More Than Skin Deep: Patient-Provider Racial and Ethnic Concordance and Discordance in Collegiate Athletics and Concussion Management

CONTEXT

There is strong evidence that racial and ethnic disparities exist in multiple arenas of health and wellness. The causes of racial and ethnic differences in healthcare are multi- dimensional, one factor that may impact injury/illness communication, interactions, and outcomes is patient-provider racial and ethnic concordance. At present, it is unclear what role patient-provider racial and ethnic concordance and discordance plays in facilitating concussion care for collegiate athletes.

OBJECTIVE

Investigate the presence of athlete-athletic trainer (AT) racial and ethnic concordance and discordance amongst diagnosed concussion cases, and examine if racial and ethnic concordance and discordance influences time (in days) until diagnosis, symptom resolution, or return-to-sport clinical milestones in collegiate athletes.

DESIGN

Retrospective cohort study.

SETTING

Collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

A total of 694 concussion cases [38.6% (n=268) sustained by women, 61.4% (n=426) sustained by men] that occurred within the 2015-2016 through 2019- 2020 sport seasons at 9 institutions.

MAIN OUTCOME MEASURE(S)

The number of days from date of injury to diagnosis, symptom resolution, and return-to-sport; and from date of diagnosis to symptom resolution and return-to- sport.

RESULTS

Overall, 68.4% (n=475) of concussion cases had patient-provider racial and ethnic concordance and 31.6% (n =219) were discordant. All concordant pairs included a White athlete and White AT. Time to diagnosis differed between the concordant and discordant groups (median[IQR]=1[0,2] versus 0[0,1], respectively) only in the model adjusted for sex, sport-type, and availability of an AT (OR[CI95]=1.46[1.07, 1.85]). There were no other group differences.

CONCLUSIONS

One-third of concussion cases had athlete-AT racial and ethnic discordance. While this group was diagnosed with a concussion 1-day sooner than the concordant group, no differences were observed for any concussion recovery milestones. These findings suggest that patient-provider racial and ethnic concordance may play a minor role in concussion recognition or reporting, but not necessarily in the management and recovery thereafter.

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.

Influence of sleep symptoms on recovery from concussion in collegiate athletes: a LIMBIC MATARS consortium investigation

OBJECTIVE

Changes in sleep quality and quantity are commonly endorsed by individuals following a concussion. Limited data exists examining the role of sleep disturbances within 72 hours, and throughout recovery, from concussion. The objective of this study was to determine if the number of days to symptom resolution varied between collegiate athletes with or without sleep-related symptoms following a concussion.

DESIGN

Retrospective chart review.

METHODS

Collegiate athletes (n = 539) who were diagnosed with a concussion between the 2015-2020 sport seasons participated in this retrospective chart review. Participants were divided into groups based on the presence or absence of sleep symptoms within 72 hours of a diagnosed concussion. A Mann-Whitney U test was used to compare days to symptom resolution between groups with α = 0.05.

RESULTS

Of the 539 participants, 250 (46.3%) reported sleep-related symptoms. Participants with sleep-related symptoms took significantly longer (U = 30656, p = 0.002) to report symptom resolution at rest (median [full range] = 8.00[0-423]) as compared to participants who did not report sleep-related symptoms (6.00[0-243] days).

CONCLUSION

Collegiate athletes that report sleep-related symptoms immediately following concussion (<72 hours) were observed to take, on median, two days longer to achieve symptom resolution at rest when compared to athletes who did not endorse the same symptoms.

Academic adjustments and concussion recoveries in NCAA student-athletes: a LIMBIC MATARS investigation

OBJECTIVE

The aim of this study was to investigate the association between academic adjustments and recovery from sport-related concussions (SRCs) in collegiate athletes.

MATERIALS AND METHODS

A retrospective medical chart review was performed between the 2015-2016 and 2019-2020 sport seasons at 11 Long-term Impact of Military-relevant Brain Injury Consortium Military and Tactical Athlete Research Study (LIMBIC MATARS) sites. Days between injury and symptom resolution, and injury and return to sport (dependent variables) for collegiate athletes who did or did not receive academic adjustments (independent variable) were analyzed using Mann-Whitney U tests.

RESULTS

The number of days between date of injury and symptom-resolution between those who did (median = 9 [interquartile range = 5,16]) and did not have (7[3,12]) academic adjustments were statistically different (z=-2.76, p < 0.01, r=-0.17). However, no differences were observed between days to return to sport among those who did (14[10,22]) and did not (13[8,20]) receive assigned academic adjustments (z= -1.66, p = 0.10, r= -.10).

CONCLUSIONS

Recovery trajectories were similar between athletes diagnosed with a SRC who did or did not receive academic adjustments.. Our findings suggest academic adjustments supported recovery for those who needed academic adjustments. Clinicians and healthcare professionals should assist and support collegiate athletes after SRCs on an individual basis, including academic adjustments when appropriate based on patient presentation.

The influence of ADHD on recovery from sport concussion among collegiate athletes in the United States: LIMBIC MATARS consortium investigation

OBJECTIVE

The present study aimed to assess the potential influence of a diagnosis of ADHD on concussion recovery among collegiate athletes.

DESIGN

Retrospective and cross-sectional.

METHODS

Data were extracted retrospectively from medical records across LIMBIC MATARS member institutions (n = 11), representing 1,044 concussion cases among collegiate athletes. After exclusions, 406 concussions were included in our analysis (ADHD: n = 38, age = 20.2 ± 1.67 years, 18.4% female; No ADHD: n = 368, age = 19.8 ± 1.39 years, 40.1% female). Mann-Whitney U tests were used to compare days from injury to diagnosis, symptom resolution, and return to sport among athletes with and without ADHD.

RESULTS

No differences were observed for days from concussion until diagnosis (z = -0.33, p = 0.74), until days to symptom resolution (z = -1.30, p = 0.19), or days until return to sport (z = -0.68, p = 0.49); among concussion cases with or without a previously reported diagnosis of ADHD.

CONCLUSION

Our findings further expand the literature that suggests ADHD is not strongly associated with recovery trajectory following sport concussion in collegiate athletes. Future research should extend these findings to be inclusive of additional preexisting health conditions and moderating effects related to medication usage among diverse athlete levels.

Exploring the relationship between contraceptive medication use and concussion recovery in female collegiate athletes: a LIMBIC MATARS consortium investigation

OBJECTIVE

While recovery from concussion is variable, women are more likely to report symptoms, experience worse outcomes, and have longer recovery trajectories following concussion than men. Preliminary data suggest that hormonal fluctuations, specifically progesterone, may be associated with this variability. This study aimed to understand the effect of contraceptive medication on concussion recovery.

