Concussion Care Research Articles

Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada

BackgroundWe described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada.MethodsA retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped.ResultsConcussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically.ConclusionsThe shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion.ImpactThis is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES.We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age.Patients increasingly received care for concussion in PO over time.Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally.Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Optimizing Concussion Care Seeking: The Influence of Previous Concussion Diagnosis Status on Baseline Assessment Outcomes

Background: The prevalence of unreported concussions is high, and undiagnosed concussions can lead to worse postconcussion outcomes. It is not clear how those with a history of undiagnosed concussion perform on subsequent standard concussion baseline assessments. Purpose: To determine if previous concussion diagnosis status was associated with outcomes on the standard baseline concussion assessment battery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Concussion Assessment, Research, and Education (CARE) Consortium participants (N = 29,934) self-reported concussion history with diagnosis status and completed standard baseline concussion assessments, including assessments for symptoms, mental status, balance, and neurocognition. Multiple linear regression models were used to estimate mean differences and 95% CIs among concussion history groups (no concussion history [n = 23,037; 77.0%], all previous concussions diagnosed [n = 5315; 17.8%], ≥1 previous concussions undiagnosed [n = 1582; 5.3%]) at baseline for all outcomes except symptom severity and Brief Symptom Inventory–18 (BSI-18) score, in which negative binomial models were used to calculate incidence rate ratios (IRRs). All models were adjusted for sex, race, ethnicity, sport contact level, and concussion count. Mean differences with 95% CIs excluding 0.00 and at least a small effect size (≥0.20), and those IRRs with 95% CIs excluding 1.00 and at least a small association (IRR, ≥1.10) were considered significant. Results: The ≥1 previous concussions undiagnosed group reported significantly greater symptom severity scores (IRR, ≥1.38) and BSI-18 (IRR, ≥1.31) scores relative to the no concussion history and all previous concussions diagnosed groups. The ≥1 previous concussions undiagnosed group performed significantly worse on 6 neurocognitive assessments while performing better on only 2 compared with the no concussion history and all previous concussions diagnosed groups. There were no between-group differences on mental status or balance assessments. Conclusion: An undiagnosed concussion history was associated with worse clinical indicators at future baseline assessments. Individuals reporting ≥1 previous undiagnosed concussions exhibited worse baseline clinical indicators. This may suggest that concussion-related harm may be exacerbated when injuries are not diagnosed.

A-185 Influence of Improved Lifetime TBI History Ascertainment on Clinical Outcomes

Abstract Objective: History of TBI/concussion earlier in life may have implications for long-term health. It is important to understand factors that influence retrospective reports of TBI/concussion history in the clinic. We examined whether providing a formal TBI/concussion definition affected self-reported TBI/concussion history and evaluated association of TBI/concussion history with current mood symptoms. Methods: Participants were 12 individuals (5 M, 7 F, average age = 40.4) seen in an interdisciplinary TBI/concussion clinic. Non-parametric Mann-Whitney-Wilcoxon tests compared the total number of reported TBI/concussions before and after providing patients a formalized definition for TBI/concussion in the overall sample and then separately for males and females. A secondary analysis used Pearson’s correlation to examine the relationship between total number of TBI/concussions and self-reported anxiety using Generalized Anxiety Disorder (GAD-7) total score. Results: Participants reported an average of 3.1 more concussions after being informed of the definition of a TBI/concussion. This result was primarily seen in men, who reported 5.8 more TBI/concussions (women = 0.5 more TBI/concussions) after the definition was provided (W = 1.5, p = 0.05). Further, there was a positive, strong correlation between total number of reported lifetime concussions post TBI/concussion definition and anxiety severity (r = 0.67, p = 0.05). Conclusions: Providing a definition of TBI/concussion increases reports of lifetime concussion, primarily in males. Higher trait anxiety may also be associated with self-reported concussion history. Larger sample sizes are needed to better understand factors that drive retrospective injury reports in those who seek concussion care.

Optimizing Concussion Care Seeking: Identification of Factors Predicting Previous Concussion Diagnosis Status.

