Case Characterization and Perceptions of Athletic Trainers Regarding Medical Disqualification Following Concussion.

CONTEXT: Medical disqualification (MDQ) following concussion is a challenging decision clinicians may encounter with little evidence-based guidance. OBJECTIVE: We aimed to 1) describe the MDQ following concussion cases athletic trainers (ATs) have been involved in, 2) describe beliefs about MDQ following concussion, and 3) explore factors that ATs believed should be involved in the MDQ following concussion process. DESIGN: Mixed methods. SETTING: Online cross-sectional survey with follow-up semi-structured interviews. PARTICIPANTS: ATs (n=502) employed at the collegiate setting completed a survey (completion rate=82.3%, n=413/502; male=175, 34.9%; female=235, 46.8%, prefer not to answer=4, 0.8%; no response=88, 17.5%; age=35.3±10.8 years). Twenty participants were also interviewed (males=13, 65.0%; females=7, 35.0%; average age=40.7±11.0years). DATA COLLECTION AND ANALYSIS: Participants completed a cross-sectional survey comprised of three sections of MDQ experience and specific case information, MDQ beliefs, and demographic items. We also interviewed participants that completed the survey and indicated involvement in at least one MDQ following concussion case. We addressed aims 1 and 2 using descriptive statistics and aim 3 with a five-cycle content analysis. RESULTS: Nearly half of respondents had been involved in an MDQ case following concussion (49.0% n=246; not involved=51.0%, n=256). ATs who had been involved in at least one MDQ case had involvement in an average of 2.3±1.9 cases (n=241). Participants often described many factors they believed should influence the MDQ decision including sport type, concussion history and recovery, health-related quality of life, and academic performance. CONCLUSIONS: Our findings highlight that nearly half of participants were involved in an MDQ case following concussion and navigated this process without guidelines. Given this, multiple factors were considered to evaluate the patient's well-being holistically. The number of ATs involved in MDQ cases following concussion and factors that guided this process warrant further research to develop evidence-based recommendations that assist clinicians in these difficult decisions.

Recommendations for Medical Discharge Documentation and Academic Supports for University Students Recovering From Concussion.

OBJECTIVE: This study sought to (1) collate the experiences of university students with concussion history and academic stakeholders through interviews and (2) develop concussion management recommendations for institutions of higher learning using a multidisciplinary Delphi procedure. SETTING: Remote semistructured interviews and online surveys. PARTICIPANTS: The first aim of this study included undergraduate university students with concussion history who did not participate in varsity athletics ( n = 21; 57.1% female), as well as academic faculty/staff with experience assisting university students with their postconcussion academic needs ( n = 7; 71.4% female). The second aim enrolled 22 participants (54.5% female) to serve on the Delphi panel including 9 clinicians, 8 researchers, and 5 academic faculty/staff. DESIGN: An exploratory-sequential mixed-methods approach. MAIN MEASURES: Semistructured interviews were conducted to unveil barriers regarding the return-to-learn (RTL) process after concussion, with emergent themes serving as a general framework for the Delphi procedure. Panelists participated in 3 stages of a modified Delphi process beginning with a series of open-ended questions regarding postconcussion management in higher education. The second stage included anonymous ratings of the recommendations, followed by an opportunity to review and/or modify responses based on the group's consensus. RESULTS: The results from the semistructured interviews indicated students felt supported by their instructors; however, academic faculty/staff lacked information on appropriate academic supports and/or pathways to facilitate the RTL process. Of the original 67 statements, 39 achieved consensus (58.2%) upon cessation of the Delphi procedure across 3 main categories: recommendations for discharge documentation (21 statements), guidelines to facilitate a multidisciplinary RTL approach (10 statements), and processes to obtain academic supports for students who require them after concussion (8 statements). CONCLUSIONS: These findings serve as a basis for future policy in higher education to standardize RTL processes for students who may need academic supports following concussion.

Achieving Consensus Through a Modified Delphi Technique to Create the Post-concussion Collegiate Return-to-Learn Protocol.

BACKGROUND: Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education. OBJECTIVE: To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery. METHODS: Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group's overall ratings. RESULTS: Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol. CONCLUSION: There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders.

The Influence of Socioeconomic Status and Academic Standing on Concussion-Reporting Intentions and Behaviors in Collegiate Athletes.

