Length of Recovery From Sports-Related Concussions in Pediatric Patients Treated at Concussion Clinics

Follow-up visits after pediatric concussion and the factors associated with early follow-up: a population-based study in British Columbia

OBJECTIVES

To explore the rates and timing of a first follow-up visit for children and adolescents with a concussive injury and to identify factors associated with follow-up timing.

METHODS

A descriptive, correlational design drawing on linked, population-based administrative data of concussed children and adolescents (ages 5-18 years) from the province of British Columbia (BC), Canada. Data were accessed through Population Data BC. Descriptive statistics and binary logistic regression were used to analyze the data.

RESULTS

From January 1, 2016 to December 31, 2017, we retrieved 22,601 cases of concussion, of which 19% had an early follow-up visit (N = 4,294), 4.9% had later follow-up (N = 1,107), and 76.1% had no follow-up (N = 17,200). The factors of older age, living in a rural area, higher socioeconomic status, and seeing a specialist physician at an initial concussion diagnosis were more likely to have an early follow-up visit.

CONCLUSION

Early follow-up is important for recovery, but most children and adolescents with a concussion do not receive follow-up in BC.

The prevalence of Black/African American individuals in concussion literature: a systematic review and meta-analysis

Introduction

Comprising approximately 13.6% of the United States population, Black/African American individuals are overrepresented in sports associated with a high risk of concussion. However, there has been a notable absence of systematic reviews examining whether concussion literature accurately reflects the participation and experiences of Black/African American individuals. Therefore, this study aims to systematically review the prevalence of Black/African American individuals compared to White individuals diagnosed with concussions in the literature.

Methods

A systematic search was performed across four electronic databases: PubMed, MEDLINE (Ovid), Scopus and Web of Science. Articles were searched from inception to January 5, 2022. Prevalence data were extracted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis of proportions was conducted within hospital records and national survey data.

Results

Among 447 identified studies, 11 were included, representing 1,839,901 individuals diagnosed with a concussion, with 73.6% identifying as White and 12.5% identifying as Black/African American. The mean proportion of Black/African American diagnosed with a concussion in hospital records (13.9%; 95% CI [12.8, 15.1]) exceeded that in national surveys (6.4%; 95% CI [3.5, 11.3]) but lower than sports-centered studies (16%).

Discussion

These findings underscore the need to address racial disparities in healthcare within the broader context of social determinants of health and systemic inequities. By identifying gaps in the current research, this study lays the foundation for future investigation aimed at elucidating and addressing healthcare disparities.

The role of concussion history and biological sex on baseline concussion clinical profile symptoms in adolescent rugby players

BACKGROUND

Accurate concussion monitoring requires access to preinjury baseline data. This is particularly important in adolescent athletes who have a high risk of concussion and are prone to prolonged recovery. As Rugby Union is governed by similar laws for men and women, it is also an ideal population to rigorously examine the impact of biological sex on concussion symptoms.

AIMS

To evaluate self-reported concussion symptoms at baseline in adolescent rugby union players, and examine if subtype-specific symptoms are affected by concussion history and biological sex.

METHODS

Adolescent rugby union players aged 16-18 years were recruited during the 2022-2023 playing season. Participants completed a series of questionnaires covering post-concussion symptoms, concussion clinical profiles, anxiety, depression and fear avoidance behaviours. Independent variables of interest in analysis were biological sex and concussion history.

RESULTS

149 participants (75% male) were included. 42% (63/149) reported at least one previous concussion (average time since concussion: 18.7 months, range 1-72). Adolescents with a concussion history reported significantly higher scores than those with no history, across two clinical profiles (ocular and sleep), concussion symptom severity, and depression, all based on medium effect sizes (SMD 0.3-0.5). Females had significantly higher scores across cognitive/fatigue, ocular and sleep clinical profiles, concussion symptoms, anxiety and depression, each with large effect sizes (SMD > 0.5).

CONCLUSIONS

Concussion history and sex are associated with higher baseline scores on specific concussion clinical profile, concussion symptom severity, and anxiety symptoms. These findings highlight the importance of considering baseline differences when interpreting post-injury clinical profile symptoms in adolescent rugby players. (Trial registration: ACTRN12622000931774).

'Do it afraid': An arts-based reflexive collective case study exploring youth responses to post-concussion communication changes in daily life

BACKGROUND

Concussion and communication researchers have yet to study how post-concussion communication changes affect youths' daily lives. The lack of attention paid to how young people respond to communication changes during concussion recovery constitutes a significant gap in current concussion management research and practices.

AIMS

To explore how youth respond to the effects of post-concussion communication changes in their daily life, including (1) daily routines, (2) relationships with family members, (3) relationships with peers and (4) participation in school/work and community activities.

METHODS & PROCEDURES

Five youths (16-25 years) and three family members participated in this arts-based reflexive collective case study. Ecocultural theory provided the theoretical framework for study design, data collection and analysis. Cases consist of (1) pre-interview demographic information, (2) three 60-90-min virtual interviews, (3) optional family member interviews, (4) multi-media arts-based participant-generated materials representing participants' experiences of communication change and concussion, and (5) researcher observations, discussions and reflexive journal entries. Reflexive thematic analysis was used to analyse the data.

OUTCOMES & RESULTS

Analysis yielded four themes that illustrate the ways youth navigated and adapted to post-concussion communication changes: (1) navigating changes in communication tasks, daily roles, and identity; (2) re-negotiating relationships and emotional reactions; (3) seeking control and learning to let go during recovery; and (4) helping youth adapt to post-concussion communication changes.

CONCLUSIONS & IMPLICATIONS

The study findings deepen our understanding of the impact of post-concussion communication changes on youths' daily lives and underscore considerations critical to the development of communication-focused concussion education programs and interventions tailored specifically for youth.

WHAT THIS PAPER ADDS

What is already known on the subject Youth is a critical period of social and emotional development. Communication is integral to identity, relationships, participation in daily activities and well-being. Concussions can affect speech clarity, fluency, understanding and use of language, and social interactions. Re-engaging in routine activities and pre-injury roles can be challenging for youth experiencing communication changes as part of complex concussion recoveries. What this paper adds to the existing knowledge Findings from this research illuminate how youth navigate and adapt to communication changes post-concussion and support the development of youth-focused communication education programs, assessments and interventions. Youth participants actively managed their recoveries by developing innovative strategies to support their communication during daily activities, learning about communication, practicing communication tasks sequentially, and facing fears. Youth also reframed and challenged narrow views of 'normal communication'. What are the potential or actual clinical implications of this work? Findings highlight the need for more youth- and communication-focused education materials and programs within youth concussion management protocols. Information about the specific ecological and sociocultural factors youth encounter during concussion recovery is needed to develop targeted communication-focused education and intervention programs for youth and their families to mitigate risks of isolation, loneliness, and mental health concerns and increase youths' participation in family, community and cultural life. By learning from youth about how communication changes affected their participation in daily activities, identity and relationships, clinicians can provide information and interventions to reduce adverse listener reactions and help young people feel supported and understood.

Response Rate Patterns in Adolescents With Concussion Using Mobile Health and Remote Patient Monitoring: Observational Study

Background

A concussion is a common adolescent injury that can result in a constellation of symptoms, negatively affecting academic performance, neurobiological development, and quality of life. Mobile health (mHealth) technologies, such as apps for patients to report symptoms or wearables to measure physiological metrics like heart rate, have been shown to be promising in health maintenance. However, there is limited evidence about mHealth engagement in adolescents with a concussion during their recovery course.

Objective

This study aims to determine the response rate and response rate patterns in concussed adolescents reporting their daily symptoms through mHealth technology. It will also examine the effect of time-, demographic-, and injury-related characteristics on response rate patterns.

Methods

Participants aged between 11-18 years (median days since injury at enrollment: 11 days) were recruited from the concussion program of a tertiary care academic medical center and a suburban school's athletic teams. They were asked to report their daily symptoms using a mobile app. Participants were prompted to complete the Post-Concussion Symptom Inventory (PCSI) 3 times (ie, morning, afternoon, and evening) per day for 4 weeks following enrollment. The primary outcome was the response rate pattern over time (by day since initial app use and the day since injury). Time-, demographic-, and injury-related differences in reporting behaviors were compared using Mann Whitney U tests.

