Disparities in Adherence to Concussion Clinical Care Recommendations in a Pediatric Population

Exploring racial disparities and inequalities among children and youth with acquired brain injury: a systematic review

PURPOSE

Racial minoritized children and youth with acquired brain injury (ABI) often experience multiple forms of discrimination. The purpose of this systematic review was to understand the racial disparities in health care among children and youth with ABI and their caregivers.

METHOD

Six international databases (Ovid Medline, Embase, Healthstar, Psychinfo, Scopus, and Web of Science) were systematically searched for peer-reviewed articles. Studies were screened by two researchers who also conducted the data extraction and quality appraisal. A narrative synthesis approach was used to analyze the data.

RESULTS

Of the 8081 studies identified in the search, 34 met the inclusion criteria, which involved 838,052 children and youth with brain injuries (or caregivers representing them) across two countries. The following themes were noted in the studies in our review: (1) racial disparities in accessing care (i.e., diagnosis, hospital admission, length of stay, rehabilitation treatment); (2) racial disparities in ABI-related health outcomes (i.e., functional outcomes and mortality rates); and (3) factors affecting racial disparities (i.e., sources in injury, insurance and expenditures, and intersectionality).

CONCLUSIONS

Our findings reveal the concerning racial disparities among children and youth with ABI. Further research should explore solutions for addressing such racial disparities and solutions to address them.

Social Determinants of Health and Health Equity in the Treatment and Rehabilitation of Sport-Related Concussion: A Content Analysis of Intervention Research and Call-To-Action

This review was designed to (i) determine the extent to which the clinical science on sport-related concussion treatment and rehabilitation has considered social determinants of health (SDoH) or health equity and (ii) offer recommendations to enhance the incorporation of SDoH and health equity in concussion treatment research and clinical care. The Concussion in Sport Group consensus statement (2023) was informed by two systematic reviews examining prescribed rest or exercise following concussion and targeted interventions to facilitate concussion recovery. We examined 31 studies, including 2,698 participants, from those two reviews. Race (k=6; 19.4%) and ethnicity (k=4; 12.9%) were usually not reported. Four studies examined ethnicity (i.e., Hispanic), exclusively as a demographic category. Five studies (16.1%) examined race as a demographic category. Three studies (9.7%) examined socioeconomic status (SES; measured as household income) as a demographic category/sample descriptor and one study (3.2%) examined SES in depth, by testing whether the treatment and control groups differed by SES. Five studies examined a SDoH domain in a descriptive manner and four studies in an inferential/intentional manner. No study mentioned SDoH, health equity, or disparities by name. Many studies (61.3%) excluded participants based on demographic, sociocultural, or health factors, primarily due to language proficiency. The new consensus statement includes recommendations for concussion treatment and rehabilitation that rely on an evidence base that has not included SDoH or studies addressing health equity. Researchers are encouraged to design treatment and rehabilitation studies that focus specifically on under-represented groups to determine if they have specific and unique treatment and rehabilitation needs, whether certain practical modifications to treatment protocols might be necessary, and whether completion rates and treatment adherence and response are similar.

Response Rate Patterns in Adolescents With Concussion Using Mobile Health and Remote Patient Monitoring: Observational Study

Background

A concussion is a common adolescent injury that can result in a constellation of symptoms, negatively affecting academic performance, neurobiological development, and quality of life. Mobile health (mHealth) technologies, such as apps for patients to report symptoms or wearables to measure physiological metrics like heart rate, have been shown to be promising in health maintenance. However, there is limited evidence about mHealth engagement in adolescents with a concussion during their recovery course.

Objective

This study aims to determine the response rate and response rate patterns in concussed adolescents reporting their daily symptoms through mHealth technology. It will also examine the effect of time-, demographic-, and injury-related characteristics on response rate patterns.

Methods

Participants aged between 11-18 years (median days since injury at enrollment: 11 days) were recruited from the concussion program of a tertiary care academic medical center and a suburban school's athletic teams. They were asked to report their daily symptoms using a mobile app. Participants were prompted to complete the Post-Concussion Symptom Inventory (PCSI) 3 times (ie, morning, afternoon, and evening) per day for 4 weeks following enrollment. The primary outcome was the response rate pattern over time (by day since initial app use and the day since injury). Time-, demographic-, and injury-related differences in reporting behaviors were compared using Mann Whitney U tests.

