The influence of prior COVID-19 diagnosis on concussion recovery outcomes.

OBJECTIVE: While the clinical presentations of COVID-19 and concussion are not identical, there is a significant overlap in symptomology (e.g., fatigue, headache) and neurological deficits (e.g., cognitive, vestibular). However, limited research has examined the effect of prior COVID-19 diagnosis on concussion outcomes. Therefore, the purpose of this study was to determine if prior diagnosis of COVID-19 influences concussion outcomes, including concussion assessment scores and recovery time, in college-aged individuals. METHODS: A prospective study of college-aged individuals (COVID-19: n = 43, mean age 21.3 [SD 2.5] years; no COVID-19: n = 51, mean age 21.0 [SD 2.5] years) diagnosed with concussion was conducted. Demographics, injury details, the Sport Concussion Assessment Tool 5th Edition (SCAT5), and the Vestibular/Ocular Motor Screening (VOMS) were completed at the acute (within 5 days after concussion) and full medical clearance (FMC) (within 3 days after FMC) visits. Mann-Whitney U-tests determined differences in concussion outcomes between groups. Cox proportional hazards regression models were fitted to assess the relationship between factors associated with concussion symptom resolution and days to FMC, and covariates were selected based on previous literature indicating potential confounds (e.g., female sex, acute symptom severity, preexisting mental health conditions). Hazard ratios with 95% confidence intervals were reported for each predictor variable. RESULTS: No significant differences were found between groups for SCAT5 and VOMS composite and total scores. Significant differences were found between COVID-19 and no-COVID-19 groups in days to symptom resolution (11.5 days vs 8 days, p = 0.021), but not in days to FMC (14 days vs 12 days, p = 0.099). The association between COVID-19 groups and days to clearance was not significant when adjusting for sex, race, history of depression/anxiety, and total number of concussion symptoms at the acute visit [χ2(5) = 8.349, p = 0.138]. However, male sex (HR 2.036, 95% CI 1.033-4.014; p = 0.040) was associated with a quicker time to FMC. CONCLUSIONS: Prior COVID-19 diagnosis did not influence cognitive abilities and vestibular/ocular functioning as measured by the SCAT5 and VOMS postconcussion. While prior COVID-19 diagnosis did result in a significantly longer duration to symptom resolution when compared with individuals who did not have a prior COVID-19 diagnosis, prior COVID-19 did not significantly influence time to FMC by a healthcare provider. Clinicians should consider that individuals with a prior diagnosis of COVID-19 might experience prolonged symptoms postconcussion.

The association between continuing to play, clinical domains, and recovery outcomes in collegiate athletes following concussion.

OBJECTIVE: Continued play following concussion can lead to worse outcomes and longer recoveries compared with athletes who immediately report. This has been well documented in youth athletes, while less attention has been paid to collegiate athletes despite differences in healthcare access, recovery trajectories, and additional pressures to play. Therefore, the purpose of this study was to determine if continuing to play immediately following a concussion influenced clinical outcomes and recovery time in collegiate athletes. METHODS: A prospective, repeated-measures design was used to compare clinical outcomes and recovery time between collegiate athletes who continued playing (n = 37) and those immediately removed (n = 56) after a concussion. Assessments were conducted within 5 days of the concussion and at full medical clearance (FMC; ± 3 days) using the Sport Concussion Assessment Tool-5th edition (SCAT5), Vestibular/Ocular Motor Screening assessment, and High-Level Mobility Assessment Tool. Mann-Whitney U-tests determined differences in clinical outcomes between groups. Cox proportional hazards regression models examined the relationship between factors associated with days to symptom resolution and days to FMC, and covariates were selected a priori based on previous literature. Hazard ratios with 95% CIs were reported for each predictor variable. RESULTS: Significant differences were found in SCAT5 concentration composite scores (p = 0.010) and SCAT5 delayed recall composite scores (p = 0.045) at the acute visit and near point of convergence average distance (cm; p = 0.005) at the FMC visit between the group who continued to play and those who were immediately removed. There were no differences between groups in days to symptom resolution (10 vs 7 days, p = 0.05) and days to clearance (13 vs 11.50 days, p = 0.13). The association between groups and days to symptom resolution (χ2[4] = 5.052, p = 0.282), and days to clearance (χ2[4] = 3.624, p = 0.459) were not significant when adjusting for covariates. CONCLUSIONS: Collegiate athletes who continued to play following concussion did not exhibit worse clinical outcomes or recovery times compared with athletes who were immediately removed. While the lack of differences found in this study could be supported by prior literature, including improved education, awareness, reporting attitudes, and concussion management at the collegiate level in recent years, the authors believe discrepancies are more likely due to study-specific differences (e.g., sample size, care setting, and timing). Therefore, these findings should not diminish the dangers of continued play and the importance of timely removal after concussion.

