Factors Influencing the Underreporting of Concussion in Sports: A Qualitative Study of Minor Hockey Participants

Prevailing theories describing sports-related concussion symptom reporting intent and behavior among adolescent athletes: a scoping review

Diagnosis of sports-related concussion (SRC) primarily relies on an athlete's self-report of injury and associated symptoms. Social pressures and attitudes surrounding SRC influence athlete reporting behavior. Unfortunately, underreporting of SRC symptoms is an issue among adolescent athletes. Nondisclosure of SRC symptoms may lead to premature return-to-play and potential persistent symptoms. This scoping review summarizes prevailing theories that explain SRC symptom reporting intent and behavior among adolescent athletes. Literature was reviewed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Review guidelines. Inter-rater reliability was calculated at each stage. Thirty-four articles published between 2013-2024 were included. Inter-rater reliability was fair to perfect across all review stages. Of the 16 unique theories described, the Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB) was the most frequently cited theory explaining SRC symptom reporting behavior. Although the TRA/TPB framework was useful when predicting SRC symptom reporting intent, it did not adequately predict reporting behavior, consistent with the broader health behavior literature which has established that intention is not a good predictor of behavior. In light of these findings, new frameworks must be considered that consider neurodevelopmental, cognitive, and cultural factors, as these may be more useful for understanding SRC symptom reporting behavior in adolescence.

After the buzzer sounds: Adults unveil the consequences of concussions sustained during adolescence

Concussions are commonly occurring injuries in sport. The short-term impacts of concussions, including symptoms and recovery trajectories, often are the focus of concussion research. However, limited studies have explored the long-term consequences of concussions, especially in adolescents. The purpose of this study was to explore adults' experiences with concussions sustained during their adolescence (5-15 years prior). This qualitative study was guided by an interpretivist philosophy. Twenty young adults (11 men, 9 women, median age 26) who had sustained at least one sport-related concussion during their adolescence participated in a one-on-one semi-structured interview. We aimed to explore their experiences with their concussion at the time of injury and any consequences they experienced as a result of their concussion. We organized participants' concussion experiences into six main themes: (1) Concussion diagnosis and experiences with health care providers; (2) Emotional symptoms following concussion; (3) Concussion recovery; (4) Change in sport participation and engagement; (5) Concern about the potential long-term consequences; and (6) Impact on social relationships. We used the Biopsychosocial Model of Sport Injury Rehabilitation to organize the themes. Future research should explore how acute multi-disciplinary support could reduce the negative long-term consequences of concussion in adolescents.

Macular, Choroidal, and Peripapillary Perfusion Changes in Mild and Moderate Traumatic Brain Injury Using Optical Coherence Tomography and Angiography

Introduction: To compare the retinal and choroidal architecture and microvasculature between patients with mild or moderate traumatic brain injury (TBI) and controls with normal cognition using optical coherence tomography (OCT) and OCT angiography (OCTA). Methods: Patients with a documented history of TBI, and age-matched and sex-matched controls were recruited. The primary outcome measures were differences between OCT parameters, including the choroidal vascularity index, and between OCTA superficial capillary plexus metrics, including foveal avascular zone (FAZ) circularity, 3.0 mm × 3.0 mm and 6.0 mm × 6.0 mm macular vessel density and perfusion density, and 4.5 mm × 4.5 mm peripapillary capillary perfusion density and capillary flux index. Results: Sixty-seven eyes of 36 patients with TBI and 72 eyes of 36 control patients met the inclusion criteria. Twelve patients (33.3%) had a diagnosis of mild TBI without loss of consciousness (LOC), 21 (58.3%) had mild TBI with LOC, and 3 (8.3%) had moderate TBI. There was a significant reduction in FAZ circularity and in 3.0 mm × 3.0 mm macular OCTA vessel density and perfusion density in patients with TBI. In cases with TBI associated with posttraumatic stress disorder, all macular OCTA parameters were significantly reduced. There was an increase in the choroidal vascularity index across the severity of TBI; however, it was reduced in those with more than 1 TBI (P = .03). Conclusions: There was a reduction in macular perfusion in eyes of patients with mild or moderate TBI. The choroidal vascularity index helps differentiate subtle effects of more severe or mild repeated TBI. Further prospective investigation will evaluate OCT imaging and OCTA imaging as a noninvasive screening modalities to assess changes in retinal and choroidal microvasculature.

Non-reporting of sport-related concussion symptoms: a cross-sectional study of community rugby league players in the UK

Recognising and removing players with suspected sport-related concussions is crucial for community sports.

OBJECTIVES

Quantify rates and factors associated with non-reporting of concussion symptoms in community rugby league.

METHODS

Overall, 484 community rugby league players aged ≥18 years and 965 parents of rugby league players aged <18 years completed an online survey, regarding concussion history, knowledge, prevalence and reasons for non-reporting of concussion, long-term implications and perceptions of concussion.

RESULTS

Thirty-five percent of players aged ≥18 years and 22% of parents of players aged <18 years reported at least one concussion in the last two seasons. Forty-three percent of players aged ≥18 years and 5% of parents of players aged<18 years surveyed stated they did not report concussion-related symptoms sustained during 2020 and 2021 seasons. The two most common reasons for non-reporting of concussion symptoms were 'didn't want to be ruled out of a match' and 'didn't want to let down the team'. Players aged ≥18 years who received external coaching pressures around concussion were more likely to not report concussion symptoms. Over 40% of parents and players were concerned about the potential long-term implications. Ten percent of players aged ≥18 years and 7% of parents of players aged <18 years would encourage their family members/children to not play rugby league.

CONCLUSIONS

Non-reporting rates of suspected concussion symptoms in adult community players were twice as high as in professional rugby league, with similar reasons (wanting to play and not letting the team down). Engaging coaches to prioritise brain health and providing broader and appropriate education on concussion should be focused on, given the concerns reported by community players and parents.

A grounded theory of youth athlete concussion under-reporting decisions

BACKGROUND

Sport-related concussions leave youth vulnerable to significant health, physical, social, and educational disruptions. Many youth athletes under-report concussions, but the scope of the issue for this population is not well understood, nor are the underlying motivations for (under)reporting. It is necessary to examine the relationship between sport-related concussion knowledge and reporting and invite athletes to share their decision-making processes. The purpose of the research was to understand how athletes' attitudes, experiences and beliefs regarding concussions influence their under-reporting decisions and behaviours.

METHODS

We conducted semi-structured interviews with 17 elite athletes, aged 16-18 years, from individual and team sports. Data were analyzed using constructivist grounded theory and a substantive theoretical model of sport-related concussion under-reporting was developed.

