Concussion Clinic Research Articles

Association of Sleep Disturbance With Neurocognition, Symptom Severity, and Recovery in Pediatric Concussion: A 10-Year Retrospective Analysis of a Tertiary Referral Concussion Clinic.

To investigate the relationship between sleep disturbance, neurocognition, symptom severity, and recovery in children and adolescents with concussion. Sex-related comparisons were also examined. Pediatric tertiary referral concussion clinic. Children and adolescents (aged 6-18 years; n = 554) diagnosed with concussion. Cross-sectional retrospective study. Assessment data were obtained from Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Applications. Sleep disturbance was quantified using the sleep-related domains of the Post-Concussion Symptom Scale (PCSS) and self-report sleep duration. Sleep duration was categorized as short (<7 hours), intermediate (7-9 hours), and long (≥9 hours). Outcome measures included neurocognition, measured via composite scores of ImPACT cognitive domains (verbal memory, visual memory, visual motor speed, reaction time); symptom severity, using the PCSS; and concussion recovery time (days). Short sleep resulted in significantly poorer verbal memory ( P = .03), visual memory ( P = .02), and reaction time ( P = .01). Sleep disturbance was strongly associated with total symptom burden (ρ = 0.90, P < .001). Recovery time, median (interquartile range), was significantly prolonged with short sleep, 61 (30-136) days, compared with intermediate, 38 (21-72) days, and long, 34 (19-71) days, sleep ( P < .001). Overall, female participants demonstrated significantly longer recovery times than male participants (mean 91 ± 95 vs 58 ± 85 days, P < .001). Females exhibited similar concussion recovery times irrespective of reported sleep duration ( P = .95), whereas mean recovery time in males was significantly longer with short sleep (84 ± 82 days) than with intermediate (61 ± 106 days) and long (49 ± 62 days) sleep ( P < .001). Sleep disturbance following concussion poses as a promising modifiable risk factor to alleviate postinjury impairments, including cognitive deficits and symptom burden. Female children were found to experience more severe concussion symptoms and protracted recovery times than their male counterparts. Investigations into the factors that may contribute to sex-related differences following concussion are warranted.

A-29 Consistency of Clinical Profiles Across Repeat Concussions

Abstract Purpose: To evaluate the association between concussion profiles within individual patients across repeat concussions. Methods: Retrospective chart review of 100 adolescents (57.3% male) aged 10–21 years presenting to a concussion clinic within 30 days of injury for two separate injuries between 2011 and 2021. Clinicians conducted multidomain assessments including vestibular/ocular motor screening, neurocognitive testing, symptoms and medical/injury history to adjudicate the following concussion clinical profiles: vestibular, ocular, post-traumatic migraine, cognitive fatigue, and anxiety/mood. Chi-square tests with odds ratios (OR) and 95% confidence intervals (CI) were conducted to examine the association of each profile from the first to the second concussion. Results: Chi-square analyses supported associations between the first and second concussions (time between injuries = 667.1 ± 529.2 days) for the vestibular (χ2 = 10.08, p &amp;lt; 0.01, OR = 3.75, 95% CI = 1.63–8.62), ocular (χ2 = 6.51, p &amp;lt; 0.05, OR = 3.51, 95% CI = 1.30–9.46), and migraine (χ2 = 11.056, p &amp;lt; 0.001, OR = 4.01, 95% CI = 1.73–9.29) profiles, such that having that profile at first concussion was associated with increased likelihood of having the same profile at second concussion. Chi-square analyses for cognitive fatigue and anxiety/mood were not significant. Conclusions: Vestibular, ocular, and migraine profiles at first injury predicted their presence at second injury, which may reflect consistent underlying risk factors (e.g., sex migraine history) for these profiles. Conversely, no association was supported for anxiety/mood and cognitive fatigue profiles across injuries. The present findings are the first to demonstrate that certain profiles are likely to recur after repeat concussion. This information can be used by clinicians to inform earlier, targeted treatment recommendations for associated profiles.

