Academic Dysfunction After a Concussion Among US High School and College Students

Predictors of poor reading performance in student-athletes following sport-related concussion

The goal of the current study was to determine which sport/recreation-related concussion (SRC) assessments predict academic reading performance following SRC. The study included 70 concussed students aged 14-22 years (M = 16.21, SD = 1.90) evaluated 2-30 days (M = 8.41, SD = 5.88) post-injury. SRC assessments included: Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, Vestibular/Ocular Motor Screening, and King-Devick test. The Nelson-Denny Reading Test (NDRT) comprehension subtest measured academic reading accuracy and rate. Pearson correlations examined relationships among SRC assessments and reading accuracy/rate; those assessments that significantly correlated with the NDRT were included in multiple regressions (MRs) predicting reading accuracy and reading rate. Results supported positive correlations between visual motor speed and reading accuracy (r = .31, p = .01), and near point of convergence (NPC) and reading rate (r = .30, p = .01). The MRs for reading accuracy (F = 4.61, p = .01) and reading rate (F = 4.61, p = .01) were significant, and predicted approximately 40% of the variance, with visual motor speed and NPC as the only significant predictors in both models. Symptoms were not predictive of reading accuracy or rate. The present study indicates that visual motor speed and NPC are predictive of academic reading performance after SRC, suggesting clinicians should consider these clinical outcomes to better inform academic accommodations.

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

Objective: Develop and validate the Behavioral Assessment Screening Tool for Adolescents with brain injury.Setting: Concussion clinicsParticipants: Adolescents with mild traumatic brain injury 3 months after initial concussion clinic visit (n = 138).Design: Assessment development and validation (cross-sectional cohort) studyMain Measures: Behavioral Assessment Screening Tool - AdolescentResults: 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.

Predicting Risk of Sport-Related Concussion in Collegiate Athletes and Military Cadets: A Machine Learning Approach Using Baseline Data from the CARE Consortium Study

OBJECTIVE

To develop a predictive model for sport-related concussion in collegiate athletes and military service academy cadets using baseline data collecting during the pre-participation examination.

METHODS

Baseline assessments were performed in 15,682 participants from 21 US academic institutions and military service academies participating in the CARE Consortium Study during the 2015-2016 academic year. Participants were monitored for sport-related concussion during the subsequent season. 176 baseline covariates mapped to 957 binary features were used as input into a support vector machine model with the goal of learning to stratify participants according to their risk for sport-related concussion. Performance was evaluated in terms of area under the receiver operating characteristic curve (AUROC) on a held-out test set. Model inputs significantly associated with either increased or decreased risk were identified.

RESULTS

595 participants (3.79%) sustained a concussion during the study period. The predictive model achieved an AUROC of 0.73 (95% confidence interval 0.70-0.76), with variable performance across sports. Features with significant positive and negative associations with subsequent sport-related concussion were identified.

CONCLUSION(S)

This predictive model using only baseline data identified athletes and cadets who would go on to sustain sport-related concussion with comparable accuracy to many existing concussion assessment tools for identifying concussion. Furthermore, this study provides insight into potential concussion risk and protective factors.

Establishing Consensus for Essential Elements in Returning to Learn Following a Concussion

BACKGROUND

Returning to learn following a concussion is the process of managing a student's recovery during the school day by implementation of academic supports with varying intensity. Due to a lack of consensus or even guidance on Return to Learn, this paper set out to establish cross discipline consensus on some essential elements of Return to Learn using a Delphi method.

METHODS

Sixteen national organizations participated in a Delphi process to reach consensus on overarching themes of Return to Learn focused on: returning a student to school, composition of the school-based concussion management team, progress-monitoring, educational safeguards, neuropsychological testing, and legislation. Two rounds of questionnaires were disseminated via email using a Delphi process. Consensus was established during round 2.

RESULTS

Twelve national organizations were able to reach consensus and endorse 13 essential elements of Return to Learn following a concussion.

CONCLUSIONS

There continues to be limited research on concussion Return to Learn leading to confusion in the field. In this paper, we demonstrate consensus on a number of essential elements, from a wide variety of professional disciplines who participate in the care of students following a concussion, as a starting place for some guidance on Return to Learn.

Academic Performance Following Sport-Related Concussions in Children and Adolescents: A Scoping Review

Sport-related concussions (SRC) are an increasingly common concern in young athletes, with long-term cognitive, physiological, behavioral, and psychological adverse outcomes. An estimated 1.1 million to 1.9 million SRCs occur per year in children <18 years old in the United States. The post-concussive state has demonstrated consequences in several domains, including athletics and academics, although much more research has been conducted on the former. The objective of this scoping review was to ascertain findings from published studies on the effects of SRCs on academic performance and quality of life of young student athletes. A total of 175 articles were screened within the PubMed and CINAHL databases, along with a Google search. Fourteen papers fulfilled the inclusion criteria and were analyzed in the review. Quantitative and qualitative data were collated and demonstrated the heterogeneity with which, post-concussion academic performance outcomes were measured; only 4 of the 14 studies utilized formal academic metrics such as changes in grade point average (GPA) or examination scores. While the results overall did show statistically significant implications on academic performance decline after SRC, it is clear that there remains a paucity of research determining the consequences of SRCs on academic performance in the school environment. Further research is needed to better understand how to implement accommodations in the student’s learning environment and guide return-to-learn protocols for student athletes following SRC.

