Identifying Kids at Risk for Post-Concussion Symptoms

The Buffalo Concussion Physical Examination’s Risk of Delayed Recovery (RDR) score is the first decision rule to help clinicians who aren’t concussion specialists quickly identify which children are at risk for PPCS within 10 days of injury and should be referred to a specialist for focused treatment.

The research was described in a paper published Sept. 11 in the British Journal of Sports Medicine.

A decision rule is an evidence-based tool that helps clinicians make diagnostic and therapeutic decisions. In the study, the decision rule proved to be highly accurate, correctly identifying who would go on to develop PPCS in 85 percent of cases.

“The Buffalo Concussion Physical Exam takes less than 10 minutes to do and uses physician exam techniques that every clinician already has,” said Mohammad Nadir Haider, MD, PhD, research assistant professor of orthopaedics and the paper’s first author.

To promote the adoption of the Buffalo Concussion Physical Exam, Haider, assistant director of research at the UB Concussion Management Clinic and UBMD Orthopaedics & Sports Medicine, plans next to develop an app that can generate the RDR score identifying children who will experience delayed recovery based on the findings from the exam.

Children and adolescents tend to take longer to recover from concussion than adults. Still, for the majority of those who experience a concussion, symptoms will resolve within a month or less without any treatment.

For that reason, it is standard practice to wait a few weeks to see if symptoms resolve on their own before patients are referred for treatment. But as many as a third of concussed patients will experience PPCS and require focused treatment.

“The current standard of practice is to wait-and-see for the first few weeks,” Haider says. “But our research and other studies have shown that in children and adolescents, delayed treatment can lead to a higher risk of persistent impairments with poor outcomes.”

Students with PPCS continue to suffer, experience physical and cognitive symptoms, and start exhibiting difficulties with academic work and even in their social lives, Haider says. “So, preventing these negative outcomes is pretty important.”

“Right now, there is no gold standard method to identify children within a few days of injury who will have delayed recovery from their concussion. The current standard of practice is to see which children do not recover, and this leads to unnecessary delays,” Haider continues. “This scoring system may circumvent the waiting period for those children at higher risk, expediting the treatment they need for a full recovery.”

The new decision rule is based on an observational study conducted from 2016 to 2019 on 270 children and adolescents with sport-related concussions who were seen within 14 days of injury at UBMD Orthopaedics & Sports Medicine clinics in Western New York. 

Participants were aged 8-18 and 38 percent were female. They were followed until they had recovered from their concussion and were cleared to return to school or sports without restrictions.

“The purpose was to identify what is predictive of delayed recovery in children and adolescents with concussion,” Haider says. “We wanted to develop something very straightforward that any provider, from a school nurse to a medical resident to a primary care provider, could easily do.”

The UB researchers found that the primary signs that indicate that a child or adolescent with a concussion will have delayed recovery were:

• lightheadedness and dizziness on standing up from a supine position
• problems with balance and vision that indicate issues with the vestibular ocular reflex, the reflex that allows a person to maintain stability in vision while moving
• difficulty performing a tandem gait test, where participants are instructed to walk heel-to-toe

The research was funded by the National Institute of Neurological Disorders and Stroke and the National Center for Advancing Translational Science, both of the National Institutes of Health.

Co-authors on the study from the Jacobs School are:

• Adam P. Cunningham, lead statistician with UBMD Orthopaedics & Sports Medicine
• Scott R. Darling, MD, clinical assistant professor of family medicine and a physician with UBMD Orthopaedics & Sports Medicine
• Michael Freitas, MD, clinical professor of orthopaedics and a physician with UBMD Orthopaedics & Sports Medicine
• Rajiv Jain, MD, clinical assistant professor of medicine and a physician with UBMD Orthopaedics & Sports Medicine
• John J. Leddy, MD, clinical professor of orthopaedics and director of the UB Concussion Management Clinic at UBMD Orthopaedics & Sports Medicine
• Heidi N. Suffoletto, MD, clinical assistant professor or orthopaedics and emergency medicine, and a physician with UBMD Orthopaedics & Sports Medicine
• Barry S. Willer, PhD, professor of psychiatry and research director in the UB Concussion Management Clinic

Physicians in UBMD Physicians’ Group are faculty members at the Jacobs School.