A-30 Preliminary Evidence for the Vestibular/Ocular Motor Screening-Child (VOMS-C) for Patients with Concussion (ages 5–9)

Abstract Purpose: To establish preliminary evidence (i.e., predictive validity) for the new Vestibular/Ocular Motor Screening Child Version (VOMS-C) in a sample of concussed patients and controls aged 5–9 years. A secondary purpose was to identify risk factors for false positives in healthy controls. Methods: This study included 80 patients ages 5–9 (7.40+/−1.09, 41% female) years with a concussion during the past 30 days recruited from a concussion clinic, and 40 age- and sex-matched controls (7.10+/−1.26 years, 45% female). Participants completed a clinical interview, and the VOMS-C. Groups were compared with independent samples t-tests and chi-square analyses. Backwards stepwise logistic regression (LR) was used to discriminate groups and inform a receiver operating characteristic (ROC) curve analysis with area under the curve (AUC) values. Chi-square analyses with odds ratios (OR) were conducted to examine false positives in controls. Results: VOMS-C item provocation ranged from 2.5–20% in the control group and 13.2–30.3% for the concussed group. Results from the LR discriminated concussed from controls (R2 = 0.39; p &amp;lt; 0.001) with smooth pursuits (p = 0.047), family depression history (p = 0.02), and near-point of convergence distance (p = 0.01), as significant predictors. ROC curve analysis including these three predictors supported an AUC = 0.81 (95% CI: 0.73–0.89; p &amp;lt; 0.001) for differentiating concussed from controls. False positives among controls were only related to family history of anxiety (OR 13.37, CI 1.45–122.88, p = 0.007). Conclusions: The findings provide preliminary support for the VOMS-C to identify concussed patients aged 5–9 years.

A-32 Association Between Adolescent Patient Emotional Factors and Adherence to a Sport-Related Concussion Treatment

Abstract Purpose: To determine the association between Anxiety Sensitivity Index (ASI) and Positive and Negative Affect Schedule (PANAS) and adherence to an exercise treatment for sport-related concussion (SRC). We hypothesized Positive Affect (PA) score would be positively associated, while ASI and Negative Affect (NA) score would be negatively associated with odds of treatment adherence. Methods: This was a prospective (2020–2021) analysis of adolescents (aged 14–17) diagnosed with SRC by a pediatric specialty concussion clinic and subsequently prescribed daily exercise. Adherence to the exercise protocol was defined as consistently increasing physical activity volume (measured by accelerometer) during recovery. Multivariable logistic regressions evaluated the independent associations between treatment adherence and ASI; PA score; NA score. Results: The mean (standard deviation [SD]) recovery time was 16.1 (9.0) days. Among the 32 (56.1%) adherent and 25 (43.9%) not adherent participants, the majority were aged 15 years (29.8%), male (50.9%), non-Hispanic White (70.2%), and had no concussion history (61.4%). After adjusting for age and sex, the odds of treatment adherence for each additional unit increase in ASI, PA score, and NA score was 1.03 (95% CI: 0.96–1.10), 1.14 (95% CI: 0.97–1.35), and 1.18 (95% CI: 0.95–1.47), respectively. Conclusions: Despite lack of statistical significance, it appears that PA score and NA score may contribute to exercise treatment adherence for SRC. As this study may be underpowered, future studies should aim to have a larger sample and investigate the discriminate utility of PANAS to identify those who may or may not adhere to SRC exercise treatments.

A-05 Retrospective Comparison of Concussion Recovery Between School and All Star Cheerleaders

Abstract Purpose: Though often categorized together, All Star and school cheerleading are vastly different in concussion risk due to competitiveness and skill difficulty. The purpose of the current study was to compare concussion rate and recovery in school and All Star cheerleaders diagnosed with sports-related concussions (SRC). Methods: This study was a retrospective comparison of cheerleaders (aged 8–18 years) who were evaluated in a specialty concussion clinic and diagnosed with SRC from 2020–2022. A total of 64 female cheerleaders were included (33 school and 31 All Star). We compared days to clinic, prior history of concussion, Post-Concussion Symptom Scale (PCSS) total score, symptom provocation on the Vestibular Ocular Motor Screen, and recovery time in days for each group. Results: Reports of at least one prior concussion were higher in All Star cheerleaders (61%) compared to school cheerleaders (39%). Initial evaluation occurred an average of 4.0 ± 5.8 days post injury for All Star cheerleaders, with recovery occurring in 23.6 ± 17.4 days compared to school cheerleaders who were evaluated for initial evaluation an average of 4.2 ± 4.3 days post injury and recovered in 27.6 ± 19.7 days (P &amp;gt; 0.05). All Star cheerleaders experienced greater symptom provocation (P = 0.05) on horizontal vestibular-ocular reflex compared to school cheerleaders. There was no difference in symptom reporting on the PCSS (P = 0.23). Conclusions: Higher rates of prior concussion were reported in All Star cheerleaders. This may be a function of the more difficult skills being performed. Future research should investigate the impact of skill level and mechanism of injury on SRCs in All Star Cheerleading.

