Racial disparities in parent knowledge of concussion and recognition of signs and symptoms

Inequities in neurological care: Access to services, care gaps, and other barriers-A systematic review

BACKGROUND AND PURPOSE

Health disparities and inequities are an important and too long overlooked public health concern worldwide. These differences in health and health care can affect people with any disease, including neurological disorders. The aim of this systematic review is to provide an updated overview of the main health inequities faced by neurological patients worldwide, to plan valuable interventions.

METHODS

Main databases were searched systematically. Quality was assessed with the Mixed Methods Appraisal Tool. This review followed the standard guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 1797 studies were obtained, of which 49 studies were included in the final round and subjected to quality appraisal. Quality assessment yielded scores ranging from 20% to 100%. The results were divided based on the nature of inequities: (i) socioeconomic disadvantage (n = 25); and (ii) access to care, treatment, and services inequities (n = 24). Most studies were conducted in high income counties (n = 46, 93.8%) and reported health inequities in persons with cerebrovascular diseases, especially stroke (n = 20, 40.8%), followed by multiple sclerosis (n = 8, 16.3%) and neurodegenerative disorders (n = 6, 12.2%).

CONCLUSIONS

Racial and ethnic discrimination, economic issues, differences in disease management, educational level, and place of residence are the main inequities reported by neurological patients. The USA dominates the research panorama (n = 36, 73.4%), highlighting the need for more studies that cover other geopolitical contexts. Improving population health means improving health for everyone; however, historically disadvantaged groups continue to trail dramatically behind, and actions are needed to reduce the inequities.

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.

An initial assessment of an opinion leader-informed intervention to improve concussion-related outcomes among middle school parents: a randomized controlled trial

INTRODUCTION

There is a need for evidence-based prevention programming that can reduce head impacts and increase reporting and disclosure of concussion. This study assessed an intervention to decrease concussion risk and improve concussion management through improving concussion-related knowledge, attitudes, intentions, and self-efficacy among parents in the middle school (MS) sport setting.

PATIENTS AND METHODS

This randomized controlled trial (NCT04841473) examined parents of MS-aged children. Participants were randomized into one of two study arms: (1) CDC, which completed an education training module that compiled concussion education from the Centers for Disease Control and Prevention (CDC); and (2) TRAIN + CDC, which completed the CDC training module and an additional TRAIN educational module that provided strategies (originating from the Popular Opinion Leader framework) on communicating such information with one's personal peer networks and children. Validated measures of concussion-related knowledge, attitudes, intentions, and self-efficacy were collected before completing the training modules and one week following completion. Linear mixed model analyses examined differences in outcomes between study arms.

RESULTS

Overall, 103 parents completed the training modules and had valid pre- and post-intervention data (TRAIN + CDC n = 49; CDC n = 54). Analyses found that the study arms did not differ in the change scores from pre- to post-intervention across concussion-related outcomes. However, scores from pre- to post-intervention improved across both study arms for knowledge metrics, such as 'Concussions are less likely to happen when athletes play by the rules of the sport' (p < 0.001), and self-efficacy metrics, such as feeling confident in one's knowledge and recognition of concussion symptoms (p < 0.001 and p = 0.001, respectively).

CONCLUSIONS

Although study arms did not differ in change scores from pre- to post-intervention, beneficial increases were nonetheless found across both knowledge and self-efficacy. Additional research is needed to further examine the beneficial manners in which concussion education can be best delivered and the most effective.

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.

Framing racial disparities within sports related concussion (SRC): an ecological framework for understanding biases and disparities in concussion care for black athletes

Privilege and marginalization associated with racial background have been posited as contributors to why Black athletes face disparities within their care, treatment, and recovery from sport-related concussion (SRC). However, empirical findings have limited exploration on how disparate outcomes have emerged, and the interaction with systems of biases, power and disenfranchisement. To understand concussion care disparities, a qualitative content analysis was conducted in three phases: [I] identifying salient literature on racial differences for Black athletes with SRC (N = 29), [II] qualitative analysis of literature to determine salient topics, themes and patterns within the literature, and [III] constructing a novel ecological-systems framework that encapsulates the 'why' and 'how' related to psychosocial and sociocultural experiences of power, access, and biases for Black athletes. The content analysis yielded two patterns, where concussion care decisions are influenced by (1) biased, unconscious beliefs that posit Black athletes as uniquely invincible to injury and pain, and (2) inadequate access to concussion knowledge and resources, which both moderate SRC injury risk, diagnosis, recovery and outcomes. Ultimately, our novel framework provides a clear thread on how historical, macro-level policy and perceptions can impact micro-level clinical care and decision-making for Black athletes with SRC.

