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

Does early exercise intolerance effect time to return to play, symptom burden, neurocognition, Vestibular-Ocular-Motor (VOM) function and academic ability in acutely concussed student-athletes?

INTRODUCTION

Early Exercise Intolerance (EEI) is associated with delayed recovery and longer time to Return To Play (RTP), but this has not been established.Participants; (n = 52, male n = 30) UK university-aged rugby-union student-athletes.

METHODS

Student-athletes completed baseline screening (July-October 2021 and 2022). The test battery was repeated within 48 h, 4, 8 and 14 days after a Sports-Related Concussion (SRC) with the Buffalo Concussion Bike or Treadmill Test to set sub-symptom heart rate threshold. Student-athletes then completed a controlled early exercise protocol in-between reassessment (days 3, 5-7 and 9-13). Those with EEI were compared to those with early-exercise tolerance.

OUTCOME MEASURES

Post-Concussion Symptom Scale, Immediate Post-Concussion and Cognitive Test, Vestibular-Ocular Motor Screening Tool and the Revised Perceived Academic Impact Tool.

RESULTS

EEI was seen throughout the initial 14-days post-SRC (23.8%, 22.4%, 25.5%. 25.0%). EEI was associated with a slower reaction time within 48 h (-0.01 (-0.030-0.043) Vs 0.06 (0.033-0.24), p = 0.004) and greater VOMS scores within 48 h; (0.00 (0.00-4.00) Vs 5.50 (2.75-9.00), p = 0.016) and 4 days (0.00 (0.00-2.00) Vs 5.00 (0.00-6.00), p = 0.044). RTP was 12.5 days longer in those with EEI at 14-days post-SRC.

CONCLUSION

EEI is prevalent following an SRC in university-aged student-athletes and was associated with delayed recovery and RTP.

Moving from the clinic to telehealth during the COVID-19 pandemic - a pilot clinical trial comparing in-clinic rehabilitation versus telerehabilitation for persisting symptoms following a mild Traumatic brain injury

PURPOSE

The objective of this study was to compare the effects of an in-clinic cervicovestibular rehabilitation program (education, home exercises, manual techniques, sub-symptom threshold aerobic exercise [STAE] program) to a similar program (education, home-exercises, STAE program), but without manual techniques, provided in a telerehabilitation format in adults with persisting post-concussion symptoms (PCS).

MATERIALS AND METHODS DESIGN

In this parallel-group non-randomized clinical trial, 41 adults with persisting PCS were allocated to the in-clinic (n = 30) or telerehabilitation (n = 11) program. The outcome measures, which included the Post-Concussion Symptom Scale (PCSS; primary outcome), Numerical Pain Rating Scale (NPRS) for neck pain and headache and three disability questionnaires, were collected at baseline, weeks 6, 12, and 26. Non-parametric analysis for longitudinal data (NparLD) was used.

RESULTS

For the PCSS, there was a group-by-time interaction (p = 0.05) with significant between-group differences at week 6, 12, and 26 (p < 0.05) for the in-clinic group. There were also group-by-time interactions for NPRS neck pain and headache (p < 0.05) for the in-clinic group.

CONCLUSION

The study suggests that a telehealth format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement. These results must be interpreted with caution given the limited number of participants. ClinicalTrials.gov Identifier: NCT03677661.IMPLICATION FOR REHABILITATIONThe telerehabilitation format for adults with persisting post-concussion symptoms was widely implemented in the COVID-19 pandemic without any evidence of efficacy over the more traditional in-clinic rehabilitation format.The study suggests that a telerehabilitation format failed to reach the efficiency of an in-clinic rehabilitation program in terms of symptoms reduction and functional improvement.Clinicians should try to incorporate some in-clinic appointments when a telerehabilitation format is required such as for patients in underserved area.

Variables associated with days of school missed following concussion: results from the Sport Concussion Outcomes in PEdiatrics (SCOPE) study

OBJECTIVE

To understand factors associated with missed academic time after concussion to improve support for patients. Our goal was to assess patient-specific predictors of total school time lost after pediatric/adolescent concussion.

STUDY DESIGN

We performed a prospective cohort study of children and adolescents (8-18 years of age) seen within 14 days of concussion from seven pediatric medical centers across the United States. We collected outcomes via the Concussion Learning Assessment & School Survey (CLASS) and constructed a multivariable predictive model evaluating patient factors associated with school time loss.

RESULTS

167 patients participated (mean age = 14.5 ± 2.2 years; 46% female). Patients were assessed initially at 5.0 ± 3.0 days post-injury and had a final follow-up assessment 24.5 ± 20.0 days post-concussion. Participants missed a median of 2 days of school (IQR = 0.5-4), and 21% reported their grades dropped after concussion. Higher initial symptom severity rating (β = 0.06, 95% CI = 0.03-0.08, p < 0.001) and perception of grades dropping after concussion (β = 1.37, 95% CI = 0.28-2.45, p = 0.01) were significantly associated with more days of school time missed after concussion. Those who reported their grades dropping reported missing significantly more school (mean = 5.0, SD = 4.7 days missed of school) than those who reported their grades did not drop (mean = 2.2, SD = 2.6 days missed of school; p < 0.001; Cohen's d = 0.87).

CONCLUSIONS

Children and adolescents reported missing a median of 2 days of school following concussion, and more missed school time after a concussion was associated with more severe concussion symptoms and perception of grades dropping. These findings may support recommendations for minimal delays in return-to-learn after concussion.

Current Concussion Knowledge, Beliefs, Education, and Management Practices Among Irish Post-Primary PE Teachers

Purpose: Physical education (PE) teachers play an important role in concussion recognition and management in schools both in an academic and activity based setting. This study aimed to identify Irish post-primary PE teachers' concussion knowledge, beliefs, education and management practices. Methods:  An anonymous online survey, adapted to the Irish context from the validated BAKPAC-TEACH, was completed by 128 PE teachers (female = 74/123; 60.2%; male = 49/123; 39.8%, 36.1 ± 10.9 years), representing 4% of registered PE teachers in Ireland. Results: PE teachers reported 3.5 ± 4.7 students suffer with a sports-related concussion in their classroom annually and 43.9% previously had a student sustain a concussion during their PE class. Most received concussion education (58.6%), largely provided by sporting bodies. They frequently identified dizziness (93.0%) and headaches (92.2%) as concussion symptoms, but less commonly emotional (more emotional = 36.5%, nervous or anxious = 33.6%, sadness = 28.9%) or sleep (35.2%) symptoms. All PE teachers knew that a concussion requires immediate removal from a game/practice. PE teachers demonstrated less perceived knowledge and confidence relating to academic adjustments and return to learn criteria. Just 31.3% reported their school facilitates academic adjustments. Conclusion: Tailored concussion education addressing knowledge gaps highlighted in this study should be developed. A concussion policy and an academic support team in each school should be established and widely publicised to enhance the support of concussed students in returning to school.

Factors Influencing Time to Return to Learn Among NCAA Student-Athletes Enrolled in the Concussion Assessment, Research, and Education (CARE) Study

PURPOSE

The aim was to describe the demographic and post-injury factors that influence time to return to learn (RTL) among student-athletes enrolled in the Concussion Assessment, Research and Education (CARE) Consortium.

METHODS

A total of 47,860 student-athletes enrolled in the National Collegiate Athletic Association-Department of Defense (NCAA-DoD) CARE Consortium study from 2014 to 2020, with 1485 sport-related concussions (SRCs) analyzed in the present dataset. Demographic and post-injury characteristics were calculated using descriptive statistics, followed by Kaplan-Meier estimates to examine median time to return to normal academic performance (i.e., RTL) by sex (male, female), baseline psychiatric conditions (depression, anxiety) and/or learning disorder, NCAA division (I, II, III), SRC history (0, 1, 2, 3+), NCAA sport category (contact, limited contact, non-contact sport), and median difference in baseline/post-injury symptom severity scores (< 21, ≥ 21). Further, a multivariable zero-inflated negative binomial (ZINB) regression model was used to examine their association with RTL.

