Initial Concussion Research Articles

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.

Sleep Problems Following Concussion are Associated with Worse Balance and More Severe Symptoms in Youth Athletes

Background:Sleep disturbances are common following concussion and may affect symptom severity and recovery timing. Whether post-concussion sleep problems are associated with functional outcomes, such as postural stability, remains unexplored.Hypothesis/Purpose:We examined the association of self-reported sleep problems with clinical measures of postural stability, persistent post-concussion symptoms (PPCS), and symptom severity following pediatric concussion. We hypothesized that patients reporting post-concussion sleep problems would demonstrate worse postural stability, more severe symptoms at their initial clinical visit, and slower symptom recovery times than those without sleep problems.Methods:We retrospectively examined data from patients (6-18 years) evaluated by a sports medicine physician ≤21 days post-concussion. Patients performed the modified Balance Error Scoring System (mBESS) and single- and dual-task tandem gait (TG). They also reported initial concussion symptom severity they recalled within the first 24 hours post-injury and current symptoms at the first clinical visit using the Health and Behavior Inventory (HBI). Symptom duration was the number of days post-injury until the patient reported a return to baseline status. PPCS was defined as a symptom duration >28 days post-injury. We stratified patients based on those that self-reported sleep problems since injury (n=97, 14.32.9 years; 49% female; initial visit 10.25.8 days post-injury) compared to those who did not (n=110, 14.32.4 years; 46% female; initial visit 9.35.4 days post-injury) assessed with a yes/no question. Groups were compared using independent sample t-tests, Mann Whitney U tests, or Chi square analyses evaluated at a significance level of p=0.05. We examined PPCS development between groups using a logistic regression analysis adjusted for time of initial visit. Symptom severity was analyzed using a 2x2 repeated measures ANOVA with pairwise follow-up using an adjusted significance level of p=0.025.Results:Patients reporting sleep problems post-concussion had significantly more mBESS errors than those without (Table 1). We observed no between-group differences for single- or dual-task TG time or dual-task cognitive performance. Sleep problems post-concussion were associated with more severe symptoms during the first clinical visit despite similar day-of-injury symptoms (Figure 1), and a 2x greater odds of developing PPCS (adjusted odds ratio=2.02, 95% confidence interval = 1.01, 4.06; p=0.049).Conclusion:Youth athletes who reported sleep problems post-concussion demonstrated worse balance on the mBESS, increased likelihood of developing PPCS, and more severe symptoms than those who did not. Identifying sleep problems early in concussion recovery may allow clinicians to implement targeted treatment recommendations to improve sleep, and potentially reduce incidence of PPCS.Table 1.1.Postural stability outcomes assessed at the initial visit. Data are presented as mean (standard deviation).Figure 1.2.Symptom severity profiles for groups with and without sleep problems. Violin plots describe the probability density of measurements. Data are presented as the median (center dot, with corresponding number included) and interquartile range (box around the median). The retrospective rating of symptom severity at the time of concussion was not significantly different after making Bonferroni adjustment (p=0.03; where we defined statistical significance as p<0.025 due to multiple comparisons: the two time points where outcomes were compared). The sleep problem group, however, had significantly worse symptoms than the no sleep problem group at the time of initial clinical visit.

Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League–Big Ten Epidemiology of Concussion Study

ObjectiveTo examine the progression of collegiate student athletes through five stages of a return-to-activity protocol following sport-related concussion (SRC).MethodsIn a multisite prospective cohort study, we identified the frequency of initial...

