Characteristics of Pediatric Concussion across Different Mechanisms of Injury in 5 through 12-Year-Olds.

OBJECTIVE: To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and nonsport or recreation-related concussion (non-SRRC) in patients 5 through 12 years old, an understudied population in youth concussion. STUDY DESIGN: This observational study included patients aged 5 through 12 years presenting to a specialty care concussion setting at ≤28 days postinjury from 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Posthoc pairwise comparisons were employed for all analyses (α = 0.017). RESULTS: One thousand one hundred forty-one patients reported at ≤28 days of injury (female = 42.9%, median age = 11, interquartile range (IQR) = 9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (P < .001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 2 and 3 days later than SRC (P < .001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (P < .001) compared with RRC and SRC (P < .001). CONCLUSIONS: In concussion patients 5 through 12 years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury.

Migraine epidemiology in collegiate student-athletes: Findings from the Concussion Assessment, Research, and Education (CARE) Consortium.

OBJECTIVE: This cross-sectional study evaluated de-identified data from the National Collegiate Athletic Association-Department of Defense Grand Alliance from 2014 to 2020 to determine the prevalence of migraine and migraine medication and to describe differences in migraine prevalence by sex, race, and sport. BACKGROUND: Epidemiological studies can help identify underdiagnosed and undertreated populations. Understanding migraine prevalence in collegiate student-athletes is essential for positive healthcare outcomes including development of prevention and treatment plans. METHODS: From a concussion baseline assessment, participant's self-reported demographics (e.g., age, sex, sport), migraine diagnosis (i.e., yes/no), and migraine medication usage (e.g., yes/no, type) determined prevalence of migraine and medication use in collegiate student-athletes. RESULTS: Migraine was reported in 5.6% (2617/47,060; 95% confidence interval [CI] 5.4%-5.8%) of the student-athletes, with higher prevalence in females, 7.5% (1319/17,628; 95% CI 7.1%-7.9%), than males, 4.6% (1298/28,116; 95% CI 4.4%-4.9%). Medication usage was reported by 36.2% (947/2617; 95% CI 34.3%-38.0%) of individuals with migraine. Migraine reporting differed by race, with Caucasian reporting highest (5.9%; 1990/33,913; 95% CI 5.6%-6.1%) and Asian the lowest (2.7%; 55/2027; 95% CI 2.1%-3.5%). Women's sports, including golf, gymnastics, and lacrosse, and men's diving and squash had higher migraine reporting than other sports. CONCLUSION: Caucasian females reported higher rates than other groups and sport influenced rates of migraine diagnosis.

Mild traumatic brain injury caused by workplace violence in a US workers' compensation system.

OBJECTIVES: Approximately 81% of traumatic brain injury cases are considered to be mild (mTBI), but few studies have reviewed mTBI caused by workplace violence (WPV). This study aimed to (1) determine the incidence of mTBI secondary to WPV in a statewide workers' compensation system using International Classification of Disease codes and (2) analyse and compare factors associated with return-to-work outcomes between WPV mTBI cases versus other mechanisms. METHODS: Using a retrospective cohort of claims data from the California Workers' Compensation Information System during 2015-2019, cases with a return-to-work date were classified as WPV if the injury description contained keywords such as assault, gunpoint, harassed, intimidated, punch, threat, robbery, violent or verbal abuse. RESULTS: Of the 14 089 mTBI claims analysed in this study, 11.2% were caused by WPV. When comparing WPV to non-WPV claims, the variables with statistically significant (p≤0.001) differences were age, income, industry and job class. There were no significant differences between groups for leave duration. In a linear mixed model, the variable of interest (WPV) was not associated with recovery duration after adjusting for other factors. CONCLUSION: To our knowledge, this is the first study to examine WPV mTBI claims in the USA. The findings suggest that the public administration, education and healthcare and social services industries are at higher risk for WPV mTBI. WPV and job class were the only modifiable factors in the model and therefore should be the focus of additional research.

Career duration and later-life health conditions among former professional American-style football players.