Does the Association Between Concussion Measures and Social Context Factors Differ in Black and White Parents?

CONTEXT

Middle school (MS) parents may benefit from education supporting timely concussion identification and care-seeking in their young children (aged approximately 10 to 15 years). However, such education may not consider individual needs and different social context factors, including lower socioeconomic status, disadvantaged social determinants of health, and different racial and ethnic backgrounds.

OBJECTIVES

To examine the relationship between social context factors and concussion knowledge, attitudes, and communication in MS parents and to explore the possible role of race and ethnicity (Black or White) as an effect measure modifier.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A nationally representative sample of MS parents who completed an online survey (n = 1248).

MAIN OUTCOME MEASURE(S)

Parent outcomes were a history of concussion education, concussion symptom knowledge and attitudes, and communication with children about concussion. Main exposures were parental race and ethnicity (Black or White) and social context factors. Uni- and multivariable statistical analyses were performed to achieve the study aims.

RESULTS

Black parents were more likely than White parents to have received concussion education (69.5% versus 60.5%, P = .009), although median concussion knowledge scores were higher for White parents than for Black parents (40 versus 37, P < .001). Few associations were found for social context factors with concussion knowledge, attitudes, and communication in Black and White parents separately.

CONCLUSIONS

Among MS parents, race and ethnicity may not influence the association between social context factors and concussion-related knowledge, attitudes, or communication. However, differences were present by race and ethnicity regarding previous concussion education and other parental outcomes, concussion symptom knowledge in particular.

National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion

OBJECTIVE

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

BACKGROUND

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

RECOMMENDATIONS

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

Racial identity and concussion diagnosis and recovery trajectories in collegiate athletes: a LIMBIC MATARS investigation

OBJECTIVE

To determine if there were concussion diagnosis and recovery disparities between collegiate athletes with Black and White racial identities.

DESIGN

Retrospective cohort study.

METHODS

Concussion information was extracted from NCAA athlete medical files at LIMBIC MATARS member institutions from the 2015-16' to 2019-20' academic years. A total of 410 concussions from 9 institutions were included that provided all independent (i.e. racial identity of Black or White) and dependent variable information (i.e. dates of injury, diagnosis, symptom resolution, and return to sport) that were analyzed using Mann-Whitney U tests. The sample consisted of 114 (27.8%) concussions sustained by Black athletes and 296 (72.1%) sustained by White athletes.

RESULTS

The overall sample had a median of 0 days between injury occurrence to diagnosis, 7 days to symptom resolution, and 12 days to return to sport. No significant timing differences were observed for concussion diagnosis (p = .14), symptom resolution (p = .39), or return to sport (p = 0.58) between collegiate athletes with Black versus White racial identities.

CONCLUSIONS

These findings may reflect equitable access to onsite sports medicine healthcare resources that facilitate concussion management in the collegiate sport setting. Future work should explore these associations with a larger and more diverse sample of collegiate athletes.

Predicting Time to Evaluation After Pediatric Concussion: Factors Affecting Specialty Concussion Care

Background

The timing of clinical evaluation after pediatric concussion represents an important and potentially modifiable clinical milestone for diagnosis, selection of appropriate treatment pathways, and recovery prognosis. Patient demographics, socioeconomic status, or medical history may affect the time to the initial evaluation and subsequently influence recovery outcomes.