Results

A total of 56 participants were enrolled (mean age 15.3, SD 1.9 years; n=32, 57% female). The median response rate across all days of app use in the evening was 37.0% (IQR 27.2%-46.4%), which was significantly higher than the morning (21.2%, IQR 15.6%-30.5%) or afternoon (26.4%, IQR 21.1%-31.5%; P<.001). The median daily response was significantly different by sex (female: 53.8%, IQR 46.2%-64.2% vs male: 42.0%, IQR 28.6%-51.1%; P=.003), days since injury to app use (participants starting to use the app >7 days since injury: 54.1%, IQR 47.4%-62.2% vs starting to use the app ≤7 days since injury: 38.0%, IQR 26.0%-53.3%; P=.002), and concussion history (participants with a history of at least one prior concussion: 57.4%, IQR 44.5%-70.5% vs participants without concussion history: 42.3%, IQR 36.8%-53.5%; P=.03). There were no significant differences by age. Differences by injury mechanism (sports- and recreation-related injury: 39.6%, IQR 36.1%-50.4% vs non-sports- or recreation-related injury: 30.6%, IQR 20.0%-42.9%; P=.04) and initial symptom burden (PCSI scores greater than the median score of 47: 40.9%, IQR 35.2%-53.8% vs PCSI scores less than or equal to the median score: 31.9%, IQR 24.6%-40.6%; P=.04) were evident in the evening response rates; however, daily rates were not statistically different.

Conclusions

Evening may be the optimal time to prompt for daily concussion symptom assessment among concussed adolescents compared with morning or afternoon. Multiple demographic- and injury-related characteristics were associated with higher daily response rates, including for female participants, those with more than 1 week from injury to beginning mHealth monitoring, and those with a history of at least one previous concussion. Future studies may consider incentive strategies or adaptive digital concussion assessments to increase response rates in populations with low engagement.

Reduced Concussion Symptom Burden in Early Adolescent Athletes Using a Head-Neck Cooling Device

OBJECTIVE

To determine whether an investigational head-neck cooling device, Pro2cool, can better reduce symptom severity compared with standard postconcussion care in early adolescent athletes after a sports-related concussion.

DESIGN

Prospective, longitudinal, randomized trial design conducted over a 28-day period.

SETTING

Six pediatric medical centers in Ohio and Michigan.

PARTICIPANTS

The study enrolled 167 male and female 12- to 19-year-old athletes who experienced a sports-related concussion within 8 days of study enrollment and registering a Sports Concussion Assessment Tool 5 (SCAT5) composite score >7.

INTERVENTIONS

Pro2cool, an investigational head-neck cooling therapy device, was applied at 2 postinjury time points compared with postconcussion standard of care only.

MAIN OUTCOME MEASURES

Baseline SCAT5 composite symptom severity scores were determined for all subjects. Sports Concussion Assessment Tool 5 scores for concussed athletes receiving cooling treatment were analyzed across 6 independent postenrollment time points compared with subjects who did not receive cooling therapy and only standard care. Adverse reactions and participate demographics were also compared.

RESULTS

Athletes who received Pro2cool cooling therapy (n = 79) experienced a 14.4% greater reduction in SCAT5 symptom severity scores at the initial visit posttreatment, a 25.5% greater reduction at the 72-hour visit posttreatment, and a 3.4% greater reduction at the 10-day visit compared with subjects receiving only standard care (n = 88). Overall, 36 adverse events (increased blood pressure, decreased pulse, and dizziness) were reported, with 13 events associated with the device, of which 3 were classified as moderate in severity.

CONCLUSIONS

This study demonstrates the efficacy and safety of head and neck cooling for the management of concussion symptoms in adolescent athletes of an age group for which little to no prior data are available.

Athletic Fear Avoidance in Athletes Receiving Rehabilitation for Sport-Related Concussion: A Preliminary Study

BACKGROUND

Fear avoidance after musculoskeletal injury is avoiding activity due to fear of pain and contributes to persistent symptoms, depression, and disability. Little is known about fear avoidance for sport (athletic fear avoidance) in athletes with sport-related concussion (SRC).

HYPOTHESIS

Athletic fear avoidance after SRC would be elevated at the start of rehabilitation, improve over time, and be associated with postconcussion recovery outcomes.

STUDY DESIGN

Observational study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Athletes in rehabilitation after SRC participated. Testing at initial and discharge visits and 6-month follow-up included Athletic Fear Avoidance Questionnaire (AFAQ), Postconcussion Symptom Scale (PCSS), Profile of Mood States (POMS), and Dizziness Handicap Inventory (DHI). Differences were explored in AFAQ score at initial testing based on sex or age (<18 or ≥18 years). Change in questionnaire scores over time was examined. Association of AFAQ score with other questionnaire scores was determined at each timepoint.

RESULTS

A total of 48 athletes participated: 28 completed initial testing only (INITIAL ONLY), and 20 completed all testing (LONGITUDINAL). Across cohorts, the mean (SD) AFAQ score at initial testing was 24.3 (7.6) points, with no significant difference by sex or age. AFAQ, PCSS, POMS, and DHI scores improved in LONGITUDINAL; the effect size was large from initial to discharge testing (1.0, 1.0, 1.0, and 1.2, respectively) and variable from discharge to follow-up testing (0.52, -0.34, -0.08, and 0.02, respectively). AFAQ scores increased from discharge to follow-up in 3 athletes and were consistently above the mean value in 2 athletes. AFAQ score was significantly correlated to the other questionnaire scores at each timepoint (range, r = 0.36-0.75).

CONCLUSION

Athletic fear avoidance was elevated at the start of SRC rehabilitation, improved over time in most patients, and was associated with postconcussion symptoms, mood, and disability.

CLINICAL RELEVANCE

Athletic fear avoidance may impact recovery after SRC.

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

OBJECTIVE

To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion.

DESIGN

Prospective cohort study, Safe to Play (2013-2018).

SETTING

Youth hockey leagues in Alberta and British Columbia, Canada.

PARTICIPANTS

Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions.

INDEPENDENT VARIABLES

Psychosocial variables.

MAIN OUTCOME MEASURES

Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit.

RESULTS

Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery.

CONCLUSIONS

Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

Association between days for concussion recovery and initial specialty clinic evaluation within 48 hours

BACKGROUND

Researchers have highlighted the importance of early access to concussion care within one week of injury in reducing recovery times. However, a persisting question for concussion researchers is "just how early is important?" The purpose of this study was to examine differences in recovery time as predicted by the number of days elapsed since injury (DSI) to initial evaluation among patients who had access to a specialty concussion clinic within seven days. We hypothesized that DSI group membership, even within seven days, would significantly predict risk of protracted recovery (i.e., beyond 21 days).

METHODS

In this archival study, retrospective data were gathered from electronic medical records between September 2020 to March 2022. Records of participants between ages 12-18, those diagnosed with a sports-related concussion based on initial clinic visit diagnosis by a medical provider and those who established care within seven days of injury at a large pediatric specialty concussion clinic were examined. Participants were divided into three DSI groups (patients seen in < 48 h: "acute", patients seen between 49 h < and < 96 h: "sub-acute", and patients seen between 97 < and < 168 h: "post-acute"). A general linear model was constructed to examine relationships between relevant concussion factors (e.g., Post Concussion Scale Score, neurodevelopmental history, psychiatric history, concussion history, migraine history, overall VOMS change score, cognitive testing, sex, age, race, and ethnicity) that were either significant in the preliminary analysis or in clinical judgement and recovery time. Adjusted odds ratios (OR) were derived from a binary logistic regression model, in which recovery time was normal (≤ 21 recovery days) or protracted (> 21 recovery days).

RESULTS

A total of 856 participants were eligible. Adolescents in the acute group (M = 15.12, SD = 8.04) had shorter recovery times in days compared to those in the sub-acute (M = 17.98, SD = 10.18) and post-acute (M = 21.12, SD = 10.12; F = 26.00, p < .001) groups. Further, participants in the acute (OR = 4.16) and sub-acute (OR = 1.37) groups who accessed specialty concussion clinics within 48 h were 4 times more likely to have a normal recovery and recovered approximately 6 days faster than the post-acute care group.

CONCLUSIONS

Earlier concussion care access predicted recovery times and was associated with lower risk for protracted recovery.

The Role of Puberty and Sex on Brain Structure in Adolescents With Anxiety Following Concussion

BACKGROUND

Adolescence represents a window of vulnerability for developing psychological symptoms following concussion, especially in girls. Concussion-related lesions in emotion regulation circuits may help explain these symptoms. However, the contribution of sex and pubertal maturation remains unclear. Using the neurite density index (NDI) in emotion regulation tracts (left/right cingulum bundle [CB], forceps minor [FMIN], and left/right uncinate fasciculus), we sought to elucidate these relationships.

METHODS

No adolescent had a history of anxiety and/or depression. The Screen for Child Anxiety Related Emotional Disorders and Children's Depression Rating Scale were used at scan to assess anxiety and depressive symptoms in 55 concussed adolescents (41.8% girls) and 50 control adolescents with no current/history of concussion (44% girls). We evaluated if a mediation-moderation model including the NDI (mediation) and sex or pubertal status (moderation) could help explain this relationship.

