Risk factors for prolonged recovery from concussion in young patients.

OBJECTIVES: For young patients sustaining concussion, assessing recovery is vital in determining safe return to play. Identifying risk factors may aid clinicians in recognising patients at risk for prolonged recovery. The study objective is to identify risk factors for prolonged (>28 days) and extended (>90 days) recovery (defined as symptom duration) and analyse how these risk factors differ between the two groups. METHODS: We retrospectively analysed electronic health record data (n=4937) among patients aged 10-18 years collected at Nationwide Children's Hospital Sports Medicine concussion clinics between 1 July 2012 and 30 June 2019. Data collected included patient demographics, comorbidities (eg, prior psychiatric diagnoses, prior concussions) and injury characteristics (eg, loss of consciousness, injury setting). We examined patient risk factors for prolonged (>28 days) and/or extended (>90 days) recovery using modified Poisson regression models. RESULTS: Factors associated with increased risk of prolonged recovery from concussion included prior concussions (adjusted risk ratio (ARR) 1.19, 95% CI 1.02 to 1.38) for two concussions (ARR 1.36, 95% CI 1.14 to 1.61), for >3, and higher initial symptom score (ARR 2.57, 95% CI 2.34 to 2.83) for postconcussion symptom (PCS) scores 21-60 (ARR 2.89, 95% CI 2.54 to 3.29), for PCS>60. Risk factors for extended recovery included history of concussion (ARR 1.50, 95% CI 1.09 to 2.06) for two concussions (ARR 1.75, 95% CI 1.17 to 2.62), for >3 and older age (15-18 years, ARR 1.11, 95% CI 1.05 to 1.18). Additionally, comorbid attention deficit hyperactivity disorder increased risk of prolonged recovery (ARR 1.14, 95% CI 1.01 to 1.29) while anxiety increased risk for extended recovery (ARR 1.47, 95% CI 1.10 to 1.95). CONCLUSION: Overall, risk factors for prolonged recovery differ somewhat from risk factors for extended recovery. For patients who present to clinic with concussion, mental health is an important consideration which may impact the timeline for symptom recovery.

Lifetime history of TBI with loss of consciousness and disability among Appalachian and rural residents: 2016-2019 Ohio BRFSS.

BACKGROUND: While lifetime history of traumatic brain injury (TBI) is associated with increased risk of disabilities, little is known about disability and TBI among Appalachian and other rural residents. This study aimed to examine if the relationship between lifetime history of TBI with loss of consciousness (LOC) and disability differs by location of living (Appalachian vs. non-Appalachian; rural vs. urban). METHODS: We obtained data on lifetime history of TBI with LOC, location of living, and six sources of disability (auditory, visual, cognitive, mobility, self-care related, and independent living-related impairments) from the 2016-2019 Ohio Behavioral Risk Factor Surveillance System. We modeled the disability outcomes with Appalachian living (or rural living), lifetime history of TBI with LOC, and their interaction as independent variables. RESULTS: Of the 16,941 respondents included, 16.9% had a lifetime history of TBI with LOC, 19.5% were Appalachian residents and 22.9% were rural residents. Among Appalachian residents, 56.1% lived in a rural area. Appalachian (ARR = 1.92; 95%CI = 1.71-2.13) and rural residents (ARR = 1.87; 95%CI = 1.69-2.06) who had a lifetime history of TBI with LOC were at greater risk for having any disability compared to non-Appalachian and urban residents without lifetime history of TBI with LOC, respectively. CONCLUSIONS: Appalachian and rural living and lifetime history of TBI with LOC are risk factors for disability. Future research and health policies should address mechanisms for this risk as well as access to healthcare services following a TBI among Appalachian and rural residents.

Rural-Urban Differences in Behavioral Outcomes among Adults with Lifetime History of Traumatic Brain Injury with Loss of Consciousness: 2016-2019 Ohio BRFSS.

