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 (1) 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 (2) 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%) of the study samples 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 an 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 underrepresented 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.

Applying the Consensus Criteria for Traumatic Encephalopathy Syndrome Retrospectively to Case Studies of Boxers from the 20th Century.

There are no validated diagnostic criteria for traumatic encephalopathy syndrome (TES). During the early and middle 20th century, TES was described as a clinical condition that was experienced by some high-exposure boxers-and it was believed to reflect chronic traumatic brain injury. Consensus criteria for the diagnosis of TES were published in 2021. We applied the consensus criteria for TES retrospectively to cases of chronic brain damage in boxers described in articles published in the 20th century that were obtained from narrative and systematic reviews. The sample included 157 boxers identified in 21 articles published between 1929 and 1999. Two authors reviewed each case description and coded the criteria for TES. For the core clinical features, cognitive impairment was noted in 63.1%, and in 28.7% of cases the person's cognitive functioning appeared to be broadly normal. Neurobehavioral dysregulation was present in 25.5%. One third (34.4%) were identified as progressive, 30.6% were not progressive, and the course could not be clearly determined in 35.0%. In total, 29.9% met the TES consensus criteria, 28.0% did not, and 42.0% had insufficient information to make a diagnostic determination. TES, in the 20th century, was described as a neurological condition, not a psychiatric disorder-and this supports the decision of the 2021 consensus group to remove primary and secondary psychiatric diagnoses from being a core diagnostic feature. Future research is needed to determine whether, or the extent to which, cognitive impairment or neurobehavioral dysregulation described as characterizing TES are associated with chronic traumatic encephalopathy neuropathological change.

Evaluating Recovery After Two and Three Repeated Concussions Using Growth Curves.

The results of prior research concerning the effects of repeated concussions have been mixed. The aim of this study was to evaluate how concussion outcomes and presentation changed within patients who were evaluated at a concussion specialty clinic multiple times with a concussion. Subjects included 202 patients (54% male) aged 10-21 years (M = 13.17) who presented to a specialty concussion clinic for two and three concussions (77% sport-related) and were followed through formal clearance. First, growth curve models were estimated to determine recovery time and initial symptom burden across the multiple injuries. Second, covariates were added to these models to evaluate which demographic, risk factor, or injury variables predicted any change that did occur in evaluation or outcome variables. Models indicated that each subsequent concussion linearly resulted in significantly fewer days to recovery (-4.62 days, p < 0.047) across three concussions, and significantly lower (and linear) symptom scores on the post-concussion symptom scale (PCSS) (-2.16, p = 0.05). More severe presentation (i.e., days to recovery; higher symptom score) was significantly associated (-.62, p = 0.005) with greater improvement in recovery time (-.62, p = 0.005) and symptom burden (-.56, p < 0.001) at subsequent injuries. No covariates were significantly associated with improvement (or lack thereof) at subsequent injuries. This study adds to evidence suggesting multiple injuries is not associated with protracted recovery at subsequent injuries, in the context of treatment and full clearance for each injury at a multi-disciplinary clinic.

Neighborhood Disadvantage and Clinical Outcome Following Concussion in Adolescents.

Whether social determinants of health are associated with clinical outcome following concussion among adolescents is not well established. The present study examined whether neighborhood-level determinants are associated with clinical recovery time following concussion in adolescents. Participants included adolescent student athletes (n = 130; mean age = 16.6, standard deviation = 1.2; 60.8% boys, 39.2% girls) who attended one of nine selected high schools in Maine, USA. The Area of Deprivation Index (ADI), an indicator of neighborhood disadvantage was used to group high schools as either high or low in neighborhood disadvantage. Athletic trainers entered injury and recovery dates into an online surveillance application between September 2014 and January 2020. Chi-squared analyses and Kaplan-Meier survival analyses were used to compare the groups on two clinical outcomes: days to return to school and days to return to sports. Results of chi-squared tests did not reveal between-group differences in return to school at 21 or 28 days. However, groups differed in the percentage of adolescents who had returned to sports by 21 days (greater neighborhood disadvantage, 62.5%, lesser neighborhood disadvantage 82.0%, χ2 = 4.96, p = 0.03, odds ratio [OR] = 2.73, 95% confidence interval [CI], 1.11-6.74) and 28 days (greater neighborhood disadvantage, 78.6%, lesser neighborhood disadvantage 94.0%, χ2 = 5.18, p = 0.02, OR = 4.27, 95% CI, 1.13-16.16) following concussion. A larger proportion of adolescents attending schools located in areas of greater neighborhood disadvantage took more than 21 and 28 days to return to sports. These results indicate an association between a multi-faceted proxy indicator of neighborhood disadvantage and clinical outcome following concussion. Further research is needed to better characterize factors underlying group differences in time to return to sports and the interactions between neighborhood disadvantage and other correlates of clinical recovery following concussion.