RESULTS

Overall, time to RTL (mean = 4.96 ± 8.24 days, median = 3.0 [interquartile range = 0.0, 6.0] days) was found to be influenced by several factors resulting in earlier trajectories. Notably, nearly 25% of the sample demonstrated immediate RTL (i.e., 0 days). Among student-athletes who did not immediately RTL, males demonstrated a decreased rate in RTL (rate = 0.79; 95% CI 0.66-0.96) compared to females. Further, student-athletes with a ≥ 21 change in symptom severity score (post-injury baseline) demonstrated a higher rate of RTL (rate = 1.47; 95% CI 1.21-1.79) compared to student-athletes with a symptom severity change score < 21. Lastly, male student-athletes demonstrated two times higher odds (odds ratio = 1.95; 95% CI 1.02-3.73) of immediate RTL compared to female student-athletes. No other covariates were associated with time to RTL.

CONCLUSION

Collectively, the present findings suggest a rapid return to the classroom following concussion. Specifically, males demonstrated higher odds of time to RTL, whereas those with greater differences in symptom severity resulted in a higher rate of time to RTL among those who did not immediately RTL. Ultimately, these findings support prior work emphasizing an individualized approach to SRC management.

An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion

OBJECTIVE

Pediatric athletes with concussion present with a variety of impairments on clinical assessment and require individualized treatment. The Buffalo Concussion Physical Examination is a brief, pertinent clinical assessment for individuals with concussion. The purpose of this study was to identify physical examination subtypes in pediatric athletes with concussion within 2 weeks of injury that are relevant to diagnosis and treatment.

DESIGN

Secondary analysis of a published cohort study and clinician consensus.

SETTING

Three university-affiliated sports medicine centers.

PARTICIPANTS

Two hundred seventy children (14.9 ± 1.9 years).

INDEPENDENT VARIABLES

Orthostatic intolerance, horizontal and vertical saccades, smooth pursuits, vestibulo-ocular reflex, near-point convergence, complex tandem gait, neck range of motion, neck tenderness, and neck spasm.

MAIN OUTCOME MEASURES

Correlations between independent variables were calculated, and network graphs were made. k-means and hierarchical clustering were used to identify clusters of impairments. Optimal number of clusters was assessed. Results were reviewed by experienced clinicians and consensus was reached on proposed subtypes.

RESULTS

Physical examination clusters overlapped with each other, and no optimal number of clusters was identified. Clinician consensus suggested 3 possible subtypes: (1) visio-vestibular (horizontal and vertical saccades, smooth pursuits, and vestibulo-ocular reflex), (2) cervicogenic (neck range of motion and spasm), and (3) autonomic/balance (orthostatic intolerance and complex tandem gait).

CONCLUSIONS

Although we identified 3 physical examination subtypes, it seemed that physical examination findings alone are not enough to define subtypes that are both statistically supported and clinically relevant, likely because they do not include symptoms, assessment of mood or cognitive problems, or graded exertion testing.

Policy Analysis of Return to Learn After Sport and Recreational Related Concussion for Secondary Schools in New England: Relevance to School Nurses and Nursing Practice

Return to learn (RTL) is the individualized process of coordinating cognitive care and reintegration for students into the academic setting after any sport and recreational-related concussion (SRRC). The guidelines for RTL are based on empirical evidence, however, implementation differs by institution. The purpose of the policy analysis is to evaluate RTL guidelines after SRRC of student-athletes in New England secondary school public school systems. A review of the six New England states' policies surrounding RTL was conducted. The Comprehensive Analysis of Physical Activity Framework was referenced to identify the analytic components of existing legislation and because of the relatively new implementation of RTL-specific policy, a novel policy analysis tool was utilized. States with RTL-specific language scored on average 7.9 to 11.1 points higher when compared to states without RTL-specific language. This difference was associated with disparities in access to RTL resources for residents according to their geographic location. Lobbying efforts should be targeted toward states without RTL-specific language to provide equal care and opportunities for student-athletes to receive RTL services. RTL policy provides a responsibility to assist students who have suffered from an SRRC and can serve to improve health outcomes and academic achievement.

Risk of impaired school performance in children hospitalized with concussion: a population-based matched cohort study

Aim

To examine the impact of concussion on objective measures of school performance.

Materials & methods

Population-based matched cohort study using linked health and education records of young people aged ≤18 years hospitalized with concussion in New South Wales, Australia, during 2005-2018, and matched comparisons not hospitalized with any injury.

Results

Young people with concussion had higher risk of not achieving the national minimum standards for literacy and numeracy assessments, ranging from 30% for numeracy to 43% for spelling, and not completing high school, ranging from 29% for year 10 to 77% for year 12, compared with matched peers.

Conclusion

Young people hospitalized with concussion have impaired school performance compared with uninjured matched peers.

"Alone in the dark": A qualitative study of treatment experiences among young adults with a recent concussion and anxiety

PURPOSE

Young adults with anxiety are vulnerable to developing persistent symptoms following concussions. In order to develop psychosocial interventions to prevent persistent post-concussion symptoms, we need to understand patients' 1) experiences with treatments offered by health care providers; 2) experiences with attempted concussion management strategies; and 3) needs after their injury.

METHODS

We conducted in-depth interviews with 17 young adults with recent (≤ 10 weeks) concussions who have at least mild anxiety (Generalized Anxiety Disorder Assessment-7 ≥ 5). We used a hybrid deductive-inductive approach to thematic analysis.

RESULTS

Findings provide insight into recommended treatments (e.g., active/avoidant strategies, accommodations, referrals), attempted strategies (e.g., lifestyle changes, pacing, relationships, acceptance-based coping skills), and patient needs (e.g., education, accommodations, referrals for cognitive and emotional skills). Participants frequently expressed that treatment recommendations were confusing and difficult to implement. They initiated non-prescribed strategies that helped promote recovery and expressed a desire for more interdisciplinary treatment and education on concussions.

CONCLUSION

Patients' perceptions of health care provider recommendations after concussions did not fully meet patients' perceived needs. Young adults with concussions and anxiety would benefit from more education, guidance, and psychosocial and rehabilitation services. Addressing these gaps may help align treatments with patients' needs and therefore help optimize their recovery.

Investigating the Student in Returning to Learn After Concussion: A Systematic Review and Meta-Analysis

PURPOSE

Examine concussion effects on academic outcomes, including student perspectives.

METHODS

This study included a systematic review and meta-analysis examining post-concussion school attendance, academic performance, perceptions of academic difficulty, and accommodations for students in elementary through college settings. The analysis considered pre- and post-injury factors, along with injury factors that contribute to post-concussion academic outcomes.

RESULTS

The systematic review showed that students with concussion miss more school days and perceive higher levels of academic difficulty, but results about academic performance varied. Meta-analysis yielded small concussion effects on school absence and academic performance and moderate effects on perceptions of academic difficulty. Female sex, older age, history of migraine, prior concussions, severe or persistent symptoms, vestibular-ocular motor, and cognitive disruptions are risk factors, but these moderators were not identified in the meta-analysis due to lack of effect sizes.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

This study confirmed negative concussion effects on academic absences, performance, and perceptions of academic difficulty. Identified contributing factors will guide future practices to support students returning to learn after concussion.

CONCLUSIONS

Negative impacts to academics from concussion may be amplified by complicating factors. Future investigations are needed to confirm risk factors and mitigating effects of early identification and post-injury supports.

Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis

OBJECTIVE

To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

8 databases searched through 22 March 2022.

ELIGIBILITY CRITERIA

Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool.

RESULTS

278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I²=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I²=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I²=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns.

CONCLUSION

Most athletes have full RTL by 10 days but take twice as long for an RTS.

PROSPERO REGISTRATION NUMBER

CRD42020159928.

