Implication of Socio-Demographics on Cognitive-Related Symptoms in Sports Concussion Among Children

Traumatic brain injuries in paediatric patients: individual vs. team sports-related hospitalizations

Paediatric sport participation continues to increase in the United States, with a corresponding increase in sports-related concussions or traumatic brain injuries (TBIs). It is important to recognize which sports are at elevated risk and identify risk factors for hospital admission and length of stay (LOS). Paediatric patients (ages 5-18) from 2008 to 2014 were identified from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). Eight hundred and ninety-four patients included those who were hospitalized with a TBI resulting from participation in an individual (451 patients) or team (443 patients) sport. We evaluated the differences in LOS and total charges between individual and team sports and found that compared to team sports, TBI patients in individual sports had significantly longer hospital stays compared to team sports (1.75 days versus 1.34 days, p < 0.001) and costlier ($27,333 versus $19,069, p < 0.001) hospital stays. This may be due to reduced awareness and reduced compliance with return-to-play protocols in individual sports. Safety education information at a young age, increased awareness of TBIs, and additional medical support for individual sports as well as team sports may help mitigate these findings.

Latent Profiles of Acute Symptoms, Cognitive Performance, and Balance in Sport-Related Concussions

BACKGROUND

A sport-related concussion (SRC) is a common injury that affects multiple clinical domains such as cognition, balance, and nonspecific neurobehavioral symptoms. Although multidimensional clinical assessments of concussion are widely accepted, there remain limited empirical data on the nature and clinical utility of distinct clinical profiles identified by multimodal assessments.

PURPOSE

Our objectives were to (1) identify distinct clinical profiles discernible from acute postinjury scores on the Sport Concussion Assessment Tool (SCAT), composed of a symptom checklist, a cognitive assessment (Standardized Assessment of Concussion), and a balance assessment (Balance Error Scoring System), and (2) evaluate the clinical utility of the identified profiles by examining their association with injury characteristics, neuropsychological outcomes, and clinical management-related outcomes.

STUDY DESIGN

Cohort study (Prognosis); Level of evidence, 2.

METHODS

Up to 7 latent profiles were modeled for 1885 collegiate athletes and/or military cadets who completed the SCAT at 0 to 12 hours after an injury. Chi-square tests and general linear models were used to compare identified profiles on outcomes at 12 to 72 hours after the injury. Kaplan-Meier analysis was used to investigate associations between clinical profiles and time to return to being asymptomatic and to return to play.

RESULTS

There were 5 latent profiles retained: low impairment (65.8%), high cognitive impairment (5.4%), high balance impairment (5.8%), high symptom severity (16.4%), and global impairment (6.5%). The latent profile predicted outcomes at 12 to 72 hours in expectable ways (eg, the high balance impairment profile demonstrated worse balance at 12 to 72 hours after the injury). Time to return to being asymptomatic and to return to play were different across profiles, with the high symptom severity and global impairment profiles experiencing the longest recovery and the high balance impairment profile experiencing an intermediate-length recovery (vs low impairment profile).

CONCLUSION

An SRC is a heterogeneous injury that presents in varying ways clinically in the acute injury period and results in different recovery patterns. These data support the clinical prognostic value of diverse profiles of impairment across symptom, cognitive, and balance domains. By identifying distinct profiles of an SRC and connecting them to differing outcomes, the findings support more evidence-based use of accepted multimodal clinical assessment strategies for SRCs.

Language Matters: Comparisons of Concussion Assessments Among English- and Spanish-Speaking Middle School Athletes

CONTEXT

The Child Sport Concussion Assessment Tool, fifth edition (Child SCAT5), is among the most widely used international pediatric concussion evaluation tools. However, the tool's English-only aspect may limit its use for patients who speak different languages. Prior researchers have suggested one's preferred language (ie, home language) could be associated with concussion assessments in adults, yet how this might affect pediatric athletes is not well understood.

OBJECTIVE

To compare baseline Child SCAT5 assessment outcomes between middle school athletes whose home language was Spanish and matched control athletes whose home language was English.

DESIGN

Case-control study.

