Sicard Veronik, Irani Tenaaz, Ledoux Andrée-Anne, Terekhov Ivan, Webster Richard J, Sucha Ewa, Kutcher Stephen A, Duan Lauren Xinyue, Dashti Farzaneh, Cortel-Leblanc Achelle, Leddy John, Richer Lawrence, Reed Nick, Connelly Kim, Anderson Charlotte, Johnston Sharon, Zemek Roger
Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.
Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
JAMA Netw Open. 2025 Jul 1;8(7):e2522309. doi: 10.1001/jamanetworkopen.2025.22309.
Pediatric concussion can affect the autonomic nervous system. Understanding the prevalence and characteristics of physiological autonomic dysregulation (AD) and symptom provocation following concussion is crucial for optimizing recovery and developing targeted interventions.
To determine the prevalence of AD and symptom provocation upon postural change and to (1) explore the overlap between AD and symptom provocation, (2) apply adult orthostatic tachycardia criteria (heart rate [HR] ≥30 bpm) to this pediatric population, (3) explore associations of demographic and injury characteristics with AD and symptom provocation, and (4) characterize AD presentation and identify the predominant orthostatic sign.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used electronic medical record review of clinical data at tertiary care concussion clinics that operate as a learning health system in Canada. Patients aged 5 to younger than 18 years who presented to those clinics within 45 days of a diagnosed concussion between August 2022 and January 2024 were included. Analysis was conducted from April to October 2024.
Diagnosis of concussion.
Primary outcomes were AD presence (defined as the presence of either a decrease in systolic BP [≥20 mm Hg], decrease in diastolic BP [≥10 mm Hg], or increase in HR [≥40 bpm]), and symptom provocation (new or worsening). HR, blood pressure (BP), and symptoms were measured after a 2-minute supine rest and 1 minute of unsupported standing.
Of 764 eligible patients, 451 (231 female [51.22%]; 129 [28.60%] aged 5-11 years and 322 [71.40%] aged 12 to <18 years) were included; objective AD was identified in 45 patients (9.98%; 95% CI, 7.54%-13.09%), primarily by HR changes (22 of 45 patients [48.89%]). When applying adult tachycardia criteria, AD prevalence was 23.73% (95% CI, 20.03%-27.88%). Orthostatic symptom provocation occurred in 103 of 445 patients (23.15%; 95% CI, 19.47%-27.28%). Among 134 patients with either AD or symptom provocation, 12 (8.96%) exhibited both. Patients with AD had higher rates of neurodevelopmental disorders than patients without AD (15 of 45 patients [33.33%] vs 75 of 406 patients [18.47%]; P = .02), while symptom provocation was associated with female sex (63 of 103 patients [61.17%] vs 166 of 342 patients [48.54%]; P = .03), preexisting mental health disorders (28 of 103 patients [27.18%] vs 45 of 342 patients [13.16%]; P < .001), higher concussion symptom burden (median [IQR] symptom intensity score, 46.00 [16.00-67.00] vs 21.00 [6.00-46.00]; P < .001), and status of posttraumatic amnesia at injury (22 of 103 patients with posttraumatic amnesia [22.68%] vs 63 of 342 patients without [18.92%]; P = .009).
In this cohort study of children and adolescents with concussion, approximately 1 in 10 exhibited AD and 1 in 4 exhibited symptom provocation. The observed low concordance between physiological AD and symptom provocation, along with their distinct clinical profiles, might suggest these represent separate phenomena in pediatric concussion; future research should explore whether incorporating both measures into clinical assessments enhances understanding of concussion and informs targeted interventions to optimize recovery.
小儿脑震荡可影响自主神经系统。了解脑震荡后生理性自主神经功能失调（AD）的患病率及特征以及症状激发情况对于优化恢复和制定针对性干预措施至关重要。
确定姿势改变时AD和症状激发的患病率，并（1）探讨AD与症状激发之间的重叠情况，（2）将成人直立性心动过速标准（心率[HR]≥30次/分钟）应用于该儿科人群，（3）探讨人口统计学和损伤特征与AD及症状激发的关联，（4）描述AD的表现并确定主要的直立体征。
设计、设置和参与者：这项回顾性队列研究通过对加拿大作为学习健康系统的三级医疗脑震荡诊所的临床数据进行电子病历审查。纳入了2022年8月至2024年1月期间在确诊脑震荡后45天内就诊于这些诊所的5至18岁以下患者。分析于2024年4月至10月进行。
脑震荡诊断。
主要结局为AD的存在（定义为收缩压下降[≥20 mmHg]、舒张压下降[≥10 mmHg]或心率增加[≥40次/分钟]中的任何一种）以及症状激发（新发或加重）。在仰卧休息2分钟和无支撑站立1分钟后测量心率、血压（BP）和症状。
在764名符合条件的患者中，纳入了451名（231名女性[51.22%]；129名[28.60%]年龄在5至11岁，322名[71.40%]年龄在12至18岁以下）；45名患者（9.98%；95% CI，7.54%-13.09%）被确定存在客观AD，主要通过心率变化（45名患者中的22名[48.89%]）。应用成人心动过速标准时，AD患病率为23.73%（95% CI，20.03%-27.88%）。445名患者中有103名（23.15%；95% CI，19.47%-27.28%）出现直立性症状激发。在134名有AD或症状激发的患者中，12名（8.96%）两者都有。有AD的患者神经发育障碍的发生率高于无AD的患者（45名患者中的15名[33.33%]对406名患者中的75名[18.47%]；P = 0.02），而症状激发与女性性别（103名患者中的63名[61.17%]对342名患者中的166名[48.54%]；P = 0.03）、既往心理健康障碍（103名患者中的28名[27.18%]对342名患者中的45名[13.16%]；P < 0.001）、更高的脑震荡症状负担（症状强度评分中位数[IQR]，46.00 [16.00 - 67.00]对21.00 [6.00 - 46.00]；P < 0.001）以及受伤时创伤后遗忘状态（103名有创伤后遗忘的患者中的22名[22.68%]对342名无创伤后遗忘的患者中的63名[18.92%]；P = 0.009）相关。
在这项针对儿童和青少年脑震荡的队列研究中，约十分之一的患者表现出AD，四分之一的患者表现出症状激发。观察到的生理性AD与症状激发之间的低一致性，以及它们不同的临床特征，可能表明这些在小儿脑震荡中代表不同的现象；未来的研究应探索将这两种测量方法纳入临床评估是否能增强对脑震荡的理解并为优化恢复的针对性干预提供依据。
