Factors Contributing to Disparities in Baseline Neurocognitive Performance and Concussion Symptom Scores Between Black and White Collegiate Athletes

Influence of social determinants of health and adversity on computerized neurocognitive assessment

Introduction: Social determinants of health and adversity, including poverty, maltreatment, and neighborhood deprivation, are individual-level factors that may significantly affect baseline neurocognitive testing and management that have yet to be thoroughly explored within the computerized neurocognitive assessment.Objectives: Examine individual-level experiences of poverty, abuse, neighborhood deprivation, and social mobility on computerized cognitive testing.Methods: The sample included 3,845 student-athletes who completed a baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and were enrolled in the Child-Household Integrated Longitudinal Data database. Multivariable linear regressions were used to assess independent variables of Supplemental Nutrition Assistance Program enrollment, abuse or neglect cases, Area Deprivation Index scores, and other demographic factors on four baseline ImPACT composite scores: verbal and visual memory, visuomotor, and reaction time.Results: Individual-level factors of persistent poverty and neighborhood deprivation were associated with lower composite scores; however, upward social mobility was not significantly associated with cognitive performance. The effects of mother's race on computerized cognitive testing performance were attenuated when accounting for measures of adversity.Conclusion: Findings highlight the importance of social determinants of health in computerized neurocognitive testing to ensure more culturally sensitive and precise understanding of athletic baselines.

The Influence of Race on Time to Symptom Resolution Following Sport Concussion in Collegiate Athletes

CONTEXT

Race has been shown to influence computerized neurocognitive test scores, motor function test scores, and reported symptomology following sport-related concussion (SRC). However, the effect race may have on recovery time following SRC remains unknown. The objective of this study was to determine the influence of race on days until symptom free from SRC in NCAA Division 1 collegiate athletes.

DESIGN

Prospective cohort study.

METHODS

Participants were Black (n = 53 [28% female]) and White (n = 150 [43.3% female]) who were on average 19.0 (1.21) and 20.2 (1.3) years of age, respectively. Data were collected from the 2015-2016 to 2020-2021 collegiate sport seasons. Participants were evaluated before and after an SRC at empirically derived time points. The primary outcome measure was time until symptom free (days). Additional outcomes included baseline and postinjury Immediate Postconcussion Assessment and Cognitive Test and Sensory Organization Test (SOT) scores. A Mann-Whitney U test compared days to symptom free between groups. Immediate Postconcussion Assessment and Cognitive Test and SOT outcome scores were analyzed using a 2 (group) × 2 (time) analysis of variance.

RESULTS

White participants had a longer median recovery time (9 d) to symptom free compared with Black participants (6 d [P = .04]). Statistically significant differences were observed between Black 87.3 (9.84) and White 90.4 (8.30) groups for Immediate Postconcussion Assessment and Cognitive Test's verbal memory composite score (P = .03). Postinjury, White participants scored significantly higher 44.5 (5.63) on visual motor speed compared with Black participants (42.4 (5.90) [P = .02]). Within-group SOT differences between baseline and postinjury testing were observed in both groups (all P < .001).

CONCLUSIONS

Black collegiate athletes achieved symptom resolution sooner than White athletes. We did not explore underlying sociocultural factors such as socioeconomic status or previous concussion education, which may have influenced our results. Future studies should explore factors that may contextualize these findings.

Recovery Is Similar Between Black and White College Athletes Following Sport-Related Concussion

CONTEXT

Racial identity may associate with clinical outcomes following sport-related concussion (SRC). This study compared clinical outcome scores before and after recovery from a SRC between Black or White college athletes.

DESIGN

Prospective cohort.

METHODS

Participants were self-reported White (n = 61, 18.5 [1.1] y of age) and Black (n = 24, 18.3 [1.1] y of age) NCAA Division 1 college athletes. The revised Head Injury Scale (HIS-r), the Immediate Postconcussion and Cognitive Test (ImPACT) battery, and the Sensory Organization Test (SOT) at baseline (T1), upon symptom resolution (T2) following a diagnosed SRC, and upon establishing a new baseline assessment (T3). Race was collected from paper and electronic medical records. The revised Head Injury Scale total symptom severity, ImPACT's Verbal Memory, Visual Memory, Visual Motor Speed (VMS), and Reaction Time, and the SOT Equilibrium Score, were compared between groups at each time point. Multivariate analyses of variance (2 [group] × 3 [time]) were used to compare revised Head Injury Scale, ImPACT, and SOT outcome scores. Post hoc analyses consisted of independent and paired sample t tests.