There is limited understanding of factors affecting concussion diagnosis status using large sample sizes. The study objective was to identify factors that can accurately classify previous concussion diagnosis status among collegiate student-athletes and service academy cadets with concussion history. This retrospective study used support vector machine, Gaussian Naïve Bayes, and decision tree machine learning techniques to identify individual (e.g., sex) and institutional (e.g., academic caliber) factors that accurately classify previous concussion diagnosis status (all diagnosed vs 1+ undiagnosed) among Concussion Assessment, Research, and Education Consortium participants with concussion histories ( n = 7714). Across all classifiers, the factors examined enable >50% classification between previous diagnosed and undiagnosed concussion histories. However, across 20-fold cross validation, ROC-AUC accuracy averaged between 56% and 65% using all factors. Similar performance is achieved considering individual risk factors alone. By contrast, classifications with institutional risk factors typically did not distinguish between those with all concussions diagnosed versus 1+ undiagnosed; average performances using only institutional risk factors were almost always <58%, including confidence intervals for many groups <50%. Participants with more extensive concussion histories were more commonly classified as having one or more of those previous concussions undiagnosed. Although the current study provides preliminary evidence about factors to help classify concussion diagnosis status, more work is needed given the tested models' accuracy. Future work should include a broader set of theoretically indicated factors, at levels ranging from individual behavioral determinants to features of the setting in which the individual was injured.

Evaluation of the Visual System by the Primary Care Provider Following Concussion.

Concussion is a common injury in childhood and has the potential for substantial impact on quality of life. Visual issues have been increasingly recognized as a common problem after concussion. Many children initially seek care for concussion with their pediatrician, making it even more important for pediatricians to recognize, evaluate, and refer children with visual issues after concussion. This clinical report is intended to support the recommendations in the companion policy statement on vision and concussion and provides definitions of some of the physiologic aspects of the visual system as they relate to concussion. A description of clinically feasible testing methodologies is provided in more detail to aid the clinician in assessing the visual system in a focused fashion after concussion. This guidance helps direct clinical management, including support for return to school, sports, and other activities, as well as potential referral for subspecialty care for the subset of those with persistent symptoms.

Eye Tracking Metrics Differences among Uninjured Adolescents and Those with Acute or Persistent Post-Concussion Symptoms.

Eye tracking assessments that include pupil metrics can supplement current clinical assessments of vision and autonomic dysfunction in concussed adolescents. This study aimed to explore the utility of a 220-second eye tracking assessment in distinguishing eye position, saccadic movement, and pupillary dynamics among uninjured adolescents, those with acute post-concussion symptoms (≤28 days since concussion), or those with persistent post-concussion symptoms (>28 days since concussion). Two hundred fifty-six eye tracking metrics across a prospective observational cohort of 180 uninjured adolescents recruited from a private suburban high school and 224 concussed adolescents, with acute or persistent symptoms, recruited from a tertiary care subspecialty concussion care program, 13 to 17 years old, from August 2017 to June 2021 were compared. Kruskal-Wallis tests were used, and Bonferroni corrections were applied to account for multiple comparisons and constructed receiver operating characteristic curves. Principal components analysis and regression models were applied to determine whether eye tracking metrics can augment clinical and demographic information in differentiating uninjured controls from concussed adolescents. Two metrics of eye position were worse in those with concussion than uninjured adolescents, and only one metric was significantly different between acute cases and persistent cases. Concussed adolescents had larger left and right mean, median, minimum, and maximum pupil size than uninjured controls. Concussed adolescents had greater differences in mean, median, and variance of left and right pupil size. Twelve metrics distinguished female concussed participants from uninjured; only four were associated with concussion status in males. A logistic regression model including clinical and demographics data and transformed eye tracking metrics performed better in predicting concussion status than clinical and demographics data alone. Objective eye tracking technology is capable of quickly identifying vision and pupillary disturbances after concussion, augmenting traditional clinical concussion assessments. These metrics may add to existing clinical practice for monitoring recovery in a heterogeneous adolescent concussion population.

