The Role of Level of Play in Concussions in High School Athletes.

OBJECTIVES: To examine level of play (LOP) as a risk factor for concussion severity and recovery-related outcomes among high school athletes, stratified by sex, and among boys, by sport (football, non-football male sports). DESIGN/SETTING: Secondary analysis of data collected through the High School Reporting Information Online surveillance system for academic years 2007-2008 through 2018-2019. PARTICIPANTS: A total of 9916 concussions were reported between the academic years 2007-2008 and 2018-2019 from 9 sports (5189 from football; 2096 from non-football male sports; 2631 from female sports). MAIN OUTCOME MEASURE: Examined the association between LOP (Freshman, Junior Varsity [JV], and Varsity teams) and concussion outcomes (number of concussion symptoms, symptom resolution time [SRT], and time to return to play [RTP]). RESULTS: Compared with Varsity football athletes, concussed JV football athletes had on average 0.19 fewer concussion symptoms, longer SRT (>1 week vs <1 week: odds ratio [OR] = 1.3; 95% confidence interval [CI], 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.2-1.9; >3 weeks vs <1 week: OR = 1.6; 95% CI, 1.1-2.3). Compared with Varsity football athletes, Freshman football athletes had on average 0.48 fewer concussion symptoms, longer SRT (OR = 1.3; 95% CI, 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.1-2.0; >3 weeks vs <1 week: OR = 2.0; 95% CI, 1.3-3.0). Similarly, compared with female athletes on Varsity teams, concussed JV female athletes had longer RTP (1-3 weeks vs <1 week: OR = 1.8; 95% CI, 1.2-2.7). Trend analyses revealed an increase in the number of concussion symptoms between 2015-2016 and 2018-2019, a decrease between 2009-2010 and 2018-2019 for SRT of less than 1 week, and an increase between 2014-2015 and 2018-2019 for RTP of less than 1 week among Varsity football athletes. Among Varsity female athletes, there was a linear decrease during the study period for RTP of less than 1 week. CONCLUSIONS: Despite a higher number of symptoms overall and in recent years, Varsity football players had shorter RTP than Freshman and JV athletes.

Refinement of a Preliminary Case Definition for Use in Traumatic Brain Injury Surveillance.

OBJECTIVE: Current methods used to measure incidence of traumatic brain injury (TBI) underestimate its true public health burden. The use of self-report surveys may be an approach to improve these estimates. An important step in public health surveillance is to define a public health problem using a case definition. The purpose of this article is to outline the process that the Centers for Disease Control and Prevention undertook to refine a TBI case definition to be used in surveillance using a self-report survey. SETTING: Survey. PARTICIPANTS: A total of 10 030 adults participated via a random digit-dial telephone survey from September 2018 to September 2019. MAIN MEASURES: Respondents were asked whether they had sustained a hit to the head in the preceding 12 months and whether they experienced a series of 12 signs and symptoms as a result of this injury. DESIGN: Head injuries with 1 or more signs/symptoms reported were initially categorized into a 3-tiered TBI case definition (probable TBI, possible TBI, and delayed possible TBI), corresponding to the level of certainty that a TBI occurred. Placement in a tier was compared with a range of severity measures (whether medical evaluation was sought, time to symptom resolution, self-rated social and work functioning); case definition tiers were then modified in a stepwise fashion to maximize differences in severity between tiers. RESULTS: There were statistically significant differences in the severity measure between cases in the probable and possible TBI tiers but not between other tiers. Timing of symptom onset did not meaningfully differentiate between cases on severity measures; therefore, the delayed possible tier was eliminated, resulting in 2 tiers: probable and possible TBI. CONCLUSION: The 2-tiered TBI case definition that was derived from this analysis can be used in future surveillance efforts to differentiate cases by certainty and from noncases for the purpose of reporting TBI prevalence and incidence estimates. The refined case definition can help researchers increase the confidence they have in reporting survey respondents' self-reported TBIs as well as provide them with the flexibility to report an expansive (probable + possible TBI) or more conservative (probable TBI only) estimate of TBI prevalence.

