The Effect of Social Determinants of Health on Clinical Recovery Following Concussion: A Systematic Review.

CONTEXT: Concussion evaluations include a multifaceted approach; however, individual differences can influence test score interpretations and validity. Social determinants of health (SDoH) differentially affect disease risk and outcomes based upon social and environmental characteristics. Efforts to better define, diagnose, manage, and treat concussion have increased, but minimal efforts have focused on examining SDoH that may affect concussion recovery. OBJECTIVE: This review examined previous research that examined the effect of SDoH on concussion recovery of athletes. EVIDENCE ACQUISITION: CINAHL, MEDLINE, PsycInfo, and SPORTDiscus databases were used to search the terms "concussion" AND "recovery," "youth, adolescent, teen and/or adult," and "social determinants of health" and variations of these terms. The evidence level for each study was evaluated using the 2011 Oxford Center for Evidence-Based Medicine Guide. EVIDENCE SYNTHESIS: Seven thousand nine hundred and twenty-one articles were identified and screened for inclusion. Five studies met the inclusion criteria and were included in this systematic review. Using the Downs and Black Quality Index, the studies included in this review were deemed high quality. CONCLUSION: Though limited literature exists, there is preliminary evidence to suggest that SDoH (specifically, economic stability, education access and quality, and social and community context) may have an impact on the clinical recovery from concussion. The dimensions evaluated varied between studies and the results were inconsistent. No single factor consistently affected clinical recovery; however, private insurance and race appear to have an association with the speed of recovery. Unfortunately, the potential intersection of these variables and other preinjury factors limits the ability to make clear recommendations. While most of the studies in this review are retrospective in nature, future efforts should focus on training clinicians to prospectively evaluate the effect of SDoH on concussion recovery and injury outcomes. Funding and registration for this systematic review were not obtained nor required.

Concussion-Related Decision-Making by Certified Athletic Trainers: Implications for Concussion Prevention and Care.

Concussions are a common sport-related injury that require appropriate initial care. Athletic trainers, often a primary source of healthcare for student-athletes, are key individuals involved in initial concussion diagnostic and management decisions. Challenges exist within the athletic environment that may hinder the consistency, efficacy, and/or effectiveness of concussion-related decision-making by athletic trainers, thereby impacting secondary concussion prevention and patient health. The purpose of this study was to identify factors that impact the intentions of athletic trainers to make appropriate concussion-related decisions under various circumstances. Overall, 1029 participants completed a survey examining educational precursors (quantity and quality of healthcare communication educational focus), demographic precursors (age, gender, educational degree, and employment setting), theory-based mediators (attitudes, perceived norms, and personal agency), and external mediators (knowledge, salience, and communication/collaboration practices) on appropriate concussion-related decision-making intentions. Data were analyzed using a two-step structural equation modeling approach. Quality of healthcare communication educational focus indirectly impacted appropriate concussion-related decision-making intentions via perceived behavioral control and communication/collaboration practices. Additionally, several factors impacted intentions to make appropriate concussion-related decisions directly including employment setting, self-efficacy, and general attitudes towards decision-making and concussions. Concussion prevention is aided by the initial and appropriate action taken by a healthcare professional to reduce immediate consequences; however, this action may be influenced by stakeholder relationships. These influential factors of decision-making may place athletes at further injury risk and negatively impact overall athlete health. As such, a sound theoretical framework incorporating the complexity of factors that may influence decision-making is needed.

Determinants of Intention to Disclose Musculoskeletal Injury in Adolescent Athletes.

CONTEXT: Although research indicates that the key to minimizing the effect of musculoskeletal injury, improving care, and mitigating long-term effects is to improve early injury care seeking, little is known about barriers to early musculoskeletal injury disclosure and care seeking. OBJECTIVE: To identify which determinants predicted sport-related musculoskeletal (MSK) injury disclosure by adolescent athletes. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 564 adolescent athletes (58% male, age = 15.81 ± 1.8 years). MAIN OUTCOME MEASURE(S): Online survey exploring determinants of age, gender, race, socioeconomic status, injury knowledge, attitudes, perceived social norms, and perceived behavioral control surrounding MSK injury disclosure, intention to disclose MSK injury, and actual behavior of disclosing MSK injury. RESULTS: Of the respondents, 457 (80.2%) reported having sustained ≥1 (mean = 3.2 ± 2.2; range = 1-10) MSK injuries related to sport. Those who endorsed having experienced an MSK injury disclosed not reporting or purposefully hiding 77% of their suspected MSK injuries. Several factors influenced a high intention to disclose MSK injury. Specifically, for each unit increase in total MSK injury knowledge (Exp[ß] = 1.061, ß=0.054, P = .020, 95% CI = 1.031, 1.221) and attitude (Exp[ß] = 1.070, ß = 0.064, P < .001, 95% CI = 1.027, 1.115) score, 6% and 7% increases in the likelihood of a high intention to disclose an MSK injury, respectively, were observed. Moreover, for each unit increase in the social norm score (Exp[ß] = 1.178, ß=0.164, P < .001, 95% CI = 1.119, 1.241), an 18% increase in the likelihood of a high intention to disclose an MSK injury was noted. CONCLUSIONS: Designing interventions geared toward increasing the knowledge of signs and symptoms of MSK injury, improving attitudes surrounding disclosure, and better understanding the social context of disclosing MSK injuries may improve MSK injury disclosure behavior and reduce the associated social and economic burdens of these injuries.