RESULTS

A significant main effect for time (λ = 0.66, F2,82 = 21.55, P < .001, ηp2=.34) was observed for the SOT. White athletes significantly improved on the Equilibrium Score between all time points (all P < .006). Similarly, Black athletes significantly improved on the Equilibrium Score between T1-T2 and T1-T3 (all P < .001). A significant main effect of time was observed for ImPACT's Verbal Memory, Visual Memory, and VMS outcome scores (all P < .001). VMS improved for White athletes between T1-T2 (P = .02) and T3 (P = .006). Black athletes had improved VMS scores between T1-T3 (P = .015) and T2-T3 (P = .005). A between-group difference was observed for VMS at T2 (P = .004).

CONCLUSIONS

There was 1 small and not clinically significant difference between groups for the VMS score at T2. Overall, groups performed consistently or improved upon their baseline balance, cognition, and symptom outcome scores at clinically relevant time points following a SRC.

American Headache Society white paper on treatment of post-traumatic headache from concussion in youth

OBJECTIVE

To provide healthcare professionals guidance on youth at risk for prolonged recovery and post-traumatic headache (PTH), and on pharmacologic and non-pharmacologic management of PTH due to concussion and mild traumatic brain injury.

BACKGROUND

Headache is the most common persistent post-concussive symptom affecting 8% of youth for >3 months after concussion. Over the past decade, many studies have explored the treatment of PTH in youth, but there are no established guidelines.

METHODS

This white paper is based on a synthesis of an updated systematic review of the literature on treatment of PTH and a narrative review of the literature on risk factors for prolonged recovery and health disparities. Results were interpreted by a group of expert providers in PTH in children and adolescents through collaboration of the PTH and pediatric special interest groups of the American Headache Society.

RESULTS

Factors that consistently were associated with prolonged recovery from concussion and persistent PTH included female sex, a high number of acute symptoms, and adolescent age. Social determinants of health also likely play an important role in PTH and deserve consideration in the clinical and research settings. A total of 33 studies met the criteria for inclusion in the systematic review of PTH treatment in youth, although most were retrospective and of fair-to-poor quality. Treatment strategies included acute and preventive pharmacologic management, procedures, neuro-modulatory devices, physical therapy, physical activity, and behavioral health support. A collaborative care approach that includes a thoughtful combination of these management strategies is likely most effective.

CONCLUSIONS

This white paper provides a roadmap for tailoring the treatment of PTH based on factors influencing prolonged headache, the timing of therapies, and therapies with the most evidence for treating PTH in youth. We also highlight research needed for developing more definitive guidelines on PTH management in youth.

The prevalence of Black/African American individuals in concussion literature: a systematic review and meta-analysis

Introduction

Comprising approximately 13.6% of the United States population, Black/African American individuals are overrepresented in sports associated with a high risk of concussion. However, there has been a notable absence of systematic reviews examining whether concussion literature accurately reflects the participation and experiences of Black/African American individuals. Therefore, this study aims to systematically review the prevalence of Black/African American individuals compared to White individuals diagnosed with concussions in the literature.

Methods

A systematic search was performed across four electronic databases: PubMed, MEDLINE (Ovid), Scopus and Web of Science. Articles were searched from inception to January 5, 2022. Prevalence data were extracted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis of proportions was conducted within hospital records and national survey data.

Results

Among 447 identified studies, 11 were included, representing 1,839,901 individuals diagnosed with a concussion, with 73.6% identifying as White and 12.5% identifying as Black/African American. The mean proportion of Black/African American diagnosed with a concussion in hospital records (13.9%; 95% CI [12.8, 15.1]) exceeded that in national surveys (6.4%; 95% CI [3.5, 11.3]) but lower than sports-centered studies (16%).

Discussion

These findings underscore the need to address racial disparities in healthcare within the broader context of social determinants of health and systemic inequities. By identifying gaps in the current research, this study lays the foundation for future investigation aimed at elucidating and addressing healthcare disparities.

Focus areas and methodological characteristics of North American-based health disparity research in sports medicine: a scoping review

OBJECTIVE

Health disparities are widely prevalent; however, little has been done to examine and address their causes and effects in sports and exercise medicine (SEM). We aimed to summarise the focus areas and methodology used for existing North American health disparity research in SEM and to identify gaps in the evidence base.

DESIGN

Scoping review.

DATA SOURCES

Systematic literature search of PubMed, Scopus, SPORTDiscus, CINAHL Plus with Full Text, Web of Science Core Collection and Cochrane Central Register of Controlled Trials.