A-20 Factors Associated with Additional Clinic Visits in the Treatment of Sports-Related Concussion

Abstract Purpose: To determine the variables associated with additional concussion clinic visits before discharge to athletic trainer (AT). Methods: This retrospective cohort study was performed at a multi-disciplinary sports concussion center. Patients were eligible if they were ages 12–23, sustained a SRC and were seen by a clinic provider between 11/01/2017 and 10/01/2020 for concussion (n = 1504), presented to clinic within 3 months of sustaining a concussion, and had negative acute head imaging. Of 524 patients, 236 were discharged to AT after the initial clinic visit, while 288 patients required additional clinic visits. The following independent variables were assessed: age, sex, initial visit symptom score, history of prior concussions, psychiatric disorders, migraines, ADHD, and learning disorders, head imaging following concussion, family history of psychiatric disorders and migraines, and ED/Urgent Care visit. The primary disposition was patients being discharged to an AT following the initial clinic visit vs. having additional clinic visits prior to discharge to an AT. Results: The additional visit group had higher initial visit symptom scores (p = 0.002), head imaging performed more frequently (p &amp;lt; 0.02), a family history of psychiatric disorders and/or migraines (p &amp;lt; 0.001), more often reported a prior concussion (p = 0.02), and was younger (p = 0.014) compared to athletes with only one clinic visit. In a multiple variable model, family history of psychiatric disorders (OR = 3.12 [95%CI 1.53–6.34], p = 0.002), prior concussions (OR = 1.39 [95%CI 1.02–1.89], p = 0.037), greater initial symptom score (OR = 1.05 [95%CI 1.03–1.06], p &amp;lt; 0.001), and younger age (OR = 0.87 [95%CI 0.77–0.98], p = 0.021) were strongly associated with additional visits. Conclusions: Among athletes treated at a regional sports concussion center, we determined that family history of psychiatric disorders, increased symptom score at initial visit, prior concussions, and younger age were each uniquely associated with needing additional clinic visits. Understanding these variables may guide treatment protocols to optimize efficiency.

A-03 Physical Therapy Compared to a Home Exercise Program for Protracted Pediatric Sport-Related Concussion Rehabilitation

Abstract Purpose: The purpose of this study was to compare the recovery time in days between protracted recovery (greater than or equal to 28 days since injury) patients who were prescribed physical therapy and those who were prescribed a home exercise program. We hypothesized that physical therapy would be associated with shorter recovery times relative to the home exercise program. Methods: The 159 participants (aged 8–18) were drawn from an ongoing study. This study was a retrospective cohort design of sports-related concussion patients with a protracted recovery who presented to an outpatient specialty concussion clinic between 2018 and 2021, with data collected from electronic medical records. Both prescribed physical therapy (PPT) and home exercise program (HEP) patients were provided vestibular/ocular motor rehabilitation exercises to be completed at home three times per day. PPT participants must have completed at least three PPT sessions, or they were excluded from the study. Multi-variable zero-truncated negative binomial regressions were used to evaluate associations between groups. Results: Among the 48 (30.2%) PPT and 111 (69.8%) HEP participants, the majority were female (57.9%), age was 15.3 ± 1.4 (PPT) and 14.2 ± 2.8 (HEP), and days to clinic was a median 6.0 (IQR = 3.0–27.0; PPT) and 7.0 (IQR = 3.0–23.0; HEP). After adjusting for demographic (age, sex) and clinical measures (concussion history, convergence, VOMS score, and days to clinic), PPT was associated with an additional 1.21 days (95% CI: 1.06, 1.39) than HEP. Conclusions: We unexpectedly found that PPT was not associated with a shorter recovery time relative to HEP. Future research should explore this hypothesis while aiming to evaluate the effect of PPT versus HEP using a randomized design.