Does the association between concussion measures and social context factors differ in Black and white parents?

CONTEXT: Middle school (MS) parents may benefit from education supporting timely concussion identification and care-seeking in their young children (aged ∼10-15 years). However, such education may not consider individual needs and varying social context factors, including lower socioeconomic status (SES), disadvantaged social determinants of health, or different racial backgrounds. OBJECTIVE: To examine the relationship between social context factors and concussion knowledge, attitudes, and communication in MS parents, while also exploring the potential roles of race and ethnicity (Black vs. White) as an effect measure modifier. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OF OTHER PARTICIPANTS: A nationally representative sample of MS parents who completed an online survey (n=1248). MAIN OUTCOME MEASURE(S): Parent outcomes included history of previous concussion education, concussion symptom knowledge and attitudes, and communication with children about concussion. Main exposures were parent's race and ethnicity (Black vs. White) and social context factors. Uni- and multivariable statistical analyses were performed to achieve the study aims. RESULTS: Black parents were more likely than White parents to have received concussion education (69.5% vs 60.5%, p=0.009), though median concussion knowledge scores were significantly higher in White compared to Black parents (40 vs 37, p<0.001). Few associations were found within social context factors for concussion knowledge, attitudes, and communication in White and Black parents separately. CONCLUSIONS: Among MS parents, race and ethnicity may not influence the association between social context factors and concussion-related knowledge, attitudes. or communication. However, differences were found among participants by race and ethnicity regarding previous concussion education and other parent outcomes, particularly concussion symptom knowledge.

Sport culture and communication among middle school athletes, parents, and staff: A qualitative study.

Middle school (MS) is an intermediary level of education between elementary and secondary school that typically includes students aged 10-15 years. There is limited research within the MS sport setting, particularly related to sport-related injury prevention. This qualitative study aimed to better understand the sport culture within MS sports and the communication strategies used among invested groups (i.e., athletes, parents, staff inclusive of coaches and school nurses). Semi-structured interviews were conducted with 19 athletes, 20 parents, and 18 staff (e.g., coaches, school nurses) from seven MS in two school districts during the 2018/19 and 2019/20 school years. Topics focused on understanding school- and sport-related factors related to education, safety, and communication. Analysis used a consensual qualitative research tradition, in which the research team discussed individually developed themes and categories from transcribed interviews, with the goal of coming to a consensus and creating a codebook. Throughout the coding process, the research team would reconvene to discuss coding decisions until consensus was reached. This study focuses on the themes of sport culture and communication. Dominant categories identified within sport culture related to participants noting why they were interested in MS sports, and their struggles with their perceived roles and engagement (e.g., helping parents stay engaged, finding coaches, oversight of school nurses). Competitiveness and safety could have conflicting roles and priority. Dominant categories identified within communication centered around limited communication between coaches and parents. Technological assistance (e.g., phone apps, websites) was available, but often varied by school and sport. Concussions were seldom discussed unless during the preseason meeting or when one occurred. Findings highlight that the MS sport settings may struggle with incorporating primary prevention into their cultures and ensuring reliable communication among individuals. Novel and tailored approaches to injury prevention are needed to help ensure buy-in and proper implementation.

Concussion knowledge, attitudes, and norms: How do they relate?

BACKGROUND: Relationships between the constructs of concussion-related knowledge, attitudes, and norms and their influence on observed care-seeking behaviors have previously been examined. Current models posit that these constructs serve as potential mediators of care-seeking behaviors; however, the dynamics between them have yet to be reconciled. METHODS: A cross-sectional, online survey explored relationships among the latent constructs of concussion-related knowledge, attitudes, and norms in parents of middle school children who participate in sports in multiple settings. A just-identified and two overidentified path models were explored and compared in an effort to understand such relationships. RESULTS: A total of 426 parents of United States middle school students were surveyed and included in analyses (mean age = 38.7±9.9 years; 55.6% female; 51.4% white/non-Hispanic; 56.1% with at least a bachelor's degree). All parents had middle school aged children who participated in sport in both the club and school settings. The best fitting model was a just-identified model with concussion-related norms influencing concussion-related knowledge and attitudes, and concussion-related knowledge influencing attitudes. This model accounted for 14% of the variance in attitude and 12% of the variance in knowledge. CONCLUSIONS: Study findings suggest that the constructs of concussion-related knowledge, attitudes and norms are directly related to one another, yet the dynamics of such relationships may be complex. As such, a parsimonious interpretation of these constructs may not be appropriate. Future research should work to further reconcile the dynamics between these constructs, and the impact these dynamics may have in influencing care-seeking behaviors beyond serving as mediators.

