Concussion Outcomes Research Articles

Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players.

To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion. Prospective cohort study, Safe to Play (2013-2018). Youth hockey leagues in Alberta and British Columbia, Canada. Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions. Psychosocial variables. Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit. Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery. Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

Position comparison of sport-related concussions in female youth soccer players

ABSTRACT Objectives Youth soccer participation, particularly among females, continues to grow worldwide. With the high incidence of sport-related concussion (SRC) in soccer, it is important to investigate if SRC occurs disproportionally by positions. Our hypothesis was to see no positional differences in SRCs, SRC-related characteristics, and outcomes among in female youth soccer athletes. Methods Data were prospectively collected from participants at a single sports medicine institution between August 2015-April 2021. Female participants aged 8–18 diagnosed with SRC sustained during an organized soccer practice, scrimmage, or game were separated into 4 groups based on position: Forward, Midfielder, Defender, and Goalkeeper. Demographics, medical history, injury-related details, and outcomes were reviewed. A chi-square test or Fisher’s exact test was used for categorical variables. Continuous variables were compared with Mann-Whitney or Kruskal-Wallis test. Results Two hundred fourteen participants were included: 52 Forwards, 65 Midfielders, 63 Defenders, and 34 Goalkeepers. There were no significant differences between the groups in age, race, ethnicity, or previous concussion history. Differences in mechanism existed with Goalkeepers most commonly reporting Head to Body Part. Goalkeepers, which make up 1/11 of the total positions on the field, had a significantly higher proportion of SRCs compared to Field Positions. (9.1% vs 15.9%) At 3-month post-enrollment, there were no significant differences in reported symptoms or return-to-play between the different positions. Conclusion In youth female soccer players, goalkeepers sustained a higher proportion of sport-related concussions compared to field players based upon the composition of a soccer team. The mechanism of injury also differed among the different soccer positions. However, no differences in concussion characteristics, outcomes, or RTP were seen across the different soccer positions.

The Role of Level of Play in Concussions in High School Athletes.

To examine level of play (LOP) as a risk factor for concussion severity and recovery-related outcomes among high school athletes, stratified by sex, and among boys, by sport (football, non-football male sports). Secondary analysis of data collected through the High School Reporting Information Online surveillance system for academic years 2007-2008 through 2018-2019. A total of 9916 concussions were reported between the academic years 2007-2008 and 2018-2019 from 9 sports (5189 from football; 2096 from non-football male sports; 2631 from female sports). Examined the association between LOP (Freshman, Junior Varsity [JV], and Varsity teams) and concussion outcomes (number of concussion symptoms, symptom resolution time [SRT], and time to return to play [RTP]). Compared with Varsity football athletes, concussed JV football athletes had on average 0.19 fewer concussion symptoms, longer SRT (>1 week vs <1 week: odds ratio [OR] = 1.3; 95% confidence interval [CI], 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.2-1.9; >3 weeks vs <1 week: OR = 1.6; 95% CI, 1.1-2.3). Compared with Varsity football athletes, Freshman football athletes had on average 0.48 fewer concussion symptoms, longer SRT (OR = 1.3; 95% CI, 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.1-2.0; >3 weeks vs <1 week: OR = 2.0; 95% CI, 1.3-3.0). Similarly, compared with female athletes on Varsity teams, concussed JV female athletes had longer RTP (1-3 weeks vs <1 week: OR = 1.8; 95% CI, 1.2-2.7). Trend analyses revealed an increase in the number of concussion symptoms between 2015-2016 and 2018-2019, a decrease between 2009-2010 and 2018-2019 for SRT of less than 1 week, and an increase between 2014-2015 and 2018-2019 for RTP of less than 1 week among Varsity football athletes. Among Varsity female athletes, there was a linear decrease during the study period for RTP of less than 1 week. Despite a higher number of symptoms overall and in recent years, Varsity football players had shorter RTP than Freshman and JV athletes.

Role of sex and gender in concussion outcome differences among patients presenting to the emergency department: a systematic review

ObjectiveThis systematic review aimed to identify research involving adults presenting to the emergency department (ED) with a concussion to document the reporting of sex and/or gender according to the Canadian...

