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

Collegiate Athletes\u27 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\u27 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 \u3c .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

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 \u3c .001), diagnosed concussion history (P \u3c .001), concussion knowledge (P = .017), and pressure from coaches (P \u3c .001), teammates (P \u3c .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 \u3c .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

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 \u3c .001), diagnosed concussion history (P \u3c .001), concussion knowledge (P = .017), and pressure from coaches (P \u3c .001), teammates (P \u3c .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 \u3c .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

Assessing Differences in Concussion Symptom Knowledge and Sources of Information Among Black and White Collegiate-Athletes

OBJECTIVE: Basic concussion symptom knowledge is fundamental to concussion identification; however, racial disparities in concussion knowledge exist in high school and youth sports. It is unknown whether similar differences exist in collegiate-athletes. Identifying racial disparities in concussion knowledge and sources of concussion information is essential to inform equitable approaches to knowledge translation and educational interventions. This study examined how Black and White collegiate-athletes differed in their knowledge of concussion symptoms and use of concussion information sources. SETTING: National Collegiate Athletic Association (NCAA) institutions. PARTICIPANTS: Collegiate-athletes. DESIGN: Cross-sectional. MAIN MEASURES: Collegiate-athletes completed a questionnaire that assessed personal and sports demographics, concussion symptom knowledge, and use of concussion information sources. Fisher\u27s exact tests and Wilcoxon rank-sum tests examined differences in outcome measures between Black and White collegiate-athletes. A multivariable Poisson regression model examined the association between race and concussion symptom knowledge scores while accounting for sex, sports contact level, NCAA division, concussion history, and specific concussion information sources. Incidence rate ratios (IRRs) with 95% CIs excluding 1.00 were deemed significant. RESULTS: A total of 768 (82.6% White, 17.4% Black) collegiate-athletes completed the questionnaire. Black athletes were more likely to have lower concussion symptom knowledge scores than White athletes (P \u3c .001). In the multivariable Poisson regression model controlling for covariates, this finding was retained (IRR = 0.97; 95% CI, 0.94-0.997). White athletes were more likely to report school-based professional (P \u3c .001), online medical sources (P = .02), and the NCAA (P = .008) as sources of concussion information. Black athletes were more likely to report referees (P = .03) as a source of concussion knowledge. CONCLUSION: Despite NCAA concussion education requirements for athletes, Black collegiate-athletes were found to have lower concussion knowledge than White collegiate-athletes. The findings highlight the need for equitable strategies to disseminate concussion information to diverse populations by improving the physician-patient relationship and investing in culturally appropriate educational materials

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 \u3c 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 \u3c 0.01, r = 0.19) beliefs on the PCI-A. No differences were observed for those with a history of a mood disorder (P \u3e 0.05). A significant multivariate model was established (χ2 = 55.44, P \u3c 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

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 ( = 0.01) and lower overall I-PRRS than moderate injuries ( \u3c 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