OBJECTIVES: Career duration is often used as a metric of neurotrauma exposure in studies of elite athletes. However, as a proxy metric, career length may not accurately represent causal factors, and associations with health outcomes may be susceptible to selection effects. To date, relationships between professional American-style football (ASF) career length and postcareer health remain incompletely characterised. METHODS: We conducted a survey-based cross-sectional cohort study of former professional ASF players. Flexible regression methods measured associations between self-reported career duration and four self-reported health conditions: pain, arthritis, mood and cognitive symptoms. We also measured associations between career duration and four self-reported ASF exposures: prior concussion signs and symptoms (CSS), performance enhancing drugs, intracareer surgeries and average snaps per game. Models were adjusted for age and race. RESULTS: Among 4189 former players (52±14 years of age, 39% black, 34% lineman position), the average career length was 6.7±3.9 professional seasons (range=1-20+). We observed inverted U-shaped relationships between career duration and outcomes (all p<0.001), indicating that adverse health effects were more common among men with intermediate career durations than those with shorter or longer careers. Similar findings were observed for play-related exposures (eg, CSS and snaps). CONCLUSIONS: Relationships between ASF career duration and subsequent health status are non-linear. Attenuation of the associations among longer career players may reflect selection effects and suggest career length may serve as a poor proxy for true causal factors. Findings highlight the need for cautious use of career duration as a proxy exposure metric in studies of former athletes.

Categorizing Sports-Related Concussion Disparities by Key Domains of Social Determinants of Health.

PURPOSE OF REVIEW: To explore recently published data on disparities in concussion and best categorize these data into domains of social determinants of health (SDOH). RECENT FINDINGS: Disparities in concussion cover a range of SDOH domains. Questions on disparities in concussion remain. Interventions to reduce these disparities and inequities are needed. Social determinants of health may play a significant role in disparities and inequities in sports related concussion. There is interplay and overlap in SDOH domains that affect concussion outcomes. It is possible that an increase in SDOH may affect concussion disparities by moderated mediation; however, further data is needed to validate this potential effect. Moreover, attention to SDOH domains in sports related concussion may provide insight on intervention targets to ameliorate disparities in sports related concussion.

Clinical Trajectories of Comorbidity Associated With Military-Sustained Mild Traumatic Brain Injury: Pre- and Post-Injury.

BACKGROUND AND OBJECTIVE: In the US military, traumatic brain injury (TBI) is of distinct importance, at home and in the deployed setting, and is considered a "signature injury of the wars in Afghanistan and Iraq." Since 2000, an estimated 468 424 service members (SMs) have been diagnosed with at least one TBI. We examined the clinical trajectories of a group of 18 comorbidities before and after a military-sustained mild TBI (mTBI). METHODS: Without making assumptions on causality, a group of 18 conditions often co-occurring with mTBI were identified through literature review and TBI subject matter workgroup consensus. Using data from Military Health System Data Repository, we identified SMs whose first lifetime military mTBI occurred between October 1, 2016, and October 30, 2019. Correlation analyses were used to determine the linear relationship between comorbidities prior to and after mTBI diagnosis. Changes in the period prevalence of comorbidities was calculated. RESULTS: We identified 42 018 SMs with a first lifetime military mTBI, of which 77.6% had at least one comorbidity. Identified SMs were mostly young (46.1% ages 18-24 years), male (81.4%), and White (64.1%). Up to 180 days prior to an mTBI, the most frequently identified conditions were sleep-related conditions (21.7%), headaches (19.4%), posttraumatic stress disorders (PTSDs) (17.8%), anxiety disorders (11.3%), and cervicogenic disorders (eg, cervicalgia) (10.9%). In the period following mTBI diagnosis, the prevalence of diagnosed conditions increased, especially for visual disturbances (327.2%), cognitive conditions (313.9%), vestibular conditions (192.6%), those related to headache (152.2%), and hearing (72.9%). Sleep-related conditions showed moderate positive correlation with a group of co-occurring conditions, led by cognitive conditions ( ϕc = 0.50), anxiety disorders ( ϕc = 0.42), PTSDs ( ϕc =0.43), and headaches and related conditions ( ϕc = 0.38). CONCLUSION: Results indicate that caring for SMs with mild TBI requires a holistic approach, one that considers the complex nature of SM conditions, prior to sustaining their mTBI, as well as after injury. We found a complex correlation of conditions that suggest SMs with mTBI are undergoing a multifaceted experience, one that may require the development of a targeted multidimensional clinical practice recommendation and practice.

Rationale for the Development of a Traumatic Brain Injury Case Definition for the Pilot National Concussion Surveillance System.