ELIGIBILITY CRITERIA

Full-text, peer-reviewed manuscripts of primary research, conducted in North America; published in the year 2000 or after, in English; and focusing on organised sports were included.

RESULTS

103 articles met inclusion criteria. Articles were classified into five focus areas: access to and participation in sports (n=45), access to SEM care (n=28), health-related outcomes in SEM (n=24), provider representation in SEM (n=5) and methodology (n=1). Race/ethnicity (n=39), socioeconomic status (n=28) and sex (n=27) were the most studied potential causes of health disparities, whereas sexual orientation (n=5), location (rural/urban/suburban, n=5), education level (n=5), body composition (n=5), gender identity (n=4) and language (n=2) were the least studied. Most articles (n=74) were cross-sectional, conducted on youth (n=55) and originated in the USA (n=90).

CONCLUSION

Health disparity research relevant to SEM in North America is limited. The overall volume and breadth of research required to identify patterns in a heterogeneous sports landscape, which can then be used to inform positive change, need expansion. Intentional research focused on assessing the intersectionality, causes and consequences of health disparities in SEM is necessary.

Intersection of Race and Socioeconomic Status on Concussion Recovery among NCAA Student-Athletes: A CARE Consortium Study

PURPOSE

The objectives of this study are to 1) describe collegiate student-athlete (SA) race and household income and 2) evaluate time to normal academic performance (i.e., return to learn (RTL)), initiation of the return to play (iRTP) protocol, RTP protocol duration, and time to unrestricted RTP (URTP) after sustaining sport-related concussion (SRC).

METHODS

Data were collected between 2014 and 2020 by the Concussion Assessment, Research, and Education Consortium. Baseline data were used to characterize participant demographics ( N = 22,819) and post-SRC outcomes ( n = 5485 SRC) in time to RTL ( n = 1724) and RTP outcomes ( n = 2646) by race. Descriptive statistics and nonparametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox proportional hazards regression assessed the effect of race on risk of RTL and RTP recovery time points.

RESULTS

SA largely identified as White (75%) followed by Black (14%), multiracial (7%), and Asian (3%). More than half (53%) of all SA reported a household income of >$120,000, whereas 41% of Black SA reported a household income <$60,000. Race was not associated with relative risk of RTL or iRTP but was associated with RTP protocol completion and URTP. Non-Black/non-White SA were 17% less likely (adjusted hazard ratio = 0.83; 95% confidence interval = 0.71, 0.97) to complete the RTP protocol, and Black SA were 17% more likely (adjusted hazard ratio = 1.17; 95% confidence interval = 1.05, 1.31) to reach the URTP time point compared with White SA.

CONCLUSIONS

The present findings suggest collegiate SA enrolled in the Concussion Assessment, Research, and Education Consortium are primarily White and come from household incomes well above the US median. Race was not associated with RTL or iRTP but was associated with RTP protocol duration and total time to URTP. Clinicians should be conscientious of how their implicit or preconceived biases may influence SRC management among National Collegiate Athletic Association SA.

Inter-rater Reliability of the Revised Physical and Neurological Examination of Subtle Signs (PANESS) scored using video review

The Physical and Neurological Examination of Subtle Signs (PANESS) is a brief neuromotor exam designed for use in children. This study examined the inter-rater reliability of PANESS scoring using video review in 23 typically developing youth, aged 10-18 years, who were either never-concussed or evaluated following clinical recovery from concussion. Moderate to excellent inter-rater reliability was identified across PANESS subscores and total score. The strongest inter-rater reliability was observed for the Timed Motor portion of the PANESS (ICCs >.90) suggesting that this section in particular may be a strong candidate for video-based scoring or telehealth administration.

Investigation of Factors Contributing to Racial Differences in Sport-Related Concussion Outcomes

OBJECTIVE

Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors.

METHODS

Data from patients aged 12-18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) RESULTS: A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P = 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR] = 1.35, 95% CI 1.03-1.77, P = 0.030), which remained significant (HR = 1.32, 95% CI 1.002-1.73, P = 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR = 1.12, 95% CI 0.85-1.48, P = 0.410). Adding prior concussion history further reduced the association between race/recovery (HR = 1.01, 95% CI 0.77-1.34, P = 0.925).

CONCLUSIONS

Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors.