A narrative review of psychiatric features of traumatic encephalopathy syndrome as conceptualized in the 20th century.

Introduction: Some ultra-high exposure boxers from the 20th century suffered from neurological problems characterized by slurred speech, personality changes (e.g., childishness or aggressiveness), and frank gait and coordination problems, with some noted to have progressive Parkinsonian-like signs. Varying degrees of cognitive impairment were also described, with some experiencing moderate to severe dementia. The onset of the neurological problems often began while they were young men and still actively fighting. More recently, traumatic encephalopathy syndrome (TES) has been proposed to be present in athletes who have a history of contact (e.g., soccer) and collision sport participation (e.g., American-style football). The characterization of TES has incorporated a much broader description than the neurological problems described in boxers from the 20th century. Some have considered TES to include depression, suicidality, anxiety, and substance abuse. Purpose: We carefully re-examined the published clinical literature of boxing cases from the 20th century to determine whether there is evidence to support conceptualizing psychiatric problems as being diagnostic clinical features of TES. Methods: We reviewed clinical descriptions from 155 current and former boxers described in 21 articles published between 1928 and 1999. Results: More than one third of cases (34.8%) had a psychiatric, neuropsychiatric, or neurobehavioral problem described in their case histories. However, only 6.5% of the cases were described as primarily psychiatric or neuropsychiatric in nature. The percentages documented as having specific psychiatric problems were as follows: depression = 11.0%, suicidality = 0.6%, anxiety = 3.9%, anger control problems = 20.0%, paranoia/suspiciousness = 11.6%, and personality change = 25.2%. Discussion: We conclude that depression, suicidality (i.e., suicidal ideation, intent, or planning), and anxiety were not considered to be clinical features of TES during the 20th century. The present review supports the decision of the consensus group to remove mood and anxiety disorders, and suicidality, from the new 2021 consensus core diagnostic criteria for TES. More research is needed to determine if anger dyscontrol is a core feature of TES with a clear clinicopathological association. The present findings, combined with a recently published large clinicopathological association study, suggest that mood and anxiety disorders are not characteristic of TES and they are not associated with chronic traumatic encephalopathy neuropathologic change.

Race, ethnicity, and clinical outcome following sport-related concussion: a systematic review.

Introduction: This systematic review examined whether race or ethnicity are associated with clinical outcomes (e.g., time to return to school/sports, symptom duration, vestibular deficits, and neurocognitive functioning) following sport-related concussion among child, adolescent, or college-aged student athletes. Additionally, this review assessed whether the existing literature on this topic incorporated or included broader coverage of social determinants of health. Methods: The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched. Results: A total of 5,118 abstracts were screened and 12 studies met inclusion criteria, including 2,887 youth and young adults. Among the included articles, only 3 studies (25%) examined whether race and ethnicity were associated with outcomes following concussion as a primary objective. None of the studies assessed the association between social determinants of health and outcomes following concussion as a primary objective, although 5 studies (41.7%) addressed a social determinant of health or closely related topic as a secondary objective. Discussion: Overall, the literature to date is extremely limited and insufficient for drawing conclusions about whether race or ethnicity are categorically associated with outcomes from sport-related concussion, or more specifically, whether there are socioeconomic, structural, or cultural differences or disparities that might be associated with clinical outcome. Systematic review registration: identifier: PROSPERO, CRD42016041479, CRD42019128300.

Evidence for a multidomain clinical assessment of mild traumatic brain injury in older adults.