Comprehensive policies for victims of sexual assault returning to the campus classroom: Lessons from university sports-related concussion policies

ObjectiveThe current paper presents a comparison of university policies and health and academic accommodations offered to undergraduate students following sexual assault (SA) and sports-related concussions (SRC). Procedures and protocols for universities to consider adapting from their SRC policies to their SA policies are detailed.Participants: The SRC and SA policies at the 50 United States public flagship universities were analyzed.Methods: The research team coded for a number of policy details including health referrals, academic and financial accommodations, and requirements for follow-up with university personnel.Results: Compared to SA polices, SRC policies at the public flagship universities offer more comprehensive academic accommodations and physical and mental health resources. Conclusions: Comprehensive policies for student SA survivors, like those available for students who suffer SRCs, would improve student health and academic outcomes and increase SA survivors' likelihood of graduating college, thereby reducing individual and societal human capital loses.

The SUCCESS Peer Mentoring Program for College Students with Concussion: Preliminary Results of a Mobile Technology Delivered Intervention

Concussions are caused by a hit or blow to the head that alters normal brain functioning. The Success in College after Concussion with Effective Student Supports (SUCCESS) program was developed to provide students with psychosocial support and resources-both key components of concussion management-to assist in recovery and return-to-learn following concussion. In this preliminary evaluation of intervention efficacy, SUCCESS was delivered through a mobile application connecting mentors (students who have recovered from concussion and successfully returned to school) with mentees who were currently recovering. Mentor-mentee pairs met virtually through the app, using chat and videoconferencing features to share support, resources, and program-specific educational materials. Results from 16 mentoring pairs showed that mentee symptoms (V = 119, p = 0.009) and academic problems decreased (V = 114.5, p = 0.002), while academic self-efficacy increased (V = 13.5, p = 0.009) following mentoring. As expected, mentor measures were stable, indicating that providing mentoring did not exacerbate previously resolved concussion complaints. Virtual peer mentoring provided through a mobile application may be a feasible intervention to support academic success and psychosocial processing during recovery for college students with concussion.

Exercise-Induced Vision Dysfunction Early After Sport-Related Concussion Is Associated With Persistent Postconcussive Symptoms

OBJECTIVE

The purpose of this study was to determine if exercise-induced vision dysfunction [reduced performance and/or symptom exacerbation on a post-exercise King-Devick (KD) test] in adolescents early after sport-related concussion was associated with increased risk of persistent post-concussive symptoms (PPCS, recovery >28 days). We used exercise as a provocative maneuver before the KD test, hypothesizing that concussed adolescents with exercise-induced vision dysfunction would be more likely to develop PPCS.

DESIGN

Secondary analysis of data from a multi-center, randomized clinical trial comparing KD test performance before and after the Buffalo Concussion Treadmill Test in adolescents within 10 days of sport-related concussion who were randomized to aerobic exercise or placebo stretching program.

SETTING

Three university-associated sports medicine clinical programs.

PARTICIPANTS

Ninety-nine adolescents with sport-related concussion (exercise group: n = 50, 15.3 ± 1 years, 60% M, 22% with PPCS; stretching group: n = 49, 15.9 ± 1 years, 65% M, 35% with PPCS) tested a mean of 6 ± 2 days from injury.

INDEPENDENT VARIABLE

King-Devick test performed immediately before and 2 minutes after Buffalo Concussion Treadmill Test.

MAIN OUTCOME MEASURE

Persistent post-concussive symptoms.

RESULTS

Adolescents who demonstrated exercise-induced vision dysfunction upon initial evaluation developed PPCS at a significantly greater rate when compared with adolescents who did not (71% vs 34%, P < 0.001). Exercise-induced vision dysfunction corresponded to a relative risk of 3.13 for PPCS.

CONCLUSIONS

Adolescents with exercise-induced vision dysfunction had a 3-fold greater relative risk of developing PPCS than those without exercise-induced vision dysfunction.

Reconceptualizing Recovery After Concussion: A Phenomenological Exploration of College Student Experiences

PURPOSE

Typical measures of recovery from concussion-such as symptom scales, neurocognitive testing, or exertion measures-may not capture individualized experiences of concussion. This report examines how college students with concussion interact with and consider their recovery.

METHOD

Sixteen college students who sustained concussions while in college completed 40- to 75-min semistructured interviews. All were enrolling to become mentors in a peer mentoring program for students with concussion. Questions addressed experiences as a college student with concussion, life changes following concussion, and role of peers in recovery. Using phenomenological reduction, analysis focused on the phenomenon of recovery and motivation for participation in a mentoring program.

RESULTS

Two main themes were found: (a) What Recovery Looks Like and (b) Gaining Perspective, Learning to Cope and Adapting to Change. Thirteen participants denied the label of "recovered" even though all had been deemed recovered and discharged from medical care. Instead, two subthemes emerged within What Recovery Looks Like: Ongoing Recovery and Reconceptualizing Recovery. Perceptions of recovery were influenced by effort, capacity, and resilience. In the second theme, students described strategies, resources, and supports used to cope with their injuries; most commonly used was emotion-focused coping.

CONCLUSIONS

College students with concussion consider recovery as an ongoing process rather than a dichotomized condition. Student experiences may not be reflected in commonly used symptom scales or objective assessments.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21084925.

The Impact of a Recent Concussion on College-Aged Individuals with Co-Occurring Anxiety: A Qualitative Investigation

College-aged individuals with anxiety are vulnerable to developing persistent concussion symptoms, yet evidence-based treatments for this population are limited. Understanding these individuals' perspectives is critical for developing effective interventions. We conducted qualitative interviews with 17 college-aged individuals (18-24 years old) with a recent (≤10 weeks) concussion and at least mild anxiety (≥5 on the GAD-7 questionnaire) to understand the life impact of their concussion. We identified 5 themes: (1) disruption to daily activities (e.g., reduced participation in hobbies and physical activity); (2) disruption to relationships (e.g., reduced social engagement, feeling dismissed by others, stigma, and interpersonal friction); (3) disruptions in school/work (e.g., challenges participating due to light sensitivity, cognitive or sleep disturbance, and related emotional distress); (4) changes in view of the self (e.g., feeling "unlike oneself", duller, or more irritable), and (5) finding "silver linings" after the injury (e.g., increased motivation). Concussions impact the lives of college-aged individuals with co-occurring anxiety in a broad range of domains, many of which remain largely neglected in standard concussion clinical assessment and treatment. Assessing and addressing these issues has the potential to limit the negative impact of concussion, promote recovery, and potentially help prevent persistent concussion symptoms in this at-risk population.

Concussion Public Policy in Elementary and High Schools in Ontario, Canada: A Cross-Sectional Survey to Examine Implementation Compliance, Barriers, and Facilitators

BACKGROUND

Concussion public policies have been developed to address the burden of concussions. The aim of the present study was to examine implementation compliance, barriers, and facilitators of Canada's first concussion public policy, Ontario's Policy/Program Memorandum 158: School Board Policies on Concussion (PPM158).

METHODS

An electronic survey was sent to 515 randomly selected elementary and high school principals across specific geographic, language, and publicly funded school types in Ontario. Data were analyzed using both qualitative and quantitative methods.

RESULTS

One hundred and thirty-five principals responded to the survey (26%). Concussion education was provided to teachers in 81% of schools, to students in 83%, and coaches in 79%. Additionally, 89% reported having a return-to-learn protocol in place and 90% reported having a return-to-play protocol. Implementation barriers included difficulties in providing concussion education to parents (42%), obtaining notes from physicians, and maintaining the volume of documentation. Eighty-seven percent of respondents believed that PPM158 improves student well-being.

CONCLUSIONS

Identified implementation barriers and facilitators can inform concussion policy practices to improve student well-being. We recommend: (1) an appointed concussion policy lead at each school, (2) electronic documentation, (3) determining the optimal education format to improve parent/guardian education, (4) fostering relationships between schools and health care professionals, and (5) student concussion education in every grade in Ontario schools.

Perceptions of Concussion and Associated Anxiety in Irish Collegiate Athletes

BACKGROUND

Concussion nondisclosure and poor management after a concussion are a concern in Irish collegiate sports. How athletes perceive concussions and appraise their own concussion may affect their decisions and behaviors after a suspected concussion. However, this has yet to be examined in an Irish context. This study aimed to (1) establish concussion perceptions and associated anxiety in Irish collegiate athletes; (2) examine how sex, concussion, and mood disorder history influenced their perceptions; and (3) investigate factors associated with higher anxiety perceptions.

