Patient, Injury, Assessment, and Treatment Characteristics and Return-to-Play Timelines After Sport-Related Concussion: An Investigation from the Athletic Training Practice-Based Research Network

Geographic characteristics of sport- and non-sport-related concussions presenting to emergency departments in the United States

BACKGROUND

Concussion is a type of traumatic brain injury (TBI) that can be sustained through sport-related and non-sport-related (e.g., motor vehicle accidents, falls, assaults) mechanisms of injury (MOI). Variations in concussion incidence and MOI may be present throughout the four geographic regions (Midwest, Northeast, South, West) of the United States. However, there is limited evidence exploring concussion cause and diagnosis patterns based on geographic region and MOI. These factors have implications for better understanding the burden of concussion and necessary efforts that can translate to the mitigation of safety concerns.

PURPOSE

The purpose of this study was to identify patterns of sport-related concussion (SRC) and non-sport-related concussion (NSRC) across the four geographic regions of the United States.

METHODS

A descriptive epidemiology study of patient visits to the emergency department (ED) for concussion between 2010 and 2018, using publicly available data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) was conducted. The exposure of interest was geographic region while the main outcome measures were concussion diagnosis and MOI. Descriptive statistics were calculated using population-weighted frequencies and percentages. The association between geographic region and MOI (SRC vs. NSRC) was analyzed using logistic regression models. Odds ratios (OR) presented with 95% confidence intervals (CI) were included. Univariate analyses were conducted followed by multivariable analyses adjusting for sex, age, race/ethnicity, and primary source of payment. Statistical significance was set a priori at p < 0.05 for all analyses.

RESULTS

From 2010 to 2018, 1,161 visits resulted in a concussion diagnosis, representing an estimated 7,111,856 visits nationwide. A greater proportion of concussion diagnoses occurred within EDs in the South (38.2%) followed by the West (25.8%), Midwest (21.4%), and Northeast (14.6%). Compared to the West region, patients visiting the ED in the Midwest (OR = 0.75, 95% CI = 0.57-0.98) and Northeast (OR = 0.71, 95% CI = 0.51-0.98) had a lower odds of being diagnosed with a concussion. More patients sustained a NSRC MOI (94.3%) compared to SRC MOI (5.7%). For both mechanisms, the South region had the highest population-weighted frequency of SRC (n = 219,994) and NSRC diagnoses (n = 2,495,753). Univariate and multivariable logistic regression analyses did not reveal statistically significant associations for geographic region and MOI (p > 0.05).

CONCLUSION

Our findings showed that the Midwest and Northeast regions had a lower odds of concussion diagnoses in EDs. Overall, the vast majority of concussions were not sport-related, which has public health implications. These findings improve our understanding of how concussion injuries are being sustained geographically nationwide and help to explain care-seeking patterns for concussion in the ED setting.

Injury and Treatment Characteristics of Middle School-Aged Patients Under the Care of Athletic Trainers From 2010 to 2022: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Exploring sports-related musculoskeletal injuries and treatment characteristics in middle school sports may help inform patient care decisions such as appropriate medical coverage.

OBJECTIVE

To describe injury and treatment characteristics of middle school-aged athletes receiving care from athletic trainers within the Athletic Training Practice-Based Research Network (AT-PBRN).

DESIGN

Descriptive study.

SETTING

Middle school.

PATIENT OR OTHER PARTICIPANTS

Middle school-aged athletes (n = 1011; male = 503, female = 506, 2 declined to answer) with sports-related musculoskeletal injuries.

MAIN OUTCOME MEASURES

Electronic patient records were analyzed from the AT-PBRN from 59 athletic trainers across 14 states between 2010 and 2022. Summary statistics (frequency, percentages, median, and interquartile ranges [IQR]) were used to describe injury (age at injury, sex, sport, body part, and diagnosis) and treatment characteristics (type of treatment, number of visits, and number of procedures per visit).

RESULTS

Football (17.7%, n = 179), basketball (17.6%, n = 178), and soccer (14.9%, n = 151) reported the highest number of injuries. The ankle (17.2%, n = 174), knee (16.5%, n = 167), and head (14.1%, n = 143) were the most common injury locations. Concussion (13.0%, n = 131), ankle strain/sprain (12.4%, n = 125), and thigh/hip/groin sprain/strain (11.1%, n = 112) were the most reported diagnoses. Therapeutic exercise or activities (27.6%, n = 1068), athletic trainer evaluation or re-evaluation (24.7%, n = 957), and hot/cold packs (19.8%, n = 766) were the most common services, with a median of 2 visits (IQR = 1 to 4) and 2 procedures (IQR = 1 to 2) per visit.