RESULTS

Relative to control adolescents, concussed adolescents showed higher anxiety (p = .003) and lower NDI, with those at more advanced pubertal maturation showing greater abnormalities in 4 clusters: the left CB frontal (p = .002), right CB frontal (p = .011), FMIN left-sided (p = .003), and FMIN right-sided (p = .003). Across all concussed adolescents, lower NDI in the left CB frontal and FMIN left-sided clusters partially mediated the association between concussion and anxiety, with the CB being specific to female adolescents. These effects did not explain depressive symptoms.

CONCLUSIONS

Our findings indicate that lower NDI in the CB and FMIN may help explain anxiety following concussion and that adolescents at more advanced (vs less advanced) status of pubertal maturation may be more vulnerable to concussion-related injuries, especially in girls.

Can the Buffalo Concussion Treadmill Test Be Used as a Prognostic Indicator for Patients With Sport-Related Mild Traumatic Brain Injury?

OBJECTIVE

To establish whether time to exercise cessation using the Buffalo Concussion Treadmill Test (BCTT) protocol can be used as a prognostic indicator of recovery after sport-related mild traumatic brain injury (SR-mTBI).

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Specialist Concussion Clinic.

PARTICIPANTS

Three hundred and twenty one patients presenting between 2017 and 2019 who underwent BCTT for SR-mTBI.

INTERVENTIONS

Participants who remained symptomatic at a 2-week follow-up appointment after SR-mTBI underwent BCTT to develop a progressive subsymptom threshold exercise program with fortnightly follow-up until clinical recovery.

MAIN OUTCOME MEASURES

Clinical recovery was the primary outcome measure.

RESULTS

A total of 321 participants were eligible to participate in this study (mean age 22.94% and 46% female). The BCTT test duration was divided into 4-minute intervals and those who completed full 20 minutes. There was higher probability of clinical recovery in those who finished the entire 20-minute BCTT protocol compared with those who managed 17-<20 minutes (Hazard Ratio, HR 0.57), 13 to 16 minutes (HR 0.53), 9 to 12 minutes (HR 0.6), 5 to 8 minutes (HR 0.4), and 1 to 4 minutes (HR 0.7), respectively. Those seen earlier after injury ( P = 0.009), male patients ( P = 0.116), younger patients ( P = 0.0003), and those with physiological or cervical dominant ( P = 0.416) symptom clusters were more likely to achieve clinical recovery. Fifty percent of those who completed the full BCTT protocol achieved clinical recovery at day 19 post-injury.

CONCLUSIONS

The group completing full 20 minutes of BCTT achieved clinical recovery more quickly than those who did not complete full BCTT.

Trajectories of Daily Postconcussion Symptoms in Children

OBJECTIVES

To identify trajectories of daily postconcussion symptoms (PCS) from the acute postinjury period to symptom resolution among concussed children and examine demographic factors and acute PCS associated with the identified symptom trajectories.

SETTING AND PARTICIPANTS

Seventy-nine participants with a concussion were enrolled within 72 hours of injury and completed a daily survey that assessed PCS from enrollment until symptom resolution.

DESIGN

This was a prospective cohort study among concussed children aged 11-17 years.

MAIN MEASURES

Children rated their concussion symptoms daily using the Post-Concussion Symptom Scale. Symptom duration was assessed using participants' date of symptom resolution and coded as a dichotomous variable: (1) PCS duration 14 days or less or (2) PCS duration longer than 14 days.

RESULTS

Of the 79 participants, most were male ( n = 53, 67%), injured during a sporting activity ( n = 67, 85%), or had PCS that persisted for more than 14 days post-injury ( n = 41, 52%). Group-based trajectory modeling yielded 4 trajectory groups: (1) low acute/resolved PCS ( n = 39, 49%), (2) moderate/persistent PCS ( n = 19, 24%), (3) high acute/persistent PCS ( n = 13, 16%), and (4) high acute/resolved PCS ( n = 8, 10%). No significant associations were found between demographic factors and the trajectory group. A higher symptom burden at injury was associated with an increased odds of being in the high acute/resolved or high acute/persistent recovery groups than being in the low acute/resolved group (odds ratio [OR] 1.39, 95% CI = 1.11-1.74; OR = 1.33, 95% CI = 1.11-1.60, respectively), as was a higher symptom severity at injury (OR = 1.09, 95% CI = 1.03-1.15; OR = 1.06, 95% CI = 1.02-1.11, respectively).

CONCLUSION

Our findings may help clinicians identify concussed children on slower recovery trajectories, and implement early, individualized treatment plans that foster optimal recovery for concussed children.

Changes in Physician Recommendations for Early Physical Activity After Pediatric Concussion: A Retrospective Study

OBJECTIVES

This study aimed to analyze changes in physical activity (PA) recommendations after pediatric concussions and examine the associations of patient and injury characteristics with physicians' PA recommendations.

DESIGN

Retrospective observational study.

SETTING

Concussion clinics associated with a pediatric hospital.

PATIENTS

Patients aged 10 to 18 years with a concussion diagnosis, presenting to the concussion clinic within 14 days of the injury were included. A total of 4727 pediatric concussions and corresponding 4727 discharge instructions were analyzed.

INDEPENDENT VARIABLES

The independent variables for our study were time, injury characteristics (eg, mechanism and symptom scores), and patient characteristics (eg, demographics and comorbidities).

MAIN OUTCOME MEASURES

Physician PA recommendations.

RESULTS

From 2012 to 2019, the proportion of physicians recommending light activity at an initial visit increased from 11.1% to 52.6% ( P < 0.05) within 1-week postinjury and from 16.9% to 64.0% during the second week postinjury ( P < 0.05). A significantly increased odds of recommending "light activity" (odds ratio [OR] = 1.82, 95% confidence interval [CI], 1.39-2.40) and "noncontact PA" (OR = 2.21, 95% CI, 1.28-2.05), compared with "no activity" within 1-week postinjury, was observed in each consecutive year. In addition, higher symptom scores at the initial visit were associated with lower likelihood of recommending "light activity" or "noncontact PA."

CONCLUSIONS

Physician recommendation of early, symptom-limited PA after a pediatric concussion has increased since 2012, which mirrors a shift in acute concussion management. Further research assessing how these PA recommendations may facilitate pediatric concussion recovery is warranted.

Longitudinal, prospective study of head impacts in male high school football players

INTRODUCTION

Repetitive, subconcussive events may adversely affect the brain and cognition during sensitive periods of development. Prevention of neurocognitive consequences of concussion in high school football is therefore an important public health priority. We aimed to identify the player positions and demographic, behavioral, cognitive, and impact characteristics that predict the frequency and acceleration of head impacts in high school football players.

METHODS

In this prospective study, three cohorts of adolescent male athletes (N = 53, 28.3% Hispanic) were recruited over three successive seasons in a high school American football program. Demographic and cognitive functioning were assessed at baseline prior to participating in football. Helmet sensors recorded impact frequency and acceleration. Each head impact was captured on film from five different angles. Research staff verified and characterized on-field impacts. Player-level Poisson regressions and year-level and impact-level linear mixed-effect models were used to determine demographic, behavioral, cognitive, and impact characteristics as predictors of impact frequency and acceleration.

RESULTS

4,678 valid impacts were recorded. Impact frequency positively associated with baseline symptoms of hyperactivity-impulsivity [β(SE) = 1.05 impacts per year per unit of symptom severity (1.00), p = 0.01] and inattentiveness [β(SE) = 1.003 impacts per year per T-score unit (1.001), p = 0.01]. Compared to quarterbacks, the highest acceleration impacts were sustained by kickers/punters [β(SE) = 21.5 g's higher (7.1), p = 0.002], kick/punt returners [β(SE) = 9.3 g's higher (4.4), p = 0.03], and defensive backs [β(SE) = 4.9 g's higher (2.5), p = 0.05]. Impacts were more frequent in the second [β(SE) = 33.4 impacts (14.2), p = 0.02)] and third [β(SE) = 50.9 impacts (20.1), p = 0.01] year of play. Acceleration was highest in top-of-the-head impacts [β(SE) = 4.4 g's higher (0.8), p<0.001].

CONCLUSION

Including screening questions for Attention-Deficit/Hyperactivity Disorder in pre-participation evaluations can help identify a subset of prospective football players who may be at risk for increased head impacts. Position-specific strategies to modify kickoffs and correct tackling and blocking may also reduce impact burden.

Provision of Concussion Information From Coaches and the Presence of Athletic Trainers: Findings From the 2021 YouthStyles Survey

Coaches play an important role in concussion safety, and their views on concussion influence those of their athletes and the athletes' reporting behaviors. In this 2021 survey of youth, we examined how often coaches provide concussion safety information to their athletes and the association between coaches' provision of concussion information to athletes and the presence of athletic trainers (ATs) at a team's games and practices. More than 4 in 10 youth who played sports reported that their coaches did not provide any sort of concussion education or information to them in the past 12 months. Among those youth who always or sometimes had ATs at practices or games, 76.3% received some type of coach education on concussion in the past 12 months, compared with 31.9% of those who rarely or never had ATs at practices or games (P < .0001). Increasing access to ATs and adapting current concussion training and educational materials for coaches to increase coach-athlete communication may be beneficial.