BACKGROUND: There are few guidelines on the appropriate clinical tools to evaluate mTBI in older adults. OBJECTIVE: We aimed to investigate the utility of a multidomain assessment to differentiate older adults with mTBI from controls. METHODS: Participants included 68 older adults (37% male) aged 60-76 (M = 66.24, SD = 4.50) years. Thirty-four patients were diagnosed with a mTBI at a specialty mTBI clinic within 90 days of injury, and age- and sex-matched to 34 community controls. Participants completed the following assessments: Post-Concussion Symptom Scale (PCSS), Short Fall Efficacy Scale-International (Short FES-I), Generalized Anxiety Disorder-7 Item Scale (GAD-7), Geriatric Depression Scale-5 Item (GDS-5), Wide Range Achievement Test-Fourth Edition (WRAT-4) reading subtest, subtests of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), clock drawing, and Vestibular/Ocular Motor Screening for Concussion (VOMS). Independent-samples t-tests or chi-squared analyses were used to compare assessment results between groups. A logistic regression (LR) was conducted to determine which combination of assessments best identified the mTBI group from controls. RESULTS: The mTBI group endorsed significantly more symptoms of concussion (p < .001), balance concerns (p < .001), anxiety (p < .001), and depression (p = 0.04), and performed worse on cognitive (p < .001), vestibular (p < .001), and oculomotor (p = .004) screening relative to controls. The LR (p < .001; r2 = 0.90) correctly identified 98.5% of older adults and retained concussion (p = .01) and depression (p = .02) symptoms, and cognitive (p = .03) and vestibular (p = .04) screening in the final model. DISCUSSION: The current findings support a multidomain assessment model of care for evaluating mTBI in older adults.

Social Determinants of Health and Health Equity in the Diagnosis and Management of Pediatric Mild Traumatic Brain Injury: A Content Analysis of Research Underlying Clinical Guidelines.

We conducted a content analysis of the literature underlying the Centers for Disease Control and Prevention (CDC) Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (i.e., the "Guideline") to determine the extent to which social determinants of health (SDoH) were examined or addressed. The systematic review forming the basis for the Guideline included 37 studies addressing diagnosis, prognosis, and treatment/rehabilitation. We examined those studies to identify SDoH domains derived from the U.S. Department of Health and Human Services' Healthy People 2020 and 2030 websites. No study explicitly mentioned "social determinants of health," by name, and few studies addressed SDoH domains as a primary focus (ranging from 0% to 27% of studies across SDoH domains). The most frequently represented SDoH domains, described in an inferential or a descriptive manner, were Education Access and Quality (29.7% of studies), Social and Community Context (27.0% of studies), and Economic Stability (21.6% of studies). Health Care Access (13.5% of studies) was less well represented and no studies (0%) examined Neighborhood and Built Environment. In terms of the CDC clinical questions, SDoH were only examined as predictors of outcome (prognosis) and no studies examined SDoH in relation to diagnosis or treatment/rehabilitation. The Guideline includes some commentary on health literacy and socioeconomic status. Overall, social determinants of health are largely unrepresented as important or meaningful variables influencing the Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, or in the studies that informed the Guideline.

Discriminating Young Children with Concussion in an Outpatient Specialty Clinic from Healthy Controls Using the Child Sports Concussion Assessment Tool-5.

OBJECTIVE: To evaluate the clinical utility of the Sports Concussion Assessment Tool-5 Child (Child SCAT5) in an outpatient specialty clinic sample of children aged 5-9 years. STUDY DESIGN: Ninety-six children within 30 days of a concussion (mean = 8.90 ± 5.78 days) and 43 age- and sex-matched healthy controls completed the Child SCAT5, including balance items, cognitive screening, parent and child symptom severity reports, as well as each individual parent- and child-rated symptom severity (0-3). A series of receiver operating characteristic curves with area under the curve (AUC) analysis were performed to evaluate the clinical utility of the Child SCAT5 components to discriminate concussion. RESULTS: The AUC values were nondiscriminate for cognitive screening (0.32) and poor for balance (0.61) items. The AUC values were acceptable for parent-reported symptoms worsening after physical activity (0.73) and mental activity (0.72). The AUCs for symptom severity items were excellent for parent (0.89) and child-reported (0.81) headaches, and were acceptable for parent-reported tired a lot (0.75) and both parent- (0.72) and child-reported (0.72) tired easily. CONCLUSION: With the exception of parent- and child-reported symptoms, the Child SCAT5 provides limited clinical utility for evaluating concussion in children aged 5-9 years seen at an outpatient concussion specialty clinic. The cognitive screening and balance testing items were not useful in discriminating concussion. Parent- and child-reported headache were the only Child SCAT5 items with excellent ability to differentiate concussion from controls in the age group.