This study examined if the associations between lifetime history of traumatic brain injury (TBI) with loss of consciousness (LOC) and unhealthy alcohol use or mental health problems differ by location of living (rural vs. urban). The lifetime history data of TBI with LOC, location of living, unhealthy alcohol use (binge drinking, heavy drinking), and mental health problems (depression diagnosis, number of poor mental health days) were sourced from the 2016, 2017, 2018, and 2019 Ohio Behavioral Risk Factory Surveillance Surveys, and the final sample included 16,941 respondents. We conducted multivariable logistic regressions to determine the odds ratios for each of the five outcomes between individuals living in rural vs. urban areas and between individuals with vs. without a lifetime history of TBI with LOC. No interaction between location of living and lifetime history of TBI with LOC was observed for any outcomes, indicating rurality did not modify these relationships. Living in a rural area was associated with decreased binge drinking or heavy drinking but not mental health outcomes. Lifetime history of TBI with LOC was associated with an increased risk of binge drinking, heavy drinking, depression diagnoses, and poor general mental health, regardless of location of living. Our findings support the need for TBI screenings as part of mental health intake evaluations and behavioral health screenings. Though rurality was not associated with mental health outcomes, rural areas may have limited access to quality mental health care. Therefore, future research should address access to mental health services following TBI among rural residents.

Balancing safety on the road with risk from COVID-19: A content analysis of policy adaptations by Divisions of Motor Vehicles.

PURPOSE: The COVID-19 pandemic significantly altered people's daily lives, including driving. However, how state Divisions of Motor Vehicles (DMV) adapted their operation policies in response to COVID-19 remains unknown. This study analyzed adaptations to the content of state DMV operation policies during the COVID-19 pandemic across 50 US states and assessed the relationships between these policy adoptions and their state-level COVID-19 restriction orders. METHODS: We merged data on policy adaptations due to COVID-19 obtained from DMV websites for all 50 states with data on state-level restrictions obtained from the National Academy for State Health Policy (NASHP). We created a codebook and analyzed the DMV policy adaptations in the following three areas: (1) road testing, (2) licensure extension and renewals, and (3) facility reopening. Two trained coders independently reviewed and coded the adaptations of policy content related to precaution to spread of COVID-19 and ease of obtaining licensure. We calculated summary scores for policy adaptations and ease of licensure and compared these scores across three categories of state-level COVID-19 restrictions using ANOVA. RESULTS: DMVs in all 50 states adapted their policies to slow the spread of COVID-19. The ease of licensure summary scores increased in some states but decreased in others. Extensions for licensure renewals was the most common change. Adoption of COVID-19 precautions during the road test was the most common road test adaptation, while road test waivers were the most controversial. Requiring appointments, social distancing, and/or face coverings/personal protective equipment [PPE] were common adaptations during facility reopening. However, variations in level of policy adaptations and ease of licensure were not associated with the state's COVID-19 restrictions. CONCLUSIONS: Our findings provide insight into policy adaptations made by state DMVs to reduce the spread of COVID-19 and may inform future policy adaptations in DMVs and other government agencies during public health emergencies.

Relationships between Physical and Mental Health in Adolescents from Low-Income, Rural Communities: Univariate and Multivariate Analyses.

Environment (i.e., rural vs. urban) and socioeconomic status (SES) are moderating factors of physical (i.e., obesity and/or physical activity) and internalizing mental health (i.e., stress, anxiety, and depressive symptoms) in adolescents. Relationships between physical and mental health have been shown in adolescents; however, research has not addressed these relationships in those from low-income, rural backgrounds. Thus, the present study characterized physical and mental health in rural, low-SES adolescents and investigated relationships between physical and mental health in this population. Data were collected from 253 10th and 11th-grade students from Title I schools in rural Alabama. Self-report measures of mental health, self-esteem, body image, and physical activity were obtained, in addition to functional fitness and physical health assessments completed at each school. Relationships between mental and physical health were assessed using Pearson correlations and multivariate data-driven cluster analysis. Positive correlations were observed between body composition and mental health symptoms, while negative correlations were observed between body image and mental health and body composition. However, sex differences were present in these relationships. The multivariate cluster analysis identified groups of individuals based on profiles of mental and physical health. This individual-level analysis identified students with greater mental and/or physical health burdens (n = 53 and n = 40) who may benefit from targeted interventions. Overall, these results provide evidence of elevated mental and physical health burdens among rural, low-income adolescents. Moreover, targeted programs are needed to provide education about the relationship between physical and mental health to reduce health burdens in both domains in this population.

Effects of music tempo on perceived exertion, attention, affect, heart rate, and performance during isometric strength exercise.