Poster 369: Analysis of National Hockey League Player Performance After Concussion and Financial Costs Associated with Implementation of an Updated Concussion Protocol: A Retrospective Comparative Study

Objectives: Background: An updated National Hockey League (NHL) concussion protocol (NHLCP) was established in the 2016–2017 season to mitigate the negative outcomes of sport-related concussions. However, few studies on the effects of implementing the NHLCP have been performed. Purpose: To define concussion incidence and investigate differences in NHL player performance after a concussion during periods before and after implementation of the NHLCP and to assess the financial impact on NHL teams associated with NHLCP implementation. We hypothesized that concussion incidence would increase and player performance would remain the same after NHLCP implementation. Methods: A retrospective review of NHL players who sustained a concussion before (2000–2001 to 2015–2016 seasons) and after (2016–2017 to 2020–2021 seasons) implementation of the NHLCP (pre- NHLCP and post-NHLCP groups). For each group, multiple performance metrics 30 days, 1 season, and 3 seasons before and after concussion were compared for both groups. Return to play, total concussion cost, and association of return to play with cost were investigated with regression analysis. Results: For both groups, no significant differences in standard performance were observed during the 30-day and 1-season time periods before and after concussion. Mean return to play was significantly higher in the pre-NHLCP than in the post-NHLCP group (20.1 vs 15.7 days; P=0.022). Mean adjusted player salary was not different between groups, but mean adjusted replacement player salary was significantly higher in the post-NHLCP group ($744,505 vs $896,942; P= 0.032). Mean cost of time missed did not differ between groups. Mean return to play time significantly decreased over the entire study period 2000–2021 (R2=0.335, P=0.005), and mean return to play time was positively associated with cost (R2=0.215, P=0.030). Conclusions: Concussion incidence did not change after implementation of the updated NHLCP, but players had significantly less missed time from injury after protocol implementation. Changes in player performance 30 days and 1 year before and after concussion injury were not different before and after NHLCP implementation. [Table: see text][Table: see text]

The Additive Benefits of Aerobic Exercise and Cognitive Training Postconcussion: Current Clinical Concepts.

Concussion induces the rapid onset of a short-lived neurophysiological disturbance that often results in autonomic nervous system dysfunction. This dysfunction affects both cardiovascular functioning and higher cognitive processing, inducing postconcussion clinical symptoms (somatic, cognitive, or emotional or a combination) and functional disturbances (impaired balance, cognition, and visual-vestibular performance). Current concussion rehabilitation paradigms using aerobic exercise may improve concussion symptoms. Additionally, cognitive training-focused rehabilitation interventions may enhance cognitive function postinjury. Though aerobic exercise and cognitive training-based concussion rehabilitation are successful independently, the multifaceted nature of concussion suggests the potential benefit of integrating both to improve concussion outcomes and clinician implementation. To support this clinical recommendation, we critiqued the existing research in which authors investigated aerobic exercise and cognitive training as postconcussion rehabilitation modalities, identified keys gaps in the literature, and proposed a practical clinical recommendation to integrate both modalities during concussion rehabilitation.

A-35 Difficulty Speaking, Stuttering, and Missing Words Post-Concussion: Findings from Two Independent Studies

Abstract Purpose The current investigation examined the potential consequences of concussion on speech-language abilities by analyzing quantitative and qualitative data from two independent studies. Methods Study 1: 185 rugby, soccer, football, rowing, and hockey athletes (M=17.42 years, SD=3.80; 44% female) completed the Rosenbaum Concussion Attitude and Knowledge Survey (RoCKAS). Study 2: 19 varsity soccer, rugby, volleyball, and basketball athletes (M=21.74 years, SD=2.13; 37% female) with history of at least one concussion completed individual one-hour semi-structured interviews, and thematic analysis was used to identify patterns across athletes’ experiences of concussion. Results Study 1: Quantitative analysis of athletes’ endorsements of distractor and legitimate post-concussive symptoms on the RoCKAS yielded a relatively low rate of endorsement across all distractor symptoms (1–29%, M=11%), with the exception of ‘difficulty speaking’, which was endorsed by majority (70%) of the sample. Study 2: Thematic analysis of interview content identified long-term difficulties with speech articulation (i.e., stuttering and word-finding) as a post-concussive symptom for 42% of the sample. Conclusions While speech abilities are largely thought to remain intact following concussion, quantitative and qualitative findings from these two independent studies suggest that speech difficulties may be an overlooked outcome of concussion. Several neuropsychological (e.g., attention, memory, executive function, or processing speed) and neuropathophysiological (e.g., diffuse axonal damage to cortico-subcortical pathways) processes may be underlying this relationship. Exploratory studies and longitudinal data are needed to elucidate the potential consequences of concussion on speech-language abilities.