Evaluating Multiple Domains of Health in High School Athletes With Sport-Related Concussion

CONTEXT

Concussions are shown to hinder multiple health dimensions, including health-related quality of life (HRQOL), suggesting a need for a whole-person approach to assessment and treatment. Patient-reported outcome measures are one method to gather the patient's perspective regarding their HRQOL.

OBJECTIVE

To evaluate perceived HRQOL using the Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale in patients throughout concussion recovery.

DESIGN

Prospective cohort, descriptive survey.

SETTING

There were 9 high school athletic training facilities.

PARTICIPANTS

A total of 70 patients with diagnosed concussions (51 males, 7 females, 12 unreported; age = 15.7 [0.9] y, height = 174.6 [8.4] cm, mass = 72.8 [14.8] kg, grade = 10.0 [0.9] level).

INTERVENTIONS

Patient-Reported Outcomes Measurement Information System Pediatric-25 was administered at 3 days, 10 days postconcussion, and return to play (RTP).

MAIN OUTCOME MEASURES

Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale T scores and self-reported concussion history (yes/no).

RESULTS

A total of 70 patients completed the study. For the Pediatric-25 subscales, the severity of problems associated with Physical Function Mobility, Anxiety, Depression, Fatigue, and Pain Interference were highest 3 days postconcussion, decreasing at 10 days and RTP (all p < .05). No differences were found between days 3 and 10 for Peer Relationship scores, but improvements were identified at RTP (p < .05). Pediatric-25 subscale scores at the 3 measurements were not statistically associated with concussion history (all p > .05). Ceiling and floor effects were present in all subscales throughout each timepoint, except for Physical Function Mobility (14.7%), and pain interference (11.8%) at day 3 postinjury.

CONCLUSIONS

Patients who had suffered a concussion improved from day 3 through RTP on multiple health domains as demonstrated through the Pediatric-25 subscales. These findings highlight the need for health care professionals to serially monitor HRQOL and social factors that may affect the patient postconcussion as part of a multifactorial assessment. Ceiling effects in high functioning adolescent athletes were present; thus, efforts should be made to identify appropriate scales for use in managing recovery in athletic populations.

Social Communication Following Adult Traumatic Brain Injury: A Scoping Review of Theoretical Models

Purpose Social communication is the set of abilities that allows individuals to achieve relevant social goals across contexts. Speech-language pathology evaluation and treatment of traumatic brain injury (TBI)-related social communication problems should be informed by evidence-supported theories of social communication. The primary purpose of this article is to summarize the results of a scoping review of theoretical models that speech-language pathologists may apply to the evaluation and treatment of social communication problems of adults with TBI. Method A scoping review was conducted of PubMed, PsycINFO, and Embase for sources published in English between 1989 and 2020 that described human social communication and participation. Resulting sources were systematically examined for social communication models. Results Nine theoretical models were identified that speech-language pathologists may apply to their assessment and treatment of social communication abilities of adults with TBI. Identified models were categorized thematically into one of three classes: cognitive models, social competence models, and pragmatic models. Using a framework developed for the purposes of this article, each identified model was evaluated, and one exemplar model in each class is described in depth. Conclusions Social communication problems in adults post-TBI are common. The existence of multiple models empowers speech-language pathologists to select individual-focused assessment and treatment approaches to maximize intervention outcomes.

Concussion Rates Differ by Practice Type and Equipment Worn in an Autonomy Five Collegiate Football Conference

OBJECTIVE

Evaluate the rate of concussions across Big 12 Conference football programs based on (1) equipment worn, (2) contact level, (3) preseason practice versus in-season practice versus games, and (4) mechanism of injury for concussion.

DESIGN

Descriptive epidemiology study.

SETTING

Big 12 Conference football practices and competitions.

PATIENTS (OR PARTICIPANTS)

Big 12 Conference football teams.

ASSESSMENT OF RISK FACTORS

All Big 12 Conference institutions collected data on practice types, equipment worn, practice and game participation, and concussions during the fall, preseasons and regular seasons, from 2013 to 2016.

MAIN OUTCOME MEASURES

Injury rates and injury rate ratios were reported with 95% confidence intervals (CIs).

RESULTS

From 2013 to 2016, there were 375 concussions reported [0.98/1000 athlete exposures (AEs) (95% CI, 0.88-1.08)], an average of approximately 9 concussions per team per year. Concussion rates were highest in games (5.73/1000 AE), but among practices, concussion rates were highest in full-pad (1.18/1000 AEs) and live-contact (1.28/1000 AEs) practices. Concussion rates increased with increasing contact and equipment worn. Concussion rates were higher in the preseason than in the regular season, even when stratifying by contact level and equipment worn.

CONCLUSIONS

Practice concussion rates are highest during fully padded and live-contact practices, supporting limitations on practice contact and equipment worn to reduce the risk associated with head-impact exposure. Higher concussion rates in the preseason and during games indicate an effect of play intensity on concussion risk, and further research is needed to evaluate the direct effect of practice contact level and equipment guidelines and restrictions on concussion incidence.

Disparities in baseline neurocognitive testing for student concussion management in Massachusetts high schools

Purpose

There is evidence of socioeconomic disparities with respect to the implementation of student-sports concussion laws nationally. The purpose of this study was to examine school sociodemographic characteristics associated with the provision of computerised baseline neurocognitive testing (BNT) in Massachusetts (MA) high schools, and to assess whether the scope of testing is associated with the economic status of student populations in MA.