SETTING

Middle school athletics.

PATIENTS OR OTHER PARTICIPANTS

Athletes self-reported their home language (ie, language spoken at home). Those indicating their home language was Spanish were individually matched to athletes who spoke English at home on age, sex, sport, school, and pertinent comorbidities (eg, concussion history). The final sample consisted of 144 athletes (Spanish home language = 72, English home language = 72).

MAIN OUTCOME MEASURE(S)

We used Mann-Whitney U tests to compare the Child SCAT5 component scores of the home language groups (ie, Spanish versus English).

RESULTS

Athletes in the Spanish home language group scored lower on the Standardized Assessment of Concussion-Child version (P < .01, r = -0.25), Immediate Memory (P < .01, r = -0.45), and total modified Balance Error Scoring System scores (P < .01, r = -0.25) than the English home language group.

CONCLUSIONS

Matched athletes whose home language was Spanish versus English scored differently on baseline Child SCAT5 assessment components. Those with the home language of Spanish scored lower on cognitive and balance tasks than those whose home language was English. These findings may serve as a rationale for the development of future concussion assessment tools to properly capture clinically relevant data regarding language differences among pediatric athletes.

Systematic Review Examining the Reporting of Race and Ethnicity in Sport-Related Concussion Studies

OBJECTIVE

Sport-related concussion (SRC) is an evolving public health concern among youth athletes. Despite emerging evidence that race and ethnicity are important factors in determining concussion outcomes, studies examining race and ethnicity are limited. We conducted a systematic review to (1) determine the prevalence of SRC studies in which participants' race or ethnicity is reported, (2) describe how race and ethnicity are used within each study, and (3) assess predictive factors for the reporting of race and ethnicity.

DATA SOURCES

PubMed, Embase, PsycINFO, and CINAHL databases.

STUDY SELECTION

Study inclusion criteria were (1) primary and peer-reviewed research; (2) related to the diagnosis, treatment, or recovery of SRC; (3) involving school-aged athletes (ages 5 to 25); and (4) with 25 or more participants. The search was performed in March 2021 and included only studies published after March 2013.

DATA EXTRACTION

For each article, we looked at whether race and ethnicity were reported, and if so, which races or ethnicities were mentioned. For each race or ethnicity mentioned, we extracted the corresponding sample size and how they were used as variables in the study.

DATA SYNTHESIS

Of 4583 studies screened, 854 articles met inclusion criteria. Of the included articles, 132 (15.5%) reported race, and 65 (7.6%) reported ethnicity, whereas 721 (84.4%) reported neither. When examining the demographic characteristics of the 132 studies that reported race, 69.8% of athletes were White. Additionally, 79.5% of these studies used race solely as a demographic descriptor as opposed to a main exposure or covariate of interest. Studies published more recently were more likely to report race. Further, studies in specific study or journal topics and specific geographic locations of the authors were more likely to report race.

CONCLUSIONS

Reporting of race and ethnicity is limited in current SRC literature. Future authors should improve the reporting of race and ethnicity, diversify study samples by focusing on enrolling athletes from underrepresented groups, and consider the potential effect of race and ethnicity as social determinants of health on risk factors, recovery, and long-term sequelae after SRC.

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.

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.

Association of Posttraumatic Headache With Symptom Burden After Concussion in Children

Importance

Headache is the most common symptom after pediatric concussion.

Objectives

To examine whether posttraumatic headache phenotype is associated with symptom burden and quality of life 3 months after concussion.

Design, Setting, and Participants

This was a secondary analysis of the Advancing Concussion Assessment in Pediatrics (A-CAP) prospective cohort study, conducted September 2016 to July 2019 at 5 Pediatric Emergency Research Canada (PERC) network emergency departments. Children aged 8.0-16.99 years presenting with acute (<48 hours) concussion or orthopedic injury (OI) were included. Data were analyzed from April to December 2022.

Exposure

Posttraumatic headache was classified as migraine or nonmigraine headache, or no headache, using modified International Classification of Headache Disorders, 3rd edition, diagnostic criteria based on self-reported symptoms collected within 10 days of injury.