Cranial Bone Changes Induced by Mild Traumatic Brain Injuries: A Neglected Player in Concussion Outcomes?

Mild traumatic brain injuries (TBIs), particularly when repetitive in nature, are increasingly recognized to have a range of significant negative implications for brain health. Much of the ongoing research in the field is focused on the neurological consequences of these injuries and the relationship between TBIs and long-term neurodegenerative conditions such as chronic traumatic encephalopathy and Alzheimer's disease. However, our understanding of the complex relationship between applied mechanical force at impact, brain pathophysiology, and neurological function remains incomplete. Past research has shown that mild TBIs, even below the threshold that results in cranial fracture, induce changes in cranial bone structure and morphology. These structural and physiological changes likely have implications for the transmission of mechanical force into the underlying brain parenchyma. Here, we review this evidence in the context of the current understanding of bone mechanosensitivity and the consequences of TBIs or concussions. We postulate that heterogeneity of the calvarium, including differing bone thickness attributable to past impacts, age, or individual variability, may be a modulator of outcomes after subsequent TBIs. We advocate for greater consideration of cranial responses to TBI in both experimental and computer modeling of impact biomechanics, and raise the hypothesis that calvarial bone thickness represents a novel biomarker of brain injury vulnerability post-TBI.

Symptomatic and Functional Recovery Following Concussion in Adolescents With and Without a History of Psychiatric Disorder (P7-1.003)

<h3>Objective:</h3> Our study aimed to examine whether symptomatic and functional recovery post-concussion varies between adolescents with and without a history of psychiatric disorder. <h3>Background:</h3> Pre-existing comorbidities can exacerbate impairments following concussion. Psychiatric disorders are associated with emotional symptoms and altered cognition, and similar outcomes are frequently observed post-concussion. Thus, it is possible that a history of psychiatric disorder may be associated with poorer concussion outcomes. <h3>Design/Methods:</h3> We conducted a retrospective analysis of data from a pediatric concussion clinic. Adolescents who had sustained a concussion completed initial (~2 weeks) and follow-up (~5 weeks) post-injury assessments. Assessments included questionnaires regarding concussion symptoms (Rivermead Post-Concussion Symptoms Questionnaire—RPQ), depressive symptoms (Beck Depression Inventory-Youth—BDI), parent-reported executive function (Behavior Rating Inventory of Executive Function—BRIEF), and a modified CogState testing battery. Groups were categorized as adolescents with a parent-reported history of psychiatric disorder (PD+; n = 13) and those reporting no history (PD−; n = 26). <h3>Results:</h3> The PD+ group reported greater severity of RPQ—somatic, RPQ—emotional, and BDI symptoms across time points and had poorer BRIEF—behavioral regulation scores at follow-up (<i>p</i>’s &lt; .05). Compared to PD−, the PD+ group also had greater improvements in accuracy on a two-back working memory task from initial to follow-up evaluations, with higher accuracy at follow-up specifically (<i>p</i>’s &lt; .05). <h3>Conclusions:</h3> Adolescents with a history of psychiatric disorder exhibit more severe concussive and depressive symptoms and poorer behavioral regulation post-concussion than adolescents with no such history. They also display greater increase in working memory accuracy over time; however, this may be attributable to poorer initial performance and a larger subsequent improvement by follow-up. These findings demonstrate a discrepancy between adolescent behavior and parent observations, highlighting the importance of acknowledging psychiatric comorbidities in concussion recovery and incorporating the perspective of both parent and child. <b>Disclosure:</b> Miss Mangold has nothing to disclose. Mr. Kay has nothing to disclose. Dr. Wagner has nothing to disclose. Dr. Holloway has nothing to disclose. Dr. Moore has nothing to disclose.