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.

Neuroimaging for mild traumatic brain injury in children: cross-sectional study using national claims data.

BACKGROUND: Current guidelines recommend healthcare professionals avoid routine use of neuroimaging for diagnosing mild traumatic brain injury (mTBI). OBJECTIVE: This study aimed to examine current use of CT and MRI among children and young adult patients with mTBI and factors that increase likelihood of neuroimaging in this population. MATERIALS AND METHODS: Data were analyzed using the 2019 MarketScan commercial claims and encounters database for the commercially insured population for both inpatient and outpatient claims. Descriptive statistics and logistic regression models for patients ≤24 years of age who received an ICD-10-CM code indicative of a possible mTBI were analyzed. RESULTS: Neuroimaging was performed in 16.9% (CT; 95% CI=16.7-17.1) and 0.9% (MRI; 95% CI=0.8-0.9) of mTBI outpatient visits (including emergency department visits) among children (≤18 years old). Neuroimaging was performed in a higher percentage of outpatient visits for patients 19-24 years old (CT=47.1% [95% CI=46.5-47.6] and MRI=1.7% [95% CI=1.5-1.8]), and children aged 15-18 years old (CT=20.9% [95% CI=20.5-21.2] and MRI=1.4% [95% CI=1.3-1.5]). Outpatient visits for males were 1.22 (95% CI=1.10-1.25) times more likely to include CT compared to females, while there were no differences by sex for MRI or among inpatient stays. Urban residents, as compared to rural, were less likely to get CT in outpatient settings (adjusted odds ratio [aOR]=0.55, 95% CI=0.53-0.57). Rural residents demonstrated a larger proportion of inpatient admissions that had a CT. CONCLUSIONS: Despite recommendations to avoid routine use of neuroimaging for mTBI, neuroimaging remained common practice in 2019.

Comparison of self-reported lifetime concussions and mild traumatic brain injuries among adults.

INTRODUCTION: The reliability of self-reported brain injury data relies on how well people interpret the questions. OBJECTIVE: This study examines how different yet commonly used questions may impact traumatic brain injury (TBI) estimates. METHODS: Self-report data were collected from 4,053 respondents in the summer wave of Porter Novelli's 2020 ConsumerStyles survey. Respondents were randomized to be asked about lifetime experience of either concussion or mild TBI (mTBI) and then asked follow-up questions. RESULTS: Approximately 25.5% of respondents reported sustaining a concussion in their lifetime while 17.2% reported an mTBI. The circumstances of the injuries, such as location and mechanism of injury, were similar. A greater percentage of individuals who were asked about concussions (91.1%) reported receiving a diagnosis for their most serious injury compared to those who were asked about diagnosis of an mTBI (69.9%). DISCUSSION: A greater percentage of respondents reported a lifetime history of concussion than mTBI. More respondents with a lifetime history of concussion reported receiving a diagnosis. These results suggest that the terminology used can impact reporting. These findings suggest that there is a meaningful difference in the understanding of the terms 'concussion' and 'mild TBI,' with people perceiving mTBI as a more serious injury.

Intimate Partner Violence and Health Conditions Among U.S. Adults-National Intimate Partner Violence Survey, 2010-2012.

INTRODUCTION: Few studies of intimate partner violence and health outcomes include multiple forms of intimate partner victimization, so this paper sought to examine health associations with intimate partner violence (IPV), including sexual, physical, stalking, and psychological forms, as well as polyvictimization. METHODS: Data are from the 2010-2012 National Intimate Partner and Sexual Violence Survey, an on-going national random-digit-dial telephone survey of U.S. adults. There were 41,174 respondents. Logistic regression was used to compute prevalence ratios for any IPV, adjusted for demographics and non-IPV victimization. For individual forms of IPV, prevalence ratios were further adjusted for other forms of IPV. Tests for linear trend in poly-victimization were performed. RESULTS: Any IPV was associated with all health conditions for both sexes with a few exceptions for males. Female penetrative sexual victimization and male stalking victimization were associated with the most health conditions. For each health condition, a significant linear trend indicated that as the number of forms of IPV experienced increased, prevalence of each health condition increased, with a few exceptions for males. CONCLUSIONS: It is important for service providers to screen for multiple forms of IPV, including psychological aggression, because individual forms or polyvictimization may have unique and cumulative health effects.