METHODS

A retrospective chart review using consensus-based common data elements was conducted at 11 NCAA institutions as part of the LIMBIC MATARS consortium. Participants included female collegiate athletes diagnosed with a concussion who did (n = 117) or did not report (n = 339) contraceptive medication use. Number of days between diagnosis and symptom resolution were compared using Mann-Whitney U tests. Self-reported diagnosis of attention deficit hyperactivity disorder, concussion history, anxiety, and depression was compared using Chi-squared tests.

RESULTS

The proportions of participants who did or did not take contraceptive medication were similar across covariates. Female athletes regardless of contraceptive medication use recovered similarly following a concussion.

CONCLUSIONS

Our findings suggest that contraceptive medication use did not significantly impact concussion recovery. Future prospective investigations should examine documentation practices and operationalize terminology for hormonal contraceptive medication to better understand their role on recovery from sport-related concussion in female collegiate athletes.

Placing the keystone: the LIMBIC Military and Tactical Athlete Research Study

OBJECTIVE

The LIMBIC Military and Tactical Athletic Research Study (MATARS) framework was established to confirm and extend understanding of concussion with initial studies driven by clinical data collected between 2015 and 2020 in a collegiate sports setting. The LIMBIC MATARS framework will be leveraged to apply gold-standard and innovative research designs to advance the science of concussion. This manuscript provides the background, methodology, and initial demographic data associated with the LIMBIC MATARS.

METHODS

Consensus-based common data elements were used to conduct a retrospective chart review, specific to collegiate athletes diagnosed with concussions between 2015 and 2020 at 11 universities.

RESULTS

A final sample of 1,311 (47.8% female) concussions were diagnosed during the five-year study period from athletes participating in a variety of National Collegiate Athlete Association (NCAA) sports. The LIMBIC MATARS demographic data, align with the NCAA and other pioneering multi-site concussion-related studies in terms of biological sex, race and ethnicity, and sport participation.

CONCLUSION

This pragmatic, methodological approach was used to address several a priori hypotheses related to concussion, align with other multi-site studies of concussion, and establish a consortium for future investigations.

Physical activity and recovery following concussion in collegiate athletes: a LIMBIC MATARS Consortium Investigation

OBJECTIVE

To investigate whether routine daily activities (RDA), non-prescribed exercise (Non-ERx), or prescribed exercise (ERx) were associated with recovery from sport-related concussion (SRC) in collegiate athletes.

MATERIALS AND METHODS

Data for this cross-sectional, retrospective chart review of collegiate athletes diagnosed with SRC (n = 285[39.6% female], age = 19.5 ± 1.4 years) were collected during the 2015-16 to 2019-20 athletic seasons. The independent variable was group (RDA, Non-ERx, ERx). Dependent variables included days from date of diagnosis to symptom resolution (Dx-SR) and SR to return to sport (SR-RTS).

RESULTS

Those in the Non-ERx group took nearly 1.3 times longer to achieve SR (IRR = 1.28, 95% CI: 1.11, 1.46) and, 1.8 times longer for RTS (IRR = 1.82, 95% CI: 1.11, 2.71) when compared to those in the RDA group. No other comparisons were significant.

CONCLUSION

Collegiate athletes in the Non-ERx group took approximately 1 week longer to achieve SR as compared to the RDA and ERx groups. Our findings suggest that if exercise is recommended following SRC, it must be clearly and specifically prescribed. If exercise parameters cannot be prescribed, or monitored, RDA appear to be similarly beneficial during recovery for collegiate athletes with concussion.

Access to athletic trainers and sex as modifiers of time to reach clinical milestones after sport-related concussion in collegiate athletes

OBJECTIVE

Investigate whether an athlete's biological sex and exposure to a dedicated athletic trainer (AT) were related to clinical milestones after a sports-related concussion (SRC).

DESIGN

Retrospective chart review.

METHODS

Medical charts of collegiate athletes (n = 196 [70.9% female]) diagnosed with SRC were reviewed to extract: biological sex, dedicated AT exposure for their sport (yes/no), and time (days) to reaching clinical milestones (diagnosis, symptom resolution, unrestricted return to sport [RTS]). Mann-Whitney U tests were used to determine whether time to clinical milestones differed by sex, AT exposure, or their interaction. Proportions of same-day diagnoses and times to diagnosis, symptom resolution, and unrestricted RTS were evaluated with chi-squared and spearman's rank correlations, respectively.

RESULTS

There were no significant differences in times to reaching any clinical milestone by sex, AT exposure, or their interaction (ps > 0.05). Forty-three percent of participants were diagnosed on the day of their SRC. This did not differ by sex or AT exposure (ps > 0.29). Longer times to SRC diagnosis were associated with more days to symptom resolution (ρ = 0.236, p = 0.001) and unrestricted RTS (ρ = 0.223, p < 0.001).

CONCLUSIONS

Athlete sex and AT exposure were not associated with times to reach any clinical milestone; however, delayed diagnosis was associated with longer times to reach clinical recovery.

Sport Type and Risk of Subsequent Injury in Collegiate Athletes Following Concussion: a LIMBIC MATARS Consortium Investigation

OBJECTIVE

To investigate the association between sport type (collision, contact, non-contact) and subsequent injury risk following concussion in collegiate athletes.

MATERIALS AND METHODS

This retrospective chart review of 248 collegiate athletes with diagnosed concussions (age: 20.0 ± 1.4 years; height: 179.6 ± 10.9 cm; mass: 79.0 ± 13.6 kg, 63% male) from NCAA athletic programs (n = 11) occurred between the 2015-2020 athletic seasons. Acute injuries that occurred within six months following concussion were evaluated. Subsequent injuries were grouped by lower extremity, upper extremity, trunk, or concussion. The independent variable was sport type: collision, contact, non-contact. A Cox proportional hazard model was used to assess the risk of subsequent injury between sport types.

RESULTS

Approximately 28% (70/248) of athletes sustained a subsequent acute injury within six months post-concussion. Collision sport athletes had a significantly higher risk of sustaining any injury (HR: 0.41, p < 0.001, 95% CI: 0.28, 0.62), lower extremity (HR: 0.55, p = 0.04, 95% CI: 0.32, 0.97), and upper extremity (HR: 0.41, p = 0.01, 95% CI: 0.20, 0.81) injuries following concussion. No differences between sport types were observed for other injuries.

CONCLUSION

Collision sport athletes had a higher rate of any subsequent injury, lower, and upper extremity injuries following concussion. Future research should focus on sport-specific secondary injury prevention efforts.

