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

Acute Sport-Related Concussion Management and Return to Sport Time in High School Athletes

BACKGROUND

The current evidence for acute management practices of sport-related concussion (SRC) is often limited to in-clinic visits, with limited studies identifying professionals in early SRC care and the association with prolonged recovery outcomes.

PURPOSE

To describe acute SRC management practices (ie, the personnel in the initial evaluations, removal from activity) and test the association with prolonged return to sport (RTS) time.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We conducted a retrospective cohort study of 17,081 high school SRCs accrued between the 2015-2016 and 2020-2021 academic years. We reported acute management practices and RTS time as frequencies stratified by sex, sport, and event type and compared athletic trainer (AT) access in initial evaluation with chi-square tests (P < .05). Separate logistic regressions estimated odds ratios (ORs) and 95% CIs for removal from activity and prolonged RTS >21 days by acute management practices.

RESULTS

Most SRCs (n = 12,311 [72.1%]) had complete initial evaluation by an AT. Boys had an AT evaluation in 75.5% (n = 2860/3787) of practice-related and 74.8% (n = 5551/7423) of competition-related events. Girls had an AT evaluation in 61.3% (n = 1294/2110) of practice-related and 69.3% (n = 2606/3761) of competition-related events. In sex-comparable sports (n = 6501), there was no difference between boys (n = 1654/2455 [67.4%]) and girls (n = 2779/4046 [68.7%]) having an AT involved in the first evaluation (χ2 = 1.21; P = .27). Notably, 25.3% of girls' SRCs were evaluated by a coach alone, and we observed differences in personnel in initial evaluations by sport. The odds of immediate removal were higher when an AT made the initial evaluation (OR, 2.8 [95% CI, 2.54-3.08]). The odds of prolonged RTS >21 days was lower for those with an AT in the initial evaluation (OR, 0.74 [95% CI, 0.65-0.84]) adjusting for significant factors from univariate analyses, boys relative to girls (OR, 0.85 [95% CI, 0.76-0.96]), specialty care relative to PCP (OR, 2.16 [95% CI, 1.90-2.46]), specialty care relative to urgent or ready care (OR, 0.99 [95% CI, 0.82-1.22]) concussion history (OR, 1.41 [95% CI, 1.22-1.63]), and removal from activity (OR, 0.90 [95% CI, 0.78-1.05]).

CONCLUSION

This study found variability in personnel involved in initial SRC evaluations, with higher percentages of athletes with SRCs having ATs make the initial evaluation during competitive events. There was no association between sex and AT involvement in comparable sports. There was an association between prolonged RTS and AT involvement, sex, concussion history, and location of follow-up care.

Sport level and sex differences in sport-related concussion among Japanese collegiate athletes: Epidemiology, knowledge, reporting behaviors, and reported symptoms

This study investigated the incidence of sport-related concussion (SRC) in sports, effect of athlete knowledge on reporting behavior differences between collegiate and non-collegiate athletes, and differences in SRC symptoms between sexes and level of participation. In this cross-sectional survey, 1 344 Japanese collegiate and non-collegiate athletes from a single institute were analyzed. Using a web-based survey, demographics, general SRC, knowledge of SRC, the most recent SRC reporting behaviors, and symptom presentation were examined. The prevalence of SRC during the academic year 2016-2017 was 2.68 (95% confidence interval [CI]: 1.88-3.69) across all sports. The prevalence of SRC was 33.3 (95% CI: 17.96-51.83) in rugby union and 8.33 (95% CI: 1.03-27.00) in women's soccer. The prevalence of SRC in males (3.47 [95% CI: 2.38-4.86] was 3.65 times higher than that in females (0.95 [95% CI: 0.26-2.41]). In total, the mean total score of knowledge was 5.30 (4.2) across 25 questions; dizziness was the most well-known symptom (867/1 344, 64.5%), followed by headache (59.3%). Being more emotional (44/1 345, 3.3%) was the least frequently known symptom. Level of participation did not affect scores (5.16 [3.96] vs. 5.52 [4.54]; p ​= ​0.131). All 87 disclosing participants experienced drowsiness and irritability and felt more emotional. In terms of sex and participant level, no significant differences were found in any symptoms. This study found very low rates of concussion education in Japan. Dissemination of concussion education is essential in the future to recognize concussion earlier and prevent severe concussive injury.