RESULTS

The model demonstrates personal, social, cultural, and biophysical processes that contribute to under-reporting decisions and identifies multiple interconnected processes that contribute to 'high-risk' situations of under-reporting. Youth athletes navigate various barriers and facilitators to under-reporting, including their own desire to play, perceived stigma, concussion sense-making, and social influences. Results suggest that under-reporting by youth athletes implicates a collective, rather than individual, responsibility.

CONCLUSIONS

A theoretical grounded model for youth sport-related concussion under-reporting highlights the complexity of the decision-making process. This study offers a new framework for understanding why youth athletes may hide concussion symptoms. The model offers potential to be used to develop concussion interventions and tools for improved decision-making, and to address issues of risk and responsibility concerning concussion reporting.

An examination of social relations and concussion management via the blue card

Introduction

Initially developed by New Zealand Rugby in 2014, the Blue Card initiative in rugby enables match officials to remove athletes from play if they are suspected to have sustained a concussion. Considerable attention has been paid by sport and health advocates to the possibilities and limitations of this initiative in safeguarding athlete health. However, little if any attention has been paid to the well-being of those responsible for administering the Blue Card (i.e., match officials). The aim of this paper was to examine match officials' experiences with and perspectives on implementing the Blue Card initiative in Ontario, Canada, with focused attention on the tensions around their ability to manage games and participants (e.g., athletes, coaches) while attempting to safeguard athlete well-being.

Methods

Using Relational Coordination Theory (RCT) as a guiding framework and qualitative research method, we highlight the rich accounts of 19 match officials' perspectives and experiences regarding sport-related concussion (SRC) management and the Blue Card protocol.

Results

Four themes were derived from the data, reflecting latent assumptions embedded within the concussion management process, which include: assumptions of trust, respect, and cooperation; assumptions of shared responsibility; assumptions of shared understanding; and assumptions of harassment-free sport.

Discussion

Our findings emphasize the need to attend to social relations in concussion management and provide insight into match officials' fraught experiences on the frontlines of concussion management. We identify factors affecting match official well-being and provide considerations for concussion management initiatives designed to improve athlete safety, such as the Blue Card.

Navigating uncertainty: exploring parents' knowledge of concussion management and neuropsychological baseline testing

Introduction

Parents play an important role in preventing and managing sport-related concussions among youth sport participants. Research indicates that parents understand the severity and consequences associated with the injury but gaps exist in their knowledge of its management. Neuropsychological baseline testing (NBT) is a modality that has gained interest in youth sport to purportedly better manage concussion injuries. Little is known about parents' perspectives on the use of NBT in the management process.

Methods

The present qualitative study used Protection Motivation Theory as a guiding framework and employed focus groups (N = 2) with parents (N = 11) to gain insight into parents' perceptions and experiences with concussion management, specifically focusing on NBT.

Results

Inductive Content Analysis developed a core theme of navigating uncertainty. Participants expressed uncertainty about the nature of concussion and its management process, where concussion was not always easy to identify, youth were not always reliable reporters, and there was no prescribed or proscribed path for recovery. Personal experience and concussion management policy provided participants with a degree of certainty in managing concussions. Participants gave NBT mixed reviews in potentially promoting greater certainty but also held reservations about its usefulness in concussion management.

Discussion

We discuss findings relative to existing knowledge and theory in youth sport concussion and identify implications for practice.

Intersection of Race and Socioeconomic Status on Concussion Recovery among NCAA Student-Athletes: A CARE Consortium Study

PURPOSE

The objectives of this study are to 1) describe collegiate student-athlete (SA) race and household income and 2) evaluate time to normal academic performance (i.e., return to learn (RTL)), initiation of the return to play (iRTP) protocol, RTP protocol duration, and time to unrestricted RTP (URTP) after sustaining sport-related concussion (SRC).

METHODS

Data were collected between 2014 and 2020 by the Concussion Assessment, Research, and Education Consortium. Baseline data were used to characterize participant demographics ( N = 22,819) and post-SRC outcomes ( n = 5485 SRC) in time to RTL ( n = 1724) and RTP outcomes ( n = 2646) by race. Descriptive statistics and nonparametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox proportional hazards regression assessed the effect of race on risk of RTL and RTP recovery time points.

RESULTS

SA largely identified as White (75%) followed by Black (14%), multiracial (7%), and Asian (3%). More than half (53%) of all SA reported a household income of >$120,000, whereas 41% of Black SA reported a household income <$60,000. Race was not associated with relative risk of RTL or iRTP but was associated with RTP protocol completion and URTP. Non-Black/non-White SA were 17% less likely (adjusted hazard ratio = 0.83; 95% confidence interval = 0.71, 0.97) to complete the RTP protocol, and Black SA were 17% more likely (adjusted hazard ratio = 1.17; 95% confidence interval = 1.05, 1.31) to reach the URTP time point compared with White SA.

CONCLUSIONS

The present findings suggest collegiate SA enrolled in the Concussion Assessment, Research, and Education Consortium are primarily White and come from household incomes well above the US median. Race was not associated with RTL or iRTP but was associated with RTP protocol duration and total time to URTP. Clinicians should be conscientious of how their implicit or preconceived biases may influence SRC management among National Collegiate Athletic Association SA.

I won't let you down; why 20% of Men's and Women's Super League players underreported suspected concussions

OBJECTIVES

Quantify and identify factors associated with concussion underreporting in Super League rugby league players.

DESIGN

Cross sectional survey.

METHODS

During the 2022 season preseason, 422 Men's and Women's Super League players completed an online survey quantifying player demographics, rugby playing history, concussion history, prevalence of, and reasons for underreporting concussion, concussion knowledge and long-term implications and perceptions of concussion.

RESULTS

Overall, 20% of respondents stated they did not report concussion-related symptoms to medical staff during the 2020 and 2021 seasons. The two most common reasons for underreporting concussion were 'didn't want to be ruled out of a match' (35%) and 'didn't want to let down team' (24%). 65% of players reported an appropriate level of knowledge about concussion and potential long-term implications at the start of their senior rugby career, versus 89% now. In relation to concussion knowledge, symptoms were correctly identified on 74% of occasions. 57% of players surveyed were concerned about the potential long-term implications from concussion, and 11% of players would encourage their/family members' children to not play rugby league.

CONCLUSIONS

The proportion of Super League players who did not report concussion symptoms was similar to rugby league players in Australia. The main reasons for not reporting concussion appeared to be due to perceptions of what is beneficial for the team, suggesting both performance and medical staff should collectively encourage players to report concussion. A player's attitude towards concussion is potentially an individual modifiable risk factor and should be considered within the concussion management of players.

