Shared Decision-Making About Returning to Sport After Recovery From Pediatric Concussion: Clinician Perspectives.

OBJECTIVE: Describe how sports medicine clinicians support decision making about sport participation after concussion recovery with adolescent patients and their parents. Specific areas of inquiry related to how clinicians framed the decision, what factors they considered in how they approached the decision process, and how they navigated discordance within families. DESIGN: Qualitative study. SETTING: Tertiary care sports medicine clinics at 4 children's hospitals in the United States. PARTICIPANTS: Individual interviews were conducted with 17 clinicians practicing in sports medicine settings. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Semi-structured interviews explored clinician approaches to supporting decision making, with the question guide informed by components of the Ottawa Decision Support Framework. RESULTS: Clinicians routinely incorporated aspects of shared decision making (SDM) into their conversations with families. This included ensuring all parties were informed about risk and aligned behind a shared value of adolescent well-being. Mediation strategies were used to manage discordance between adolescents and their parents, and between parents. These strategies aimed to facilitate a decision that was adolescent centered. When clinicians believed that there was a medical benefit to modifying the adolescent's sport participation practices, or when they did not believe the athlete was psychologically ready to return to the sport in which they were injured, they initiated conversations about alternative activities. In such situations, they used persuasive communication practices to encourage families to strongly consider this option. CONCLUSION: The strengths and strategies used by sports medicine clinicians in this study provide a foundation for guidance or intervention development aimed at supporting SDM after concussion with adolescents and their families.

Effect of Collaborative Care for Persistent Postconcussive Symptoms on Academic Function: A Randomized Clinical Trial.

BACKGROUND: There is limited long-term data on the course of school-related problems and academic needs for youth with persistent post-concussive symptoms (PPCS). METHODS: This was a randomized trial comparing collaborative care to usual care for 200 youth 11-18 years of age with PPCS. In this report, the main outcomes were academic functioning, GPA, school absences, date of return to school, and school days missed. RESULTS: Youth were mean age of 14.7 (SD = 1.7), 62.0% female. New or worsening academic problems occurred in half of participants in both groups at 12 months after injury. Students were most concerned about grades and falling behind. There were no significant differences by study group on school problems or GPA, but number of days missed was lower in the collaborative care group compared at 3 months (12.5 [SD = 14.5] vs 16.1 days [20.4] adjusted relative risk [aRR] 0.67 [95% CI: 0.61, 0.74; p < .001]), 6 months (14.5 [22.1] vs 19.3 [26.6] aRR 0.77 [95% CI: 0.71, 0.84; p < .001]), and 12 months (16.9 [25.4] vs 19.6 [27.7], aRR 0.68 [95% CI: 0.62, 0.74; p < .001]). CONCLUSIONS: Youth with PPCS are at high risk of school problems in the year after injury.

Effect of Collaborative Care on Persistent Postconcussive Symptoms in Adolescents: A Randomized Clinical Trial.

Importance: Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. Objective: To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. Design, Setting, and Participants: The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreational-related concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. Interventions: The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. Main Outcomes and Measures: Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parent-reported symptoms. Results: Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3- to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, -6.6 to -0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, -7.7 to -0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes. Conclusions and Relevance: Although both groups improved over time, youth receiving the collaborative care intervention had fewer symptoms and better quality of life over 1 year. Intervention delivery through telehealth broadens the reach of this treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT03034720.

Early Single Sport Specialization in a High-Achieving US Athlete Population: Comparing National Collegiate Athletic Association Student-Athletes and Undergraduate Students.

CONTEXT: Early single-sport specialization and the relative age effect are often cited as improving the chances of sport success. Both concepts suggest that genetics and the environment have little influence on sport success. OBJECTIVE: To compare National Collegiate Athletic Association Division I student-athletes (SAs) with their undergraduate nonathlete peers (NAs) in terms of birth month, age of sport initiation, and age of single-sport specialization. A family history of sport participation was examined as a potential marker for genetic and social influences. DESIGN: Cross-sectional survey. SETTING: Large urban university. PATIENTS OR OTHER PARTICIPANTS: A total of 273 Division I SAs (138 women, 135 men) and 155 NAs (78 women, 77 men) participated. The NAs had been involved in competitive youth sports before entering the university. MAIN OUTCOME MEASURE(S): Participants were asked to complete a questionnaire that addressed the age of sport initiation, birth month, age of single-sport specialization, and parental and sibling sport achievement. MAIN RESULTS: Neither birth month nor the age of sport initiation differed between groups (age of sport initiation = 7.16 ± 2.6 years for the SAs versus 7.71 ± 3.5 for the NAs; P = .176). A larger proportion of SAs began participating before 10 years of age (80% versus 63%; P = .02). The parents of SAs were more likely to have participated in collegiate (32.4% versus 8.4%; P < .0001) and professional (10.9% versus 1.3%; P = .0005) sports. The SAs specialized in a single sport at an older age (15.38 ± 2.7 years versus 14.30 ± 2.6 years; P = .002). Both groups participated in multiple sports in childhood (SAs = 3.9 ± 1.8 sports, NAs = 3.2 ± 1.8 sports; P = .366). CONCLUSIONS: The Division I SAs did not specialize in a single sport at a younger age than the NAs. No evidence of a relative age effect was present. Importantly, higher levels of sport achievement among the parents and siblings of SAs suggest that genetic endowment and family or other environmental dynamics play a large role in athletic performance. Overall, the results are not consistent with deliberate practice theory and point toward an alternative model that includes not only sport-specific skill development but also genetic and social factors as key elements of long-term sport achievement.

Qualitative study of barriers to concussive symptom reporting in high school athletics.

PURPOSE: To identify barriers to concussive symptom reporting in high school athletics. METHODS: We conducted a qualitative focus group study with varsity high school athletes from three football, two boys' soccer, and four girls' soccer teams in the Seattle, WA, area (50 participants). Professional moderators led the groups with a standardized script that discussed concussion knowledge as well as hypothetical concussion scenarios. Focus groups were recorded and transcribed, and transcripts were analyzed by two investigators using thematic analysis with Atlas.ti. RESULTS: Athletes could describe multiple signs and symptoms of concussion. Athletes also understood the dangers of concussions, and all groups mentioned the possibility of death or long-term disability. However, when confronted with scenarios involving concussive symptoms, athletes reported they would not stop playing. They would either continue to play (6/9 groups) or would take a brief break and then return to play (3/9 groups). Several barriers seemed to explain athletes' responses. Athletes wanted to keep playing and knew that reporting symptoms might result in being removed from the game. In addition, concussive symptoms were nonspecific, and thus could be mistaken for another etiology. Finally, athletes were hesitant to report symptoms to coaches if they did not result in significant pain or disability. CONCLUSIONS: There are several barriers to concussive symptom reporting in high school athletics. Athlete concussion knowledge does not seem to be a barrier, but coach approachability may be an issue. Interventions that seek to improve coach communication with athletes regarding concussion management might increase symptom reporting.