A-13 A Description of Patient Characteristics and Predictors for Vestibular Therapy Referral Following Concussion

Abstract Purpose: To describe patient characteristics and predictors for vestibular therapy referral among concussion patients with vestibular and ocular motor dysfunction. Methods: Medical records from 1083 patients (12-50 yrs) seeking care for concussion within 30 days of injury were extracted. Demographics and clinical outcomes (symptoms, vestibular/oculomotor change scores, and state anxiety) were described and associations between referral and these variables were explored with chi-square analyses and a logistic regression. Results: Twenty-one percent (229/1083, Mage = 22.34, SD = 10.26 yrs, 64% female) of patients received vestibular therapy referral. The most frequent risk factors included symptom burden (94%), vestibular/ocular motor symptom provocation (88%), convergence insufficiency (73%), state anxiety (66%), and post-traumatic migraine (PTM) (52%). The LR (χ2(13, 1083) = 142.24, p &amp;lt; 0.001) revealed vestibular/ocular motor provocation (adjusted OR = 3.88, p &amp;lt; 0.001) showed the greatest likelihood for referral followed by symptom burden (adjusted OR = 2.78, p &amp;lt; 0.001), convergence insufficiency (adjusted OR = 2.77, p &amp;lt; 0.001), first clinical visit longer than one week (adjusted OR = 1.90, p &amp;lt; 0.001), and on-field dizziness (adjusted OR = 1.51, p = 0.03). Conclusions: Approximately 25% of concussed patients receive vestibular therapy. These patients have more vestibular/ocular motor impairment, dizziness, and overall symptom burden.

Group Differences in Postconcussion Cognitive, Physical, Sleep-Arousal, and Affective Symptom Subscales in High School and Collegiate Athletes by Race, Gender, and Competitive Level.

Prior psychometric research has identified symptom subscales for the Post-Concussion Symptom Scale (PCSS) based on confirmatory factor analysis (CFA), including cognitive, physical, sleep-arousal, and affective symptom factors. Study objectives included: (1) replicate the 4-factor PCSS model in a diverse sample of athletes with concussion, (2) test the model for invariance across race, gender, and competitive level, and (3) compare symptom subscale and total symptom scores across concussed groups with established invariance. Three regional concussion care centers. A total of 400 athletes who completed the PCSS within 21 days of concussion (64% boys/men, 35% Black, and 69.5% collegiate athletes). Cross-sectional. A CFA tested the 4-factor model and measurement invariance testing was performed across racial, competitive level, and gender groups. Symptom subscales and total symptom severity scores were compared based on demographic groupings with established invariance. The 4-factor model fit well and strong invariance was established across all demographic categories, indicating symptom subscales could be meaningfully compared across groups. Black and White athletes differed on total symptoms (U = 15 714.5, P = .021, r = 0.12), sleep-arousal symptoms (U = 15 953.5, P = .026, r = 0.11), and physical symptoms (U = 16 140, P = .051, r = 0.10), with Black athletes reporting slightly more symptoms. Collegiate athletes reported greater total symptom severity (U = 10 748.5, P < .001, r = 0.30), with greater symptom reporting on the cognitive (U = 12 985, P < .001, r = 0.21), sleep-arousal (U = 12 594, P < .001, r = 0.22), physical (U = 10 959, P < .001, r = 0.29), and emotional (U = 14 727.5, P = .005, r = 0.14) symptom subscales. There were no significant differences by gender in the total symptom score or subscale scores. After controlling for time since injury, no racial differences persisted, but a significant difference by competitive level in physical symptom reporting (F = 7.39, P = .00, η2 = 0.02) and total symptom reporting (F = 9.16, P = .003, η2 = 0.02) remained. These results provide external validation for the PCSS 4-factor model and demonstrate that symptom subscale measurements are comparable across race, genders, and competitive levels. These findings support the continued use of the PCSS and 4-factor model for assessing a diverse population of concussed athletes.

The Toronto Concussion Study: Reference Data for Balance and Gait Measures in Community-Dwelling Adults With Concussion.