Parent and Youth Athlete Perceptions of Concussion Injury: Establishing a Factor Structure

OBJECTIVE

The first objective was to establish the respective factor structures of a concussion perceptions inventory that was adapted for youth athletes (ages 8-14 years) and their parents from the Perceptions of Concussion Inventory for Athletes. The second objective was to understand the associations between the concussion perceptions of youth athlete-parent dyads.

METHOD

In this cross-sectional study, 329 parent-youth athlete dyads completed a respective concussion perception inventory. Mean age of youth respondents was 10.9 ± 1.8 years (70.1% male) and mean age of parent respondents was 40.5 ± 13.6 years (60.9% female).

RESULTS

Exploratory factor analyses revealed unique 7-factor structures for both the youth athlete and parent inventories (youth athlete: anxiety, clarity, treatment, permanent injury, symptom variability, long-term outcomes, and personal control; parent: anxiety, clarity, treatment, permanent injury, symptom variability, and long-term outcomes, and affect others). Weak associations were found between dyads on the 5 factors that were composed of identical items (anxiety, clarity, treatment, permanent injury, and symptom variability).

CONCLUSIONS

Findings suggest that this adapted inventory has adequate psychometric properties to be used in the study of the concussion perceptions of youth athletes and their parents. Weak correlations across the concussion perceptions in the dyads suggest that parents and children hold different concussion perceptions and this should be considered in instrument selection of future studies.

Perceptions of personal control and treatment efficacy of sport-related concussions in collegiate athletes

OBJECTIVE

The purpose of this study was to examine healthy collegiate athletes' perceptions of personal control and beliefs regarding the treatment efficacy related to sport-related concussion (SRC) along with identifying factors that may be associated with these perceptions.

METHODS

This cross-sectional study included collegiate athletes (n = 956) between the age of 18-26 years. Participants completed a 10- to 15-min survey regarding their demographics, diagnosed SRC history, SRC knowledge, and Perceptions of Concussion Inventory for Athletes (PCI-A). Chi-squared analysis and multivariable logistic regressions were conducted to identify factors associated with the PCI-A outcomes of personal control and treatment efficacy perceptions.

RESULTS

24.2% of respondents reported higher perceptions of personal control, while 77.3% reported higher perceptions of treatment efficacy. The multivariable logistic regression revealed males had higher odds of greater perceptions of personal control (OR = 1.50; 95% CI: 1.10-2.03), while those with a history of diagnosed SRC had lower odds of having favorable treatment efficacy beliefs (OR: 0.69; 95% CI: 0.50-0.96).

CONCLUSIONS

This study established that collegiate athletes generally have lower perceptions of personal control and higher perceptions of treatment efficacy related to SRC recovery. Comprehensive SRC education should be expanded for individuals to understand that they have power over their own health outcomes and that SRC is a treatable injury.

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.

Agreement between parent reported and child self-reported sport-related concussion history: A brief report

This cross sectional investigation measured the agreement between parent report of their 8-14 year old child's sport-related concussion (SRC) history and their child's self-report of their own SRC history. Parent-child dyads (n = 405) within a youth contact sports (e.g., football, ice hockey, lacrosse, soccer) setting participated in the study. Parents (6.2%) and 8.6% of children self-reported a history of at least one diagnosed SRC. We observed substantial agreement between the number of parent-reported and child self-reported SRCs (κ = 0.613, p ≤ .001). Partial agreement regarding the number of SRCs reported by both groups was also substantial (weighted κ = 0.693, p ≤ .001). Removing dyads where neither the parent nor the child reported a diagnosed SRC, sensitivity analyses revealed only fair agreement in parent-child SRC recall. These results indicate that parents and youth athletes overall accounts of their diagnosed SRC history correspond. However determining specifics (e.g., total concussion counts) may benefit from concurrent parent reports, or documented events in medical histories.

Question Format Matters: Do Athletes Really Know the Signs and Symptoms of a Sport-Related Concussion?

Authors of previous studies commonly used a multiselect checklist method to assess an athlete's ability to recognize true sport-related concussion (SRC) signs and symptoms (S&S) among incorrect distractor options. However, this may overinflate the evaluation of participants' knowledge because the multiselect method does not test athletes' ability to retrieve knowledge from their long-term memory. To examine this hypothesis, we sent an online survey to registered members of the Japan Lacrosse Association (n = 8530) to assess differences in reported SRC S&S by open-ended-question and multiselect formats. We also evaluated whether previous exposure to SRC education and a history of SRC influenced athletes' SRC S&S knowledge. The numbers and proportions of responses were calculated using descriptive statistics. The Pearson correlation was calculated to analyze the relationship between scores from the 2 question formats. Unpaired-samples t tests were conducted to compare the mean scores for each question format by previous SRC education and history of diagnosed SRC. Odds ratios were computed to express the relationship between the proportion of correct answers by question format per symptom. The response rate of the survey was 35.9% (n = 3065), and scores from the 2 question formats were correlated (r = 0.34, 95% CI = 0.31, 0.37; P < .001). For both question formats, athletes with previous exposure to SRC education and a history of SRC had a greater number of correct answers; however, the mean differences were trivial. Researchers and clinicians should acknowledge the difference between multiselect (recognition) and open-ended (free recall) formats when assessing one's understanding of SRC and managing athletes with a suspected SRC.

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.

Perceptions of Concussion and Associated Anxiety in Irish Collegiate Athletes

BACKGROUND

Concussion nondisclosure and poor management after a concussion are a concern in Irish collegiate sports. How athletes perceive concussions and appraise their own concussion may affect their decisions and behaviors after a suspected concussion. However, this has yet to be examined in an Irish context. This study aimed to (1) establish concussion perceptions and associated anxiety in Irish collegiate athletes; (2) examine how sex, concussion, and mood disorder history influenced their perceptions; and (3) investigate factors associated with higher anxiety perceptions.

HYPOTHESIS

Irish collegiate athletes will display negative concussion perceptions and anxiety related to concussion, especially in female athletes and those without a concussion history.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Irish collegiate athletes [n = 268 (141 women,127 men), mean age = 21.5 ± 2.2 years] from high-risk sports completed a survey including the Perceptions of Concussion Inventory for Athletes (PCI-A), demographics, diagnosed concussion history, self-reported mood disorder history, and a concussion knowledge assessment. Differences in concussion perceptions by sex, concussion history, mood disorder history were examined using Mann-Whitney U tests, and factors associated with anxiety-related concussion perceptions were identified using multivariate logistic regression.