Methods

A cross-sectional secondary analysis of surveys conducted with MA athletic directors (n=270) was employed to investigate school characteristics associated with the provision of BNT. Correlation and regression analyses were used to assess whether the scope of testing is associated with the economic status of student populations in MA.

Results

The scope of BNT was independently associated with the economic disadvantage rate (EDR) of the student population (β=−0.02, p=0.01); whether or not the school employs an athletic trainer (AT) (β=0.43, p=0.03); and school size (β=−0.54, p=0.03). In a multivariable regression model, EDR was significantly associated with the scope of baseline testing, while controlling for AT and size (β=−0.01, p=0.03, adj-R²=0.1135).

Conclusion

Among public high schools in MA, disparities in the provision of BNT for students are associated with the economic characteristics of the student body. Schools that have a greater proportion of low-income students are less likely to provide comprehensive BNT. The clinical implications of not receiving BNT prior to concussion may include diminished quality of postconcussive care, which can have short-term and long-term social, health-related and educational impacts.

Non-disclosure in Irish collegiate student-athletes: do concussion history, knowledge, pressure to play and gender impact concussion reporting?

Objectives: Non-disclosure of concussions by collegiate student-athletes is documented internationally. This study aims to examine, for the first time, concussion non-disclosure frequency in Irish collegiate student-athletes and ascertain whether concussion history, knowledge, pressure to play and gender impacts this behavior.Methods: A cross-sectional study was implemented. A convenience sample of 268 Irish collegiate student-athletes from high-risk sports completed an anonymous survey developed from previous reliable, validated instruments.Results: One in four Irish collegiate student-athletes reported concussion non-disclosure. While a significant statistical model was generated to predict concussion non-disclosure (χ²= 13.07 p = 0.004) with high specificity (99.5%), the sensitivity was non-existent (0.0%) and explained just 4.8-7.0% of the variance in non-disclosure. Just previous history of a concussion diagnosis contributed significantly to the model (OR = 2.6, 95% CI: 1.46-4.6). Gaps in concussion knowledge were evident and some participants previously felt pressure to return to play after sustaining a blow to the head by coaches (50.0%), teammates (45.5%) and fans (38.0%).Conclusion: Non-disclosure of concussions is common in this population. While gender, concussion knowledge and pressure to play do not seem to impact non-disclosure, a previous history of concussion increases the odds of concussion non-disclosure by 2.6 times. Thus, creating a positive concussion reporting culture in high-risk Irish collegiate sports is critical, particularly for those with a previous medically diagnosed concussion. Multifaceted strategies that incorporate the complexity of why athletes choose to not report a concussion targeted to the specific issues identified in this population and to all key stakeholders involved in collegiate sport are needed.

Return-to-Learn Accommodations and Concussion Perceptions Among Indiana High School Principals

OBJECTIVE

Care after concussion is important for all patients, although especially critical in children and adolescents because of continued rapid brain growth and maturation. Postconcussion symptoms often lead to impaired school performance. Conflicting data regarding best return-to-learn practices make it difficult for school administrators to develop policies to best accommodate concussed students. We sought to assess high school principals' knowledge of concussion, the personnel responsible for implementing accommodations, and the overall willingness to enact recommended academic accommodations.

METHODS

In our cross-sectional study, we surveyed 410 Indiana high school principals (157 responded). Assistant principals were excluded.

RESULTS

One-third of the respondents received academic accommodations training for concussed students and more than 80% were somewhat or very comfortable with academic management. Greater than 90% were willing to provide accommodations as long as necessary. However, nearly 40% of responding principals were unlikely or unwilling to implement accommodations for standardized testing. National and state data suggest the median Indiana high school should expect 30 and more concussions per year; more than 90% of principals estimated that fewer than 30 concussions occurred each year at their school.

CONCLUSIONS

The underestimation of concussion frequency highlights an opportunity for further education of high school principals to ensure all concussed students receive appropriate return-to-learn accommodations.

Family Hardship Following Youth Concussion: Beyond the Medical Bills

PURPOSE

The costs facing families after pediatric concussion are not limited to medical expenses for treatment and rehabilitation care. The objective of this research was to examine the economic hardship facing families following concussion.

DESIGN AND METHODS

Eighteen youth (10-18 years old) with a diagnosed concussion injury and sixteen parents (13 parent/youth dyads) answered open-ended questions regarding experiences associated with concussion care and recovery, specifically as they related to cost. Participants were recruited from a concussion clinic, social media, and via snowball sampling. Interviews were audio recorded, transcribed verbatim, and coded using deductive qualitative content analysis.

RESULTS

In addition to direct health care expenses (e.g. copays and deductibles), families of youth with concussion faced indirect costs associated with tutoring and transportation to medical appointments, in some cases over long distances. Financial cost-sharing for concussion care varied widely across participants.

CONCLUSIONS

Lost productivity included parents missing work to care for their child and for travel to appointments. Research that describes costs of care using claims or survey data lack the experiential perspective of the economic burden on families following concussion.

PRACTICE IMPLICATIONS

To fully understand the impact of concussion on patients and families, healthcare providers must consider non-monetary costs, such as opportunity costs, transportation required to obtain healthcare, or the productivity cost associated with missed work and school.