Results

A total of 56 participants were enrolled (mean age 15.3, SD 1.9 years; n=32, 57% female). The median response rate across all days of app use in the evening was 37.0% (IQR 27.2%-46.4%), which was significantly higher than the morning (21.2%, IQR 15.6%-30.5%) or afternoon (26.4%, IQR 21.1%-31.5%; P<.001). The median daily response was significantly different by sex (female: 53.8%, IQR 46.2%-64.2% vs male: 42.0%, IQR 28.6%-51.1%; P=.003), days since injury to app use (participants starting to use the app >7 days since injury: 54.1%, IQR 47.4%-62.2% vs starting to use the app ≤7 days since injury: 38.0%, IQR 26.0%-53.3%; P=.002), and concussion history (participants with a history of at least one prior concussion: 57.4%, IQR 44.5%-70.5% vs participants without concussion history: 42.3%, IQR 36.8%-53.5%; P=.03). There were no significant differences by age. Differences by injury mechanism (sports- and recreation-related injury: 39.6%, IQR 36.1%-50.4% vs non-sports- or recreation-related injury: 30.6%, IQR 20.0%-42.9%; P=.04) and initial symptom burden (PCSI scores greater than the median score of 47: 40.9%, IQR 35.2%-53.8% vs PCSI scores less than or equal to the median score: 31.9%, IQR 24.6%-40.6%; P=.04) were evident in the evening response rates; however, daily rates were not statistically different.

Conclusions

Evening may be the optimal time to prompt for daily concussion symptom assessment among concussed adolescents compared with morning or afternoon. Multiple demographic- and injury-related characteristics were associated with higher daily response rates, including for female participants, those with more than 1 week from injury to beginning mHealth monitoring, and those with a history of at least one previous concussion. Future studies may consider incentive strategies or adaptive digital concussion assessments to increase response rates in populations with low engagement.

A comparison of public views about sports concussion recovery with current guidelines: where are the gaps and overlaps?

Background Sports concussion (SC) management guidelines have recently been updated. A key focus is the emphasis on rest (immediately postinjury) followed by gradual resumption of activity (active recovery). This study aimed to explore community views on SC management and compared these with the guidelines. Methods A total of 157 volunteers completed an online SC survey, including listing three pieces of advice for a concussed person immediately postinjury, and after 2weeks (subacute). Quantitative data were statistically compared, and qualitative data underwent content analysis. Results Almost all participants offered different immediate versus subacute advice; however, rest featured highly at both timepoints. Commonly expressed themes, consistent with guidelines were immediate rest; safety and reinjury prevention; and symptom monitoring. Two themes were identified in the community advice with limited emphasis in the guidelines: general health advice and psychological and social support. Expert clinical assessment was not always identified in community advice. Conclusion Community members hold some views that align with expert advice for SC, particularly the importance of immediate postinjury rest. However, there is scope to grow public awareness of some recommended practices, including expert clinical assessment following injury and when to engage in active recovery.

Head Injury Treatment With Healthy and Advanced Dietary Supplements: A Pilot Randomized Controlled Trial of the Tolerability, Safety, and Efficacy of Branched Chain Amino Acids in the Treatment of Concussion in Adolescents and Young Adults

Concussion is a common injury in the adolescent and young adult populations. Although branched chain amino acid (BCAA) supplementation has shown improvements in neurocognitive and sleep function in pre-clinical animal models of mild-to-moderate traumatic brain injury (TBI), to date, no studies have been performed evaluating the efficacy of BCAAs in concussed adolescents and young adults. The goal of this pilot trial was to determine the efficacy, tolerability, and safety of varied doses of oral BCAA supplementation in a group of concussed adolescents and young adults. The study was conducted as a pilot, double-blind, randomized controlled trial of participants ages 11-34 presenting with concussion to outpatient clinics (sports medicine and primary care), urgent care, and emergency departments of a tertiary care pediatric children's hospital and an urban tertiary care adult hospital, between June 24, 2014 and December 5, 2020. Participants were randomized to one of five study arms (placebo and 15 g, 30 g, 45 g, and 54 g BCAA treatment daily) and followed for 21 days after enrollment. Outcome measures included daily computerized neurocognitive tests (processing speed, the a priori primary outcome; and attention, visual learning, and working memory), symptom score, physical and cognitive activity, sleep/wake alterations, treatment compliance, and adverse events. In total, 42 participants were randomized, 38 of whom provided analyzable data. We found no difference in our primary outcome of processing speed between the arms; however, there was a significant reduction in total symptom score (decrease of 4.4 points on a 0-54 scale for every 500 g of study drug consumed, p value for trend = 0.0036, [uncorrected]) and return to physical activity (increase of 0.503 points on a 0-5 scale for every 500 g of study drug consumed, p value for trend = 0.005 [uncorrected]). There were no serious adverse events. Eight of 38 participants reported a mild (not interfering with daily activity) or moderate (limitation of daily activity) adverse event; there were no differences in adverse events by arm, with only two reported mild adverse events (both gastrointestinal) in the highest (45 g and 54 g) BCAA arms. Although limited by slow enrollment, small sample size, and missing data, this study provides the first demonstration of efficacy, as well as safety and tolerability, of BCAAs in concussed adolescents and young adults; specifically, a dose-response effect in reducing concussion symptoms and a return to baseline physical activity in those treated with higher total doses of BCAAs. These findings provide important preliminary data to inform a larger trial of BCAA therapy to expedite concussion recovery.