HYPOTHESIS

Irish collegiate athletes will display negative concussion perceptions and anxiety related to concussion, especially in female athletes and those without a concussion history.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Irish collegiate athletes [n = 268 (141 women,127 men), mean age = 21.5 ± 2.2 years] from high-risk sports completed a survey including the Perceptions of Concussion Inventory for Athletes (PCI-A), demographics, diagnosed concussion history, self-reported mood disorder history, and a concussion knowledge assessment. Differences in concussion perceptions by sex, concussion history, mood disorder history were examined using Mann-Whitney U tests, and factors associated with anxiety-related concussion perceptions were identified using multivariate logistic regression.

RESULTS

Over half (53.0%, n = 142) of participants reported concerns regarding concussion. The thoughts of sustaining a concussion made participants feel upset (63.4%, n = 170), fearful (47.7%, n = 128), and anxious (35.1%, n = 94). Women reported significantly higher anxiety (P < 0.01, r = 0.23), effects (P = 0.04, r = 0.12), and clarity (P = 0.01, r = 0.16) perception scores. Participants with a diagnosed concussion history displayed greater symptom variability perception scores (P = 0.04, r = 0.12), but lower anxiety (P = 0.03, r = 0.13) and treatment (P < 0.01, r = 0.19) beliefs on the PCI-A. No differences were observed for those with a history of a mood disorder (P > 0.05). A significant multivariate model was established (χ² = 55.44, P < 0.01), with female sex [odds ratio (OR) = 1.53], concussion history (OR = 0.63), effects (OR = 1.31), and treatment (OR = 1.15) subscales associated with greater anxiety.

CONCLUSION

Concerns about sustaining a concussion are prevalent in Irish collegiate athletes. Women displayed more negative perceptions and those with a concussion history displayed fewer perceived benefits of treatment.

CLINICAL RELEVANCE

The findings support the need for concussion awareness campaigns to provide accurate concussion information to mitigate anxiety-related concussion perceptions and injury belief misconceptions.

Academic skills, self-perceptions, and grades in university students with a history of multiple concussions: The mediating roles of processing speed and psychological symptoms

This study determined if university students with a history of multiple concussions may be at risk for academic difficulties and poor academic performance. We investigated if executive functioning, processing speed, and/or psychological symptoms might partially account for differences in academic performance of students with and without a history of multiple concussions.

University students with a history of three or more concussions (n = 58), one concussion (n = 57), or no concussion (n = 57) completed academic, cognitive, and psychological assessments.

Students with a history of multiple concussions read fewer words per minute and reported more learning difficulties than the no concussion group. Processing speed mediated the association between concussion status and reading rate. Psychological symptoms mediated the association between concussion status and self-reported learning difficulties.

University students with a history of multiple concussions may be at risk for poor academic outcomes due, at least in part, to slower processing speed and psychological symptoms.Treatment of psychological symptoms, cognitive rehabilitation to augment processing speed, and academic accommodations might improve academic outcomes for students with a history of three or more concussions.

Association of Concussion History and Prolonged Recovery in Youth

OBJECTIVE

To determine the number of prior concussions associated with increased incidence of persistent postconcussive symptoms (PPCS) in a cohort of acutely concussed pediatric patients.

DESIGN

Prospective observational cohort study.

SETTING

Three university-affiliated concussion clinics.

PARTICIPANTS

Two hundred seventy participants (14.9 ± 1.9 years, 62% male, 54% with prior concussion) were assessed within 14 days of concussion and followed to clinical recovery. Participants with a second head injury before clinical recovery were excluded.

MEASURES AND MAIN OUTCOME

Concussion history, current injury characteristics, recovery time, and risk for prolonged recovery from current concussion.

RESULTS

There was no statistically significant change in PPCS risk for participants with 0, 1 or 2 prior concussions; however, participants with 3 or more prior concussions had a significantly greater risk of PPCS. Twelve participants sustained a subsequent concussion after clinical recovery from their first injury and were treated as a separate cohort. Our secondary analysis found that these participants took longer to recover and had a greater incidence of PPCS during recovery from their latest concussion.

CONCLUSION

Pediatric patients with a history of 3 or more concussions are at greater risk of PPCS than those with fewer than 3 prior concussions.

Responsiveness of the Post-Concussion Symptom Scale to Monitor Clinical Recovery After Concussion or Mild Traumatic Brain Injury

Background

The Post-Concussion Symptom Scale (PCSS) is used to assess the number and intensity of symptoms after a concussion/mild traumatic brain injury. However, its responsiveness to monitor clinical recovery has yet to be determined.

Purpose

To evaluate the responsiveness of the PCSS to change and longitudinal validity in patients with persistent postconcussive symptoms as well as to explore the responsiveness of other clinical outcome measures to monitor recovery of physical symptoms in patients with persistent postconcussive symptoms.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

Patients with persistent symptoms after a concussion (N = 109) were evaluated using self-reported questionnaires at baseline and after a 6-week rehabilitation program. The program consisted of an individualized symptom-limited aerobic exercise program combined with education. Questionnaires included the PCSS, Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), and Numeric Pain Rating Scale (NPRS) related to 1) neck pain and 2) headache. Internal responsiveness was evaluated using the effect size (ES) and standardized response mean (SRM), and external responsiveness was determined with the minimal clinically important difference (MCID) calculated using a receiver operating characteristic curve. The global rating of change was used as the external criterion. Pearson correlations were used to determine the longitudinal validity.

Results

The PCSS was highly responsive (ES and SRM, >1.3) and had an MCID of 26.5 points (of 132) for the total score and 5.5 (of 22) for the number of symptoms. For longitudinal validity, low to moderate correlations were found between changes in PCSS and changes in NDI, HDI, and DHI. The NDI, HDI, DHI, and NPRS were also highly responsive (ES and SRM, >0.8).

Conclusion

All questionnaires including the PCSS were highly responsive and can be used with confidence by clinicians and researchers to evaluate change over time in a concussion population with persistent symptoms.

The School-Based Speech-Language Pathologist and Students With Concussion: An Examination of Evolving Knowledge and Confidence

PURPOSE

This study examines school-based speech-language pathologists' (SLPs') experience, knowledge, and confidence in supporting students as they return to the classroom following concussion, with a particular focus on knowledge of new management guidelines over the last decade.

METHOD

Participants were 74 school-based SLPs who completed an electronic survey about their knowledge and experiences serving students with concussion. We examined participants' accuracy and confidence across knowledge questions using Kruskal-Wallis tests. We also conducted linear regression to explore the relationships between training, work experiences, knowledge, and confidence.

RESULTS

Nearly half of participants who are currently working with students with concussion reported having no clinical or training experiences related to concussion. Participants who had more concussion-related training or working experiences reported higher confidence. Participants were confident about general concussion knowledge but less confident about providing assessment and supporting students with concussion as they returned to school. Participants had the lowest confidence and accuracy for the most recent guidelines around rest and activity, as well as the differential impact of concussion on children as compared to adults.

CONCLUSIONS

Many school-based SLPs have limited training around concussion management and are often not specifically consulted to work with students following concussion. Despite this, SLPs have good awareness of their knowledge about concussion, but show gaps in knowledge surrounding more recent evidence-based guidelines. Additional investigation is needed to determine better ways to move research into clinical practice and to increase the involvement of SLPs in school-based concussion teams.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20361969.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

University educators' perceptions of academic adjustments following a concussion for student-athletes and non-student-athletes

Objective: To identify (1) university educators' perceptions of academic adjustments (AA), and (2) if teaching experience correlated with AA perceptions following concussion. Participants: Two hundred twenty educators. Methods: University educators were invited to complete a survey containing four subsections; this manuscript focuses on AA following concussion. Objective 1 was descriptive; we conducted spearman's rho correlations between years of teaching experience and AA perceptions to address objective 2. Results: Educators were moderately familiar with AA but were not confident in their knowledge about AA following concussion. Participants who provided AA following concussion most often allowed excused absences and extra time for exams/assignments. There were no significant relationships between teaching experience and perceptions of AA. Conclusions: University educators largely feel unprepared to provide or recommend AA following concussion but had favorable AA perceptions following concussion. Standardized policies or referral sites within the university system may be warranted to improve post-concussion AA.