Hard-Headed Decisions: Intrapersonal Factors Underlying Concussion Reporting in University Athletes

Most of the research investigating sports concussion (SC) disclosure has been conducted using questionnaires with a pre-determined set of questions. Hence, significant gaps remain in our understanding of which factors weight in the decision-making process underlying SC disclosure and how they contribute to it. This present study aims to fill some of these gaps using qualitative methods to identify intrapersonal determinants of SC disclosure and describe their influence on an athlete's decision-making process. Our results are based on in-depth, semistructured interviews (range, 56-79 min; total = 587 min) with 9 university athletes (5 females, 4 males) from three team sports (soccer, rugby, and cheerleading). Using constant comparative analysis guided by Straussian grounded theory, we identified 13 concepts, across three major intrapersonal categories (i.e., attitudes and behaviors; concussion knowledge; and subjective evaluation of the concussion), contributing to SC disclosure, including novel determinants such as prioritization of athletic versus intellectual activities and maturity level. Our results suggest that a comparison between experiential knowledge and severity of the injury plays a major role in determining an athlete's disclosure behaviors. Athletes with a history of concussion seem to adopt a non-disclosure default strategy and are inclined to disclose their concussion symptoms only if they judge their current concussion to be worse than their previous most severe injury. Other concepts identified appear to contribute to the decisional process by modulating the adoption of this non-disclosure default strategy. Our work highlights the benefits and necessity of using qualitative methods to study the decision-making process underlying concussion disclosure.

Predictors of concussion reporting intentions in adolescent hockey players

Young athletes who do not report a concussion injury are at greater risk for a prolonged recovery time and further neurocognitive impairments. Despite the seriousness of the issue and the scale of the problem, not enough is known about the behavioural underpinnings of concussion underreporting in minor athletes. This paper aims to apply the Knowledge, Attitude, and Behaviour (KAB) framework to the issue of injury reporting in adolescents, with the specific purpose of exploring to which degree concussion knowledge, concussion attitudes, and gender affect concussion reporting intentions of both male and female athletes. We recruited 97 young athletes between the ages of 14 and 19 (M = 16.22, SD = 11.06) from the Okanagan Hockey Academy (Canada) and employed a self-administered supervised survey approach to measuring the target variables. A hierarchical multiple regression was conducted, and consistent with the prior literature, females were more likely to report a sport-related concussion than males. It was further found that attitudes around concussions (i.e., taking concussions seriously) were significant predictors of concussion reporting intention. At the same time, there was no significant relationship between concussion knowledge and concussion reporting intention. These results highlight that knowledge about concussion symptoms is insufficient to warrant proper injury reporting. It will therefore be essential to work on changing the attitudes of young athletes regarding the significance of concussions to achieve meaningful behavioural change.

Concussion Evaluation Patterns Among US Adults

OBJECTIVE

The objective of this study was to compare individuals who were not evaluated by a doctor or nurse for a self-reported concussion versus individuals who were evaluated for a concussion by demographic variables, concussion history, and concussion circumstances.

SETTINGS AND PARTICIPANTS

Data were collected from 2018 SpringStyles, a web-based panel survey of US adults 18 years or older ( n = 6427), fielded in March-April.

DESIGN

Cross-sectional.

MAIN MEASURES

Respondents were asked whether they believed they had sustained a concussion in their lifetime and details about their most recent concussion, including whether they were evaluated by a doctor or nurse.

RESULTS

Twenty-seven percent of adults in the survey reported a lifetime concussion ( n = 1835). Among those individuals, 50.4% were not evaluated by a healthcare provider for their most recent concussion. Not being evaluated was higher among individuals whose concussion was caused by a slip, trip, or fall (adjusted prevalence ratio [APR] = 2.22; 95% CI, 1.65-2.99), riding a bicycle (APR = 2.28; 95% CI, 1.58-3.27), being struck by or against something by accident (APR = 2.50; 95% CI, 1.88-3.34), or being struck by or against something during a fight or argument (APR = 2.89; 95% CI, 2.11-3.97), compared with individuals whose concussion was caused by a motor vehicle crash. No evaluation was also higher among individuals whose concussion occurred while engaging in a sports or recreational activity (APR = 1.39; 95% CI, 1.07-1.82) or engaging in regular activities around the house (APR = 1.65; 95% CI, 1.27-2.14), compared with individuals whose concussion occurred while working for pay.

CONCLUSION

More than a quarter of adults reported a lifetime concussion; however, half of them were not evaluated for their last concussion by a healthcare provider. Examination by a healthcare professional for a suspected concussion may prevent or mitigate potential long-term sequelae. Furthermore, current US surveillance methods may underestimate the burden of TBI because many individuals do not seek evaluation.

Putative Concussion Biomarkers Identified in Adolescent Male Athletes Using Targeted Plasma Proteomics

Sport concussions can be difficult to diagnose and if missed, they can expose athletes to greater injury risk and long-lasting neurological disabilities. Discovery of objective biomarkers to aid concussion diagnosis is critical to protecting athlete brain health. To this end, we performed targeted proteomics on plasma obtained from adolescent athletes suffering a sports concussion. A total of 11 concussed male athletes were enrolled at our academic Sport Medicine Concussion Clinic, as well as 24 sex-, age- and activity-matched healthy control subjects. Clinical evaluation was performed and blood was drawn within 72 h of injury. Proximity extension assays were performed for 1,472 plasma proteins; a total of six proteins were considered significantly different between cohorts (P < 0.01; five proteins decreased and one protein increased). Receiver operating characteristic curves on the six individual protein biomarkers identified had areas-under-the-curves (AUCs) for concussion diagnosis ≥0.78; antioxidant 1 copper chaperone (ATOX1; AUC 0.81, P = 0.003), secreted protein acidic and rich in cysteine (SPARC; AUC 0.81, P = 0.004), cluster of differentiation 34 (CD34; AUC 0.79, P = 0.006), polyglutamine binding protein 1 (PQBP1; AUC 0.78, P = 0.008), insulin-like growth factor-binding protein-like 1 (IGFBPL1; AUC 0.78, P = 0.008) and cytosolic 5'-nucleotidase 3A (NT5C3A; AUC 0.78, P = 0.009). Combining three of the protein biomarkers (ATOX1, SPARC and NT5C3A), produced an AUC of 0.98 for concussion diagnoses (P < 0.001; 95% CI: 0.95, 1.00). Despite a paucity of studies on these three identified proteins, the available evidence points to their roles in modulating tissue inflammation and regulating integrity of the cerebral microvasculature. Taken together, our exploratory data suggest that three or less novel proteins, which are amenable to a point-of-care immunoassay, may be future candidate biomarkers for screening adolescent sport concussion. Validation with protein assays is required in larger cohorts.