CONCLUSIONS

Football, basketball, and soccer reported the most musculoskeletal injuries for middle school-aged athletes. Concussions were the most frequent diagnosis, followed by ankle sprains/strains. Our findings are similar to prior investigations at the high school and collegiate levels. Treatments at the middle school level were also similar to those that have been previously reported at the high school level with therapeutic exercise/activity, athletic trainer evaluation or re-evaluation, and hot/cold packs being the most common treatments. This information may be useful for informing patient care decisions at the middle-school level.

Sports-Related Concussion Is a Personalized Issue—Evaluation of Medical Assessment and Subjective Feeling of the Athlete in a German Level 1 Trauma Center

Sports-related concussions (SRC) have developed into a highly discussed topic in sports medicine over the last few years and demonstrate a severe issue in the personalized treatment of patients. This retrospective cohort study investigated 86 patients with sports-related concussions in a level 1 trauma center, relating to the mechanism, symptoms, medical history, acute therapy including first assessment and the return to sport. The research is based on medical records as well as questionnaires six months after hospitalization. Loss of consciousness for under 30 min (41.2%), headache (36.5%) and amnesia (29.4%) were the most frequent symptoms when presenting in the emergency room. During the hospitalization, mainly headache and vertigo were documented. Most concussions occurred after incidents in equitation and cycling sports; the most common mechanism was falling to the ground with a subsequent impact (59.3%). At the time of discharge from hospital, in 13.4% of all cases, concussion symptoms were still documented in medical records, in contrast to 39.5% of the concerned athletes who reported symptoms for longer than 24 h, and 41.0% who reported ongoing post-concussion symptoms after six months. Concussions are difficult-to-treat disorders with a challenging diagnostic process and many symptoms in various values and levels of persistence. Therefore, a patient-involving treatment with a complaint-dependent return to sport process should be applied to concerned athletes.

Cost and Treatment Characteristics of Sport-Related Knee Injuries Managed by Athletic Trainers: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Knee injuries are common during sport participation. However, little is known about the overall management and estimated direct costs of care associated with these injuries when under the care of athletic trainers.

OBJECTIVE

To describe the treatment characteristics and direct costs of care for athletic training services provided for patients with knee injuries.

DESIGN

Descriptive study.

SETTING

Ninety-five athletic training facilities across 24 states.

PATIENTS OR OTHER PARTICIPANTS

A total of 117 athletic trainers (females = 56.4%, age = 29.4 ± 8.7 years, years certified = 4.7 ± 6.0, years employed at site = 1.6 ± 4.1).

MAIN OUTCOME MEASURE(S)

Complete patient cases were identified using International Classification of Disease-10 diagnostic codes between 2009 and 2020. Summary statistics were calculated for patient demographics, treatment characteristics, and direct costs of care. Treatment characteristics included the type of athletic training service, duration, amount (eg, number of visits), and direct costs of care.

RESULTS

A total of 441 patient cases were included. The most common injuries reported were cruciate ligament sprain (18.1%, n = 80), medial collateral ligament sprain (15.4%, n = 68), and knee pain (14.1%, n = 62). Injuries occurred most frequently during football (35.4%, n = 156), basketball (14.7%, n = 65), and soccer (12.7%, n = 56). A total of 8484 athletic training services were recorded over 4254 visits, with therapeutic exercise (29.8%, n = 2530), hot or cold pack (25.8%, n = 2189), and therapeutic activities (11.2%, n = 954) being the most frequently reported services. The median duration of care was 23 days and number of visits was 8. The median total cost of care was $564 per injury and $73 per visit.

CONCLUSIONS

Patients with knee injuries demonstrated greater time loss than those with other lower extremity injuries. Thus, it is unsurprising that knee injuries were associated with a longer duration and higher cost of care than other lower extremity injuries such as ankle sprains. Future researchers should examine the effectiveness of common treatment strategies and aim to identify treatments that can reduce costs and improve patient outcomes.

Time to Authorized Clearance from Sport-Related Concussion: The Influence of Healthcare Provider and Medical Facility

CONTEXT

Return-to-play following sport-related concussion(SRC) requires authorized clearance from a healthcare provider(HCP). Variability in HCPs and facilities where athletes seek care may influence return time.

OBJECTIVE

Determine the initial examiner, HCPs that authorize clearance, and medical facilities authorizing clearance among high school student-athletes following SRC, and compare authorized clearance time by HCPs and medical facilities.

DESIGN

Prospective Cohort Study.

SETTING

High school.

PATIENTS OR OTHER PARTICIPANTS

Student-athletes(n=16,001) with SRC participating in STATE-XXX High School Athletic Association(XHSAA)-sponsored athletics.

