Abstract
Objectives:
To (1) determine the frequency of neck pain in patients diagnosed with mild traumatic brain injury (mTBI) or concussion in a pediatric level I trauma center emergency department (ED), (2) identify variables associated with neck pain in this population, and (3) report on aspects of care received in the ED including imaging and medication use.
Methods:
A retrospective chart review of 652 patients presenting to a pediatric emergency department (ED) with diagnosis of concussion/mTBI. Charts were reviewed for the following information: baseline demographic information, mechanism of injury, cause of mTBI, presence or absence of neck pain, point tenderness in the neck on physical exam, and whether the patient followed up within our health system in the 6 months after injury. Charts were also reviewed for other concussion related symptoms, medication given in the ED, imaging performed in the ED, cervical spine clearance in the ED, and referrals made. For those patients who did have follow-up appointments within our system, additional chart review was performed to determine if they sought follow-up treatment for symptoms related to concussion/neck pain and the duration of follow-up. Statistical analyses focused on the prevalence of neck pain in the sample. We subsequently explored the degree to which neck pain was associated with other collected variables.
Results:
Out of 652 patients, 90 (13.8%) reported neck pain. Acceleration/deceleration injury and motor vehicle accident were predictive of neck pain. Neck pain was less common in those reporting nausea and vomiting. Direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables, this was no longer statistically significant. Patients with neck pain were older than those without neck pain. Patients with neck pain were more likely to receive ibuprofen or morphine as well as undergo imaging of the spine. They were also more likely to receive a referral and follow up with neurosurgery. There was no significant difference between groups with respect to concussion-related follow-up visits or follow-up visits to a dedicated concussion clinic.
Conclusion:
Neck pain is a common symptom in pediatric patients with mTBI, though it was more likely in older patients and those presenting with acceleration/deceleration mechanisms. While patients with neck pain were more likely to receive a referral and follow up with neurosurgery, they were not more likely to have concussion-related follow-up visits. Indeed, most patients had no follow-up visits related to their concussion, which supports the notion that concussion is a self-limiting condition.
Keywords: pediatric, Brain concussion, traumatic brain injury, emergency service, hospital, neck pain, rehabilitation
Introduction
Traumatic brain injury (TBI) in the United States resulted in 2.5 million emergency department (ED) visits, hospitalizations, and/or deaths in 2014.[1] TBI is defined by the Centers for Disease Control as “a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury.”[2] The vast majority of TBIs are considered mild TBIs (mTBI), a term often used interchangeably with concussion. In recent years, our understanding of this clinical entity has grown significantly. However, there has been limited research on the frequency of concomitant injury. Specifically, little is known about the relationship between mTBI and neck pain in the pediatric population.
Consensus and position statements regarding concussion have identified the comorbid injury to the cervical spine as a possible cause of prolonged symptoms in some concussion patients.[3] The consensus statement from the 5th International Conference on Concussion in Sport stated, “Sport-related concussions can result in diverse symptoms and problems and can be associated with concurrent injury to the cervical spine and peripheral vestibular system.”[4]
Despite expert consensus statements acknowledging the possibility of cervical spine injury in mild traumatic injury (mTBI) patients, there have been few studies of neck pain in the pediatric population. One retrospective analysis of 1953 patients presenting to a pediatric sports medicine clinic within 30 days of injury found that 37.1% reported neck pain.[5] Although the authors did not report on mechanism of injury, the majority were sports-related concussions. A second prospective study of 693 pediatric patients presenting to a pediatric emergency department (ED) with sports-related concussion found that 25.9% of patients reported neck pain at a telephone follow-up between three weeks and three months following injury.[6] A study of sports related concussion found that patients with concurrent neck and shoulder pain were more likely to have delayed recovery in comparison to those without concurrent neck and shoulder pain. [7] As many ED patients are likely not to receive follow-up after discharge, it would be valuable to establish how often neck pain is identified in the ED setting itself. Furthermore, better understanding of injury or personal factors that predict neck pain and the impact of neck pain on the number follow-up visits may inform clinical care of pediatric patients with mTBI as these symptoms may need to be addressed by targeted therapy as has been suggested in previous position statements on concussion. [3]
The primary purpose of the study was to evaluate the frequency of neck pain in patients diagnosed with mTBI or concussion in a pediatric ED. Secondarily, we assessed for any relationship between the mechanism of injury, cause of TBI, demographic factors, and neck pain. We also compared the number of follow-up visits for concussion-related symptoms between those with and without neck pain. We hypothesized that neck pain would be present in >25% of patients diagnosed with concussion in this pediatric ED population and that motor vehicle accidents would be predictive of neck pain concurrent with diagnosis of mTBI based on previous work.[8] We also hypothesized that patients with neck pain would have a greater number of follow up visits related to their symptoms than those without neck pain. We also aimed to describe the use of pain medication and imaging rates between those with and without neck pain.