Race, ethnicity, and clinical outcome following sport-related concussion: a systematic review

Introduction

This systematic review examined whether race or ethnicity are associated with clinical outcomes (e.g., time to return to school/sports, symptom duration, vestibular deficits, and neurocognitive functioning) following sport-related concussion among child, adolescent, or college-aged student athletes. Additionally, this review assessed whether the existing literature on this topic incorporated or included broader coverage of social determinants of health.

Methods

The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched.

Results

A total of 5,118 abstracts were screened and 12 studies met inclusion criteria, including 2,887 youth and young adults. Among the included articles, only 3 studies (25%) examined whether race and ethnicity were associated with outcomes following concussion as a primary objective. None of the studies assessed the association between social determinants of health and outcomes following concussion as a primary objective, although 5 studies (41.7%) addressed a social determinant of health or closely related topic as a secondary objective.

Discussion

Overall, the literature to date is extremely limited and insufficient for drawing conclusions about whether race or ethnicity are categorically associated with outcomes from sport-related concussion, or more specifically, whether there are socioeconomic, structural, or cultural differences or disparities that might be associated with clinical outcome.

Systematic review registration

identifier: PROSPERO, CRD42016041479, CRD42019128300.

When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review

OBJECTIVE

To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC.

DATA SOURCES

Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically.

STUDY ELIGIBILITY CRITERIA

Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery.

RESULTS

Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC.

CONCLUSION

No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC.

PROSPERO REGISTRATION NUMBER

CRD42022155121.

Back from the sideline, but back to baseline? A pediatric case study examining neuropsychological functioning after sustaining multiple sport-related concussions

Most individuals recover quickly from a concussion; however, youth who sustain multiple concussions may be at risk for long-term cognitive impairments. This case study examines the neuropsychological performance of a 13-year-old malewith five head injuries. After his first concussion during study participation (fourth injury overall), several improvements were observed, likely due to practice effects, yet after sustaining another concussion <2 years later,declines were observed in visuoconstruction, verbal memory, and intellectual functioning. Across serial re-evaluation, his vocabulary knowledge declined, and fewer improvements were observed than anticipated when accounting for serial practice effects, highlighting the possible cumulative impact of multiple concussions.

Prior Concussion History and Clinical Recovery Following Sport-Related Concussion in High School Athletes

Clinical recovery following sport-related concussion varies as a function of preinjury and acute factors. Whether, or the extent to which, concussion history is associated with clinical outcome following sport-related concussion is uncertain, as research has produced mixed findings. The present study aimed to assess whether a history of prior concussions is associated with prolonged clinical recovery following a subsequent sport-related concussion. The sample was comprised of 780 adolescent student athletes (mean age= M=16.3, SD=1.3 years; 56.8% boys, 43.2% girls) whose school participated in the Maine Concussion Management Initiative (MCMI). Survival analyses were used to compare recovery times among adolescents with a history of 0, 1, or 2 prior concussions following a subsequent sport-related concussion. The two primary outcomes of interest were the number of days to return to school and sports. There were no statistically significant differences in total time to return to school and sports, or the proportion of adolescents who returned to school and sports at most intervals (e.g., 7, 14, 28 days), between those with 0, 1, or 2 prior concussions. However, a greater proportion of adolescents with a history of 2 prior concussions remained out of sports at 28 days as compared to those with no prior concussions (23.5% vs. 12.7%; OR=2.10, 95% CI 1.18-3.73). Having sustained prior concussions was not associated with time to return to school following a subsequent sport-related concussion. However, a greater proportion of adolescents with two or more prior concussions experienced a prolonged return to sports. Further research is warranted to identify risk factors for worse outcomes among the subset of adolescents with a history of multiple prior concussions who experience prolonged recoveries.

Follow-up visits after a concussion in the pediatric population: An integrative review

BACKGROUND

Concussions are a significant health issue for children and youth. After a concussion diagnosis, follow-up visits with a health care provider are important for reassessment, continued management, and further education.

OBJECTIVE

This review aimed to synthesize and analyse the current state of the literature on follow-up visits of children with a concussive injury and examine the factors associated with follow-up visits.

METHODS

An integrative review was conducted based on Whittemore and Knafl's framework. Databases searched included PubMed, MEDLINE, CINAHL, PsycINFO, and Google Scholar.

RESULTS

Twenty-four articles were reviewed. We identified follow-up visit rates, timing to a first follow-up visit, and factors associated with follow-up visits as common themes. Follow-up visit rates ranged widely, from 13.2 to 99.5%, but time to the first follow-up visit was only reported in eight studies. Three types of factors were associated with attending a follow-up visit: injury-related factors, individual factors, and health service factors.

CONCLUSION

Concussed children and youth have varying rates of follow-up care after an initial concussion diagnosis, with little known about the timing of this visit. Diverse factors are associated with the first follow-up visit. Further research on follow-up visits after a concussion in this population is warranted.

Concussion Recovery in Children and Adolescents: A Retrospective Study

Background

Concussion is a common injury among children and adolescents, with a growing body of literature supporting a variety of diagnostic and treatment modalities. Recovery is variable and depends on multiple factors that can be evaluated through a clinic visit: a thorough history, physical examination, and use of the Post-concussion Symptom Scale (PCSS).

Purpose/Hypothesis

The purpose of this study was to evaluate factors associated with overall recovery from concussion in children and adolescents in the clinical setting. It was hypothesized that the presence of 1 of a number of pre- or postinjury characteristics will be associated with poor concussion recovery.

Study Design

Case-control study; Level of evidence, 3.

Methods

We conducted a retrospective chart review of adolescents and children aged 6 to 17 years with a diagnosis of concussion who were evaluated at a single sports medicine center between January 2015 and December 2019. Cases were categorized into recovered (PCSS <7) and poorly recovered (PCSS ≥7) cohorts based on the last PCSS scores during clinical follow-ups for concussion management.

Results

Of the 162 charts reviewed, 110 cases met inclusion criteria. Significant statistical differences were found between the recovered and poorly recovered cohorts regarding mean days from injury to last clinic visit, previous migraine diagnosis, and emergency room (ER) visit before the first clinic visit (P < .01 for all). Binary logistic regression analysis revealed that the most predictive factors associated with poorer recovery were having an ER visit before the first clinic evaluation (P = .01) and previous migraine diagnosis (P = .04).

Conclusion

While many factors may contribute to overall recovery from concussion in pediatric populations, our study suggested that a history of migraine and an ER visit before clinic evaluation may be associated with poor recovery of concussive symptoms.

Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in Adolescents

We examined the association between the severity of acute concussion symptoms and time to return to school and to sports in adolescent student athletes. We hypothesized that there would be an association between the severity of acute symptoms experienced in the first 72 hours and functional recovery such that adolescents with the lowest burden of acute symptoms would have the fastest return to school and sports and those with the highest burden of symptoms would have the slowest return to school and sports. This injury surveillance cohort included 375 adolescent student athletes aged 14-19 years who sustained a sport-related concussion between 2014 and 2020. Athletic trainers documented time to return to school and to sports. A greater proportion of adolescents with the highest acute symptoms remained out of school at 3 (odds ratio [OR] = 2.5, 95% confidence interval [CI] 1.5-4.4), 5 (OR = 2.4, 95% CI 1.4-4.0), 7 (OR = 2.6, 95% CI 1.5-4.3), and 10 days (OR = 2.3, 95% CI 1.3-3.9) compared to those with the lowest acute symptoms. Similarly, a greater proportion of athletes with the highest acute symptoms remained out of sports at 7 (OR = 3.5, 95% CI 1.5-8.1), 10 (OR = 3.1, 95% CI 1.8-5.6), 14 (OR = 1.8, 95% CI 1.1-3.0), and 21 days (OR = 1.9, 95% CI 1.0-3.6) compared to those with the lowest acute symptoms. This study underscores the adverse effect of high acute symptom burden following concussion on return to school and to sports among adolescent student athletes. Conversely, student athletes with a low burden of acute symptoms have a faster return to school and to sports.

