Association Between Concussion History and Factors Relating to Cognitive, Behavioral, and Emotional Health Among American High School Athletes: A Cross-sectional Analysis

Cannabis Use in Adolescent and Young Adult Athletes: A Clinical Review

CONTEXT

Cannabis use among the general population has increased over time, in part due to decriminalization of use and greater social acceptance of cannabis use. These changes have contributed to increased availability of cannabis products, thus raising the likelihood that a subset of adolescent and young adult athletes will use cannabis. Therefore, it is imperative that clinicians and other providers working with young athletes have a thorough understanding of the impact cannabis can have on the athletic performance and overall health of a young athlete.

EVIDENCE ACQUISITION

PubMed (Medline), CINAHL, PsycINFO, and SportDiscus databases were used to perform a literature search of articles published between January 1, 2010 and December 31, 2022. Additional articles were reviewed based on references obtained from initial articles.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Survey studies suggest that up to 1 in 4 athletes have used cannabis at least once in the last year. Age, sex, race, sexual orientation, level of competition, and country of residence of an athlete all contribute to differing rates of cannabis use among athletes. The scientific literature does not support using cannabis for athletic performance, and multiple studies have demonstrated notable impairments in objective athletic performance measures. Cannabis use can also negatively impact an athlete's overall health via cardiovascular, gastrointestinal, and mental health symptoms and disorders.

CONCLUSION

Cannabis use among adolescent and young adult athletes is common, and rates of use are influenced by many different factors. Current evidence suggests that cannabis use can worsen sport performance, negatively impact an athlete's general health, and contribute to negative mental health outcomes.

Emotional Regulation and Adolescent Concussion: Overview and Role of Neuroimaging

Emotional dysregulation symptoms following a concussion are associated with an increased risk for emotional dysregulation disorders (e.g., depression and anxiety), especially in adolescents. However, predicting the emergence or worsening of emotional dysregulation symptoms after concussion and the extent to which this predates the onset of subsequent psychiatric morbidity after injury remains challenging. Although advanced neuroimaging techniques, such as functional magnetic resonance imaging and diffusion magnetic resonance imaging, have been used to detect and monitor concussion-related brain abnormalities in research settings, their clinical utility remains limited. In this narrative review, we have performed a comprehensive search of the available literature regarding emotional regulation, adolescent concussion, and advanced neuroimaging techniques in electronic databases (PubMed, Scopus, and Google Scholar). We highlight clinical evidence showing the heightened susceptibility of adolescents to experiencing emotional dysregulation symptoms following a concussion. Furthermore, we describe and provide empirical support for widely used magnetic resonance imaging modalities (i.e., functional and diffusion imaging), which are utilized to detect abnormalities in circuits responsible for emotional regulation. Additionally, we assess how these abnormalities relate to the emotional dysregulation symptoms often reported by adolescents post-injury. Yet, it remains to be determined if a progression of concussion-related abnormalities exists, especially in brain regions that undergo significant developmental changes during adolescence. We conclude that neuroimaging techniques hold potential as clinically useful tools for predicting and, ultimately, monitoring the treatment response to emotional dysregulation in adolescents following a concussion.

Mild Traumatic Brain Injury and Behavior and Sleep Among 9- and 10-Year Old Children: Initial Findings From the Adolescent Brain Cognitive Development (ABCD) Study

There has been concern about the potential sequelae of mild traumatic brain injury (mTBI) in children. This study used data from the Adolescent Brain Cognitive DevelopmentSM (ABCD) study to investigate associations between mTBI and behavior and sleep in school-aged children. Generalized additive mixed models were run to examine the association between TBI and parent-reported Child Behavior Checklist and Sleep Disturbance Scale for Children scores. mTBI with or without loss of consciousness (LOC) in 9- and 10-year old children was associated with 1) higher internalizing, externalizing and total problems and 2) greater sleep disturbance scores on the CBCL. The study also demonstrated a higher incidence of mTBI with and without LOC in boys compared to girls. This study shows a statistically significant but modest association between mTBI and behavioral and sleep changes, suggesting that in a non-clinical, sociodemographically diverse community sample of school-aged children mTBI does not result in clinically significant behavioral or psychological sequelae.

Exploring Vestibular/Ocular and Cognitive Dysfunction as Prognostic Factors for Protracted Recovery in Sports-Related Concussion Patients Aged 8 to 12 Years

OBJECTIVE

To explore the prognostic ability of the vestibular/ocular motor screening (VOMS), King-Devick (K-D) Test, and C3 Logix Trails A and B to identify protracted recovery from sports-related concussion (SRC) in patients aged 8 to 12 years.