Methods
We conducted a retrospective chart review by searching the electronic medical record (EMR) for patients seen in the pediatric ED of a level 1 trauma center that were diagnosed with mTBI or concussion between November 1, 2015 and June 30, 2018. Our trauma center is the only freestanding children’s hospital in the state and one of the busiest pediatric health systems in the nation with over 66,000 ED visits and 344,000 outpatients visits annually. We defined our population of interest as all ED visits with a primary ICD-9/ICD-10 diagnosis matching one of the following concussion and mild traumatic brain injury related codes: 959.01, 850.X, 854.X, S06.X. Charts were excluded if the patient was under 5 years of age (as pre-school aged children are not reliably diagnosed with concussion[9]), the patient was not discharged home from the ED, or if an intracranial abnormality or cervical spine fracture was identified on imaging. Patients with intracranial abnormalities may no longer meet the definition of pediatric mTBI. Patients with abnormal cervical spine imaging were excluded as these are no longer soft tissue injuries, and the abnormality typically has a greater impact on clinical decision making, e.g., return to activity, than concussion management. These exclusions mirror similar studies on this topic.[7] Methods were approved by the local Institutional Review Board.
To obtain a representative sample, we utilized a semi-randomized process by which charts were abstracted in numeric order by medical record number, until we abstracted at least 50% of charts from each month over the 3-year study period. Charts were reviewed for the following information: age, race, ethnicity, sex, mechanism of injury (e.g., acceleration/deceleration), cause of mTBI (e.g., motor vehicle traffic accident), presence or absence of neck pain, point tenderness in the neck on physical exam, and whether the patient followed up within our health system in the 6 months after injury. Absence of neck pain was defined as absence of documented neck pain or documentation of no neck pain on history or exam. We also reviewed charts for information regarding loss of consciousness, presence of headache, nausea/vomiting, medications given (ibuprofen, acetaminophen, oxycodone, morphine, fentanyl, ondansetron, and ketorolac), administration of intravenous fluids, imaging performed, cervical spine clearance in the ED, and referrals made. National Institute of Neurological Disease and Stroke established lists were used to categorize cause of mTBI and mechanism of injury. [10] For those patients who did have follow-up appointments within our system, all visits within 6 months of injury, regardless of provider specialty or type, were reviewed to determine if the visit was related to a concussion. Additional chart review was performed to determine if there was mention of follow-up occurring outside of our system for treatment for symptoms related to concussion and/or neck pain and the duration of follow-up. Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at the principal investigator’s institution.[11] REDCap is a secure, web-based software platform designed to support data capture for research studies.
Statistical Analysis
Statistical analyses focused on the prevalence of neck pain in the sample which will be reported as percentages with 95th percentile confidence intervals. We subsequently explored the degree to which neck pain was associated with demographic and injury variables as well as the difference in the number and duration of follow-up visits in patients with and without neck pain for whom follow-up data were available. Medications received in the ED as well as spine imaging rates between those with and without neck pain were also analyzed. Patients who had no documentation regarding neck pain and those who were noted to have a lack of neck pain were combined for purpose of analysis. There were 56 patients with no documentation regarding neck pain and 506 patients who were noted to have a lack of neck pain. Age of patients as well as number of follow-up tests were compared using Wilcoxon rank-sum tests. All other variables were assessed using chi-squared independence tests. An exact chi-square test was used when the expected count in one of the cells was at or below 5. Stepwise selection method was performed on the logistic model with a p-value threshold of 0.3 for entry, and 0.35 for staying in the model. The following variables are included in the model selection: age, sex, race, ethnicity and 11 kinds of injury mechanisms. The final model can be seen in table 5. Analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). Alpha was set to 0.05.
Table 5.
