)
[22]. Symptoms were graded by the subject from
absent to severe (0 ¼ absent, 1 ¼ mild, 2 ¼ moderate,
3 ¼ severe). Subjects were asked to grade the severity
of their symptoms described using standardized
simple age-appropriate words. Answers were
recorded by a research assistant trained in adminis-
tration of the SAC. There were no missing symptom
data for any subject. Computed tomography (CT)
imaging of the brain was done at the discretion of the
treating physician.
This study used a chi-square or Fisher’s exact test
to compare symptom frequency among the three
groups. Symptoms with different frequencies among
groups were subjected to pair-wise comparisons
between cases with AMS and controls and between
cases with AMS and those without AMS. The
relationships of individual symptoms between cases
with AMS and controls and between cases with and
without AMS were evaluated using backwards
logistic regression analysis. In the regression analysis
individual symptoms were dichotomized based on
the absence (0) or presence (1–3) of symptoms. Of
note, ‘memory problems’ were excluded during
analysis of data as that variable was included in the
case definition for AMS. All analyses were carried
out using SAS software (9.2) (SAS Institute Inc.,
Cary, NC). The study was approved by the
Colorado Multiple Institutional Review Board.
Results
Four hundred and fifty-five patients were approached
for enrolment. Forty-one patients declined participa-
tion and 66 patients met exclusion criteria.
944 J. A. Grubenhoff et al.
Brain Inj Downloaded from informahealthcare.com by University of Colorado on 09/07/11
For personal use only.
The remaining 348 patients (183 controls, 66 cases
without AMS and 99 cases with AMS) were enrolled
in the study. The mean age in years and standard
deviation (SD) for the groups were 11.6 3.2,
10.8 3.3 and 11.9 3.1 respectively. Males
accounted for 62%, 68% and 68% of subjects,
respectively. There was no difference in age or
gender between cases and controls; 96% of cases
had a Glasgow Coma Scale score of 15. CT scans
were obtained on 51 subjects with head injury (31%).
Eight subjects (5%) had abnormal findings.
Seven subjects had non-depressed skull fractures.
Three subjects had epidural haematomas, none of
which required neurosurgery; one of these three also
had a non-depressed skull fracture. One subject had
a depressed skull fracture. No subjects suffered a
cerebral contusion or a subdural or subarachnoid
haemorrhage.
Total symptom checklist scores were not normally
distributed in any of the groups (Figures 1–3). The
median and interquartile ranges for total symptom
checklist scores for controls, cases without AMS and
cases with AMS were 1 (IQR 0–3), 5 (IQR 2–12)
and 12 (IQR 5–18), respectively ( p < 0.001).
Figure 1. Distribution of graded symptom checklist scores among controls.
Figure 2. Distribution of graded symptom checklist scores among cases without AMS.
Figure 3. Distribution of graded symptom checklist scores among cases with AMS.
Detailed concussion symptom analysis in the ED 945
Brain Inj Downloaded from informahealthcare.com by University of Colorado on 09/07/11
For personal use only.
When ‘memory problems’ was excluded, the median
aggregate scores for controls and cases without AMS
did not change and the score fell only 2-points in
cases with AMS (10). Differences remained signif-
icant at p < 0.001.
Cases with AMS displayed significantly more
symptoms than controls for all 15 symptoms
( p < 0.0001). Dizziness, nausea, phonophobia, pho-
tophobia, blurry or double vision, headache and
tinnitus were all significantly more common in cases
with AMS compared to cases without AMS
( p < 0.05, Table I).
In the logistic regression analysis comparing con-
trols to cases with AMS, the presence of five symp-
toms (headache, nausea, dizziness, blurred/double
vision and not feeling ‘sharp’) best identified those
with mTBI (Table II). For the presence of all five
symptoms, sensitivity was 97% and specificity was
78%. When comparing cases without AMS to cases
with AMS, only dizziness distinguished between the
two groups: the odds of AMS was 2.2-times greater
if patients reported dizziness (95% CI 1.1–4.3;
p ¼ 0.03). However, sensitivity and specificity for
dizziness were 69% and 58%, respectively.