Geographic characteristics of sport- and non-sport-related concussions presenting to emergency departments in the United States.

BACKGROUND: Concussion is a type of traumatic brain injury (TBI) that can be sustained through sport-related and non-sport-related (e.g., motor vehicle accidents, falls, assaults) mechanisms of injury (MOI). Variations in concussion incidence and MOI may be present throughout the four geographic regions (Midwest, Northeast, South, West) of the United States. However, there is limited evidence exploring concussion cause and diagnosis patterns based on geographic region and MOI. These factors have implications for better understanding the burden of concussion and necessary efforts that can translate to the mitigation of safety concerns. PURPOSE: The purpose of this study was to identify patterns of sport-related concussion (SRC) and non-sport-related concussion (NSRC) across the four geographic regions of the United States. METHODS: A descriptive epidemiology study of patient visits to the emergency department (ED) for concussion between 2010 and 2018, using publicly available data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) was conducted. The exposure of interest was geographic region while the main outcome measures were concussion diagnosis and MOI. Descriptive statistics were calculated using population-weighted frequencies and percentages. The association between geographic region and MOI (SRC vs. NSRC) was analyzed using logistic regression models. Odds ratios (OR) presented with 95% confidence intervals (CI) were included. Univariate analyses were conducted followed by multivariable analyses adjusting for sex, age, race/ethnicity, and primary source of payment. Statistical significance was set a priori at p < 0.05 for all analyses. RESULTS: From 2010 to 2018, 1,161 visits resulted in a concussion diagnosis, representing an estimated 7,111,856 visits nationwide. A greater proportion of concussion diagnoses occurred within EDs in the South (38.2%) followed by the West (25.8%), Midwest (21.4%), and Northeast (14.6%). Compared to the West region, patients visiting the ED in the Midwest (OR = 0.75, 95% CI = 0.57-0.98) and Northeast (OR = 0.71, 95% CI = 0.51-0.98) had a lower odds of being diagnosed with a concussion. More patients sustained a NSRC MOI (94.3%) compared to SRC MOI (5.7%). For both mechanisms, the South region had the highest population-weighted frequency of SRC (n = 219,994) and NSRC diagnoses (n = 2,495,753). Univariate and multivariable logistic regression analyses did not reveal statistically significant associations for geographic region and MOI (p > 0.05). CONCLUSION: Our findings showed that the Midwest and Northeast regions had a lower odds of concussion diagnoses in EDs. Overall, the vast majority of concussions were not sport-related, which has public health implications. These findings improve our understanding of how concussion injuries are being sustained geographically nationwide and help to explain care-seeking patterns for concussion in the ED setting.

Preliminary Baseline Vestibular Ocular Motor Screening Scores in Pediatric Soccer Athletes.

CONTEXT: The utility of baseline vestibular and ocular motor screening (VOMS) in high school and collegiate athletes is demonstrated throughout the literature; however, baseline VOMS data at the youth level are limited. In addition, with the recent adoption of the change scoring method, there is a need to document baseline VOMS total and change scores in a pediatric population. OBJECTIVE: To document baseline VOMS total and change scores and to document the internal consistency of the VOMS in pediatric soccer athletes. We hypothesized that the VOMS would demonstrate strong internal consistency in pediatric soccer athletes. DESIGN: Cross-sectional study. METHODS: Pediatric soccer athletes (N = 110; range = 5-12 y) completed the VOMS at baseline. Descriptive statistics summarized demographic information, VOMS total scores, and VOMS change scores. Cronbach α assessed internal consistency for VOMS total scores and change scores. RESULTS: Twenty-one (19.1%) participants had at least one total score above clinical cutoffs (≥2 on any VOMS component and ≥5 cm on average near point convergence). Forty (36.4%) participants had at least one change score above clinical cutoffs (≥1 on any VOMS component and ≥3 cm on average near point convergence). The internal consistency was strong for total scores with all VOMS components included (Cronbach α = .80) and change scores (Cronbach α = .89). CONCLUSIONS: Although results suggest VOMS items measure distinct components of the vestibular and ocular motor systems, caution should be taken when interpreting VOMS total and change scores in pediatric athletes, as overreporting symptoms is common, thereby impacting the false-positive rate.