Multiple Past Concussions in High School Hockey Players: Examining Cognitive Functioning and Symptom Reporting

OBJECTIVE

To investigate (1) if there are meaningful differences in baseline preseason cognitive functioning or symptom reporting between high school ice hockey players with and without prior concussions and (2) determine which health history variables predict symptom reporting.

DESIGN

Cross-sectional study.

SETTING

High schools across the state of Maine.

PARTICIPANTS

Participants were 1616 male high school ice hockey players (mean age = 15.6 years; SD = 1.5 years) who completed baseline testing between 2009 and 2015.

INDEPENDENT VARIABLES

Athletes were grouped according to their self-reported concussion history [0 (n = 1136), 1 (n = 321), 2 (n = 112), or 3+ (n = 47) previous concussions].

MAIN OUTCOME MEASURES

Cognitive functioning was measured by the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery, and symptom ratings were obtained from the Post-Concussion Symptom Scale.

RESULTS

There were no statistically significant differences between groups in cognitive functioning as measured by ImPACT. The group with ≥3 prior concussions endorsed higher total symptom scores, but the effect sizes were small and not statistically significant. In a multivariate model, prior treatment for headaches (not necessarily migraines), prior treatment for a psychiatric condition, and prior treatment for substance/alcohol use all significantly predicted total symptom scores, with concussion history being the weakest independent predictor.

CONCLUSIONS

Players with a history of prior concussions performed similarly to players with no prior concussions on cognitive testing. Health history factors were more strongly associated with symptom reporting than concussion history.

Do Mountain Bikers Know When They Have Had a Concussion and, Do They Know to Stop Riding?

OBJECTIVE

To establish the prevalence of concussions in mountain bikers and to determine factors that increase their risk of concussion. Secondary objectives include determination of whether mountain bikers have undiagnosed concussions, continue to ride after experiencing concussion symptoms, and if they knowingly ride with a broken helmet.

DESIGN

Retrospective survey.

SETTING

Seven-day mountain bike stage race.

PARTICIPANTS

Two hundred nineteen mountain bikers.

MAIN OUTCOME MEASURES

Number of rider concussions diagnosed, number of riders experiencing concussion symptoms without diagnosed concussions, number of riders who continue to ride after experiencing a concussion symptom, and number of riders who rode with a broken helmet.

INDEPENDENT VARIABLES

The independent variables studied included age, gender, nationality, number of times riding in past year, style of riding (cross-country, downhill, or freeride), years mountain biking, years mountain bike racing, whether they are a sponsored cyclist, and whether they also ride a road bike.

RESULTS

Fifteen of 219 mountain bikers (6.9%) had a diagnosed concussion after being hit in the head while mountain biking within the past year, with older riders having a decreased risk [odds ratio (OR), 0.91; P = 0.04], and sponsored riders having a 5-fold increased risk compared with nonsponsored riders (OR, 4.20; P = 0.05). Twenty-eight riders (12.8%) experienced a concussion symptom without being diagnosed with a concussion and 67.5% of the riders who experienced a concussion symptom continued to ride afterward. Overall, 29.2% of riders reported riding with a broken helmet.

CONCLUSIONS

The yearly prevalence of diagnosed concussions in mountain bikers is 6.9%. More than one-third of mountain bikers do not recognize when they have had a concussion and continue riding after experiencing concussion symptoms or with a broken helmet. These behaviors increase their risk of worsening concussion symptoms and acquiring a second injury.

Two Sports, Two Systems, One Goal: A Comparative Study of Concussion Policies and Practices of the Australian Football League and Hockey Canada

Concussion in sport is today regarded as both a public health issue and high profile injury concern in many contact and collision sports. This paper undertakes a comparative review of the current policies and practices of two high profile national sporting organisations of such sports-the Australian Football League (AFL) and Hockey Canada (HC)-in governing the issue as a regulatory concern. By examining the policies and practices of the AFL and HC, this study aims to identify common themes, divergent practices, and nuanced sport-specific approaches to develop understandings on the regulation and governance of this high profile sports injury. The paper aims to contribute to understanding concussion as a regulatory concern, while at the same time recognising the heterogeneity of sport and reinforcing nuanced understandings that align to specific social and cultural settings. We make recommendations based on regulatory and cultural legitimacy. The paper concludes that these NSOs are institutional actors with historical and cultural roots who assert regulatory legitimacy by steering and influencing behaviour and directing the regulatory agenda to manage and mitigate the harm associated with concussion.

A deep neural network approach for sentiment analysis of medically related texts: an analysis of tweets related to concussions in sports

Annually, over three million people in North America suffer concussions. Every age group is susceptible to concussion, but youth involved in sporting activities are particularly vulnerable, with about 6% of all youth suffering a concussion annually. Youth who suffer concussion have also been shown to have higher rates of suicidal ideation, substance and alcohol use, and violent behaviors. A significant body of research over the last decade has led to changes in policies and laws intended to reduce the incidence and burden of concussions. However, it is also clear that youth engaging in high-risk activities like sport often underreport concussion, while others may embellish reports for specific purposes. For such policies and laws to work, they must operate effectively within a facilitative social context so understanding the culture around concussion becomes essential to reducing concussion and its consequences. We present an automated deep neural network approach to analyze tweets with sport-related concussion context to identify the general public's sentiment towards concerns in sport-related concussion. A single-layer and multi-layer convolutional neural networks, Long Short-Term Memory (LSTM) networks, and Bidirectional LSTM were trained to classify the sentiments of the tweets. Afterwards, we train an ensemble model to aggregate the predictions of our networks to provide a final decision of the tweet's sentiment. The system achieves an evaluation F1 score of 62.71% based on Precision and Recall. The trained system is then used to analyze the tweets in the FIFA World Cup 2018 to measure audience reaction to events involving concussion. The neural network system provides an understanding of the culture around concussion through sentiment analysis.

Brain Injury: What Influences the Beliefs U.S. Service Members Have About Reporting and Seeking Care?

INTRODUCTION

Despite the recent Department of Defense emphasis on traumatic brain injury (TBI) education and improvements in treatment, social, and attitudinal beliefs instilled in the military community hinder seeking medical assistance at the time of injury. This survey research presents injury reporting and care seeking behavioral patterns of service members (SMs) stationed in the Landstuhl catchment area in the context of TBI. This descriptive study investigated whether sociocultural factors influence health decision-making among SMs stationed abroad and how these compare to the SMs stationed in Fort Bliss and Fort Hood.