RESULTS

Over half (53.0%, n = 142) of participants reported concerns regarding concussion. The thoughts of sustaining a concussion made participants feel upset (63.4%, n = 170), fearful (47.7%, n = 128), and anxious (35.1%, n = 94). Women reported significantly higher anxiety (P < 0.01, r = 0.23), effects (P = 0.04, r = 0.12), and clarity (P = 0.01, r = 0.16) perception scores. Participants with a diagnosed concussion history displayed greater symptom variability perception scores (P = 0.04, r = 0.12), but lower anxiety (P = 0.03, r = 0.13) and treatment (P < 0.01, r = 0.19) beliefs on the PCI-A. No differences were observed for those with a history of a mood disorder (P > 0.05). A significant multivariate model was established (χ² = 55.44, P < 0.01), with female sex [odds ratio (OR) = 1.53], concussion history (OR = 0.63), effects (OR = 1.31), and treatment (OR = 1.15) subscales associated with greater anxiety.

CONCLUSION

Concerns about sustaining a concussion are prevalent in Irish collegiate athletes. Women displayed more negative perceptions and those with a concussion history displayed fewer perceived benefits of treatment.

CLINICAL RELEVANCE

The findings support the need for concussion awareness campaigns to provide accurate concussion information to mitigate anxiety-related concussion perceptions and injury belief misconceptions.

Post-injury fear-avoidance and confidence in readiness to return to sport in Irish collegiate athletes

Fear avoidance and low confidence in their ability to return to sport can impede athletes' subsequent recovery and return to sport. This study aimed to identify fear avoidance and confidence in readiness to return to sport following injury in Irish collegiate athletes. Male (416) and female (256) athletes from 24 field-sport teams at one university were prospectively followed for one season. The Athlete Fear Avoidance Questionnaire (AFAQ) and pain on the Visual Analogue Scale was completed following a time-loss injury. Prior to return to sport, participants completed the AFAQ and the Injury Psychological Readiness to Return to Sport (I-PRRS). We recorded 179 injuries. Fear avoidance was evident post-injury (21.8 ± 6.7), and the mean total I-PRRS score was 48.4 ± 8.9. Those with severe injuries presented with higher fear avoidance and lower confidence. Higher pain was associated with greater fear avoidance following injury (r = 0.32, p < 0.0001), prior to return to sport (r = 0.38, p < 0.0001), and with lower confidence (r = -0.27, p < 0.0001).   Low confidence and fear avoidance was identified, particularly in those with a severe injury or high pain levels. Identifying, and providing psychosocial support to athletes experiencing, these issues is recommended.

Diagnosed and Nondisclosed Sport-Related Concussion: An Exploratory Comparison Study by ADHD Status in Collegiate Athletes

OBJECTIVE

To determine if ADHD status in collegiate athletes was associated with differences in the number of diagnosed and nondisclosed sport-related concussions, and reasons why suspected concussive injuries were not reported.

METHOD

A cross-sectional survey was completed by 858 collegiate athletes (65 with ADHD; 793 without ADHD). The survey included self-report items regarding ADHD status and histories of diagnosed and nondisclosed sport-related concussions. Groups were matched for gender, age, and sport with a ratio of one participant with ADHD to four without ADHD.

RESULTS

Collegiate athletes with ADHD reported significantly more diagnosed sport-related concussions and were more likely to have a history of diagnosis compared to those without ADHD. There were no significant differences between groups regarding sport-related concussion nondisclosure history.

CONCLUSION

Collegiate athletes with ADHD have an increased prevalence rate of diagnosed sport-related concussions compared to those without ADHD; however, this developmental disorder may not influence injury nondisclosure decisions.

Factors associated with parent and youth athlete concussion knowledge

INTRODUCTION

On-site health care providers are not routinely present at all youth sport events. Therefore, parents and youth athletes are often responsible for identifying and making appropriate immediate care decisions regarding concussions, which may be influenced by their injury health literacy. Previous studies have investigated the level of concussion knowledge of parents and athletes, but few have investigated factors associated with greater awareness at the youth sport level specifically.

METHOD

A total of 466 parents and 390 youth contact sport athletes from Pennsylvania and Michigan completed separate surveys of concussion knowledge and personal and family demographic information.

RESULTS

Parents had a mean concussion knowledge score of 39.3 ± 4.6 out of a possible 47 points. Having a medical occupation (p = .04) and being older in age (p = .03) were associated with higher concussion knowledge scores in parents (R² = 0.018; 95% CI = 32.77-38.99). Youth athletes had a mean concussion knowledge score of 35.0 ± 5.7 out of 47. Having learned about concussion previously (p < .001), having a history of diagnosed concussion(s) (p = .01), sport type (relative to girls' ice hockey, p < .001), older age (p < .001), and parent concussion knowledge (p = .04) were associated with higher youth athlete concussion knowledge (R² = 0.176; 95% CI = 19.08-31.72).

CONCLUSIONS

More evidence-based concussion awareness resources are needed at the youth sport level. While it did not significantly influence concussion knowledge for parents, concussion education is a modifiable factor that may be essential for improving concussion knowledge of youth athletes, thus warranting further study into effective awareness strategies for this population. Practical Applications: The factors found to influence concussion knowledge in this study could be considered in future educational concussion initiatives for youth athletes and their parents in order to increase awareness regarding the potential dangers of participating in sport while concussed.

Concussion Nondisclosure in Youth Sports

CONTEXT

Studies regarding sport-related concussion (SRC) reporting behaviors and reasons for nondisclosure primarily focus on older athletic populations. Youth athletes participating in contact sports are also at risk for SRC; however, little is known about their SRC disclosure patterns and reasons for nondisclosure.

OBJECTIVE

To examine self-reported SRC history and reasons for SRC nondisclosure of youth athletes ages 8-14 years.

DESIGN

Cross-sectional study.

SETTING

Youth athletes in organized football, ice hockey, lacrosse, and soccer.

PATIENTS OR OTHER PARTICIPANTS

411 youth athletes (male: 70.0% (n=287/410); median age: 11 (IQR 10-13) years).

MAIN OUTCOME MEASURES

A 15-minute survey including self-reported demographics, diagnosed and non-disclosed SRC history, and reasons for nondisclosure of suspected SRCs.

RESULTS

Ten percent of respondents (n=41/411) recounted one or more diagnosed SRC; 12.7% (n = 52/411) did not report a suspected SRC, and 13.1% (n = 53/404) indicated they continued to practice and 12.3% (n = 50/425) reported they continued to play in a game after a suspected SRC. Significant associations between sport and nondisclosure exisited (p < .001), but not self-reported concussion history (p = .14). In sex comparable analyses boys lacrosse players had higher frequency of nondisclosure compared to girls (p = .05). Most common reasons for nondisclosure were not wanting to lose playing time 66.7% (n=32/48), miss a game 56.3% (n=27/48), and let the team down 43.8% (n=21/48); and uncertainty over injury severity and presence of SRC 43.8% (n=21/48).