Service Delivery Models for the Management of Pediatric and Adolescent Concussion: A Systematic Review

Objective

To examine the current peer-reviewed literature on pediatric concussion and mild traumatic brain injury (mTBI) service delivery models (SDMs) and relevant cost analyses.

Data Sources

PubMed, Embase (Elsevier), CINAHL Plus (EBSCO), APA PsycINFO (EBSCO), and Web of Science Core Collection, limited to human trials published in English from January 1, 2001, to January 10, 2022.

Study Selection

Included articles that (1) were peer-reviewed; (2) were evidence-based; (3) described service delivery and/or associated health care costs; and (4) focused on mTBI, concussion, or postconcussion symptoms of children and adolescents. Studies describing emergency department-based interventions, adults, and moderate to severe brain injuries were excluded.

Data Extraction

The initial search resulted in 1668 articles. Using Rayyan software, 2 reviewers independently completed title and abstract screening followed by a full-text screening of potentially included articles. A third blinded reviewer resolved inclusion/exclusion conflicts among the other reviewers. This resulted in 28 articles included.

Data Synthesis

Each of the 28 articles were grouped into 1 of the following 3 categories: generalist-based services (7), specialist-based services (12), and web/telemedicine services (6). One article discussed both generalists and specialists. It was clear that specialists are more proactive in their treatment of concussion than generalists. Most of the research on generalists emphasized the need for education and training. Four studies discussed costs relevant to SDMs.

Conclusions

This review highlights the need for more discussion and formalized evaluation of SDMs to better understand concussion management. Overall there is more literature on specialist-based services than generalist-based services. Specialists and generalists have overarching similarities but differ often in their approach to pediatric concussion management. Cost analysis data are sparse and more research is needed.

Pregnancy After Concussion: A Clarion Call for Attention?

OBJECTIVE

Emerging research shows that women who sustain a mild traumatic brain injury, also termed concussion, have a higher risk of menstrual irregularities and sexual dysfunctions. However, no research exists on how these reproductive disruptions affect women's subsequent pregnancies. The objective of this study was to evaluate pregnancy outcomes after concussion in a cohort of reproductive-aged women (aged 18-45 years), 24 months post-injury. We hypothesized that, compared with their extremity-injured peers in the same cohort, women with concussion will have lower incidence of pregnancies.

SETTING

Emergency department of a level 1 trauma center.

PARTICIPANTS

Women of reproductive age (aged 18-45 years) seeking care for concussion or extremity injury.

DESIGN

Longitudinal cohort study that used data collected at 3 distinct time points: t0, baseline: an original cohort of 245 women recruited in January to July 2017 for exposure assessment; t1, 6(+4) weeks post-injury: evaluation of self-reported postinjury menstrual and sexual changes for subgroup analyses-data collected in March to September 2017 ( n = 135); t2, 24 months post-injury: March 2020 chart review for documentation of pregnancies/pregnancy-related events ( N = 245).

MAIN MEASURE

Poisson regression estimates used to model the incidence rate (IR) of pregnancies, comparing concussion with extremity injury.

RESULTS

We reviewed the charts of 254 women from the t0 cohort. After excluding 9 patients who were either deceased or missing relevant data, we had the 245 (96.5%) charts of 102 concussed and 143 extremity-injured study participants. After adjusting for race and obstetric history, women with concussion had 80% lower incidence of pregnancies than their extremity-injured peers (adjusted [adj] IR = 0.20; 95% CI: 0.07-0.59; P = .003). When we excluded women who were using birth control, the IR of pregnancy for women with concussions was 76% lower than for those who had sustained extremity injuries (adj IR = 0.24; 95% CI: 0.07-0.81; P = .02). Pregnancy incidence remained consistently lower for concussed women in additional sensitivity analyses excluding assault/domestic violence victims and those with a prior/new concussion at t0 and t2. Subgroup analyses of the 135 women who had experienced menstrual and/or sexual dysfunctions at t1 showed 84% reduced incidence of pregnancy for women with concussions compared with those who had sustained an extremity injury (adj IR = 0.16; 95% CI: 0.04-0.73; P = .02).

CONCLUSION AND RELEVANCE

Our study potentially serves as a clarion call to understand the long-term reproductive effects of female concussions.

Recovery of symptoms, neurocognitive and vestibular-ocular-motor function and academic ability after sports-related concussion (SRC) in university-aged student-athletes: a systematic review

BACKGROUND

Physiological differences between a maturing and matured brain alters how Sports-Related Concussion (SRC) affects different age groups; therefore, a review specific to university-aged student-athletes is needed.

OBJECTIVES

Determine time to recovery for symptom burden, neurocognitive and Vestibular-Ocular-Motor (VOM) function and academic impact in university-aged student-athletes.

METHODS

Searches were conducted in PubMed, SpringerLink, PsycINFO, Science Direct, Scopus, Cochrane, Web of Science and EMBASE. Articles were included if they contained original data collected within 30 days in university-aged student-athletes, analysed SRC associated symptoms, neurocognitive or VOM function or academic ability and published in English. Two reviewers independently reviewed sources, using the Oxford Classification of Evidence-Based Medicine (CEBM) and the Downs and Black checklist, and independently extracting data before achieving consensus.

RESULTS

58 articles met the inclusion criteria. Recovery of symptoms occurred by 7 and 3-5.3 days for neurocognition. The evidence base did not allow for a conclusion on recovery time for VOM function or academic ability. Few papers investigated recovery times at specified re-assessment time-points and have used vastly differing methodologies.

CONCLUSIONS

To fully understand the implication of SRC on the university-aged student-athlete' studies using a multi-faceted approach at specific re-assessments time points are required.Systematic review registration number: CRD42019130685.

Exploring the value of the SCHOOLFirst return-to-school resource: Evaluating usability and satisfaction

OBJECTIVE

To cocreate an evidence-based resource to enable educators to support students returning to school after concussion; evaluate the usability of and users' satisfaction with the resource; understand the role of the resource in supporting students' return to school; and describe changes in concussion knowledge following a concussion education and training workshop.

DESIGN

Survey during a concussion education and training workshop.

SETTING

Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ont, and York Region District School Board in Richmond Hill, Ont.

PARTICIPANTS

Fifty-six educators, of whom 64% were teachers, 11% were school administrators, 23% fulfilled other roles (eg, child and youth worker), and 2% fulfilled unspecified roles.

MAIN OUTCOME MEASURES

The survey collected demographic information, usability data via the System Usability Scale, and satisfaction data. Thematic analysis was used for open-ended questions.

RESULTS

Participants reported the resource to be easy to use (69.6%), not complex (62.5%), and most felt confident using this resource (83.9%). Participants indicated they were satisfied with the resource (73.2%) and would use it in the future (87.5%). Some found the resource overwhelming and recommended it be summarized in a reference guide. Participants found the links, videos, and classroom accommodations or academic supports to be helpful.

CONCLUSION

SCHOOLFirst is an evidence-based, user-driven resource that was created for educators to support students returning to school following concussion. Educators, health care providers, youth, and families collaborated on developing SCHOOLFirst to improve students' successful return to school following concussion. Educators were satisfied with the resource and saw opportunities to use it to support their students.

Barriers to and facilitators of return to learning following a sport-related concussion: Perspectives of female secondary school students

OBJECTIVE

To identify barriers to and facilitators of return to learning (RTL) for female secondary school students following a sport-related concussion (SRC), and to identify critical junctures on the injury-to-recovery continuum that can be targeted to enhance the RTL process.

DESIGN

A grounded theory approach using in-depth qualitative interviews.