Concussion education have served as a keystone for improving concussion reporting. Numerous factors affecting concussion reporting have been explored; however, the role of socioeconomic status (SES) in reporting has not been established. We examined the influence of SES and academic achievement (high-school grade point average [HS-GPA] and American College Testing [ACT] composite scores) on athletes' concussion-reporting intentions and behaviors. A cross-sectional study was employed among 191 athletes (94 female; age 19.3 ± 1.2 years). Athletes reported SES metrics (parental education and occupation, household income, HS-GPA, and ACT composite score) prior to their athletic season and completed a survey assessing symptom- and concussion-reporting intentions. Symptom- and concussion-reporting behaviors were assessed among athletes who experienced a concussion within the past year. SES was determined using the Hollingshead Four-Factor Index grouping athletes into SES strata. Athletes were grouped into low/high categories for academic achievement and household income variables. The 191 athletes were included for symptom- and concussion-reporting intentions analyses, while 46 and 41 were included for symptom- and concussion-reporting behavior, respectively. Nonparametric statistics with false discovery rate adjusted p values were employed. We found symptom- and concussion-reporting intentions, and symptom- and concussion-reporting behaviors were not significantly different based on SES strata (all p values ≥.64), household income (all p values ≥.64), HS-GPA (all p values ≥.24), or ACT scores (all p values ≥.25). Overall, SES and academic achievement may not play a role in understanding concussion reporting among middle- to high-SES collegiate athletes. Implementing policies targeting certain SES and academic levels might be an ineffective health care strategy for increasing reporting.

Examination of collegiate student-athlete concussion reporting intentions and behavior.

BACKGROUND: Clinicians rely on student-athletes to self-report concussion symptoms, but more than 50% of concussions go undisclosed. AIM: The aim of this study was to determine whether knowledge, attitudes, subjective norms, self-efficacy, social identity, and athletic identity explain variability in student-athlete concussion reporting intentions and behavior. MATERIALS AND METHODS: One hundred and forty-seven Division I and II collegiate student-athletes (male=23, female=56, missing=168; age=19.04±1.98 years) completed survey segments regarding the following predictor variables: Concussion knowledge, attitudes, subjective norms, self-efficacy, social identity, and athletic identity; and the following criterion variables: Reporting intentions (symptom and concussion reporting) and reporting behavior (symptom and concussion reporting) (completion rate=29.2%). Separate linear and logistic regressions were performed for each criterion variable. Backward elimination Akaike Information Criterion was applied to determine the best fit model. RESULTS: A one-point increase in knowledge, attitudes, and self-efficacy predicted a significant 0.55, 0.23, and 0.31 increase in symptom reporting intentions, and 0.24, 0.30, and 0.33 increase in concussion reporting intentions of concussion reporting. As self-efficacy increased, symptom reporting behavior increased by 140%. When knowledge increased, concussion reporting behavior decreased by 23%. Whereas when subjective norms increased, concussion reporting behavior increased by 23%. CONCLUSIONS: A student-athletes' confidence, or self-efficacy, was a frequent predictor of concussion reporting intentions and behavior. RELEVANCE FOR PATIENTS: Clinicians should aim to increase student-athlete knowledge, attitudes, and subjective norms, but most importantly their confidence in reporting concussions.

Coach, sports medicine, and parent influence on concussion care seeking intentions and behaviors in collegiate student-athletes.

BACKGROUND: Sport is a socio-ecological framework where student-athletes are part of a larger community of stakeholders, including coaches, sports medicine professionals (SMPs), and parents. This framework may hold influence over whether student-athletes seek care for a concussion. AIM: We aimed to describe, compare, and determine the influence of stakeholder concussion knowledge, attitudes, and concussion scenario responses. MATERIALS AND METHODS: We recruited a sample of 477 student-athletes and their 27 coaches (response rate=46.6%), 24 SMPs (48.7%), and 31 parents/guardians (4.8%). Stakeholder surveys assessed their concussion knowledge, attitudes toward care seeking, and concussion scenario responses. Surveys administered to student-athletes assessed their concussion care seeking intentions and behaviors. Kruskal-Wallis tests were used to compare responses between stakeholder groups and to determine the differences in student-athlete intentions and behaviors (alpha=0.05). RESULTS: SMPs had significantly better knowledge (p<0.001) and concussion scenario responses (p<0.001) compared to both coaches and parents. SMPs also had significantly better attitudes compared to parents, but not coaches (p=0.038). Coach concussion scenario responses (p=0.044) and SMP knowledge positively influenced student-athletes' concussion care seeking intentions (p=0.049). Parent responses were not associated with their child's concussion care seeking intentions and behaviors. CONCLUSIONS: The gap in coach and parent concussion knowledge and concussion scenario response relative to SMPs is a preliminary target for stakeholder concussion education and supports the current sports medicine model where SMPs primarily disseminate concussion education. Stakeholders, specifically coaches and SMPs, do hold influence over collegiate athlete concussion care seeking intentions and behaviors. RELEVANCE FOR PATIENTS: Stakeholders should be addressed within educational efforts aimed at student-athletes and should also complete stakeholder-specific concussion education.