CONCLUSIONS

Ten percent of youth athletes self-reported at least one diagnosed SRC. However, youth athletes also report continuing to practice or play within a game after a suspected SRC. Reasons for nondisclosure at this age are similar to those reported in high school and college athletes. Recent research suggests negative consequences of continued play with SRC, especially in acute stages. Future educational initiatives should emphasize these risks, and focus on reasons why athletes of both sexes withhold reporting.

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.

Fear Avoidance After Injury and Readiness to Return to Sport in Collegiate Male and Female Gaelic Games Players

BACKGROUND

Injuries are common in collegiate Gaelic games, and negative psychological responses to injury, such as fear avoidance and a lack of psychological readiness to return to sport, can affect players during their rehabilitation and their subsequent return to sport. Thus, identifying these responses in players can allow clinicians to address these issues during rehabilitation. This study aimed to examine fear avoidance and psychological readiness to return to sport in collegiate Gaelic games players.

HYPOTHESIS

Collegiate Gaelic games players will experience similar levels of fear avoidance and psychological readiness to return to sport as other adult athletes.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Male (n = 150) and female (n = 76) players from 1 Irish collegiate institution were recruited. Players that were injured over 1 collegiate season completed the Athlete Fear Avoidance Questionnaire (AFAQ) immediately after the injury and the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale once cleared to return to sport. An injury report form was also completed. The overall AFAQ (sum of 10 items) and I-PRRS (sum of 6 items/10) scores were calculated.

RESULTS

Seventy-three injuries (n = 73) occurred, and injured players had a mean overall AFAQ and I-PRRS score of 22.6 ± 5.3 and 46.4 ± 8.8, respectively. Just less than half (47.9%) of players were deemed psychologically unready to return to sport when cleared physically. After severe injuries, significantly higher overall AFAQ scores than mild injuries (P = 0.01) and lower overall I-PRRS than moderate injuries (P < 0.0001) was noted. For the overall scores, no gender differences were observed.

CONCLUSION

Fear avoidance and lowered confidence levels before return to sport occurs in collegiate Gaelic games players similar to other student-athletes.

CLINICAL RELEVANCE

Identification of fear avoidance or low readiness to return to sport, particularly after serious injury, is important to implement psychosocial support during their rehabilitation.

The burden of unsubstantiated messaging: collegiate athletes' chronic traumatic encephalopathy mechanism beliefs

OBJECTIVE

To investigate factors associated with collegiate athletes' beliefs regarding chronic traumatic encephalopathy (CTE) mechanism.

DESIGN

Cross-sectional study.

METHODS

A total of 838 collegiate athletes (61.9% men) from seven institutions completed a 10-minute survey that captured information relative to demographics, diagnosed concussion history, formal sport-related concussion education, additional sources of concussion information, and beliefs about multiple concussions and premature return-to-play following a head impact as mechanisms for CTE.

RESULTS

More than half of collegiate athletes believed that multiple concussions (58.2%) and premature return-to-play (59.1%) may cause CTE. Those who reported getting concussion information from sports news had higher odds of believing multiple concussions and premature return-to-play were CTE mechanisms compared to those who did not get information from sports news sources. Additionally, CTE mechanism beliefs were significantly greater in collegiate athletes who were male, had sustained a previous diagnosed concussion, or had acquired concussion information from the NCAA.

CONCLUSIONS

Sports news' reporting of CTE storylines, which highlight former male athletes with complex brain injury histories, may influence collegiate athletes' beliefs about concussion. Therefore, it is recommended that concussion awareness initiatives incorporate information related specifically to CTE to empower collegiate athletes with evidence-based, patient-oriented information and knowledge regarding this condition.

Factors Associated With Concussion Nondisclosure in Collegiate Student-Athletes

CONTEXT

Mandated concussion education has aimed to improve student-athlete knowledge; however, some collegiate student-athletes continue to not disclose concussion. Concussion knowledge may not be the only factor influencing reporting, as student-athlete sex, sport, and pressure from external stakeholders (eg, coaches, teammates, fans, parents or family) have all been documented as influencing collegiate concussion-reporting behavior.

OBJECTIVE

To examine factors associated with concussion nondisclosure in collegiate student-athletes.

DESIGN

Cross-sectional study.

SETTING

Four National Collegiate Athletic Association Division I and two Division II universities.

PATIENTS OR OTHER PARTICIPANTS

A total of 1125 collegiate student-athletes completed the survey, and 741 provided viable responses and were included for data analysis.

MAIN OUTCOME MEASURE(S)

We used a 10- to 15-minute electronic or paper-and-pencil survey that asked about personal and sport demographics, diagnosed concussions and nondisclosed concussion history, concussion knowledge, and level of agreement regarding pressure to play after a head impact experienced during collegiate sport participation. Significant univariable factors were entered into a multivariable logistic regression analysis.

RESULTS

Sex (P = .005), sport-risk type (P < .001), diagnosed concussion history (P < .001), concussion knowledge (P = .017), and pressure from coaches (P < .001), teammates (P < .001), fans (P = .024), and parents or family (P = .003) were factors associated with concussion nondisclosure in individual univariable logistic regressions. After we conducted multivariable analyses, male sex (P = .001), high concussion-risk sport participation (P = .048), diagnosed concussion history (P < .001), increased concussion knowledge (P = .013), and experiencing pressure from coaches to continue playing after sustaining a hit to the head (P = .002) were factors associated with concussion nondisclosure in collegiate student-athletes.

CONCLUSIONS

Our results suggest that concussion-education programs should go beyond the identification of signs and symptoms to include the dangers of continuing to play, long-term consequences, and transparency about concussion protocols. Comprehensive concussion-education programs should involve coaches and athletes to improve the reporting culture.

Time-to-Event Analyses: Return to Unrestricted Participation After Sport-Related Concussion in a Cohort of High School Athletes

CONTEXT

Understanding time loss resulting from sport-related concussion (SRC) within individual sports allows high school athletic trainers to provide accurate and evidence-based clinical information. Currently, research regarding patterns of clinical recovery outcomes in high school student-athletes across sports is lacking.

OBJECTIVE

To describe the time to authorized unrestricted return to participation (RTP) after SRC in a large cohort of high school student-athletes in a variety of sports using a time-to-event analysis.

DESIGN

Descriptive epidemiology study.