Categorizing Sports-Related Concussion Disparities by Key Domains of Social Determinants of Health

PURPOSE OF REVIEW

To explore recently published data on disparities in concussion and best categorize these data into domains of social determinants of health (SDOH).

RECENT FINDINGS

Disparities in concussion cover a range of SDOH domains. Questions on disparities in concussion remain. Interventions to reduce these disparities and inequities are needed. Social determinants of health may play a significant role in disparities and inequities in sports related concussion. There is interplay and overlap in SDOH domains that affect concussion outcomes. It is possible that an increase in SDOH may affect concussion disparities by moderated mediation; however, further data is needed to validate this potential effect. Moreover, attention to SDOH domains in sports related concussion may provide insight on intervention targets to ameliorate disparities in sports related concussion.

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.

The effect of a home exercise program on visio-vestibular function in concussed pediatric patients

Background

A visio-vestibular home exercise program (VV-HEP) can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. The effects of a VV-HEP on improving concussion symptoms and visio-vestibular function are unclear.

Purpose

Determine the effect of VV-HEP on symptoms and visio-vestibular function in concussed pediatric patients.

Methods

This study included 527 patients [294 female (55.8%); age = 14.4 ± 2.1 years] reporting to a specialty care concussion center within 28 days of injury and for a first follow-up within 60 days of injury. Patients completed the Post-Concussion Symptom Inventory (PCSI) and Visio-Vestibular Examination (VVE). Patients were prescribed the VV-HEP at initial visit, with exercises including saccades, gaze stability, convergence, and balance, and instructed to complete these 1-2 times/day. At follow-up, patients self-reported their VV-HEP progress as (1) has not done, (2) in progress, or (3) completed. Primary outcomes included VV-HEP progress at follow-up, PCSI endorsement and severity, VVE subtests (normal/abnormal), and total VVE score (abnormal = 2 + abnormal subtests). Kruskal-Wallis tests and chi-square were used to determine if concussion symptoms or the proportion of abnormal VVE outcomes, respectively, were associated with VV-HEP status. Post-hoc pairwise comparisons with Bonferonni corrections were used to determine concussion symptom (α = 0.017 a priori) and VVE (α = 0.005 a priori) differences in VV-HEP status.

Results

At follow-up, patients who had completed the VV-HEP reported lower symptom endorsement (median = 1, IQR = 0-3) and lower symptom severity (median = 1, IQR = 0-4) relative to patients who had not started the VV-HEP (endorsement median = 7, IQR = 1-13, p < 0.0001; severity median = 15.5, IQR = 2-32.5, p < 0.0001) and those in progress (endorsement median = 8, IQR = 3-14, p < 0.0001; severity median = 15, IQR = 4-30, p < 0.0001). A lower proportion of patients who completed the VV-HEP reported with abnormal vestibular-ocular reflex (22.2%), tandem gait (0%), and total VVE score (22.2%) relative to those who had not started or those in progress (p < 0.005).

Conclusion

Our findings indicate that patients who completed the VV-HEP had lower symptom burden and improved visio-vestibular function relative to those who did not start or were in progress. This suggests that a VV-HEP can effectively reduce visio-vestibular dysfunction following concussion and may serve as a means to minimize inequities in access to care.