Exploring the Social Determinants of Health and Health Disparities in Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) is a global health concern, that can leave lasting physical, cognitive, and/or behavioral changes for many who sustain this type of injury. Because of the heterogeneity of this population, development of appropriate intervention tools can be difficult. Social determinants of health (SDoH) are factors that may impact TBI incidence, recovery, and outcome. The purpose of this study is to describe and analyze the existing literature regarding the prevailing SDoH and health disparities (HDs) associated with TBI in adults. A scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to explore three electronic databases-PubMed, Medline, and CINAHL. Searches identified peer-reviewed empirical literature addressing aspects of SDoH and HDs related to TBI. A total of 123 records were identified and reduced to 27 studies based on inclusion criteria. Results revealed race/ethnicity was the most commonly reported SDoH impacting TBI, followed by an individual's insurance status. Health disparities were noted to occur across the continuum of TBI, including TBI risk, acute hospitalization, rehabilitation, and recovery. The most frequently reported HD was that Whites are more likely to be discharged to inpatient rehabilitation compared to racial/ethnic minorities. Health disparities associated with TBI are most commonly associated with the race/ethnicity SDoH, though insurance status and socioeconomic status commonly influence health inequities as well. The additional need for evidence related to the impact of other, lesser researched, SDoH is discussed, as well as clinical implications that can be used to target intervention for at-risk groups using an individual's known SDoH.

Group Differences in Postconcussion Cognitive, Physical, Sleep-Arousal, and Affective Symptom Subscales in High School and Collegiate Athletes by Race, Gender, and Competitive Level

OBJECTIVE

Prior psychometric research has identified symptom subscales for the Post-Concussion Symptom Scale (PCSS) based on confirmatory factor analysis (CFA), including cognitive, physical, sleep-arousal, and affective symptom factors. Study objectives included: (1) replicate the 4-factor PCSS model in a diverse sample of athletes with concussion, (2) test the model for invariance across race, gender, and competitive level, and (3) compare symptom subscale and total symptom scores across concussed groups with established invariance.

SETTING

Three regional concussion care centers.

PARTICIPANTS

A total of 400 athletes who completed the PCSS within 21 days of concussion (64% boys/men, 35% Black, and 69.5% collegiate athletes).

DESIGN

Cross-sectional.

MAIN MEASURES

A CFA tested the 4-factor model and measurement invariance testing was performed across racial, competitive level, and gender groups. Symptom subscales and total symptom severity scores were compared based on demographic groupings with established invariance.

RESULTS

The 4-factor model fit well and strong invariance was established across all demographic categories, indicating symptom subscales could be meaningfully compared across groups. Black and White athletes differed on total symptoms (U = 15 714.5, P = .021, r = 0.12), sleep-arousal symptoms (U = 15 953.5, P = .026, r = 0.11), and physical symptoms (U = 16 140, P = .051, r = 0.10), with Black athletes reporting slightly more symptoms. Collegiate athletes reported greater total symptom severity (U = 10 748.5, P < .001, r = 0.30), with greater symptom reporting on the cognitive (U = 12 985, P < .001, r = 0.21), sleep-arousal (U = 12 594, P < .001, r = 0.22), physical (U = 10 959, P < .001, r = 0.29), and emotional (U = 14 727.5, P = .005, r = 0.14) symptom subscales. There were no significant differences by gender in the total symptom score or subscale scores. After controlling for time since injury, no racial differences persisted, but a significant difference by competitive level in physical symptom reporting (F = 7.39, P = .00, η2 = 0.02) and total symptom reporting (F = 9.16, P = .003, η2 = 0.02) remained.

CONCLUSION

These results provide external validation for the PCSS 4-factor model and demonstrate that symptom subscale measurements are comparable across race, genders, and competitive levels. These findings support the continued use of the PCSS and 4-factor model for assessing a diverse population of concussed athletes.

The Post-Concussion Symptom Scale: Normative Data for Adolescent Student-Athletes Stratified by Gender and Preexisting Conditions

BACKGROUND

The Post-Concussion Symptom Scale (PCSS) is a self-report questionnaire measuring symptoms that commonly occur after a concussion; however, these symptoms are nonspecific and can be related to co-occurring orthopaedic injuries (eg, cervical strain) or patient characteristics and preexisting conditions, even in the absence of a recent injury. As such, clinicians may have difficulty determining whether symptom elevations are attributable to a recent concussion as opposed to a confounding injury or a preexisting condition, which may be especially difficult when preinjury baseline symptom data are unavailable.