MATERIALS AND METHODS

A total of 969 of U.S. Army, Air Force, and Navy SMs completed a voluntary and anonymous 2- to 5-minute paper survey during the month of March 2019. As a result of illegibility and incompleteness, 15 survey responses were removed from the total sample.

RESULTS

Data analyses show three main findings about SMs in the Landstuhl catchment area: (a) older population (25-34, ≥48%; 18-24, 26.1%; +35, 25.4%) when compared to Fort Hood and Fort Bliss (≥48%; 18-24); (b) more years in service (7-13 years; 30.2%) versus 6 years or less in both Fort Hood and Fort Bliss (≥69%); (c) 54.8% of participants did not think TBI requires care versus 63.5% in both Fort Bliss and Fort Hood.

CONCLUSION

Results suggest that TBI beliefs and influences are constant variables hindering health decision-making choices in the military population. Beliefs about thinking that the injury does not require care, fear to jeopardize the career, and knowledge about TBI and treatments vary among the respondents and all these components influence treatment-seeking behaviors. The findings provide a preliminary framework to further investigate the role of culture in reporting and seeking treatment behaviors among SMs.

Professional footballers have a limited understanding of the precompetition medical assessment and the possible outcomes including disqualification: a cross-sectional survey

Objectives

To determine professional footballers’ level of understanding of the purpose of the precompetition medical assessment (PCMA) and to evaluate their knowledge of potential outcomes following a PCMA, including disqualification.

Methods

Professional footballers from the Australasian A-League and Westfield W-League were asked to complete a 25-question survey. The relationship between dichotomised outcomes and explanatory variables was analysed with multivariate logistic regression; p<0.05 was considered statistically significant.

Results

A total of 212 players participated (response rate=48.8%). Most respondents selected ‘To detect medical conditions that may affect performance’ and ‘To detect current injuries’ (n=137, 64.6%; n=130, 61.3%) as the purpose of a PCMA. Approximately one-third (n=74, 38.1%) were neutral or believed that a normal PCMA prevented cardiac arrest. Receiving more PCMAs (p<0.0003) and receiving an explanation during their PCMA (p=0.0175) led to greater awareness of the assessment’s limitations. Most participants did not know the definitions of syncope (n=181, 93.3%) or Marfan syndrome (n=183, 94.3%). Fifty players (28.1%) did not know that disqualification was a possible outcome of a PCMA, and younger players were less aware of this possible outcome (p=0.0216).

Conclusion

Professional footballers appear to have a limited understanding of the purpose of a PCMA, emphasising the musculoskeletal system and performance. They also appear unfamiliar with the components of the PCMA and medical terms. Finally, many are unaware that disqualification can result from an abnormal PCMA. Player health knowledge must be improved; the informed consent process appears an ideal time to provide this education.

An Examination of Perceived Pressure From Stakeholders on Concussion Reporting Intentions and Behavior in Ice Hockey Athletes

OBJECTIVE

We aimed to assess whether perceived pressure predicts concussion reporting intentions and behavior in youth, high school, and collegiate ice hockey athletes, and, secondarily, whether perceived pressure from stakeholders differed between sex or level of play.

SETTING

Online survey.

PARTICIPANTS

One hundred fifty-two ice hockey athletes (males: n = 96, 63.2%; females: n = 55, 36.2%; missing: n = 1, 0.7%; age = 14.04 ± 3.6 years).

DESIGN

Cross-sectional.

MAIN MEASURES

Respondents answered a survey that elicited information about demography, perceived pressure from 6 stakeholders, and concussion reporting intentions and behavior. For the first aim, we used a generalized linear model to determine whether perceived pressure from any stakeholder predicted intention (symptom reporting, concussion reporting, and intention beliefs) or behavior ("all concussions," "not obvious concussions"; α < .05) while controlling for level of play. To determine whether pressure from any stakeholder predicted symptom reporting behavior, we used logistic regression while controlling for level of play. For the second aim, to examine sex differences in perceived pressure from each stakeholder, we employed Mann-Whitney tests and to examine level of play differences, we used Kruskal-Wallis tests.

RESULTS

Controlling for level of play, a 1-point increase in perceived pressure from parents and athletic administrators decreased concussion reporting intentions by 0.92 (P = .004) and 1.09 (P = .005) points, respectively. Perceived pressure from a sports medicine professional decreased intention beliefs by 0.17 (P = .029) points. Perceived pressure from stakeholders did not predict symptom reporting (P = .440) or "not obvious concussion" reporting (P = .655) behavior. We observed no difference in perceived pressure across stakeholders (all P values >.05); however, collegiate ice hockey respondents perceived greater pressure from coaches than youth or high school athletes (P < .001). We noted no other differences in perceived pressure across levels of play (all P values >.05).

CONCLUSIONS

Concussion reporting intentions were negatively influenced by perceived pressure from parents, athletic administrators, and sports medicine professionals, but these findings did not translate to reporting behavior.

Sensitivity and Specificity of a Multimodal Approach for Concussion Assessment in Youth Athletes

CONTEXT

Current international consensus endorses a multimodal approach to concussion assessment. However, the psychometric evaluation of clinical measures used to identify postconcussion performance deficits once an athlete is asymptomatic remains limited, particularly in the pediatric population.

OBJECTIVE

To describe and compare the sensitivity and specificity of a multimodal assessment battery (balance, cognition, and upper and lower body strength) versus individual clinical measures at discriminating between concussed youth athletes and noninjured controls when asymptomatic.

DESIGN

Prospective cohort study.

SETTING

Hospital laboratory setting.

PARTICIPANTS

A total of 32 youth athletes with a concussion and 32 matched (age and sex) noninjured control participants aged 10-18 years.

INTERVENTION(S)

Participants were administered preinjury (baseline) assessments of cognition (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]), balance (BioSway), and upper and lower body strength (grip strength and standing long jump). Assessments were readministered when concussed participants reported symptom resolution (asymptomatic time point). Noninjured control participants were reassessed using the same time interval as their concussion matched pair. Sensitivity and specificity were calculated using standardized regression-based methods and receiver operating characteristic curves.

MAIN OUTCOME MEASURES

Outcome measures included baseline and postinjury ImPACT, BioSway, grip strength, and standing long jump scores.