Racial differences in concussion diagnosis and mechanism of injury among adults presenting to emergency departments across the United States.

OBJECTIVES: The purpose of this study was to examine the association between race and concussion diagnosis as well as the association between race and mechanism of injury (MOI) for concussion diagnoses in adult patients (>19 years old) visiting the emergency department (ED). METHODS: A retrospective analysis of patient visits to the ED for concussion between 2010 and 2018, using the National Hospital Ambulatory Medical Care Survey, was conducted. Outcome measures included concussion diagnosis and MOI. Multivariable and multinomial logistic regression analyses were conducted to assess associations between race and outcome variables. The results were weighted to reflect population estimates with a significance set at p < 0.05. RESULTS: Overall, 714 patient visits for concussions were identified, representing an estimated 4.3 million visits nationwide. Black adults had lower odds of receiving a concussion diagnosis [p < 0.05, Odds Ratio (OR), 0.54; 95% Confidence Interval (CI), 0.38-0.76] compared to White adults in the ED. There were no significant differences in MOI for a concussion diagnosis by race. CONCLUSION: Racial differences were found in the ED for concussion diagnosis. Disparities in concussion diagnosis for Black or other minoritized racial groups could have significant repercussions that may prolong recovery or lead to long-term morbidity.

Concussion History and the Emotional and Behavioral Dyscontrol Domains of Health-Related Quality of Life in College Students.

CONTEXT: Injury or illness can affect individual perceptions of health status and health-related quality of life (HRQOL). Concussion can result in different symptoms, impairments, and functional limitations that have been found to lower HRQOL. Furthermore, concussion is known to influence the emotional and behavioral dyscontrol domains of HRQOL in pediatric populations; however, this has yet to be explored in other populations. OBJECTIVE: To compare individuals with and those without a concussion history and (1) HRQOL and (2) the emotional and behavioral dyscontrol domains of HRQOL in college students. DESIGN: Cross-sectional study. SETTING: University laboratory setting. PATIENTS OR OTHER PARTICIPANTS: Of a total of 252 participants (155 women; age = 19.95 ± 1.53 years), 76 (30.2%) had a history of concussion and 176 (69.8%) did not. For participants with a history of concussion, the mean time since injury was 5.29 ± 2.77 years. MAIN OUTCOME MEASURE(S): The Patient-Reported Outcome Measures Information System (PROMIS) Global Health, version 1.1, and Quality of Life in Neurological Disorders Emotional and Behavioral Dyscontrol Short Form (Neuro-QOL). RESULTS: No differences were seen between median scores in individuals with and those without a history of concussion in the PROMIS Physical Health (13.0 versus 14.0; P = .24), PROMIS Mental Health (12.0 versus 12.0; P = .99), and Neuro-QOL (16.0 versus 16.0; P = .47) scores. Additionally, when gender was controlled, the associations between a history of concussion and PROMIS Physical Health score (odds ratio [OR] = 1.04; 95% CI = 0.43, 2.52), PROMIS Mental Health score (OR = 0.66; 95% CI = 0.13, 3.25), and Neuro-QOL score (OR = 1.16; 95% CI = 0.66, 2.04) were not significant. CONCLUSIONS: Preliminary findings suggested that the emotional and behavioral dyscontrol domains were not influenced by a concussion history of > 1 year in college-aged participants. Future researchers should continue to explore specific HRQOL domains affected by concussion as well as the influences of prior mental health conditions and behavioral dysfunction after a subsequent injury.

Changes in State and Trait Anxiety Throughout Concussion Recovery in High School- and College-Aged Individuals.