SETTING

Aggregate injury and player exposure data from the Michigan High School Athletic Association Head Injury Reporting System.

PATIENTS OR OTHER PARTICIPANTS

High school student-athletes.

MAIN OUTCOME MEASURE(S)

Dates for SRC injury events and authorized unrestricted RTP were entered into the Head Injury Reporting System for each case and were used to calculate time to unrestricted RTP. Survival analysis indicated the time to authorized RTP for males and females in weekly increments across sports and academic years. Separate Kaplan-Meier analyses adjusted for SRC cases with a history of concussion also identified the proportions of student-athletes who obtained authorized medical clearance in weekly increments.

RESULTS

A total of 15 821 SRCs, 10 375 (65.6%) in males and 5446 (34.4%) in females, were reported during the 2015-2016 through 2018-2019 academic years. The median time to authorized unrestricted RTP was 11 days for all patients. Approximately 30% of concussed student-athletes were not cleared for unrestricted RTP by 14 days after their SRC diagnosis, with 13% taking longer than 21 days to return to unrestricted RTP after SRC.

CONCLUSIONS

The results from this multisite, state-based injury surveillance system indicated that it is not abnormal for high school student-athletes to take longer than 14 days to fully recover from an SRC. This information may be useful for educating high school student-athletes and sport stakeholders, normalizing SRC recovery trajectory perceptions, and establishing realistic RTP timeline expectations.

Predictors of Concussion Nondisclosure in Collegiate Student-Athletes

CONTEXT

Mandated concussion education has aimed to improve student-athlete knowledge; however, some collegiate student-athletes continue to not disclose concussion. Concussion knowledge may not be the only factor influencing reporting, as student-athlete sex, sport, and pressure from external stakeholders (eg, coaches, teammates, fans, parents or family) have all been documented as influencing collegiate concussion-reporting behavior.

OBJECTIVE

To examine predictors of concussion nondisclosure in collegiate student-athletes.

DESIGN

Cross-sectional study.

SETTING

Four National Collegiate Athletic Association Division I and two Division II universities.

PATIENTS OR OTHER PARTICIPANTS

A total of 1125 collegiate student-athletes completed the survey, and 741 provided viable responses and were included for data analysis.

MAIN OUTCOME MEASURE(S)

We used a 10- to 15-minute electronic or paper-and-pencil survey that asked about personal and sport demographics, diagnosed concussions and nondisclosed concussion history, concussion knowledge, and level of agreement regarding pressure to play after a head impact experienced during collegiate sport participation. Significant univariable predictor variables were entered into a multivariable logistic regression analysis.

RESULTS

Sex (P = .005), sport-risk type (P < .001), diagnosed concussion history (P < .001), concussion knowledge (P = .017), and pressure from coaches (P < .001), teammates (P < .001), fans (P = .024), and parents or family (P = .003) were predictors of concussion nondisclosure in individual univariable logistic regressions. After we conducted multivariable analyses, male sex (P = .001), high concussion-risk sport participation (P = .048), diagnosed concussion history (P < .001), increased concussion knowledge (P = .013), and experiencing pressure from coaches to continue playing after sustaining a hit to the head (P = .002) were predictors of concussion nondisclosure in collegiate student-athletes.

CONCLUSIONS

Our results suggest that concussion-education programs should go beyond the identification of signs and symptoms to include the dangers of continuing to play, long-term consequences, and transparency about concussion protocols. Comprehensive concussion-education programs should involve coaches and athletes to improve the reporting culture.

Collegiate Athletes' Concussion Awareness, Understanding, and -Reporting Behaviors in Different Countries With Varying Concussion Publicity

CONTEXT

Concussions are a global public health concern, and education on the importance of self-reporting may not reach all athletes to the same degree around the world.

OBJECTIVE

To determine if differences were present in the concussion awareness, understanding, and -reporting behaviors of collegiate athletes' in 3 countries with varied degrees of concussion publicity.

DESIGN

Cross-sectional survey.

SETTING

Collegiate sports medicine clinics.

PATIENTS OR OTHER PARTICIPANTS

Collegiate athletes in the United States (n = 964; high publicity), Ireland (n = 302; moderate publicity), and Jordan (n = 129; low publicity). The degree of concussion publicity was categorized based on the extent of national public health awareness initiatives, care guidelines, research publications, and mass media coverage.

MAIN OUTCOME MEASURE(S)

Participants completed a 10- to 15-minute survey on concussion awareness, understanding, and -reporting behaviors. The main outcome measures were concussion education (awareness; 21 options; select all sources of concussion information), concussion knowledge (understanding; maximum score of 49), and diagnosed/nondisclosed concussion history (reporting behaviors; self-report yes/no items).

RESULTS

A higher proportion of Jordanian athletes reported never having received concussion information previously (73.6%) than Irish (24.2%) or US athletes (9.4%). Knowledge differed among countries (P < .0001, η2 = .28), with US athletes displaying higher total knowledge scores (40.9 ± 4.5) than Jordanian (35.1 ± 5.6) and Irish (32.1 ± 3.5) athletes. Greater percentages of Irish and US athletes reported a history of a diagnosed concussion (31.8% and 29.6%, respectively) and history of concussion nondisclosure (25.2% and 15.5%, respectively) than Jordanian athletes (2.3% and 0.0% for history of a diagnosed concussion and history of concussion nondisclosure, respectively).

CONCLUSIONS

In the United States, where concussion publicity is high, formal legislation exists, and sports medicine resources and concussion awareness and understanding were increased. More culturally appropriate concussion initiatives are needed globally to ensure that athletes around the world can identify concussive injuries and understand the dangers of continued sport participation while concussed.

Development and factor structure of the perceptions of concussion inventory for athletes (PCI-A)

Purpose: This study evaluated the factor structure of the Perceptions of Concussion Inventory for Athletes (PCI-A) using exploratory factor analytic (EFA) techniques in a sample of collegiate student-athletes. Perception differences by sex and sport-related concussion (SRC) risk level were explored.Methods: This cross-sectional-design study included 298 male and 183 female collegiate student-athletes from 18 sports at six institutions. Participants completed a demographic and concussion history survey, and the PCI-A.Results: The EFA revealed a 6-factor solution (Anxiety, Effects, Clarity, Treatment, Control, and Symptom Variability) that accounted for 56.1% of the variance in responses. Female collegiate student-athletes displayed statistically higher levels of Anxiety, Clarity, Symptom Variability, and Control than males. Lower concussion risk sport athletes reported statistically higher levels of anxiety surrounding SRC and concerns relating to the long-term and major effects of an SRC.Conclusions: This study provides evidence that the PCI-A is an acceptable measure to examine the perceptions of collegiate student-athletes regarding SRC. The findings supported a six-factor structure of the PCI-A in the current study for collegiate student-athletes compared to the seven-factor structure indicated in previous research. The findings reveal sex and concussion risk sport differences in PCI-A responses.

