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Disruptions in gait function are common after concussion in adolescents; however, the neuromotor control deficits driving these gait disruptions are not well known. Fifteen concussed (age mean [SD]): 17.4 [0.6], 13 females, days since injury: 26.3 [9.9]) and 17 uninjured (age: 18.0 [0.7], 10 females) adolescents completed 3 trials each of single-task gait and dual-task gait (DT). During DT, participants simultaneously walked while completing a serial subtraction task. Gait metrics and variability in instantaneous mean frequency in lower extremity muscles were captured by inertial sensors and surface electromyography, respectively. A 2-way analysis of covariance was used to compare gait metrics across groups and conditions. Functional principal components analysis was used to identify regions of variability in instantaneous mean frequency curves. Functional principal component scores were compared across groups using a Welch statistic. Both groups displayed worse performance on gait metrics during DT condition compared to single-task, with no differences between groups (P <.001). Concussed adolescents displayed significantly greater instantaneous mean frequency, indicated by functional principal component 1, in the tibialis anterior, biceps femoris, and semitendinosus (P <.05) during single-task and DT compared with uninjured adolescents. Our observations suggest that concussed adolescents display inefficient motor unit recruitment lasting longer than 2 weeks following injury, regardless of the addition of a secondary task. [ABSTRACT FROM AUTHOR]

Concussion research has primarily focused on sport-related mechanisms and excluded non–sport-related mechanisms. In adult populations, non–sport-related concussions (non-SRCs) demonstrated worse clinical outcomes compared with sport-related concussions (SRCs); however, investigations of non-SRCs in college-aged patients are limited. To examine clinical outcomes in collegiate athletes with non-SRCs compared with SRCs and explore sex differences in outcomes among collegiate athletes with non-SRCs. Prospective cohort study. Clinical setting. A total of 3500 athletes were included (n = 555 with non-SRCs, 42.5% female) from colleges or universities and service academies participating in the National Collegiate Athletic Association Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. Dichotomous outcomes (yes or no) consisted of immediate reporting, mental status alterations, loss of consciousness, posttraumatic amnesia, retrograde amnesia, motor impairments, delayed symptom presentation, and required hospital transport. Continuous outcomes were symptom severity, days with concussion symptoms, and days lost to injury. Data were collected within 24 to 48 hours of injury and at return to play. Adjusted relative risks (ARRs) compared the likelihood of dichotomous outcomes by mechanism and by sex within patients with non-SRCs. Multivariate negative binomial regressions were used to assess group differences in continuous variables. Athletes with non-SRCs were less likely to report immediately (ARR = 0.73, 95% CI = 0.65, 0.81) and more likely to report delayed symptom presentation (ARR = 1.17, 95% CI = 1.03, 1.32), loss of consciousness (ARR = 3.15, 95% CI = 2.32, 4.28), retrograde amnesia (ARR = 1.77, 95% CI = 1.22, 2.57), and motor impairment (ARR = 1.45, 95% CI = 1.14, 1.84). Athletes with non-SRCs described greater symptom severity, more symptomatic days, and more days lost to injury (P <.001) compared with those who had SRCs. Within the non-SRC group, female athletes indicated greater symptom severity, more symptomatic days, and more days lost to injury (P <.03) than male athletes. Athletes with non-SRCs had worse postinjury outcomes compared with those who had SRCs, and female athletes with non-SRCs had worse recovery metrics than male athletes. Our findings suggest that further investigation of individuals with non-SRCs is needed to improve concussion reporting and management. [ABSTRACT FROM AUTHOR]

Background: While concussions are common pediatric injuries, a lack of agreement on a standard definition of recovery creates multiple challenges for clinicians and researchers alike. Hypothesis: The percentage of concussed youth deemed recovered as part of a prospective cohort study will differ depending on the recovery definition. Study Design: Descriptive epidemiologic study of a prospectively enrolled observational cohort Level of Evidence: Level 3. Methods: Participants aged 11 to 18 years were enrolled from the concussion program of a tertiary care academic center. Data were collected from initial and follow-up clinical visits ≤12 weeks from injury. A total of 10 recovery definitions were assessed: (1) cleared to full return to sports; (2) return to full school; (3) self-reported return to normal; (4) self-reported full return to school; (5) self-reported full return to exercise; (6) symptom return to preinjury state; (7) complete symptom resolution; (8) symptoms below standardized threshold; (9) no abnormal visio-vestibular examination (VVE) elements; and (10) ≤1 abnormal VVE