PURPOSE

This study aimed to further validate the 4-factor model of the PCSS (ie, cognitive, sleep-arousal, physical, and affective symptoms) with adolescent student-athletes and provide normative reference data for each factor and the total score, stratified by gender and preexisting health conditions.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Participants were 9358 adolescent student-athletes who completed the PCSS during a preseason baseline evaluation (mean age, 14.9 years; SD, 1.3 years [range, 13-18 years]; 49.3% boys). The 4-factor model of the PCSS was tested for the full sample and separately for boys and girls using confirmatory factor analysis. Symptom severity percentiles were created for the PCSS total score and each factor, stratified by gender and preexisting conditions (ie, attention-deficit/hyperactivity disorder, mental health history, headache/migraine history, learning disability/dyslexia, academic problems, and concussion history).

RESULTS

The 4-factor model of the PCSS replicated in the full sample (comparative fit index [CFI] = 0.959) and in both gender groups (boys: CFI = 0.961; girls: CFI = 0.960). The total PCSS score at the 84th percentile varied by preexisting conditions as follows: healthy participants = 8, attention-deficit/hyperactivity disorder = 18, mental health history = 26, headache/migraine history = 18, learning disability = 19, and academic problems = 17. On all PCSS subscales, participants with a mental health history had the highest scores, and high scores were associated with having >1 preexisting condition. Girls had higher scores than boys for each stratification.

CONCLUSION

The 4-factor model of the PCSS replicates for adolescent student-athletes. Gender, number of preexisting conditions, and mental health history are important factors to account for when interpreting PCSS symptom severity. The normative data provided herein could assist clinicians in determining whether an adolescent student-athlete is presenting with persistent postconcussion symptoms or a typical symptom experience based on their gender and personal health history.

Understanding racial differences in computerized neurocognitive test performance and symptom-reporting to deliver culturally competent patient-centered care for sport-related concussion

OBJECTIVE

This study examined neurocognitive performance and symptoms between concussed Black and White collegiate athletes at baseline, post-injury, and change from baseline to post-injury.

METHOD

The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) was used to measure neurocognitive performance and four concussion symptom clusters for 235 concussed collegiate athletes. Between-groups differences were documented at baseline and post-injury, along with change in scores for sex/race, and sport/race groups, using ANOVAs. Baseline scores, and days-to-post-test were covariates in post-injury comparisons. Symptom endorsement by race was evaluated using chi-square analyses.

RESULTS

At baseline, group comparisons by race and sex showed that Black male/female athletes scored lower on reaction time (RT; p = .008), White females scored higher on verbal memory (VerbMem; p = .001), Black females scored lower on visual motor processing speed (VMS; p = .001), and Black football athletes scored slower/poorer on RT (p = .001) and VMS (p = .006). Post-injury, Black males scored lower on visual memory (VisMem; p = .005) and VMS (p = .002), and Black football athletes scored slower on VMS (p = .005), whereas White non-football athletes scored higher on VerbMem (p = .002) and reported fewer symptoms. Significant time-by-sport/race interactions were found for VerbMem (p < .001), VisMem (p < .001) and reported symptoms. With respect to post-injury symptom scores/endorsement, Black athletes scored significantly higher for physical (p = .01) and sleep (p = .01) symptoms.

CONCLUSION

These findings drive the conversation of how subjective measures of symptoms, and objective clinical concussion measures, may relate to the concussion recovery process and providing a culturally competent clinical management approach for diverse patients.

The Frequency of Low Scores on ImPACT in Adolescent Student-Athletes: Stratification by Race and Socioeconomic Status Using Multivariate Base Rates

This study examined the associations between the frequency of low scores on the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) by race and socioeconomic status (SES), using the proxy of Title I school status, among adolescent student-athletes and calculated multivariate base rates. There were 753 participants assigned to groups based on race (White: n = 430, 59.8%; Black: n = 289, 40.2%) and SES. Black student-athletes obtained more low neurocognitive test scores, which was associated with lower SES. The current study offers a resource to clinicians involved in concussion management who may wish to consider race and SES when interpreting ImPACT test performances.

Exploring the outcomes and experiences of Black and White athletes following a sport-related concussion: a retrospective cohort study

OBJECTIVE

Young American athletes, at risk of sport-related concussion (SRC), represent many races; however, it is unknown how race may influence the experience and outcome of SRC. The authors' objective was to compare White and Black athletes' recovery and subjective experiences after SRC.

METHODS

A retrospective study was performed using the Vanderbilt Sports Concussion registry. Self-reported White and Black young athletes (ages 12-23 years) who had been treated for SRC between 2012 and 2015 were included. Athletes with learning disabilities or psychiatric conditions were excluded. Data were collected by electronic medical record review and phone calls to athletes and parents or guardians. The primary outcomes were as follows: 1) days to symptom resolution (SR), 2) days to return to school, and changes in 3) any daily activity (binary) and 4) sport behavior (binary). Secondary outcomes were changes (more, unchanged, or less) in specific activities such as sleep, schoolwork, and television time, as well as equipment (binary) or playing style (more reckless, unchanged, or less reckless) and whether the athlete retired from sport. Descriptive analyses, multivariable Cox proportional hazards models, and logistic regression were performed.