The Identification and Comparison of Factors Affecting Musculoskeletal and Concussion Injury Disclosure.

CONTEXT: Despite the increased risk of musculoskeletal (MSK) injury after a concussion, little is known about the determinants of such a risk. Moreover, the authors of previous reports of increased risk of MSK injury after a concussion have neglected to account for the high level of undisclosed concussions. OBJECTIVE: To explore the association between the intention to disclose a possible concussion and the intention to disclose an MSK injury. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: One hundred seven National Collegiate Athletic Association Division I athletes (females = 79%, age = 19.4 ± 1.4 years). MAIN OUTCOME MEASURE(S): Online survey exploring determinants such as injury knowledge, attitudes, perceived social norms, and perceived behavioral control surrounding concussive and MSK injury disclosure. RESULTS: A significant association between high intention to disclose a concussion and high intention to disclose an MSK injury (χ2 = 19.276, P < .001, Cramer V = 0.482) was observed. Spearman rank correlations suggested no correlation between concussion nondisclosure (25%) and MSK injury nondisclosure (52%). Multivariate binomial regressions indicated that perceived social norms were the strongest determinant (ß = 1.365, P = .002) of high intention to disclose concussion, while attitudes toward MSK injury (ß = 1.067, P = .005) and perceived social norms (ß = 1.099, P = .013) were the strongest determinants of high intention to report MSK injury. CONCLUSIONS: Individuals with high intention to report concussion symptoms also demonstrated high intention to report MSK injury. Strong positive associations were seen between known determinants of intention to disclose concussion and adapted versions of those same determinant domains in intention to disclose MSK injury. As those with high intention to disclose concussion also displayed high intention to disclose MSK injury, intention to disclose injuries generally may play a role in explaining the increase in MSK injury after a concussion.

Biopsychosocial Experiences of Elite Athletes Retiring From Sport for Career-Ending Injuries: A Critically Appraised Topic.

CLINICAL SCENARIO: Injuries cause individuals varying amounts of time loss from participation, which may depend on injury and sport-specific factors such as level of participation. Athletes who never return to sport either choose or are forced to retire due to numerous factors. At elite levels of play, when an athlete chooses retirement, they have the opportunity to create and execute a retirement plan; however, if unexpected (eg, due to career-ending injury), athletes may struggle to transition out of sport effectively, impacting physical, mental, and social health. The biopsychosocial model looks at the relationship between biology, psychology, and socio-environmental factors. Therefore, the purpose of this study was to better understand the biopsychosocial experiences elite athletes face after a career-ending injury so that sport stakeholders can develop and implement strategies to support a healthy transition. CLINICAL QUESTION: How does suffering a career-ending injury affect elite athletes' biopsychosocial experiences during retirement from sport? SUMMARY OF KEY FINDINGS: All studies found that a career-ending injury negatively impacted athlete's biopsychosocial health during the transition period. In addition, social support was identified as a positive coping mechanism and research highlighted the role of education in promoting successful transitions. Sport stakeholders should educate athletes regarding the importance of creating secondary plans. By creating a culture of athletic and nonathletic identity, athletes can feel empowered to navigate different phases of their life despite transition being forced upon them due to injury. CLINICAL BOTTOM LINE: Career-ending injuries negatively impact the biopsychosocial experiences of elite athletes as they transition out of sport. Athletes may face many transitional challenges including a loss of identity, a lack of external support, and/or mental health decline; those more closely identifying with their role as an athlete tend to have a harder transition. Therefore, it is important for all athletes to be adequately prepared for sport retirement, especially given the uncertainty about when and how retirement may occur. STRENGTH OF RECOMMENDATION: Collectively, the body of evidence included to answer the clinical question aligns with the strength of recommendation of C.

The Epidemiology of Ankle Sprains in US High School Sports, 2011-2012 to 2018-2019 Academic Years.