Normative Reference Values for Crystallized-Fluid Discrepancy Scores for the NIH Toolbox Cognition Battery.

INTRODUCTION: The purpose of this study was to translate NIH Toolbox Cognition Battery (NIHTB-CB) Crystallized-Fluid discrepancy scores into research and clinical practice with adults by providing normative data for discrepancy scores for both age-adjusted standard scores (SSs) and demographically adjusted T-scores. METHOD: We included adult participants from the NIHTB-CB standardization sample who denied having neurodevelopmental, medical, psychiatric, or neurological conditions (n = 730; M = 47.4 years old, SD = 17.6, range: 18-85; 64.4% women; 63.1% White). Descriptive statistics were calculated for the Fluid and Crystallized composite scores and Crystallized-Fluid discrepancy score, along with correlations between the composite scores and reliability estimates of the discrepancy score. Percentiles were calculated for the discrepancy score, with stratifications by the gender, education, and Crystallized composite for the age-adjusted SSs and demographically adjusted T-scores (T). RESULTS: Crystallized-Fluid discrepancy scores ranged from -40 to 44 (M = -0.63, SD = 14.89, Mdn = -1, interquartile range [IQR]: -11 to 10) for age-adjusted SSs and from -29 to 27 (M = -0.39, SD = 10.49, Mdn = -1, IQR = -8 to 7) for demographically adjusted T-scores. Crystallized-Fluid discrepancy scores of SS = 15 and T = 11 were at the 16th percentile (1 SD below the mean) and discrepancy scores of SS = 21 and T = 15 were at the 7th percentile (1.5 SD below the mean). CONCLUSIONS: Crystallized-Fluid discrepancy scores may be, with future research, a useful within-person interpretive approach for detecting a decline from pre-injury or pre-disease levels of cognitive functioning. These normative reference values assist clinicians and researchers in determining the frequency at which given Crystallized-Fluid discrepancy scores occurred among healthy adults in the normative sample.

Examining Whether Loss of Consciousness Is Associated With Worse Performance on the SCAT5 and Slower Clinical Recovery After Concussion in Professional Athletes.

Video surveillance has almost universally been employed by professional sports to identify signs of concussion during competition. This study examined associations between video-identified possible loss of consciousness (LOC), acute concussion evaluation findings, and recovery time in concussed professional rugby league players. Medical personnel and sideline video operators identified head impact events sustained during three seasons of National Rugby League (NRL) matches to determine the need for further medical evaluation. If a concussion was suspected, players were removed from play and underwent a Head Injury Assessment, including the Sports Concussion Assessment Tool, Fifth Edition (SCAT5). Video footage was later examined to identify signs of possible LOC (i.e., observed LOC, no protective action in the fall, and unresponsiveness or lying motionless). Possible LOC was identified in 99 of the 1706 head impact events (5.8%). The median duration of apparent unresponsiveness was 4.2 sec (M = 7.4, standard deviation [SD] = 12.8, interquartile range [IQR] = 2.5-6.6). In the 661 athletes for whom SCAT5 data were available, those with possible LOC endorsed more SCAT5 symptoms and performed worse on Maddocks questions, Standardized Assessment of Concussion (SAC) total scores, orientation, immediate recall, concentration, and delayed recall. For the 255 players with medically diagnosed concussions, SCAT5 data were available for 245. Concussed players with possible LOC performed significantly worse on Maddocks questions. However, there were no group differences in SCAT5 symptom endorsement, SAC total scores, orientation, immediate recall, concentration, delayed recall, or the modified version of the Balance Error Scoring System (mBESS) total errors. Further, the presence or absence of possible LOC was not associated with number of games missed or time to medical clearance for match play. The duration of possible LOC was not associated with the number of games missed or time to medical clearance for match play. According to video review in NRL players, brief LOC might be more common than previously thought. The present study reveals possible LOC is not predictive of missed games or time to recover following concussion.

Clinical Outcome Following Concussion Among College Athletes with a History of Prior Concussion: A Systematic Review.