Primary and Secondary Risk Factors Associated With Concussion Symptom Clusters in Collegiate Athletes: Results From the NCAA-DoD Grand Alliance CARE Consortium

There is a broad and diverse range of symptoms after a concussion, from irritability to nausea. This heterogeneity of symptoms is a challenge for clinicians managing the different presentations among injuries. Prior research has investigated the structure of postconcussive symptoms to determine if they can be grouped into clusters of related symptoms. The purpose of this study was to identify symptom clusters during the acute phase after a sports-related concussion using exploratory factor analysis and to understand the relationship between risk factors for postconcussion symptoms (ie, demographics, injury characteristics, mental health, and sleep qualities) and different symptom clusters. We hypothesized that certain factors would be predictive of specific symptom clusters. Cross-sectional study; Level of evidence, 3. Collegiate athletes (N = 1104) from the Concussion, Assessment, Research, and Education (CARE) Consortium completed the Sport Concussion Assessment Tool-Third Edition symptom assessment tool 24 to 48 hours after concussion. Exploratory factor analysis was conducted on the symptom evaluation to determine symptom clusters 24 to 48 hours after concussion. Regression analysis was used to examine the effects of pre- and postinjury characteristics. Exploratory factor analysis revealed a 4-cluster structure for acute postconcussive symptoms that explained 62% of the variance in symptom reporting: vestibular-cognitive, migrainous, cognitive fatigue, and affective. Delayed reporting, less sleep before assessment, female sex, and being hurt outside of competition (during practice/training) was correlated with increased symptoms for 4 symptom clusters. Depression predicted higher vestibular-cognitive and affective symptoms. Amnesia was correlated with higher vestibular-cognitive and migrainous symptoms, whereas migraine history was associated with more migrainous and affective symptoms. Symptoms can be grouped into 1 of 4 distinct clusters. Certain variables were associated with increased symptoms across multiple clusters and may be indicative of greater injury severity. Other factors (ie, migraine history, depression, amnesia) were associated with a more specific symptom presentation and may be mechanistically related to concussion outcomes and biological markers.

Investigation of Factors Contributing to Racial Differences in Sport-Related Concussion Outcomes

Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors. Data from patients aged 12-18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) RESULTS: A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P= 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR]= 1.35, 95% CI 1.03-1.77, P=0.030), which remained significant (HR= 1.32, 95% CI 1.002-1.73, P= 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR=1.12, 95% CI 0.85-1.48, P= 0.410). Adding prior concussion history further reduced the association between race/recovery (HR= 1.01, 95% CI 0.77-1.34, P= 0.925). Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors.

Hormonal Contraceptives Do Not Influence Concussion Recovery in Collegiate Athletes: Data from the NCAA-DoD CARE Consortium.

The hormonal withdrawal hypothesis suggests that progesterone reduction in women after concussion may lead to greater symptom burden and longer recoveries. Current evidence indicates that hormonal stability after head injury may be an important moderator of postconcussive recovery. Thus, female athletes using hormonal contraceptives (HC) may exhibit better recovery profiles as their hormone levels are artificially stabilized. Our investigation sought to examine the relation between HC use and concussion outcomes in female student-athletes. This longitudinal study examined concussion outcomes from female student-athletes participating in the NCAA-DoD CARE Consortium Research Initiative, including academic years 2014 to 2020. Eighty-six female collegiate athletes reporting HC use (HC+) were group matched on age, body mass index, race/ethnicity, sport contact level, concussion history, and current injury characteristics (i.e., amnesia, loss of consciousness) to 86 female collegiate athletes reporting no HC use (HC-). All participants had sustained a concussion and completed the Sport Concussion Assessment Tool, 3rd edition Symptom Scale, Brief Symptom Inventory-18, and Immediate Post-concussion Assessment and Cognitive Testing at preinjury baseline, 24 to 48 h postinjury, and when cleared for unrestricted return to play. To provide an index of recovery trajectory, days between injury and unrestricted return to play were calculated. Groups did not differ on length of recovery, postconcussion symptoms, psychological health, or cognitive assessments. No differences were observed between groups on any measure when accounting for baseline levels of performance. Our findings suggest that HC use does not influence recovery trajectory, symptoms, or recovery of cognitive function after concussion.

The propensity of non-concussive and concussive head contacts during elite-level women's rugby league matches: A prospective analysis of over 14,000 tackle events.

