Fear avoidance behavior in youth with poor recovery from concussion: measurement properties and correlates of a new scale

Experienced Clinical Decision-Making in Physical Therapist Management of Concussion: A Qualitative Study

OBJECTIVE

The recent publication of the Physical Therapy Evaluation and Treatment After Concussion Clinical Practice Guideline is intended to assist clinicians in their decision-making specific to evaluation and intervention. Clinical practice guidelines are supported by best available evidence, though it is unknown what other factors drive clinical decision-making in the realm of concussion management. The purpose of this study was to explore factors related to the process of clinical decision-making of experienced physical therapists who treat individuals with concussion.

METHODS

This grounded theory approach used semi-structured interviews of physical therapists who have practiced concussion management ≥3 years and have treated ≥15 individuals for postconcussion symptoms in the last year. Following the inductive approach, deductive qualitative methodology was used to explore alignment with recent guidelines. Member checking was used to ensure trustworthiness.

RESULTS

Ten therapists' experience in treating concussion ranged from 5 to 20 years. Four overarching themes were identified that contribute to clinical decision-making: expert practice behaviors through use of reflection in action, clinical reasoning, collaboration, and evidenced informed practice; therapeutic alliance building using individualized education, reassurance, and relationship building; adaptability in prioritizing, assessing, and responding to patients' needs; and listening and observing. Clinician decision-making statements showed alignment with clinical practice guideline recommendations.

CONCLUSION

Experienced therapists demonstrate a consistent approach that parallels the current clinical practice guideline while building off clinical experience to tailor individualized care focusing on patient centeredness. These factors may assist more novice clinicians to develop and improve their management strategies for optimal outcomes.

IMPACT

Identified themes may broaden frameworks and guidelines for the management of individuals postconcussion specific to the field of physical therapy.

Psychological Constructs From the Fear Avoidance Model and Beyond as Predictors for Persisting Symptoms After Concussion: An Integrative Review

OBJECTIVES

To identify the range of evidence for relationships between psychological factors using the Fear Avoidance Model (FAM) as a guiding framework and relevant clinical outcomes in adult patients with persisting symptoms after concussion (PSaC), develop a comprehensive understanding of psychological factors that have been identified as predictors of clinical outcomes for PSaC, and contribute to the theoretical framework of the FAM for PSaC.

DATA SOURCES

Six databases (CINAHL, Embase, PsycINFO, PubMed, SportDiscus, and Web of Science) were searched by a librarian for empirical and theoretical publications and experimental and quasi-experimental study designs. The literature search was not limited by publication date restrictions. Gray literature, with the exception of doctoral dissertations, was excluded.

STUDY SELECTION

We included studies in the English language consisting of human participants aged ≥18 years. Articles must have included both outcomes pertaining to PSaC (≥3mo after injury) and psychological constructs.

DATA EXTRACTION

One reviewer extracted data from the resulting studies using a standardized data extraction form designed for this review. Two reviewers independently assessed risk of bias using the Quality in Prognosis Studies tool.

DATA SYNTHESIS

This review found numerous psychological constructs, some directly linked to the FAM, that have potential prognostic relationships with PSaC. However, research remains limited and some psychological factors central to FAM were only identified in a small number of studies (catastrophizing, cogniphobia, and avoidance), whereas other psychological factors were studied more extensively (anxiety and depression).

CONCLUSIONS

There is the need for additional evidence, and this integrative review provides an adaptation of the FAM for PSaC to be used as a guiding preliminary framework for future research. Future research should aim to include psychological factors proposed in this modified FAM to fully understand PSaC.

The role of concussion history and biological sex on baseline concussion clinical profile symptoms in adolescent rugby players

BACKGROUND

Accurate concussion monitoring requires access to preinjury baseline data. This is particularly important in adolescent athletes who have a high risk of concussion and are prone to prolonged recovery. As Rugby Union is governed by similar laws for men and women, it is also an ideal population to rigorously examine the impact of biological sex on concussion symptoms.

AIMS

To evaluate self-reported concussion symptoms at baseline in adolescent rugby union players, and examine if subtype-specific symptoms are affected by concussion history and biological sex.