SETTING

Secondary schools within the York Region District School Board in Ontario.

PARTICIPANTS

Ten female secondary school students who presented to a sports medicine physician with an SRC in 2015 or 2016. Five of the students received a Green Folder intervention containing an RTL strategy, while 5 students received no RTL intervention following their SRC.

METHODS

In-depth interviews were conducted in person or by telephone. All interviews were audiorecorded and transcribed. The transcriptions were analyzed, coded, and examined for common themes by 2 independent reviewers.

MAIN FINDINGS

Barriers to RTL included a lack of a graduated RTL process, students' own internal stress, poor communication of expectations, lack of concussion education, and inadequate support from teachers. Facilitators of RTL included academic accommodations and having a primary contact person within the school system. Owing to inconsistent implementation, the impact of the Green Folder intervention as a facilitator of RTL remains unknown.

CONCLUSION

Results of this study support existing findings in the realm of concussion research. A novel finding includes the importance of a primary contact person as a facilitator of RTL. This person could help to overcome some of the identified barriers to RTL and improve outcomes by assisting with academic accommodations, providing reassurance regarding these accommodations, improving education among teachers and students, and enhancing communication between stakeholders.

Gaps in concussion management across school-aged children

OBJECTIVE

Examine how demographic and injury factors impact identification and management of concussion in students.

METHODS

Prospective observational cohort. Pre-K - 12th grade students within a large, urban school district reported to school with concussion during 2015-2019. Participants were grouped into Elementary/Middle School (E/MS) and High School (HS) and compared by sex, concussion history, injury setting and mechanism, time to medical evaluation and clearance, absences, and recommended accommodations.

RESULTS

154 E/MS and 230 HS students reported to school with physician-diagnosed concussion. E/MS students experienced fewer concussions at school and from sports than HS. More E/MS males than females sustained concussions, while this difference was reversed for HS. Time-to-evaluation was longer for E/MS, specifically female E/MS students and those injured outside of school. E/MS males were cleared more quickly than females. In contrast, no differences were found between sexes for HS by injury setting, mechanism of injury, or management factors.

CONCLUSION

Differences observed in E/MS students by demographic and injury factors are not observed in HS students. Younger students, particularly females or those not injured in school or sports, may be at risk for delayed identification and prolonged time to clearance. Future research should further characterize concussion management in E/MS children.

Cervicovestibular Rehabilitation in Adults with Mild Traumatic Brain Injury: A Randomised Clinical Trial

The objective of this study was to compare the effects of a cervicovestibular rehabilitation program combined with symptom-limited aerobic exercise (SLAE) program to a SLAE program alone in adults with persistent symptoms following mild traumatic brain injury (mTBI) on severity of symptoms and other indicators of clinical recovery. In this single-blind, parallel-group randomised clinical trial, 60 adults with persistent symptoms following mTBI were randomly assigned to: 1) a 6-week SLAE program or 2) a 6-week cervicovestibular rehabilitation program combined with SLAE program. All participants took part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome was the Post-Concussion Symptoms Scale (PCSS). The secondary outcomes were Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), time to return to function, and physical cervical and vestibular measures. Nonparametric analysis for longitudinal data was used to evaluate the effect of interventions on outcomes. For PCSS, NPRS, NDI, HDI, DHI and return to function, there were no group-by-time interactions at any time-points follow-up (p>0.05); clinically significant time effects were however observed (p0.05). There were group-by-time interactions at weeks 6 and 12 for vestibulo-ocular reflex (p0.003) and the cranio-vertebral mobility (p0.001) measures in favor of the cervicovestibular rehabilitation group. The study indicates that a cervicovestibular rehabilitation program combined with SLAE was not superior to a SLAE program alone in term of symptoms and functional level improvement but resulted in improved physical cervical and vestibular function. Keywords: mild traumatic brain injury, rehabilitation, neck pain, dizziness, headache.

Associations between interpersonal violence victimisation and concussions among US college students

Interpersonal violence is common on college campuses and is associated with many adverse health outcomes; however, it remains unknown whether experiencing interpersonal violence victimisation is associated with concussions. The aim of this study was to estimate the associations between interpersonal violence, including emotional abuse, physical abuse and sexual assault, and concussions among a large, diverse sample of college students. We analysed cross-sectional data from the 2018-2019 national (US) Healthy Minds Study (N = 1,478). Multiple logistic regression analyses were conducted to estimate the association between interpersonal violence victimisation (any violence victimisation, emotional abuse, physical abuse and sexual assault) and concussion history (any concussion, diagnosed concussion and undiagnosed concussion), while adjusting for potential confounders. Analyses were conducted among the overall sample and separately by male and female participants. Results showed patterns of significant associations between interpersonal violence victimisation and concussions among the overall sample and among male and female participants. Among the overall sample, any interpersonal violence victimisation (adjusted odds ratio [AOR] 1.45, 95% confidence interval [CI] 1.13-1.88), emotional abuse (AOR 1.36, 95% CI 1.06-1.76), physical abuse (AOR 1.61, 95% CI 1.07-2.44) and sexual assault (AOR 2.17, 95% CI 1.44-3.26) were associated with higher odds of any concussion history. Sexual assault victimisation had the strongest association with any concussion history among male (AOR 1.96, 95% CI 1.04-3.71) and female (AOR 2.96, 95% CI 1.62-5.43) participants. These results expand on prior interpersonal violence and concussion research by showing an association with multiple victimisation measures among a large and diverse sample of college students. Medical professionals should screen for concussions among college students who experience emotional abuse, physical abuse and sexual assault to provide appropriate guidance. Information on the symptoms of concussions should be incorporated into campus violence awareness and prevention efforts.

Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists

PURPOSE OF REVIEW

Concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another. This review summarizes the medical management of patients with concussion and persistent post-concussive symptoms (PPCS).

RECENT FINDINGS

Management of concussion and PPCS relies on identifying underlying symptom generators. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments. Evidence-based treatments have emerged to treat post-concussion symptom generators for sport-related concussion and for patients with PPCS.

Concussion symptoms and temporary accommodations using a student-centered return to learn care plan

BACKGROUND

Many students return to school after concussion with symptoms but without formal support.

OBJECTIVE

To examine concussion symptoms and temporary academic accommodations during school use of a four-week student-centered return to learn (RTL) care plan.

METHODS

Five public high schools used the RTL care plan and contributed student-level data after student report of concussion. Data on concussion symptoms, temporary academic accommodations corresponding to reported symptoms, and accommodations provided during RTL care plan use were examined.

RESULTS

Of 115 students, 55%used the RTL care plan for three (34%) or four (21%) weeks. Compared to students whose symptoms resolve within the first two weeks, students who used the RTL care plan for three or four weeks reported more unique symptoms (P = 0.038), higher total severity score (P = 0.005), and higher average severity per symptom (P = 0.007) at week one. Overall, 1,127 weekly accommodations were provided. While least reported, emotional symptoms received corresponding accommodations most often (127/155 reports: 82%of occurrences).

CONCLUSIONS

Use of an RTL care plan can facilitate the RTL of students with a concussion and may aid in the identification of students who are in need of longer-term support.

Prospective study with specific Re-Assessment time points to determine time to recovery following a Sports-Related Concussion in university-aged student-athletes

BACKGROUND

Time to recovery for symptom burden and neurocognition following a Sports-Related Concussion (SRC) has previously been determined by consolidating varying re-assessment time points into a singular point, and has not been established for Vestibular-Ocular-Motor (VOM) function or academic ability.

OBJECTIVES

Establish when recovery of symptom burden, neurocognition, VOM function, and academic ability occurs in university-aged student-athletes.

METHODS

Student-athletes completed an assessment battery (Post-Concussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), Vestibular Ocular-Motor Screening (VOMS), Perceived Academic Impairment Tool (PAIT)) during pre-season (n = 140), within 48 hours, 4, 8 and 14 days post-SRC and prior to Return To Play (RTP) and were managed according to the Rugby Football Union' community pathway (n = 42). Student-athletes were deemed recovered or impaired according to Reliable Change Index' (RCI) or compared to their individual baseline.