Factors Associated With a Prolonged Time to Return to Play After a Concussion

Background: Prognosticating recovery times for individual athletes with a concussion remains a challenge for health care providers. Several preinjury and postinjury factors have been proposed to be predictive of prolonged return-to-play (RTP) times, but the data in this area are still sparse. Purposes: This study aimed to identify risk factors associated with prolonged recovery times and determine which are most predictive of prolonged recovery times in a head-to-head comparison. Study Design: Case-control study; Level of evidence, 3. Methods: All concussions occurring between September 2017 and August 2020 at a single National Collegiate Athletic Association Division I institution were reviewed and included in this study. Preinjury modifiers including age, sex, sport, concussion history, and past medical problems were collected from the electronic medical records. Postinjury modifiers analyzed included initial and follow-up Sport Concussion Assessment Tool 5th Edition scores, vestibular evaluation findings, and eye tracking results. Results: A total of 159 athletes and 187 concussion cases were included. Preinjury factors that were correlated with prolonged RTP times included a history of concussions (P = .015), a history of migraines (P = .013), and whether an athlete participated in an individual sport (P = .009). Postinjury factors correlated with prolonged RTP times included the total number (P = .020) and severity (P = .023) of symptoms as well as abnormal Vestibular Ocular Motor Screening findings (P = .002). Overall, 6 different symptoms (balance problems, difficulty concentrating, light sensitivity, drowsiness, fatigue/low energy, and difficulty remembering) were significantly correlated with prolonged RTP times. The study also found that the number and severity of symptoms were additive in a dose-dependent fashion. On multivariable analysis of all these factors, a history of concussions was found to be the most predictive of prolonged RTP times, while participation in an individual sport had the largest effect on recovery times. Conclusion: Several preinjury and postinjury risk factors were identified as being correlated with prolonged recovery times. Many of these risk factors were also found to be additive in nature. This information provides clinicians with a valuable tool in prognosticating and estimating recovery times for athletes. The study also revealed that athletes participating in individual sports had longer RTP times compared with athletes in team sports, which is a novel finding that requires further research.

Same-Year Repeat Concussions in the National Football League: Trends from 2015 Through 2019

Sport-related concussion (SRC) prevention and management is a focus of the National Football League (NFL). While most prior reports evaluated sport-related concussion incidence, few have studied same-year repeat concussions. This study aimed to evaluate the frequency of same-year repeat concussions in the NFL. A retrospective, observational cohort study of same-year repeat concussions in the NFL from 2015 to 2019 was performed. The NFL's electronic health record was reviewed for players sustaining concussions and same-year repeat concussions. Wilcoxon rank sum tests were used to calculate same-year repeat concussion rates, and risk ratios and 95% confidence intervals were estimated using log-binomial regression. From 2015 to 2019, the risk of sustaining a same-year repeat concussion in the NFL was 0.38%-0.69% per season. Among players who sustained a concussion, the risk of a same-year repeat concussion was 5.3%-8.3%, which did not differ significantly from the risk of sustaining a single concussion (6.2%-8.3%). There was a median of 38 participation days between initial and same-year repeat concussion. Players missed more time from same-year repeat concussions (median 12 days) compared with both single (median 9 days; P < 0.0001) and initial (median 9.5 days; P= 0.002) concussions. The risk of a repeat concussion was similar to the risk of sustaining a single concussion among NFL players. More time was missed following a same-year repeat concussion compared with single or initial concussions. Further research is needed to maximize player safety and minimize same-year repeat concussions.

Examining the association between psychosocial functioning and concussion symptom severity in youth

ABSTRACT Objective Guidelines recommend examining psychosocial variables as contributors to postconcussive symptoms. However, few studies examined this relation in a clinic-referred sample and fewer accounted for parent perspective, limiting practitioners implementation of this guidance. Therefore, this longitudinal study examined youth and parent-reported psychosocial variables and their association with concussion symptom severity in a clinic-referred sample of youth receiving treatment for concussion. Methods Youth (n = 121; mean age = 15.3 years) with a recent concussion and their parents completed measures assessing youth depression, anxiety, academic stress, quality of life and concussion symptom severity at the initial treatment appointment and again approximately three-months later or at discharge, whichever came first. Results Differences were observed in psychosocial functioning across parent and youth report. Youth-reported depression was strongly associated with concussion symptom severity whereas parent-reported depression, academic stress, and quality of life were significantly related to concussion symptom severity. Exploratory findings of the relation between psychosocial variables at initial evaluation and concussion symptom severity at follow-up are offered. Conclusion Results offer guidance on the underlying psychosocial variables that may be useful to consider when developing interventions for youth recovering from concussion, especially those with a prolonged recovery.