Concussion can cause deficits in balance and gait. Much of what is known about how concussion affects balance and gait has been derived from studies involving youth, high school, and university athletes. However, investigation into the effects of concussion on balance and gait in community-dwelling young, middle-age, and older aged adults is limited. This study aimed to present descriptive reference values for common balance and gait measures in community-dwelling adults between the ages of 20 and 69years with concussion. In this observational study, 318 participants were enrolled from a concussion care clinic at a rehabilitation hospital in an urban center and were assessed within 7days of injury. Balance measures included the Balance Error Scoring System (BESS), modified BESS, and center-of-pressure root mean square during quiet standing. Gait measures included velocity (absolute and height adjusted), cadence, and step length during self-paced gait. Data were binned by decade-long age range. Mean (SD) per-decade scores for the BESS ranged from 14.8 (5.1) to 21.8 (5.6) errors and 4.0 (3.0) to 9.4 (4.6) errors for the modified BESS. Mean values for center-of-pressure root mean square in the anteroposterior direction ranged from 0.42 (0.18) to 0.52 (0.26) with the eyes open, and from 0.49 (0.19) to 0.62 (0.39) with eyes closed. Mean absolute gait velocity ranged from 98.5 (9.1) to 119.3 (21.3) cm/s. The range of step length values was 58.2 (6.8) to 66.3 (7.3) cm and cadence ranged from 102.1 (9.8) to 108.6 (10.8) steps/min across age groups. These data provide insight into the impact of concussion on balance and mobility in community-dwelling adults across the lifespan. Community-dwelling adults can experience concussion across the lifespan. Availability of reference values for commonly used balance and gait measures can help to inform clinical strategies and progression of recovery of balance and mobility after injury.

Stratifying Risk for Failure to Receive Concussion Care (P10-8.007)

Stratifying Risk for Failure to Receive Concussion Care (P10-8.007)

Non-Private Health Insurance Plans and Delayed Access to a Specialty Pediatric Concussion Clinic

Background:Delayed access to specialty concussion clinic results in a 5.5 times greater risk of protracted recovery and higher costs to the healthcare system. Previous research highlighting health equity disparities has shown that being female, of minoritized status, or having non-private health insurance doubles the risk of delayed access to specialty concussion clinic.Purpose:The purpose of this project was to better characterize those with non-private insurance receiving care at a specialty concussion clinic and examine factors potentially contributing to delayed access to specialty care.Methods:Medical records of 231 patients with non-private insurance were reviewed. Patients were divided into two categories (Equivocal, Unequivocal) based on handbook language requiring PCP referral. Equivocal were insurance plans with ambiguous language requiring PCP referral. Unequivocal were insurance plans with a specific statement requiring a referral. Access to clinic was defined as early (0-7 days) or delayed (8-20 days). Descriptive stats were run to determine the number of males/females, providers previously seen, and if previously seen in the Emergency Room (ER). A one-way analysis of variance (ANOVA) was run along with Tukey post hoc to determine if there were any significant differences between number of previous providers seen and previous ER visit in the average number of days to specialty care.Results:Most patients, 97% (n=224) were in the equivocal category. The equivocal category was mostly male (n=145, 64.7%) and of minoritized status (n=177, 79%) with over 35% (n=80) being delayed to clinic (M=6.8 days, SD=4.7). The majority of those in the equivocal category (n=157, 67.9%) saw at least one previous provider, 53% being evaluated first in an ER (n=119). Those with a previous provider visit took longer to seek specialty care (F(2,230) = 3.54, p = 0.03). Those seeing two previous providers (M=9.4 days) on average took more days to get to initial specialty care compared to seeing one previous provider (M=6.8 days) or going straight to clinic (M=6.2 days).Conclusion:Patients with a non-private health insurance plan experience delayed access to specialty concussion care. Those with equivocal insurance plan language were delayed to clinic, seen by multiple providers, and first evaluated in the Emergency Room. Non-private insurance is often financially subsidized, yet the equivocal language in these policies could be a detriment contributing to overall increases in health care costs and quality of care for those who have sustained a concussion.

Functional Cognition: An Opportunity to Highlight the Role of Occupational Therapy in Post-Concussion Care

As concern surrounding concussion and the associated long-term effects grow, a continued need for comprehensive, holistic concussion care emerges. Occupational therapists are well-equipped to address the wide variety of symptoms and deficits that clients may experience post-concussion. Functional cognition is one area in which occupational therapists can demonstrate their unique value on the interdisciplinary treatment team. In this Opinions in the Profession paper, we describe how occupational therapists are poised to further establish their role in post-concussion care by becoming the primary discipline for assessing and treating functional cognition. The aim of this paper is to outline the role of occupational therapy in post-concussion care in regard to becoming the primary discipline for assessing and treating functional cognition and distinguishing occupational therapists as experts in functional cognition. Implications for practice, education, and research are discussed.

Disparities in concussion diagnoses compared to ankle injuries.