This study examined the effects of slow and fast music tempi on effort-related thoughts, rating of perceived exertion (RPE), affect, heart rate, and performance during isometric strength exercises. Participants were randomly assigned to one of three conditions (no-music control, fast-tempo music, and slow-tempo music) and performed two isometric strength exercises (wall-sit and plank). RPE, attention allocation, and affect were measured during each exercise task. Participants in both the fast- and slow-tempo music conditions maintained a dissociative state for longer than those in the no-music control condition during the wall-sit exercise; however, this effect did not manifest during the plank exercise. Neither music condition influenced HR, RPE, time to volitional exhaustion, or affect. Within the first few minutes of exercise, participants exhibited an increase in HR and perceived exertion, as well as a corresponding shift towards associative attention and a high arousal state. The results are discussed with reference to potential underlying mechanisms and current theories pertaining to RPE, attention allocation, and affect.

Motivational Interviewing for Weight Management Among Women: a Meta-Analysis and Systematic Review of RCTs.

BACKGROUND: Motivational interviewing (MI) is a communication skill set used by clinicians to help facilitate adherence to numerous health behaviors. Currently, MI's evidence supports its use among adults in various realms; however, clarity is needed regarding weight management among females. The purpose of this systematic review and meta-analysis is to synthesize the literature examining the use of MI and its impact on anthropometric measures among adult females. METHOD: The authors conducted a modified Cochrane method of systematic search and review in several relevant databases to explore and report evidence and gaps in the literature for MI in weight management among females in addition to meta-analyses for weight and BMI. Criteria for retention included randomized controlled trials with open inclusion of studies with varied settings, methods, interventionists, target behaviors, and outcomes. RESULTS: Of the 3289 references initially identified, 10 intervention arms met the criteria across review tiers. Seven of 10 intervention groups reported significant anthropometric changes compared with a control group, as well as significant changes in non-anthropometric outcomes related to weight management. Using a random-effects model, the effect size of MI on reduction in body weight (kg) was 0.19 (95% CI - 0.13, 0.26; p < 0.01), and the effect size of MI on reduction in BMI was 0.35 (95% CI 0.12, 0.58; p < 0.01). CONCLUSIONS: Results suggest that MI interventions are useful for weight management among females. Future studies would enhance the current base of literature by utilizing advanced anthropometric outcomes, including sex-specific results, and including more diverse and larger sample sizes.

P3b as an electroencephalographic index of automatic associations of exercise-related images.

OBJECTIVE: Interest in automatic associations of exercise and physical activity as potential contributors to behavior is rising. However, the measurement of these associations presents a challenge, since the reliability and validity of behavioral tests (despite their widespread usage) is unsatisfactory by most accounts. As a possible alternative, an electroencephalographic (EEG) index (i.e., P3b amplitude) was examined in the present study. DESIGN: We used a mixed-factor design, with one group of insufficiently and one group of sufficiently physically active participants being compared across different experimental conditions. METHODS: Thirty-seven insufficiently and thirty-six sufficiently active participants viewed exercise-related images presented within series of negative, neutral, or positive images and rated all images as negative (unpleasant) or positive (pleasant) while EEG recordings were obtained. The amplitude of the P3b component of the EEG-derived event-related potential, time-locked to the onset of exercise images in each context (series), was extracted as the dependent variable. RESULTS: Insufficiently active participants rated the exercise-related images as neutral-to-positive, whereas sufficiently active participants rated the images as positive. However, all participants exhibited the smallest P3b amplitude when the images were presented in the neutral context, suggesting that the images were registering as neutral. CONCLUSION: Exercise-related images may evoke neutral automatic associations, but these associations may differ from how individuals reflectively rate the same images. P3b amplitude may be useful in detecting such discrepancies and potentially a promising (evidence-based) option for assessing automatic associations of exercise stimuli.

A Systematic Review of the Effectiveness of Concussion Education Programs for Coaches and Parents of Youth Athletes.

Coach and parent concussion education programs are essential for the prevention, diagnosis, management, and return to play of youth athletes. This systematic review examined the content and efficacy (changes in knowledge, impact on concussion incidence) of concussion education programs for coaches and parents of youth and high school athletes. Six databases were searched: SPORTDiscus, Academic Search Premiere, CINAHL, PsycINFO, PubMed, and Google Scholar. Studies evaluated the use and/or efficacy of concussion education programs among coaches or parents of youth athletes. A total of 13 articles (out of 1553 articles) met selection criteria. Although different concussion education programs exist, only three have been evaluated in the literature: ACTive Athletic Concussion Training™, USA Football's Heads Up Football, and the Center for Disease Control and Prevention's HEADS UP. These programs are well liked among coaches and parents and the suggested practices are easily implemented by coaches. These programs increased concussion knowledge among coaches and parents and promoted behavioral changes among coaches to reduce the concussion risk in high school sports. Few studies have assessed the efficacy of concussion education programs on youth athlete health outcomes. No studies included a longitudinal follow up to determine the degree of knowledge retention following the intervention. While online educational programs are sufficient to improve coach knowledge, in-person training may be a more effective educational tool for reducing the incidence of youth sport concussion. Future studies addressing the efficacy of concussion education programs should include a longitudinal follow up to assess knowledge retention and fidelity.