CONTEXT: Continued monitoring of ankle sprain rates and distributions is needed to assess temporal patterns and gauge how changes in incidence may be associated with prevention efforts. OBJECTIVE: To describe the epidemiology of ankle sprains in 16 US high school sports during the 2011-2012 to 2018-2019 school years. DESIGN: Descriptive epidemiology study. SETTING: Online injury surveillance from high school sports. PATIENTS OR OTHER PARTICIPANTS: High school athletes who participated in practices and competitions during the 2011-2012 to 2018-2019 school years. MAIN OUTCOME MEASURE(S): A convenience sample of high school athletic trainers provided injury and athlete-exposure (AE) data to the National High School Sports-Related Injury Surveillance Study (data provided by High School Reporting Information Online [HS RIO]). Ankle sprain rates per 10 000 AEs with 95% CIs and distributions were calculated. Yearly rates were examined overall and by event type, injury mechanism, and recurrence. RESULTS: Overall, 9320 ankle sprains were reported (overall rate = 2.95/10 000 AEs; 95% CI = 2.89, 3.01). The highest sport-specific rates were reported in girls' basketball (5.32/10 000 AEs), boys' basketball (5.13/10 000 AEs), girls' soccer (4.96/10 000 AEs), and boys' football (4.55/10 000 AEs). Most ankle sprains occurred during competition (54.3%) and were due to contact with another person (39.5%) or noncontact (35.0%). Also, 14.5% of injuries were recurrent. Across the included academic years, ankle sprain rates generally increased. Compared with the 2011-2012 academic year, rates in the 2018-2019 academic year overall were 22% higher; noncontact-related and recurrent ankle sprain rates also generally increased by 91% and 29%, respectively. CONCLUSIONS: Time trends suggested that ankle sprain rates have increased across the past decade, particularly among those with noncontact-related mechanisms, contrasting with previous research that indicated decreases in incidence. These findings may pinpoint specific etiologic factors that should direct prevention efforts, including considering both person-contact and noncontact mechanisms by mitigating illegal contact through rule changes and enforcement, as well as bracing and proprioceptive and balance-training programs.

Association between Sensation-Seeking Behaviors and Concussion-Related Knowledge, Attitudes, Perceived Norms, and Care-Seeking Behaviors among Collegiate Student-Athletes.

There are limited data connecting personality and behavioral tendencies and traits related to concussion care-seeking/disclosure behaviors and minimal research exists surrounding the relationship between risky behaviors, sensation-seeking, and concussion-related outcomes. This study examined the association between sensation-seeking and a student-athlete's concussion-related knowledge, attitudes, perceived social norms, and concussion care-seeking/disclosure behaviors (intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury). The current study utilized a retrospective cohort of collegiate student-athletes at a single National Collegiate Athletic Association Division I institution. Separate multivariable linear regression models estimating mean differences (MD) and 95% Confidence Intervals (CI) estimated the association between sensation-seeking and concussion knowledge, concussion attitudes, and perceived social norms. Separate multivariable binomial regression models estimating adjusted prevalence ratios (PR) and 95%CI estimated the association between sensation-seeking and intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury. All models were adjusted for sex, sport participation, and concussion history. Higher sensation-seeking was significantly associated with less favorable concussion attitudes (adjusted MD = -1.93; 95%CI = -3.04,-0.83), less favorable perceived social norms surrounding concussion (adjusted MD = -1.39; 95%CI = -2.06,-0.72), and continuing to play while experiencing concussion symptoms (adjusted PR = 1.50; 95%CI = 1.10, 2.06). Student-athletes with increased sensation-seeking could be at risk for failing to disclose a concussion, decreasing athlete safety and resulting in less optimal care post-injury. Results will inform future theory-based concussion education programs which consider behavioral tendencies and traits as well as sport culture to promote concussion care-seeking/disclosure and individualized interventions based on risky behavior engagement.

Reporting of Concussion Symptoms by a Nationwide Survey of United States Parents of Middle School Children.

This cross-sectional study assessed concussion symptom knowledge of parents of middle school (MS) children (aged 10-15 years) through a free-response item that solicited concussion symptoms and compared findings to a pre-validated scale-based measure. A self-administered online questionnaire was sent to a panel of randomly selected United States residents who were recruited by a third-party company, aged ≥ 18 years, and identified as parents of MS children. Via a free-response item, parents listed what they believed were concussion symptoms. Multiple sections later, parents identified potential concussion symptoms via a scale measure, which featured 25 items (22 actual symptoms, three distractor symptoms) with three response options: yes, no, maybe. Free-response item responses were coded into specific symptoms. The 1062 eligible parents that provided complete data commonly identified the symptoms of dizziness (90.2%), blurred vision (87.4%), and balance problems (86.4%) on the scale-based measure. However, these and other symptoms were less commonly identified via the free-response item (dizziness: 44.4%; blurred vision: 16.5%; balance problems: 3.5%). Concussion symptoms commonly reported via the scale-based measure were reported less frequently within the free-response item. Future research must explore strategies to help clinicians working with parents and their children to measure and assess concussion symptom reporting and knowledge.