RESULTS

When asymptomatic, declines in performance on each individual clinical measure were seen in 3% to 22% of the concussion group (sensitivity = 3%-22%) compared with 3% to 13% of the noninjured control group (specificity = 87%-97%) (90% confidence interval). The multimodal battery of all combined clinical measures yielded a sensitivity of 41% and a specificity of 77% (90% confidence interval). Based on discriminative analyses, the multimodal approach was statistically superior compared with an individual measures approach for balance and upper and lower body strength, but not for cognition.

CONCLUSIONS

Results provide a foundation for understanding which domains of assessment (cognition, balance, and strength) may be sensitive and specific to deficits once symptoms resolve in youth athletes. More work is needed prior to clinical implementation of a preinjury (baseline) to postinjury multimodal approach to assessment following concussion in youth athletes.

Concussion Acutely Decreases Plasma Glycerophospholipids in Adolescent Male Athletes

Concussions are frequent in sports and can contribute to significant and long-lasting neurological disability. Adolescents are particularly susceptible to concussions, with accurate determination of the injury challenging. Our previous study demonstrated that concussion diagnoses could be aided by metabolomics profiling and machine learning, with particular weighting on changes in plasma glycerophospholipids (PCs). Here, our aim was to report directional change of PCs after concussion and develop a diagnostic concussion panel utilizing a minimum number of plasma PCs. To this end, we enrolled 12 concussed male athletes at our academic Sport Medicine Concussion Clinic, as well as 17 sex-, age-, and activity-matched healthy controls. Blood was drawn and 71 plasma PCs were measured for statistically significant changes within 72 h of injury, and individual PCs were further analyzed with receiver operating characteristic (ROC) curves. Our data demonstrated that 26 of 71 PCs measured were significantly decreased after sports-related concussion (p < 0.01). None of the PCs increased in plasma after concussion. ROC curve analyses identified the top four PCs with areas under the curve (AUCs) ≥0.86 for concussion diagnosis: PCaeC36:0 (0.92; p < 0.001); PCaaC42:6 (0.90; p < 0.001); PCaeC36:2 (0.86; p = 0.001), and PCaaC32:0 (0.86; p = 0.001). Cut-off values in μM were ≤0.31, 0.22, 5.07, and 4.63, respectively. Importantly, combining these four PCs produced an AUC of 0.96 for concussion diagnoses (p < 0.001; 95% confidence interval, 0.89, 1.00). Our data suggest that as few as four circulating PCs may provide excellent diagnostic potential for adolescent concussion. External validation is required in larger cohorts.

Concussion Experiences in New England Private Preparatory High School Students Who Played Sports or Recreational Activities

BACKGROUND

Sports- and recreation-related (SRR) activities are a major cause of adolescent concussions. Most adolescent SRR concussion research has been conducted among public school students. As private schools are qualitatively different from public schools (eg, location, socioeconomic status, sports played), this study explores the concussion experiences of a large group of private high school students.

METHODS

We surveyed 2047 New England private preparatory high school students who played sports or engaged in a recreational activity in 2018 about the sports they played, and their self-reported concussion experiences (eg, age at first concussion, if concussions were sports- or recreation-related). Descriptive, bivariate, and multivariate statistics are presented.

RESULTS

One-third (33.0%) of students who reported engaging in sport- or recreation-related activities self-reported experiencing a concussion in their lifetime. A higher percentage of boys, students who played contact sports, and those who played multiple seasons of school sports reported a concussion. Sex, contact level of primary sport played, and age of first concussion were also significantly associated with reporting a sports- or recreation-related concussion.

CONCLUSIONS

A sizeable proportion of private preparatory high school students reported experiencing a concussion, with some students at higher risk. Private preparatory high school-specific concussion prevention strategies may be needed.

A comparison of frequency and magnitude of head impacts between Pee Wee And Bantam youth ice hockey

The purpose of this research was to compare the frequency and magnitude of head impact events between Pee Wee and Bantam ice hockey players. Videos of Pee Wee and Bantam boys' ice hockey were analysed to determine the frequency and type of head impact events. The head impact events were then reconstructed in the laboratory using physical and finite element models to determine the magnitude of strain in the brain tissues. The results showed that Pee Wee boys experienced more head impacts from elbows and boards, while Bantam players had more head impacts to the glass. Pee Wee and Bantam players experienced similar frequency and magnitudes of very low, low, and medium and above (med+) levels of strain to the brain. This research suggests to ice hockey leagues and coaches that to reduce the incidence of these levels of brain trauma, consideration must be given to either reducing the level of contact along the boards or the removal of body checking. In addition, companies who innovate in ice hockey should develop protective devices and equipment strategies that aim to reduce the risk of head injury from shoulder and glass impacts for Bantam players.

A Systematic Review of Barriers and Facilitators for Concussion Reporting Behavior Among Student Athletes

Despite increasing attention to concussion safety, many young athletes still do not report concussion-like symptoms to athletic staff. This systematic review was conducted to identify barriers and facilitators to reporting of concussions by high school and collegiate athletes. The review was conducted using PubMed, SCOPUS, CINAHL Complete, and Cochrane Library. Original research articles were deemed eligible if they contained either qualitative or quantitative data on barriers and facilitators of high school and collegiate athletes self-reporting concussion symptoms to athletic staff. For those articles that met inclusion criteria, both authors critically read each article, summarized reasons given by the authors, and then categorized this information into a barrier or a facilitator of concussion-reporting behavior. Of the 878 articles returned, 24 articles met inclusion criteria. Major facilitators were female sex and younger age. Major barriers were a fear of losing current or future playing time, a misconception that concussive injury is not serious, a fear of letting one's team down, and a lack of knowledge of concussion signs and symptoms. Future interventions should address these issues, incorporate primary and secondary prevention strategies, and emphasize the long-term risks of playing while concussed.

The Epidemiology of Sport-Related Concussion: What the Rehabilitation Clinician Needs to Know

Sport-related concussion is common in full-contact and collision sports. Epidemiology studies use different types of surveillance systems and concussion definitions. Concussion incidence rates vary across age, sex, sport, and level of competition. Incidence rates are increasing, likely due to higher rates of reporting following improved knowledge and increased regulations. In this review, we summarize 7 key concepts related to concussion epidemiology: concussion definition, changes in concussion knowledge, reliability and accuracy of injury surveillance systems, conservative management and return to play, reliability of self-report, incidence of concussion across levels of play, and understanding the behaviors of players, coaches, and medical personnel from a multidisciplinary management perspective. J Orthop Sports Phys Ther 2019;49(11):768-778. doi:10.2519/jospt.2019.9105.