RESULTS

Symptom burden recovers by four days post-SRC on RCI and to baseline by eight days. VOM function and academic ability recovers by 8 days. Some student-athletes demonstrated worse performance at RTP on all tests by RCI and to baseline, except for on VOMS score and near point convergence by RCI change.

CONCLUSIONS

Variation in individual university-aged student-athletes requires a multi-faceted approach to establish what dysfunctions post-SRC exist and when recovery occurs.

Cognitions That Support Concussion Reporting in Collegiate Athletes: An Analysis of a Worksheet Activity

BACKGROUND

Sports related concussions continue to be a public health concern and improving reporting behavior a focus of educational programs. While educational programs have addressed changes in knowledge of concussion symptoms, it has been challenging to design educational programs which have lasting effects on reporting behavior.

AIMS

The current analysis describes an intervention in which thoughts about reporting behavior are actively written down in a worksheet exercise to "pre-arm" athletes with cognitions designed to enhance reporting behavior prior to the injury event.

METHOD

A total of 503 male and female college athletes participating in collision (football, field hockey, ice hockey, lacrosse, and soccer) and contact sports (baseball, basketball, and softball) from 7 colleges/universities competing across all three NCAA divisions provided data collected during a randomized trial of a peer concussion education program.

RESULTS

Qualitative analysis revealed 10 themes that would improve reporting including short-term benefits, faster recover, safe and healthy return to play, reporting helps the team, reporting protects the brain, risk aversion, long-term benefits, coach will be supportive, teammates will be supportive and understanding, and academic performance will be affected.

DISCUSSION

Athletes had awareness of key risks involved in concussions and understood both short- and long-term consequences.

CONCLUSION

These findings have important implications for understanding how to change athletes' thoughts about reporting concussions.

First-Line Health Care Providers' Reported Knowledge of and Referrals to Speech-Language Pathologists for Clients With Mild Traumatic Brain Injury

Purpose People with mild traumatic brain injury (mTBI) may experience deficits in cognition or communication that go unnoticed by first-line health care providers (FHPs). Speech-language pathologists (SLPs) assess and treat these domains yet are often underrepresented on mTBI multidisciplinary teams. This study's aim was to evaluate FHPs' reported knowledge of and referral practices to SLPs for individuals across the life span with mTBI. Method Physicians, physician assistants, nurse practitioners, nurses, and athletic trainers (n = 126) completed an online survey, including two Likert scale questions and one free response question relating to SLPs' role in mTBI. Results More than half of FHPs rate their knowledge of the SLP's role in mTBI management as low (somewhat knowledgeable, 29%; not very knowledgeable, 23%). Similarly, nearly two thirds of FHPs indicated rarely (19%) or never (44%), referring to SLPs for management of patients with mTBI. The majority of FHPs' open responses on the role of the SLP in mTBI management were incomplete, with many including domains that were not relevant to an SLP's role in the management of mTBI (e.g., dysphagia). Within the article, we provide results overall and according to individual profession. Conclusions Results suggest a majority of FHPs lack knowledge in the role of the SLP in the management of mTBI, which may underpin the low referral patterns reported by FHPs for SLP services. Future educational efforts for FHPs regarding the role of SLPs in mTBI care are necessary.

Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms

OBJECTIVE

The Buffalo Concussion Physical Examination (BCPE) is a brief, but pertinent physical examination designed for the subacute, outpatient assessment of concussion. The purpose of this study was to perform the BCPE on a larger sample and derive a scoring system to identify children at risk for Persistent Post-Concussive Symptoms (PPCS, recovery ≥30 days).

METHODS

This prospective, observational cohort study from September 2016 to March 2019 was performed at three university-affiliated concussion clinics. Male and female children (n=270, 14.92±1.86 years, range 8-18, 38% female) were diagnosed with a concussion within 14 days of injury and followed-up until recovery. Logistic regression was used with history and physical examination variables to predict PPCS and a weighted scoring metric was derived.

RESULTS

Out of 15 predictor variables, the main effects of 1 preinjury variable (≥3 previous concussions), 2 injury characteristic variables (days-since-injury and type-of-injury), 3 physical examination variables (orthostatic intolerance (OI), vestibulo-ocular reflex (VOR) and tandem gait) and 2 interaction terms (OI/VOR and tandem gait/type-of-injury) produced a score that was 85% accurate for identifying children with low-risk, medium-risk and high-risk for PPCS on cross-validation.

CONCLUSION

The Risk for Delayed Recovery (RDR)-Score allows physicians in an outpatient setting to more accurately predict which children are at greater risk for PPCS early after their injury, and who would benefit most from targeted therapies. The RDR-Score is intended to be used as part of a comprehensive assessment that should include validated symptom checklists, mental health history and adjunct testing (eg, cognitive or physical exertion) where clinically indicated.

Occupational Performance Limitations After Concussion in College Students

IMPORTANCE

Occupational performance limitations (OPLs) are poorly understood sequelae of concussion. This study aimed to establish the need for occupational therapy services for people who have sustained a concussion and to support the profession's role in facilitating occupational performance for college students experiencing signs and symptoms after concussion.

OBJECTIVE

To describe the types and frequency of, and assess risk factors for, OPLs in college students after concussion.

DESIGN

Cross-sectional descriptive study.

SETTING

Web-based survey on Qualtrics.

PARTICIPANTS

A total of 220 participants completed the survey; of those, 52 (23.6%) self-identified as having sustained a concussion and were further asked about OPLs after the concussion.

RESULTS

Eighty-nine percent (n = 46) of the participants reported an OPL in at least one area, and higher OPL scores were associated with the number of concussion symptoms (r = .34, p = .02) and increased recovery time (≥3 days vs. <3 days, p = .006).

CONCLUSIONS AND RELEVANCE

College students reporting concussions with more symptoms that persisted for longer periods were more likely to experience occupational performance loss. Frequent OPLs were reported in occupations associated with the participants' primary role of student. These results indicate a unique need for occupational therapy intervention with students to facilitate their continued success in academic pursuits. What This Article Adds: People who have sustained a concussion experience OPLs. Occupational therapy has a role in facilitating a return to occupational performance during recovery, especially in helping college students with concussion return to the classroom.

Symptom Factors and Neuropsychological Performance in Collegiate Athletes with Chronic Concussion Symptoms

OBJECTIVE

The present study explored the relationship between specific types of postconcussion symptoms and cognitive outcomes in student-athletes with chronic concussion symptoms.

METHOD

Forty student-athletes with chronic concussion symptoms were given a battery of neuropsychological tests and rated themselves on a variety of postconcussion symptoms, which included the following factors derived from prior work: Physical, Sleep, Cognitive, Affective, and Headache. Cognitive outcomes included performance on composites for the memory and attention/executive functioning speed tests, respectively. The following covariates were also explored: Sex, depression symptoms, number of previous concussions, and time since injury.

RESULTS

Headache was the only individual symptom factor that significantly (p < .05) predicted worse attention/executive functioning performance. None of the symptom factors were significantly related to memory performance over and above the variable of time since injury, such that longer time since injury was related to worse memory performance.

CONCLUSION

Comparable to work examining symptom predictors of cognitive outcomes in acutely concussed samples, headache predicted worse attention/executive functioning performance. Additionally, we found that the longer athletes had been symptomatic since injury, the "worse" their memory functioning. Understanding how headache and the length of time an individual is symptomatic are related to cognitive outcomes can help inform treatment and recommendations for athletes with prolonged symptom recovery.

Risk factors associated with concussions in a college student population

PURPOSE

To determine risk factors associated with concussion among the general collegiate population using a unique data linkage methodology.

METHODS

Student health medical, counseling, and disability access service data were linked with university enrollment data to provide a comprehensive, deidentified dataset of students who sought care at the student health center for concussion from 2016-2020. Using chi-squared tests and logistic regression, characteristics of students with and without concussion were evaluated.