Health disparities related to concussions have been reported in the literature for certain minority populations. Given the significant impact of concussions on long- and short-term function, the mitigation of barriers to accessing care is an important public health objective. To determine if racial and ethnic disparities exist in patients who seek care for concussions compared to a control group with orthopedic ankle injuries (sprains and fractures) to minimize confounding factors that predispose to injury. Cohort study. Single institution between February 2016 and December 2020. A retrospective review of electronic medical records was completed for patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for concussion, ankle sprain, and ankle fracture. A total of 10,312 patients were identified: 1568 (15.2%) with concussion, 4871 (47.3%) with ankle sprain, and 3863 (37.5%) with ankle fracture. Patients were stratified by demographic factors, including sex, ethnicity, race, and insurance type. Diagnosis of concussion. The concussion group was the youngest (28.3 years ± 18.0) and had the fewest females (53.1%) compared to the ankle sprain (35.1 years ± 19.7; 58.7%) and fracture groups (44.1 years ± 21.3; 57.3%). The concussion group had a smaller proportion of Hispanic patients than the ankle sprain group (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.55-0.92, p=.010) and fracture group (OR 0.58, 95% CI 0.44-0.75, p=<.001). In addition, the concussion group was less likely to be Asian (OR 0.70, CI 0.52-0.95, p=.023) than the sprain group and less likely to be Black/African American than both sprain (OR 0.65, 95% CI 0.46-0.93, p=.017) and fracture groups (OR 0.62, 95% CI 0.43-0.89, p=.010). There were no differences across racial groups between ankle sprains and fractures. Patients with Medicaid/Medicare and self-pay had a higher likelihood of being in the concussion group than those with private insurance. Differences in concussion diagnosis may exist between certain demographic groups compared to those with ankle injuries. Efforts to mitigate disparities in concussion care are worthwhile with a focus on patient and caregiver education.

Current Use and Future Considerations for Concussion Telemedicine Healthcare in Canada.

To examine the use of telemedicine among Canadian concussion providers and clinics before and after the COVID-19 pandemic onset and identify barriers and facilitators for future use. Ninety-nine concussion clinics and healthcare providers across Canada that offered one or more clinical concussion-related service were identified using standardized online searches and approached to complete a cross-sectional online survey. Thirty clinics or providers completed the survey and two completed subsections of the survey (response rate of 32.3%). Only 28.1% of respondents indicated that they used telemedicine to provide care prior to the COVID-19 pandemic. Providers most commonly using telemedicine prior to the pandemic were occupational therapists and physicians, while the most commonly used services were in-person videoconferencing and eConsultation. Most respondents (87%) indicated their clinic's use of telemedicine changed following the onset of the COVID-19 pandemic including new use of in-person video-conferencing, telephone calls, and eConsultation. Ninety-three percent indicated that they would consider using telemedicine to provide care to their concussion patients once the pandemic was over. Barriers needed to be overcome to facilitate use or greater use of telemedicine-based services were the inability to conduct a complete physical examination, lack of appropriate reimbursement, lack of start-up, and maintenance funding and medico-legal risk. Telemedicine was used by a minority of Canadian concussion clinics and providers prior to the COVID-19 pandemic but was rapidly adopted by many facilities. This study provides important insight into the factors that must be considered to optimize use of telemedicine in concussion care in the future.

Assault-Related Concussion in a Pediatric Population.

The aim of this study was to compare demographic characteristics, medical care, and outcomes among patients with assault-related concussion (ARC) versus sports and recreation-related concussion (SRC). We conducted a retrospective chart review of 124 patients (62 ARC, 62 SRC) aged 8 to 17 years presenting to the care network of a large tertiary care pediatric hospital between July 1, 2012, and June 30, 2014 with a concussion diagnosis at time of presentation. We abstracted patient demographics, initial medical care visit characteristics, and outcome data, and compared proportions using χ2 testing and Fisher exact test and medians using Wilcoxon rank sum test. Patients with ARC were more likely to be Black, publicly insured, and present first for care to the emergency department. Significantly fewer patients with ARC received visio-vestibular testing at initial visit (27% vs 74%, P < 0.001). During recovery, the total number of reported physical, cognitive, emotional, and sleep symptoms did not differ between groups; however, more than twice as many patients with ARC reported decline in grades postinjury compared with patients with SRC (47% vs 20%, P = 0.012). There were trends toward prolonged symptom recovery and time to physician clearance for full return to activities among patients with ARC compared with SRC. This study highlights potential disparities in the initial evaluation and outcomes of pediatric concussion patients based on mechanism of injury. Patients with ARC were less likely to receive a concussion-specific diagnostic evaluation and reported a greater impact on educational outcomes, suggesting differences in concussion diagnosis and management among assault-injured patients. Further examination in larger populations with prospective studies is needed to address potential inequities in concussion care and outcomes among patients with ARC.