Characteristics of youth who leave the emergency department without being seen following sports-related concussion

Aim:

Despite the rising incidence of emergency department (ED) visits for sports-related concussion, the frequency and characteristics of youth leaving before being seen are unknown.

Methodology:

National estimates of ED visits for sports-related head injuries among youth (10–18 years) were generated for 2006–2017 using the National Electronic Injury Surveillance System. Logistic regression models estimated the odds of leaving without being seen across patient characteristics and time.

Results:

From 2006 to 2017, 985,966 (95% CI: 787,296–1,184,637) ED visits were identified for sports-related concussions, of which 5015 (95% CI: 3024–7006) left without being seen.

Conclusion:

Youth with sports-related concussion must receive timely care and ED improvements may reduce rates of leaving without being seen.

Over the last decade, more and more youth have visited the emergency department (ED) for sports-related concussion. At the same time, EDs are becoming more crowded, with long wait times and many patients leaving before being evaluated. An increase in the proportion of youth with concussion who left without being seen (LWBS) is possible. We used national data of ED visits to examine the rate of youth (aged 10–18 years) who LWBS for sports-related concussion from 2006 to 2017. While the rate of LWBS has not changed over time, more nonwhite youth and youth who were not injured at school left before being evaluated.

Concussion and Academic Impairment Among U.S. High School Students

INTRODUCTION

Sports and physical activities are a frequent cause of traumatic brain injury, primarily concussions, among adolescents. These concussions may adversely affect students' ability to learn and impair academic achievement in educational settings.

METHODS

The 2017 Youth Risk Behavior Survey, conducted among a nationally representative sample of 14,765 U.S. high school students, was analyzed in 2018 to examine associations between self-reported sports- and physical activity-related concussions and symptoms of cognitive impairment (difficulty concentrating, remembering, or making decisions) and self-reported academic grades (mostly A's=4.0, mostly B's=3.0, mostly C's=2.0, mostly D's=1.0, mostly F's=0.0). Adjusted prevalence ratio and the difference in self-reported estimated grade point average were adjusted for sex, race/ethnicity, grade, and athlete status (participation on sports teams) and considered statistically significant if p<0.05.

RESULTS

Male students were more likely than female students (17.1% vs 13.0%), and athletes were more likely than nonathletes (21.4% vs 7.6%) to have a self-reported sports- and physical activity-related concussion in the 12 months preceding the survey. Students with a reported sports- and physical activity-related concussion were more likely than students without one to report symptoms of cognitive impairment regardless of whether they were male (adjusted prevalence ratio=1.49), female (adjusted prevalence ratio=1.37), athletes (adjusted prevalence ratio=1.45), or nonathletes (adjusted prevalence ratio=1.42). Self-reported grade point averagedecreased significantly from 3.14 among students who reported no concussions (referent), to 3.04 among students who reported a single concussion, and 2.81 among students who reported ≥2 concussions.

CONCLUSIONS

School-based programs are needed to monitor students' academic performance and provide educational support and resources to promote academic success following a concussion.

Language Comprehension After Mild Traumatic Brain Injury: The Role of Speed

Purpose The aim of this study was to characterize language comprehension in mild traumatic brain injury (mTBI) by testing a speed-based hypothesis. We hypothesized that adults with mTBI would perform worse than a group of adults with orthopedic injuries (OIs) on an experimental language comprehension task. Method The study employed a prospective experimental design. Participants were 19 adults with mTBI and 19 adults with OI ages 18-55 years. Participants completed the Whatdunit task, a sentence agent selection task in speeded and unspeeded conditions. Results In the unspeeded condition, the mTBI group performed with a marginally significant higher accuracy than the OI group. In the speeded condition, the mTBI group performed with lower accuracy than the OI group; however, this difference did not reach statistical significance. There was a marginally significant interaction of Sentence Type × Group for reaction time in the speeded condition. Conclusions While our task might have been sensitive to cognitive processing abilities in both groups (as evidenced by the main effects of condition and sentence type), the task was not specific enough to capture mTBI-related deficits. The similarities in performance between both groups have clinical implications for the treatment of not just brain-related trauma but also trauma in general.

Cervicovestibular rehabilitation in adult with mild traumatic brain injury: a randomised controlled trial protocol

Background

Mild traumatic brain injury (mTBI) is an acknowledged public health problem. Up to 25% of adult with mTBI present persistent symptoms. Headache, dizziness, nausea and neck pain are the most commonly reported symptoms and are frequently associated with cervical spine and vestibular impairments. The most recent international consensus statement (2017 Berlin consensus) recommends the addition of an individualized rehabilitation approach for mTBI with persistent symptoms. The addition of an individualized rehabilitation approach including the evaluation and treatment of cervical and vestibular impairments leading to symptoms such as neck pain, headache and dizziness is, however, recommended based only on limited scientific evidence. The benefit of such intervention should therefore be further investigated.

Objective

To compare the addition of a 6-week individualized cervicovestibular rehabilitation program to a conventional approach of gradual sub-threshold physical activation (SPA) alone in adults with persistent headache, neck pain and/or dizziness-related following a mTBI on the severity of symptoms and on other indicators of clinical recovery. We hypothesize that such a program will improve all outcomes faster than a conventional approach (between-group differences at 6-week and 12-week).