Identify the frequency, propensity, and factors related to tackle events which result in contact with the head in elite-level women's rugby league. Prospective video analysis study. Video footage from 59 Women's Super League matches were analysed (n = 14,378 tackle events). All tackle events were coded as no head contact or head contact. Other independent variables included: area contacting head, impacted player, concussion outcome, penalty outcome, round of competition, time in match and team standard. There were 83.0 ± 20.0 (propensity 304.0/1000 tackle events) head contacts per match. The propensity of head contact was significantly greater for the tackler than ball-carrier (178.5 vs. 125.7/1000 tackle events; incident rate ratio 1.42, 95 % confidence interval 1.34 to 1.50). Head contacts occurring from an arm, shoulder, and head occurred significantly more than any other contact type. The propensity of concussions was 2.7/1000 head contacts. There was no significant influence of team standard or time in match on the propensity of head contacts. The observed head contacts can inform interventions, primarily focusing on the tackler not contacting the ball-carrier's head. The tackler's head should also be appropriately positioned to avoid contact with the ball-carrier's knee (highest propensity for concussion). The findings are consistent with other research in men's rugby. Law modifications and/or enforcement (reducing the number of un-penalised head contacts), concurrent with coaching interventions (optimising head placement or reducing the head being contacted) may help minimise head contact risk factors for women's rugby league.

Influence of Personal and Injury-Related Factors Predicting Deficits in Quality of Life Domains Among Pediatric Athletes: Findings From the Sport Concussion Outcomes in Pediatrics Study.

To examine patient and injury factors that may predict quality of life (QoL) and symptom duration after concussion. Prospective, longitudinal. Six children's hospital-based medical centers and 9 secondary school athletic training facilities. Pediatric patients (8-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit for a diagnosis of sport-related concussion. Patients completed a medical history, the Postconcussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP). Eight predictor variables [age, sex, assessment time, loss of consciousness, amnesia and history of concussion, migraines, or attention-deficit hyperactivity disorder or (ADHD)] were assessed using regression models constructed for each dependent variable. A total of 244 patients (15.1 ± 2.1 years, 41% female) were enrolled (mean = 5 ± 3 days after concussion; range = 1-14 days). Female sex, later initial assessment, and presence of amnesia were associated with lower QoL scores on several domains, whereas loss of consciousness was associated with higher QoL for fatigue. A history of migraines was associated with lower peer relationship QoL. Patients who subsequently developed persisting symptoms had lower mobility scores and higher anxiety, depressive symptom, fatigue, and pain interference scores. Female sex, later clinic presentation, and amnesia were associated with a lower QoL related to mobility, anxiety, depressive symptoms, fatigue, and pain interference. Interestingly, previous concussion and preinjury ADHD diagnosis did not negatively impact postinjury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later postinjury time points using a concussion-specific outcomes instrument.

A-180 Clinical Outcome Following Concussion Among Children and Adolescents with a History of Prior Concussion: A Systematic Review

Abstract Purpose: This systematic review examined the association between prior concussion history and clinical outcomes following concussion among children and adolescents. Data Selection: This review was registered with PROSPERO database for systematic reviews (protocol ID: CRD42016041479 &amp; CRD42019128300) and adhered to PRISMA guidelines. Three searches of nine online databases were conducted: (a) database inception to June of 2016; (b) January 1, 2016 to February 1, 2019; and (c) February 1, 2019 to May 15, 2021. We screened 5,118 abstracts and 51 studies were reviewed. We utilized a likelihood heuristic to assess evidence for an association between concussion history and clinical outcomes. Risk of bias was assessed using the Newcastle-Ottawa scale and level of evidence was appraised using the Oxford Classification for Evidence-Based Medicine. Data Synthesis: Concussion recovery or outcome was reported for 26,643 youth. A median of 36% had a prior history of concussion. Across all studies and outcomes, the majority (k=37, 72.5%) did not find a statistically significant association between lifetime history of concussion and outcome from a subsequent concussion. Important methodological limitations in the literature were identified (e.g., many studies were underpowered and/or coded prior concussion history as a binary variable as opposed to the number of prior concussions). Conclusions: Available studies do not provide compelling evidence that children and adolescents with a history of concussions are at increased risk for worse clinical outcome following a subsequent concussion. Clinicians are cautioned against routinely treating children and adolescents with one or more prior injuries more conservatively. Doing so, in some cases, might be counterproductive.

Clinical Outcome following Sport-Related Concussion among Children and Adolescents with a History of Prior Concussion: A Systematic Review.