Concussion Evaluation Patterns Among US Adults.

OBJECTIVE: The objective of this study was to compare individuals who were not evaluated by a doctor or nurse for a self-reported concussion versus individuals who were evaluated for a concussion by demographic variables, concussion history, and concussion circumstances. SETTINGS AND PARTICIPANTS: Data were collected from 2018 SpringStyles, a web-based panel survey of US adults 18 years or older ( n = 6427), fielded in March-April. DESIGN: Cross-sectional. MAIN MEASURES: Respondents were asked whether they believed they had sustained a concussion in their lifetime and details about their most recent concussion, including whether they were evaluated by a doctor or nurse. RESULTS: Twenty-seven percent of adults in the survey reported a lifetime concussion ( n = 1835). Among those individuals, 50.4% were not evaluated by a healthcare provider for their most recent concussion. Not being evaluated was higher among individuals whose concussion was caused by a slip, trip, or fall (adjusted prevalence ratio [APR] = 2.22; 95% CI, 1.65-2.99), riding a bicycle (APR = 2.28; 95% CI, 1.58-3.27), being struck by or against something by accident (APR = 2.50; 95% CI, 1.88-3.34), or being struck by or against something during a fight or argument (APR = 2.89; 95% CI, 2.11-3.97), compared with individuals whose concussion was caused by a motor vehicle crash. No evaluation was also higher among individuals whose concussion occurred while engaging in a sports or recreational activity (APR = 1.39; 95% CI, 1.07-1.82) or engaging in regular activities around the house (APR = 1.65; 95% CI, 1.27-2.14), compared with individuals whose concussion occurred while working for pay. CONCLUSION: More than a quarter of adults reported a lifetime concussion; however, half of them were not evaluated for their last concussion by a healthcare provider. Examination by a healthcare professional for a suspected concussion may prevent or mitigate potential long-term sequelae. Furthermore, current US surveillance methods may underestimate the burden of TBI because many individuals do not seek evaluation.

Substance Use and Sports- or Physical Activity-Related Concussions Among High School Students.

History of concussion is associated with substance use. Data from the 2017 National Youth Risk Behavior Survey (N = 14,765) were used in this study to examine associations between sports- or physical activity-related concussions and current cigarette, alcohol, and marijuana use among high school students, and whether other factors moderate those associations. In addition to having played on a sports team, potential moderators examined included persistent feelings of sadness or hopelessness, hours of sleep, and serious difficulty concentrating, remembering, or making decisions. The association between sports- or physical activity-related concussions and current cigarette, alcohol, and marijuana use was significant when controlling for sex, grade, and race/ethnicity and the potential moderators with the exception of cigarette smoking while controlling for hours of sleep. Those involved in the care of high school students after a concussion may consider assessing current cigarette, alcohol, and marijuana use.

Symptom profile of affirmative responses to a self-report concussion question, United States 2019.

Information is limited about signs and symptoms experienced by individuals who self-report a concussion within surveys. The objective of this study was to assess the number and types of signs/symptoms adults experienced and whether or not medical attention was reported after sustaining a self-reported concussion in the past year. A sample of 3,624 adults responded to the web-based 2019 FallStyles survey. Respondents were asked if they had sustained a concussion in the past 12 months and if so, which (if any) signs/symptoms they experienced following the injury. The frequency and percentages of symptoms were calculated. Approximately 2.9% of respondents reported a concussion in the past year. Approximately two-thirds of respondents who reported sustaining a recent concussion stated that they experienced two or more signs/symptoms; the remaining one-third reported zero or one symptom. The findings suggest self-report concussion questions need additional improvement, particularly those that capture concussion using a single question, to improve the validity of self-reports.