Methods

In this single-blind, parallel-group randomized controlled trial, 46 adults with subacute (3 to12 weeks post-injury) persistent mTBI symptoms will be randomly assigned to: 1) a 6-week SPA program or 2) SPA combined with a cervicovestibular rehabilitation program. The cervicovestibular rehabilitation program will include education, cervical spine manual therapy and exercises, vestibular rehabilitation and home exercises. All participants will take part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome will be the Post-Concussion Symptoms Scale. The secondary outcomes will be time to clearance to return to function, number of recurrent episodes, Global Rating of Change, Numerical Pain Rating Scale, Neck Disability Index, Headache Disability Inventory and Dizziness Handicap Inventory. A 2-way ANOVA and an intention-to-treat analysis will be used.

Discussion

Controlled trials are needed to determine the best rehabilitation approach for mTBI with persistent symptoms such as neck pain, headache and dizziness. This RCT will be crucial to guide future clinical management recommendations.

Trial registration

ClinicalTrials.gov Identifier - NCT03677661, Registered on September, 15th 2018.

Preliminary evidence-based recommendations for return to learn: a novel pilot study tracking concussed college students

Aim:

Students re-entering the academic setting after a concussion is commonly referred to as return-to-learn and, to date, very few studies have examined the return-to-learn aspect of concussion recovery.

Methodology:

Nine college-aged, full-time students who were diagnosed with concussions were monitored throughout their concussion recovery. The severity for five chief symptoms (headache, dizziness, difficulty concentrating, fatigue, anxiety) were recorded six-times per day through text messages, and daily phone calls recorded participant's behavioral traits.

Results:

We identified five behavioral variables which significantly influenced symptom resolution (music, sleep, physical activity, water and time) (p = 0.0004 to p = 0.036). Additionally, subjects reported math and computer-oriented courses as the most difficult (33 and 44%, respectively).

Conclusion:

We introduce a novel approach to monitor concussed students throughout their recovery, as well as factors that may influence concussion recovery process.

Concussed students and student-athletes returning to the classroom is commonly referred as return-to-learn. To date, there are very few recommendations that can aid students’ concussion recovery in relation to their academic responsibilities. This is trouble giving that every student-athlete is first and foremost a ‘student’. In light of this, we sought to track behavioral factors that might influence the resolution of college students’ concussion symptoms as they recover from their injury and return to their coursework. Students also gave a perception of their recovery, including what types of activities and school accommodations appeared beneficial. In turn, behaviors such as minimizing music, getting more sleep, introducing more physical activity, drinking more water and overall time since injury appeared to help resolving the concussion symptoms. Additionally, students reported that math and computer-oriented courses were the most difficult, and that additional time on assignments/exams and reducing screen brightness were the most beneficial accommodations. These results are the first of their kind and will optimistically lead to recommendations utilized by healthcare professionals.

Assessing concussion knowledge and awareness in faculty and staff in a collegiate setting

Purpose

To examine faculty and academic support staff members’ awareness and knowledge regarding concussions.

Design

Cross-sectional, web-based questionnaire.

Setting

Division II collegiate setting.

Subjects

A total of 123 collegiate faculty, administrative and academic support staff participated in the study. Measure(s): Participants completed the Faculty and Staff Concussion Awareness and Knowledge Survey. Analysis: Descriptive statistics were compiled for demographic information within the survey. Analysis of variance was performed on concussion awareness and concussion knowledge survey questions.

Results

The majority of the sample had teaching responsibilities in the University (75%). There was a significant effect of college departments within the university on individuals’ level of awareness (F (5, 117) = 9.74, p < .001). The Athletics department scored the highest in awareness of concussion symptomology, while the Business department scored the lowest. Females demonstrated significantly more awareness of concussion symptoms than males (F (1, 121) = 10.488, p = .002). University department significantly impacted knowledge of concussion treatments (F (5, 117) = 3.67, p < .004). The Health Sciences department scored the highest in knowledge of concussion treatments, while the Business department scored the lowest. Past experience with academic accommodations was associated with respondents’ knowledge of concussion treatment (F (1, 121) = 4.046, p = .047).

Conclusions

Concussion management in a collegiate setting should include the faculty and academic support staff. Colleges and Universities should consider educational programming regarding etiology and recovery from concussions for effective management when student experience a concussion.

The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Middle and High School-Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention

Purpose The Centers for Disease Control and Prevention (CDC) recently released guidelines for rehabilitation professionals regarding the care of children with mild traumatic brain injury (mTBI). Given that mTBI impacts millions of children each year and can be particularly detrimental to children in middle and high school age groups, access to universal recommendations for management of postinjury symptoms is ideal. Method This viewpoint article examines the CDC guidelines and applies these recommendations directly to speech-language pathology practices. In particular, education, assessment, treatment, team management, and ongoing monitoring are discussed. In addition, suggested timelines regarding implementation of services by speech-language pathologists (SLPs) are provided. Specific focus is placed on adolescents (i.e., middle and high school-age children). Results SLPs are critical members of the rehabilitation team working with children with mTBI and should be involved in education, symptom monitoring, and assessment early in the recovery process. SLPs can also provide unique insight into the cognitive and linguistic challenges of these students and can serve to bridge the gap among rehabilitation and school-based professionals, the adolescent with brain injury, and their parents. Conclusion The guidelines provided by the CDC, along with evidence from the field of speech pathology, can guide SLPs to advocate for involvement in the care of adolescents with mTBI. More research is needed to enhance the evidence base for direct assessment and treatment with this population; however, SLPs can use their extensive knowledge and experience working with individuals with traumatic brain injury as a starting point for post-mTBI care.