Multi-predictor logistic regression model predicting neck pain from demographic and injury variables
| Effect | Odds Ratio | 95% Confidence Limits | P Value |
|---|---|---|---|
| Age (in years) | 1.11 | 1.02 – 1.20 | 0.020 |
| Acceleration/deceleration | 2.89 | 1.30 – 6.43 | 0.009 |
| Ground level fall | 1.47 | 0.86 – 2.52 | 0.158 |
| Fall from height > 1m | 2.40 | 1.18 – 4.87 | 0.015 |
| Direct impact (head against object) | 0.65 | 0.40 – 1.07 | 0.089 |
Results
Sample Characteristics
The retrospective analysis yielded 1,468 ED visits for concussion or mTBI. After applying the exclusion criteria, 1,112 eligible visits were identified. A CONSORT diagram detailing the charts reviewed is available in Figure 1. Ultimately, a representative sample of 652 (58.6%) index ED visits (and all associated follow-up within 6 months) were abstracted.
Figure 1:
Consort Flow Diagram
The demographic makeup of our sample, including age, sex, race, and ethnicity, are presented in Table 1.
Table 1.
Demographics and Injury Details1
| Total N=652 (%) | No neck pain N=562 (%) | Neck pain N=90 (%) | P Value | |
|---|---|---|---|---|
| Age in years (Mean ± SD) | 10.9 ± 3.0 | 10.8 ± 2.9 | 11.7 ± 2.9 | 0.006 W |
| Female | 218 (33.4) | 183 (32.6) | 35 (38.9) | 0.238C |
| Race | 0.556C+ | |||
| American Indian/Alaska Native | 2 (0.3) | 2 (0.4) | 0 (0.0) | |
| Asian | 13 (2.0) | 12 (2.2) | 1 (1.1) | |
| Black/African American | 194 (30.1) | 163 (29.4) | 31 (34.4) | |
| White/Caucasian | 389 (60.4) | 334 (60.3) | 55 (61.1) | |
| Other/Unknown/Not reported | 46 (7.2) | 43 (7.6) | 3 (3.3) | |
| Ethnicity | 0.296C+ | |||
| Hispanic or Latino | 100 (15.3) | 91 (16.2) | 9 (10.0) | |
| Not Hispanic or Latino | 535 (82.1) | 455 (81.0) | 80 (88.9) | |
| Unknown/Refused | 17 (2.6) | 16 (2.8) | 1 (1.1) | |
| Mechanism of Injury | ||||
| Acceleration/deceleration | 45 (6.9) | 34 (6.0) | 11 (12.2) | 0.032 C |
| Direct impact: head against object | 341 (52.3) | 305 (54.3) | 36 (40.0) | 0.012 C |
| Ground level fall | 263 (40.3) | 227 (40.4) | 36 (40.0) | 0.944C |
| Direct impact: blow to head | 153 (23.5) | 133 (22.7) | 20 (22.2) | 0.764C |
| Fall from height > 1 meter (3 ft) | 77 (11.8) | 62 (11.0) | 15 (16.7) | 0.124C |
| Unknown | 5 (0.8) | 5 (0.9) | 0 (0.0) | 0.617C+ |
| Cause of TBI | ||||
| Motor vehicle traffic accidents | 47 (7.2) | 36 (6.4) | 11 (12.2) | 0.048 C + |
| Motor vehicle nontraffic accidents | 3 (0.5) | 2 (0.4) | 1 (1.1) | 0.360C+ |
| Other road vehicle accidents | 16 (2.5) | 15 (2.7) | 1 (1.1) | 0.495C+ |
| Vehicle accidents not elsewhere classifiable | 1 (0.2) | 1 (0.2) | 0 (0.0) | 1.000C+ |
| Accidental falls | 322 (49.4) | 273 (48.6) | 49 (54.4) | 0.553C |
| Injury purposely inflicted | 11 (1.7) | 10 (1.8) | 1 (1.1) | 0.649C+ |
| Other accidents | 271 (41.6) | 242 (43.1) | 29 (32.2) | 0.083C |
| Injury undetermined | 2 (0.3) | 2 (0.4) | 0 (0.0) | 1.000C+ |
| Mode of Arrival | < 0.001 C + | |||
| Ambulance | 91 (14.0) | 62 (11.0) | 29 (32.2) | |
| Car | 557 (85.4) | 497 (88.4) | 60 (66.7) | |
| Other | 1 (0.2) | 1 (0.2) | 0 (0.0) | |
| Unknown | 3 (0.5) | 2 (0.4) | 1 (1.1) |
Exact test
Wilcoxon rank-sum test
Chi-square test
Frequency of neck pain
The frequency of neck pain in patients diagnosed with mTBI in the ED was 13.8% (95% CI 11.2% – 16.7%) (n=90).
