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Measuring Dynamic Symptom Response in Concussion: Children's Exertional Effects Rating Scale

Objective: To introduce and evaluate a measure of momentary symptom response to cognitive activity, a core feature of concussion. Setting: Concussion clinic at a large regional children's hospital. Participants: Individuals aged 5 to 18 years, comprising 3 clinical groups: uninjured (n = 590), recently concussed but clinically recovered (n = 160), and recently concussed but not yet recovered (n = 570). Design: Participants completed pretest symptom ratings, underwent neurocognitive assessment and completion of questionnaires, and then completed posttest ratings. An exertional effects index was computed by subtracting pretest from posttest ratings. Main Measures: Children's Exertional Effects Rating Scale, which includes 4 symptoms (Headache, Fatigue, Concentration Problems, and Irritability) rated pre- and postactivity. Results: Children's Exertional Effects Rating Scale was found to have adequate reliability and validity. There were negligible differences in ratings (pretest and exertional effects) between the Uninjured and Recovered groups, while individuals who were Not Recovered rated higher levels of pretest and exertional effects. Base rates showed that an exertional effects index of 4 or more points is rare in individuals who do not have a current concussion. Conclusion: Children's Exertional Effects Rating Scale is a psychometrically sound scale for evaluating momentary symptom increase in response to cognitive activity. Clinicians can use this scale as part of a multimodal battery for concussion assessment and treatment.