assessments. Results: In total, 174 participants were enrolled. By week 4, 63.8% met at least 1 recovery definition versus 78.2% by week 8 versus 88.5% by week 12. For individual measures of recovery at week 4, percent recovered ranged from 5% by self-reported full return to exercise to 45% for ≤1 VVE abnormality (similar trends at 8 and 12 weeks). Conclusion: There is wide variability in the proportion of youth considered recovered at various points following concussion depending on the definition of recovery, with higher proportions using physiologic examination-based measures and lower proportions using patient-reported measures. Clinical Relevance: These results further emphasize the need for a multimodal assessment of recovery by clinicians as a single and standardized definition of recovery that captures the broad impact of concussion on a given patient continues to be elusive. [ABSTRACT FROM AUTHOR]

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., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Approximately 20% of students with sport-related concussion (SRC) report new symptoms of anxiety and depression which may be associated with delayed recovery and increased risk for developing a mood disorder. Early prescribed aerobic exercise facilitates recovery in athletes with concussion-related exercise intolerance. We studied the effect of aerobic exercise treatment on new mood symptoms early after SRC., Design: Exploratory secondary analysis of 2 randomized controlled trials (RCT)., Setting: Sports medicine clinics associated with UB (Buffalo, NY), CHOP (Philadelphia, PA), and Boston Children's Hospital (Boston, MA)., Participants: Male and female adolescents (aged 13-18 years) diagnosed with SRC (2-10 days since injury)., Interventions: Participants were randomized to individualized targeted heart rate aerobic exercise (n = 102) or to a placebo intervention designed to mimic relative rest (n = 96)., Main Outcome Measures: Incidence of Persisting Post-Concussive Symptoms (PPCS, symptoms ≥28 days)., Results: First RCT recruited from 2016 to 2018 and the second from 2018 to 2020. Of 198 adolescents, 156 (79%) reported a low burden (mean 1.2 ± 1.65/24) while 42 (21%) reported a high burden (mean 9.74 ± 3.70/24) of emotional symptoms before randomization. Intervention hazard ratio for developing PPCS for low burden was 0.767 (95% CI, 0.546-1.079; P = 0.128; β = 0.085) and for high burden was 0.290 (95% CI, 0.123-0.683; P = 0.005; β = 0.732)., Conclusions: High burden of mood symptoms early after injury increases risk for PPCS, but the sports medicine model of providing early targeted aerobic exercise treatment reduces it. Nonsports medicine clinicians who treat patients with a high burden of new mood symptoms after concussion should consider prescribing aerobic exercise treatment to reduce the risk of PPCS and a mood disorder., Competing Interests: The authors do not declare any relevant conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Paediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the benefit of early, active, targeted therapeutic strategies. However, these are primarily prescribed from the specialty setting. Early access to concussion specialty care has been shown to improve recovery times for those at risk for persisting symptoms, but there are disparities in which youth are able to access such care. Mobile health (mHealth) technology has the potential to improve access to concussion specialists. This trial will evaluate the feasibility of a mHealth remote patient monitoring (RPM)-based care handoff model to facilitate access to specialty care, and the effectiveness of the handoff model in reducing the incidence of PPCS., Methods and Analysis: This study is a non-randomised type I, hybrid implementation-effectiveness trial. Youth with concussion ages 13-18 will be enrolled from the emergency department of a large paediatric healthcare network. Patients deemed a moderate-to-high risk for PPCS using the predicting and preventing postconcussive problems in paediatrics (5P) stratification tool will be registered for a web-based chat platform that uses RPM to collect information on symptoms and activity. Those patients with escalating or plateauing symptoms will be contacted for a specialty visit using data collected from RPM to guide management. The primary effectiveness outcome will be the incidence of PPCS, defined as at least three concussion-related symptoms above baseline at 28 days following injury. Secondary effectiveness outcomes will include the number of days until return to preinjury symptom score, clearance for full activity and return to school without accommodations. The primary implementation outcome will be fidelity, defined as the per cent of patients meeting specialty care referral criteria who are ultimately seen in concussion specialty care. Secondary implementation outcomes will include patient-defined and clinician-defined appropriateness and acceptability., Ethics and Dissemination: This study was approved by the Institutional Review Board of the Children's Hospital of Philadelphia (IRB 22-019755). Study findings will be published in