Optimizing Concussion Care Seeking: Connecting Care-Seeking Behaviors and Neurophysiological States Through Blood Biomarkers

BACKGROUND

Timely and appropriate medical care after concussion presents a difficult public health problem. Concussion identification and treatment rely heavily on self-report, but more than half of concussions go unreported or are reported after a delay. If incomplete self-report increases exposure to harm, blood biomarkers may objectively indicate this neurobiological dysfunction.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare postconcussion biomarker levels between individuals with different previous concussion diagnosis statuses and care-seeking statuses. It was hypothesized that individuals with undiagnosed concussions and poorer care seeking would show altered biomarker profiles.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Blood samples were collected from 287 military academy cadets and collegiate athletes diagnosed with concussion in the Advanced Research Core of the Concussion Assessment, Research and Education Consortium. The authors extracted each participant's self-reported previous concussion diagnosis status (no history, all diagnosed, ≥1 undiagnosed) and whether they had delayed or immediate symptom onset, symptom reporting, and removal from activity after the incident concussion. The authors compared the following blood biomarkers associated with neural injury between previous concussion diagnosis status groups and care-seeking groups: glial fibrillary acidic protein, ubiquitin c-terminal hydrolase-L1 (UCH-L1), neurofilament light chain (NF-L), and tau protein, captured at baseline, 24 to 48 hours, asymptomatic, and 7 days after unrestricted return to activity using tests of parallel profiles.

RESULTS

The undiagnosed previous concussion group (n = 21) had higher levels of NF-L at 24- to 48-hour and asymptomatic time points relative to all diagnosed (n = 72) or no previous concussion (n = 194) groups. For those with delayed removal from activity (n = 127), UCH-L1 was lower at 7 days after return to activity than that for athletes immediately removed from activity (n = 131). No other biomarker differences were observed.

CONCLUSION

Individuals with previous undiagnosed concussions or delayed removal from activity showed some different biomarker levels after concussion and after clinical recovery, despite a lack of baseline differences. This may indicate that poorer care seeking can create neurobiological differences in the concussed brain.

Optimizing Concussion Care Seeking: A Longitudinal Analysis of Recovery

BACKGROUND

Approximately half of concussions go undisclosed and therefore undiagnosed. Among diagnosed concussions, 51% to 64% receive delayed medical care. Understanding the influence of undiagnosed concussions and delayed medical care would inform medical and education practices.

PURPOSE

To compare postconcussion longitudinal clinical outcomes among (1) individuals with no concussion history, all previous concussions diagnosed, and ≥1 previous concussion undiagnosed, as well as (2) those who have delayed versus immediate symptom onset, symptom reporting, and removal from activity after concussion.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Participants included 2758 military academy cadets and intercollegiate athletes diagnosed with concussion in the CARE Consortium. We determined (1) each participant's previous concussion diagnosis status self-reported at baseline (no history, all diagnosed, ≥1 undiagnosed) and (2) whether the participant had delayed or immediate symptom onset, symptom reporting, and removal from activity. We compared symptom severities, cognition, balance, and recovery duration at baseline, 24 to 48 hours, date of asymptomatic status, and date of unrestricted return to activity using tests of parallel profiles.

RESULTS

The ≥1 undiagnosed concussion group had higher baseline symptom burdens (P < .001) than the other 2 groups and poorer baseline verbal memory performance (P = .001) than the all diagnosed group; however, they became asymptomatic and returned to activity sooner than those with no history. Cadets/athletes who delayed symptom reporting had higher symptom burdens 24 to 48 hours after injury (mean ± SE; delayed, 28.8 ± 0.8; immediate, 20.6 ± 0.7), took a median difference of 2 days longer to become asymptomatic, and took 3 days longer to return to activity than those who had immediate symptom reporting. For every 30 minutes of continued participation after injury, days to asymptomatic status increased 8.1% (95% CI, 0.3%-16.4%).

CONCLUSION

Clinicians should expect that cadets/athletes who delay reporting concussion symptoms will have acutely higher symptom burdens and take 2 days longer to become asymptomatic. Educational messaging should emphasize the clinical benefits of seeking immediate care for concussion-like symptoms.