Incidence and Severity of Concussions Among Young Soccer Players Based on Age, Sex, and Player Position

Background:Previously studied risk factors for sports-related concussion in soccer players include sex, age, and player position. However, prior studies were limited in number, they reported conflicting results, and most did not assess initial concussion severity.Purpose/Hypothesis:The purpose of this study was to conduct an in-depth analysis of soccer players across key demographic groups (sex, age, position) for both concussion incidence and severity. It was hypothesized that concussion incidence and severity would be higher among male players, players aged ≥17 years, and goalkeepers.Study Design:Cohort study; Level of evidence, 3.Methods:The authors analyzed baseline and postinjury ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) scores for athletes aged 12 to 22 years between July 2009 and June 2019. Players were assigned to an age group based on when they had their most recent baseline test. Concussion incidence and concussion severity index were compared using t tests and multivariate logistic regression.Results:For 1189 individuals who reported soccer as their primary sport, 1032 contributed 1754 baseline ImPACT tests (some individuals had multiple baseline tests), whereas 445 individuals were suspected of sustaining a concussion and then referred for a postinjury 1 test. Of these players, 254 (24.6%) had both a baseline and a postinjury test and were analyzed for concussion severity. Linear regression showed that forwards had a lower incidence of ImPACT-proxied concussions than goalkeepers had (P = .008). Female players had a significantly higher incidence of ImPACT concussions compared with male players (mean, 0.07 [female] vs 0.04 [male] concussions per person-year; P = .05). Players in the ≥17-year age group had a higher incidence of ImPACT concussions than players in the 15- to 16-year age group (P = .04), although the 15- to 16-year age group had more severe concussions than the ≥17-year age group (mean severity index, 2.91 [age 15-16 years] vs 1.73 [age ≥17 years]; P = .001).Conclusion:Female soccer players experienced a higher incidence of concussion than did male players, and goalkeepers experienced a greater incidence of ImPACT concussions than did forwards. Players of both sexes and all positions in the 15- to 16-year age group showed increased initial concussion severity compared with the ≥17-year age group, despite a lower comparative incidence of ImPACT concussions. Further study is needed to understand whether sex and player position affect concussion severity.

Nonsteroidal anti-inflammatory drug use and concussions in adolescent athletes: incidence, severity, and recovery.

Given concerns about the potential long-term effects of concussion in young athletes, concussion prevention has become a major focus for amateur sports leagues. Athletes have been known to frequently use anti-inflammatory medications to manage injuries, expedite return to play, and treat concussion symptoms. However, the effects of baseline nonsteroidal anti-inflammatory drug (NSAID) use on the susceptibility to head injury and concussion remain unclear. This study aims to assess the effects of preinjury NSAID use on concussion incidence, severity, and recovery in young athletes. Data from 25,815 ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) tests were obtained through a research agreement with ImPACT Applications Inc. Subjects ranged in age from 12 to 22 years old. Those who reported NSAID use at baseline were assigned to one (anti-inflammatory [AI]) cohort, whereas all others were assigned to the control (CT) cohort. Differences in head trauma and concussion incidence, severity, and recovery were assessed using chi-square tests, unpaired t-tests, and Kaplan-Meier plots. The CT cohort comprised a higher percentage (p < 0.0001) of males (66.30%) than the AI cohort (44.16%) and had a significantly greater portion of athletes who played football (p = 0.004). However, no statistically significant differences were found between the two cohorts in terms of the incidence of head trauma (CT = 0.489, AI = 0.500, p = 0.9219), concussion incidence (CT = 0.175, AI = 0.169, p = 0.7201), injury severity, or median concussion recovery time (CT = 8, AI = 8, p = 0.6416). In a multivariable analysis controlling for baseline differences between the cohorts, no association was found between NSAID use and concussion incidence or severity. In this analysis, the authors found no evidence that preinjury use of NSAIDs affects concussion risk in adolescent athletes. They also found no indication that preinjury NSAID use affects the severity of initial injury presentation or concussion recovery.