Risk of female sexual dysfunction following concussion in women of reproductive age

Objectives: Traumatic Brain Injury (TBI) has frequently been associated with changes in sexual functioning. The TBI and sexuality literature, however, has limited generalizability to concussed females, who often use the emergency department (ED) as their first line of care after head injury. Primary Objective: The primary objective of this study was to evaluate the impact of concussions on female sexual functioning. Secondary Objective: Secondarily, we evaluated if concussed women with sexual dysfunction also report more post-concussion symptoms (PCS) and/or mood changes. Research Design: This was a prospective cohort, with outcomes assessed at 6-10 weeks after ED enrollment. Methods and Procedures: Sexual dysfunction was defined as ≤ 45 on the Brain Injury Questionnaire on Sexuality (BIQS). The Rivermead Post-concussion Symptoms Questionnaire (RPQ) and the Hospital Anxiety and Depression Scale (HADS) assessed PCS and post-injury mood, respectively. Main Outcomes & Results: Eighty-nine eumenorrheic females (8-14 menstrual cycles/year) completed the study; 31(36%) had concussions, and 55(64%) were extremity injured. Concussed women had 70% increased risk of sexual dysfunction (adj.RR:1.70, 95% CI: 1.04,2.76; p = .03) versus extremity injured. Of clinical relevance, concussed women with sexual dysfunction also reported more PCS symptoms (adj.β = 5.5, 95% CI: -6.7,18.2; p = .37) and mood scores (adj.β = 8.0; 95% CI: -0.4, 16.4; p = .06). Conclusions: This study highlights the need for more research and interventions for one of the fastest growing subgroups within the TBI population.

Academic outcomes following adolescent sport-related concussion or fracture injury: A prospective cohort study

Objectives

The objectives were 1) to compare the effects of adolescent sport-related concussion (SRC) and sport-related extremity fracture (SRF) on academic outcomes including change in school grades and school attendance; and 2) to determine which specific academic accommodations were most helpful during recovery from these injuries.

Methods

A prospective cohort study was conducted to compare changes in school grades, school attendance and academic accommodations among students (grades 8–12) with an SRC or SRF. School grades were extracted from student immediate pre- and post-injury report cards. Students completed attendance log books and an exit interview to determine which accommodations were helpful and how accommodating they perceived their school to be during their recovery.

Results

Overall, 124 students (92 with SRC and 32 with SRF) submitted both pre- and post-injury report cards. Students who sustained an SRC or SRF experienced similar decreases in grades post-injury (SRC: -1.0%; 95% CI: -2.1, 0.1 and SRF: -0.9%: 95% CI: -2.1, 0.3). Students with an SRC missed significantly more days of school compared to those with an SRF (median of 4 days [IQR: 1, 7] versus 1 day [IQR: 0, 4], p<0.0001). In total, 60/113 (53.1%) SRC students reported their school to be very accommodating while only 31/77 (40.3%) SRF students reported their school to be very accommodating (p = 0.082).

Conclusions

Students who sustain an SRC miss significantly more days of school but demonstrate similar changes in school grades post-injury compared to those with an SRF. Future studies are needed to identify the pre- and post-injury factors associated with poor academic functioning following concussion and identify measures that can be taken to help optimize academic outcomes in these patients.

Trouble Falling Asleep After Concussion Is Associated With Higher Symptom Burden Among Children and Adolescents

Our objective was to identify factors associated with trouble falling asleep postconcussion. Patients seen for care after sport-related concussion were assessed ≤10 days postinjury and were between 6 and 19 years of age. Outcomes included symptoms (Post-Concussion Symptom Scale), postural steadiness, missed school, and medical history. There were 261 patients (49% female; mean age=14.8±2.5 years): 45% reported trouble falling asleep. A greater proportion of patients who reported trouble falling asleep missed ≥2 days of school (64% vs 49%; P = .02). Patients who reported trouble falling asleep endorsed more severe symptom severity than those who did not (median=38 vs 18; P < .001). After covariate adjustment, confusion (aOR = 1.95, 95% CI = 1.131-3.375), missing ≥2 days of school (aOR = 4.52, 95% CI = 1.553-13.16), and noise sensitivity (aOR = 1.48, 95% CI = 1.1.042-2.010) were independently associated with trouble falling asleep. Sleep disturbances are associated with poorer clinical outcomes after concussion. Inclusion of sleep assessments may help to provide early therapeutic pathways for pediatric concussion patients.

Mechanisms underlying vulnerabilities after repeat mild traumatic brain injuries

Traumatic brain injury (TBI) has drawn national attention for its high incidence and mechanistic complexity. The majority of TBI cases are "mild" in nature including concussions and mild TBI (mTBI). Concussions are a distinct form of mTBI where diagnosis is difficult, quantification of the incidence is challenging and there is greater risk for subsequent injuries. While concussions occur in the general population, it has become a hallmark injury consistently observed among adolescent and young adult athletes and the risks for repeat TBI (rTBI) is significant. Clinical and experimental evidence shows that the magnitude and duration of deficits is dependent on the number and the interval between injuries. Several studies suggest that metabolic vulnerabilities after injury may contribute to the window for cerebral vulnerability from rTBI. In addition to metabolism, this review addresses how age, sex and hormones also play an important role in the response to repeat concussions. Understanding how these factors collectively contribute to concussion and rTBI recovery is critically important in establishing age/sex appropriate return to play guidelines, injury prevention, therapeutic interventions and mitigation of long-term consequences of rTBI.