Purpose/Hypothesis

The purpose of this investigation was to evaluate the association of patient characteristics with the time to specialty evaluation after a concussion. It was hypothesized that patients with a history of concussion, a preexisting relationship with our specialty concussion program, or a higher ZIP code-based income estimate would present for care more quickly after a concussion than patients without these characteristics.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included were patients with a concussion between 6 and 18 years old who were seen for care at a single sports medicine center between January 1 and December 31, 2019. Patient demographic, socioeconomic, injury, and clinical characteristics were collected through a retrospective review of the medical records. The primary outcome was the number of days between the date of the concussion and the patient's initial specialty evaluation.

Results

Overall, 220 patients (mean age, 14.4 ± 2.5 years; 46% female) were seen for care at a mean of 9.7 ± 5.6 days (range, 1-21 days) after concussion. A shorter time to specialty evaluation was associated with a history of concussion (β = -1.72 [95% CI, -3.24 to -0.20]; P = .03) and a prior clinical relationship with the treating clinical department (β = -1.85 [95% CI, -3.52 to -0.19]; P = .03). Referral by a primary care provider was associated with a longer time to evaluation (β = 3.86 [95% CI, 2.39-5.33]; P < .0001).

Conclusion

A history of concussion and having a preexisting clinical relationship with the deparment were associated with a shorter time to evaluation after concussion. Referral from a primary care physician was associated with a longer time to evaluation. Issues may exist in the propensity to access care after an injury, resulting in delays for initiating early treatment.

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.

Uses of Health Care System Medical Care Services by Athletes After Injury at the High School Level

BACKGROUND

Health care utilization can vary by age group, geographic location, and socioeconomic status (SES). A paucity of information exists regarding the availability and utilization of medical care by injured scholastic athletes. The purpose of this study was to describe and compare injuries and health care service utilization by school SES over an academic year.

METHODS

Injury and health care service data was collected from 1 large school district. Percentage of free and reduced lunch (FRPL) for each school was calculated to stratify schools into high (<50% FRPL) and low (≥50.1% FRPL) SES groups. Incidence proportion and relative risk (RR) with 95% confidence intervals (95% CI) were calculated.

RESULTS

About 1756 injuries were reported among over 7000 participating athletes from 14 high schools. Similar injury incidence proportions were reported between high and low SES schools (RR = 1.10 [1.00-1.20]). Athletes from low SES schools were twice (RR = 2.01 [1.21-3.35]) and over three (RR = 3.42 [1.84-6.55]) times more likely to receive emergency and physical therapy care. SES was not associated with the use of physician, imaging, or surgery services.

IMPLICATIONS FOR SCHOOL HEALTH, POLICY, AND EQUITY

School medical providers and administrators should have ready and provide a list of trusted outside primary care and specialty providers that have experience in sports medicine. They should also enquire and follow up on which outside provider the high school athlete will seek care when referring out to outside providers.

CONCLUSIONS

Injury incidence was similar between high and low SES schools. However, athletes from low SES high schools were over 2-fold more likely to use emergency department services. Understanding factors influencing health care services choice and usage by student athletes from different socioeconomic backgrounds may assist sport medicine clinicians in identifying barriers and potential solutions in improving time to health restoration, athlete outcomes, and health care monetary burden.

Dynamic cognitive inhibition in the context of frustration: Increasing racial representation of adolescent athletes using mobile community-engaged EEG methods

Introduction

Concussive events and other brain injuries are known to reduce cognitive inhibition, a key aspect of cognition that supports ones' behaviors and impacts regulation of mood or affect. Our primary objective is to investigate how induction of negative affect (such as frustration) impacts cognitive inhibition and the dynamic process by which youth athletes modulate responses. Secondary objective is to address the lack of Black representation in the scientific literature that promotes brain health and investigates pediatric sports-related brain injury. In particular, neuroscience studies predominantly include White participants despite broad racial representation in sport, in part due to technological hurdles and other obstacles that challenge research access for Black participants.

Methods

Using electroencephalography (EEG), we evaluate the dynamic brain processes associated with cognitive inhibition in the context of frustration induction in adolescent athletes during pre-season conditioning (i.e., prior to contact; N = 23) and a subset during post-season (n = 17).

