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AAN: Human Foible May Undermine Concussion Tx

By John Gever, Senior Editor | MedPage Today | March 23, 2013

SAN DIEGO — Clinicians seeking to establish a medical history for children and teens with concussions should recognize that people tend to downplay ill health they or loved ones suffered in the past, a researcher said here.

Parents of children 5- to 12-years old, interviewed a month after the children had suffered a concussion, remembered pre-injury symptoms as being much less severe than they had indicated in the emergency department (ED) when the children were being evaluated, said Basil Kadoura, a student at McGill University in Montreal.

A similar pattern was seen in health histories provided by teen victims of mild traumatic brain injury at 1 and 3 months after the injury, he said during a presentation of the findings at the American Academy of Neurology’s annual meeting. Their mean self-reported severity of pre-concussion symptoms declined noticeably at the 3-month versus 1-month interview.

Kadoura said the finding was an example of “good old days bias,” in which patients remember being healthier in the past than they really were, especially in the wake of a new and serious health problem.

He also noted that accurate history-taking is a vital part of concussion management. Clinicians routinely ask about symptoms and health problems that patients experienced leading up to the injury, which could affect the diagnosis or management of the patient.

In addition, when patients or their surrogates downplay illnesses present before an injury, they and their physicians may then overestimate any changes in functioning brought on by the injury.

Kadoura helped conduct the study at the University of Calgary in Alberta, where the pediatric concussion patients were treated. A total of 412 such patients, and the parents of those 5- to 12-years-old, participated in the prospective study.

The mean age of the total cohort was 10.9, with 63% boys. About 20% had lost consciousness following the injury.

For the younger patients, parents were asked about their children’s pre-injury neurological symptoms while in the ED and by telephone 1 and 3 months later, using the Post-Concussion Symptom Inventory (PCSI).

The mean PCSI score reported in the ED was 7.1 (SD 10.1), with about two-thirds of parents reporting at least one PCSI symptom.

These included headaches (reported in 33% of cases), trouble falling asleep (31%), nausea (24%), irritability (25%), vomiting (24%), and emotional issues (22%).

At month one, the mean score plummeted to 1.4 (P<0.001), with only one-quarter of parents remembering at least one pre-concussion symptom included in the PCSI. Findings at month 3 were largely unchanged from month one.

The steep decline in remembered symptoms was seen irrespective of the children’s concussion outcomes, that is, between those who still had persistent symptoms and those who had recovered at the time of the interview. Initial PCSI scores were higher among children whose concussion symptoms lasted a month or more (mean 9.3 versus 6.0) but the subsequent declines in scores were similar.

Teenage concussion victims in the study were interviewed themselves, but only starting 1 month after injury. At that point, the mean PCSI score for their reports of pre-injury symptoms was 6.8. By month 3, their mean score was 5.0 (P=0.005).

As with parents of the younger children, teens who had not yet fully recovered reported more numerous or more severe pre-injury symptoms than those who had recovered at the time of the interview.

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