Differences in Head Impact Exposures Between Youth Tackle and Flag Football Games and Practices: Potential Implications for Prevention Strategies.

BACKGROUND: Interventions designed to reduce the risk for head impacts and concussion in youth football have increased over the past decade; however, understanding of the role of regular game play on head impact exposure among youth tackle and flag football athletes is currently limited. PURPOSE: To explore head impact exposure among youth tackle and flag football athletes (age range, 6-14 years) during both practices and games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Using the Vector MouthGuard sensor, the authors collected head impact data from 524 tackle and flag youth football athletes over the course of a football season. Quantities of interest were estimated from regression models using Bayesian methods. RESULTS: For impacts ≥10g, a tackle football athlete had an estimated 17.55 (95% CI, 10.78-28.96) times more head impacts per practice compared with a flag football athlete (6.85 [95% CI, 6.05-7.76] and 0.39 [95% CI, 0.24-0.62] head impacts, respectively). Additionally, a tackle football athlete had an estimated 19.48 (95% CI, 12.74-29.98) times more head impacts per game compared with a flag football athlete (13.59 [95% CI, 11.97-15.41] and 0.70 [95% CI, 0.46-1.05] head impacts, respectively). Among tackle football athletes, the estimated average impact rate was 6.51 (95% CI, 5.75-7.37) head impacts during a practice and 12.97 (95% CI, 11.36-14.73) impacts during a game, resulting in 2.00 (95% CI, 1.74-2.29) times more ≥10g head impacts in games versus practices. Tackle football athletes had 2.06 (95% CI, 1.80-2.34) times more high-magnitude head impacts (≥40g) during a game than during a practice. On average, flag football athletes experienced an estimated 0.37 (95% CI, 0.20-0.60) head impacts during a practice and 0.77 (95% CI, 0.53-1.06) impacts during a game, resulting in 2.06 (95% CI, 1.29-3.58) times more ≥10g head impacts in games versus practices. Because of model instability caused by a large number of zero impacts for flag football athletes, a comparison of high-magnitude head impacts is not reported for practices or games. CONCLUSION: This study provides a characterization of the head impact exposure of practices and games among a large population of youth tackle and flag football athletes aged 6 to 14 years. These findings suggest that a greater focus on game-based interventions, such as fair play interventions and strict officiating, may be beneficial to reduce head impact exposures for youth football athletes.

Head Impact Exposures Among Youth Tackle and Flag American Football Athletes.

BACKGROUND: Promoted as a safer alternative to tackle football, there has been an increase in flag football participation in recent years. However, examinations of head impact exposure in flag football as compared with tackle football are currently limited. HYPOTHESIS: Tackle football athletes will have a greater number and magnitude of head impacts compared with flag football athletes. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: Using mouthguard sensors, this observational, prospective cohort study captured data on the number and magnitude of head impacts among 524 male tackle and flag football athletes (6-14 years old) over the course of a single football season. Estimates of interest based on regression models used Bayesian methods to estimate differences between tackle and flag athletes. RESULTS: There were 186,239 head impacts recorded during the study. Tackle football athletes sustained 14.67 (95% CI 9.75-21.95) times more head impacts during an athletic exposure (game or practice) compared with flag football athletes. Magnitude of impact for the 50th and 95th percentile was 18.15g (17.95-18.34) and 52.55g (51.06-54.09) for a tackle football athlete and 16.84g (15.57-18.21) and 33.51g (28.23-39.08) for a flag football athlete, respectively. A tackle football athlete sustained 23.00 (13.59-39.55) times more high-magnitude impacts (≥40g) per athletic exposure compared with a flag football athlete. CONCLUSION: This study demonstrates that youth athletes who play tackle football are more likely to experience a greater number of head impacts and are at a markedly increased risk for high-magnitude impacts compared with flag football athletes. CLINICAL RELEVANCE: These results suggest that flag football has fewer head impact exposures, which potentially minimizes concussion risk, making it a safer alternative for 6- to 14-year-old youth football athletes.

Sports- and Physical Activity-Related Concussion and Risk for Youth Violence.