Optimizing Concussion Care Seeking: The Influence of Previous Concussion Diagnosis Status on Baseline Assessment Outcomes

BACKGROUND

The prevalence of unreported concussions is high, and undiagnosed concussions can lead to worse postconcussion outcomes. It is not clear how those with a history of undiagnosed concussion perform on subsequent standard concussion baseline assessments.

PURPOSE

To determine if previous concussion diagnosis status was associated with outcomes on the standard baseline concussion assessment battery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Concussion Assessment, Research, and Education (CARE) Consortium participants (N = 29,934) self-reported concussion history with diagnosis status and completed standard baseline concussion assessments, including assessments for symptoms, mental status, balance, and neurocognition. Multiple linear regression models were used to estimate mean differences and 95% CIs among concussion history groups (no concussion history [n = 23,037; 77.0%], all previous concussions diagnosed [n = 5315; 17.8%], ≥1 previous concussions undiagnosed [n = 1582; 5.3%]) at baseline for all outcomes except symptom severity and Brief Symptom Inventory-18 (BSI-18) score, in which negative binomial models were used to calculate incidence rate ratios (IRRs). All models were adjusted for sex, race, ethnicity, sport contact level, and concussion count. Mean differences with 95% CIs excluding 0.00 and at least a small effect size (≥0.20), and those IRRs with 95% CIs excluding 1.00 and at least a small association (IRR, ≥1.10) were considered significant.

RESULTS

The ≥1 previous concussions undiagnosed group reported significantly greater symptom severity scores (IRR, ≥1.38) and BSI-18 (IRR, ≥1.31) scores relative to the no concussion history and all previous concussions diagnosed groups. The ≥1 previous concussions undiagnosed group performed significantly worse on 6 neurocognitive assessments while performing better on only 2 compared with the no concussion history and all previous concussions diagnosed groups. There were no between-group differences on mental status or balance assessments.

CONCLUSION

An undiagnosed concussion history was associated with worse clinical indicators at future baseline assessments. Individuals reporting ≥1 previous undiagnosed concussions exhibited worse baseline clinical indicators. This may suggest that concussion-related harm may be exacerbated when injuries are not diagnosed.

Parent influence on concussion reporting in first-year collegiate athletes

OBJECTIVE

To assess the relationship between sport-parenting practices and concussion reporting intentions of collegiate athletes across two levels of competition.

PARTICIPANTS

Entering first-year student-athletes (varsity and club) at a mid-sized university in the Southeast region of the United States (n = 327).

METHODS

Written surveys were completed prior to the start of the 2015 academic year. Structural equation modeling was used to test a model predicting concussion-reporting intentions.

RESULTS

College athletes were more likely to intend to report a suspected concussion when they believed their parents wanted them to report (B=-0.88, SD = 0.94), and when they experienced less sport achievement pressure from their parents (B=-0.12, SD = 8.07).

CONCLUSIONS

Parents influence the concussion safety of entering collegiate athletes at both the varsity and club level. Lower pressure sport parenting prior to college entry may help foster safer concussion reporting behaviors and may be an appropriate target for future intervention development work.

Number of prior concussions predict poorer concussion care seeking in military cadets

PRIMARY OBJECTIVE

To determine whether concussion history predicts concussion care seeking, self-management practices, or confidence to recognize/report.

RESEARCH DESIGN

Cross-sectional.

METHODS & PROCEDURES

706 United States Air Force Academy (USAFA) cadets completed survey items regarding concussion history (0,1,2,3+), likelihood of reporting a concussion, self-management, and confidence to recognize/report. We used multivariate ordinal and binary logistic regression models to predict responses using concussion history, sex, and race.Main outcomes & results: cadets with 1 (OR = 0.59, 95%CI:0.43-0.82), 2 (OR = 0.55, 95%CI:0.31-0.98), or 3+ (OR = 0.36, 95%CI:0.17-0.78) concussions while at USAFA had respective 41%, 45%, and 64% lower likelihood to report the concussion scenario (ref = no history, p < .001). USAFA cadets with more extensive concussion histories had higher prevalence of not seeking care for a concussion (p < .001); more strongly endorsed self-management (p = .001-0.010); and had greater confidence in their ability to recognize a concussion (p = .005), but not to report (p = .198-0.413).