Influence of insurance type on rate and type of initial concussion-related medical visits among youth

BackgroundA growing number of studies report increased concussion-related health care utilization in recent years, but factors impacting care-seeking behaviors among youth following a concussion are not well described. This study aimed to evaluate the influence of insurance type on the rate and type of initial concussion visits and the time from injury to the initial visit in youth.MethodsWe extracted and analyzed initial concussion-related medical visits for youth ages 10 to 17 from electronic health records. Patients must have visited Nationwide Children’s Hospital’s (NCH) concussion clinic at least once between 7/1/2012 and 12/31/2017. We evaluated the trends and patterns of initial concussion visits across the study period using regression analyses.ResultsOf 4955 unique concussion visits included, 60.1% were males, 80.5% were white, and 69.5% were paid by private insurance. Patients’ average age was 13.9 years (SD = 3.7). The rate of the initial concussion visits per 10,000 NCH visits was consistently higher in privately insured than publicly insured youth throughout the study period (P < .0001). Privately insured youth had greater odds of initial concussion visits to sports medicine clinics (AOR = 1.45, 95% CI = 1.20, 1.76) but lower odds of initial concussion visits to the ED/urgent care (AOR = 0.74, 95% CI = 0.60, 0.90) than publicly insured youth. Days from injury to initial concussion visit significantly decreased among both insurance types throughout the study (P < .0001), with a greater decrease observed in publicly insured than privately insured youth (P = .011).ConclusionsResults on the differences in the rate, type, and time of initial concussion-related visits may help inform more efficient care of concussion among youth with different types of insurance.

Cognitive Impairment Among Collegiate African American Student-Athletes Who Have One Or More Concussions

The purpose of this research was to examine concussion induced cognitive impairment among collegiate athletes for a long term. This study attempted to determine if there was a significant decrease in cognitive function in student-athletes with a history of concussion after one year of concussion. Totally 46 student athletes who were qualified was included in this study. Of all the 46 student athletes, 14 are females, and 32 males from the following sports: Women’s Basketball (n=3), Men’s Basketball (n=2), Football (n=30), Softball (n=7), Women’s Tennis (n=2), and Women’s Volleyball (n=2) (Table 1). The age range was18-23 years old. Seven of them had two or more concussions Results of this study showed that while all the scores of the ImPACT test improved after one year of concussion for the student-athletes with one or more concussions, there was significant improvement only in the processing speed. For the student-athletes with two or more concussions, the processing speed score after one year of concussions was a little lower even than the score after initial concussion, but it is not statistically significant.&#x0D;

Personality Predictors of Time to Return to Play After Sports-Related Concussion: Analysis of Survey Data From an Undergraduate Sample.

This study aimed to address a gap in concussion literature by investigating the relation between personality and return to play. It is important to know that earlier return to play places individuals at higher risk of sustaining a new concussion after an initial concussion. Participants were undergraduate students recruited from psychology courses in 2019 who reported medically confirmed sports-related concussion and medically advised return to play (N = 202). Participants completed an online battery in a supervised laboratory setting that included self-report survey measures, concussion history items, and behavioral impulsivity tasks. Kaplan-Meier analysis and Cox proportional hazards models were used to analyze time to return to play after participants' first reported sports-related concussion. Results showed that one subdimension of sensation seeking, experience seeking, and two subdimensions of self-reported impulsivity, attentional and motor impulsivity, were positively associated with earlier return to play after a sports-related concussion. In contrast, higher levels of conscientiousness were associated with later return to play. Despite a heterogeneous sample, significant relations were found between timing of return to play and sensation seeking, impulsivity, and conscientiousness. Because earlier return to play can heighten the risk of sustaining a new concussion after an initial concussion, it is important to identify characteristics-such as personality traits-that influence individuals' return-to-play behaviors. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. Upon completion of this article, the reader should be able to: (1) Distinguish between personality traits that resulted in earlier versus later return to play in this sample; (2) Describe why certain personality traits might be related to an earlier or later return-to-play timeline; and (3) List practical ways that these study results could be used to reduce adverse outcomes related to early return to play. Advanced. The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

ANXIETY, FEAR, AND MOVEMENT FOLLOWING SPORTS-RELATED CONCUSSION: HOW DOES KINESIOPHOBIA CORRELATE TO SYMPTOMS AND REACTION TIME?