BACKGROUND: Current methods of traumatic brain injury (TBI) morbidity surveillance in the United States have primarily relied on hospital-based data sets. However, these methods undercount TBIs as they do not include TBIs seen in outpatient settings and those that are untreated and undiagnosed. A 2014 National Academy of Science Engineering and Medicine report recommended that the Centers for Disease Control and Prevention (CDC) establish and manage a national surveillance system to better describe the burden of sports- and recreation-related TBI, including concussion, among youth. Given the limitations of TBI surveillance in general, CDC took this recommendation as a call to action to formulate and implement a robust pilot National Concussion Surveillance System that could estimate the public health burden of concussion and TBI among Americans from all causes of brain injury. Because of the constraints of identifying TBI in clinical settings, an alternative surveillance approach is to collect TBI data via a self-report survey. Before such a survey was piloted, it was necessary for CDC to develop a case definition for self-reported TBI. OBJECTIVE: This article outlines the rationale and process the CDC used to develop a tiered case definition for self-reported TBI to be used for surveillance purposes. CONCLUSION: A tiered TBI case definition is proposed with tiers based on the type of sign/symptom(s) reported the number of symptoms reported, and the timing of symptom onset.

Association of mild traumatic brain injury, post-traumatic stress disorder, and other comorbidities on photosensitivity.

SIGNIFICANCE: Photosensitivity is common after mild traumatic brain injury. However, this study demonstrates that photosensitivity is also impacted by common comorbidities that often occur with mild traumatic brain injury. Understanding how physical and psychological traumas impact photosensitivity can help improve provider care to trauma survivors and guide novel therapeutic interventions. PURPOSE: This study aimed to characterize the association between mild traumatic brain injury and common comorbidities on photosensitivity in post-9/11 veterans. METHODS: Existing data from the Translational Research Center for TBI and Stress Disorders cohort study were analyzed including traumatic brain injury history and post-traumatic stress disorder clinical diagnostic interviews; sleep quality, anxiety, and depression symptoms self-report questionnaires; and photosensitivity severity self-report from the Neurobehavioral Symptom Inventory. Analysis of covariance and multiple ordinal regression models were used to assess associations between mild traumatic brain injury and common comorbidities with photosensitivity severity. RESULTS: Six hundred forty-one post-9/11 veterans were included in this study. An initial analysis showed that both mild traumatic brain injury and current post-traumatic stress disorder diagnosis were independently associated with higher photosensitivity ratings compared with veterans without either condition, with no interaction observed between these two conditions. Results of the ordinal regression models demonstrated positive associations between degree of photosensitivity and the number of mild traumatic brain injuries during military service and current post-traumatic stress disorder symptom severity, particularly hyperarousal symptoms, even when controlling for other factors. In addition, the degree of sleep disturbances and current anxiety symptoms were both positively associated with photosensitivity ratings, whereas depression symptoms, age, and sex were not. CONCLUSIONS: Repetitive mild traumatic brain injury, post-traumatic stress disorder, anxiety, and sleep disturbances were all found to significantly impact photosensitivity severity and are therefore important clinical factors that eye care providers should consider when managing veterans with a history of deployment-related trauma reporting photosensitivity symptoms.

A systematic review of pre-injury anxiety disorder and post-concussion outcomes in youth and young adult athletes.

Pre-injury anxiety disorder may be a risk factor for poor outcomes following sportsrelated concussion. A systematic review was performed to characterize the relationship between pre-injury anxiety disorder and post-concussion symptom presentation and recovery time after sports-related concussions among children, adolescents, and young adults. A PRISMA-compliant literature search was conducted in Ovid MEDLINE, PsycINFO, EMBASE, and Scopus for articles published up to 25 January 2024. The initial query yielded 1358 unique articles. Articles that analyzed the relationship between pre-injury anxiety disorder and post-concussion symptoms and recovery time were included. A final cohort of 11 articles was extracted, comprising a total of 8390 study participants, of whom 921 had a history of pre-injury anxiety disorder. Pre-injury anxiety disorder was associated with prolonged time to return to sports activity and an increased incidence of physical, emotional, cognitive, and sleep-related symptoms. While the results of this review suggest an association between pre-injury anxiety disorder and post-concussion symptoms and recovery time, future studies should be more stringent regarding standardized anxiety disorder definitions, longitudinal assessment of post-concussion symptoms, anxiety disorder subtypes, and anxiety treatment history.

Sport-related concussions in baseball and softball: do mechanisms of injury affect recovery?