Authoritative sources advise clinicians and parents that a history of prior concussion confers increased risk for worse outcome from a future concussion. However, the strength of the evidence supporting such pronouncements and thus the extent to which clinicians should incorporate this information into their care and management of pediatric concussion is unclear. This systematic review critically analyzed and synthesized the literature on the association between a history of prior concussion and prognosis/clinical outcome following a subsequent sport-related concussion among children and adolescents. The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched from inception to May 15, 2021. From 5118 total records screened, 51 studies (46 cohort studies and five case-control studies) met inclusion criteria, reporting concussion recovery or outcome for 26,643 youth. A median of 36% had a prior history of concussion. Across all studies and outcomes, the majority (k = 37, 72.5%) did not find a statistically significant association between lifetime history of concussion and outcome from a subsequent concussion. Important methodological limitations in the literature were identified. Available studies do not provide consistent or compelling evidence that children and adolescents with a history of concussion are at increased risk for worse clinical outcome following a subsequent sport-related concussion-although methodological limitations temper the strength of this conclusion. Clinicians are cautioned against routinely treating children and adolescents with one or more prior injuries differently and more conservatively, because doing so, in some cases, might be counterproductive.

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.

Findings from the Prism Concussion Rig: Does the 5P Risk Score Predict Persistent Postconcussive Symptoms in a Multi-Center Sample of Youth Athletes?

Background:Persistent postconcussive symptoms (PPCS) can negatively impact quality of life, school, and return to sport. The Predicting and Preventing Postconcussive Problems in Pediatrics [5P] clinical risk score has been validated in the Emergency Department setting to predict pediatric patients at risk of PPCS using 9 variables.Hypothesis/Purpose:To determine if the 5P risk score, obtained within 14 days of concussion, predicts which athletes seen in an athletic training or pediatric sports medicine clinic setting develop PPCS in a multi-center sample.Methods:Data were prospectively collected from participants enrolled in the Sport Concussion Outcomes in Pediatrics (SCOPE) study between September 2018-May 2021 across seven sites. Participants aged 6-18 years diagnosed with a concussion who presented within 14 days of injury were included. Demographics, medical history, and the Postconcussion Symptom Inventory (PCSI) were reviewed to calculate the 5P risk score. 5P risk scores were stratified as low (0-3 points), medium (4-8 points), and high risk (9-12 points). Participants were grouped based on symptom resolution time: PPCS (≥28 days) and no PPCS (<28 days). We compared total symptom resolution time among the 5P risk categories using one-way ANOVA and assessed the odds of developing PPCS based on 5P risk score using a binary logistic regression model.Results:We included 117 participants: 23 with PPCS (19.7%). A higher proportion of the PPCS group were female, were seen in a sports medicine clinic setting, and had a longer time to initial presentation (Table 1). Both PCSI symptom severity and 5P risk score were significantly higher in the PPCS group compared to the no PPCS group (p<0.001). Participants with high risk 5P scores had a significantly longer mean symptom resolution time compared to those with low risk scores (Figure 1; 28.4±18.2 vs 7.1±6.8 days, p=0.009). After adjusting for potential confounding variables of initial symptom severity, time to presentation, and assessment setting, each point increase on the 5P risk score was associated with a 1.7x odds of developing PPCS (odds ratio=1.66; 95% CI=1.13, 2.41; p=0.009).Conclusion:In a multi-center sample of youth athletes, the 5P risk score accurately predicted which athletes were at risk for developing PPCS. The odds of developing PPCS increases with each point increase on the risk score. The 5P risk score can help clinicians identify which athletes are likely to develop PPCS, which may aid in educating families on expectations of recovery and/or provide opportunities for targeted intervention to facilitate sooner recovery.Table 1.5 P Variables and other Patient Characteristics Comparing PPCS and no PPCS groupsFigure 1.Symptom resolution time among the three 5P risk categories (Low: n=15; Medium: n=80; High: n=25; p=0.009)

Higher Student Confidence in their Schools’ Academic Support Associated with Lower Adverse Academic Concern Following Concussion