RESULTS

The final cohort included 247 student-athletes (36 Black, 211 White). Black athletes were male (78% vs 58%) more often than White athletes, but both races were similar in age, sport, and medical/family histories. Black athletes more frequently had public insurance (33.3% vs 5.7%) and lived in areas with a low median income (41.2% vs 26.6%). After adjusting for age, sex, concussion history, insurance status, and zip code median income, Black athletes reached an asymptomatic status (HR 1.497, 95% CI 1.014-2.209, p = 0.042) and returned to school earlier (HR 1.522, 95% CI 1.020-2.270, p = 0.040). Black athletes were less likely to report a change in any daily activity than White athletes (OR 0.368, 95% CI 0.136-0.996, p = 0.049). Changes in sport behavior were comparable between the groups.

CONCLUSIONS

Racial differences appear to exist in the outcomes and experience of SRC for young athletes, as Black athletes reached SR and return to school sooner than White athletes. Race should be considered as an important social determinant in SRC treatment.

Diversifying sport-related concussion measures with baseline balance and ocular-motor scores in professional Zambian football athletes

PURPOSE

Normative values of common sport-related concussion assessment tools may assist clinical diagnosis and management. However, current baseline normative values are not representative of athletic participants across international domains. This study develops healthy baseline norms on the Balance Error Scoring System (BESS), and King-Devick (K-D), providing baseline reference values for professional Zambian football athletes.

METHODS

Of the 125 male participants (aged 24.48 ± 5.41 years) screened for this study, 9 (7.2%) reported a previous history of concussion, 98 (78.4%) completed the Balance Error Scoring System and 88 (70.4%) completed the King-Devick. Descriptive statistics calculated for the BESS and the K-D test included mean, standard deviation, median, interquartile range (IQR), and percentiles ranks.

MAIN FINDINGS

Participants scored a mean ± standard deviation of 10.15 ± 5.6 and a median [IQR] of 9 [6-12.25] errors on the total BESS and completed the K-D test in a mean ± standard deviation 56.85 ± 10.55 seconds and a median [IQR] 55.28 [48.7-64.8] seconds.

CONCLUSIONS

Cross-cultural awareness and management of sport-related concussion are continuously improving the safety and well-being of athletic participants around the world. The diverse representation in these data may aid in interpretation of post-injury performance during sport-related concussion management in Zambia. This study develops baseline reference values currently lacking within African cultures and demonstrates the feasibility and global clinical utility of two sport-related concussion assessment resources.

Preseason Baseline Neurocognitive Performances and Symptom Reporting on Immediate Post-Concussion Assessment and Cognitive Testing: A Comparison of Adolescent Student-Athletes Tested in Spanish and English

CONTEXT

Student-athletes are commonly administered the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery at preseason baseline and postconcussion. The ImPACT is available in many languages, but few researchers have examined differences in cognitive performances and symptom ratings based on the language of administration.

OBJECTIVE

To examine differences in ImPACT neurocognitive composites and symptom reporting at preseason baseline testing between student-athletes who completed ImPACT in Spanish versus English.

DESIGN

Cross-sectional study.

SETTING

Preseason baseline testing for a high school concussion-management program in Maine.

PATIENTS OR OTHER PARTICIPANTS

Adolescent student-athletes who completed testing in Spanish (n = 169) and English (n = 169) were matched on age, gender, and health and academic history. Language groups were compared on each outcome for the full sample and for gender-stratified subsamples.

MAIN OUTCOME MEASURE(S)

Neurocognitive composite scores and individual and total symptom severity ratings from the ImPACT battery.

RESULTS

Athletes tested in Spanish displayed lower levels of neurocognitive performance on 2 of 5 composite scores (visual motor speed: P < .001, d = 0.51; reaction time: P = .004, d = 0.33) and reported greater symptom severity (P < .001, r = 0.21). When the analyses were stratified by gender, similar visual motor speed differences were observed between language groups among boys (P = .001, d = 0.49) and girls (P = .001, d = 0.49), whereas reaction time showed a larger group difference for boys (P = .012, d = 0.42) than for girls (P = .128, d = 0.21). Language-group differences in symptom reporting were similar for boys (P = .003, r = 0.22) and girls (P = .008, r = 0.21), with more frequent endorsement of physical and affective symptoms by athletes tested in Spanish.