Time-to-Event Analyses: Return to Unrestricted Participation Following Sport-Related Concussion in a Cohort of High School Athletes

CONTEXT

Understanding time-loss resulting from sport-related concussion (SRC) within individual sports allows high school athletic trainers to provide accurate and clinically evidence-based information. Currently there is a lack of research regarding patterns of clinical recovery outcomes in high school student-athletes across sports.

OBJECTIVE

To describe the time to authorized unrestricted RTP following SRC in a large cohort of high school student-athletes in variety of sports using a time-to-event analysis.

DESIGN

Descriptive Epidemiology Study.

SETTING

Aggregate injury and player exposure data from the STATE-XXX High School Athletic Association (XHSAA) Head Injury Reporting System (HIRS).

PATIENTS OR OTHER PARTICIPANTS

High school student-athletes.

MAIN OUTCOME MEASURE(S)

Dates for SRC injury events and authorized unrestricted RTP were entered into the HIRS for each case, and were used to calculate time to unrestricted RTP. Survival analysis determined time to authorized RTP for males and females in weekly increments across sports and academic years. Separate Kaplan-Meier analyses adjusted for SRC cases with a history of concussion also identified the proportions of student-athletes that obtained authorized medical clearance in weekly increments.

RESULTS

There was a total of 15,821 SRC cases, 10,375 (65.6%) male and 5,446 (34.4%) female, reported during the 2015-16 through 2018-19 academic years. The median time to authorized unrestricted RTP was 11 days for all cases. Approximately, 30% of concussed student-athletes were not cleared for unrestricted RTP by 14 days following their SRC diagnosis, with 13% taking longer than 21 days to unrestricted RTP after SRC.

CONCLUSIONS

The results from this multi-site, State-based injury surveillance system indicate that it is not abnormal for high school student-athletes to take longer than 14 days to fully recovery from a SRC. This information may be useful for educating high school student-athletes and sport stakeholders, normalizing SRC recovery trajectory perceptions, and establishing realistic RTP timeline expectations.

The Underreporting of Concussion: Differences Between Black and White High School Athletes Likely Stemming from Inequities

Previous studies have found that Black high school athletes have poorer knowledge about concussions and have fewer sports medicine healthcare resources than White athletes, but research on concussion disclosure by race is still needed. Therefore, the purpose of this study was to examine racial differences in concussion reporting behaviors between Black and White high school athletes. This cross-sectional study administered surveys to 577 high school athletes (64.5% Black; 72.3% males; 16.02 ± 1.2 years) from 14 schools (title I, n = 9; non-title I, n = 5). The survey included self-reported items on concussions and bell-ringers experienced during games and practices and the number of these episodes that were reported to an authoritative figure. Reasons for reporting and not reporting were also assessed. Results found that White athletes were more likely to recall experiencing a bell-ringer in games compared with Black athletes. They were also more likely to report a bell-ringer or concussion that occurred in a game. There was a significantly higher proportion of Black athletes compared with White athletes that did not report their bell-ringer experienced in games and concussions experienced in practices. White athletes were more likely than Black athletes to disclose a concussion because they thought they had a concussion, while there were no racial differences in the reasons for not reporting. The findings of this study highlight the critical role that race, as a social determinant of health, may play in concussion reporting in high school athletes. Future public health efforts should seek to further understand and overcome inequities in healthcare resources for concussion education and management.

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.

A-09 Time to Unrestricted Participation Following Sport-Related Concussion in High School Athletes

Objective

To measure time-to-unrestricted participation in high school athletes following a sport-related concussion (SRC) diagnosis.

Method

This was a descriptive epidemiological study using the Michigan High School Athletic Association (MHSAA) online Head Injury Reporting System (HIRS). This study included 10,411 (65.9%) male and 5,412 (34.1%) female SRC cases that occurred in 20 sports with greater than 30 SRC cases during the 2015–2016 to 2018–2019 academic years. The HIRS includes dates for SRC injury events and medical clearance for unrestricted return-to-participation for each case; dates were used to calculate recovery time. Kaplan-Meier time-to-event analysis identified crude proportions of athletes that had not obtained medical clearance in weekly increments (e.g., 7 days, 14 days, 21 days, 28 days, 35 days) across sports.

Results

The median time-to-unrestricted participation was 11 days. Overall, 71.8% of SRC cases took longer than 7 days to return, 29.6% of SRC cases took longer than 14 days, 13.1% of cases took longer than 21 days to return, and 6.5% took longer than 28 days to return to their respective sports. Results by sport show that over 25% of gymnasts took longer than 28 days to return-to-unrestricted participation, followed by competitive cheerleaders (15.5%), wrestlers (12.1%), and male divers (12.0%).

Conclusions

Almost one in three high school athletes with SRC took longer than 14 days to return-to-unrestricted participation. These results serve as proportional time estimates for return-to-unrestricted participation across a sample of 20 high school sports; and provide rationale to further evaluate recovery patterns in individual sport groups.

Going Beyond the State Law: Investigating High School Sport-Related Concussion Protocols

CONTEXT

State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination.

OBJECTIVE

To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality.

DESIGN

Qualitative document analysis.

SETTING

High school athletics.

PARTICIPANTS

In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018-2019 academic year.

MAIN OUTCOME MEASURES

Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test.

RESULTS

There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5-22.5] versus 6 [3-10.5] median components; U = 377.5, p < .001) Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

Non-disclosure in Irish collegiate student-athletes: do concussion history, knowledge, pressure to play and gender impact concussion reporting?

Objectives: Non-disclosure of concussions by collegiate student-athletes is documented internationally. This study aims to examine, for the first time, concussion non-disclosure frequency in Irish collegiate student-athletes and ascertain whether concussion history, knowledge, pressure to play and gender impacts this behavior.Methods: A cross-sectional study was implemented. A convenience sample of 268 Irish collegiate student-athletes from high-risk sports completed an anonymous survey developed from previous reliable, validated instruments.Results: One in four Irish collegiate student-athletes reported concussion non-disclosure. While a significant statistical model was generated to predict concussion non-disclosure (χ²= 13.07 p = 0.004) with high specificity (99.5%), the sensitivity was non-existent (0.0%) and explained just 4.8-7.0% of the variance in non-disclosure. Just previous history of a concussion diagnosis contributed significantly to the model (OR = 2.6, 95% CI: 1.46-4.6). Gaps in concussion knowledge were evident and some participants previously felt pressure to return to play after sustaining a blow to the head by coaches (50.0%), teammates (45.5%) and fans (38.0%).Conclusion: Non-disclosure of concussions is common in this population. While gender, concussion knowledge and pressure to play do not seem to impact non-disclosure, a previous history of concussion increases the odds of concussion non-disclosure by 2.6 times. Thus, creating a positive concussion reporting culture in high-risk Irish collegiate sports is critical, particularly for those with a previous medically diagnosed concussion. Multifaceted strategies that incorporate the complexity of why athletes choose to not report a concussion targeted to the specific issues identified in this population and to all key stakeholders involved in collegiate sport are needed.