CONTEXT: Researchers have indicated that individuals may experience anxiety symptoms after concussion. A potential mechanism for these presentations is shifts in anxiety throughout recovery. OBJECTIVE: To examine the levels of state and trait anxiety in individuals after concussion throughout recovery compared with the levels in individuals serving as uninjured matched control participants. DESIGN: Prospective cohort study. SETTING: University laboratory. PATIENTS OR OTHER PARTICIPANTS: Seventy-eight high school- and college-aged individuals (concussion group = 39, age = 18.4 ± 2.3 years; matched control group = 39, age = 18.4 ± 2.3 years) were enrolled. MAIN OUTCOME MEASURE(S): The State-Trait Anxiety Inventory was administered within 72 hours of injury (day 0: first test session), 5 days (±1 day) after the first test session (day 5), and at the time of full medical clearance (+2 days). Separate 2 × 3 repeated-measures analyses of variance were used to investigate differences in state and trait anxiety for each group throughout recovery. RESULTS: State and trait anxiety were higher in the concussion group than in the control group at day 0, day 5, and full medical clearance. For state anxiety, we observed a group × time interaction (F2,150 = 10.45, P < .001, ƞp2 = 0.12). For trait anxiety, we did not note an interaction (F1.74,150 = 1.5, P = .22, ƞp2 = 0.02) but did find main effects for time (F1.74,150 = 25.7, P < .001, ƞp2 = 0.3) and group (F1,75 = 7.23, P = .01, ƞp2 = 0.09). CONCLUSIONS: Participants with concussion experienced higher levels of state anxiety throughout recovery than matched control individuals. Although trait anxiety was higher in the concussion group and decreased over time, no interaction was seen, demonstrating that concussion may not affect this aspect of personality. Postinjury anxiety may result from increased state anxiety, and clinicians should screen for and manage these symptoms throughout recovery.

Application of Theory for Those With Sport-Related Concussion: Understanding the Effect of Athletic Identity on Health Outcomes.

Athletic identity is a psychological factor of concern for athletes after sport-related concussion (SRC). The integrated model of response to sport injury includes athletic identity as a psychological factor within its model, but it has often been overlooked as a consideration affecting outcomes of SRC. In this review, we applied the integrated model of response to sport injury to the current available evidence about the negative consequences of a stronger athletic identity on health outcomes after SRC. Theory-based research recommendations will be provided to facilitate research in this area. Recommendations for athletic training clinical practice to assess and consider athletic identity as part of routine clinical care for those after SRC will also be discussed.

MICK (Mobile Integrated Cognitive Kit) app: Feasibility of an accessible tablet-based rapid picture and number naming task for concussion assessment in a division 1 college football cohort.

Although visual symptoms are common following concussion, quantitative measures of visual function are missing from concussion evaluation protocols on the athletic sideline. For the past half century, rapid automatized naming (RAN) tasks have demonstrated promise as quantitative neuro-visual assessment tools in the setting of head trauma and other disorders but have been previously limited in accessibility and scalability. The Mobile Interactive Cognitive Kit (MICK) App is a digital RAN test that can be downloaded on most mobile devices and can therefore provide a quantitative measure of visual function anywhere, including the athletic sideline. This investigation examined the feasibility of MICK App administration in a cohort of Division 1 college football players. Participants (n = 82) from a National Collegiate Athletic Association (NCAA) Division 1 football team underwent baseline testing on the MICK app. Total completion times of RAN tests on the MICK app were recorded; magnitudes of best time scores and between-trial learning effects were determined by paired t-test. Consistent with most timed performance measures, there were significant learning effects between the two baseline trials for both RAN tasks on the MICK app: Mobile Universal Lexicon Evaluation System (MULES) (p < 0.001, paired t-test, mean improvement 13.3 s) and the Staggered Uneven Number (SUN) (p < 0.001, mean improvement 3.3 s). This study demonstrated that the MICK App can be feasibly administered in the setting of pre-season baseline testing in a Division I environment. These data provide a foundation for post-injury sideline testing that will include comparison to baseline in the setting of concussion.

A Comparison of Generalized and Individualized Vestibular Rehabilitation Therapy in a Military TBI Sample.