Collaboration is key to concussion management in family medicine.

Collaboration is essential to many aspects of the work of family physicians. Concussion care is certainly no exception—multiple stakeholders have the potential to do better collectively through collaboration on this important public health issue, both in the community and within the health care

Hope for "Continued Vitality": Qualitative Study of Adults With Traumatic Brain Injury and Low Mood on Their Rehabilitation.

ObjectiveDepression is highly comorbid with traumatic brain injury (TBI) with often complex and interacting symptomology that contributes to the experience of disability. Comorbid depression results in poorer TBI rehabilitation and downstream participation outcomes yet perspectives of this group regarding person-centered care is unknown.PurposeThis study aimed to explicate the perspectives of persons with TBI and depression on their values, preferences, and desired outcomes for optimal rehabilitation.MethodsA qualitative descriptive approach was taken. Thirteen adults [mean age: 40.5 (standard deviation 9.8)] diagnosed with TBI and with self-reported low mood were recruited through convenience sampling. Participants were predominantly female (n = 12) with concussion/mild TBI and at least 6 months post-injury. One-on-one, semi-structured interviews were conducted by phone with Canadian participants (March-May 2020). Interviews were transcribed; data were analyzed thematically by two researchers and the thematic map refined by the research team.ResultsThree themes were identified on values, preferences, and desired outcomes in person-centered care. Participants valued “validation” from healthcare providers and the health system to feel seen and believed about their conditions and concerns. They preferred for healthcare providers to “share the burden of managing care” through improved interactions and better access to concussion care. Participants expressed that “meaningful outcomes” were to be symptom free, to resume valued life activities, and to be able to adapt/be resilient. The latter indicated hope for “continued vitality” for life participation despite past and ongoing challenges.ConclusionsMany adults with TBI and self-identified low mood expressed rehabilitation experiences that were invalidating. Their identified values, preferences, and desired outcomes provide directions for better person-centered care by healthcare providers and health systems to support participation.

Anxiety Is Associated With Diverse Physical and Cognitive Symptoms in Youth Presenting to a Multidisciplinary Concussion Clinic.

IntroductionPre-injury and post-injury anxiety are prevalent and important to consider in the medical management of concussions in youth. We examined the association between anxiety and other physical, cognitive, and emotional symptoms in injured adolescents and young adults undergoing an initial evaluation in a specialty concussion clinic.MethodsParticipants were 158 adolescents and young adults presenting to a multidisciplinary concussion clinic for evaluation and treatment (54.4% girls and women; mean age = 17.3 years; SD = 2.9). Their median days post injury was 29 (interquartile range = 14–49; range = 7–349). They were divided into binary groups based on whether they had a pre-injury history of anxiety diagnosis or treatment and whether they were experiencing current anxiety in the week prior to the evaluation, and then compared on the Post-Concussion Symptom Scale.ResultsYouth with a pre-injury history of anxiety reported greater post-concussion symptoms (Md total score = 36.0, IQR = 21.5–53.0) compared to youth with no pre-injury history of anxiety (Md total score = 20.5, IQR = 6.0–36.0; MW U = 1,520.00 p = 0.001, r = 0.26, small-medium effect size). They reported significantly worse headaches, nausea, balance difficulty, dizziness, vision problems, fatigue, concentration difficulty, irritability, nervousness, sadness, feeling more emotional, trouble falling asleep, and sleeping more than usual. Youth with high post-injury anxiety reported greater post-concussion symptoms (Md total score = 55.0, IQR = 33.0–62.5) compared to youth with low post-injury anxiety (Md total score = 19.0, IQR = 6.0–35.0; MW U = 681.00, p < 0.001, r = 0.49, large effect size). They reported significantly worse headaches, nausea, vomiting, dizziness, vision problems, fatigue, sensitivity to light, feeling mentally foggy, feeling slowed down, concentration difficulty, memory difficulty, irritability, sadness, feeling more emotional, drowsiness, trouble falling asleep, sleeping less than usual, and sleeping more than usual. Logistic regressions revealed that both pre-injury and post-injury anxiety were strong predictors of persistent post-concussion symptoms, with high post-injury anxiety presenting the strongest independent predictor, while attention-deficit hyperactivity disorder and pre-injury migraines were not significant predictors. Essentially all adolescents with high post-injury anxiety (97.1%) and nearly 9 of 10 adolescents with pre-injury treatment for anxiety (87.8%) met criteria for persistent post-concussion symptoms.DiscussionPre-injury and post-injury anxiety are important risk factors for greater post-concussion symptoms among adolescents and young adults. Elevated post-injury anxiety was the strongest predictor of persistent post-concussion symptoms. Assessment of anxiety is important among adolescents presenting for concussion care and delivery of evidence-supported treatments for anxiety are important considerations for treatment planning for these youth.