Main Outcomes and Measures

Self-reported postconcussion symptoms and quality-of-life were measured at 3 months after concussion using the validated Health and Behavior Inventory (HBI) and Pediatric Quality of Life Inventory-Version 4.0 (PedsQL-4.0). An initial multiple imputation approach was used to minimize potential biases due to missing data. Multivariable linear regression evaluated the association between headache phenotype and outcomes compared with the Predicting and Preventing Postconcussive Problems in Pediatrics (5P) clinical risk score and other covariates and confounders. Reliable change analyses examined clinical significance of findings.

Results

Of 967 enrolled children, 928 (median [IQR] age, 12.2 [10.5 to 14.3] years; 383 [41.3%] female) were included in analyses. HBI total score (adjusted) was significantly higher for children with migraine than children without headache (estimated mean difference [EMD], 3.36; 95% CI, 1.13 to 5.60) and children with OI (EMD, 3.10; 95% CI, 0.75 to 6.62), but not children with nonmigraine headache (EMD, 1.93; 95% CI, -0.33 to 4.19). Children with migraine were more likely to report reliable increases in total symptoms (odds ratio [OR], 2.13; 95% CI, 1.02 to 4.45) and somatic symptoms (OR, 2.70; 95% CI, 1.29 to 5.68) than those without headache. PedsQL-4.0 subscale scores were significantly lower for children with migraine than those without headache only for physical functioning (EMD, -4.67; 95% CI, -7.86 to -1.48).

Conclusions and Relevance

In this cohort study of children with concussion or OI, those with posttraumatic migraine symptoms after concussion had higher symptom burden and lower quality of life 3 months after injury than those with nonmigraine headache. Children without posttraumatic headache reported the lowest symptom burden and highest quality of life, comparable with children with OI. Further research is warranted to determine effective treatment strategies that consider headache phenotype.

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.

A framework for health equity in people living with epilepsy

Epilepsy is a disease where disparities and inequities in risk and outcomes are complex and multifactorial. While most epilepsy research to date has identified several key areas of disparities, we set out to provide a multilevel life course model of epilepsy development, diagnosis, treatment, and outcomes to highlight how these disparities represent true inequities. Our piece also presents three hypothetical cases that highlight how the solutions to address inequities may vary across the lifespan. We then identify four key domains (structural, socio-cultural, health care, and physiological) that contribute to the persistence of inequities in epilepsy risk and outcomes in the United States. Each of these domains, and their core components in the context of epilepsy, are reviewed and discussed. Further, we highlight the connection between domains and key areas of intervention to strive towards health equity. The goal of this work is to highlight these domains while also providing epilepsy researchers and clinicians with broader context of how their work fits into health equity.

Physician recommended school accommodations and student outcomes following a mild traumatic brain injury among youth with persistent post-concussive symptoms

BACKGROUND

Post-concussion return-to-learn (RTL) guidelines include implementation of school accommodations. Yet, little is known about physician recommendations for school accommodations and their impact, particularly among youth experiencing persistent post-concussive symptoms (PPCS).

OBJECTIVE

We examined the association between physician recommended school accommodations and student outcomes among youth experiencing PPCS.

METHODS

Data from a randomized comparative effectiveness trial was used. Physician recommended school accommodations (≤90 days post-injury) were collected via chart abstraction. Grade point average was extracted from school records. Reports of problems at school, concussion symptoms, health-related quality of life (HRQOL), anxiety symptoms, and depressive symptoms were collected by survey (at baseline, three months, and 12 months post study entry).

RESULTS

Of 200 participants (Mage = 14.7, 62% female), 86% were recommended school accommodations. Number of recommended school accommodations was positively associated with number of school problems at three months (aRR 1.18, 95% CI:1.12-1.24) and 12 months (aRR 1.11, 95% CI:1.05-1.18). No significant associations were found between recommended school accommodations and GPA, HRQOL, anxiety symptoms, or depressive symptoms.

CONCLUSIONS

Physicians recommend more school accommodations for students experiencing more school problems post-concussion. Appropriate implementation of RTL recommendations made by physicians by fostering partnerships among physicians, students, and schools may be needed to achieve student-centered RTL.