Discussion
One of the most significant obstacles in the diagnosis
and management of mTBI is the lack of a prospec-
tively evaluated, evidenced-based measure of the
severity of injury. Many different severity grading
scales exist but none are sufficiently evidence-based
to be universally accepted [23, 24]. Two of the most
widely used scales focus on either LOC or post-
traumatic amnesia and incorporate few if any other
symptoms [25, 26]. Concussion symptom invento-
ries have been incorporated in multiple studies of
high school and collegiate athletes and appear to be
sensitive in identifying mTBI [27, 28]. However,
some have argued that mTBI symptoms are non-
specific and may have a limited role in diagnosing
and monitoring recovery among patients with mTBI
[3–9]. Little previous research has explored the
symptom complex following minor head trauma in
younger children evaluated in the ED.
This study demonstrates that children with head
injury experience more mTBI symptoms immedi-
ately following injury compared to a control popu-
lation in the ED despite 96% of the case sample
having a GCS of 15. The distribution of total
symptom checklist scores shows that victims with
extremity trauma endorse very few mTBI symptoms
and symptoms are milder in comparison to victims
with head injury.
The study showed that a sub-set of checklist
symptoms is associated with AMS and highly sen-
sitive for identifying those patients. Prior research
has demonstrated the ability of loss of consciousness
and post-traumatic amnesia to predict the likelihood
of mTBI symptoms [29–32]. Other authors have
demonstrated that dizziness, headache and fatigue
tend to be relatively common among patients with
persistent post-concussive symptoms in the early
post-injury period [33–35]. In the present study,
headache, nausea, dizziness, blurred/double vision
and not feeling ‘sharp’ accounted for the majority of
variability in symptom scores between controls and
cases with AMS.
Other symptoms included on the checklist appear
to be less useful in the acute evaluation of children
with mTBI. Fatigue, photophobia, phonophobia,
tinnitus, poor concentration, poor balance, irritabil-
ity, vomiting and sadness were not associated with
AMS in this sample. However, vomiting remains an
important symptom to elicit from patients with head
injuries when considering the need for emergent
brain imaging [36].
The authors chose to dichotomize symptoms in
the logistic regression analysis rather than grading
them for two reasons. From an analytic perspective,
the 4-point symptom checklist scale is an ordinal
variable and did not prove to better reflect the
Table I. Symptom frequency by groups.
Control
Case
(AMS)
Case
(þAMS)
% Difference
(95% CI)*
Dizziness 9% 42% 69% 27% (11, 41)
Nausea 3% 32% 55% 23% (8, 38)
Photophobia 3% 15% 35% 20% (7, 33)
Fatigue 36% 62% 82% 20% (6, 34)
Phonophobia 2% 17% 33% 16% (4, 30)
Vision changes 2% 23% 39% 16% (3, 31)
Headache 9% 65% 81% 16% (2, 30)
Tinnitus 2% 8% 19% 11% (2, 22)
Not feeling ‘sharp’ 10% 45% 60% 15% (1, 30)
Poor concentration 9% 30% 43% 13% (2,28)
Poor balance 13% 32% 44% 12% (3, 27)
Irritable 8% 23% 34% 11% (3, 25)
Vomiting 1% 14% 23% 9% (2, 21)
Sadness 7% 17% 24% 7% (5, 20)
Differences for þAMS vs controls were significant for all
symptoms and are not shown ( p < 0.0001).
*Differences in symptom frequency between AMS and þAMS.
The values in italics were significant ( p < 0.05).
Table II. Significant odds ratios (OR) and 95% confidence
intervals (CI) comparing controls to cases with AMS.
OR for mTBI 95% CI P
Headache 14.8 6.0–36.3 <0.0001
Nausea 11.5 3.3–40.3 <0.0001
Vision changes 6.4 1.3–31.7 0.02
Dizziness 4.9 1.9–12.8 0.001
Not feeling ‘sharp’ 2.8 1.0–7.8 0.05
946 J. A. Grubenhoff et al.
Brain Inj Downloaded from informahealthcare.com by University of Colorado on 09/07/11
For personal use only.
relationship with AMS than when dichotomized.
