Group Differences in Postconcussion Cognitive, Physical, Sleep-Arousal, and Affective Symptom Subscales in High School and Collegiate Athletes by Race, Gender, and Competitive Level.

OBJECTIVE: Prior psychometric research has identified symptom subscales for the Post-Concussion Symptom Scale (PCSS) based on confirmatory factor analysis (CFA), including cognitive, physical, sleep-arousal, and affective symptom factors. Study objectives included: (1) replicate the 4-factor PCSS model in a diverse sample of athletes with concussion, (2) test the model for invariance across race, gender, and competitive level, and (3) compare symptom subscale and total symptom scores across concussed groups with established invariance. SETTING: Three regional concussion care centers. PARTICIPANTS: A total of 400 athletes who completed the PCSS within 21 days of concussion (64% boys/men, 35% Black, and 69.5% collegiate athletes). DESIGN: Cross-sectional. MAIN MEASURES: A CFA tested the 4-factor model and measurement invariance testing was performed across racial, competitive level, and gender groups. Symptom subscales and total symptom severity scores were compared based on demographic groupings with established invariance. RESULTS: The 4-factor model fit well and strong invariance was established across all demographic categories, indicating symptom subscales could be meaningfully compared across groups. Black and White athletes differed on total symptoms (U = 15 714.5, P = .021, r = 0.12), sleep-arousal symptoms (U = 15 953.5, P = .026, r = 0.11), and physical symptoms (U = 16 140, P = .051, r = 0.10), with Black athletes reporting slightly more symptoms. Collegiate athletes reported greater total symptom severity (U = 10 748.5, P < .001, r = 0.30), with greater symptom reporting on the cognitive (U = 12 985, P < .001, r = 0.21), sleep-arousal (U = 12 594, P < .001, r = 0.22), physical (U = 10 959, P < .001, r = 0.29), and emotional (U = 14 727.5, P = .005, r = 0.14) symptom subscales. There were no significant differences by gender in the total symptom score or subscale scores. After controlling for time since injury, no racial differences persisted, but a significant difference by competitive level in physical symptom reporting (F = 7.39, P = .00, η2 = 0.02) and total symptom reporting (F = 9.16, P = .003, η2 = 0.02) remained. CONCLUSION: These results provide external validation for the PCSS 4-factor model and demonstrate that symptom subscale measurements are comparable across race, genders, and competitive levels. These findings support the continued use of the PCSS and 4-factor model for assessing a diverse population of concussed athletes.

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's 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 < .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 < .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.

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.

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.

Social support and the stress-buffering hypothesis: Effects on stress and mental health in adolescent football athletes.

CONTEXT: Football sports participation has been linked to both positive and negative effects on overall health. Social support, a network which provides individuals with resources to effectively cope, may positively influences one's stress and mental health. However, little research has been conducted in this population. OBJECTIVE: To examine the relationships between social support, psychological stress, and mental health in adolescent football athletes. DESIGN: Cross-Sectional. SETTING: High school athletes, pre-and-post-competitive football season in XXX. PARTICIPANTS: Black/African American adolescent athletes (N=93) competing for a school-sponsored football team. MAIN OUTCOME MEASURES: Participants completed a battery of social support, psychological stress, and mental health symptom measures using the National Institutes of Health Toolbox Application and Patient-Reported Outcomes Measurement Information System following a competitive season. T-score means, Pearson correlations, and multiple regression analyses were conducted. RESULTS: Social support was negatively correlated with psychological stress (Emotional support r=-.386, Family relationships r=-.412, Peer relationships r=-.265) and mental health (Depression r=-.367 and r=-.323 for Emotional support and Family relationships, respectively), whereas psychological stress and mental health (Depression r=.751 and Anxiety r=.732) were positively correlated with one another. In regression analyses, social support measures (i.e., Emotional Support, Family Relationships, and Peer Relationships) were used to predict psychological stress (F=7.094, p<.001, R2=0.191), depression symptoms (F=5.323, p<.001, R2=0.151), and anxiety symptoms (F=1.644, p=.190, R2=0.052). CONCLUSIONS: In line with the stress buffering hypothesis, social support in the form of family relationships and overall emotional support garnered through sport participation may reduce psychological stress and help to preserve mental health of football athletes. Findings indicate perceived social support may act as a positive resource for the coping of Black/African American adolescent athletes. Further research is warranted to understand the effects of stress and social support on the mental health of adolescents, particularly racial and ethnic minorities who are underrepresented in athletic training literature.

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.

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.