Personal subjectivity in clinician discussion about retirement from sport post-concussion

BACKGROUND

There is increasing focus on the number of concussions after which an athlete should discontinue participating in contact or collision sports. This is a clinically subjective and, in some cases, a preference-sensitive decision.

PURPOSE

Our goal was to assess whether there is personal subjectivity in when athletic trainers (ATs) discuss the possibility of sport retirement post-concussion with athletes.

METHODS

A national sample of ATs who provide clinical care to college athletes completed a questionnaire (n = 677, 34% response rate). Structural equation modeling was used to assess the association between risk perceptions, risk tolerance, social influences (beliefs about athlete, coach and parent preferences), expectancies about athlete success (on and off field), and the number of concussions after which retirement would be discussed.

RESULTS

There was a significant direct effect of AT risk tolerance on the number of concussions after which sport retirement would be discussed, among both male and female ATs (male B = 0.54, p < 0.001; female B = 0.31, p < 0.001). ATs who more strongly prioritized athletes' on-field achievements indicated that they would discuss sport retirement after a larger number of concussions compared to their peers who less strongly valued athletic achievement.

CONCLUSIONS

The results suggest the potential utility of standardized approaches to communicating concussion risk consistently to athletes. This can help ensure that all athletes are uniformly able to make informed decisions about continued exposure to concussion risk that are based on their values and preferences.

Sex Differences in the Clinical Incidence of Concussions, Missed School Days, and Time Loss in High School Student-Athletes: Part 1

BACKGROUND

Sports-related concussion (SRC) injury rates are well established in collegiate athletics through epidemiological studies using the National Collegiate Athletic Association Injury Surveillance System. However, few studies have examined sex differences, time loss, and missed school days in high school athletes, especially at the state level.

PURPOSE

To identify sex differences in the clinical incidence of SRCs, missed school days, and time loss in high school student-athletes.

STUDY DESIGN

Descriptive epidemiological study.

METHODS

A total of 193,757 (116,434 male and 77,323 female) student-athletes (10th grade ± 1.1) participating in Michigan High School Athletic Association (MHSAA)-sponsored athletic activities were recorded in the Head Injury Reporting System. Certified athletic trainers, school athletic administrators, and coaches from MHSAA high schools reported SRC data and overall participation for the 2015-2016 academic year. Total concussive injuries, as well as missed school days and time loss for each concussive injury, were reported. The clinical incidence was calculated by dividing the number of SRCs in a particular category by the number of participants in that category and presented with 95% CIs. Relative risk ratios (RRs) were determined for sex-comparable sports.

RESULTS

The overall clinical incidence for all sports was 1.7 per 100 player-seasons (95% CI, 1.6-1.8) and 1.9 (95% CI, 1.8-2.0) for male sports and 1.5 (95% CI, 1.4-1.6) for female sports. Female athletes were at a 1.9 (95% CI, 1.8-2.2) times greater risk for enduring SRCs than male athletes in sex-comparable sports, with a greater risk in baseball/softball (RR, 2.7 [95% CI, 1.9-3.8]), basketball (RR, 2.5 [95% CI, 2.1-2.9]), and soccer (RR, 1.6 [95% CI, 1.4-1.9]). Female student-athletes had significantly longer time loss than male student-athletes ( P < .001). The mean number of missed school days did not differ between sexes ( P = .70).

CONCLUSION

High school female student-athletes have a higher risk for an SRC in all sex-comparable sports except lacrosse. This may be because of biomechanical differences of the head-neck segment, hormonal differences, and the fact that female athletes are more likely to report symptoms after a suspected SRC.

CLINICAL RELEVANCE

Despite sex differences in the clinical incidence of SRCs and time loss from participation in high school sports, the numbers of missed school days are relatively similar between sexes.

A Preliminary Examination of Concussion Knowledge by Collegiate Athletes and Non-Athletes

PURPOSE

Concussions affect various populations, including collegiate athletes and non-athletes. The purpose of this study was to compare collegiate varsity athletes, recreational athletes, and non-athletes' knowledge of concussion definition, symptoms, and support services available following injury. Preferred method of concussion education delivery was also examined.

METHOD

We surveyed 306 current college students using an online survey system. The survey included free recall and forced-choice question formats. Quantitative analyses were used to analyze results and compare responses among groups.

RESULTS

Collegiate athletes and non-athletes demonstrate incomplete knowledge of concussion definition, related symptoms, and professionals involved in postinjury management. Varsity athletes rated self-knowledge of concussion parameters significantly higher than the other groups (p < .001), though few significant differences in actual knowledge levels were observed. Overall, respondents reported having the highest preference for concussion education delivered by medical professionals.

CONCLUSION

Knowledge concerning concussion is incomplete in the collegiate population. Varsity athletes' exposure to formal education did not result in higher knowledge levels compared with other groups. Further examination of concussion educational delivery models' effect on change in concussion-related behavior in this population is warranted.