OBJECTIVE: Baseball and softball pose unique risks for sport-related concussion (SRC). Although these are not collision sports, concussions in baseball and softball can nonetheless involve high-speed impacts. In a regional, single-institution cohort of baseball and softball athletes who sustained an SRC, the current study sought to 1) describe the mechanisms of injury that led to SRC, and 2) compare initial symptom burden and recovery metrics across mechanisms, including time to return to learn (RTL), time to symptom resolution, and time to return to play (RTP) by mechanism of injury. METHODS: A retrospective cohort study was performed of baseball and softball athletes 12 to 23 years old who sustained an SRC between November 2017 and April 2022. Mechanisms of injury were divided into two categories: 1) contact mechanism (i.e., what initiated contact with the injured player, such as head-to-ball), and 2) player mechanism (i.e., the action the injured player was performing at the time of injury, such as fielding). The recovery outcomes of time to RTL, symptom resolution, and RTP were compared between mechanisms using bivariate analysis and multivariable regression analysis, controlling for sex, age, time to present to concussion clinic, and initial total symptom score. RESULTS: The sample included 58 baseball and softball players (60.3% female, mean age 16.0 ± 1.9 years). Most SRCs (62.1%) occurred during competition. Head-to-ball (50.0%) was the most common contact mechanism, followed by head-to-head/body (31.0%) and head-to-wall/ground/equipment (17.2%). Fielding (63.8%) was the most common player mechanism, followed by drills (20.7%) and running (13.8%). SRCs sustained in practice had significantly longer RTL (median 10.0 [interquartile range (IQR) 3.3-16.3] vs 4.0 [IQR 2.0-8.0] days; U = 421.5, p = 0.031) and symptom resolution (37.0 [IQR 18.0-90.0] vs 14.0 [IQR 7.0-41.0] days; U = 406.5, p = 0.025) compared with SRCs sustained in competition. Multivariable regression analysis revealed that head-to-wall/ground/equipment contact mechanism was associated with longer RTL (ß = 0.30, 95% CI 0.07-0.54, p = 0.013). CONCLUSIONS: The current study found that SRCs in baseball and softball occurred more often in competition than in practice. Head-to-ball and fielding were the most common contact and player mechanisms, respectively. SRCs sustained in practice were associated with longer time to RTL and symptom resolution, and head-to-wall/ground/equipment was associated with longer RTL in multivariable regression analysis. These results provide empirical data to improve concussion safety in baseball/softball.

Concussions in ice hockey: mixed methods study including assessment of concussions on games missed and cap hit among National Hockey League players, systematic review, and concussion protocol analysis.

OBJECTIVE: Concussions can occur at any level of ice hockey. Incidence estimates of concussions in ice hockey vary, and optimal prevention strategies and return-to-play (RTP) considerations have remained in evolution. The authors performed a mixed-methods study with the aim of elucidating the landscape of concussion in ice hockey and catalyzing initiatives to standardize preventative mechanisms and RTP considerations. METHODS: The authors performed a five-part mixed-methods study that includes: 1) an analysis of the impact of concussions on games missed and income for National Hockey League (NHL) players using a publicly available database, 2) a systematic review of the incidence of concussion in ice hockey, 3) a systematic review of preventative strategies, 4) a systematic review of RTP, and 5) a policy review of documents from major governing bodies related to concussions in sports with a focus on ice hockey. The PubMed, Embase, and Scopus databases were used for the systematic reviews and focused on any level of hockey. RESULTS: In the NHL, 689 players had 1054 concussions from the 2000-2001 to 2022-2023 seasons. A concussion led to a mean of 13.77 ± 19.23 (range 1-82) games missed during the same season. After cap hit per game data became available in 2008-2009, players missed 10,024 games due to 668 concussions (mean 15.13 ± 3.81 per concussion, range 8.81-22.60 per concussion), with a cap hit per game missed of $35,880.85 ± $25,010.48 (range $5792.68-$134,146.30). The total cap hit of all missed games was $385,960,790.00, equating to $577,635.91 per concussion and $25,724,052.70 per NHL season. On systematic review, the incidence of concussions was 0.54-1.18 per 1000 athlete-exposures. Prevention mechanisms involved education, behavioral and cognitive interventions, protective equipment, biomechanical studies, and policy/rule changes. Rules prohibiting body checking in youth players were most effective. Determination of RTP was variable. Concussion protocols from both North American governing bodies and two leagues mandated that a player suspected of having a concussion be removed from play and undergo a six-step RTP strategy. The 6th International Conference on Concussion in Sport recommended the use of mouthguards for children and adolescents and disallowing body checking for all children and most levels of adolescents. CONCLUSIONS: Concussions in ice hockey lead to substantial missed time from play. The authors strongly encourage all hockey leagues to adopt and adhere to age-appropriate rules to limit hits to the head, increase compliance in wearing protective equipment, and utilize high-quality concussion protocols.