Reporting Skill: The Missing Ingredient in Concussion Reporting Intention Assessment

BACKGROUND

Extant literature suggests that a substantial portion of athletes may not report a possible concussion and that concussion knowledge is insufficient to predict concussion reporting behavior. One area that has not been explored is reporting skill; that is, mastery of the actions required to report a concussion. This study evaluated the relationship between reporting skill and reporting intention, introducing a measure of the reporting skill construct.

HYPOTHESES

Reporting intentions will be more closely associated with reporting skill than with concussion/symptom knowledge. The relationship between concussion (or symptom) knowledge and reporting intentions will differ by level of reporting skill.

STUDY DESIGN

Repeated cross-sectional study.

LEVEL OF EVIDENCE

Level 2.

METHODS

A set of items was administered to young adults aged 18 to 24 years from the Survey Sampling International panel. Exploratory/confirmatory factor analyses were conducted on 2 waves of data to develop the scale (n = 899). Hypotheses were tested using structural equation modeling on the responses from the third wave of participants (n = 406).

RESULTS

Knowing the actions to take in reporting was more important than having knowledge of concussions or concussion symptoms. Reporting skill, not concussion or concussion symptom knowledge, was associated with higher intentions to report symptoms. Among those with higher levels of reporting skill, concussion symptom knowledge (but not general concussion knowledge) was associated with higher intentions to report symptoms.

CONCLUSION

Reporting skill is an important and, until now, missing ingredient in the concussion literature and practice.

CLINICAL RELEVANCE

Incorporating reporting skill development in concussion education and team activities to teach athletes how to report is likely to improve actual reporting intentions. While further study is needed with particular sports and additional age groups, reporting skill holds promise as a new avenue for increased concussion reporting.

Exploring Sex-Based Differences in Concussion Knowledge, Attitudes and Resources in Young First Nations Hockey Players: A Cross-Sectional Survey from Ontario, Canada

Objective:

Indigenous youth are vulnerable to concussion when playing hockey. A clear characterisation of sex differences among Indigenous youth could assist in tailoring future education programmes for prevention and management of concussion. The purpose of this study was to compare and contrast concussion knowledge, attitudes and resources in First Nations girls and boys playing recreational hockey.

Method:

The cross-sectional survey was conducted in partnership with a First Nations’ chief, other Indigenous community leaders and a tertiary care head injury clinic. In Canada, researchers engaging with Indigenous peoples are expected to adhere to principles of Ownership, Control, Access and Possessions. The study included Indigenous boys and girls between the ages of 10 and 18 years of age.

Results:

More girls attending the hockey tournament participated in the study as compared to boys (girlsn= 46, boysn= 29). More girls reported they had never experienced a concussion (73.9%), as compared to boys (58.6%) self-reports. Less than half of all study participants were able to identify some signs and symptoms of concussion such as vomiting/nausea, memory problems, fatigue and blurred vision and recognition of several concussion symptoms varied by sex.

Conclusions:

We created a unique partnership between Indigenous leaders and tertiary care clinic staff. Among Indigenous youth reasons for not reporting concussion symptoms to the coach varied by sex (although not reaching statistical significance), suggesting concussion education warrants tailoring for girls and boys.

Medical assessment of potential concussion in elite football: video analysis of the 2016 UEFA European championship

OBJECTIVE

The objective is to determine if suspected concussions in elite football are medically assessed according to the International Conferences on Concussion in Sport consensus statement recommendations.

SETTING

Men's Union of European Football Association (UEFA) Football Championship.

PARTICIPANTS

All professional football players in the UEFA 2016 Championship Tournament.

DESIGN

Observational study.

OUTCOME MEASURES

Potential concussive events (PCEs) were defined as direct head collision incidents resulting in the athlete being unable to immediately resume play following impact. PCEs identified and description of PCE assessment and outcome were accomplished through direct standardised observation of video footage by trained observers in 51 games played in the Men's UEFA European Championship (10 June-10 July 2016).

RESULTS

Sixty-nine total PCEs (1.35 per match) were identified in 51 games played during the 2016 Men's UEFA European Championship. Forty-eight PCEs (69.6%) resulted in two observable signs of concussion, 13 (18.8%) resulted in three signs and 1 (1.4%) resulted in four signs in the injured athletes. Nineteen (27.5%) PCEs were medically assessed by sideline healthcare personnel while 50 (72.5%) were not. Of the 50 PCEs that were not medically assessed, 44 (88%) PCEs resulted in two or more signs of concussion among injured athletes. Of the 19 medically assessed PCEs, 8 resulted in 3 signs of concussion, and 1 resulted in 4 signs; all assessments concluded in the same-game return for the injured athletes.

CONCLUSIONS

PCEs were frequent events in the 2016 UEFA Euro championship, but were rarely assessed concordant with the International Conferences on Concussion in Sport consensus statement recommendations. There is an imperative need to improve the assessment and management of players suspected of concussion in elite football.

Health-related quality of life following adolescent sports-related concussion or fracture: a prospective cohort study

OBJECTIVE

The longitudinal effects of sports-related concussion (SRC) in adolescents on health-related quality of life (HRQOL) remain poorly understood. Hence, the authors established two objectives of this study: 1) compare HRQOL outcomes among adolescents with an acute SRC or a sports-related extremity fracture (SREF) who were followed up until physician-documented clinical recovery; and 2) identify the clinical variables associated with worse HRQOL among adolescent SRC patients.

METHODS

The authors conducted a prospective cohort study of adolescents with acute SRC and those with acute SREF who underwent clinical assessment and follow-up at tertiary subspecialty clinics. Longitudinal patient-reported HRQOL was measured at the time of initial assessment and at each follow-up appointment by using the adolescent version (age 13-18 years) of the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale and Cognitive Functioning Scale.

RESULTS

A total of 135 patients with SRC (60.0% male; mean age 14.7 years; time from injury to initial assessment 6 days) and 96 patients with SREF (59.4% male; mean age 14.1 years; time from injury to initial assessment 8 days) participated in the study. At the initial assessment, the SRC patients demonstrated significantly worse cognitive HRQOL and clinically meaningful impairments in school and overall HRQOL compared to the SREF patients. Clinical variables associated with a worse HRQOL among SRC patients differed by domain but were significantly affected by the patients' initial symptom burden and the development of delayed physician-documented clinical recovery (> 28 days postinjury). No persistent impairments in HRQOL were observed among SRC patients who were followed up until physician-documented clinical recovery.

CONCLUSIONS

Adolescent SRC is associated with temporary impairments in HRQOL that have been shown to resolve in patients who are followed up until physician-documented clinical recovery. Future studies are needed to identify the clinicopathological features that are associated with impaired HRQOL and to assess whether the initiation of multidisciplinary, targeted rehabilitation strategies would lead to an improvement in HRQOL.