INTRODUCTION: Sports and physical activities are an important cause of traumatic brain injury among adolescents. Childhood traumatic brain injury has been associated with cognitive impairment, emotional problems, and impaired behavior control, and these neuropsychological changes may place these youth at increased risk for engagement in violence-related behaviors. METHODS: Data from the 2017 National Youth Risk Behavior Survey (N=14,765), a nationally representative survey of U.S. high school students, were analyzed in 2019 to examine the associations between sports- and physical activity-related concussion and violence-related behaviors occurring in the community and at school. Multivariable logistic regression models were used to calculate sex-stratified, adjusted (for race/ethnicity, grade, athlete status, impaired cognitive functioning, feeling sad/hopeless, and current substance use) prevalence ratios. Prevalence ratios were considered statistically significant if p<0.05. RESULTS: Male students (17.1%) were more likely than female students (13.0%) to experience a sports- and physical activity-related concussion during the 12 months preceding the survey. Compared with students who did not have a concussion, those who experienced ≥1 sports- and physical activity-related concussion were more likely to be in a physical fight (male students, adjusted prevalence ratio=1.45; female students, adjusted prevalence ratio=1.55), carry a weapon (male students, adjusted prevalence ratio=1.24; female students, adjusted prevalence ratio=1.79), and fight at school (male students, adjusted prevalence ratio=1.40; female students, adjusted prevalence ratio=1.77). In addition, male students were more likely to carry a gun (adjusted prevalence ratio=1.62) and carry a weapon at school (adjusted prevalence ratio=1.73). CONCLUSIONS: Although the direction of these associations is unknown, return-to-school programs may benefit from inclusion of assessment and counseling around issues of psychological and social functioning, conflict resolution, and coordination with violence prevention programs.

Comparing prevalence estimates of concussion/head injury in U.S. children and adolescents in national surveys.

BACKGROUND AND OBJECTIVES: Reports on pediatric lifetime concussions/head injuries (LCHI) from national surveys have offered estimates on prevalence that range from 2.5% to 18% in the general population. The purpose of this study is to examine national surveys to compare methodologies and limitations pertaining to LCHI data collection. METHODS: Three nationally representative surveys that measure LCHI in children, including the National Survey of Children's Health, the National Health Interview Survey, and the Monitoring the Future Survey were examined. Children were grouped by ages 3-17 years and adolescent ages 13-17 years, stratified by selected demographic characteristics. Participants in the surveys included parents (NSCH and NHIS) and adolescents (MTF survey). The primary outcome measure is an estimate of LCHI in children. RESULTS: Estimates of prevalence of LCHI ranged from 3.6% to 7.0% for children ages 3-17 years and from 6.5% to 18.3% for adolescents 13-17 years. Survey modality, question wording, and respondent may contribute to differing estimates. Prevalence showed consistent variation by age, sex, and race/ethnicity across surveys. Associations were inconsistent between LCHI and insurance status, parental education, and household primary language. CONCLUSIONS: Although there are methodological differences in capturing pediatric LCHI across surveys, the prevalence estimates and correlational associations generated can offer awareness about the burden of these injuries and insights to research and clinical care.

Understanding Traumatic Brain Injury in Females: A State-of-the-Art Summary and Future Directions.

In this report, we identify existing issues and challenges related to research on traumatic brain injury (TBI) in females and provide future directions for research. In 2017, the National Institutes of Health, in partnership with the Center for Neuroscience and Regenerative Medicine and the Defense and Veterans Brain Injury Center, hosted a workshop that focused on the unique challenges facing researchers, clinicians, patients, and other stakeholders regarding TBI in women. The goal of this "Understanding TBI in Women" workshop was to bring together researchers and clinicians to identify knowledge gaps, best practices, and target populations in research on females and/or sex differences within the field of TBI. The workshop, and the current literature, clearly highlighted that females have been underrepresented in TBI studies and clinical trials and have often been excluded (or ovariectomized) in preclinical studies. Such an absence in research on females has led to an incomplete, and perhaps inaccurate, understanding of TBI in females. The presentations and discussions centered on the existing knowledge regarding sex differences in TBI research and how these differences could be incorporated in preclinical and clinical efforts going forward. Now, a little over 2 years later, we summarize the issues and state of the science that emerged from the "Understanding TBI in Women" workshop while incorporating updates where they exist. Overall, despite some progress, there remains an abundance of research focused on males and relatively little explicitly on females.