Sources of Acquired Concussion Information Reported by Parents of Youth Athletes

Purpose

Examining the relationships between demographics (sex, geographic location) and sources of acquired concussion information, and where parents would take their child for concussion evaluation.

Methods

A cross-sectional survey collecting demographics and concussion knowledge of parents (male: n=136/359, 38%; female: n=22/359, 62%) of youth athletes (i.e., football, ice hockey, lacrosse, soccer) in Michigan (n=131/359, 36.5%) and Pennsylvania (n=228/359, 62%). Separate Chi-square tests for independence examined the relationship between demographics (sex, geographic location) and sources of acquired concussion information, and where parents would take their child for concussion evaluation.

Results

Overall, parents recognized common concussion signs and symptoms and had general knowledge of concussion. There was a significant association between sex and acquiring information from sports medicine physicians (male: 31.6%, female: 18.9%; χ2 (1, n=358)=6.83, p=.009), and sports news outlets (male: 32.4%, female: 18.9%; χ2 (1, n=358)=7.62, p=.006). There was a significant association between geographic location and acquiring information from a coach (Michigan: 72.5%, Pennsylvania: 40.4%; χ2 (1, n=359)=32.22, p<.001), recreational league officials/league mandated paperwork (Michigan: 50.4%, Pennsylvania: 26.3%; χ2 (1, n=359)=20.11, p<.001), and youth sport state concussion laws (Michigan: 38.2%, Pennsylvania: 10.5%; χ2 (1, n=359)=37.18, p<.001). There was a significant association between geographic location and where parents would take their child for concussion evaluation (χ2 (3, n=338)=19.76, p<.001).

Conclusion

Sex and geographic location may influence where parents of youth athletes acquire concussion information and where they may seek medical attention.

Sport-Related Concussion: Knowledge and Reporting Behaviors Among Collegiate Club-Sport Athletes

CONTEXT: 

Previous literature on sport-related concussion (SRC) knowledge and reporting behaviors has been limited to high school and National Collegiate Athletic Association collegiate athletes; however, knowledge regarding collegiate club-sport athletes is limited.

OBJECTIVE: 

To determine the level of SRC knowledge and reporting behaviors among collegiate club-sport athletes and to investigate differences between athletes in traditional and nontraditional sports.

DESIGN: 

Cross-sectional study.

SETTING: 

Survey.

PATIENTS OR OTHER PARTICIPANTS: 

A total of 410 athletes (247 males, 163 females) involved in traditional (n = 244) or nontraditional (n = 165) collegiate club sports.

MAIN OUTCOME MEASURE(S): 

The survey consisted of demographics, recognition of SRC signs and symptoms, general SRC knowledge, and reasons why athletes would not report SRCs. The independent variable was sport type. Sport-related concussion signs and symptoms and general knowledge were assessed by the frequency of correct answers to SRC signs and symptoms and general knowledge questions. Sport-related concussion-reporting behavior frequencies were evaluated by asking participants to indicate reasons why they did not or would not report an SRC.

RESULTS: 

The SRC signs and symptoms knowledge score was 23.01 ± 3.19 and general SRC knowledge score was 36.49 ± 4.16 (maximal score = 43). No differences were present for SRC signs and symptoms knowledge ( F_1,408 = 1.99, P = .16) or general SRC knowledge ( F_1,408 = 3.28, P = .07) between athletes in traditional and nontraditional collegiate club sports. The most common reason for not reporting an SRC was not recognizing it as a serious injury (n = 165, 40.3%). Chi-square tests demonstrated significant relationships between sport type and 5 reasons for not reporting an SRC.

CONCLUSIONS: 

The participants displayed moderate to high levels of knowledge of SRCs but indicated they had failed to or would fail to report SRCs for a variety of reasons. The lack of sports medicine coverage and disconnect between knowledge and injury recognition may make collegiate club-sport athletes more likely to participate while concussed.

Sex Differences in High School Athletes' Knowledge of Sport-Related Concussion Symptoms and Reporting Behaviors

CONTEXT

  Recent researchers have reported that athletes' knowledge of sport-related concussion (SRC) has increased but that athletes still lack knowledge of all the signs and symptoms of SRC. Understanding the signs and symptoms of SRC and the dangers of playing while symptomatic are critical to reporting behaviors in high school athletes.

OBJECTIVE

  To examine sex differences in knowledge of SRC symptoms and reasons for not reporting a suspected SRC to an authoritative figure in high school athletes.

DESIGN

  Cross-sectional study.

SETTING

  Survey.

PATIENTS OR OTHER PARTICIPANTS

  A total of 288 athletes across 7 sports (198 males [68.8%] and 90 females [31.2%]).

MAIN OUTCOME MEASURE(S)

  A validated knowledge-of-SRC survey consisted of demographic questions, a list of 21 signs and symptoms of SRC, and reasons why athletes would not report their SRC. The independent variable was sex. Athlete knowledge of SRC symptoms was assessed by having participants identify the signs and symptoms of SRC from a list of 21 symptoms. Knowledge scores were calculated by summing the number of correct answers; scores ranged from 0 to 21, with a score closer to 21 representing greater knowledge. Reporting-behavior questions asked athletes to choose reasons why they decided not to report any possible SRC signs and symptoms to an authoritative figure.

RESULTS

  A sex difference in total SRC symptom knowledge was found (F₂₈₆ = 4.97, P = .03, d = 0.26). Female high school athletes had more total SRC symptom knowledge (mean ± standard deviation = 15.06 ± 2.63; 95% confidence interval = 14.54, 15.57) than males (14.36 ± 2.76; 95% confidence interval = 13.97, 14.74). Chi-square tests identified significant relationships between sex and 8 different reasons for not reporting an SRC.

CONCLUSIONS

  High school males and females had similar SRC symptom knowledge; however, female athletes were more likely to report their concussive symptoms to an authoritative figure.