DESIGN

Retrospective cohort analysis.

SETTING

Specialty pediatric sports concussion clinic.

PARTICIPANTS

A total of 114 youth athletes aged 8 to 12 years who were diagnosed with an SRC within 7 days of injury.

INDEPENDENT VARIABLES

A positive screen on the VOMS, K-D, and C3 Logix Trails A and Trails B. Combined positive screens on multiple tests (ie, 2, 3, or all 4 positive screens of 4 possible).

MAIN OUTCOME MEASURES

Recovery time in days and protracted recovery (recovery time ≥30-days) were the primary outcomes of interest.

RESULTS

A positive VOMS screen was associated with 1.31 greater days to SRC recovery ( P = 0.02) than a negative VOMS screen. The K-D and C3 Logix tests were not significantly associated with recovery time, nor were any combinations of tests ( P > 0.05). The VOMS demonstrated moderate prognostic ability to predict normal recovery (negative predictive value = 80.78% [95% CI = 63.73-90.95]). Overall predictive accuracy of normal versus protracted recovery was strongest when a participant screened positive on all 4 tests (Accuracy = 76.32% [95% CI = 67.45-83.78]).

CONCLUSIONS

The VOMS was associated with overall recovery time and proved to be a useful test to identify those who would experience a normal recovery time. Combining the 4 tests improved the prognostic accuracy of the protocol in predicting protracted versus normal recovery. These findings suggest that combining multiple, varied assessments of cognition and vestibular/ocular functions may better explain factors contributing to protracted recovery.

Presence of persistent parent reported emotional and behavioral-related concussion symptoms is associated with lower health-related quality of life in adolescent athletes

Persistent concussion symptoms in adolescents are associated with lower health-related quality of life (HRQOL). However, the association between persistent emotional and behavioral-related concussion symptoms (EBS) and HRQOL is unknown. This study was a prospective cohort of adolescent athletes presenting to a concussion clinic within three days post-concussion and completing a one-month follow up. The independent variable in these analyses was parent reported EBS symptom presence grouped as: 1) no EBS; 2) EBS present at pre-concussion levels; and 3) EBS worse than pre-concussion. EBS included the following concussion symptoms: feeling irritable, depressed, frustrated/impatient, restless, reduced tolerance to stress/emotion, poor concentration, and fear of permanent symptoms. Dependent variables were parent reported psychosocial, physical, and total HRQOL. Separate multivariable linear regression models controlling for age, sex, and concussion history were used to assess the association between EBS and HRQOL. Estimated adjusted mean differences (MD) and 95% confidence intervals (CI) were used to assess associations; MDs with a 95%CI excluding 0.0 were considered statistically significant. Overall, n=245 presented to the study clinic three days post-concussion and completed the one-month follow-up (Mage=14.28±2.09 years, 59.02% male, 90.64% Caucasian, 31.84% with concussion history). At one-month post-concussion, adolescents with pre-concussion EBS levels had significantly lower psychosocial, physical, and total HRQOL than those with no EBS. Additionally, those with EBS worse than pre-concussion had significantly lower psychosocial, physical, and total HRQOL than those with no EBS and EBS at pre-concussion levels. These findings highlight the importance of HRQOL assessments and that targeted interventions may be needed for those with EBS at one-month post-concussion to improve HRQOL.

Machine learning to predict sports-related concussion recovery using clinical data

OBJECTIVES

Sport-related concussions (SRCs) are a concern for high school athletes. Understanding factors contributing to SRC recovery time may improve clinical management. However, the complexity of the many clinical measures of concussion data precludes many traditional methods. This study aimed to answer the question, what is the utility of modeling clinical concussion data using machine-learning algorithms for predicting SRC recovery time and protracted recovery?

METHODS

This was a retrospective case series of participants aged 8 to 18 years with a diagnosis of SRC. A 6-part measure was administered to assess pre-injury risk factors, initial injury severity, and post-concussion symptoms, including the Vestibular Ocular Motor Screening (VOMS) measure, King-Devick Test and C3 Logix Trails Test data. These measures were used to predict recovery time (days from injury to full medical clearance) and binary protracted recovery (recovery time > 21 days) according to several sex-stratified machine-learning models. The ability of the models to discriminate protracted recovery was compared to a human-driven model according to the area under the receiver operating characteristic curve (AUC).