peer-reviewed journals and disseminated at national and international meetings., Trial Registration Number: NCT05741411., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and nonsport or recreation-related concussion (non-SRRC) in patients 5 through 12 years old, an understudied population in youth concussion., Study Design: This observational study included patients aged 5 through 12 years presenting to a specialty care concussion setting at ≤28 days postinjury from 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Posthoc pairwise comparisons were employed for all analyses (α = 0.017)., Results: One thousand one hundred forty-one patients reported at ≤28 days of injury (female = 42.9%, median age = 11, interquartile range (IQR) = 9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (P < .001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 2 and 3 days later than SRC (P < .001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (P < .001) compared with RRC and SRC (P < .001)., Conclusions: In concussion patients 5 through 12 years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury., Competing Interests: Declaration of Competing Interest This study was funded by the National Institute of Neurologic Disorders and Stroke of the National Institutes of Health under award numbers R01NS097549 (Christina Master and Kristy Arbogast) and T32NS043126 (Patricia Roby) and the Pennsylvania Department of Health. The authors declare no conflicts of interest. The funder/sponsor did not participate in the work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: A concussion is a common adolescent injury that can result in a constellation of symptoms, negatively affecting academic performance, neurobiological development, and quality of life. Mobile health (mHealth) technologies, such as apps for patients to report symptoms or wearables to measure physiological metrics like heart rate, have been shown to be promising in health maintenance. However, there is limited evidence about mHealth engagement in adolescents with a concussion during their recovery course., Objective: This study aims to determine the response rate and response rate patterns in concussed adolescents reporting their daily symptoms through mHealth technology. It will also examine the effect of time-, demographic-, and injury-related characteristics on response rate patterns., Methods: Participants aged between 11-18 years (median days since injury at enrollment: 11 days) were recruited from the concussion program of a tertiary care academic medical center and a suburban school's athletic teams. They were asked to report their daily symptoms using a mobile app. Participants were prompted to complete the Post-Concussion Symptom Inventory (PCSI) 3 times (ie, morning, afternoon, and evening) per day for 4 weeks following enrollment. The primary outcome was the response rate pattern over time (by day since initial app use and the day since injury). Time-, demographic-, and injury-related differences in reporting behaviors were compared using Mann Whitney U tests., Results: A total of 56 participants were enrolled (mean age 15.3, SD 1.9 years; n=32, 57% female). The median response rate across all days of app use in the evening was 37.0% (IQR 27.2%-46.4%), which was significantly higher than the morning (21.2%, IQR 15.6%-30.5%) or afternoon (26.4%, IQR 21.1%-31.5%; P<.001). The median daily response was significantly different by sex (female: 53.8%, IQR 46.2%-64.2% vs male: 42.0%, IQR 28.6%-51.1%; P=.003), days since injury to app use (participants starting to use the app >7 days since injury: 54.1%, IQR 47.4%-62.2% vs starting to use the app ≤7 days since injury: 38.0%, IQR 26.0%-53.3%; P=.002), and concussion history (participants with a history of at least one prior concussion: 57.4%, IQR 44.5%-70.5% vs participants without concussion history: 42.3%, IQR 36.8%-53.5%; P=.03). There were no significant differences by age. Differences by injury mechanism (sports- and recreation-related injury: 39.6%, IQR 36.1%-50.4% vs non-sports- or recreation-related injury: 30.6%, IQR 20.0%-42.9%; P=.04) and initial symptom burden (PCSI scores greater than the median score of 47: 40.9%, IQR 35.2%-53.8% vs PCSI scores less than or equal to the median score: 31.9%, IQR 24.6%-40.6%; P=.04) were evident in the evening response rates; however, daily rates were not statistically different., Conclusions: Evening may be the optimal time to prompt for daily concussion symptom assessment among concussed adolescents compared with morning or afternoon. Multiple demographic- and injury-related characteristics were associated with higher daily response rates, including for female participants, those with more than 1 week from injury to beginning mHealth monitoring, and those with a history of at least one previous concussion. Future studies may consider incentive strategies or adaptive digital concussion assessments to increase response rates in populations with low engagement., (© Sicong Ren, Catherine C McDonald, Daniel J Corwin, Douglas J Wiebe, Christina L Master, Kristy B Arbogast. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org).)