A-42 Emotional Health and Recovery in Adolescent and Young Adult Athletes Who Experienced a Sports-Related Concussion

Abstract Purpose: This quantitative study explored the relation between mood and recovery time in. athletes with sports-related concussion. Methods: Deidentified data were extracted from an existing database of an outpatient concussion clinic. Subjects (n = 89; 39.3% female; mean age = 15.57) were included if they were ages 13 to 25, sustained concussion while participating in sport, were assessed within 10 days of injury, and had no evidence of structural brain injury. Total scores from the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) were predictor variables. Recovery time was defined as time from injury to return-to-play. Results: Mean recovery time was consistent with prior research (24.41 days, SD = 16.36). Anxiety and depression total scores considered together predicted recovery time (multiple linear regression; F(2,86) = 8.84, p &amp;lt; 0.001). Anxiety did not predict recovery time when controlling for depression. Depression (mean total = 3.78, SD = 3.41) predicted recovery time when controlling for anxiety, (standardized ß = 0.44, t = 3.34, p = 0.001). Conclusions: The GAD-7 and PHQ-9 are easy-to-use mood screening instruments that do not require a considerable amount of time to administer. Higher scores on the PHQ-9 and the combination of both instruments when administered within 10 days of injury were related to longer recovery times in athletes. For every 3.41 points that the total PHQ-9 score increased, recovery time increased by approximately 7 days. This underscores the importance of examining mood state as part of a comprehensive assessment after sport-related concussion.

Characteristics of concussion subtypes from a multidomain assessment.

The aim of this study was to analyze the best combination of clinical variables associated with concussion subtypes using a multidomain assessment comprising medical history; symptoms; and cognitive, ocular, and vestibular impairment in a cohort of patients presenting to a concussion specialty clinic. Adolescent patients (n = 293) completed demographics and medical history, Concussion Clinical Profiles Screening, Immediate Post-Concussion Assessment and Cognitive Testing, and vestibular ocular motor screening at their first visit (mean 7.6 ± 7.8 days postinjury) to a concussion specialty clinic. Each participant was adjudicated to have one or more subtype (anxiety/mood, cognitive, migraine, ocular, and vestibular) by a healthcare professional based on previously published criteria. A series of backward, stepwise logistic regressions were used to identify significant predictors of concussion subtypes, and predictive probabilities from the logistic regression models were entered into area under the receiver operating characteristic curve (AUC) models. Each of 5 logistic regression models predicting primary subtypes accounted for 28%-50% of the variance (R2 = 0.28-0.50, p < 0.001) and included 2-8 significant predictors per model. Each of the models significantly differentiated the primary subtype from all other subtypes (AUC = 0.76-0.94, p < 0.001). These findings suggest that each concussion subtype can be identified using specific outcomes from a multidomain assessment. Clinicians can employ such an approach to better identify and monitor recovery from subtypes as well as guide interventions.

Ambulatory Assessment in Concussion Clinical Care and Rehabilitation.

Concussion is a mild traumatic brain injury that is characterized by a wide range of physical, emotional, and cognitive symptoms as well as neurocognitive, vestibular, and ocular impairments that can negatively affect daily functioning and quality of life. Clinical consensus statements recommend a targeted, clinical profile-based approach for management and treatment. This approach requires that clinicians utilize information obtained via a clinical interview and a multi-domain assessment battery to identify clinical profile(s) (e.g., vestibular, mood/anxiety, ocular, migraine, cognitive fatigue) and prescribe a corresponding treatment/rehabilitation program. Despite this comprehensive approach, the clinical picture can be limited by the accuracy and specificity of patient reports (which often conflate timing and severity of symptomology), as well as frequency and duration of exposure to symptom exacerbating environments (e.g., busy hallways, sitting in the back seat of a car). Given that modern rehabilitation programs leverage the natural environment as a tool to promote recovery (e.g., expose-recover approach), accurate characterization of the patient clinical profile is essential to improving recovery outcomes. Ambulatory assessment methodology could greatly benefit concussion clinical care by providing a window into the symptoms and impairments experienced by patients over the course of their daily lives. Moreover, by evaluating the timing, onset, and severity of symptoms and impairments in response to changes in a patient's natural environment, ambulatory assessments can provide clinicians with a tool to confirm clinical profiles and gauge effectiveness of the rehabilitation program. In this perspective report, we review the motivations for utilizing ambulatory assessment methodology in concussion clinical care and report on data from a pilot project utilizing smart phone-based, ambulatory assessments to capture patient reports of symptom severity, environmental exposures, and performance-based assessments of cognition for 7 days following their initial evaluation.

Moving on from Concussion?