Background:Fear of pain with movement, also known as kinesiophobia, has been widely studied in various musculoskeletal injuries, yet little is known about its relationship to concussion. Given that concussion can negatively affect neuromuscular control and anxiety, re-integration into sports following a concussion may be associated with kinesiophobia.Hypothesis/Purpose:Our primary purpose was to examine kinesiophobia, among youth athletes with concussion compared to uninjured controls. Secondarily, we sought to examine correlations between kinesiophobia with concussion symptom severity and reaction time. We hypothesized adolescents with concussion would demonstrate greater kinesiophobia compared to controls. Additionally, we hypothesized that greater kinesiophobia would be correlated with higher symptom severity and slower reaction times.Methods:We conducted a repeated measures study of 48 youth athletes. Participants were evaluated at two time points. The concussion group was assessed within 14 days of injury and once cleared for return to play (RTP) by physician. The control group was tested initially and again approximately 28 days later. Participants completed Tampa Scale of Kinesiophobia (TSK), Post-Concussion Symptom Inventory (PCSI), and clinical reaction time (CRT) assessments. We compared mean group differences and assessed the correlation of TSK with PCSI and CRT, at each assessment.Results:We included 26 participants with a concussion and 16 controls (Table 1). The concussion group reported significantly greater TSK scores at the initial assessment (38.0±5.6 vs. 29.3±6.9; p<0.001; Figure 1) and a significantly greater proportion of “high” TSK scores (>36) compared to controls (69% vs. 19%; p = 0.004; Table 1). At the follow-up assessment, there were no significant between group differences in TSK scores (32.8±7.0 vs. 30.4±7.5; p=0.35; Figure 1), or the proportion of “high” TSK scores (38% vs. 25%; p=0.51; Figure 1). TSK scores were significantly and moderately correlated with PCSI for the concussion group at both assessments (r=0.53; p=0.006 at visit 1, r=0.47; p=0.01 at visit 2; Figure 2), but not for controls (Figure 2). Furthermore, TSK scores were significantly and moderately correlated with CRT for the concussion group (r=0.50; p=0.01; Figure 2), but not controls (r= -0.26; p=0.37; Figure 2) at the follow-up assessment.Conclusion:Adolescents recovering from concussion commonly reported high kinesiophobia at initial concussion assessment, while many no longer reported high kinesiophobia when given RTP clearance. Furthermore, kinesiophobia was significantly correlated with self-reported concussion symptoms and clinical reaction time scores. The correlation between kinesiophobia and reaction time suggests a perception-behavior relationship with post-concussion movement deficits may exist.Tables/Figures:Figure 1.Individual data points describing the distribution of TSK scores for concussion and control groups at the initial and follow-up (return-to-play) assessments. The line within the plot defines the median value for each group.Figure 2.Scatterplots and lines of best fit describing the relationship between fear of movement (TSK) ratings with concussion symptom severity (A and B), and with clinical reaction time (C and D).