Results

The N2 component was sensitive to frustration induction (decreased N2 amplitude, slower N2 latency), although effects were less robust at postseason. Trial-by-trial changes indicated a steady decrease of the N2 amplitude during the frustration block during the preseason visit, suggesting that affective interference had a dynamic effect on cognitive inhibition. Lastly, exploratory analyses provide preliminary evidence that frustration induction was less effective for athletes with a previous history of concussion or migraines (trending result) yet more effective for athletes endorsing a history with mental health disorders.

Discussion

We emphasize the urgent need to improve representation in cognitive neuroscience, particularly as it pertains to brain health. Importantly, we provide detailed guides to our methodological framework and practical suggestions to improve representative participation in studies utilizing high-density mobile EEG.

Association of concussion with high school academic standing: sex, school grade and race as stratifiers

INTRODUCTION

The purpose was to examine the association between concussion history and academic standing among high school students, and whether the association varies by sex, school grade and race/ethnicity.

METHODS

Data from the 2019 Youth Risk Behaviour Survey were used for our cross-sectional study. Exposure was self-reported history of concussions in the past 12 months. Outcome was self-reported academic standing in the past 12 months. Poisson regression was used to analyse the exposure-outcome association, and whether there were differences by our stratifying variables.

RESULTS

Having a history of concussion in the past 12 months was significantly associated with a higher risk of poor academic standing during the same period, and the association varied by race/ethnicity.

DISCUSSION

Youth with a history of concussion may be at risk for poorer academic standing, indicating to the importance of prevention. Future studies are needed to examine the interaction of race/ethnicity on the presented association.

Association between mild traumatic brain injury, brain structure, and mental health outcomes in the Adolescent Brain Cognitive Development Study

BACKGROUND

Children that experience a mild traumatic brain injury (mTBI) are at an increased risk of neural alterations that can deteriorate mental health. We test the hypothesis that mTBI is associated with psychopathology and that structural brain metrics (e.g., volume, area) meaningfully mediate the relation in an adolescent population.

METHODS

We analyzed behavioral and brain MRI data from 11,876 children who participated in the Adolescent Brain Cognitive Development (ABCD) Study. Mixed-effects models were used to examine the longitudinal association between mTBI and mental health outcomes. Bayesian methods were used to investigate brain regions that are intermediate between mTBI and symptoms of poor mental health.

RESULTS

There were 199 children with mTBI and 527 with possible mTBI across the three ABCD Study visits. There was a 7% (IRR = 1.07, 95% CI: 1.01, 1.13) and 15% (IRR = 1.16, 95% CI: 1.05, 1.26) increased risk of emotional or behavioral problems in children that experienced possible mTBI or mTBI, respectively. Possible mTBI was associated with a 17% (IRR: 1.17, 95% CI: 0.99, 1.40) increased risk of experiencing distress following a psychotic-like experience. We did not find any brain regions that meaningfully mediated the relationship between mTBI and mental health outcomes. Analysis of volumetric measures found that approximately 2% to 5% of the total effect of mTBI on mental health outcomes operated through total cortical volume. Image intensity measure analyses determined that approximately 2% to 5% of the total effect was mediated through the left-hemisphere of the dorsolateral prefrontal cortex.

CONCLUSION

Results indicate an increased risk of emotional and behavioral problems in children that experienced possible mTBI or mTBI. Mediation analyses did not elucidate the mechanisms underlying the association between mTBI and mental health outcomes.

Effects of prior concussion on symptom severity and recovery time in acute youth concussion

OBJECTIVE

Many studies have identified factors associated with increased symptom burden and prolonged recovery after pediatric and adolescent concussion. Few have systematically examined the effects of prior concussion on these outcomes in patients with concussion due to any mechanism. An improved understanding of the short- and long-term effects of a multiple concussion history will improve counseling and management of this subgroup of patients.

METHODS

A retrospective review of adolescent and young adult acute concussion patients presenting to the multidisciplinary concussion clinic between 2018 and 2019 was conducted at a single center. Patient demographic data, medical history including prior concussion, initial symptom severity score (SSS), injury mechanisms, and recovery times were collected. Univariate and multivariable analyses were conducted to identify associations of history of prior concussion and patient and injury characteristics with symptom score and recovery time.