Variables associated with neck pain
Mechanism of injury, cause of TBI, and mode of arrival to the ED are detailed in Table 1. More than one mechanism of injury could be reported, e.g., an acceleration/deceleration injury in which the patient also struck his/her head. Neck pain was more prevalent in children who were older, had an acceleration/deceleration injury, were involved in a motor vehicle traffic accident, and arrived to the ED via ambulance. By itself, direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables this effect was not statistically significant. No other demographic or injury variables were significantly associated with neck pain.
Care and management
Presenting symptoms such as loss of consciousness, headache, and nausea/vomiting are presented in Table 2. Experiencing nausea/vomiting was associated with lower prevalence of neck pain (P=0.002). Medications given to patients to the ED are presented in Table 3. Several medications were statistically more likely to be given to a patient with neck pain than without.
Table 2.
Presenting Symptoms
| Total N=652 (%) | No neck pain N=562 (%) | Neck pain N=90 (%) | P Value | |
|---|---|---|---|---|
| Point tenderness in the neck | < 0.001C | |||
| Yes | 48 (7.4) | 2 (0.4) | 46 (51.1) | |
| No | 455 (69.8) | 422 (75.1) | 33 (36.7) | |
| Not documented | 149 (22.9) | 138 (24.6) | 11 (12.2) | |
| Headache | 0.292C+ | |||
| Yes | 583 (89.4) | 500 (89.0) | 83 (92.2) | |
| No | 46 (7.1) | 43 (7.7) | 3 (3.3) | |
| Not documented | 23 (3.5) | 19 (3.4) | 4 (4.4) | |
| Nausea/vomiting | 0.002 C + | |||
| Yes | 318 (48.8) | 289 (51.4) | 29 (32.2) | |
| No | 298 (45.7) | 246 (43.8) | 52 (57.8) | |
| Not documented | 36 (5.5) | 27 (4.8) | 9 (10.0) | |
| Loss of consciousness | 0.219C+ | |||
| Yes | 105 (16.1) | 84 (14.9) | 21 (23.3) | |
| No | 500 (76.7) | 436 (77.6) | 64 (71.1) | |
| Unknown | 34 (5.2) | 30 (5.3) | 4 (4.4) | |
| Not documented | 13 (2.0) | 12 (2.1) | 1 (11) |
Exact test
Chi-square test
Table 3.
ED Treatment and Evaluation
| Total N=652 (%) | No neck pain N=562 (%) | Neck pain N=90 (%) | P Value | |
|---|---|---|---|---|
| Medications | ||||
| Ibuprofen | 235 (36.0) | 190 (33.8) | 45 (50.0) | 0.003 C |
| Acetaminophen | 112 (17.2) | 98 (17.4) | 14 (15.6) | 0.660C |
| Ketorolac | 15 (2.3) | 12 (2.1) | 3 (3.3) | 0.707C+ |
| Oxycodone | 3 (0.5) | 1 (0.2) | 2 (2.2) | 0.052C+ |
| Morphine | 2 (0.3) | 0 (0.0) | 2 (2.2) | 0.019 C + |
| Fentanyl | 9 (1.4) | 6 (1.1) | 3 (3.3) | 0.115C+ |
| Ondansetron | 105 (16.1) | 93 (16.5) | 12 (13.3) | 0.441C |
| Compazine | 4 (0.6) | 4 (0.7) | 0 (0.0) | 0.645C+ |
| None | 263 (40.3) | 240 (42.7) | 23 (25.6) | 0.002 C |
| IV Fluids | 17 (2.6) | 14 (2.5) | 3 (3.3) | 0.718C+ |
| Imaging | ||||
| Imaging ordered in ED | 169 (25.9) | 117 (20.8) | 52 (57.8) | < 0.001 C |
| Head/Brain | 126 (19.3) | 109 (19.4) | 17 (18.9) | 0.910C |
| Cervical Spine/Neck | 59 (9.0) | 11 (2.0) | 48 (53.3) | < 0.001 C |
| Thoracic/Lumbar Spine | 29 (4.4) | 11 (2.0) | 18 (20.0) | < 0.001 C + |
| Outside Hospital Imaging | 0.313C+ | |||
| Yes | 16 (28.1) | 14 (31.8) | 2 (15.4) | |
| No | 41 (71.9) | 30 (68.2) | 11 (84.6) | |
| Outpatient Referral | ||||
| PCP | 569 (87.3) | 485 (86.3) | 84 (93.3) | 0.063C |
| Concussion Clinic | 137 (21.0) | 118 (21.0) | 19 (21.1) | 0.980C |
| Neurosurgery | 20 (3.1) | 3 (0.5) | 17 (18.9) | < 0.001 C + |
| Other | 12 (1.8) | 11 (2.0) | 1 (11) | 0.712C+ |
| None | 15 (2.3) | 15 (2.7) | 0 (0.0) | 0.148C+ |
Exact test
Chi-square test
Imaging was obtained in the ED in 25.9% of patients, while 28.1% had imaging performed at an outside hospital prior to arrival at our institution. Details regarding imaging are presented in Table 3. Patients with neck pain were statistically more likely to receive any type of imaging in the ED (P<0.001), imaging of the cervical spine (P=0.001), and imaging of the thoracic or lumbar spine (P<0.001).