RESULTS

For 293 males (mean age 14.0 years) and 362 females (mean age 13.7 years), the median (interquartile range) time to recover from an SRC was 26 (18-39) and 21 (14-31) days, respectively. Among 9 machine-learning models trained, the gradient boosting on decision-tree algorithms achieved the best performance to predict recovery time and protracted recovery in males and females. The models' performance improved when VOMS data were used in conjunction with the King-Devick Test and C3 Logix Trails Test data. For males and females, the AUC was 0.84 and 0.78 versus 0.74 and 0.73, respectively, for statistical models for predicting protracted recovery.

CONCLUSIONS

Machine-learning models were able to manage the complexity of the vestibular-ocular motor system data. These results demonstrate the clinical utility of machine-learning models to inform prognostic evaluation for SRC recovery time and protracted recovery.

Sports- and Physical Activity-Related Concussions, Binge Drinking and Marijuana Use among Adolescents: The Mediating Role of Depression and Suicidal Ideation

BACKGROUND

Although past studies have examined the adverse impact of sports- and physical activity-related concussions (SPACs) on health and mental health outcomes, there is a dearth of research investigating the association between SPACs and binge drinking and marijuana use.

OBJECTIVE

The objective of this study is to examine the cross-sectional association between SPACs and binge drinking and marijuana use among adolescents and whether symptoms of depression and suicidal ideation mediate this association.

METHODS

Data for this study came from the 2017 and 2019 National Youth Risk Behavior Survey. An analytic sample of 17,175 adolescents aged 14-18 years (50.2% male) was analyzed using binary logistic regression.

RESULTS

Of the 17,175 adolescents, 13.7% engaged in binge drinking and 19.3% used marijuana 30 days preceding the survey date. Approximately one in seven (14.1%) adolescents had SPACs during the past year. Upon controlling for the effects of other factors, adolescents who had SPACs had 1.74 times higher odds of engaging in binge drinking (AOR = 1.74, p<.001, 95% CI = 1.47-2.06) and 1.42 times higher odds of using marijuana (AOR = 1.42, p<.001, 95% CI = 1.24-1.62) than those who did not have SPACs. Symptoms of depression and suicidal ideation explained 12% of the association between SPACs and binge drinking, and 19% of the association between SPACs and marijuana use.

CONCLUSIONS

Understanding the association between SPACs and substance use and mental health could contribute to early identification of adolescents who may engage in substance use.

Prescription Opioid Misuse and Sports-Related Concussion Among High School Students in the United States

STUDY OBJECTIVE

Concussion is highly prevalent in adolescents and associated with a higher risk of substance use. With the rising use of opioids among adolescents, one form of substance use of concern is the misuse of prescription opioids. This study aimed to examine the association between a history of sports-related concussion in the past year and current prescription opioid misuse among high school students in the United States.

SETTING

Secondary data analysis from the 2019 Youth Risk Behavior Survey.

PARTICIPANTS

Nationally representative sample of high school students (n = 7314).

DESIGN

Cross-sectional study.

MAIN MEASURES

Participants were asked whether they experienced any concussions related to sports or being physically active during the past 12 months and whether they had any prescription opioid misuse within the past 30 days.

RESULTS

Among this cohort, 14.0% reported sustaining a concussion in the past 12 months and 6% reported current prescription opioid misuse. The prevalence of prescription opioid misuse was higher among those with a history of concussion (9.9%) than among those without concussion (5.5%, P = .002). Controlling for covariates (sex, race/ethnicity, other substance use, depressive symptoms), the odds of prescription opioid misuse was 1.5 times higher for adolescents with concussion than those without (adjusted odds ratios [aOR] = 1.5; 95% CI, 1.0-2.3; P = .029).

CONCLUSION

Concussion was associated with prescription opioid misuse among the US youth, even after accounting for depressive symptoms and other substance use. Longitudinal studies are needed to test causal relationships and understand biobehavioral mechanisms that underlie associations between concussion and opioid misuse in adolescents.

An Integrative Review of Return to Driving After Concussion in Adolescents

Concussion is a common injury among adolescents. It is unknown how a concussion affects driving behavior and performance in adolescents. Although there are guidelines for return to learn, exercise, and sports that school nurses can help support in school, little is known about return to driving after concussion. The goal of this integrative review was to summarize the current literature on return to driving after concussion in adolescents. Six articles published between 2016 and 2020 were included in the review. Physicians and nurse practitioners find providing driving recommendations to adolescents to be appropriate; however, they are unclear what metrics to use to determine whether a patient is fit to drive. Future studies should explore clinical predictors of readiness to return to driving in adolescents. School nurses have an opportunity to support adolescents in their resumption of typical activities after concussion including school, sports, and, as more evidence becomes available, driving.