Furthermore, the dichotomous analysis has practical
implications for the clinician. It is easier to ascertain
from the patient the presence or absence of a
symptom than the severity of that symptom which
is inherently more subjective and variable from
patient to patient.
The findings must be considered in the context
of the study’s limitations. First, there is no ‘gold
standard’ for the diagnosis of mTBI. Therefore, one
cannot determine the true sensitivity and specificity
of the symptom checklist. However, the findings do
suggest that a more abbreviated dichotomous rather
than graded checklist may be clinically useful and
intuitively would be easier to administer.
The second limitation is the lack of longitudinal
follow-up of subjects. Optimal clinical utility of any
acute grading scale is derived from its ability to
differentiate those patients who have more intensive
post-discharge clinical need or otherwise display an
atypical outcome (e.g. persistent symptoms). In a
large epidemiological study of post-concussion syn-
drome, more severe injuries (i.e. those with either
LOC or post-traumatic amnesia) were associated
with more prominent symptoms shortly after injury
[20]. In light of those results, the finding in this
study that altered mental status is associated with
more frequent symptoms suggests that both mental
status and symptom complex may be important
factors to include in the development of an mTBI
grading scale.
The third limitation of this study is that responses
were elicited to the concussion symptom inventory
using only a scripted interview and no attempt was
made at an assessment of symptom validity during
the interview. It is possible that different results
would have been obtained had symptoms been
evaluated using other methods (e.g. written ques-
tionnaire) or examined response bias [37, 38].
Although age-appropriate language was used, some
children may not have understood what was asked
and therefore reported not having a symptom that
was present. Both controls and cases would be
expected to suffer from this limitation.
A final limitation is the choice to compare subjects
with extremity injuries to those with head injuries.
It may be argued that the difference in symptom
frequency and severity between cases and controls is
not a useful distinction as patients with isolated
extremity injuries are not expected to sustain a
mTBI. Several other studies have used similar
groups for comparison including that by Naunheim
et al. [14], which was specifically focused on the ED
course of patients with mTBI [10–14]. Head injuries
do not always occur in isolation and may frequently
be associated with musculoskeletal injury. From this
data, it is reasonable to conclude that mTBI
symptoms identified systematically by a checklist in
a patient with both head and musculoskeletal injury
are more likely attributable to mTBI.
Conclusion
Children with head injury complain of more fre-
quent symptoms commonly associated with mTBI
than do children with minor extremity injuries.
Symptoms are greater in patients with other signs
of cerebral dysfunction, including those who
incurred a witnessed loss of consciousness, post-
traumatic amnesia or had a GCS of 13 or 14. The
symptoms of headache, nausea, dizziness, blurred/
double vision and not feeling ‘sharp’ appear to be
particularly important in the assessment of acute
symptoms.
A concussion symptom inventory is an integral
part of documenting the symptom complex of mTBI
in children. Improved documentation could reason-
ably be expected to lead to more appropriate
diagnosis, which in turn may improve patient out-
comes by directing access to improved clinical
management resources. In an emergency depart-
ment setting, a shorter symptom inventory with
dichotomous data elements is more likely to be
adopted by clinicians who often feel the burden of
wait times and heavy patient volumes. Certain
symptoms appear more useful than others but
additional work is required to determine if a brief
concussion symptom inventory (five-to-six items)
performs as well as a more expanded inventory (12–
15 items). Further prospective research is required
that compares initial symptom checklist scores to the
time to resolution of symptoms and development of
persistent symptoms.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
References
1. Rutland-Brown W, Langlois JA, Thomas KE, Xi YL.
Incidence of traumatic brain injury in the United States,
2003. Journal of Head Trauma and Rehabilitation 2006;21:
544–548.
2. Bazarian JJ, McClung J, Shah MN. Mild traumatic
brain injury in the United States 1998–2000. Brain Injury
2005;19:85–91.
3. Lees-Haley PR, Fox DD, Courtney JC. A comparison of
complaints by mild brain injury claimants and other claimants
describing subjective experiences immediately following their
injury. Archives of Clinical Neuropsychology 2001;16:
689–695.
Detailed concussion symptom analysis in the ED 947
Brain Inj Downloaded from informahealthcare.com by University of Colorado on 09/07/11
For personal use only.