Examining for gender differences in return to learn following sport-related concussion in high school student athletes.

OBJECTIVE: Prior studies have investigated associations between gender, symptom resolution, and time to return to play following sport-related concussion (SRC). However, there is a notable gap in research regarding the association between gender and return to learn (RTL) in adolescents. Therefore, this study 1) compared the patterns of RTL between boys and girls who are high school student athletes, and 2) evaluated the possible association between gender and time to RTL after adjusting for covariates. METHODS: A retrospective cohort study of a prospective surveillance program that monitored concussion recovery of athletes in high schools throughout the state of Maine between February 2015 and January 2023 was performed. The primary independent variable was gender, dichotomized as boys and girls. The primary outcome was time to RTL, defined by the number of days for an athlete to return to school without accommodations. Mann-Whitney U-tests were used to compare RTL between the boys and girls. Each athlete's RTL status was dichotomized (i.e., returned vs had not returned) at several time points following injury (i.e., 1, 2, 3, and 4 weeks), and chi-square tests were performed to compare the proportions who achieved RTL between groups. Multivariable linear regression analyses were performed to evaluate the predictive value of gender on RTL. Covariates included age, number of previous concussions, history of learning disability or attention-deficit disorder or attention-deficit/hyperactivity disorder, history of a psychological condition, history of headaches or migraines, initial Sport Concussion Assessment Tool (SCAT3/SCAT5) score, and days to evaluation. RESULTS: Of 895 high school athletes, 488 (54.5%) were boys and 407 (45.5%) were girls. There was no statistically significant difference in median [IQR] days to RTL between genders (6.0 [3.0-11.0] vs 6.0 [3.0-12.0] days; U = 84,365.00, p < 0.375). A greater proportion of boys successfully returned to learn without accommodations by 3 weeks following concussion (93.5% vs 89.4%; χ2 = 4.68, p = 0.030), but no differences were found at 1, 2, or 4 weeks. A multivariable model predicting days to RTL showed that gender was not a significant predictor of RTL (p > 0.05). Longer days to evaluation (ß = 0.10, p = 0.021) and higher initial SCAT3/SCAT5 scores (ß = 0.15, p < 0.001) predicted longer RTL. CONCLUSIONS: In a cohort of high school athletes, RTL did not differ between boys and girls following SRC. Gender was not a significant predictor of RTL. Longer days to evaluation and higher initial symptom scores were associated with longer RTL.

Pediatric sport and nonsport concussions presenting to emergency departments: injury circumstances, characteristics, and clinical management.

OBJECTIVE: The aim of this study was to compare injury circumstances, characteristics, and clinical management of emergency department (ED) presentations for sports-related concussion (SRC) and non-SRC. METHODS: This multicenter prospective observational study identified patients 5-17 years old who presented to EDs within 24 hours of head injury, with one or more signs or symptoms of concussion. Participants had a Glasgow Coma Scale score of 13-15 and no abnormalities on CT (if performed). Data were stratified by age: young children (5-8 years), older children (9-12 years), and adolescents (13-17 years). RESULTS: Of 4709 patients meeting the concussion criteria, non-SRC accounted for 56.3% of overall concussions, including 80.9% of younger child, 51.1% of older child, and 37.0% of adolescent concussions. The most common mechanism of non-SRC was falls for all ages. The most common activity accounting for SRC was bike riding for younger children, and rugby for older children and adolescents. Concussions occurring in sports areas, home, and educational settings accounted for 26.2%, 21.8%, and 19.0% of overall concussions. Concussions occurring in a sports area increased with age, while occurrences in home and educational settings decreased with age. The presence of amnesia significantly differed for SRC and non-SRC for all age groups, while vomiting and disorientation differed for older children and adolescents. Adolescents with non-SRC were admitted to a ward and underwent CT at higher proportions than those with SRC. CONCLUSIONS: Non-SRC more commonly presented to EDs overall, with SRC more common with increasing age. These data provide important information to inform public health policies, guidelines, and prevention efforts.

Elucidating differences in concussion subtype symptomatology in sports-related versus non-sports-related concussions: a retrospective cohort study.