BACKGROUND: There is long-standing interest in, and concern about, whether collegiate athletes with a history of concussion will experience worse clinical outcomes, or prolonged recovery, should they sustain a subsequent concussion. OBJECTIVES: This systematic review examined the association between prior concussion history and clinical outcomes following a subsequent sport-related concussion among college-age student athletes. STUDY DESIGN: Systematic review. METHODS: We screened 5,118 abstracts and 619 full-text articles that were appraised to determine whether they met inclusion criteria. We utilized a likelihood heuristic to assess the probability of observing a specific number of statistically significant and nonsignificant studies reporting an association between concussion history and clinical outcomes. We conducted a narrative synthesis of the study findings. RESULTS: Sixteen studies met the inclusion criteria. Thirteen studies reported the number of participants with a history of prior concussions (≥ 1), which totaled 1690 of 4573 total participants (on average 37.0% of study participants; median = 46.0%, range 5.6-63.8%). On the Newcastle-Ottawa Quality Assessment Scale, the risk of bias ratings ranged from 3 to 9 (mean = 5.4, SD = 1.4). Across all studies, 43.8% (k = 7/16) reported at least one statistically significant result among primary analyses showing an association between concussion history and worse clinical outcome. A minority of studies reporting on symptom duration (4/13, 30.8%) and time to return to play (2/7, 28.6%) found an association between concussion history and worse outcome. Studies included in the review reported limited information pertaining to the characteristics of prior concussions, such as presence or duration of loss of consciousness or posttraumatic amnesia, age at first lifetime concussion, time since most recent past concussion, or length of recovery from prior concussions. CONCLUSION: The question of whether college athletes with a prior history of concussion have worse clinical outcome from their next sport-related concussion remains unresolved. The published results are mixed and in aggregate show modest evidence for an association. Many studies have small samples, and only three studies were designed specifically to address this research question. Important outcomes, such as time to return to academics, have not been adequately studied. Larger hypothesis-driven studies considering the number of prior concussions (e.g., 3 or more) are needed. TRIAL REGISTRATION: PROSPERO CRD42016041479, CRD42019128300.

Clinical Outcome following Sport-Related Concussion among Children and Adolescents with a History of Prior Concussion: A Systematic Review.

Authoritative sources advise clinicians and parents that a history of prior concussion confers increased risk for worse outcome from a future concussion. However, the strength of the evidence supporting such pronouncements and thus the extent to which clinicians should incorporate this information into their care and management of pediatric concussion is unclear. This systematic review critically analyzed and synthesized the literature on the association between a history of prior concussion and prognosis/clinical outcome following a subsequent sport-related concussion among children and adolescents. The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched from inception to May 15, 2021. From 5118 total records screened, 51 studies (46 cohort studies and five case-control studies) met inclusion criteria, reporting concussion recovery or outcome for 26,643 youth. A median of 36% had a prior history of concussion. Across all studies and outcomes, the majority (k = 37, 72.5%) did not find a statistically significant association between lifetime history of concussion and outcome from a subsequent concussion. Important methodological limitations in the literature were identified. Available studies do not provide consistent or compelling evidence that children and adolescents with a history of concussion are at increased risk for worse clinical outcome following a subsequent sport-related concussion-although methodological limitations temper the strength of this conclusion. Clinicians are cautioned against routinely treating children and adolescents with one or more prior injuries differently and more conservatively, because doing so, in some cases, might be counterproductive.

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.

Lower post-injury psychological resilience is associated with increased recovery time and symptom burden following sport-related concussion.

The purpose of this study was to compare athletes with high and low resilience scores on concussion outcomes, and identify significant predictors associated with protracted recovery (>30 days). Forty-five adolescent and young adult athletes (28 males; aged 15.13 ± 2.74; range of 11-22) were diagnosed with an SRC within 14 days of injury (M = 4.9 days) and grouped as high or low resilience based on score on the Connor-Davidson Resilience Scale-10 (CD-RISC-10). Primary dependent measures included days to full clearance, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Depression Anxiety and Stress Scale-21 (DASS-21), and Vestibular/Ocular Motor Screening (VOMS). The low resilience group (n = 22) had a longer recovery (36.0 ± 27.6 vs 17.8 ± 11.2 days), endorsed more mood symptoms (PCSS Affective cluster; 3.8 ± 0.8 vs 0.9 ± 0.7), and were more likely to have VOMS scores above cut off (p = 0.01-0.02), compared to those with high psychological resilience (n = 23). Logistic regression found low resilience scores was the only significant predictor for protracted recovery among injury characteristics and risk factors. Psychological resilience is a critical factor associated with recovery time following sport-related concussions. Low resilience was also associated with other poor clinical outcomes, greater subjective symptom report, more severe vestibular dysfunction, and elevated levels of mood symptoms following injury.