CONCLUSIONS

Language-group differences in total symptom severity were small (r = 0.21) and in neurocognitive performances were small to medium (d = 0.05-0.51). Versus previous authors who compared athletes tested in Spanish and English with ImPACT, we observed smaller effects, which may be attributable to close matching on variables related to neurocognitive performances and symptom reporting.

Assessing Differences in Concussion Symptom Knowledge and Sources of Information Among Black and White Collegiate-Athletes

OBJECTIVE

Basic concussion symptom knowledge is fundamental to concussion identification; however, racial disparities in concussion knowledge exist in high school and youth sports. It is unknown whether similar differences exist in collegiate-athletes. Identifying racial disparities in concussion knowledge and sources of concussion information is essential to inform equitable approaches to knowledge translation and educational interventions. This study examined how Black and White collegiate-athletes differed in their knowledge of concussion symptoms and use of concussion information sources.

SETTING

National Collegiate Athletic Association (NCAA) institutions.

PARTICIPANTS

Collegiate-athletes.

DESIGN

Cross-sectional.

MAIN MEASURES

Collegiate-athletes completed a questionnaire that assessed personal and sports demographics, concussion symptom knowledge, and use of concussion information sources. Fisher's exact tests and Wilcoxon rank-sum tests examined differences in outcome measures between Black and White collegiate-athletes. A multivariable Poisson regression model examined the association between race and concussion symptom knowledge scores while accounting for sex, sports contact level, NCAA division, concussion history, and specific concussion information sources. Incidence rate ratios (IRRs) with 95% CIs excluding 1.00 were deemed significant.

RESULTS

A total of 768 (82.6% White, 17.4% Black) collegiate-athletes completed the questionnaire. Black athletes were more likely to have lower concussion symptom knowledge scores than White athletes (P < .001). In the multivariable Poisson regression model controlling for covariates, this finding was retained (IRR = 0.97; 95% CI, 0.94-0.997). White athletes were more likely to report school-based professional (P < .001), online medical sources (P = .02), and the NCAA (P = .008) as sources of concussion information. Black athletes were more likely to report referees (P = .03) as a source of concussion knowledge.

CONCLUSION

Despite NCAA concussion education requirements for athletes, Black collegiate-athletes were found to have lower concussion knowledge than White collegiate-athletes. The findings highlight the need for equitable strategies to disseminate concussion information to diverse populations by improving the physician-patient relationship and investing in culturally appropriate educational materials.

Cross-cultural exploration of baseline ImPACT Quick Test performance among football athletes in Zambia

OBJECTIVE

Concussion is a global sport injury; however, this public health issue has yet to be studied across Africa. It is unknown if tests such as the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) Quick Test (QT) are culturally appropriate for implementation as part of a concussion screening protocol in Zambia or other African nations. Study objectives included: 1) establish that Zambian athletes are able to complete the iPad-based ImPACT QT with respect to language or cultural barriers that may exist, and 2) document baseline neurocognitive percentile ranks among Zambian football athletes on the ImPACT QT.

METHODS

This study was completed with adult premiere league football athletes in Zambia (n = 125) aged 24.48 ± 5.41. Participants completed the ImPACT QT neurocognitive assessment prior to a preseason practice. Outcome measures were average performance on 3 factor scores: Motor Speed, Memory, and Attention Tracker, presented as percentile ranks using normative data built-into the ImPACT QT.

RESULTS

Zambian athletes scored nearly two standard deviations below the mean on Motor Speed (7^th percentile), using North American normative data. However, performance on Attention Tracker (44^th percentile) and Memory (56^th percentile) was within the average range.

CONCLUSION

Results of the current study show that Zambian athletes are able to complete the ImPACT QT, despite any language or cultural differences that may exist. In addition, preliminary percentile ranks suggest Zambian football athletes have average scores on Attention and Memory and below average scores on Motor Speed. These data are the first to explore Zambian athletes' performance on a cognitive concussion measure.

Baseline preseason ImPACT® testing in Mandarin with adolescent student-athletes in the United States

Researchers have examined differences on ImPACT^® in baseline symptom reporting and neurocognitive performances based on the language of administration and racial/ethnic identity. This is the first study to examine differences between student-athletes tested in Mandarin versus English on ImPACT^® during preseason baseline assessments conducted in high schools in the United States. Participants included 252 adolescent student-athletes who completed ImPACT^® testing in the state of Maine in Mandarin and 252 participants who completed testing in English, matched on age, gender, and health and academic history. Participants were compared on neurocognitive composite scores and symptom ratings. Boys tested in Mandarin, but not girls, had modestly better neurocognitive performance on one of four composite scores (i.e., Visual Motor Speed, p < .001, d = .45). Although language groups did not differ in total symptom severity, boys tested in Mandarin endorsed multiple physical symptoms at higher rates than boys tested in English. These results suggest that the current ImPACT^® neurocognitive normative data are reasonably appropriate for use with adolescents evaluated in Mandarin. There were some differences in the reporting of physical symptoms, with greater rates of symptom endorsement by boys tested in Mandarin than boys tested in English; but overall symptom severity ratings were comparable between the language groups.