Close to a million children are evaluated emergently each year in the United States for traumatic brain injury, and most of these injuries are mild traumatic brain injury, or concussion. Symptoms, such as headache, fatigue, and dizziness, lasting more than four weeks are termed persistent post-concussive symptoms (PPCS) and can be quite disabling for children and adolescents. What proportion of children develop PPCS? In this issue of The Journal Chadwick et al present a systematic review to address this question. This particular meta-analysis was conducted rigorously with robust statistical methods, adhered to PRISMA and MOOSE guidelines, and deployed the Newcastle-Ottawa scales to address study quality. The estimated proportion of children with PPCS was 35.1% (95% CI 26.3% to 45.0%). This finding is striking. While this meta-analysis has limitations and is subject to underlying biases from studies often derived from specialty concussion clinics, we must acknowledge that perhaps more than 300 000 children each year experience PPCS, particularly teens and females. This finding highlights the burden that PPCS is placing on our health care and educational systems. While preventing concussion is a major children's health priority, such traumatic brain injury and PPCS have likely been highly prevalent for decades, long before the recent explosion of attention to and research on concussion in children. Interventions for PPCS are clearly needed for the reintegration of affected children back to school and daily activities. No matter how we consider the data, this meta-analysis makes clear that PPCS is common, and we need to develop ways for children to move on effectively from concussion. Article page 131

Psychological Contributions to Symptom Provocation Testing After Concussion.

Following concussion, symptoms such as headache, dizziness, and fatigue may transiently worsen or reemerge with increased exertion or activity. Standardized tests have been developed to assess symptom increases following aerobic, cognitive, or vestibular/oculomotor challenge. Although neurophysiological mechanisms are proposed to underlie symptom increases following exertion, psychological factors such as anxiety and misinterpretation of normal bodily sensations may also play a role. In this study, we examined the contribution of psychological factors to symptom provocation testing outcomes. Two outpatient concussion clinics in British Columbia, Canada. Adults with persistent symptoms following concussion ( N = 79; 62% women). In a single session, participants completed self-report questionnaires measuring the psychological factors of interest and underwent symptom provocation testing including aerobic (Buffalo Concussion Bike Test; BCBT), cognitive (National Institutes of Health Toolbox-Cognition Battery; NIHTB-CB), and vestibular/oculomotor (Vestibular/Ocular Motor Screening for Concussion; VOMS) challenge. Psychological factors of interest included premorbid and current anxiety (Generalized Anxiety Disorder-7; GAD-7), catastrophizing (Pain Catastrophizing Scale-Adapted; PCS-A), fear avoidance behavior (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and somatization (Patient Health Questionnaire-15; PHQ-15). Our primary outcome variables were self-reported symptom change during each symptom provocation test. We found that current anxiety ( B = 0.034; 95% CI = 0.003, 0.065), symptom catastrophizing ( B = 0.013; 95% CI = 0.000, 0.026), fear avoidance behavior ( B = 0.029; 95% CI = 0.008, 0.050), and somatization ( B = 0.041; 95% CI = 0.007, 0.075) were associated with increased symptoms during the VOMS in univariate models adjusted for time postinjury but not in a multivariable model that included all covariates. The psychological variables of interest were not significantly related to symptom change during the BCBT or NIHTB-CB. Our findings suggest that symptom provocation test failure should be interpreted with caution because it might indicate psychological maladjustment rather than lingering brain injury or incomplete neurophysiological recovery.

Cutaneous heat and light-induced pain thresholds in post-traumatic headache attributed to mild traumatic brain injury.