Sex-Related Differences in the Incidence, Severity, and Recovery of Concussion in Adolescent Student-Athletes Between 2009 and 2019

Background: The sex of an athlete is thought to modulate concussion incidence; however, the effects of sex on concussion severity and recovery are less clear. Purpose: To evaluate sex differences in concussion severity and recovery using a large, heterogeneous sample of young student-athletes with the goal of understanding how sex affects concussion outcomes in young athletes. Study Design: Cohort study; Level of evidence, 3. Methods: The Immediate Post-Concussion Assessment and Cognitive Testing results of 11,563 baseline and 5216 postinjury tests were used to calculate the incidence of concussion of adolescent male and female student-athletes ages 12 to 22 years (median, 15 years). The postinjury tests of 3465 male and 1751 female student-athletes evaluated for concussion or head trauma were used to assess differences in the Severity Index (SI) and recovery. Chi-square tests and t tests were used to compare differences in demographic characteristics, incidence, and SI between the 2 cohorts. Multivariable linear, logistic, and Cox proportional hazards regressions were used to control for differences between cohorts in analyses of incidence, SI, and recovery. Results: When we controlled for demographic differences, female participants had higher odds of concussion (odds ratio, 1.62; 95% CI, 1.40-1.86; P < .0001) and higher SI after concussion (β = 0.67; 95% CI, 0.02-1.32; P = .04). This discrepancy in SI was a result of differences in Symptom (2.40 vs 2.94; P < .0001) and Processing Speed (0.91 vs 1.06; P = .01) composite scores between male and female participants, respectively. We found no effect of sex on time to recovery when controlling for initial concussion SI (hazard ratio, 0.94; 95% CI, 0.78-1.12; P = .48). Conclusion: Using large, multisport cohorts, this study provides evidence that female athletes are at higher risk for more concussions and these concussions are more severe, but male and female athletes have similar recovery times when the analysis controls for initial concussion SI.

Concussion History and Balance Performance in Adolescent Rugby Union Players

Background: Sports-related concussion is a worldwide problem. There is a concern that an initial concussion can cause prolonged subclinical disturbances to sensorimotor function that increase the risk of subsequent injury. The primary aim of this study was to examine whether a history of sports-related concussion has effects on static and dynamic balance performance in adolescent rugby players. Hypothesis: Dynamic balance would be worse in players with a history of concussion compared with those with no history of concussion. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Male adolescent rugby players aged 14 to 18 years from 5 schools were recruited before the start of the 2018-2019 playing season. Participants completed questionnaires and physical tests, including dynamic Y balance and single-leg static balance (eyes closed) tests, while performing single and dual tasks. Dynamic balance was assessed using inertial sensor instrumentation. Dependent variables were normalized reach distance and the sample entropy (SEn) of the 3 axes (x, y, and z). Results: Of the 195 participants, 100 reported a history of concussion. Those with a history of concussion demonstrated higher SEn in all directions, with highest values during anterior (standardized mean difference [SMD], 0.4; 95% CI, 0.0-0.7; P = .027) and posteromedial (SMD, 0.5; 95% CI, 0.2-0.9; P = .004) reach directions compared with those with no history. There was no difference between groups (concussion history vs control) in traditional Y balance reach distances in the anterior or posteromedial directions or single-leg static balance during both single- (P = .47) and dual-task (P = .67) conditions. Conclusion: Adolescent rugby union athletes with a history of concussion had poorer dynamic balance during performance tasks compared with healthy controls. Static single-leg balance tests, either single or dual task, may not be sensitive enough to detect sensorimotor deficits in those with a history of concussion.

Frequency of oculomotor disorders in adolescents 11 to 17 years of age with concussion, 4 to 12 weeks post injury