A Pilot Randomized Controlled Trial of Docosahexaenoic Acid for the Treatment of Sport-Related Concussion in Adolescents

The objective was to examine the use of docosahexaenoic acid (DHA) for the treatment of sport-related concussion (SRC) in adolescent athletes. We hypothesize that participants who intake 2 g of DHA daily will not experience differences in recovery compared with participants who take a placebo. This double-blind, randomized controlled pilot trial was performed in a tertiary pediatric sports medicine clinic from 2013 to 2017 in adolescents (14-18 years) presenting with diagnosed SRC within 4 days of injury. Forty participants were randomized into DHA or PLACEBO group and were instructed to take 2 capsules twice daily for 12 weeks. Participants in the DHA group were symptom-free earlier than the PLACEBO group (11.0 vs 16.0 days, P = .08) and were cleared to begin the Return to Sport progression (14.0 vs 19.5 days, P = .12) sooner. The use of 2 g/day of DHA was well-tolerated and did not significantly affect recovery times in adolescent athletes following SRC.Clinical Trial Registration: ClincalTrials.gov, NCT01903525.

Age of First Concussion and Cognitive, Psychological, and Physical Outcomes in NCAA Collegiate Student Athletes

OBJECTIVE

Concussions are common among youth athletes and could disrupt critical neurodevelopment. This study examined the association between age of first concussion (AFC) and neurocognitive performance, psychological distress, postural stability, and symptoms commonly associated with concussion in healthy collegiate men and women student athletes.

METHODS

Participants included 4267 collegiate athletes from various contact, limited-contact, and non-contact sports (1818 women and 2449 men) who completed baseline assessments as part of the Concussion Assessment, Research and Education (CARE) Consortium. Psychological distress was assessed with the Brief Symptom Inventory 18; neurocognitive performance was assessed with the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT); symptoms commonly associated with concussion were assessed with the ImPACT Post-Concussion Symptom Scale; postural stability was assessed with the Balance Error Scoring System. Generalized linear models were used to examine the effects of AFC on clinical outcomes separately in men and women.

RESULTS

Later AFC was associated with lower global (Exp(B) = 0.96, P = 0.001) and somatic (Exp(B) = 0.96, P = 0.002) psychological distress on the Brief Symptom Inventory 18 and faster ImPACT reaction time (B =  - 0.003, P = 0.001) in women. AFC was not associated with any clinical outcomes in men.

CONCLUSION

Younger AFC was associated with some differences in psychological distress and reaction time among women but not men; however, these results are likely not clinically meaningful. Sociodemographic disparities, pre-existing conditions, and sport type may impact clinical and cognitive outcomes in collegiate athletes more than concussion history. Future work should examine the relationship between AFC and lifespan-related outcomes.

Early psychological symptoms predict concussion recovery time in middle and high school athletes

INTRODUCTION

Lingering concussion symptoms can negatively impact a child's well-being, yet variability in recovery is poorly understood. To aid detection of those at risk for prolonged symptom duration, we explored postconcussion mood and sleep symptoms as predictors of recovery time in adolescent athletes.

METHOD

We utilized analyses designed to control for potentially confounding variables, such as concussion severity indicators and premorbid psychiatric history. Participants included 393 adolescent athletes (aged 12-18 years) evaluated in outpatient concussion clinics within 2 weeks after injury. Provider-documented date of symptom resolution was obtained via medical record review. Survival analysis for recovery time was conducted in the total sample, and separately for males and females using prior medical history (psychiatric disorder, prior concussion), injury-related factors (loss of consciousness, post-traumatic amnesia [PTA], concussion symptom severity), and psychological symptoms (General Anxiety Disorder-7 Item Scale, Patient Health Questionnaire-8 Item Depression Scale, Pittsburgh Sleep Quality Index) collected at initial clinic visit.

RESULTS

PTA, concussion symptoms, and sleep quality were associated with recovery in the total sample (HRs = 0.64-0.99, ps < .05). When analyzed by sex, only concussion symptoms were associated with recovery for females (with females reporting greater symptom severity than males), while for males PTA and greater depression symptoms were significant predictors of recovery (HRs = 0.54-0.98, ps < .05).

CONCLUSIONS

These findings identified differences in symptom presentation between sexes, particularly for mood symptoms, and suggest that assessment of postconcussive symptoms is useful in helping to identify individuals at risk for longer recovery. Continued exploration of post-injury psychological difficulties in athletes is warranted for better concussion management.

Salivary miRNA Expression in Children With Persistent Post-concussive Symptoms

Background

Up to one-third of concussed children develop persistent post-concussive symptoms (PPCS). The identification of biomarkers such as salivary miRNAs that detect concussed children at increased risk of PPCS has received growing attention in recent years. However, whether and how salivary miRNA expression levels differ over time between concussed children with and without PPCS is unknown.

Aim

To identify salivary MicroRNAs (miRNAs) whose expression levels differ over time post-concussion in children with vs. without PPCS.

Methods

We conducted a prospective cohort study with saliva collection at up to three timepoints: (1) within one week of injury; (2) one to two weeks post-injury; and (3) 4-weeks post-injury. Participants were children (ages 11 to 17 years) with a physician-diagnosed concussion from a single hospital center. We collected participants' daily post-concussion symptom ratings throughout their enrollment using the Post-concussion Symptom Scale, and defined PPCS as a total symptom score of ≥ 5 at 28 days post-concussion. We extracted salivary RNA from the saliva samples and measured expression levels of 827 salivary miRNAs. We then compared the longitudinal expression levels of salivary miRNAs in children with vs. without PPCS using linear models with repeated measures.

Results

A total of 135 saliva samples were collected from 60 children. Of the 827 miRNAs analyzed, 91 had expression levels above the calculated background threshold and were included in the differential gene expression analyses. Of these 91 miRNAs, 13 had expression levels that differed significantly across the three timepoints post-concussion between children with and without PPCS (i.e., hsa-miR-95-3p, hsa-miR-301a-5p, hsa-miR-626, hsa-miR-548y, hsa-miR-203a-5p, hsa-miR-548e-5p, hsa-miR-585-3p, hsa-miR-378h, hsa-miR-1323, hsa-miR-183-5p, hsa-miR-200a-3p, hsa-miR-888-5p, hsa-miR-199a-3p+hsa-miR-199b-3p). Among these 13 miRNAs, one (i.e., hsa-miR-203a-5p) was also identified in a prior study, with significantly different expression levels between children with and without PPCS.

Conclusion

Our results from the longitudinal assessment of miRNAs indicate that the expression levels of 13 salivary miRNAs differ over time post-injury in concussed children with vs. without PPCS. Salivary miRNAs may be a promising biomarker for PPCS in children, although replication studies are needed.

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

Authoritative sources advise clinicians and parents that a history of prior concussion confers increased risk for worse outcome from a future concussion. However, the strength of the evidence supporting such pronouncements and thus the extent to which clinicians should incorporate this information into their care and management of pediatric concussion is unclear. This systematic review critically analyzed and synthesized the literature on the association between a history of prior concussion and prognosis/clinical outcome following a subsequent sport-related concussion among children and adolescents. The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched from inception to May 15, 2021. From 5,118 total records screened, 51 studies (46 cohort studies and 5 case-control studies) met inclusion criteria, reporting concussion recovery or outcome for 26,643 youth. A median of 36% had a prior history of concussion. Across all studies and outcomes, the majority (k=37, 72.5%) did not find a statistically significant association between lifetime history of concussion and outcome from a subsequent concussion. Important methodological limitations in the literature were identified. Available studies do not provide consistent or compelling evidence that children and adolescents with a history of concussions are at increased risk for worse clinical outcome following a subsequent sport-related concussion-although methodological limitations temper the strength of this conclusion. Clinicians are cautioned against routinely treating children and adolescents with one or more prior injuries differently, and more conservatively, because doing so, in some cases, might be counterproductive.

Mobile Subthreshold Exercise Program (MSTEP) for concussion: study protocol for a randomized controlled trial

BACKGROUND

Subthreshold exercise, defined as aerobic exercise below the level that causes symptoms, has been utilized as a treatment for youth with persistent postconcussive symptoms (PPCS), but there is currently little evidence to guide use. In addition, prior studies of exercise for PPCS have all required multiple in-person visits. We developed a virtual approach for delivering subthreshold exercise to youth with PPCS called the Mobile Subthreshold Exercise Program (MSTEP), and we have now been funded to conduct a large national randomized controlled trial (RCT) to test its efficacy for reducing concussive symptoms and improving health-related quality of life.

METHODS

This investigation is an RCT comparing MSTEP to an active control. We will recruit 200 adolescents 11-18 years old with postconcussive symptoms persisting for at least 1 week but less than 1 year. Youth will be randomized to receive either 6 weeks of subthreshold exercise (MSTEP) or a stretching condition (control). Youth and parents will complete surveys of concussive symptoms at baseline, weekly during the intervention, and at 3 and 6 months. The primary outcomes will be trajectory of concussive symptoms and health-related quality of life over the 6 months of the study. Secondary outcomes will include depression, anxiety, and sleep quality. We will also assess potential mediators of treatment effects including moderate-vigorous physical activity and fear avoidance of concussive symptoms.