CONCLUSIONS

Prior concussion experiences may deter cadets from seeking medical care for future concussions. Interventions should address concussion history and clinicians should consider how the post-concussion management process might deter care seeking.

Pluralistic Ignorance as a Contributing Factor to Concussion Underreporting

BACKGROUND

Concussion underreporting is endemic, and social norms are an established predictor of concussion reporting behavior. However, pluralistic ignorance-a situation in which most individuals in a group hold the belief that their peers' views differ from their own, despite views actually being similar-has not been studied in this context.

AIM

To assess whether pluralistic ignorance contributes to concussion underreporting.

METHOD

We surveyed 2,504 military service academy cadets. Each cadet was presented with a survey asking about their willingness to self-report a concussion, their perception of other cadets' willingness to report a concussion, and personal and demographic factors.

RESULTS

Most cadets viewed themselves as more willing to report a concussion than others (mean difference = 1.12, 95% CI [1.02, 1.21]), a belief consistent with pluralistic ignorance. Demographic characteristics were associated with holding this belief. For example, female cadets and upper-class cadets were more likely to show this disparity than male or under-class cadets, respectively. Collegiate athletes not only showed similar willingness to report concussion as nonathletes but also perceived other cadets as less likely to report concussions. Meanwhile, future pilots showed less self-report willingness and perceived that others were similarly unwilling to report concussions.

DISCUSSION

A majority of this economically and geographically diverse population displays characteristics of pluralistic ignorance: They largely share proconcussion reporting sentiments but incorrectly perceive that others do not. This belief is not held uniformly in all subpopulations, which may inform how these beliefs are developed and maintained.

CONCLUSIONS

Pluralistic ignorance is an important consideration in concussion education efforts.

Concussion-Reporting Behavior in Rugby: A National Survey of Rugby Union Players in the United States

BACKGROUND

Rugby is the fastest growing team sport in the United States for male and female athletes. It is a contact/collision sport with an injury risk profile that includes concussions.

PURPOSE

To examine the prevalence of concussions in male and female rugby players in the United States and to characterize behaviors around reporting concussions that could be a target for prevention and treatment efforts.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

An online survey distributed to active members on the USA Rugby membership list was used to examine self-reported concussions in male and female athletes. Concussion-reporting behaviors and return to play after a concussion were also explored. Statistical analysis was used to compare male with female athletes and report differences, with years of experience as a dependent variable.

RESULTS

The proportion of athletes with a history of at least 1 concussion was 61.9% in all respondents. Of those who reported a concussion, 50.8% reported the concussion during the game or practice in which it occurred, and 57.6% reported at least 1 concussion to a qualified medical provider. Overall, 27.7% of participants who reported ≥1 rugby-related concussion in our survey noted that at least 1 of these concussions was not formally reported. The most commonly cited reasons for not reporting a concussion included not thinking that it was a serious injury, not knowing that it was a concussion at the time, and not wanting to be pulled out of the game or practice. Additionally, 61.0% of athletes did not engage in recommended return-to-play protocols after their most recent rugby-related concussion.

CONCLUSION

US rugby union athletes may not report concussions to medical personnel or follow return-to-play protocols guided by medical advice. This could result from a lack of education on concussion recognition and the risks associated with continued play after a concussion as well as limited access to health care. Further education efforts focusing on the identification of concussions, removal from play, and return-to-play protocols are necessary in the US rugby union population.

Coach, sports medicine, and parent influence on concussion care seeking intentions and behaviors in collegiate student-athletes

BACKGROUND

Sport is a socio-ecological framework where student-athletes are part of a larger community of stakeholders, including coaches, sports medicine professionals (SMPs), and parents. This framework may hold influence over whether student-athletes seek care for a concussion.

AIM

We aimed to describe, compare, and determine the influence of stakeholder concussion knowledge, attitudes, and concussion scenario responses.

MATERIALS AND METHODS

We recruited a sample of 477 student-athletes and their 27 coaches (response rate=46.6%), 24 SMPs (48.7%), and 31 parents/guardians (4.8%). Stakeholder surveys assessed their concussion knowledge, attitudes toward care seeking, and concussion scenario responses. Surveys administered to student-athletes assessed their concussion care seeking intentions and behaviors. Kruskal-Wallis tests were used to compare responses between stakeholder groups and to determine the differences in student-athlete intentions and behaviors (alpha=0.05).