Background:Concussion may cause physical and cognitive deficits that can affect the ability of students to perform at their typical academic level in school. Symptomatic students and their parents have previously reported concern about the impact of concussion on school performance. However, student confidence in their school’s ability to support return to school and its relationship with recovery time and overall academic concern has not been investigated.Hypothesis/Purpose:To determine if student confidence in their school’s ability to support return to school following concussion is associated with recovery time and other academic concerns.Methods:Student-athletes were enrolled in the Sport Concussion Outcomes in Pediatrics (SCOPE) study by a physician or athletic trainer across seven sites. Students and their parent/guardian completed the Concussion Learning Assessment and School Survey (CLASS) along with other standardized assessments. Participants were grouped based on responses to the CLASS question about confidence in their school’s ability to support return to school (very confident vs. not/mildly/moderately confident). Symptom resolution time, initial symptom severity, academic outcomes and parent-reported expected academic supports were evaluated using separate Chi-squared analyses.Results:A total of 141 patients were included; 72 (51%) reported being very confident in their school’s ability to support return to school. There was no significant difference in time to symptom resolution between groups (p = 0.84; mean difference= 0.9 days [95% CI= -7.4, 9.2]). The group who was very confident in school support reported a significantly lower initial symptom severity (p <0.001; mean difference= 0.12 [95% CI= 0.05, 0.18]). A higher proportion of those who felt very confident in school support reported no concern about concussion affecting school learning and performance (Table 2; 36% vs 10%, p=0.005). A lower proportion of those who felt very confident in their school support felt the concussion might affect their grades compared to those who expressed no/mild/moderate confidence in school support (Table 2; 56% vs 23%, p=0.001).Conclusion:In this multi-center study, although there was no difference in symptom resolution between groups, students who reported being very confident in their schools’ ability to support return to school had a lower initial symptom severity, expressed less concern about the concussion affecting their school learning, performance, and grades. These findings support recommendations for a collaborative team to assist students returning to school following concussion.Table 1.Patient characteristics for the two participant groups. Data are presented as mean (sd) or number within group (% within group).Table 2.Academic outcomes for both participant groups.

Self-Reported Amnesia Following Concussion Predicts Greater Deficits in Quality of Life Domains Among Pediatric Athletes

Background:Concussion produces diverse symptoms, functional impairment, and societal limitations that may result in decreased quality of life (QoL). Various factors, including sex, prior concussion and mental health history have been associated with a reduction of QoL compared to baseline. However, the influence of various factors on post-concussion QoL has not been investigated in a prospective, multi-site investigation.Hypothesis/Purpose:To examine factors that may predict decreased post-concussion QoL and increased symptom severity.Methods:Pediatric patients (6-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study at 6 children’s medical centers and 9 secondary schools during the initial visit for a diagnosis of sport-related concussion. Patients completed a medical history, the Post-Concussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP). The PCSI is an age-specific, validated symptom survey on which patients rate their current concussion symptoms. Higher numbers indicate greater symptom severity. The PROMIS-PP includes six domains: physical functioning and mobility, anxiety, depressive symptoms, fatigue, peer relationships, and pain interference. Lower scores indicate higher QoL for all domains, except peer relationships, where a higher score indicates better QoL. Eight predictor variables (Table 1) were assessed using negative binomial regression models constructed for each dependent variable.Results:The analysis included 141 patients (14.9±2.4 years, 40.4% female). Patients were enrolled 5.2±3.1 days post-concussion (range=1-14 days). The percentage (frequency) of patients with a positive self-reported medical history included prior concussion (38%, n=55), migraines (4% (n=5), ADD/ADHD (11%, n=55), LOC at time of injury (7%, n=10), and amnesia at time of injury (20%, n=29). Table 1 presents the pre-injury characteristics associated with each QoL domain and the total PCSI score. Self-reported amnesia was a significant predictor of lower QoL for the anxiety, depressive symptoms, fatigue, and pain interference domains. Migraines were associated with higher QoL scores in the anxiety domain. Younger age and longer time since injury were associated with higher symptom severity.Conclusion:Self-reported amnesia at the time of concussion was associated with a lower QoL related to anxiety, depressive symptoms, fatigue, and pain interference. Interestingly prior concussion and other pre-injury factors did not significantly impact post-injury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later post-injury time points using a concussion-specific outcomes instrument. Patients may be able to better reflect on the impact of the concussion on QoL over time during recovery.Table 1.Patient characteristics associated with each quality-of-life domain and total PCSI score. Due to the zero-inflated count variable nature of the PROMIS variables, negative binomial regression models were constructed for each domain. *Significant predictor of QoL domain.