Disparities on Baseline Performance Using Neurocognitive and Oculomotor Clinical Measures of Concussion

BACKGROUND

Given the high participation of Black/African American individuals in high school sports, especially high-risk sports for concussion, it is important to note if racial and socioeconomic status (SES) differences exist in baseline performance on clinical measures of concussion.

PURPOSE

To explore the association between race and SES on baseline concussion assessments of neurocognitive performance and oculomotor function in adolescent athletes.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

A total of 564 high school athletes (mean ± SD age, 15.33 ± 1.1 years) completed the baseline Immediate Post-Concussion Assessment and Cognitive Test and King-Devick (KD) battery before the start of their competitive season. Race was defined as either White/non-Hispanic or Black/African American. SES status was determined by whether the individual's participating high school was a Title I or non-Title I school. A series of multivariable linear regression analyses were conducted to evaluate the association of computerized neurocognitive test scores (verbal memory, visual memory, motor processing speed, and reaction time), symptom severity scores, and KD scores by race and SES.

RESULTS

White/non-Hispanic individuals performed significantly better than Black/African American individuals on verbal memory (P < .01), visual memory (P < .01), visual motor processing speed (P < .01), and reaction time (P < .01) and had a lower symptom score (P < .01). Regarding SES, individuals from non-Title I schools performed better on visual memory (P = .05) and reaction time (P = .02) than individuals from Title I schools. Examination of cumulative KD test reading time revealed that there was no association between race on baseline reading times (P = .12). There was a significant association between cumulative reading time and SES (P = .02). Individuals from non-Title I schools performed significantly faster than individuals from Title I schools on KD test time.

CONCLUSION

Overall, race and SES influence neurocognitive and oculomotor concussion baseline performance in high school athletes. These findings add to the growing literature on the influence of race and SES on neurocognitive and oculomotor function baseline concussion assessments; they highlight the necessity for individualized concussion baseline measurements or race-specific normative reference values.

The effects of socioeconomic status on baseline neurocognitive testing scores

Baseline neurocognitive testing has been recommended to provide a more accurate representation of the pre-concussion cognitive status of individual athletes. Socioeconomic status is not typically controlled for when obtaining baseline scores, which may lead to inaccurate findings if post-injury scores are compared to normative data. Understanding the role of socioeconomic status in baseline testing is important for the accurate analysis of test scores and proper evaluation of patients if individualized baseline data are not available. Our purpose was to investigate the effects of socioeconomic status, as determined by eligibility for free or reduced cost lunch on baseline neurocognitive test scores in secondary school athletes. 1,788 secondary school athletes (females = 778, males = 1,010, age = 14.96 ± 1.11 years, height = 171.25 ± 17.83 cm, mass = 66.82 ± 21.63 kg) completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) upon starting scholastic athletics. ImPACT components (symptom severity scores and composite scores of verbal memory, visual memory, visual motor speed, and reaction time) served as the dependent variables. School administration coded free or reduced cost lunch eligibility (N = 1255 not eligible, N = 563 eligible) for each participant (group), which served as the independent variable. Free or reduced cost lunch eligibility significantly altered the combined dependent variables (multivariate F_5,1780=14.41, p < .001, ɳ² = .04) when sex and age were controlled. Follow up ANOVAs showed that participants eligible for free or reduced cost lunch scored significantly worse on verbal memory (F_1,1784 = 24.81, p < .001, ɳ² = .01), visual memory (F_1,1784 = 24.90, p < .001, ɳ² = .01), and visual motor speed (F_1,1784 = 50.54, p < .001, ɳ² = .03). In addition, slower reaction times (F_1,1784 = 35.10, p < .001, ɳ² = .02) and higher symptom severity scores (F_1,1784 = 10.37, p < .01, ɳ² = .01) were observed in those eligible for free or reduced cost lunch. If normative data are used instead of individual baselines, potential modifiers such as socioeconomic status should be taken into account when analyzing concussion scores to provide accurate diagnoses.