OBJECTIVE: To compare clinical outcomes between active duty service members receiving generalized versus individualized vestibular rehabilitation treatment (GVRT and IVRT, respectively) for persistent vestibular-related symptoms following mild traumatic brain injury (mTBI). SETTING: An outpatient TBI rehabilitation clinic. PARTICIPANTS: Fifty-seven participants with persistent vestibular-related symptoms following mTBI were randomly assigned to the GVRT ( n = 28) or IVRT ( n = 29) group, stratified by dizziness-related impairment severity. Forty-two participants ( n = 21 per group) completed the posttreatment evaluation and were included in analyses. DESIGN: We employed a single-site, randomized, pre-/posttest experimental design. The GVRT program consisted of eight 45-minute group-based treatment sessions and IVRT consisted of three 30-minute one-on-one treatment sessions both to be completed within 8 weeks. Group assignment was not blinded to study personnel or participants. Research evaluations were completed approximately 2 weeks prior to treatment initiation and following treatment completion. MAIN MEASURES: Outcome measures included Dizziness Handicap Inventory (DHI) and Activities-specific Balance Confidence Scale (ABC) total scores, Sensory Organization Test (SOT) composite equilibrium and sensory input ratio scores, Head Shake SOT (HS-SOT) conditions 2 and 5, and horizontal and vertical Dynamic Visual Acuity. Separate mixed-effects models were used to compare clinical outcomes between the GVRT and IVRT groups. RESULTS: Both groups demonstrated significant improvement from pre- to posttreatment on self-reported dizziness-related impairment (DHI [ F(1,41) = 16.28, P < .001]) and balance performance with and without head movement (composite equilibrium score [ F(1,41) = 16.58, P < .001, effect size [ES] = 0.43], somatosensory [ F(1,41) = 6.79, P = .013, ES = 0.26], visual [ F(1,41) = 6.49, P = .015, ES = 0.29], vestibular [ F(1,41) = 22.31, P < .001, ES = 0.55], and HS-SOT condition 5 [ F(1,38) = 23.98, P < .001, ES = 0.64]). Treatment effects did not differ between groups on any of the outcome measures. CONCLUSIONS: We provide preliminary evidence that differences in clinical outcomes do not exist between participants receiving generalized versus individualized VR. Further research is needed to determine comparative effectiveness between these 2 treatment approaches for persistent vestibular-related symptoms following mTBI.

Implementation of a Generalized Vestibular Rehabilitation Approach.

INTRODUCTION: Vestibular dysfunction is common in military populations as the result of traumatic brain injury, blast exposure, and/or repetitive acoustic insult. Vestibular rehabilitation (VR) has been proven to be an effective approach in the treatment of vestibular dysfunction. VR consists of a series of exercises prescribed on the basis of individual patient needs by a vestibular trained physical therapist (PT). A generalized approach to VR in a military setting could help widen the system capacity to take care of patients with vestibular symptoms, shorten waiting times for patients without impacting the burden on PTs. The rehabilitation team at the Warrior Recovery Center on Fort Carson, Colorado, developed a generalized approach in which a series of exercises were administered to individuals with vestibular dysfunction. The implementation of this approach was evaluated for quality improvement purposes and is presented below. MATERIALS AND METHODS: We utilized a combined observational/survey approach to evaluate the patients' tolerance to a variety of exercises provocative of dizziness symptoms, their overall satisfaction with the intervention, the appropriateness of the allocated resources, and the providers' confidence with the treatment and its administration. Research staff members were present as observers in all therapy sessions during the 3-month implementation period and administered surveys to patients and clinical staff at pre-established time points. Descriptive analysis was performed to summarize observations and responses to surveys. Linear regression was utilized to evaluate if a reduction in the number of patient:provider interactions occurred over the course of the implementation period. RESULTS: A total of 25 therapy sessions took place during the implementation period. Each visit lasted an average of 56 minutes with 6 minutes allocated for set up, 45 minutes for intervention and 5 minutes for cleanup. The mean number of patients per session was 3 (Max 6, Min 1) with one staff member running the intervention 56% of the time and two staff members running the intervention 44% of the time. Exercise tolerance was at 99% and the need for one-on-one interactions between providers and patients was easily attained at a 3:1 patient:provider rate. Survey assessment demonstrated 100% patient satisfaction with the program and 100% provider confidence with treatment delivery. CONCLUSION: Generalized Vestibular Rehabilitation Treatment (GVRT) was successfully implemented at the Warrior Recovery Center at Fort Carson, Colorado. The individual exercises used during the interventions were challenging to patients yet well tolerated. Resource allocation was appropriate in terms of personnel, time, and equipment. Both the clinical staff and the patients felt comfortable with the therapy and subjectively found it to be effective. The project provided valuable information to clinical staff, administrators, and the organization.