METHODS

Adolescent rugby union players aged 16-18 years were recruited during the 2022-2023 playing season. Participants completed a series of questionnaires covering post-concussion symptoms, concussion clinical profiles, anxiety, depression and fear avoidance behaviours. Independent variables of interest in analysis were biological sex and concussion history.

RESULTS

149 participants (75% male) were included. 42% (63/149) reported at least one previous concussion (average time since concussion: 18.7 months, range 1-72). Adolescents with a concussion history reported significantly higher scores than those with no history, across two clinical profiles (ocular and sleep), concussion symptom severity, and depression, all based on medium effect sizes (SMD 0.3-0.5). Females had significantly higher scores across cognitive/fatigue, ocular and sleep clinical profiles, concussion symptoms, anxiety and depression, each with large effect sizes (SMD > 0.5).

CONCLUSIONS

Concussion history and sex are associated with higher baseline scores on specific concussion clinical profile, concussion symptom severity, and anxiety symptoms. These findings highlight the importance of considering baseline differences when interpreting post-injury clinical profile symptoms in adolescent rugby players. (Trial registration: ACTRN12622000931774).

Quantifying Fear Avoidance Behaviors in People With Concussion: A COSMIN-Informed Systematic Review

OBJECTIVE: The validity of existing fear avoidance behavior patient-reported outcome measures (PROMs) for concussion is unknown. This study aims to (1) identify PROMs that assess fear avoidance behavior in individuals with concussion and (2) assess the measurement properties of these PROMs. DESIGN: A systematic review of outcome measurement instruments using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. LITERATURE SEARCH: We performed a systematic search of 7 databases. STUDY SELECTION CRITERIA: Studies were included if they assessed fear avoidance behavior (eg, kinesiophobia or cogniphobia) in participants with concussion, occurring in all settings (eg, sport, falls, assaults). DATA SYNTHESIS: Methodological quality of the PROMs was assessed using the COSMIN checklist, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS: We identified 40 studies assessing fear avoidance. Four studies (n = 875 participants, representing 3 PROMs) were eligible for COSMIN assessment. Content validity for all PROMs was insufficient due to extreme risk of bias. The Fear Avoidance Short Form Scale demonstrated the greatest validity: moderate-certainty evidence for sufficient structural validity and internal consistency, and low-certainty evidence for measurement invariance. CONCLUSION: Current PROMs for measuring fear avoidance behaviors in people with concussion have insufficient content validity and should be used with caution in research and clinical practice. J Orthop Sports Phys Ther 2023;53(9):540-565. Epub: 10 August 2023. doi:10.2519/jospt.2023.11685.

Multisystem recovery after sport-related concussion in adolescent rugby players: a prospective study protocol

INTRODUCTION

Sport-related concussion is one of the most common injuries in adolescent rugby players with evidence of prolonged recovery in some concussed athletes. Concussion is a complex pathophysiological process that can affect a variety of subsystems with multifactorial presentation. Most research on adolescents recovery after concussion focuses on neurocognitive functioning and symptom outcomes over the short term. There is a need to explore concussion recovery over time across multiple subsystems in adolescent rugby players.

METHODS AND ANALYSIS

This prospective study will use sensorimotor and oculomotor outcomes in adolescent male and female rugby players aged 16-18 years. Players will be recruited from school or club rugby teams across the province of Ulster. Baseline assessment will be undertaken at the start of the playing season and will include questionnaires, Quantified Y Balance Test and Pupillary Light Reflex. Players who sustain a concussive event will be reassessed on all outcomes at 3 days, 7 days, 14 days, 23 days, 90 days, 180 days and 365 days postconcussion. For serial outcome data, we will examine response curves for each participant and make comparisons between known groups. We will use logistic regression to explore any association between demographic variables and recovery. The strength of the predictive model will be determined using R2, p values and ORs, with 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been granted for this study from Ulster University Research Ethics Committee (REC/14/0060). This study will be published in an open-access research journal on completion.

TRIAL REGISTRATION NUMBER

ACTRN12622000931774p.

Management of Psychological Complications Following Mild Traumatic Brain Injury

PURPOSE OF REVIEW

It has been clear for decades that psychological factors often contribute to mild traumatic brain injury (mTBI) outcome, but an emerging literature has begun to clarify which specific factors are important, when, for whom, and how they impact recovery. This review aims to summarize the contemporary evidence on psychological determinants of recovery from mTBI and its implications for clinical management.