Child Sport Concussion Assessment Tool 5th Edition: Normative Reference Values in Demographically Diverse Youth

OBJECTIVES

Examine sociodemographic differences (gender, age, and language spoken at home) on baseline Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) scores and establish normative reference data for the Child SCAT5 among middle school student athletes.

DESIGN

Cross-sectional study.

SETTING

Nine middle schools in Virginia.

PARTICIPANTS

A sample of 1355 athletes playing competitive school-sponsored sports (ages 11-13, M = 12.3 ± 0.8; 40.1% girls, 59.9% boys) during the 2017 and 2018 school year. Certified athletic trainers administered the Child SCAT5 within the first 2 weeks of the sport season.

INDEPENDENT VARIABLES

Self-reported gender, age, and language spoken at home.

MAIN OUTCOME MEASURES

All Child SCAT5 outcome measures.

RESULTS

Gender, age, and language spoken at home were associated with Child SCAT5 scores, but the magnitude of differences was generally small. Specifically, girls endorsed more symptoms (girls: M = 8.4 ± 5.7, boys: M = 7.5 ± 5.7; P = 0.003) and greater symptom severity (girls: M = 11.6 ± 9.4, boys: M = 10.4 ± 9.3; P = 0.006) than boys and performed slightly better than boys on cognitive and balance tasks. Older students performed slightly better than younger students on tests of cognition (eg, SAC-C: 11-year-olds: M = 21.3 ± 2.1, 13-year-olds: M = 21.7 ± 2.1; P = 0.02). Total symptoms (P = 0.01), symptom severity (P = 0.01), immediate memory (P < 0.001), delayed recall (P = 0.001), and SAC-C total scores (P = 0.002) differed across language groups.

CONCLUSIONS

Gender, age, and language spoken in the home are associated with baseline scores on multiple components of the Child SCAT5 among middle school students, although the magnitudes of observed differences are small. Normative reference values are provided for clinicians when interpreting Child SCAT5 scores.

Healthcare Navigation of Black and White Adolescents Following Sport-Related Concussion: A Path Towards Achieving Health Equity

CONTEXT

Care-seeking behaviors for sport-related concussion (SRC) are not consistent across demographic subgroups. These differences may not only stem from health inequities but can further perpetuate disparities in care for SRCs.

OBJECTIVE

To determine whether racial differences exist in the care pathway from injury to SRC clinic within adolescent athletes.

DESIGN

Retrospective cohort Setting: Regional SRC center Participants: Of 582 total athletes, 486 (83.5%) White and 96 (16.5%) Black adolescent athletes were diagnosed with SRC and evaluated within 3 months at the SRC clinic.

MAIN OUTCOME MEASURES

Race was the defined exposure, dichotomized as Black or White. The four primary outcomes included: 1)location of first health system contact, 2)time from injury to first health system contact 3) time to in-person SRC clinic visit, and 4) whether the athlete established care (>1 visit), was released immediately to an athletic trainer, or lost to follow-up.

RESULTS

Black and White athletes mostly presented directly to SRC clinic (61.5% vs 62.3%) at a median[interquartile range] of 3[1,5] vs 4[1,8] days respectively (p=0.821). Similar proportions of Black and White athletes also first presented to the ED (30.2% vs 27.2%) at a median of 0[0,1] vs 0[0,1] days (p=0.941). Black athletes more frequently had care transferred to their athletic trainer (39.6% vs 29.6%) and less frequently established care (56.3% vs 64.0%), however these differences were not statistically significant (p=0.138). Lost to follow-up was uncommon among Black and White athletes alike (4.2% vs 6.4%).

CONCLUSIONS

This study demonstrated that within an established SRC referral network and multidisciplinary clinic, there were no observed racial disparities in how athletes were initially managed and/or ultimately presented to SRC clinic despite racial differences in school type and insurance coverage. SRC center assimilation and affiliation with school systems may be helpful in improving access and providing equitable care across diverse patient demographics.

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.

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.