DISCUSSION

This multisite RCT of MSTEP will provide vital information regarding the efficacy of a virtually delivered subthreshold exercise program for youth with PPCS, and insight regarding potential mediators of treatment effects, including objectively measured physical activity and fear avoidance of concussive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04688255. Registered on December 29, 2020.

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

OBJECTIVE

(i) To analyze data of adolescents who have sustained a sport-related concussion (SRC) through the use of Complete Concussion Management Inc. (CCMI) concussion database system; and (ii) to determine an optimal time to assess and manage an athlete with an SRC by prospectively analyzing data from CCMI concussion database system.

METHOD

A cohort of patients, ages 8-18 years, who sustained an SRC, assessed 30 days or less from injury and were treated at partnered CCMI clinics across Canada were prospectively followed. The primary outcome measure was recovery, defined as CCMI discharge, which includes an athlete having completed all return-to-school and return-to-play steps and passed the Gapski-Goodman test without symptom exacerbation.

RESULTS

1213 athletes (482 female) were included for analysis. Days between injury and initial assessment (p = 0.00), male sex (p = 0.00), and previous concussion history (p = 0.00) were significant predictors of time to discharge. A log-rank test revealed a significant difference (p = 0.00) in time to discharge with athletes assessed <10 days of injury discharged at a mean of 23.5 days (95% CI, 22.5, 24.5) and those assessed at day 10 to 30 were discharged at a mean of 37.1 days (95% CI, 33.7, 40.5). Athletes who were assessed at 0 to 9 days from injury were two times more likely to be discharged sooner compared to those athletes assessed 10 to 30 days from injury (HR 2.03, p = 0.00).

CONCLUSION

Time from SRC to initial assessment significantly predicted time to discharge, with those being evaluated earlier experiencing a faster discharge. The results aid in establishing recommended timelines for evaluation following an SRC in order to prevent or mitigate athletes experiencing a prolonged recovery and encourage timely access to care and a quicker return to life post-concussive injury.

Post-concussive mTBI in Student Athletes: MRI Features and Machine Learning

Purpose: To determine and characterize the radiomics features from structural MRI (MPRAGE) and Diffusion Tensor Imaging (DTI) associated with the presence of mild traumatic brain injuries on student athletes with post-concussive syndrome (PCS).

Material and Methods: 122 student athletes (65 M, 57 F), median (IQR) age 18.8 (15–20) years, with a mixed level of play and sports activities, with a known history of concussion and clinical PCS, and 27 (15 M, 12 F), median (IQR) age 20 (19, 21) years, concussion free athlete subjects were MRI imaged in a clinical MR machine. MPRAGE and DTI-FA and DTI-ADC images were used to extract radiomic features from white and gray matter regions within the entire brain (2 ROI) and the eight main lobes of the brain (16 ROI) for a total of 18 analyzed regions. Radiomic features were divided into five different data sets used to train and cross-validate five different filter-based Support Vector Machines. The top selected features of the top model were described. Furthermore, the test predictions of the top four models were ensembled into a single average prediction. The average prediction was evaluated for the association to the number of concussions and time from injury.

Results: Ninety-one PCS subjects passed inclusion criteria (91 Cases, 27 controls). The average prediction of the top four models had a sensitivity of 0.80, 95% CI: [0.71, 0.88] and specificity of 0.74 95%CI [0.54, 0.89] for distinguishing subjects from controls. The white matter features were strongly associated with mTBI, while the whole-brain analysis of gray matter showed the worst association. The predictive index was significantly associated with the number of concussions (p < 0.0001) and associated with the time from injury (p < 0.01).

Conclusion: MRI Radiomic features are associated with a history of mTBI and they were successfully used to build a predictive machine learning model for mTBI for subjects with PCS associated with a history of one or more concussions.

Lifetime History of Concussion Among Youth With ADHD Presenting to a Specialty Concussion Clinic

Child and adolescent student athletes with attention-deficit/hyperactivity disorder (ADHD) report a greater lifetime history of concussion than those without ADHD. This case-control study compared youth with and without ADHD presenting for care at a specialty concussion clinic on their lifetime history of concussion. We hypothesized that a greater proportion of youth with ADHD would report a history of prior concussion. Archival clinical data from patients presenting to a specialty concussion clinic in Montreal, Québec, Canada between September 2015 and August 2019 were analyzed. The sample included 2,418 children and adolescents (age: M = 13.6, SD = 2.7, range 5–18 years; 50.9% girls), including 294 (12.2%) with ADHD and 2,124 (87.8%) without ADHD. The proportion with prior concussion among youth with ADHD (43.9%) was significantly greater than youth without ADHD [37.5%, χ² = 4.41, p = 0.04, OR = 1.30, 95% confidence interval (CI): 1.02–1.67]. A significantly higher proportion of boys with ADHD had a prior concussion history (48.1%) than boys without ADHD [38.4%, χ² = 5.33, p = 0.02, OR = 1.48 (95% CI: 1.06–2.09)], but this difference was not observed for girls (χ² = 0.31, p = 0.58). Youth with ADHD did not differ with regard to their estimated longest duration of symptoms from a prior concussion (Z = 1.52, p = 0.13) and the proportion who reported taking longer than 28 days to recover from a prior concussion did not differ between those with ADHD (15.3%) and without ADHD (12.2%), χ² = 2.20, p = 0.14. Among youth presenting to a specialty clinic, ADHD was associated with greater lifetime history of concussion but not a greater duration of symptoms from a prior injury.

Predictors of Treatment Response to Multidisciplinary Care for Persistent Symptoms after Pediatric Concussion

PURPOSE

To assess which pediatric patients experiencing persistent post-concussive symptoms (PCS) benefit most from multidisciplinary treatment including specialists in Neurology, Neuropsychology, Physical Therapy, and Athletic Training, and to explore the effectiveness of this approach.

METHODS

A retrospective chart review of 56 adolescents 10-20 years old (M = 15.0 ± 2.1) receiving multidisciplinary care for PCS (>30 days) was conducted.

RESULTS

Systolic blood pressure and Body Mass Index predicted time to concussion resolution (p < .05), such that higher values were associated with slower resolution. PCS scores significantly decreased between participants' initial and final clinic visits, p < .01, and among the 25 participants for whom pre-intervention PCS scores were available, symptom severity scores significantly declined following multidisciplinary intervention compared to pre-referral values (p < .01).

CONCLUSIONS

Exploratory analyses reveal that multidisciplinary treatment is a promising approach for reducing symptoms among adolescents with PCS, and that those with greater levels of physical fitness may benefit most.

Parent knowledge of and attitudes towards youth sport-related concussion and associations with child and parent factors

Aim:

This cross-sectional study aimed to better understand parental knowledge and attitudes regarding pediatric sport-related concussions, and association with parent/child biopsychosocial factors.

Methods:

A community sample of ninety families (n = 140 children) were included. Parental concussion knowledge and attitudes, concussion history, sport participation and social risk status score (SRS) were collected.

Results:

Parents scored an average of 76% accuracy on factual concussion knowledge, with 74% confidence in responses. Parents endorsed a favorable attitude toward concussion reporting and management. Low SRS had higher perceived accuracy of knowledge than medium or high SRS (p = 0.003). SRS influenced over-and-underestimations of factual knowledge (p = .04). Age at first sport and sport contact level influenced factual and perceived concussion knowledge.

Conclusion:

These findings identify common gaps in concussion knowledge in parents.

In search of scientific objectivity: Is there such a property for paediatric concussion?

Concussions are a significant public health problem worldwide. This brain injury is problematic in the paediatric population for a variety of reasons; however, the enquiry into these problems has been mainly through the biomedical perspective. This approach has impacted nursing knowledge and practice of children and youth with a concussion, primarily since other perspectives are viewed as not being objective. In this manuscript, I draw on Thomas Kuhn's view of objectivity to evaluate the biomedical perspective of concussion. I utilize current research and clinical examples to illustrate the advantages and drawbacks of this perspective for nursing. From this discussion, I propose an alternative perspective to capture the complexity of paediatric concussions for nursing, a systems perspective. Although I argue for an alternative perspective to approach paediatric concussions for nursing, I maintain that the biomedical perspective can be incorporated as one part of nursing knowledge and practice for paediatric concussion.