RESULTS

During the study period, 506 concussions from 474 students were identified (cumulative incidence rate of 51.7 per 10,000 students). Significant predictors of concussion included: younger age (<21 years): odds ratio (OR) = 3.52 (95% confidence intervals [CI], 2.78, 4.50), Greek affiliation: OR = 1.89 (95% CI, 1.56, 2.30), and utilization of counseling and psychological services: OR = 1.92 (95% CI 1.59, 2.32). Of the students with concussion, 47% had at least one other concussion within the preceding year. History of prior hospitalization or medical imaging for head injury increased subsequent concussion risk by 4.5 fold.

CONCLUSIONS

Linking unique datasets provides a richer understanding of the characteristics and risk factors associated with student concussions than analysis of a single data source. This comprehensive dataset will enable future targeted interventions to prevent and treat college student concussions.

Critical Elements of Return to Learn for Students With Concussion: A Scoping Review

OBJECTIVE

To identify critical elements of return to learn (RTL) for students with concussion and examine the state of the peer-reviewed published literature through a scoping review.

METHODS

Three electronic databases were systematically searched, and reference lists screened for articles addressing components of RTL protocols and accommodations for students with concussion. In total, 100 articles met inclusion criteria, including 56 empirical studies and 44 expert articles.

RESULTS

Four key components to RTL protocols were identified: RTL teams, management approaches, outcome measurement, and accommodations. Both bodies of literature agree on the importance of RTL teams, but evidence for specific monitoring tools and management approaches is less robust. Accommodations have been better addressed by experts than empirical evaluation. Empirical studies are largely cross-sectional, and many are survey based. Just 24 include student perspectives. Publication of expert literature has declined in frequency, as empirical studies have become more common.

CONCLUSION

This scoping review describes the current landscape of RTL and provides guidance toward expanding the empirical literature to systematically determine best practices to serve students with concussion.

Does Vestibular-Ocular-Motor (VOM) Impairment Affect Time to Return to Play, Symptom Severity, Neurocognition and Academic Ability in Student-Athletes following acute Concussion?

Introduction: Research indicates Sports-Related Concussion (SRC) impairs Vestibular-Ocular-Motor (VOM) function. The aim was to explore if VOM impairment correlates with longer Return To Play (RTP), symptom burden, neurocognitive performance and academic capability.Participants: 40 (61.4% male) Loughborough University, UK, rugby union student-athletes who sustained 42 SRCs.Methods: Student-athletes completed an assessment battery during pre-season (baseline), 2, 4, 8 and 14 days post-SRC and prior to RTP and were managed according to the rugby Football Union' community pathway.Outcome measures: Vestibular Ocular-Motor Screening (VOMS), Immediate Post-Concussion Assessment and Cognitive Test, Post-Concussion Symptom Scale, Perceived Academic Impairment Tool questionnaire and percentage of academic activities specifically missed due to SRC.Results: VOMS scores were significantly (p < 0.005) greater than baseline at all time points except RTP. Presence of VOM dysfunction at 14 days post-SRC significantly correlated with a longer RTP, greater symptom burden and increased odds ratio at 2, 4 and 8 days and academic time loss at 2, 4 and 8 days post-SRC.Conclusion: VOM impairment is associated with an increased symptom burden and impaired academic capability, and a longer time to RTP when present at 14 days post-SRC.

Student Perspectives on the Role of Peer Support Following Concussion: Development of the SUCCESS Peer Mentoring Program

Purpose College students with concussion are often ill-equipped to manage their health and learning needs, and college campuses are slow to react. We present the development of a peer mentoring program for college students with concussion: Success in College after Concussion with Effective Student Supports (SUCCESS), focusing on the process by which student needs and preferences drove development of the program for testing. Method Principles of person-centered design were used to guide program development, engaging stakeholders at each stage of development and resulting in the intervention package presented to student participants here. A series of interviews and focus groups with 11 students with concussion addressed student needs after concussion, student perceptions of the role of peers in recovery, and feedback on program development. Results Findings indicate students have limited knowledge about concussion, and concussion impacts extend beyond school, although students are most concerned about their studies. Students reported struggling to communicate with professors and find resources on campus to aid in their reentry to learning. Regarding peer mentoring, students report benefiting from hearing about other's successes and sharing personal narratives of injury and recovery. Students reported high acceptability of a peer mentoring program, both for psychosocial support and access to resources. Conclusions College students with concussion have unmet needs as they return to learn. The SUCCESS peer mentoring program is highly acceptable to students, who report that they would expect such a program to be engaging and to meet their needs. The program's impact on student academic and psychosocial outcomes should be investigated through comparative efficacy trials.

Differences in Sport-Related Concussion History, Reporting Behavior, and Return to Learn and Sport Timelines in Public versus Private High School Student Athletes

Objective: To compare: 1) history of sport-related concussion (SRC), 2) Return to learn (RTL) timelines, 3) Return to play (RTP) timelines, and 4) SRC reporting behaviors in high-school student athletes based on school type (public vs. private).Methods: A total of 2,998 athletes recruited from eleven private (n = 2121) and two public schools (n = 877) during the 2018-2019 school year completed an online questionnaire regarding sport participation and SRC history. The questionnaire examined self-reported history of SRC, reporting behavior, and RTL and RTP timelines.Results: Private school athletes were approximately twice as likely to report a history of SRC compared to public school athletes (OR [95% CI]: 2.01 [1.61-2.50], p < .001). There were no significant differences in RTL or RTP timelines between public and private-school athletes (p > .05). For those who did not report their SRC (22.4%), the most common reasons were "a desire to keep playing" (53.7%) and "not believing it was serious enough to report" (52.1%).Conclusions: Athletic trainers and healthcare professionals should be aware of the factors that may influence secondary student athletes' SRC reporting behavior, and associated RTL, and RTP timelines, so they can better target concussion education and overall management for student-athletes.Abbreviations: SRC: Sport-related concussion; RTP: Return to play; RTL: Return to learn.

Clinical Recovery Timelines following Sport-Related Concussion in Men's and Women's Collegiate Sports

CONTEXT

Past work has identified sex differences in sport-related concussion (SRC) incidence and recovery time; however, few have examined sex differences in specific recovery trajectories: time to symptom resolution, return-to-academics, and return-to-athletic activity across collegiate sports.

OBJECTIVE

To examine sex differences in SRC recovery trajectories across a number of varsity sports with differing levels of contact.

DESIGN

Descriptive Epidemiology Study.

SETTING

College varsity and club sports.

PATIENTS OR OTHER PARTICIPANTS

SRCs sustained by student-athletes (N=1,974; 38.7% female) participating in Ivy League sports were tracked from 2013/14-2018/19.

INTERVENTION(S)

Athletic trainers collected concussive injury and recovery characteristics as part of the Ivy League-Big Ten Epidemiology of Concussion Study's surveillance system.

MAIN OUTCOME MEASURE(S)

Time to symptom resolution, return-to-academics, and return-to-limited and full athletic activity were collected. Survival analyses determined time from injury to each recovery outcome for males and females by sport. Peto tests compared recovery outcomes between males and female athletes and by sport.

RESULTS

The median time to symptom resolution overall was 9 days [IQR:4,18], return-to-academics was 8 days [IQR:3,15], return-to-limited activity was 12 days [IQR:8,23], and return-to-full activity was 16 days [IQR:10,29]. There were significant differences overall between sexes for median time to symptom resolution (males: 8 days [IQR:4,17], females: 9 days [IQR:5,20], p=0.029) and return-to-academics (males: 7 days [IQR:3,14], females: 9 days [IQR:4,17], p<.001), but not return to athletics (limited activity, p=0.107; full activity, p=0.578). Within-sport comparisons found that female lacrosse athletes had longer symptom resolution (p=0.030) and return to academics (p=0.035) compared to males, while male volleyball athletes took longer to return to limited (p=0.020) and full (p=0.049) athletic activity compared to females.

CONCLUSION

There were significant differences in recovery timelines between sexes. Females experienced longer symptom duration and time to return-to-academics compared to male athletes, but females and males presented similar timelines for return-to-athletics.

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

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