4. Iverson GL. Misdiagnosis of the persistent postconcussion
syndrome in patients with depression. Archives of Clinical
Neuropsychology 2006;21:303–310.
5. Suhr JA, Gunstad J. Postconcussive symptom report: The
relative influence of head injury and depression. Journal of
Clinical and Experimental Neuropsychology 2002;24:
981–993.
6. Iverson GL, Lange RT. Examination of ‘‘Postconcussion-
like’’ symptoms in a healthy sample. Applied
Neuropsychology 2003;10:137–144.
7. Gouvier WD, Uddo-Crane M, Brown LM. Base rates of
post-concussional symptoms. Archives of Clinical
Neuropsychology 1988;3:273–278.
8. Machulda MM, Bergquist TF, Ito V, Chew S. Relationship
between stress, coping, and post concussion symptoms in
a healthy adult population. Archives of Clinical
Neuropsychology 1998;13:415–424.
9. Garden N, Sullivan K. An examination of the base rates of
post-concussion symptoms: The influence of demographics
and depression. Applied Neuropsychology 2001;17:1–7.
10. Mittenberg W, Wittner MS, Miller LJ. Post-concussion
syndrome occurs in children. Neuropsychology 1997;11:
447–452.
11. Taylor HG, Wright M, Bangert B, Minich N, Yeates KO.
Post-concussive symptoms in children with mild traumatic
brain injury. Neuropsychology 2010;24:148–159.
12. Yeates KO, Taylor HG, Rusin J, Bangert B, Dietrich A,
Nuss K, Wright M, Nagin DS, Jones BL. Longitudinal
trajectories of postconcussive symptoms in children with mild
traumatic brain injury and their relationship to acute clinical
status. Pediatrics 2009;123:735–743.
13. Sheedy J, Harvey E, Faux S, Geffen G, Shores EA.
Emergency department assessment of mild traumatic brain
injury and prediction of postconcussive symptoms: A 3-
month prospective study. Journal of Head Trauma and
Rehabilitation 2009;24:333–343.
14. Naunheim RS, Matero D, Fucetola R. Assessment of patients
with mild concussion in the emergency department. Journal
of Head Trauma and Rehabilitation 2008;23:116–122.
15. McCrea M, Kelly JP, Randolp C, Cisler R, Berger L.
Immediate neurocognitive effects of concussion.
Neurosurgery 2002;50:1032–1040.
16. McCrea M, Guskiewicz K, Marshall S, Barr W, Randolph C,
Cantu RC, Onate JA, Yang J, Kelly JP. Acute effects and
recovery time following concussion in collegiate football
players: The NCAA concussion study. The Journal of the
American Medical Association 2003;290:2556–2563.
17. Randolph C, Millis S, Barr WB, McCrea M,
Guskiewicz KM, Hammeke TA, Kelly JP. Concussion
symptom inventory: An empirically derived scale for moni-
toring resolution of symptoms following sport-related con-
cussion. Archives of Clinical Neuropsychology 2009;24:
219–229.
18. Ryu WH, Feinstein A, Colantonio A, Streiner DL,
Dawson DR. Early identification and incidence of mild TBI
in Ontario. Canadian Journal of Neurological Sciences
2009;36:429–435.
19. Bazarian JJ, McClung J, Cheng YT, Flesher W,
Schneider SM. Emergency department management of
mild traumatic brain injury in the USA. Emergency
Medical Journal 2005;22:473–477.
20. Barlow KM, Crawford S, Stevenson A, Sandhu SS,
Belanger F, Dewey D. Epidemiology of postconcussion
syndrome in pediatric mild traumatic brain injury.
Pediatrics 2010;126:e374–e381.
21. Grubenhoff JA, Kirkwood M, Gao D, Deakyne S, Wathen J.
Evaluation of the standardized assessment of concussion in a
pediatric emergency department. Pediatrics 2010;126:
688–695.
22. McCrea M, Kelly JP, Randolph C, Kluge J, Bartolic E,
Finn G, Baxter B. Standardized assessment of concussion
(SAC): On-site mental status evaluation of the athlete.