MAIN OUTCOME MEASURE(S)

Frequencies of initial examiner and authorized clearance for each HCP(Doctor of Osteopathic Medicine(DO), Doctor of Medicine(MD), Nurse Practitioner(NP), Physician Assistant(PA)) and medical facility (Neurologist's Office, Team Physician, Primary Care Physician or Pediatrician's Office(PCP), Hospital, Urgent/Ready Care) for each SRC case. Kaplan-Meier curves and Peto tests evaluated differences in median time to authorized clearance between HCPs and facilities. Only cases with a follow-up authorized clearance date(80.3%, n=12,856) were included in authorized clearance and time to return analyses.

RESULTS

An athletic trainer was at least one of the initial examiners for 71.3%(n=11,404) of cases; 80.2%(n=12,990) had only one initial examiner. There was an association between initial examiner and medical facility providing clearance for athletic director(χ2=52.6, p≤.001, V=.06), athletic trainer(χ2=172.0, p≤.001, V=.12), coach(χ2=161.5, p≤.001, V=.11), DO(χ2=59.4, p≤.001, V= 07), and NP(χ2=10.0, p .03, V=.12). The majority(n=8,218, 63.9%) received clearance by an MD; 70.8%(n=9,099) were cleared at a PCP. Median time to authorized clearance varied by facility(Urgent/Ready Care: 7 days[4,11], Hospital: 9 days[6,14], PCP: 10 days[6,14], Team Physician: 12 days[8,16], Neurologist Office: 13 days[9,20]; p ≤ .001).

CONCLUSIONS

Clearance was frequently provided by an MD and at a PCP. Median time to return to unrestricted participation following SRC varied by HCP and medical facility. Future research should elucidate why differences exist and determine why athletes seek care at different medical facilities.

Research at the Point of Care: Using Electronic Medical Record Systems to Generate Clinically Meaningful Evidence

CONTEXT

Health care leaders have recommended the use of health information technology to improve the quality of patient care. In athletic training, using informatics, such as electronic medical records (EMRs), would support practice-based decisions about patient care. However, athletic trainers (ATs) may lack the knowledge to effectively participate in point-of-care clinical research using EMRs.

OBJECTIVES

To discuss the role of EMRs in athletic training and identify methodologic approaches to conducting clinical research at the point of care.

DESCRIPTION

The 2020 Commission on Accreditation of Athletic Training Education curricular content standards included the use of an electronic patient record to document care, mitigate error, and support decision making through the collection and use of patient data (Standard 64). Patient data are collected by ATs at the point of care via routine documentation, and these data can be used to answer clinical questions about their practice. Observational or descriptive study designs are ideal for this type of data. Observational research (ie, case-control, cross-sectional, cohort studies) evaluates factors that influence patients' lives in the "real world," whereas descriptive research (ie, case study or series, descriptive epidemiology studies) identifies characteristics of individuals and groups. If ATs are comprehensively documenting patient care using an EMR, they have the means to participate in observational and descriptive research.

CLINICAL AND RESEARCH ADVANTAGES

Using an EMR to its full capacity allows ATs to collect meaningful data at the point of care, conduct practice-based research, and improve health care for the patient and clinician. However, to ensure data quality, these approaches must include routine and comprehensive documentation habits.

A technology-enabled electronic incident report to document and facilitate management of sport concussion: A cohort study of youth and young adults

Despite the widespread awareness of concussion across all levels of sport, the management of concussion from youth to college is inconsistent and fragmented. A fundamental gap contributing to inconsistent care is the lack of a scalable, systematic approach to document initial injury characteristics following concussion. The purpose of this study was to determine differences in injury profiles and management of youth, high school, and college athletes using a mobile application for incident report documentation.A cohort study was conducted in which concussion electronic incident report data from 46 high schools and colleges, and Cleveland Clinic ambulatory concussion clinics were gathered and analyzed.In sum, 1421 (N = 88 youth, N = 1171 high school and N = 162 college) athletes with sport-related concussions were included.Despite the relative absence of red flags, youth athletes had a greater probability of being sent to the emergency department than high school and collegiate athletes. Over 60% of athletes were removed from play immediately post-injury. Injury recognition was delayed in 25% of athletes due to delayed symptom reporting (20% of males, 16% of females) or delayed symptom onset (5% of males, 9% of females). A significantly greater incidence of red flags was evident in males, and in high school and collegiate athletes compared to youth athletes.The high frequency of youth athletes sent to the emergency department, despite the absence of red flags, may be a reflection of inadequate medical coverage at youth events, ultimately resulting in unnecessary utilization of emergency medicine services. The relatively high incidence of delayed injury reporting implies that additional educational efforts targeting student-athletes and the utilization of resources to improve injury detection are warranted. The systematic collection of injury-related demographics through the electronic mobile application facilitated interdisciplinary communication and improved the efficiency of managing athletes with concussion.