Characteristics of Diagnosed Concussions in Children Aged 0 to 4 Years Presenting to a Large Pediatric Healthcare Network.

OBJECTIVE: The aim of the study was to comprehensively describe the natural history of concussion in early childhood between 0 and 4 years. METHODS: Retrospective cohort study of 329 patients aged 0 to 4 years, with an International Classification of Diseases, Ninth Revision, concussion diagnosis in the Children's Hospital of Philadelphia healthcare network from October 1, 2013, to September 30, 2015. Clinical data were abstracted from the Children's Hospital of Philadelphia electronic health record, which captured all clinical care visits and injury characteristics. RESULTS: Nearly 9 (86.6%) of 10 patients sought care in the emergency department or urgent care setting, most commonly on the day of injury (56.2%) and as a result of a fall (64.4%). More than two-thirds (64.4%) of patients or their parent/caregiver reported somatic symptoms (ie, vomiting or headache), whereas close to half (49.2%) reported sleep issues. One of 5 patients identified emotional symptoms (21.9%) or visio-vestibular dysfunction (20.4%). Many patients also experienced symptoms not included in standard assessment tools including personality changes (34.0%) and change in appetite (12.8%). CONCLUSIONS: These results provide insight into the clinical characteristics of concussion in early childhood up to 4 years of age. Because assessment in this group relies heavily on parent/caregiver symptom reporting, rather than patient self-report, these results will aid clinicians with the challenge of diagnosing concussions in this population. These findings highlight the need to develop additional tools to adequately and systematically assess common signs and symptoms of concussion in early childhood that may not be included in standard assessment scales routinely used in older adolescents and adults.

The Association Between Sports- or Physical Activity-Related Concussions and Suicidality Among US High School Students, 2017.

BACKGROUND: This study examined the association between sports- or physical activity-related concussions and having seriously considered attempting suicide, made a suicide plan, or attempted suicide (ie, suicidality), and tested potential moderators of the association. HYPOTHESIS: Risk factors such as persistent feelings of sadness or hopelessness, low academic grades, few hours of sleep, and current alcohol or marijuana use will increase the odds of suicidality among those who self-reported sports- or physical activity-related concussions, while protective factors such as physical activity and having played on a sports team will decrease the odds. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: This study used data from the 2017 Youth Risk Behavior Survey, a biennial, school-based, nationally representative survey of US students in grade levels 9 to 12 (N = 14,765). Logistic regression models examined associations between self-reported sports- or physical activity-related concussions and suicidality among the students, and whether physical activity, having played on a sports team, persistent feelings of sadness or hopelessness, academic grades, hours of sleep, or current alcohol or marijuana use moderated those associations. RESULTS: Sports- or physical activity-related concussions were found to be associated with suicidality. The associations remained significant in models that adjusted for demographic characteristics, and they did not appear to be moderated by physical activity, having played on sports team, academic grades, or sleep. CONCLUSIONS: Given the findings of this study and others, health care providers are advised to ask students who have experienced a concussion about their emotional well-being as part of their symptom-based assessment, using validated, age- appropriate concussion symptom scales. Comprehensively assessing students who have experienced a sports- or physical activity-related concussion for persistent feelings of sadness or hopelessness may alert providers to thoughts of suicidal ideation and will allow for earlier intervention. CLINICAL RELEVANCE: If thoughts of suicide are discovered among adolescents with a concussion, or if other risk factors are observed, referrals to medical and mental health providers for a more comprehensive assessment may be warranted.

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management.

OBJECTIVE: To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN: A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS: Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS: Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

Examination of sports and recreation-related concussion among youth ages 12-17: results from the 2018 YouthStyles survey.