Journal of Head Trauma and Rehabilitation 1998;13:
27–35.
23. Guskiewicz KM, Bruce SL, Cantu RC, Ferrara MS, Kelly JP,
McCrea M, Putukian M, Valovich McLeod TC. National
athletic trainers’ association position statement: Management
of sport-related concussion. Journal of Athletic Training
2004;39:280–287.
24. Leclerc S, Lassonde M, Delaney JS, Lacroix VJ,
Johnston KM. Recommendations for grading of concussion
in athletes. Sports Medicine 2001;31:629–636.
25. American Academy of Neurology Quality Standards
Subcommittee. Practice parameter: The management of
concussion in sports (summary statement). Neurology
1997;48:581–585.
26. Cantu RC. Posttraumatic and retrograde and anterograde
amnesia: Pathophysiology and implications in grading and
safe return to play. Journal of Athletic Training 2001;36:
244–248.
27. Broglio SP, Macciocchi SN, Ferrara MS. Sensitivity of the
concussion assessment battery. Neurosurgery 2007;60:
1050–1057.
28. Lovell MR, Iverson GL, Collins MW, Podell K,
Johnston KM, Pardini D, Pardini J, Norwig J, Maroon JC.
Measurement of symptoms following sports-related concus-
sion: Reliability and normative data for the post-concussion
scale. Applied Neuropsychology 2006;13:166–174.
29. Erlanger D, Kaushik T, Cantu R, Barth JT, Broshek DK,
Freeman JR, Webbe FM. Symptom-based assessment of the
severity of concussion. Journal of Neurosurgery 2003;98:
477–484.
30. Shores EA, Lammel A, Hullick C, Sheedy J, Flynn M,
Levick W, Batchelor J. The diagnostic accuracy of the revised
Westmead PTA scale as an adjunct to the Glasgow Coma
Scale in the early identification of cognitive impairment in
patients with mild traumatic brain injury. Journal of
Neurology, Neurosurgery and Psychiatry 2008;79:
1100–1106.
31. Drake AI, McDonald EC, Magnus NE, Gray N, Gottshall K.
Utility of Glasgow coma scale-extended in symptom predic-
tion following mild traumatic brain injury. Brain Injury
2006;20:469–475.
32. Ahmed S, Bierley R, Sheikh JI, Date ES. Post-traumatic
amnesia after closed head injury: A review of the literature
and some suggestions for future research. Brain Injury
2000;14:765–780.
33. Sheedy J, Geffen G, Donnelly J, Faux S. Emergency
department assessment of mild traumatic brain injury and
prediction of post-concussion symptoms at one month post
injury. Journal of Clinical and Experimental
Neuropsychology 2006;28:755–772.
34. Roe C, Sveen U, Alvsaker K, Bautz-Holter E. Post-
concussion symptoms after mild traumatic brain injury:
Influence of demographic factors and injury severity in a
1-year cohort study. Disability and Rehabilitation 2009;31:
1235–1243.
35. Yang C, Hua M, Tu Y, Huang S. Early clinical character-
istics of patients with post-concussion symptoms: A prospec-
tive study. Brain Injury 2009;23:299–306.
948 J. A. Grubenhoff et al.
Brain Inj Downloaded from informahealthcare.com by University of Colorado on 09/07/11
For personal use only.
36. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr,
Atabaki SM, Holubkov R, Nadel FM, Monroe D,
Stanley RM, et al. Identification of children at very low risk
of clinically-important brain injuries after head trauma: A
prospective cohort study. Lancet 2009;374:1160–1170.
37. Iverson GL, Brooks BL, Ashton VL, Lange RT. Interview
versus questionnaire symptom reporting in people with the
postconcussion syndrome. Journal of Head Trauma and
Rehabilitation 2010;25:23–30.
38. Lange RT, Iverson GL, Brooks BL, Ashton Rennison VL.
Influence of poor effort on self-reported symptoms and
neurocognitive test performance following mild traumatic
brain injury. Journal of Clinical and Experimental
Neuropsychology 2010;30:1–12.
Detailed concussion symptom analysis in the ED 949
Brain Inj Downloaded from informahealthcare.com by University of Colorado on 09/07/11
For personal use only.