RESULTS

A total of 266 patients with an average age of 15.4 years (age range 13-27 years) were included. Prior concussion was reported in 35% of patients. The number of prior concussions per patient was not significantly associated with presenting symptom severity, recovery time, or recovery within 28 days. Male sex and sports-related concussion (SRC) were associated with lower presenting SSS and shorter recovery time on univariate but not multivariable analysis. However, compared to non-sport concussion mechanisms, SRC was associated with 2.3 times higher odds of recovery within 28 days (p = 0.04). A history of psychiatric disorders was associated with higher SSS in univariate analysis and longer recovery time in univariate and multivariable analyses. Multivariable log-linear regression also demonstrated 5 times lower odds of recovery within 28 days for those with a psychiatric history.

CONCLUSIONS

The results of this study demonstrated that an increasing number of prior concussions was associated with a trend toward higher presenting SSS after youth acute concussion but did not show a significant association with recovery time or delayed (> 28 days) recovery. Presence of psychiatric history was found to be significantly associated with longer recovery and lower odds of early (≤ 28 days) recovery. Future prospective, long-term, and systematic study is necessary to determine the optimal counseling and management of adolescent and young adult patients with a history of multiple concussions.

Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment

Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.

Exploration of Race and Ethnicity, Sex, Sport-Related Concussion, Depression History, and Suicide Attempts in US Youth

IMPORTANCE

Racial, ethnic, and sex disparities for concussion incidence and suicide attempts in youth have been reported, but data on the interaction of these variables in a large national data set are lacking. Understanding how race and ethnicity interact with sex and concussion to influence suicide attempts could yield critical information on the sociocultural impact of brain injury and mental health in US youth.

OBJECTIVE

To examine the associations of concussion history, race and ethnicity, and sex with reported suicide attempts among adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional cohort study used data from US Youth Risk Behavior Surveillance System (YRBSS) survey respondents between 2017 and 2019. Data were analyzed from May 2021 to January 2022.

EXPOSURES

Respondents reported sport- or recreation-related concussion (yes or no), depression (yes or no), and suicide attempt (yes or no) over the previous 12 months, along with race and ethnicity (categorized as American Indian or Alaska Native, Asian, Black, Hispanic/Latino, multiracial, Native Hawaiian or other Pacific Islander, and White), and sex (male or female).

MAIN OUTCOMES AND MEASURES

Two Chi-Square Automatic Interaction Detection (CHAID) decision tree models were built. The first was suicide attempt with depression history (SA-DEP), the second was suicide attempt without depression history (SA-NO DEP). CHAID uses risk factors (eg, number of concussions, race and ethnicity, sex) to divide the study sample into a series of subgroups that are nested within each other. Risk ratios (RRs) and 95% CIs were calculated for each subgroup to provide effect estimates.

RESULTS

A total of 28 442 youths aged up to 18 years (mean [SD] age, 14.6 [3.0] years; 14 411 [50.7%] female) responded to the survey. The CHAID decision trees revealed a complex interaction between race, sex, and concussion history for attempting suicide, which differed by depression history (overall accuracy, 84.4%-97.9%). Overall, depression history was the variable most strongly associated with SA (adjusted odds ratio, 11.24; 95% CI, 10.27-12.29). Concussion was the variable most strongly associated with SA-DEP (RR, 1.31; 95% CI, 1.20-1.51; P < .001). Black, Hispanic/Latino, or multiracial race and ethnicity were associated with increased risk for SA-DEP compared with others (RR, 1.59; 95% CI, 1.38-1.84; P < .001). American Indian or Alaska Native, Black, and Hispanic/Latino race and ethnicity were associated with increased risk for SA-NO DEP (RR, 1.89; 95% CI, 1.54-2.32; P < .001) compared with the remaining population.

CONCLUSIONS AND RELEVANCE

These findings suggest that clinicians should consider race, ethnicity, and sex when evaluating the role of sport- or recreation-related concussion on suicide risk among US youth.