RECENT FINDINGS

Comorbid mental health disorders and specific illness beliefs and coping behaviors (e.g., fear avoidance) are associated with worse recovery from mTBI. Proactive assessment and intervention for psychological complications can improve clinical outcomes. Evidence-based treatments for primary mental health disorders are likely also effective for treating mental health disorders after mTBI, and can reduce overall post-concussion symptoms. Broad-spectrum cognitive-behavioral therapy may modestly improve post-concussion symptoms, but tailoring delivery to individual psychological risk factors and/or symptoms may improve its efficacy. Addressing psychological factors in treatments delivered primarily by non-psychologists is a promising and cost-effective approach for enhancing clinical management of mTBI. Recent literature emphasizes a bio-psycho-socio-ecological framework for understanding mTBI recovery and a precision rehabilitation approach to maximize recovery. Integrating psychological principles into rehabilitation and tailoring interventions to specific risk factors may improve clinical management of mTBI.

Adolescents with a concussion have altered brain network functional connectivity one month following injury when compared to adolescents with orthopedic injuries

Concussion is a mild traumatic brain injury (mTBI) with increasing prevalence among children and adolescents. Functional connectivity (FC) within and between the default mode network (DMN), central executive network (CEN) and salience network (SN) has been shown to be altered post-concussion. Few studies have investigated connectivity within and between these 3 networks following a pediatric concussion. The present study explored whether within and between-network FC differs between a pediatric concussion and orthopedic injury (OI) group aged 10-18. Participants underwent a resting-state functional magnetic resonance imaging (rs-fMRI) scan at 4 weeks post-injury. One-way ANCOVA analyses were conducted between groups with the seed-based FC of the 3 networks. A total of 55 concussion and 27 OI participants were included in the analyses. Increased within-network FC of the CEN and decreased between-network FC of the DMN-CEN was found in the concussion group when compared to the OI group. Secondary analyses using spherical SN regions of interest revealed increased within-network FC of the SN and increased between-network FC of the DMN-SN and CEN-SN in the concussion group when compared to the OI group. This study identified differential connectivity patterns following a pediatric concussion as compared to an OI 4 weeks post-injury. These differences indicate potential adaptive brain mechanisms that may provide insight into recovery trajectories and appropriate timing of treatment within the first month following a concussion.

Which psychosocial factors are associated with return to sport following concussion? A systematic review

BACKGROUND

Psychosocial factors predict recurrent injury and return to preinjury level of performance following orthopedic injury but are poorly understood following concussion. Current management protocols prioritize physical measures of recovery. Therefore, the objective of this study was to describe the psychosocial factors associated with return to sport (RTS) and how they are measured in athletes who sustained a concussion.

METHODS

MEDLINE, Embase, APA PsycINFO, CINAHL, and SPORTDiscus were searched through February 2, 2021. Eligible studies included original peer-reviewed publications describing psychosocial factors associated with RTS following a diagnosed concussion. The primary outcome was scales or measures employed and/or key thematic concepts.

RESULTS

Of the 3615 studies identified, 10 quantitative cohort studies (Oxford Centre for Evidence-Based Medicine Level-3) representing 2032 athletes (85% male; high-school and collegiate collision/contact athletes) and 4 qualitative studies representing 66 athletes (74% male; 70% American football; aged 9-28 years) were included. We identified 3 overarching themes and 10 outcome measures related to psychosocial factors associated with RTS following concussion: (a) fear (e.g, of recurrent concussion, of RTS, of losing playing status); (b) emotional factors (e.g, depression, anxiety, perceived stress, mental health, disturbance mood); and (c) contextual factors (e.g, social support, pressure, sense of identity).

CONCLUSION

Although current medical clearance decisions prioritize physical measures of recovery, evidence suggests diverse psychosocial factors influence RTS following concussion. It remains unclear which psychosocial factors contribute to a successful RTS, including the influence of sex/gender and age. Future studies should evaluate the association of psychological readiness with physical measures of recovery at medical clearance, preinjury level of performance, and risk of recurrent concussion to support RTS clinical decision-making.