The purpose of the study was to determine the frequency of vision diagnoses after concussion in adolescents and evaluate the sensitivity and specificity of physician-administered screening for detecting convergence and accommodative disorders post-concussion. We enrolled participants 11 to 17 years old, assessed 4 to 12 weeks following a diagnosed concussion. During the initial concussion examination, a sports medicine physician measured the near point of convergence (NPC), monocular accommodative amplitude (AA), and symptoms using the Convergence Insufficiency Symptom Survey (CISS). A comprehensive oculomotor evaluation was performed by an optometrist. One hundred and thirteen adolescents were enrolled, with a mean age of 15.2 years. Seventy-nine of the 113 (70%) participants had at least one oculomotor diagnosis after concussion, with the most common problems being vergence disorders (60%) and accommodative disorders (57%). The most common vergence disorder was convergence insufficiency (35%). Among accommodative disorders, the most common problem was accommodative insufficiency (35%). In all, 47% of the participants had more than one oculomotor diagnosis following concussion. The sensitivity of physician screening using measures of NPC, AA, and CISS for detecting convergence and accommodative insufficiency was 63%, 43%, 48%, respectively. The results of this study provide additional evidence that vision problems are common in adolescents with persistent concussion symptoms in the sub-acute phase 4 to 12 weeks post-concussion, and current physician screening methods using the NPC, AA, or the CISS underperform. Thus, it is prudent that adolescents with post-concussion symptoms lasting more than 4 weeks post injury receive a comprehensive oculomotor examination.

Do male and female adolescents report symptoms differently after concussion?

ABSTRACT We investigated sex-based differences in the presence and severity of aggregated symptom indicators as well as individual concussion symptoms. Materials and Methods: A cross-sectional examination of sex differences in symptoms reported by adolescents upon initial concussion evaluation at a concussion clinic. Nine hundred and eighty-six adolescents completed the Sport Concussion Assessment Tool (SCAT5) symptom checklist. Chi-square and Mann-Whitney U tests were used for differences in the presence and severity of symptoms, respectively. Sex differences in global indices of symptom distress were compared. Results: Females endorsed more symptoms (Female: Median (M)=15, Interquartile range (IQR):9–18 vs. Male: M=11, IQR: 6–15, p<0.001) and a greater total symptom score (Female: M=37, IQR:16–45 vs. Male: M=20, IQR:8–39). After False Discovery Rate (FDR) adjustment, females endorsed the presence of 21 of 22 individual symptoms more frequently than males (p≤ 0.039), with greater symptom severity for 20 of 22 individual symptoms (p≤0.036). Moderate ESs were observed for sex-based differences in the total symptom score and the global severity index. Small ESs was observed for differences in most individual symptoms. Conclusions: The greater frequency and severity of concussion symptoms reported by female adolescents highlights the importance of considering sex as a modifier for the management of concussion.

Examining how time from sport-related concussion to initial assessment predicts return-to-play clearance

ABSTRACT Objective (i) To analyze data of adolescents who have sustained a sport-related concussion (SRC) through the use of Complete Concussion Management Inc. (CCMI) concussion database system; and (ii) to determine an optimal time to assess and manage an athlete with an SRC by prospectively analyzing data from CCMI concussion database system. Method A cohort of patients, ages 8–18 years, who sustained an SRC, assessed 30 days or less from injury and were treated at partnered CCMI clinics across Canada were prospectively followed. The primary outcome measure was recovery, defined as CCMI discharge, which includes an athlete having completed all return-to-school and return-to-play steps and passed the Gapski–Goodman test without symptom exacerbation. Results 1213 athletes (482 female) were included for analysis. Days between injury and initial assessment (p = 0.00), male sex (p = 0.00), and previous concussion history (p = 0.00) were significant predictors of time to discharge. A log-rank test revealed a significant difference (p = 0.00) in time to discharge with athletes assessed <10 days of injury discharged at a mean of 23.5 days (95% CI, 22.5, 24.5) and those assessed at day 10 to 30 were discharged at a mean of 37.1 days (95% CI, 33.7, 40.5). Athletes who were assessed at 0 to 9 days from injury were two times more likely to be discharged sooner compared to those athletes assessed 10 to 30 days from injury (HR 2.03, p = 0.00). Conclusion Time from SRC to initial assessment significantly predicted time to discharge, with those being evaluated earlier experiencing a faster discharge. The results aid in establishing recommended timelines for evaluation following an SRC in order to prevent or mitigate athletes experiencing a prolonged recovery and encourage timely access to care and a quicker return to life post-concussive injury.