The Role of Reported Affective Symptoms and Anxiety in Recovery Trajectories After Sport-Related Concussion

BACKGROUND

There is growing awareness and clinical interest in athletes with affective symptoms after sport-related concussion (SRC), as these symptoms may contribute to overall symptoms and represent a modifiable risk factor of longer recovery. However, evidence of their effects on the entire return-to-play (RTP) trajectory, particularly among women and men, is limited.

PURPOSE/HYPOTHESIS

To examine the relationship between affective symptom reporting and RTP progression after SRC among a cohort of Division 1 student-athletes. We hypothesized that those endorsing affective symptoms, specifically nervous-anxious symptoms, spend more time in RTP progression and recovery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Using SRC data from the Ivy League-Big Ten Epidemiology of Concussion Study among varsity athletes through February 2020, we identified the 4 affective symptoms from the Sport Concussion Assessment Tool symptom inventory. We modeled the relationship between a 4-category affective symptom variable and time to symptom resolution, RTP, and RTP progression, adjusting for nonaffective symptom prevalence and concussion history. Cox regressions were used to estimate hazard ratios for time to event outcomes, and linear regressions were used to evaluate mean differences for continuous outcomes.

RESULTS

Among 2077 student-athletes (men, 63.5%) with SRC symptoms, affective symptom prevalence was 47.6% and 44.3% in women and men, respectively, and nervous-anxious prevalence was 24.2% and 22.5%, respectively. When comparing women with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with affective symptoms, and women with nervous-anxious symptoms spent significantly longer in RTP progression. When comparing men with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with co-occurring affective symptoms, and affective symptoms were not associated with time in RTP progression.

CONCLUSION

Student-athletes with affective symptoms and nervous-anxious symptoms exhibited delayed clinical recovery and RTP timelines, particularly for time in RTP. Symptom prevalence and concussion history contributed to this; however, unmeasured confounding remains, as indicated by the poor model fit. This study motivates future work to explore affective symptoms and RTP timelines, considering anxiety and risk/protective factors over time.

Healthcare Navigation of Black and White Adolescents Following Sport-Related Concussion: A Path Towards Achieving Health Equity

CONTEXT

Care-seeking behaviors for sport-related concussion (SRC) are not consistent across demographic subgroups. These differences may not only stem from health inequities but can further perpetuate disparities in care for SRCs.

OBJECTIVE

To determine whether racial differences exist in the care pathway from injury to SRC clinic within adolescent athletes.

DESIGN

Retrospective cohort Setting: Regional SRC center Participants: Of 582 total athletes, 486 (83.5%) White and 96 (16.5%) Black adolescent athletes were diagnosed with SRC and evaluated within 3 months at the SRC clinic.

MAIN OUTCOME MEASURES

Race was the defined exposure, dichotomized as Black or White. The four primary outcomes included: 1)location of first health system contact, 2)time from injury to first health system contact 3) time to in-person SRC clinic visit, and 4) whether the athlete established care (>1 visit), was released immediately to an athletic trainer, or lost to follow-up.

RESULTS

Black and White athletes mostly presented directly to SRC clinic (61.5% vs 62.3%) at a median[interquartile range] of 3[1,5] vs 4[1,8] days respectively (p=0.821). Similar proportions of Black and White athletes also first presented to the ED (30.2% vs 27.2%) at a median of 0[0,1] vs 0[0,1] days (p=0.941). Black athletes more frequently had care transferred to their athletic trainer (39.6% vs 29.6%) and less frequently established care (56.3% vs 64.0%), however these differences were not statistically significant (p=0.138). Lost to follow-up was uncommon among Black and White athletes alike (4.2% vs 6.4%).

CONCLUSIONS

This study demonstrated that within an established SRC referral network and multidisciplinary clinic, there were no observed racial disparities in how athletes were initially managed and/or ultimately presented to SRC clinic despite racial differences in school type and insurance coverage. SRC center assimilation and affiliation with school systems may be helpful in improving access and providing equitable care across diverse patient demographics.

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.