The purpose of this study was to characterize cutaneous heat and light-induced pain thresholds in people with post-traumatic headache (PTH) compared with healthy controls (HCs). Photophobia and allodynia are common in PTH, and there is emerging evidence to support multimodal sensory dysfunction. In this age- and sex-matched cohort study, individuals with PTH (n=20) and HCs (n=20), aged 18-65 years, were recruited from an institutional database of research volunteers, from the concussion clinic, and via the use of approved flyers posted on the Mayo Clinic Campus in Scottsdale, Arizona. Participants were assessed using the Allodynia Symptom Checklist (ASC-12), Photosensitivity Assessment Questionnaire (PAQ), State Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI). Quantitative sensory testing quantified heat pain thresholds. A light stimulation device quantified light-induced pain thresholds. Subsequently, heat pain thresholds were obtained immediately, 10, and 40min after a bright light stressor. The mean photophobia symptom severity score, based on the PAQ, was higher in participants with PTH compared with HCs, mean 0.62 (SD=0.25) versus mean 0.24 (SD=0.24), p<0.001. Light-induced pain thresholds were lower in participants with PTH (median=90.5lux and quartiles=17.8 to 378.5) compared with HCs (median=863.5lux and quartiles=519.9 to 4906.5) and were independent from BDI and STAI (p<0.001). Allodynia scores did not differ between participants with PTH and HCs after adjusting for BDI and STAI scores. Baseline forehead heat pain thresholds were not different, participants with PTH mean 41.9°C (SD=0.89) versus HCs mean 44.3°C (SD=0.89), p=0.061; however, forearm heat pain thresholds were lower in participants with PTH compared with HCs, mean 40.8°C (SD=0.80) versus mean 44.4°C (SD=0.80), p=0.002. The forehead heat pain threshold change from baseline post bright light stressor in participants with PTH versus HCs was different immediately (mean -1.2 (SD=0.53), p=0.025), 10min (mean -1.8 (SD=0.74), p=0.015), and 40min (mean -1.8 (SD=0.88), p=0.047). The forearm heat pain threshold change immediately post bright light stressor in participants with PTH versus HCs was different, mean -1.9°C (SD=0.58), p=0.001, however, not different at 10 and 40min. Photophobia is higher and light-induced pain thresholds are lower in participants with PTH. Exposure to a light stressor reduced heat pain thresholds in participants with PTH immediately post bright light stressor, but not in HCs. This study provides evidence for multimodal sensory dysfunction in people with PTH.

Presence of Persistent Parent Reported Emotional and Behavioral-Related Concussion Symptoms Is Associated with Lower Health-Related Quality of Life in Adolescent Athletes

Persistent concussion symptoms in adolescents are associated with lower health-related quality of life (HRQOL). The association between persistent emotional and behavioral-related concussion symptoms (EBS) and HRQOL is unknown, however. This study was a prospective cohort of adolescent athletes presenting to a concussion clinic within three days post-concussion and completing a one-month follow-up. The independent variable in these analyses was parent reported EBS symptom presence grouped as: (1) no EBS; (2) EBS present at pre-concussion levels; and (3) EBS worse than pre-concussion. The EBS included the following concussion symptoms: feeling irritable, depressed, frustrated/impatient, restless, reduced tolerance to stress/emotion, poor concentration, and fear of permanent symptoms. Dependent variables were parent reported psychosocial, physical, and total HRQOL. Separate multi-variable linear regression models controlling for age, sex, and concussion history were used to assess the association between EBS and HRQOL. Estimated adjusted mean differences (MD) and 95% confidence intervals (CI) were used to assess associations; MDs with a 95%CI excluding 0.0 were considered statistically significant. Overall, n = 245 presented to the study clinic three days post-concussion and completed the one-month follow-up (Mage = 14.28 ± 2.09 years, 59.02% male, 90.64% Caucasian, 31.84% with concussion history). At one-month post-concussion, adolescents with pre-concussion EBS levels had significantly lower psychosocial, physical, and total HRQOL than those with no EBS. In addition, those with EBS worse than pre-concussion had significantly lower psychosocial, physical, and total HRQOL than those with no EBS and EBS at pre-concussion levels. These findings highlight the importance of HRQOL assessments and that targeted interventions may be needed for those with EBS at one-month post-concussion to improve HRQOL.

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.

Effect of Menstrual Dysfunction in Adolescent Concussion Patients on Length of Time to Recovery and Symptom Burden

Background:Concussions are one of the most common sport-related-injuries seen in the adolescent population. It is well known that female athletes are at higher risk for concussion, but factors that influence this risk, including hormonal influences, are not entirely known. There is no literature to date that explores the relationship between menstrual dysfunction (MD) and outcome measures of concussion.Hypothesis/Purpose:Our primary purpose is to determine if MD predicts prolonged recovery from concussion and our secondary purpose is to determine if MD predicts a higher initial symptom burden.Methods:Patients who presented to a pediatric sports medicine concussion clinic for an initial visit, were ≤18 years-old, and were at least 2 years post-menarchal were included in the study. Those who reported taking any hormonal medications, were pregnant, or who suffered symptoms greater than 180 days were excluded. Subjects who were >15 years old at menarche, experienced <10 menstrual periods per year or >35 days between cycles were categorized as having MD. Two linear regressions were analyzed to determine differences in initial symptom score and time to recovery between those with and without MD while controlling for age, history of headaches, and history of prior concussions.Results:A total of 801 participants were included in the study (697 controls and 108 MD patients). There was no statistically significant difference in time to recovery between the groups (p=0.12). However, MD patients took 5 days longer to recover than controls (51.23 vs. 46.42 days). There was no statistical difference in initial symptom score between the MD and control groups (p=0.67, 56.04 for controls and 58.47 for MD).Conclusion:No statistically significant differences were found in time to recovery after concussion or in initial symptom burden between subjects with MD and controls. Additional study is warranted to further characterize these relationships.