Medical Disqualification Following Concussion in Collegiate Student-Athletes: Findings from the CARE Consortium.

BACKGROUND: The absence of evidence-based guidelines make medical disqualification (MDQ) following concussion one of the most challenging decision-making processes faced by sports medicine professionals. OBJECTIVE: We aimed to compare premorbid and postmorbid factors between student-athletes that were and were not medically disqualified from sport following a concussion. METHODS: Among 1832 student-athletes diagnosed with concussion within the CARE Consortium, 53 (2.9%) were medically disqualified (MDQ +) and 1779 (97.1%) were not medically disqualified (MDQ-). We used contingency tables and descriptive statistics for an initial evaluation of a broad list of premorbid and postmorbid factors. For those factors showing association with MDQ status, we calculated odds ratios and 95% confidence intervals for the odds of being MDQ + in the presence of the identified factor. RESULTS: History of 2 (OR: 3.2, 95% CI 1.5, 6.9) or 3 + (OR: 7.4, 95% CI 3.4, 15.9) previous concussions; 1 + headaches in past 3 months (OR: 1.8, 95% CI 1.0, 3.2); immediate removal from play (OR: 2.4, 95% CI 1.2, 4.9); alcohol (OR: 2.6, 95% CI 1.2, 5.4), tobacco (OR: 3.3, 95% CI 1.1, 9.5), or marijuana use since injury (OR: 5.4, 95% CI 1.5, 19.0); as well as prolonged recovery due to mental health alterations (OR: 5.3, 95% CI 2.0, 14.1) or motivation/malingering (OR: 7.5, 95% CI 3.3, 17.0) increased odds of being MDQ + . The MDQ + group took longer to become asymptomatic relative to the MDQ- group (MDQ + : 23.5 days, 95% CI 15.8, 31.2; MDQ-: 10.6 days, 95% CI 9.5, 11.6; p < 0.001). CONCLUSIONS: MDQ following concussion was relatively rare. We identified three patterns related to MDQ following concussion: (1) concussion and headache history were the only premorbid factors that differed (2) initial concussion presentation was more severe and more immediate in the MDQ + group, and (3) post-concussion recovery outcomes expressed the greatest differences between groups.

United States Air Force Academy Cadets' Perceived Costs of Concussion Disclosure.

INTRODUCTION: Concussion is unique among sport-related injuries as effective clinical diagnosis and treatment often rely on symptom-report for clinician diagnosis and treatment. However, at-risk populations such as collegiate athletes and military academy cadets often have been shown to under-report concussions and symptoms, complicating diagnosis, treatment, and policy-based interventions. The purpose of this study was to explore factors influencing concussion reporting in United States Air Force Academy (USAFA) cadets. MATERIALS AND METHODS: Semi-structured interviews were conducted on 34 cadets (18 with concussion history; 16 without concussion history). This study was approved by the USAFA Institutional Review Board. Analysis included a five-cycle process of clarifying the topic at hand through an introduction, conducting a literature review, data collection and summarization, relating current findings to current literature, and making final interpretations. Data were summarized by creation of a codebook after reading five transcripts and identifying meaningful units. A four-person research team read and identified meaningful units individually, then met to discuss common meaningful units and codebook creation. Once the codebook was created, the lead researcher used the codebook to code all transcripts. RESULTS: Eight themes were generated from interview transcripts. This manuscript focuses on the perceived costs following a concussion theme and the following subthemes: perceived costs to physical fitness, military career aspirations, pilot qualifications, sport, reputation, academics, and lack of time. CONCLUSIONS: Cadet interviews described a complex environment where concussions were often viewed as costly to future career ambitions and provided potential reasons for non-disclosure largely including disruption in daily life. Reduction in perceived and actual harms due to concussion disclosure will require not only improving clinical care, but also addressing barriers to self-disclosure. Additionally, research suggests the sooner one reports a concussion, the sooner they return to physical or military activity. Educational interventions should be designed to address the perceived costs identified from our study and educate cadets that while some costs may be reality, others may not. Secondly, it should also be stressed to cadets that the sooner one seeks medical attention following a concussion, the sooner they may return to activity. Messaging around these themes may decrease the costs associated with time removed from academics, athletics, or military activities therefore minimizing attempts at concussion self-management. Lastly, if efforts are made to improve the overall concussion disclosure stigma, cadets may increase seeking care after injury because their reputation may not be as impacted.