Concussion reporting intentions for incoming military athletes and cadets

ABSTRACT Cultures of concussion reporting exist outside athletics; however, athlete-only studies dominate the literature. Comparing athletes and similar high-risk populations broadens our understanding of concussion reporting acculturation. We aimed to (1) describe and compare concussion self-report willingness as measured by anticipated concussion reporting (ACR), perceived costs, perceived rewards, brain health knowledge, and correct symptom identification for incoming cadets at the United States Air Force Academy (USAFA) (n = 1,136; female = 276, 24.43%) and (2) determine whether those variables predict ACR. Univariate analyses were performed to compare intercollegiate status, sex, and parental income for perceived costs and rewards, and brain health knowledge (α = 0.05) and multinomial logistic regressions to determine if those variables predicted ACR. A $40,000 parental increase in income resulted in one additional symptom identified (β = 0.80, p = 0.026). Athletes demonstrated greater brain health knowledge by nearly one symptom correctly identified (β = 0.98, p = 0.002); non-athletes reported significantly greater ACR (β = 5.92; p < 0.001). Our model accounted for 37% of the variance in ACR (χ2 = 393.86, p < 0.001, Nagelkerke R2 = 0.37). Before military acculturation, athletes had less intention to seek medical care for concussion, likely from prior athletic experiences.

Applying knowledge translation frameworks, approaches and principles to co-create a dissemination plan: Optimizing the spread of a pediatric concussion guideline

Background Clinical practice guidelines are evidence-based statements that assist healthcare professionals with improving patient care. Achieving guideline aims depends on successful knowledge translation (KT) and includes dissemination and implementation efforts. Dissemination efforts are important precursors to implementation, help to maximize awareness and reach of best practices, and prepare for evidence adoption. This article shares the application of KT frameworks, approaches and principles in the creation of a dissemination plan and KT products for the Living Guideline for Pediatric Concussion Care. The target audience for dissemination are healthcare professionals delivering clinical care to patients between 5–18 years. Methods Guided by the Framework for Knowledge Transfer and an integrated KT (iKT) approach, 46 concussion experts participated in an iKT workshop and knowledge board activity to: 1) establish a Living Guideline dissemination plan; 2) identify products to share the Living Guideline; and, 3) prepare for Living Guideline implementation planning. Post-workshop, a snowball approach invited knowledge users including educators and youth/young adults with lived experience in concussion via interviews and focus groups, to expand upon the dissemination plan and recommended products. Results The dissemination plan yielded a reach of nearly 42,000 Living Guideline page views from September, 2019-January, 2022. Dissemination efforts included 13 multi-media interviews, over 40 activities (e.g. webinars), and 28 engagement emails to help raise awareness. Eight KT products were developed to foster sharing and use of the Living Guideline, with over 3000 downloads across all KT products. Conclusions Applying an iKT approach alongside appropriate frameworks and principles allowed for interaction and partnership building, resulting in the development of a robust dissemination plan and essential KT products. By showing the breadth and impact of the KT activities undertaken, it is hoped that the concussion community will explore how KT practices can bolster efforts to drive evidence into practice and optimize concussion care.