Staying true to Rowan's Law: how changing sport culture can realize the goal of the legislation

Rowan's Law was recently introduced into Ontario legislation following the death of Rowan Stringer, a young rugby player for whom a string of head injuries culminated in her death. The law mandates the removal from play of any youth athlete suspected to have a concussion and makes concussion education mandatory for certain individuals involved with youth sport. This commentary addresses the larger issues within sport culture that may limit the effectiveness of the law, and describes how awareness alone is not sufficient to generate change. The law can sometimes lead to a false sense of security, as well as retaliatory actions for those who are motivated to hide concussion. We describe the role of all persons involved with youth sport in facilitating a cultural shift to honour the intent behind Rowan's Law.

Concussion, Cagney, Captains of the Clouds

The case of James Cagney adds interesting details to the history of concussion. It is underappreciated that a movie-star of Cagney's stature incurred multiple concussions over many years. Moreover, the fact that he sustained one of these concussions in Canada while filming Captains of the Clouds, a major Hollywood film, is essentially unknown, and was seldom discussed by Cagney despite his willingness to discuss his many other concussions. The scene showing this concussion was left in the final released version of the movie, making it one of the earliest filmed concussions and the first concussion ever filmed in Technicolor.

Knowledge, Attitudes and Concussion Information Sources Among First Nations in Ontario

OBJECTIVE

Hockey is a popular sport played by many First Nation youth. Concussion frequently goes unrecognized and unreported in youth hockey. Unintentional injuries among Indigenous youth occur at rates three to four times the national Canadian average. The study sought to examine knowledge, attitudes and sources of concussion information among First Nations people attending a provincial hockey tournament.

METHODS

A cross-sectional survey was undertaken. The survey by Mzazik et al. were modified to use in this study. Participants included youth (6-18 years) hockey players (n=75), parents (n=248) and coaches (n=68). The main outcome measure was total knowledge index (TKI) which consisted of the sum of correct responses to 15 multiple choice questions. Additional data gathered included demographics, concussion history, attitudes toward concussion and sources of information. Descriptive statistics included proportion comparisons. Variables were tested using χ 2 and analysis of variance.

RESULTS

Overall TKI scores (out of a total of 15) were low; players (5.9±2.8), parents (7.5±2.6) and coaches (7.9±2.6). Participants with higher knowledge scores reported more appreciation of the seriousness of concussion. Sources of information about concussion differed by study group, suggesting the need for multiple knowledge translation strategies to reach youth, parents and coaches.

CONCLUSIONS

Future initiatives are urgently needed to improve education and prevention of concussion in First Nations youth hockey. Collaborating and engaging with communities can help to ensure an Indigenous lens for culturally safe interventions.

Twitter and traumatic brain injury: A content and sentiment analysis of tweets pertaining to sport-related brain injury

Objectives:

Sport-related traumatic brain injuries are a significant public health burden, with hundreds of thousands sustained annually in North America. While sports offer numerous physical and social health benefits, traumatic brain injuries such as concussion can seriously impact a player’s life, athletic career, and sport enjoyment. The culture in many sports encourages winning at all costs, placing athletes at risk for traumatic brain injuries. As social media has become a central part of everyday life, the content of users’ messages often reflects the prevailing culture related to a particular event or health issue.

Methods:

We hypothesized that Twitter data might be useful for understanding public perceptions and misperceptions of sport-related traumatic brain injuries. We performed a content and sentiment analysis of 7483 Twitter^® tweets related to traumatic brain injuries in sports collected during June and July 2013.

Results:

We identified five major themes. Users tweeted about personal traumatic brain injuries experiences, reported traumatic brain injuries in professional athletes, shared research about sport-related concussions, and discussed policy and safety in injury prevention, such as helmet use. We identified mixed perceptions of and sentiment toward traumatic brain injuries in sports: both an understanding that brain injuries are serious and disregard for activities that might reduce the public burden of traumatic brain injuries were prevalent in our Twitter analysis.

Conclusion:

While the scientific and medical community considers a concussion a form of traumatic brain injuries, our study demonstrates a misunderstanding of this fact among the public. In our current digital age, social media can provide useful insight into the culture around a health issue, facilitating implementation of prevention and treatment strategies.

Assessment of Head Collision Events During the 2014 FIFA World Cup Tournament

This study uses video footage observations of all 64 matches of the 2014 FIFA World Cup to assess the incidence, characteristics, and sideline outcome assessments of player head collisions.

Cross-sectional examination of the association of co-occurring alcohol misuse and traumatic brain injury on mental health and conduct problems in adolescents in Ontario, Canada

OBJECTIVE

This study describes the impact of traumatic brain injury (TBI) and hazardous drinking on mental health and behavioural issues among Ontario adolescents. In particular, we assessed the incremental co-occurrence of hazardous drinking with a history of TBI, in comparison to experiencing just one of these conditions.

METHODS

A cross-sectional subsample of 3130 Ontario adolescents attending grades 9-12, and aged 10-21 were surveyed in 2013 as a part of the Centre for Addiction and Mental Health's Ontario Student Drug Use and Health Survey. Recent (past year) and former (lifetime and excluding the last year) TBI were defined as trauma to the head that resulted in loss of consciousness for at least 5 min or overnight hospitalisation. Current hazardous drinking was derived using the Alcohol Use Disorders Identification Test (AUDIT).

RESULTS

An estimated 11.8% of Ontario adolescents (95% CI 10.1% to 13.8%) reported a history of former TBI and were not hazardous drinkers; 4.0% (95% CI 2.9% to 5.5%) reported recent TBI and were not hazardous drinkers; 13.7% (95% CI 12.3% to 15.3%) were hazardous drinkers who never had a TBI; 4.1% (95% CI 2.9% to 5.8%) had former TBI with co-occurring hazardous drinking; and 2.2% (95% CI 1.6% to 3.0%) had recent TBI with co-occurring hazardous drinking. Most odds increased significantly and were two to three times higher for reporting compromised mental health, violent and non-violent conduct behaviours, and reported victimisation for classifying as a hazardous drinker at the time of testing with co-occurring either former or recent TBI compared to classifying as not having either of these conditions. Adolescents classified as hazardous drinkers with former TBI had numerous and higher ORs for conduct behaviours than those with recent TBI.

CONCLUSIONS

Results emphasise the strong interplay between TBI and hazardous drinking and point to the need for integrating prevention efforts to reduce these conditions and their co-occurrence among adolescents.