    • "The inherent high variability among the mTBI subject group is also an accurate reflection of presentation in the emergency room. In this sense, our results here do not differ dramatically from previous studies using symptom reports for concussion [1, 7, 8]. However, a more detailed analysis of the data gives us the ability to gain deeper insight into mTBI-related symptoms.Principal component analysis of the symptom questionnaires from all subjects identified five uncorrelated components that represent clusters of co-varying symptoms. "
    [Show abstract] [Hide abstract] ABSTRACT: Mild Traumatic Brain Injury (mTBI) is a prominent public health issue. To date, subjective symptom complaints primarily dictate diagnostic and treatment approaches. As such, the description and qualification of these symptoms in the mTBI patient population is of great value. This manuscript describes the symptoms of mTBI patients as compared to controls in a larger study designed to examine the use of vestibular testing to diagnose mTBI. Five symptom clusters were identified: Post-Traumatic Headache/Migraine, Nausea, Emotional/Affective, Fatigue/Malaise, and Dizziness/Mild Cognitive Impairment. Our analysis indicates that individuals with mTBI have headache, dizziness, and cognitive dysfunction far out of proportion to those without mTBI. In addition, sleep disorders and emotional issues were significantly more common amongst mTBI patients than non-injured individuals. A simple set of questions inquiring about dizziness, headache, and cognitive issues may provide diagnostic accuracy. The consideration of other symptoms may be critical for providing prognostic value and treatment for best short-term outcomes or prevention of long-term complications.
    Full-text · Article · Jan 2016
    • "Gerberich et al (1983) found that 14% of the 3063 secondary school varsity football players had blurred/double vision [32]. In contrast to these rates, recent study by Grubenhoff et al (2011) showed that the rate for depression, fatigue, and blurred/double vision in concussed children with altered mental state is 24%, 82%, and 39%, respectively [33]. The rate variations are likely from a number of sources, such as the studied cohorts, the time of study subjects taking questionnaires related to the time course of their concussion, the mechanisms of the injury, the type of sports, etc. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: To evaluate the awareness of concussion-related symptoms amongst members of the sports community in Canada. Methods: A cross-sectional national electronic survey was conducted. Youth athletes, parents, coaches and medical professionals across Canada were recruited through mailing lists from sports-related opt-in marketing databases. Participants were asked to identify, from a list of options, the symptoms of a concussion. The proportion of identified symptoms (categorized as physical, cognitive, mental health-related and overall) as well as participant factors associated with symptom recognition were analyzed. Results: The survey elicited 6,937 responses. Most of the respondents (92.1%) completed the English language survey, were male (57.7%), 35-54 years of age (61.7%), with post-secondary education (58.2%), or high reported yearly household income (>$80,000; 53.0%). There were respondents from all provinces and territories with the majority of respondents from Ontario (35.2%) or British Columbia (19.1%). While participants identified most of the physical (mean = 84.2% of symptoms) and cognitive (mean = 91.2% of symptoms), they on average only identified 53.5% of the mental health-related symptoms of concussions. Respondents who were older, with higher education and household income, or resided in the Northwest Territories or Alberta identified significantly more of the mental health-related symptoms listed. Interpretation: While Canadian youth athletes, parents, coaches and medical professionals are able to identify most of the physical and cognitive symptoms associated with concussion, identification of mental health-related symptoms of concussion is still lagging.
    Full-text · Article · Nov 2015
  • [Show abstract] [Hide abstract] ABSTRACT: Concussion (mild traumatic brain injury (mTBI)) is a significant pediatric public health concern. Despite increased awareness, a comprehensive understanding of the acute and chronic effects of concussion on central nervous system structure and function remains incomplete. Here we review the definition, epidemiology, and sequelae of concussion within the developing brain, during childhood and adolescence, with current data derived from studies of pathophysiology and neuroimaging. These findings may contribute to a better understanding of the neurological consequences of traumatic brain injuries, which in turn, may lead to the development of brain biomarkers to improve identification, management and prognosis of pediatric patients suffering from concussion.
    Article · Mar 2012
Show more

    Recommended publications

    Discover more