Patient, parent and educator perspectives on paediatric concussion

Background Past research on paediatric concussion awareness, management, impact and outcome priorities has focused on health care professionals and sports organizations, yet little is known about patient, parent and educator perspectives. Methods To address this knowledge gap, we conducted a qualitative descriptive study using semi-structured interviews with three participant groups: patient-participants including children with acute or chronic concussion; parent-participants including caregivers of children at risk for or with history of concussion; and educator-participants including teachers and athletic coaches from three Ontario secondary schools. We designed our interview guide to elicit participants’ perspectives across four domains: concussion awareness, concussion experience, support and resources, and outcome priorities. We analyzed our resultant data using a qualitative content analysis approach. Results Nine paediatric patient-participants, 17 parent-participants, and 14 educator-participants completed the study. Participants described concussion as a serious health concern and attributed greater concussion awareness to increased media attention and concussion protocol implementation within schools/sports. While most educator-participants regarded concussion protocols positively, some feared student manipulation. Parent- and educator-participants desired consistent information and resources from reliable sources. The impact of concussion ranged from a few days to prolonged absences (from school, sports, and socializing) and necessitated accommodations in both academic and sport settings. Short-term problems (e.g., decreased peer-contact) primarily troubled patient-participants, whereas long-term problems (e.g., impaired academics, psychological stress) concerned parent and educator groups. Conclusion Patients, parents and educators worry about the consequences of paediatric concussion. Initial concussion recovery in youth should focus on a timely return to academics and on minimizing social isolation by ensuring peer-contact during recovery.

Factor analysis of the adolescent version of the behavioural assessment screening tool (BAST-A) in adolescents with concussion

ABSTRACT Objective: Develop and validate the Behavioral Assessment Screening Tool for Adolescents with brain injury. Setting: Concussion clinics Participants: Adolescents with mild traumatic brain injury 3 months after initial concussion clinic visit (n = 138). Design: Assessment development and validation (cross-sectional cohort) study Main Measures: Behavioral Assessment Screening Tool – Adolescent Results: Expert panel members added or modified items specific to adolescents to the original Behavioral Assessment Screening Tool for adults. The Content Validity Index was 97.2%. Exploratory factor analysis of the Behavioral Assessment Screening Tool – Adolescent reduced the initial 70 items to 46 primary items with a 3-factor solution: Negative Affect & Fatigue, Executive & Social Function, and Risk Behaviors. Internal consistency reliabilities ranged from good to excellent for all factors (Cronbach’s α =.80-.95). We retained four secondary maladaptive coping items (from an initial six), though these require further modification and testing (Cronbach’s α =.67). Conclusion: The Behavioral Assessment Screening Tool for Adolescents, a measure of neurobehavioral symptoms after mild traumatic brain injury in adolescents, has a multidimensional factor structure with evidence of good internal consistency reliabilities. Future work will further evaluate its convergent and discriminant validity and employ item response theory analyses for validation in a new sample of adolescents with concussion.

Perceived Recovery and Self-Reported Functioning in Adolescents with Mild Traumatic Brain Injury: The Role of Sleep, Mood, and Physical Symptoms

ABSTRACT Purpose: To determine the contributions of anxiety, depressive, and concussion symptoms and sleep quality to self-perceived recovery in adolescents with concussion. Method: Adolescents aged 12–20 (n = 298) completed anxiety, depression, concussion symptoms, and sleep measures at an initial concussion clinic visit and three-month follow-up. At follow-up, they reported self-perceived recovery as percent back to normal. Results: Injury-related factors alone did not predict self-perceived recovery (R2 Adj =.017, p =.074). More concurrent physical, mental health, and sleep symptoms explained 18.8% additional variance in poorer self-perceived recovery (R2 Adj Change =.188, p <.05). Physical symptoms (Bstand = −.292) and anxiety (Bstand = −.260) accounted for the most variance in self-perceived recovery. Conclusion: Post-concussive symptoms, in particular anxiety and self-reported physical symptoms, seem to characterize protracted recovery. Self-perceived recovery as an outcome measure may provide a more holistic understanding of adolescents’ experiences after concussion.