RESULTS

SMPs had significantly better knowledge (p<0.001) and concussion scenario responses (p<0.001) compared to both coaches and parents. SMPs also had significantly better attitudes compared to parents, but not coaches (p=0.038). Coach concussion scenario responses (p=0.044) and SMP knowledge positively influenced student-athletes' concussion care seeking intentions (p=0.049). Parent responses were not associated with their child's concussion care seeking intentions and behaviors.

CONCLUSIONS

The gap in coach and parent concussion knowledge and concussion scenario response relative to SMPs is a preliminary target for stakeholder concussion education and supports the current sports medicine model where SMPs primarily disseminate concussion education. Stakeholders, specifically coaches and SMPs, do hold influence over collegiate athlete concussion care seeking intentions and behaviors.

RELEVANCE FOR PATIENTS

Stakeholders should be addressed within educational efforts aimed at student-athletes and should also complete stakeholder-specific concussion education.

Randomized Controlled Trial of a Novel Peer Concussion-Education Program for Collegiate Athletes

CONTEXT

The National Collegiate Athletic Association and US Department of Defense have called for educational programs to change the culture of concussion reporting, increase reporting behavior, and enhance the safety of players and service members.

OBJECTIVE

To evaluate the effects of a novel peer concussion-education program (PCEP) in changing knowledge, attitudes, and norms about concussion reporting among collegiate student-athletes and assess program implementation.

DESIGN

Randomized controlled trial and qualitative analysis of interviews.

SETTING

National Collegiate Athletic Association athletic teams from randomly selected colleges or universities.

PATIENTS OR OTHER PARTICIPANTS

A total of 1614 male and female student-athletes from 60 teams at 10 colleges and universities and 8 athletic trainers.

INTERVENTION(S)

The PCEP intervention trains 2 peer concussion educators to provide 2 education modules to their teammates. Knowledge, attitudes (oneself and teammates), and concussion occurrence or reporting were assessed at baseline, postintervention, and 1 month later. Eight athletic trainers were interviewed about program implementation.

RESULTS

Compared with the control group, the intervention group showed greater increases occurred postintervention and at 1 month in concussion knowledge (F_1,2648 = 51.3, P < .0001), intention to report (oneself, F_2,2633 = 82.3, P < .0001; teammates, F_2,2624 = 53.9, P < .0001), return-to-play protocol knowledge, (F_2,2632 = 28.4, P < .0001), direct subjective norms (oneself, F_2,2625 = 51.7, P < .0001; teammates, F_2,2644 = 40.6, P < .0001), direct perceived behavioral control (oneself, F_2,2628 = 53.7, P < .0001; teammates, F_2,2615 = 68.2, P < .0001), and indirect attitudes (oneself, F_2,2626 = 47.1, P < .001; teammates, F_2,2623 = 40.9, P < .0001). Peer concussion-education program participants discussed concussion more often with a teammate (F_1,1396 = 13.96, P < .0001) or athletic staff (F_1,1396 = 6.62, P < .001). Qualitative program analysis revealed both positive aspects of the PCEP and areas for improvement.

CONCLUSIONS

The PCEP showed promise in increasing concussion knowledge, intention to report concussion, reporting a teammate's concussion, and facilitating attitudinal changes that support reporting among student-athletes.

Implementation and effect of concussion education in collegiate women's ice hockey

Objective: This study aimed to determine whether collegiate women's ice hockey players are receiving pre-season concussion education and evaluate the nature and delivery of this education. Secondarily, we aimed to assess whether players who recall receiving this education have greater knowledge about concussion or are more likely to have reported suspected concussions than their peers.Methods: An anonymous survey was completed by 459 NCAA women's ice hockey players. Players self-reported receipt of pre-season concussion education, year in school, division of competition, player position, and average length of ice hockey career. Players also completed scales assessing concussion knowledge, attitudes and prior reporting behavior for suspected concussions.Results: 65.3% of athletes affirmed that they received pre-season concussion education. Lecture by an athletic trainer was the most common modality. There were no differences in concussion knowledge or attitudes by concussion education status, NCAA division of competition, or year in school. Players with higher knowledge scores were more likely than their peers to have experienced a suspected concussion and to have not reported it (p = 0.056).Conclusions: Not all NCAA women's ice hockey players are receiving (or recall receiving) mandated concussion education from their institution. The inverse association between concussion knowledge and concussion reporting behavior, while not statistically significant, is concerning and warrants further study. More work is needed to develop educational materials about concussion that are acceptable and memorable to this population, and that help increase concussion care-seeking behaviors.