The Emerging Role of Telehealth for Concussion Clinical Care During the Coronavirus (COVID-19) Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has substantially altered the delivery of healthcare for providers and their patients. Patients have been reticent to seek care for many diseases and injuries including concussion due to fears of potential exposure to COVID-19. Moreover, because of social distancing recommendations and stay-at-home orders, patient screening, evaluation, and delivery of care have become less efficient or impossible to perform via in-person clinic visits. Consequently, there was a sudden need to shift healthcare delivery from primarily in-person visits to telehealth. This sudden shift in healthcare delivery brings with it both challenges and opportunities for clinical concussion care. This article is designed to discuss these challenges and opportunities and provide an experiential-based framework for providing concussion care via telehealth. We first provide an overview of a clinical concussion model utilized at concussion specialty clinics from 3 geographically disparate healthcare systems for in-person service delivery prior to COVID-19. We then discuss the creation of new clinical workflows to facilitate the continued provision of concussion specialty care using telehealth. Finally, we examine lessons learned during this healthcare delivery shift including limitations and potential barriers for telehealth for concussion care, as well as opportunities for expansion of concussion care in rural and underserved areas. We also discuss the need to empirically evaluate the comparative efficacy of telehealth and in-person concussion care moving forward.

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).

Performance of college athletes on the 10-item word list of SCAT5.

OBJECTIVES: The Sport Concussion Assessment Tool-5 (SCAT5) was published in 2017; however, normative performance within the college athlete population on the optional 10-item word list has not been described. This study reports normative values for immediate memory trials, total immediate memory score and delayed recall of the 10-item word list. METHODS: The SCAT5 was administered as part of the preparticipation medical testing to 514 collegiate student-athletes, aged 17-23 (M=19.65, SD=1.40; 64% male) prior to the 2017-2018 athletic season. RESULTS: On the SCAT5's optional 10-item word list, with a total possible immediate memory score of 30, participants recalled an average of 20.57 (SD=3.22) words over three learning trials, with an average for trial 3 of 8.13 (SD=1.32). The average delayed memory score was 6.59 (SD=1.85). Small but significant demographic comparisons were found. Women scored higher on both immediate and delayed recall, non-native speakers scored higher on delayed recall, and Black/African-American athletes scored lower than White athletes on immediate, and lower than White and Hispanic/Latino athletes on delayed recall. CONCLUSION: The 10-item word list on the SCAT5 eliminates the ceiling effect observed on the five-item word list of the SCAT3, therefore, increasing its clinical utility in the diagnosis of sports-related concussions. Significant demographic differences suggest use of category-specific norms for sex, native language and race/ethnicity.

Rumination and the mood-as-input hypothesis: Does congruence matter?

BACKGROUND AND OBJECTIVES: The mood-as-input hypothesis (MAIH), which emphasizes the role of mood and stop rules on perseverative thinking, has been extensively studied in relation to worry (Meeten & Davey, 2011). However, relatively few studies have focused on the applicability of the MAIH to depressive rumination. Consequently, two studies were conducted to further examine the potential relevance of the MAIH to depressive rumination. METHODS: In the first study, a sample of undergraduate students completed a rumination interview under one of four conditions, including mood (positive vs. negative) and stop rule (as-many-as can (AMA) and feel like stopping (FL)). It was anticipated that participants in the negative mood/AMA and the positive mood/FL conditions would exhibit the most persistence in the rumination interview. A second, follow-up study was conducted in which a positive rumination condition was added to examine the role of congruence between mood induction and task valence on interview performance. RESULTS: In the first study, support for predictions of the MAIH was found in the negative mood conditions but not the positive mood conditions. In the second study, as predicted, under conditions of mood congruence, the original predictions of the MAIH were supported. However, under conditions of mood incongruence, participants appeared to default to the assigned stop rule. LIMITATIONS: Although the findings are promising, it is noteworthy that the sample was non-clinical. Further, this approach to studying depressive rumination may have somewhat limited ecological validity, as the research was conducted in a controlled laboratory setting. CONCLUSIONS: Overall, the current findings provide insight into the conditions under which depressive rumination is most likely to occur.