Socioeconomic status and race as social determinants of health to be considered in clinical use of pre-season vestibular and oculomotor tests for concussion

BACKGROUND

Aside from racial and socioeconomic disparities in computerized neurocognitive testing and symptomology, there is a scarcity of research representing more diverse populations on other widely used tests for concussion, including vestibular and visual assessment.

AIM

The aim of the study was to investigate if racial and socioeconomic differences exist on baseline vestibular/ocular motor screening (VOMS) and King-Devick (K-D) test performance in high school student-athletes.

METHODS

A total of 670 participants (66.1% White, 33.9% Black) with a mean age of 15.43±1.2 years were administered a baseline VOMS, average Near Point of Convergence (NPC) distance, and K-D test. The exposure variables included race (White or Black) and socioeconomic status (SES), defined as free and reduced lunch status (FRL or No-FRL). FRL status was determined by each participant's school SES. The outcome variables consisted of baseline VOMS item symptom provocation scores, average NPC distance, and K-D baseline time. A series of Mann-Whitney U tests were performed for K-D baseline time, NPC distance, and VOMS items with FRL status or race as a between-subject factor. Two multivariable linear regressions were run to assess the association of (1) K-D baseline times using FRL, race, sex, and corrected vision as variables in the model and (2) average NPC distance using FRL, race, sex, and corrected vision as variables in the model.

RESULTS

When adjusting for multiple comparisons, FRL athletes had slower (worse) K-D times (P<0.001) than non-FRL athletes. Black athletes had significantly lower mean NPC distance compared to White athletes at baseline (P=0.02) and FRL status athletes reported a significantly greater (worse) mean symptom provocation following the visual motion sensitivity item on the VOMS (P=0.02); however, these findings were no longer significant following adjustments for multiple comparisons. No differences were noted for any remaining VOMS items. The first model explained 3.9% of the total variance of K-D baseline times, whereas the second model was not significant.

CONCLUSIONS

Racial and SES differences existed on average NPC distance and the K-D test at baseline. Possible explanations for group differences may be neurobiological, anatomical, and/or disparity in nature. With a higher probability of undiagnosed and uncorrected vision impairment, vestibular dysfunction, and saccadic eye tracking deficits likely to be more apparent as a consequence of poverty or health inequities, it is important that healthcare providers, especially those that diagnose and treat concussions, understand that performance on the VOMS and K-D tests at baseline may be subject to sociodemographic factors of SES and race.

RELEVANCE FOR PATIENTS

To provide the most culturally competent care, clinicians should consider sociodemographic variables of race and SES as social determinants of health worthy of attention on objective and subjective measures of baseline concussion assessment.

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.

Disparities in baseline neurocognitive testing for student concussion management in Massachusetts high schools

Purpose

There is evidence of socioeconomic disparities with respect to the implementation of student-sports concussion laws nationally. The purpose of this study was to examine school sociodemographic characteristics associated with the provision of computerised baseline neurocognitive testing (BNT) in Massachusetts (MA) high schools, and to assess whether the scope of testing is associated with the economic status of student populations in MA.

Methods

A cross-sectional secondary analysis of surveys conducted with MA athletic directors (n=270) was employed to investigate school characteristics associated with the provision of BNT. Correlation and regression analyses were used to assess whether the scope of testing is associated with the economic status of student populations in MA.

Results

The scope of BNT was independently associated with the economic disadvantage rate (EDR) of the student population (β=−0.02, p=0.01); whether or not the school employs an athletic trainer (AT) (β=0.43, p=0.03); and school size (β=−0.54, p=0.03). In a multivariable regression model, EDR was significantly associated with the scope of baseline testing, while controlling for AT and size (β=−0.01, p=0.03, adj-R²=0.1135).

Conclusion

Among public high schools in MA, disparities in the provision of BNT for students are associated with the economic characteristics of the student body. Schools that have a greater proportion of low-income students are less likely to provide comprehensive BNT. The clinical implications of not receiving BNT prior to concussion may include diminished quality of postconcussive care, which can have short-term and long-term social, health-related and educational impacts.