A Systematic Review and Meta-Analysis of School-Based Stress, Anxiety, and Depression Prevention Programs for Adolescents.

Given the recent rise in adolescent mental health issues, many researchers have turned to school-based mental health programs as a way to reduce stress, anxiety, and depressive symptoms among large groups of adolescents. The purpose of the current systematic review and meta-analysis is to identify and evaluate the efficacy of school-based programming aimed at reducing internalizing mental health problems of adolescents. A total of 42 articles, including a total of 7310 adolescents, ages 11-18, met inclusion for the meta-analyses. Meta-analyses were completed for each of the three mental health outcomes (stress, depression, and anxiety) and meta-regression was used to determine the influence of type of program, program dose, sex, race, and age on program effectiveness. Overall, stress interventions did not reduce stress symptoms, although targeted interventions showed greater reductions in stress than universal programs. Overall, anxiety interventions significantly reduced anxiety symptoms, however higher doses may be necessary for universal programs. Lastly, depression interventions significantly reduced depressive symptoms, but this reduction was moderated by a combination of program type, dose, race, and age group. Although, school-based programs aimed at decreasing anxiety and depression were effective, these effects are not long-lasting. Interventions aimed at reducing stress were not effective, however very few programs targeted or included stress as an outcome variable. Implications for practice, policy and research are discussed.

A systematic review of acute concussion assessment selection in research.

Background: Several organisations developed guidelines and assessments for aiding in the diagnosis of concussions. The growing number of concussion assessments increases the difficulty for researchers and clinicians to determine the best method of concussion diagnosis. Purpose: To systematically review the current assessments selected for acute sports-related concussion. Methods: Academic Search Premier, CINHAL, MEDLINE, PsycINFO and SPORTDiscus were searched. English-language, peer-review published studies of acute (<72 h) concussion assessments were included. Results: A total of 31 studies met inclusion criteria (of 291 evaluated); 27 studies provided sufficient information to be included in the descriptive statistics of the assessments. Six of these assessments were used in at least three studies. Only 12 percent of the population studied was female. The age range for these assessments was 9-67 years, although most participants ranged in age between 18 and 35 years. Conclusion: There is a need for a 'gold' standard concussion assessment to enable consistency across research and clinical outcomes. We found a large discrepancy between the number of males and females assessed, suggesting that future studies are needed to determine if these current assessments identify concussion signs and symptoms unique to females. Further studies are needed to determine which assessments are appropriate and valid for youth athletes.

Opportunities to sit and stand trigger equivalent reward-related brain activity.

A recent theory contends that behaviors minimizing energetic cost are rewarding (Cheval et al., 2018). However, direct experimental evidence supporting this theory is lacking. To fill this knowledge gap, we investigated the effect of energy expenditure on reward-related brain activity in a pre-registered study. This preregistered study included thirty-one participants who were equipped with an electroencephalography (EEG) cap and performed a monetary incentive delay task. After attempting to quickly respond to a target, participants were given feedback instructing them to retrieve a token (reward condition) or to wait (no reward condition). In half of the rewarding trials, participants stood up to retrieve a token, thereby increasing energy expenditure. In the other half, participants just had to extend their arm to retrieve a token, thereby minimizing energy expenditure. The contingent negative variation event-related potential (ERP) component preceding the motor response was used as an indicator of reward pursuit. The reward positivity ERP component time-locked to feedback onset was used to determine reward valuation. Results showed that response time, contingent negative variation, and the reward positivity were not influenced by energy expenditure (remaining seated vs. standing up). This null effect of conditions was confirmed using equivalence tests. These results do not support the theory of energetic cost minimization but the equivalent effect of sitting and standing on reward-related brain activity is new knowledge that could contribute to shed light on the neural processes underlying the pandemic of physical inactivity.