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

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

Temporal Differences in Concussion Symptom Factors in Adolescents following Sports-Related Concussion.

OBJECTIVE: To evaluate temporal differences in concussion symptoms up to 30 days following a sports-related concussion. STUDY DESIGN: Adolescent and young adult athletes (n = 782) were separated based on time since injury at presentation as Early (0-7 days; n = 321, age: 15.4 ± 1.9 years, 51.7% female), Middle (8-14 days; n = 281, age: 15.8 ± 2.2 years, 54.8% female), and Late (15-30 days; n = 180, age: 15.6 ± 1.8 years, 52.8% female). All participants completed the 22-item Post-Concussion Symptom Scale at first visit. A confirmatory factor analysis was completed separately for each time since injury cohort using a 4-component model reported previously. RESULTS: The confirmatory factor analysis model fit was acceptable for Early, Middle, and Late (using cognitive-migraine-fatigue, affective, sleep, and somatic factors). Both affective (change = 0.30; P = .01; Cohen d = 0.30) and sleep (change = 0.51; P ≤ .001; Cohen d = 0.47) factors were significantly greater in the Late group compared with the Early, but not Middle, groups. The previously reported 4-factor symptom model, including cognitive-migraine-fatigue, affective, somatic, and sleep factors, was appropriate for adolescents up to 30 days' postinjury. However, adolescents who presented between 15 and 30 days' postinjury reported greater affective and sleep symptoms than those who presented within 1 week. CONCLUSIONS: Clinicians should consider these temporal differences when evaluating concussion symptoms in adolescents, as greater affective and sleep symptoms can be predictive of prolonged recovery/persistent complications.

Does time since concussion alter the factor structure of a multidomain assessment in adolescents?

The utilization of principal component analysis (PCA) approaches to concussion is beneficial to inform the interpretation of clinical outcome data in adolescent patients. While researchers have identified factors using post-concussive symptom scales and cognitive testing, there has yet to be a PCA that incorporates vestibular or oculomotor outcomes, or that focuses exclusively on adolescents. Moreover, the role of time since injury has not been examined in relation to concussion factors in this at-risk population. PCA methods were applied to two independent samples of 237 adolescents who presented to an outpatient concussion clinic: 1) ≤7 days (n = 145), and 2) 8 days-1 month (n = 92). The two separate PCAs included nine clinical assessments comprised of: a) four symptoms factors (cognitive/fatigue/migraine, affective, somatic, sleep), b) memory and speeded cognitive performance, c) near point of convergence (NPC), d) oculomotor, and e) vestibular outcomes. A three-component model including 1) symptoms, 2) cognitive, and 3) vestibular/oculomotor factors that accounted for 69.2% of the variance was supported for the ≤7 days sample. All items except somatic symptoms loaded. A different three-component model was supported for the 8 days-1 month sample, including 1) vestibulo-ocular migraine, 2) visuo-cognitive, and 3) affective-sleep that accounted for 72.1% of the variance, with all items loading. The findings supported two different concussion factor models that highlight the influence of time since injury and importance of considering vestibular and oculomotor outcomes in adolescents. Clinicians should evaluate these different factors using a comprehensive, multi domain approach to better inform assessment and monitor recovery in adolescent patients following concussion.Abbreviations: Principal Components Analysis (PCA), Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Post-concussion Symptom Scale (PCSS), Vestibular/Ocular Motor Screening (VOMS).