An Analysis of the Increased Risk for Lower Extremity Injury Within 12 Months After Concussion and Utilization of Lower Extremity Measures for Return to Sport

Background:According to the Concussion Clinical Practice Guidelines, the typical recovery timeline post-concussion is about 7-14 days. However, recent research has shown an increased risk for lower extremity (LE) injury as early as 90 days and up to 1 year post-concussion.Purpose:The primary purpose of this study was to determine the prevalence of youth athletes who sustained a LE injury within 1 year post-concussion at Texas Children’s Hospital. The secondary purpose of this study was to describe the prevalence and utilization of LE functional testing performed by Physicians (MDs), Physical Therapists (PTs), and Athletic Trainers (ATs) as part of return to sport (RTS) clearance post-concussion.Methods:A retrospective chart review was completed consisting of patients diagnosed with a concussion by a Sports Medicine Physician from September 2018 to September 2020. The inclusion criteria were as follows: male or female, ages 8-21, and active participation in 1 or more sports. The data was collected in Microsoft Forms. Additionally, a Microsoft Forms survey was sent to Sports Medicine MDs, PTs, and ATs to assess utilization of LE functional tests. SPSS 25.0 was used for analysis with alpha level at .05. A one-sample chi-square test was utilized to compare re-injury rate to the known rate of 1%. Other proportional comparisons were run using two-sample chi-square analyses.Results:A total of 635 charts were reviewed with 527 patients participating in at least 1 sport. 12.7% (N=54) of those who sustained a concussion had either a musculoskeletal injury or another concussion within 1 year, with the highest proportion of injuries being a second concussion (33.3%) or ligament sprain (35.2%). Of the providers polled, 52.8% do not currently use a LE functional measure as part of RTS criteria. The most commonly reported reasons that providers do not use LE measures were as follows: not included in their standard of practice, lack of time, and lack of knowledge.Conclusion:The results suggest a LE test battery may be beneficial to assess LE injury risk post-concussion. Additionally, the majority of providers do not currently use LE functional measures when assessing RTS criteria. Considering the increased risk for LE injury and lack of LE functional testing completed by providers, further education about current, available LE functional testing should be provided to decrease the prevalence of LE injury after concussion. Future studies should analyze the effects of LE strengthening and functional testing on subsequent LE injury risk post-concussion.

Influence of Anxiety Sensitivity and Negative Affect on Concussion Outcomes

Background:Approximately two million children sustain a concussion annually, with negative mood being associated with elevated initial symptom reporting and longer recoveries. Despite this finding, minimum research has explored the predictive value of a person’s negative mood and propensity to misinterpret internal sensations (anxiety sensitivity) on concussion outcomes.Hypothesis/Purpose:The purpose of this study was to examine how the relationship between anxiety sensitivity, negative affect, and positive affect relate to various concussion outcomes. It was hypothesized that higher anxiety sensitivity, higher negative affect, and lower positive affect would be predictive of higher initial concussion symptom reporting, increased number of total visits, and longer time to medical clearance.Methods:Children aged 8-18 years who sustained a concussion were examined in an acute concussion clinic for diagnosis and treatment of injury. Patients were evaluated within 14 days of injury and remained under clinical care until cleared to return to activity/sport. Patients were administered the Anxiety Sensitivity Index-3 (ASI-3), The International Positive and Negative Affect-Short Form (I-PANAS-SF) and Post-Concussion Symptom Scale (PCSS). Independent t-tests were run for all independent variables. Linear regressions were run to determine potential predictive value of ASI-3 (cognitive, physical, social subscale and total score) and I-PANAS-SF (negative and positive affect) on concussion outcomes (initial visit concussion symptom scores calculated by PCSS, total number of clinical visits, and days till medically cleared).Results:A total of 43 children (age: 15.6±1.6 years) were enrolled. Independent t-tests for all independent variables resulted in females on average having higher ASI-3 subscale and total scores (p<0.01). Sex was therefore entered as a control variable in the regression models. Higher negative affect was significantly predictive (β = 0.38, p=0.030) of higher initial visit concussion symptom reporting (R2 =0.46, F(5,36)=4.48, p=0.003). More days to clinic (β = 0.88, p≤0.001) and higher ASI-3 physical subscale scores (β = 0.25, p=0.008) were predictive of more days until medical clearance (R2 =0.88, F(5,35)=5.33, p=0.001).Conclusion:Results from this study show that both a person’s negative affect and anxiety sensitivity are not just related to concussion outcomes but also predictive. Negative affect and anxiety sensitivity are easy to measure and amenable to treatment. Targeted interventions on improving negative affect and normalizing symptoms to minimize misinterpretations (anxiety sensitivity), could improve concussion outcomes.