Background: This paper sought to examine the frequency of self-reported sports- and recreation-related (SRR) concussion, as well as care-seeking behaviors and potential activity restrictions after concussions, in a sample of youth.Methods: A sample of 845 youth ages 12-17 years responded to the web-based YouthStyles survey in 2018. The survey measured the frequency of self-reported lifetime SRR concussion, the setting of their most recent SRR concussion, whether a doctor or nurse evaluated them, and the types of activity restrictions they experienced.Results: Forty-three percent of youth surveyed sustained their most recent concussion while playing on a sports team, 21.1% while playing on a community-based team, and 36.0% while engaged in a sport or recreational activity. Nearly half (45.3%) reported having to miss playing sports or participating in physical activity for at least one day; about two in ten (19.7%) reported having to miss time on their phone or computer for at least one day.Conclusion: Despite wide-spread efforts to promote protocols for SRR concussion among youth, a third of participants in this study did not seek medical care and more than half did not miss at least one day of sports or physical activity participation following a concussion.

Self-Reported Lifetime Concussion Among Adults: Comparison of 3 Different Survey Questions.

OBJECTIVE: Because of limitations in current national data sets, respondent self-report may be critical to obtaining concussion prevalence estimates. We examined whether self-report of lifetime concussion among adults varies with the provision of a concussion definition and by the content of that definition. SETTING AND PARTICIPANTS: A convenience sample of 6427 American adults who participated in the 2018 Porter Novelli SpringStyles survey. DESIGN: Cross-sectional. MAIN MEASURES: Frequency of self-reported concussion by variation in concussion definition. RESULTS: A quarter of respondents (28.9%) reported experiencing a concussion in their lifetime. While concussion prevalence varied by demographic characteristics, it did not vary significantly by concussion definition. Variation in concussion definition did not result in differences related to recency of last concussion, mechanism of injury, or respondent activity engaged in during which they sustained their most recent concussion. CONCLUSION: The current study suggested that in this sample of adults, the percentage reporting a concussion did not significantly vary by whether a concussion definition was provided or by the content of the definition. However, research suggests that prompting about mechanism of injury, listing symptoms individually, and considering only athletic populations may affect estimates and these factors should be included in future question comparisons.

Concussion and Academic Impairment Among U.S. High School Students.

INTRODUCTION: Sports and physical activities are a frequent cause of traumatic brain injury, primarily concussions, among adolescents. These concussions may adversely affect students' ability to learn and impair academic achievement in educational settings. METHODS: The 2017 Youth Risk Behavior Survey, conducted among a nationally representative sample of 14,765 U.S. high school students, was analyzed in 2018 to examine associations between self-reported sports- and physical activity-related concussions and symptoms of cognitive impairment (difficulty concentrating, remembering, or making decisions) and self-reported academic grades (mostly A's=4.0, mostly B's=3.0, mostly C's=2.0, mostly D's=1.0, mostly F's=0.0). Adjusted prevalence ratio and the difference in self-reported estimated grade point average were adjusted for sex, race/ethnicity, grade, and athlete status (participation on sports teams) and considered statistically significant if p<0.05. RESULTS: Male students were more likely than female students (17.1% vs 13.0%), and athletes were more likely than nonathletes (21.4% vs 7.6%) to have a self-reported sports- and physical activity-related concussion in the 12 months preceding the survey. Students with a reported sports- and physical activity-related concussion were more likely than students without one to report symptoms of cognitive impairment regardless of whether they were male (adjusted prevalence ratio=1.49), female (adjusted prevalence ratio=1.37), athletes (adjusted prevalence ratio=1.45), or nonathletes (adjusted prevalence ratio=1.42). Self-reported grade point averagedecreased significantly from 3.14 among students who reported no concussions (referent), to 3.04 among students who reported a single concussion, and 2.81 among students who reported ≥2 concussions. CONCLUSIONS: School-based programs are needed to monitor students' academic performance and provide educational support and resources to promote academic success following a concussion.