White Matter Abnormalities Associated With Prolonged Recovery in Adolescents Following Concussion

Background: Concussion symptoms in adolescents typically resolve within 4 weeks. However, 20 - 30% of adolescents experience a prolonged recovery. Abnormalities in tracts implicated in visuospatial attention and emotional regulation (i.e., inferior longitudinal fasciculus, ILF; inferior fronto-occipital fasciculus, IFOF; uncinate fasciculus; UF) have been consistently reported in concussion; yet, to date, there are no objective markers of prolonged recovery in adolescents. Here, we evaluated the utility of diffusion MRI in outcome prediction. Forty-two adolescents (12.1 - 17.9 years; female: 44.0%) underwent a diffusion Magnetic Resonance Imaging (dMRI) protocol within the first 10 days of concussion. Based on days of injury until medical clearance, adolescents were then categorized into SHORT (<28 days; N = 21) or LONG (>28 days; N = 21) recovery time. Fractional anisotropy (FA) in the ILF, IFOF, UF, and/or concussion symptoms were used as predictors of recovery time (SHORT, LONG). Forty-two age- and sex-matched healthy controls served as reference. Higher FA in the ILF (left: adjusted odds ratio; AOR = 0.36, 95% CI = 0.15 - 0.91, P = 0.030; right: AOR = 0.28, 95% CI = 0.10 - 0.83, P = 0.021), IFOF (left: AOR = 0.21, 95% CI = 0.07 - 0.66, P = 0.008; right: AOR = 0.30, 95% CI = 0.11 - 0.83, P = 0.020), and UF (left: AOR = 0.26, 95% CI = 0.09 - 0.74, P = 0.011; right: AOR = 0.28, 95% CI = 0.10 - 0.73, P = 0.010) was associated with SHORT recovery. In additional analyses, while adolescents with SHORT recovery did not differ from HC, those with LONG recovery showed lower FA in the ILF and IFOF (P < 0.014). Notably, inclusion of dMRI findings increased the sensitivity and specificity (AUC = 0.93) of a prediction model including clinical variables only (AUC = 0.75). Our findings indicate that higher FA in long associative tracts (especially ILF) might inform a more objective and accurate prognosis for recovery time in adolescents following concussion.

Association Between Preinjury Symptoms and Postconcussion Symptoms at 4 Weeks in Youth

OBJECTIVE

To investigate whether preinjury physical, emotional, cognitive, and sleep symptoms on the Post-Concussion Symptoms Inventory (PCSI) are associated with persistent postconcussion symptoms (PPCS) at 4 weeks and whether any associations are moderated by sex or age.

STUDY SETTING AND PARTICIPANTS

A total of 3063 participants with acute concussion, presenting to 9 Canadian pediatric emergency departments, were enrolled from August 2013 to June 2015.

DESIGN

A planned secondary analysis of a prospective, multicenter cohort study (Predicting Persistent Post-concussive Problems in Pediatrics or 5P). Primary outcome was PPCS at 4 weeks, defined as 3 or more new or worsening individual symptoms compared with the preinjury score at 28 days on the PCSI. The association between preinjury scores and PPCS was analyzed with a multivariable logistic regression analysis that included preinjury, sex, age, sex × preinjury, and age × preinjury interactions as predictors. Missing baseline covariates were imputed.

RESULTS

A total of 2123 (n = 844 [39.8%] girls; median [IQR] age = 12.9 [10.7, 15.0] participants were included in the analysis. Preinjury physical symptom score was associated with PPCS at 4 weeks (χ2 = 13.87, df = 6, P = .031). The preinjury emotional score also contributed to the variability in PPCS (χ2 = 11.79, df = 6, P = .067). While girls reported higher preinjury physical, emotional, and cognitive scores than boys, neither sex nor age interacted with preinjury to predict PPCS at 4 weeks. Independent of age and sex, preinjury physical symptoms were associated with PPCS at 4 weeks (OR = 1.40; 95% CI, 1.15-1.70).

CONCLUSION

Preinjury physical symptoms are associated with the probability of having PPCS at 4 weeks postconcussion independent of age and sex. Providers should consider preinjury symptoms to inform prognosis and recovery management.

Evidence based management of sports related concussion

Sports related concussion (SRC) is a common condition evaluated by healthcare professionals. In an article entitled "Return to Play After Concussion: Clinical Guidelines for Young Athletes" published in the December 2019 issue of the Journal of the American Osteopathic Association, guidelines for the management of SRC were presented to assist healthcare professionals in the management of patients with SRC. However, much of the information presented in that article is contradicted by current expert recommendations and evidence based practice guidelines. The management of SRC has evolved to a nuanced, domain driven diagnosis requiring a multidisciplinary treatment team and a customized management plan for each patient to ensure competent treatment of patients with SRC. As such, this Commentary summarizes current recommendations for diagnosis and management of SRC.

Personality Traits and Social Supports in Adolescents With Persistent Postconcussion Symptoms

OBJECTIVES

To determine whether adolescents with persistent postconcussion symptoms (PPCS) differ from healthy peers in their personality traits and social supports.

SETTING

Specialty Concussion Clinic and Primary Care Clinic affiliated with an academic medical center.

PARTICIPANTS

Ninety-seven adolescents (42 with PPCS, 55 healthy peers; age: 15 ± 2 years).

DESIGN

Participants completed a web-based survey that included medical and demographic characteristics, mechanisms of concussion, 10-item Big Five Inventory, and Child and Adolescent Social Support Scale. A Student's 2-tailed t test with multiple testing corrections was used to compare the youths with PPCS to healthy peers.

MAIN MEASURES

The primary outcome was PPCS, defined by the presence of 2 or more concussion-related symptoms on the Post-Concussion Symptom Scale (PCSS), lasting for more than 4 weeks after initial injury. The secondary outcome was perceived personality traits and social support, based on the 10-item Big Five Inventory and the Child and Adolescent Social Support Scale, respectively.

RESULTS

The PPCS group had higher neuroticism scores on their Big Five Inventory than healthy peers. They also reported less social support from teachers and classmates than healthy peers.

CONCLUSION

Youths with PPCS report specific personality and social support characteristics that differ from their peers. These findings suggest that individual personality and school-based social supports may influence concussion recovery.

Sports- and Physical Activity-Related Concussion and Risk for Youth Violence

INTRODUCTION

Sports and physical activities are an important cause of traumatic brain injury among adolescents. Childhood traumatic brain injury has been associated with cognitive impairment, emotional problems, and impaired behavior control, and these neuropsychological changes may place these youth at increased risk for engagement in violence-related behaviors.

METHODS

Data from the 2017 National Youth Risk Behavior Survey (N=14,765), a nationally representative survey of U.S. high school students, were analyzed in 2019 to examine the associations between sports- and physical activity-related concussion and violence-related behaviors occurring in the community and at school. Multivariable logistic regression models were used to calculate sex-stratified, adjusted (for race/ethnicity, grade, athlete status, impaired cognitive functioning, feeling sad/hopeless, and current substance use) prevalence ratios. Prevalence ratios were considered statistically significant if p<0.05.

RESULTS

Male students (17.1%) were more likely than female students (13.0%) to experience a sports- and physical activity-related concussion during the 12 months preceding the survey. Compared with students who did not have a concussion, those who experienced ≥1 sports- and physical activity-related concussion were more likely to be in a physical fight (male students, adjusted prevalence ratio=1.45; female students, adjusted prevalence ratio=1.55), carry a weapon (male students, adjusted prevalence ratio=1.24; female students, adjusted prevalence ratio=1.79), and fight at school (male students, adjusted prevalence ratio=1.40; female students, adjusted prevalence ratio=1.77). In addition, male students were more likely to carry a gun (adjusted prevalence ratio=1.62) and carry a weapon at school (adjusted prevalence ratio=1.73).

CONCLUSIONS

Although the direction of these associations is unknown, return-to-school programs may benefit from inclusion of assessment and counseling around issues of psychological and social functioning, conflict resolution, and coordination with violence prevention programs.

Network Analysis of Sport-Related Concussion Research During the Past Decade (2010-2019)

CONTEXT

Research into sport-related concussion (SRC) has grown substantially over the past decade, yet no authors to date have synthesized developments over this critical time period.

OBJECTIVE

To apply a network-analysis approach in evaluating trends in the SRC literature using a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 15, 2019.

DESIGN

Narrative review.

MAIN OUTCOME MEASURE(S)

Bibliometric maps were derived from a comprehensive search of all published, peer-reviewed SRC articles in the Web of Science database. A clustering algorithm was used to evaluate associations among journals, organizations or institutions, authors, and key words. The online search yielded 6130 articles, 528 journals, 7598 authors, 1966 organizations, and 3293 key words.

RESULTS

The analysis supported 5 thematic clusters of journals: (1) biomechanics/sports medicine (n = 15), (2) pediatrics/rehabilitation (n = 15), (3) neurotrauma/neurology/neurosurgery (n = 11), (4) general sports medicine (n = 11), and (5) neuropsychology (n = 7). The analysis identified 4 organizational clusters of hub institutions: (1) University of North Carolina (n = 19), (2) University of Toronto (n = 19), (3) University of Michigan (n = 11), and (4) University of Pittsburgh (n = 10). Network analysis revealed 8 clusters for SRC key words, each with a central topic area: (1) epidemiology (n = 14), (2) rehabilitation (n = 12), (3) biomechanics (n = 11), (4) imaging (n = 10), (5) assessment (n = 9), (6) mental health/chronic traumatic encephalopathy (n = 9), (7) neurocognition (n = 8), and (8) symptoms/impairments (n = 5).