OBJECTIVE: Postconcussive symptom questionnaires (PCSQs) are often used in concussion patient assessment, yet there is a lack of knowledge as to whether symptom subtype prevalence is dependent on the mechanism of injury (MOI). These subtypes can be defined as cognitive, atlanto-occipital/cervical spine, autonomic, balance, low energy/fatigue/sleep, emotional changes, eyes, and somatic. Using an institutional PCSQ that quantitatively addressed these subtypes, this retrospective study aimed to provide insight into differences in subtype symptomatology between sports-related (SR) and non-sports-related (NSR) injuries. METHODS: Consecutive concussion patients with Glasgow Coma Scale (GCS) score ≥ 13 and ≥ 16 years of age who were treated at a concussion clinic affiliated with an academic level I trauma center in the United States between December 2009 and January 2020 were eligible for inclusion. The authors extracted data on MOI, comorbidities, habits, prior injuries, and PCSQ results. Multivariate analysis of covariance was then conducted to determine the correlations between subtype scores and MOI while considering covariates. RESULTS: Of the 194 patients remaining after applying inclusion and exclusion criteria, analysis included 91 patients in the SR group consisting of 54 (59%) males with mean ± SD (range) age of 20.9 ± 7.3 (16-58) years and 103 patients in the NSR group consisting of 38 (37%) males with mean age of 39.2 ± 14.8 (17-71) years. Demographic characteristics differed significantly between groups. Estimated marginal mean scores were significantly lower in the SR injury group compared to the NSR injury group (with comparing main effects) for the cognitive (p < 0.001), autonomic (p < 0.000), balance (p < 0.025), energy (p < 0.006), emotional (p < 0.000), and total score (p < 0.001) subtypes. Multivariate tests identified three comorbidities that contributed to differences in subtype scores between groups: migraines (p < 0.012), vertigo (p < 0.004), and anxiety (p < 0.038). No significant results were found for the remaining comorbidities of (but not limited to) depression, neuropsychiatric disorders, seizures, syncope, sleep disorder, or none. CONCLUSIONS: The findings indicate that patients who sustain a concussion via an NSR injury present with more severe symptoms but similar concussion subtype frequency as those presenting with SR concussion. This suggests that the MOI may correlate more closely to symptom severity than concussion subtype composition, although larger patient populations with more definitive control of MOI are needed to further elucidate these claims.

Motor vehicle collision characteristics and hospitalization outcomes associated with mild traumatic brain injury and concomitant whiplash injury.

OBJECTIVE: Few large studies have investigated the factors and outcomes related to concomitant injuries occurring alongside mild traumatic brain injury (mTBI) after motor vehicle collisions (MVCs). Thus, the objective of this study was to assess whether MVC characteristics predict which patients with mTBI will have concomitant whiplash injury, and whether concomitant whiplash injury affects care utilization for these patients. METHODS: This retrospective cohort study included 22,213 patients with mTBI after MVC identified from the American College of Surgeons Trauma Quality Programs dataset. A hierarchical logistic regression model was constructed to investigate patient and MVC factors associated with concomitant whiplash injury. Propensity score matching on whiplash status, in conjunction with a multivariable logistic regression model, assessed if concomitant whiplash affected odds of hospitalization. In the subgroup of patients who were hospitalized, associations with hospital length of stay (LOS) and discharge disposition were investigated. RESULTS: The median (IQR) age was 34 (24-51) years, with a median Glasgow Coma Scale score at presentation of 15 (15-15). Patients with concomitant whiplash were older (median 36 years vs 34 years, p = 0.03) and had higher rates of hospitalization (75% vs 64%, p < 0.001). In the hierarchical model for associations with concomitant whiplash injury, patients with blood alcohol content (BAC) greater than the federal driving limit had lower odds of concomitant whiplash (OR 0.63, 95% CI 0.49-0.81) along with those who had airbag deployment (OR 0.80, 95% CI 0.68-0.95), but seatbelt use was associated with greater odds (OR 1.41, 95% CI 1.16-1.71). After matching, concomitant whiplash was independently associated with increased odds of hospitalization (OR 1.67, 95% CI 1.40-1.99) while seatbelt use was associated with decreased odds (OR 0.88, 95% CI 0.81-0.95). Among hospitalized patients, concomitant whiplash was not associated with hospital LOS or discharge disposition. CONCLUSIONS: MVC characteristics such as alcohol consumption and airbag deployment were protective toward development of concomitant whiplash for mTBI patients, while seatbelt use was associated with higher risk. Concomitant whiplash increases the odds of hospitalization for mTBI patients but does not affect hospital LOS or discharge disposition, while seatbelt use is associated with lower rates of hospitalization and a more favorable hospital course. These findings provide context to injury patterns and care provision after a common mechanism of injury.