School Nurses' Perceived Challenges With Concussion Management Procedures in the Secondary School Setting

School nurses have an integral role in managing student health concerns throughout the school day, yet little is known about their specific role in concussion management. Therefore, the purpose of this study was to explore the challenges encountered by school nurses regarding concussion management in the secondary school setting. Twenty-two school nurses employed in the secondary school setting were interviewed via phone. We analyzed the data via the consensual qualitative research paradigm. Overall, we found school nurses face consistent challenges with their role on the concussion management team, specifically related to education of school personnel, parents, and community health-care providers. Challenging topics included the inconsistency of community health-care provider recommendations and others' perceptions of school nurses' preparation and training to be important members of the concussion management team. Efforts to increase concussion education and improve communication across all stakeholders of the concussion management team should be implemented.

Lived Experiences of Adolescent Athletes Following Sport-Related Concussion

Background:

Previous studies have identified the effect of sport-related concussion on health-related quality of life through the use of patient-reported outcome measures. However, there has been little research exploring the underlying mechanisms that influence these perceptions of health-related quality of life among adolescent athletes who have sustained a sport-related concussion.

Purpose:

To explore the psychosocial aspects of concussion among adolescent athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 12 interscholastic athletes (4 girls, 8 boys; mean ± SD age, 15.7 ± 1.7 years; grade level, 10.2 ± 1.4) were interviewed via a semistructured interview protocol between 15 and 30 days postinjury. Data analysis was guided by the consensual qualitative research tradition. Themes and categories emerged through consensus by a 3-person research team, and bias was minimized through the use of multiple-analyst triangulation.

Results:

Participants identified numerous postconcussion symptoms that resulted in increasing difficulty with emotions (eg, irritable, easily frustrated), roles at school (eg, concentration difficulties, fatigue), and roles in their social environment (eg, letting the team down, not being able to contribute to sport). As a result, participants expressed how they tried to minimize or mask symptoms to decrease the potential of being viewed differently by their peers.

Conclusion:

Adolescent athletes perceived a significant effect of sport-related concussion on numerous areas of psychosocial and emotional health and well-being. Anticipatory guidance—with education regarding the possible signs and symptoms, risk factors, and recovery expectations following a concussion—is important to include in postinjury management. A better understanding of sport-related concussion and expected recovery could help to improve perceptions of this injury among interscholastic athletes. Additionally, best practices should be identified to assist health care professionals and school personnel in the development of temporary adjustments or formal academic adjustment policies in the secondary school setting, therefore ensuring that the patients receive the support that they need to maintain their roles as students.

Concussion management application for amateur sports

Concussion management has become one of the most popular topics in sports medicine. Significant resources are being invested in developing protocols for professional sport associations such as the NFL and FIFA. These protocols are often expensive and require substantial resources to implement. The problem, however, runs much deeper than just professional sports. Currently there exists little infrastructure to effectively manage concussion in amateur settings such as high school, club and university sport. A more holistic approach is required to ensure that the same standard of concussion management is being implemented across the board, regardless of the available medical and financial resources. An application was developed that will allow for easily accessible baseline testing and access to a player's concussion history from anywhere in the world. The application will be used to monitor players from the day they start playing sport until they potentially become professional sport players.

Academic outcomes and accommodations following adolescent sport-related concussion: a pilot study

Aim:

The purpose of this study was to examine academic achievement, absenteeism and school accommodations following adolescent sport-related concussion (SRC).

Methods:

A case-series was conducted among grade 8–12 students who suffered an SRC. The primary outcomes were change in pre- and post-concussion overall, core report card grade point average (GPA) and absenteeism due to concussion. The most helpful school accommodations were tabulated.

Results:

Pre- and post-concussion GPA was obtained from 33 students – 16 (48%) developed persistent post-concussion symptoms (symptoms lasting >4 weeks). There was no significant difference in pre- and post-concussion grades among students with a SRC for overall (p = 0.75) or core (p = 0.56) GPA. The median number of missed school days was 4 (interquartile range [IQR]: 2–8). Allowing for physical and cognitive rest was identified as the most helpful accommodation (30%).

Conclusion:

Larger studies should investigate the role that school accommodations and development of persistent post-concussion symptoms have on academic outcomes.

The Effect of Concussion or Mild Traumatic Brain Injury on School Grades, National Examination Scores, and School Attendance: A Systematic Review

Concussion often results in symptoms, including difficulty concentrating, focusing, and remembering, that are typically managed with cognitive and physical rest. Often, the school environment is not conducive to cognitive rest and may lead to worsening or prolonged symptoms that can contribute to impaired academic performance. The objective of the review was to identify and summarize literature concerning the effects of concussion or mild traumatic brain injury (mTBI) on academic outcomes. MEDLINE, Embase, Scopus, and CINAHL were searched until June 1, 2016. Studies must have been primary literature examining students enrolled in primary, secondary, or post-secondary education, have received a physician diagnosis of concussion or mTBI, and have post-injury academic outcomes assessed in numeric or alphabet grade/grade point average (GPA), school attendance records, or national examination scores. Data were extracted and checked by a second reviewer for accuracy and completeness. Nine studies were included. Among four studies that examined grades, one found a significant difference in pre- and post-grades only in the subject Afrikaans. Three examined national test scores and no significant differences were found between cases and controls. Four examined school absenteeism and found that students who developed post-concussion syndrome missed significantly more school days and took longer to return to school than students with extremity injuries. Although mTBI or concussion is associated with missed school, the results demonstrate minimal impact on school grades and national examination scores at a group level. Further research is needed to identify risk factors for impaired school functioning following mTBI and concussion in individual patients.