Referrals made from the ED are detailed in Table 3. The only referral location which was associated with concurrent neck pain was to neurosurgery, with 18.9% of those with neck pain receiving a referral, while only 0.5% of those without neck pain received a referral to neurosurgery (P<0.001). Of note, 100% of patients with concomitant neck pain received some type of referral from the ED.
Follow-up visits
Details regarding follow-up visits are presented in Table 4. There was no difference in number of follow up visits between those with or without neck pain for total concussion related follow-up visits, follow-up visits to a concussion clinic, or concussion related follow-up at the ED. Patients with neck pain were more likely to follow up at a neurosurgery clinic.
Table 4.
Follow Up Visits
| Total N=652 (Mean ± SD) | No neck pain N=562 (Mean ± SD) | Neck pain N=90 (Mean ± SD) | P Value | |
|---|---|---|---|---|
| Total Related Visits | 1.0 ± 2.7 | 1.0 ± 2.8 | 0.9 ± 2.1 | 0.848W |
| Concussion Clinic | 0.4 ± 1.2 | 0.4 ± 1.3 | 0.2 ± 0.6 | 0.450W |
| Neurosurgery Clinic | 0.0 ± 0.2 | 0.0 ± 0.1 | 0.2 ± 0.5 | < 0.001 W |
| ED | 0.0 ± 0.2 | 0.0 ± 0.2 | 0.0 ± 0.1 | 0.338W |
Wilcoxon rank-sum test
Discussion
Neck pain is known to co-occur in a portion of patients with concussions, but its prevalence in children with concussion presenting to a pediatric ED is not known, nor is there evidence-based guidance for intervention strategies for children based on the co-occurrence of neck pain. In this sample of children presenting to a level 1 trauma center pediatric ED, 13.8% of patients diagnosed with concussion reported neck pain. Although this prevalence estimate is less than reported for children seen during follow-up visits,[5–7] the findings demonstrate that a substantial minority of the pediatric concussion patients may have comorbid neck injury. As comorbid neck pain can signal a need for distinct personalized clinical management strategies, the findings imply that it would be valuable for emergency medicine providers to routinely screen for neck pain. Additional research is needed to evaluate whether personalized treatment based on such evaluations leads to better outcomes.”
Analyses of factors that predicted neck pain in this sample further expand our limited understanding of who is at highest risk of comorbid neck/concussive injury and therefore what subpopulations of pediatric concussion warrant particular attention in considering neck injury as a potential comorbid diagnosis. When the mechanism of injury included acceleration/deceleration (as commonly occurs in the setting of motor vehicle/traffic crashes), patients were more likely to have neck pain. This is consistent with findings from adult concussion patients and our expectations, as the acceleration forces necessary to cause a concussion exceed the acceleration forces capable of causing a whiplash injury in adults.[8, 12] This may be more impactful in children as they have a greater head to body ratio than adults and less cervical strength which may increase these forces in an acceleration/deceleration moment.[13] That acceleration/deceleration events can cause both concussion and whiplash-type injuries complicates clinical diagnoses of both conditions given overlap in the symptom profile of whiplash and mTBI such as headache, fatigue, and concentration problems.[14] In contrast, in our sample, pediatric patients who had a direct impact to the head were significantly less likely to report neck pain as the head striking an object would be less likely to cause an acceleration/deceleration event to cause neck pain.