SCAT5 baseline values, test-retest reliability, and reliable change metrics in high school athletes.

OBJECTIVE: In the United States, more than 1 million sport-related concussions afflict children annually, with many cases undetected or unreported. The Sport Concussion Assessment Tool (SCAT) is widely used to detect concussions in high school, collegiate, and professional sports. The objective of this study was to establish baseline values for the SCAT version 5 (SCAT5) in high school athletes. METHODS: Baseline SCAT5 evaluations were conducted in students (ages 14-19 years) from 19 high schools in central Illinois who were participating in various school-sponsored sports. The SCAT5 evaluations were retrospectively extracted from the electronic medical record system for analysis. Statistical analyses included the Wilcoxon rank-sum test for continuous variables and the chi-square test for categorical variables, considering significance at p < 0.05. Test-retest reliability at < 6 months, 10-14 months, and 16-20 months was computed using intraclass correlation and Spearman's rho (ρ). Reliable change indices are provided using the Iverson formula. RESULTS: A total of 2833 unique athletes were included, and the average age was 15.5 ± 1.14 (SD) years. There were 721 female (25.5%) and 2112 male (74.5%) athletes. Students ≥ 15 years old had more prior concussions (p < 0.001), and male athletes were more frequently hospitalized for head injury (p = 0.013). Female athletes exhibited a significantly higher prevalence of mood disorders (14.7% vs 4.6%, p < 0.001), whereas attention-deficit/hyperactivity disorder was more common in male athletes (5.2% vs 13.2%, p < 0.001). Symptom number and severity were significantly greater in female athletes (3.17 ± 4.39 vs 2.08 ± 3.49, p < 0.001; 5.47 ± 9.21 vs 3.52 ± 7.26, p < 0.001, respectively), with mood-related symptoms representing the largest differences. Female athletes and students ≥ 15 years old performed better on most cognitive assessments. Female athletes and students < 15 years old performed better on the modified Balance Error Scoring System (p < 0.001). Test-retest reliability was poor to moderate for most assessment components. Reliable change index cutoff values differed slightly by sex, with female athletes often having a greater cutoff value. CONCLUSIONS: This study underscores the variability of SCAT5 baseline values influenced by age, sex, and medical history among adolescent athletes. It provides a robust dataset, delineating baseline values stratified by sex and age within this demographic. Additionally, the results provide enhanced guidance to clinicians for interpretation of change and reliability of baselines.

Avenues for prevention using the epidemiology of sport-related concussion from a large high school surveillance study.

OBJECTIVE: Epidemiology provides fundamental opportunities to protect student-athlete health. The goal of this study was to describe the epidemiology of sport-related concussion (SRC) across 8 years (2015/2016-2022/2023) and compare boys' and girls' sports for SRC incidence and SRC mechanisms. METHODS: This was a retrospective cohort study performed using a statewide high school head injury surveillance system of high school student-athletes (n = 2,182,128; boys, n = 1,267,389; girls, n = 914,739). Exposures of interest included study year and boys and girls in comparable sports. Clinical incidence was calculated by dividing SRC counts in each sport by the number of participants per 100 player-seasons and presented with 95% CIs. The 2019/2020 and 2020/2021 data were included in the analysis, however caution is warranted due to the COVID-19 pandemic. Clinical incidence ratios (CIRs) were estimated for sex-comparable sports, and significance was determined if 95% CIs excluded 1.00. The authors compared mechanism of injury in boys' and girls' comparable sports with chi-square analyses (p < 0.05). RESULTS: Among 25,482 total SRCs, the overall clinical incidence of SRC for all boys and girls was 1.17 (95% CI 1.15-1.18) per 100 player-seasons across all years. Across all years, the overall clinical incidence in boys' sports was 1.34 (95% CI 1.32-1.36) per 100 player-seasons, and 0.93 (95% CI 0.91-0.95) per 100 player-seasons in girls' sports. Boys' sports with the highest clinical incidence included football, ice hockey, and wrestling. Girls' sports with the highest clinical incidence included basketball, soccer, lacrosse, competitive cheer, and gymnastics. Girls consistently had higher SRC rates relative to boys for baseball/softball, basketball, and soccer (CIR range 1.65 [95% CI 1.41-1.93] to 3.32 [95% CI 2.67-4.16]). Girls had lower SRC in lacrosse in 2015/2016 (CIR 0.63, 95% CI 0.40-0.97); no difference in 2016/2017-2020/2021, but had higher clinical incidence in 2021/2022 (CIR 1.69, 95% CI 1.18-2.44) relative to boys. In boys the most common mechanism of SRC occurred from person-to-person contact (n = 8752, 62.8%), whereas girls commonly sustained SRC from person-to-object contact (n = 2369, 33.4%) and from person-to-person contact (n = 2368, 33.4%). There were significant associations between boys' versus girls' sports and mechanism of injury within baseball/softball (χ2 = 12.71, p = 0.005); basketball (χ2 = 36.47, p < 0.001); lacrosse (χ2 = 185.15, p < 0.001); and soccer (χ2 = 122.70, p < 0.001). CONCLUSIONS: These findings can help understand the potential impact of interventions aimed at preventing or reducing SRC. Including girls' sports within this study extends research for a largely underrepresented group.