Examining Concussion Nondisclosure in Collegiate Athletes Using a Health Disparities Framework and Consideration of Social Determinants of Health

CONTEXT

Limited research exists concerning the relationship between the social determinants of health (SDOHs), including race, socioeconomic status (SES), health care access and physical environment and concussion nondisclosure in collegiate athletes. However, among high school athletes, disparities have been noted, with Black athletes who attended under-resourced schools and lacked access to an athletic trainer (AT) disclosing fewer concussions.

OBJECTIVE

To investigate whether concussion nondisclosure disparities existed by (1) race, (2) SES, or (3) AT health care access before college and understand the differential reasons for concussion nondisclosure between White and Black collegiate athletes.

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics.

PARTICIPANTS

A total of 735 college athletes (84.6% White, 15.4% Black).

MAIN OUTCOME MEASURE(S)

Participants completed a questionnaire that directly assessed concussion nondisclosure, including reasons for not reporting a suspected concussion. With the premise of investigating SDOHs, race was the primary exposure of interest. The outcome of interest, nondisclosure, was assessed with a binary (yes or no) question, "Have you ever sustained a concussion that you did not report to your coach, AT, parent, teammate, or anyone else?"

RESULTS

Among the White and Black athletes, 15.6% and 17.7%, respectively, reported a history of concussion nondisclosure. No differences were found by race for distributions of history of concussion nondisclosure (P = .57). Race was not associated with concussion nondisclosure when evaluated as an effect modification measure or confounder, and no significant associations were noted by SES or high school AT access. Differences by race for reported reasons for nondisclosure were present for "At the time, I did not think it was a concussion" (P = .045) and "I thought my teammates would think I am weak" (P = .03), with Black athletes selecting these more frequently than White athletes.

CONCLUSIONS

These data help to contextualize race and its intersection with other SDOHs that could influence concussion nondisclosure outcomes in collegiate athletes.

Reporting of Concussion Symptoms by a Nationwide Survey of United States Parents of Middle School Children

This cross-sectional study assessed concussion symptom knowledge of parents of middle school (MS) children (aged 10-15 years) through a free-response item that solicited concussion symptoms and compared findings to a pre-validated scale-based measure. A self-administered online questionnaire was sent to a panel of randomly selected United States residents who were recruited by a third-party company, aged ≥ 18 years, and identified as parents of MS children. Via a free-response item, parents listed what they believed were concussion symptoms. Multiple sections later, parents identified potential concussion symptoms via a scale measure, which featured 25 items (22 actual symptoms, three distractor symptoms) with three response options: yes, no, maybe. Free-response item responses were coded into specific symptoms. The 1062 eligible parents that provided complete data commonly identified the symptoms of dizziness (90.2%), blurred vision (87.4%), and balance problems (86.4%) on the scale-based measure. However, these and other symptoms were less commonly identified via the free-response item (dizziness: 44.4%; blurred vision: 16.5%; balance problems: 3.5%). Concussion symptoms commonly reported via the scale-based measure were reported less frequently within the free-response item. Future research must explore strategies to help clinicians working with parents and their children to measure and assess concussion symptom reporting and knowledge.

Continued play following adolescent sport-related concussion: Prospective data from the North Texas Concussion Registry (ConTex)

Our study aims were to identify the frequency of continued play following sport-related concussion (SRC), defined as continuing athletic activity on the same day following a suspected SRC, characteristics associated with continued play, and whether continued play was associated with worse outcomes. A prospective study of participants ages 13-18 years diagnosed with SRC at a pediatric sports medicine clinic over a 4-year period was conducted. A comparison was performed between athletes who reported continued play following SRC (PLAY) and those who did not (NO PLAY). Of 441 participants, 231 (52.4%) were in the PLAY group. The PLAY group recalled less severe balance problems from the day of injury (p = 0.02), but reported greater symptoms of trouble falling asleep, concentrating, and remembering at their initial clinic visit (p < 0.05). There was no difference in recovery time between groups. Greater symptom severity score at the initial clinic visit and longer time to presentation were associated with prolonged recovery in both groups (p < 0.01). In conclusion, more than half of the athletes in this sample continued to play on the same day following SRC. Our results indicate the need for a heightened focus on education and additional efforts to reduce continued play following SRC in adolescents.