Managing Concussion Patients Via Telehealth Services Compared to In-Person Clinic Visits

Background:Sports medicine is increasingly relying on telehealth to provide patients with better access to care, timelier visits, and reduced cost. Telehealth technology is a growing modality that needs more research to demonstrate its utility in the clinical management of concussion.Hypothesis/Purpose:The purpose of this study was to compare the total number of visits, days since injury, and recovery time of pediatric concussion patients evaluated via telehealth versus those in-person. We hypothesized that telehealth patients would have fewer total visits, fewer days since injury, and shorter recovery times compared to in-person patients.Methods:Retrospective data from 2019-2021 were abstracted from the medical record for patients aged 4-18 years who were referred to a specialty pediatric concussion clinic. Demographic data included age, sex, and race/ethnicity. Concussion injury and treatment data were examined based on total number of visits, time since injury (days), and recovery time (days). Descriptive statistics were reported as proportions (counts), means (± standard deviations [SD]), and medians (interquartile range [IQR]), as appropriate. The difference between telehealth and in-person treatment data was tested using independent-samples median tests with a significance level set at 0.05.Results:A total of 381 patients were included in the study, 21.5% (82) were managed via telehealth services and 78.5% (299) were seen in-person. Of the telehealth patients, 40.2% (33) were males, 54.9% (45) were non-Hispanic white, and the mean age was 13.95 (±2.99) years. For in-person patients, 52.5% (157) were male, 56.2% (168) were non-Hispanic white, and the mean age was 14.75 (±2.05) years. Telehealth patients were seen a median 4.0 (IQR=2.0-6.0) days since injury and in-person patients were seen a median 3.0 (IQR=2.0-5.0) days since injury (P =0.98). Telehealth patients’ median total visits was 2.0 (IQR=1.0-2.0), while in-person patients was 2.0 (IQR=2.0-3.0) (P=0.36). Telehealth patients recovered a median 15.0 (IQR=9.0-22.3) days and in-person patients recovered a median of 16.0 (IQR=11-24) days (P =0.58).Conclusion:In this preliminary study, telehealth and in-person patients did not differ based on concussion treatment and recovery. These findings demonstrate the potential equivalence of pediatric concussion telehealth and in-person treatments; however, future research should examine differences in treatment costs and treatment access (e.g., distance to clinic, insurance types, etc.), while also considering the potential influence of concussion severity on the likelihood to utilize telehealth versus in-person treatment.

Sex Differences on the Concussion Clinical Profiles Screening in Adolescents With Sport-Related Concussion.

Sex differences influence symptom presentations after sport-related concussion and may be a risk factor for certain concussion clinical profiles. To examine sex differences on the Concussion Clinical Profile Screen (CP Screen) in adolescents after sport-related concussion. Cross-sectional study. A concussion specialty clinic. A total of 276 adolescent (age = 15.02 ± 1.43 years; girls = 152 [55%]) athletes with a recently diagnosed concussion (≤30 days). The 5 CP Screen profiles (anxiety mood, cognitive fatigue, migraine, vestibular, ocular) and 2 modifiers (neck, sleep), symptom total, and symptom severity scores were compared using a series of Mann-Whitney U tests between boys and girls. Girls (n = 152) scored higher than boys (n = 124) on the cognitive fatigue (U = 7160.50, z = -3.46, P = .001) and anxiety mood (U = 7059, z = -3.62, P < .001) factors but not on the migraine (U = 7768, z = -2.52, P = .01) factor. Girls also endorsed a greater number of symptoms (n = 124; U = 27233, z = -3.33, P = .001) and scored higher in symptom severity (U = 7049, z = -3.60, P < .001) than boys. Among adolescents, symptom endorsement on the CP Screen varied based on sex, and clinicians need to be aware of these differences, especially when evaluating postconcussion presentation in the absence of baseline data.