The majority of patients (68.7%) had no follow-up visits within our healthcare system related to their concussion. Although we cannot rule out the possibility that patients sought follow-up care outside our healthcare system, this is consistent with other literature that suggest most patients do not seek follow up for mild traumatic brain injury seen in the ED. In a study of pediatric patients recruited from two similar pediatric emergency departments, at baseline, 68% of patients did not seek follow up within 4 weeks of diagnosis of concussion. This lack of follow up may be because most concussions are self-limiting in nature, as the largest prospective pediatric concussion study to date demonstrated that nearly 70% of patients recover from concussion within 28 days.[15]
Of the patients in our cohort who did have follow-up visits related to concussion, there was no statistically significant difference in the number of follow-up visits related to concussion between patients with and without neck pain. Patients with neck pain were also not more likely to seek follow up at a dedicated multimodal pediatric concussion clinic within our institution. There was a statistically significant difference in the number of referrals made to neurosurgery from the ED as well as the number of actual follow-up visits in neurosurgery clinic between patients who had neck pain and those who did not. This is most likely due to local clinical protocols that refer patients with persistent neck pain to neurosurgery for cervical collar clearance. The total number of patients who were seen in neurosurgery clinic regardless of neck pain was low, so this finding should be considered with caution.
Our data showed that patients with neck pain received imaging more frequently than those without neck pain. Similarly, we found that patients with mTBI and concomitant neck pain were more likely to receive ibuprofen or morphine than those without neck pain. It bears highlighting that the bulk of imaging ordered in the neck pain population was of the cervical spine, likely related to clinical protocols to treat pain and obtain cervical spine imaging in the setting of traumatic neck pain to rule out cervical fracture and instability. Given that neck pain was associated with acceleration/deceleration as well as motor vehicle accidents, this difference may be due to the need to rule out cervical fracture and instability related with these mechanisms of injury. There was no significant difference between those with and without neck pain with respect to imaging of the brain.
Limitations for this study include the fact that this was a retrospective chart analysis at a single site. However, the number of charts reviewed was large (652) and representative of the mTBI/concussion population seen at the institution over a contemporary, nearly three-year period. Another limitation to our study was that we were not able to evaluate any follow-up care that may have been completed outside of our health care system. This may have caused us to miss patients that reported neck pain later in the clinical course of their injury. Records did not reliably detail length of recovery. As such we were unable to address one of our objectives of how the presence of neck pain impacted recovery length. As the study assessed only neck pain on presentation, we could not assess the number of patients who develop neck pain after the ED visit. Finally, because we treated records with no mention of neck pain to indicate the absence of neck pain, the prevalence of neck pain may be underestimated. However, the numbers of these cases without such documentation was sufficiently small (n=56/652) to have minimal impact on the prevalence estimate.
In summary, in this sample of pediatric ED patients with mTBI, the frequency of neck pain was 13.8%. Patients with neck pain were significantly more likely to be older, be involved in a motor vehicle collision, and/or sustain an acceleration/deceleration injury. Patients with neck pain were more likely to receive ibuprofen or morphine and undergo imaging in the ED. For the minority of patients who required follow up after their injury, there was no significant difference in concussion related follow up visits between patients with and without neck pain. However, patients with neck pain were more likely to receive a referral and follow up with neurosurgery. The findings provide foundational preliminary data to support examining all concussion patients for concurrent neck injury and continued research on the natural history and treatment needs of the substantial minority of concussion patients with comorbid neck pain. Future studies should focus on prospectively studying the effect of neck pain on concussion recovery.
Acknowledgments
The REDCap electronic database service used for the study was supported by the Medical College of Wisconsin Clinical and Translational Science Institute under the National Institutes of Health award (grant no. UL1TR001436). Financial support for statistical analysis was provided by the Neuroscience Research Center at The Medical College of Wisconsin. Funding sources had no role in study design
Abbreviations:
- ED
Emergency Department
- mTBI
Mild traumatic brain injury
- TBI
Traumatic brain injury
- EMR
Electronic Medical Record
- REDCap
Research Electronic Data Capture
Footnotes
None of the authors have any conflicts of interest to disclose.
Preliminary results of this study were presented:
Virtual power point presentation at: 2020 Sports Concussion Virtual Conference. American Academy of Neurology. 2020 July 31- August 2; Virtual Meeting.
CANCELLED d/t Covid-19. Poster session presented at: Emergency Medicine: Head Injury. Pediatric Academic Societies 2020 Meeting 2020 May 2–5; Philadelphia, PA.
Suppliers:
A: Hughes SAS 9.4S SAS institute Cary, NC
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