CONCLUSIONS

The findings suggest that during the past decade SRC research has (1) been published primarily in sports medicine, pediatric, and neuro-focused journals, (2) involved a select group of researchers from several key institutions, and (3) concentrated on new topical areas, including treatment or rehabilitation and mental health.

Prolonged elevation of serum neurofilament light after concussion in male Australian football players

Background

Biomarkers that can objectively guide the diagnosis of sports-related concussion, and consequent return-to-play decisions, are urgently needed. In this study, we aimed to determine the temporal profile and diagnostic ability of serum levels of neurofilament light (NfL), ubiquitin carboxy-terminal hydrolase L1 (UCHL1), glial fibrillary acidic protein (GFAP), and tau in concussed male and female Australian footballers.

Methods

Blood was collected from 28 Australian rules footballers (20 males, 8 females) at 2-, 6-, and 13-days after a diagnosed concussion for comparison to their levels at baseline (i.e. pre-season), and with 27 control players (19 males, 8 females) without a diagnosis of concussion. Serum concentrations of protein markers associated with damage to neurons (UCHL1), axons (NfL, tau), and astrocytes (GFAP) were quantified using a Simoa HD-X Analyzer. Biomarker levels for concussed players were compared over time and between sex using generalised linear mixed effect models, and diagnostic performance was assessed using area under the receiver operating characteristic curve (AUROC) analysis.

Results

Serum NfL was increased from baseline in male footballers at 6- and 13-days post-concussion. GFAP and tau were increased in male footballers with concussion at 2- and 13-days respectively. NfL concentrations discriminated between concussed and non-concussed male footballers at all time-points (AUROC: 2d = 0.73, 6d = 0.85, 13d = 0.79), with tau also demonstrating utility at 13d (AUROC = 0.72). No biomarker differences were observed in female footballers after concussion.

Conclusions

Serum NfL may be a useful biomarker for the acute and sub-acute diagnosis of concussion in males, and could inform neurobiological recovery and return-to-play decisions. Future adequately powered studies are still needed to investigate biomarker changes in concussed females.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40364-020-00256-7.

Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion

OBJECTIVES

To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion.

STUDY DESIGN

Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury.

RESULTS

Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009).

CONCLUSIONS

Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.

Differences in sport-related concussion for female and male athletes in comparable collegiate sports: a study from the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium

OBJECTIVES

To examine sex differences in sport-related concussion (SRC) across comparable sports.

METHODS

Prospective cohort of collegiate athletes enrolled between 2014 and 2017 in the Concussion Assessment, Research and Education Consortium study.

RESULTS

Among 1071 concussions (females=615; 57.4%), there was no difference in recovery (median days to full return to play) (females=13.5 (IQR 9.0, 23.1) vs males=11.8 (IQR 8.1, 19.0), p=0.96). In subgroup analyses, female recovery was longer in contact (females=12.7 days (IQR 8.8, 21.4) vs males=11.0 days (IQR 7.9, 16.2), p=0.0021), while male recovery was longer in limited contact sports (males=16.9 days (IQR 9.7, 101.7) vs females=13.8 days (IQR 9.1, 22.0), p<0.0001). There was no overall difference in recovery among Division I schools (females=13.7 (IQR 9.0, 23.1) vs males=12.2 (IQR 8.2 19.7), p=0.5), but females had longer recovery at the Division II/III levels (females=13.0 (IQR 9.2, 22.7) vs males=10.6 (IQR 8.1, 13.9), p=0.0048).

CONCLUSION

Overall, no difference in recovery between sexes across comparable women's and men's sports in this collegiate cohort was found. However, females in contact and males in limited contact sports experienced longer recovery times, while females had longer recovery times at the Division II/III level. These disparate outcomes indicate that, while intrinsic biological sex differences in concussion recovery may exist, important, modifiable extrinsic factors may play a role in concussion outcomes.

A Within-Subjects Comparison of Clinical Outcomes for Patients' First and Second Concussions

OBJECTIVES

To examine the difference between an individual's first and second concussion using a comprehensive, multidomain assessment including symptoms, neurocognitive, vestibular, ocular, and individual demographic and medical history risk factors associated with protracted recovery.

SETTING

Concussion Specialty Clinic.

PARTICIPANTS

Seventy-three patients (aged 13-21 years; 57% female) diagnosed with 2 separate concussions (380.5 ± 278.7 days between injuries) from August 2016 to August 2018.

DESIGN

Retrospective within-subjects cohort study.

MAIN MEASURES

ImPACT, PCSS, and Vestibular-Ocular Motor Screen (VOMS) at each visit. Patients were divided into "normal" (≤30 days) and "protracted" recovery (>30 days) for χ2 analyses.

RESULTS

There were no differences between the first and second injuries in recovery time, VOMS, visual and verbal memory, or reaction time. Visual motor speed scores were higher at the second injury time point and reported sleep symptoms were higher at the first injury time point. In addition, participants reported to the clinic on average 3 days earlier for an evaluation for their second injury. Results from χ2 analyses indicated that female sex predicted protracted recovery (>30 days) from concussion at the first injury time point (OR = 4.1; 95% CI, 1.5-11.6; P = .006).

CONCLUSIONS

The findings provide preliminary evidence that there is no clinical difference between patients' first and second concussions when both injuries were treated through a concussion specialty clinic.

Sports and non-sports-related concussions among Medicaid-insured children: health care utilization before and after Ohio's concussion law

Objective

To evaluate patterns of health care utilization for sports-related concussions (SRCs) and non-sports-related concussions (NSRCs) among Medicaid-insured children before and after the enactment of Ohio’s concussion law in April 2013.

Methods

We analyzed claim data from the Partners For Kids (PFK) Ohio Medicaid database. Concussion diagnoses were identified between April 1, 2008 and June 30, 2017. We compared frequency of concussions by age and sex across the law period. We evaluated type of health care utilization before and after law enactment using multinomial logistic regression.

Results

Over the 9 year study period, 6157 concussions were included, most of which (70.4%) were NSRCs. The proportion of SRCs increased with age. Among children younger than 5 years old, the majority (96.1%) of concussions were NSRCs. During the post-law period, greater odds of primary care visits than emergency department (ED) visits were observed for both SRCs (OR = 1.53; 95% CI 1.34, 1.75) and NSRCs (OR = 1.73; 95% CI 1.58, 1.90) compared to the pre-law period.

Conclusions

We observed higher proportions of health care utilization for NSRCs than SRCs in Medicaid insured children and a shift in health care utilization from the ED to primary care in the post-law period. SRCs and NSRCs are likely to have different patterns of health care utilization before and after the enactment of Ohio’s concussion law. Our results demonstrate that Ohio’s youth concussion law had a quantifiable impact on health care utilization.

Assessing the predictive value of primary evaluation with the Immediate Post-Concussion Assessment and Cognitive Test following head injury

OBJECTIVE

Concussions are a major public health concern, especially for high school and college student athletes. However, there are few prognostic metrics that can accurately quantify concussion severity in order to anticipate recovery time and symptom regression. The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) is a widely used neurocognitive assessment that can diagnose and track recovery from concussions. This study assesses whether initial ImPACT scores, collected within 48 hours of the injury, can predict persistence of concussion at follow-up.

METHODS

Results from 6912 ImPACT tests were compiled in 2161 unique student athletes, ages 12-22 years. The authors defined a novel metric, the Severity Index (SI), which is a summation of the number of standard deviations from baseline at the 80% CI for each of the 5 composite scores reported by ImPACT. Patients were binned into groups based on SI (0-3.99, 4-7.99, 8-11.99, 12+) and the relationships between SI groups, composite scores, symptom profiles, and recovery time were characterized using 1-way and 2-way ANOVAs and Kaplan-Meier plots. A logistic regression assessed the value of SI for predicting concussion at follow-up.

RESULTS

Patients with a higher SI at diagnosis were more likely to still be concussed at their first follow-up (F3,2300 = 93.06; p < 0.0001). Groups with a higher SI also displayed consistently slower recovery over a 42-day period and were more likely to report symptoms in all 4 symptom clusters (Migraine, Cognition, Sleep, and Neuropsychiatric). When controlling for sex, age, number of previous concussions, days between assessments, and location, SI significantly increased the odds of being concussed at follow-up (OR 1.122, 95% CI 1.088-1.142; p < 0.001). This model showed good discrimination with an area under the curve of 0.74.

CONCLUSIONS

SI is a useful prognostic tool for assessing head injury severity. Concussions with higher initial SI tend to last longer and have broader symptomatic profiles. These findings can help patients and providers estimate recovery based on similar ImPACT score profiles.