Investigation of strategies to improve concussion reporting in American football

While research on sport-related concussion has increased dramatically over the past decade, research investigating concussion reporting is in its early stages. The purpose of this project was to assess concussion reporting and work with stakeholders to develop and assess strategies to improve reporting. We used a multi-site, repeated measures design with three NCAA Division I football programs, including 223 athlete participants. A modified community-based participatory research (CBPR) approach was used to develop intervention strategies (Fall 2017 season) with stakeholders designed to increase concussion reporting intentions. Preseason and postseason surveys were administered to determine effectiveness. Main outcome measures included concussion knowledge, intervention effectiveness, and reporting intention measures. For all three programs, concussion knowledge was unrelated to reporting intentions. Two of the three programs implemented the intervention strategies and for these programs there was evidence that the interventions were effective. Specifically, athletes from these two programs perceived more support from coaches about reporting (P< 0.05; t= 2.83), received education more frequently (P< 0.05; t= 2.67), and reported being more likely to report concussion symptoms (P< 0.05; t= 2.14). Our study demonstrates that working with stakeholders to develop site-specific strategies to improve concussion reporting is an effective approach to help improve reporting behaviours.

Immediate Removal From Activity After Sport-Related Concussion Is Associated With Shorter Clinical Recovery and Less Severe Symptoms in Collegiate Student-Athletes

BACKGROUND

Timely removal from activity after concussion symptoms remains problematic despite heightened awareness. Previous studies indicated potential adverse effects of continuing to participate in physical activity immediately after sustaining a concussion. Hypothesis/Purpose: The purpose was to determine the effect of timing of removal from play after concussion on clinical outcomes. It was hypothesized that immediate removal from activity after sport-related concussion (SRC) would be associated with less time missed from sport, a shorter symptomatic period, and better outcomes on acute clinical measures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were reported from the National Collegiate Athletic Association and Department of Defense Grand Alliance: Concussion Awareness, Research, and Education (CARE) Consortium. Participants with 506 diagnosed SRCs from 18 sports and 25 institutions and military service academies were analyzed and classified as either immediate removal from activity (I-RFA) or delayed removal from activity (D-RFA). Outcomes of interest included time missed from sport attributed to their SRC, symptom duration, and clinical assessment scores.

RESULTS

There were 322 participants (63.6%) characterized as D-RFA. I-RFA status was associated with significantly less time missed from sport ( R² change = .022-.024, P < .001 to P = .001) and shorter symptom duration ( R² change = .044-.046, P < .001 [all imputations]) while controlling for other SRC recovery modifiers. These athletes missed approximately 3 fewer days from sport participation. I-RFA athletes had significantly less severe acute SRC symptoms and were at lower risk of recovery taking ≥14 days (relative risk = .614, P < .001, small-medium effect size) and ≥21 days (relative risk = .534, P = .010, small effect size).

CONCLUSION

I-RFA is a protective factor associated with less severe acute symptoms and shorter recovery after SRC. Conveying this message to athletes, coaches, and others involved in the care of athletes may promote timely injury reporting.

Concussion knowledge among amateur motocross riders

AIM

There has been considerable increase in concussion awareness and risks; however, extreme sports such as motocross have received scant attention. The purpose of this study was to assess concussion knowledge among motocross riders and determine differences based on demographic factors.

METHODOLOGY & RESULTS

782 motocross riders responded to an Internet-based questionnaire, and participant's knowledge score was 14.3 ± 2.7 out of 20 and symptom recognition was 6.8 ± 1.4 out of 8. Riders who had performed baseline concussion testing or received formal concussion education demonstrated higher knowledge scores. Rider's demographics did not predict outcome measures.

CONCLUSIONS

Considerable misconceptions and lack of symptom knowledge persist among motocross riders and these results can be used for future interventions to improve concussion reporting.