Co-existence of depression and post-concussion syndrome one month after mild traumatic brain injury.

BACKGROUND: Previous studies suggest an association between Post-concussion syndrome (PCS) and depression, both highly prevalent after mTBI. OBJECTIVE: To assess the prevalence and risk-factors of depression among patients with PCS 1 month after mTBI. METHODS: We prospectively screened 372 mTBI patients admitted in two academic Emergency Departments between 2017 and 2019. One month after mTBI, we administered the Rivermead Post-concussion symptoms Questionnaire (RPQ) and the Patient Health Questionnaire (PHQ-9) questionnaires over the telephone. PCS and depression were defined by RPQ ≥ 12 and PHQ-9 ≥ 10. Multivariate multinomial regression identified baseline factors associated with PCS and depression. RESULTS: Two hundred and eight completed RPQ and PHQ-9. Forty-seven patients (22.5%) met criteria for PCS, among which 22 (46.8%) met criteria for depression (PCS+D+). Patients with PCS but without depression were less likely to present with an associated injury (Coefficient = -1.6, p = 0.047) and to report initial sadness (Coefficient = -2.5, p = 0.03). Initial sadness (Coefficient = -1.3, p = 0.047), associated injury (Coefficient = -1.9, p = 0.008), as well as initial nausea (Coefficient = -1.8, p = 0.002), and male sex (Coefficient = 1.8, p = 0.002), were associated with the absence of depression and PCS in comparison with PCS+D+ patients. CONCLUSION: Among patients with PCS 1 month after mTBI, those with depression are more likely to present with initial sadness and with an associated injury.

Using machine learning to discover traumatic brain injury patient phenotypes: national concussion surveillance system Pilot.

OBJECTIVE: The objective is to determine whether unsupervised machine learning identifies traumatic brain injury (TBI) phenotypes with unique clinical profiles. METHODS: Pilot self-reported survey data of over 10,000 adults were collected from the Centers for Disease Control and Prevention (CDC)'s National Concussion Surveillance System (NCSS). Respondents who self-reported a head injury in the past 12 months (n = 1,364) were retained and queried for injury, outcome, and clinical characteristics. An unsupervised machine learning algorithm, partitioning around medoids (PAM), that employed Gower's dissimilarity matrix, was used to conduct a cluster analysis. RESULTS: PAM grouped respondents into five TBI clusters (phenotypes A-E). Phenotype C represented more clinically severe TBIs with a higher prevalence of symptoms and association with worse outcomes. When compared to individuals in Phenotype A, a group with few TBI-related symptoms, individuals in Phenotype C were more likely to undergo medical evaluation (odds ratio [OR] = 9.8, 95% confidence interval[CI] = 5.8-16.6), have symptoms that were not currently resolved or resolved in 8+ days (OR = 10.6, 95%CI = 6.2-18.1), and more likely to report at least moderate impact on social (OR = 54.7, 95%CI = 22.4-133.4) and work (OR = 25.4, 95%CI = 11.2-57.2) functioning. CONCLUSION: Machine learning can be used to classify patients into unique TBI phenotypes. Further research might examine the utility of such classifications in supporting clinical diagnosis and patient recovery for this complex health condition.