Background: Few previous studies have investigated how different injury mechanisms leading to sport-related concussion (SRC) in soccer may affect outcomes., Purpose: To describe injury mechanisms and evaluate injury mechanisms as predictors of symptom severity, return to play (RTP) initiation, and unrestricted RTP (URTP) in a cohort of collegiate soccer players., Study Design: Cohort study; Level of evidence, 2., Methods: The Concussion Assessment, Research and Education (CARE) Consortium database was used. The mechanism of injury was categorized into head-to-ball, head-to-head, head-to-body, and head-to-ground/equipment. Baseline/acute injury characteristics-including Sports Concussion Assessment Tool-3 total symptom severity (TSS), loss of consciousness (LOC), and altered mental status (AMS); descriptive data; and recovery (RTP and URTP)-were compared. Multivariable regression and Weibull models were used to assess the predictive value of the mechanism of injury on TSS and RTP/URTP, respectively., Results: Among 391 soccer SRCs, 32.7% were attributed to a head-to-ball mechanism, 27.9% to a head-to-body mechanism, 21.7% to a head-to-head mechanism, and 17.6% to a head-to-ground/equipment mechanism. Event type was significantly associated with injury mechanism [χ 2 (3) = 63; P < .001), such that more head-to-ball concussions occurred in practice sessions (n = 92 [51.1%] vs n = 36 [17.1%]) and more head-to-head (n = 65 [30.8%] vs n = 20 [11.1]) and head-to-body (n = 76 [36%] vs n = 33 [18.3%]) concussions occurred in competition. The primary position was significantly associated with injury mechanism [χ 2 (3) = 24; P < .004], with goalkeepers having no SRCs from the head-to-head mechanism (n = 0 [0%]) and forward players having the least head-to-body mechanism (n = 15 [19.2%]). LOC was also associated with injury mechanism ( P = .034), with LOC being most prevalent in head-to-ground/equipment. Finally, AMS was most prevalent in head-to-ball (n = 54 [34.2%]) and head-to-body (n = 48 [30.4%]) mechanisms [χ 2 (3) = 9; P = .029]. In our multivariable models, the mechanism was not a predictor of TSS or RTP; however, it was associated with URTP ( P = .044), with head-to-equipment/ground injuries resulting in the shortest mean number of days (14 ± 9.1 days) to URTP and the head-to-ball mechanism the longest (18.6 ± 21.6 days)., Conclusion: The mechanism of injury differed by event type and primary position, and LOC and AMS were different across mechanisms. Even though the mechanism of injury was not a significant predictor of acute symptom burden or time until RTP initiation, those with head-to-equipment/ground injuries spent the shortest time until URTP, and those with head-to-ball injuries had the longest time until URTP., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This project was supported, in part, by the Grand Alliance Sport-Related Concussion Assessment, Research, and Education (CARE) Consortium, funded, in part by the National Collegiate Athletic Association (NCAA) and the DoD. The U.S. Army Medical Research Acquisition Activity is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under award No. W81XWH-14-2-0151. A.J.B. has been part of projects that have received funding from the DoD, the National Operating Committee on Standards from Athletic Equipment, the National Athletic Trainer's Association (NATA) Research and Education Foundation, and the NCAA. P.F.P. is an employee of the DoD and has previously received other DoD-related grants. T.W.M. has received research support from the NCAA, the US DoD, and the National Institutes of Health (NIH). He also reports textbook royalties from American Psychiatric Press Publishing Inc and serves on the Concussion Committee Scientific Advisory Board for the Australian Football League. M.A.M. has received research funding from the NIH, the Centers for Disease Control and Prevention (CDC), the DoD, the NCAA, the National Football League (NFL), and Abbott Laboratories. S.P.B. has received research funding from the NIH, the CDC, the DoD-USA Medical Research Acquisition Activity, the NCAA, the NATA Research and Education Foundation, the NFL/Under Armour/GE, Simbex, and ElmindA. He has consulted for US Soccer, US Cycling, the University of Calgary SHRed Concussions external advisory board, and medicolegal litigation. S.L.Z. is a member of the NFL Head, Neck, and Spine Committee. D.P.T. serves as a scientific advisor for HitIQ. He previously consulted for REACT Neuro Inc. He has a consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild traumatic brain injury (including former athletes). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objective: To understand factors associated with missed academic time after concussion to improve support for patients. Our goal was to assess patient-specific predictors of total school time lost after pediatric/adolescent concussion., Study Design: We performed a prospective cohort study of children and adolescents (8-18 years of age) seen within 14 days of concussion from seven pediatric medical centers across the United States. We collected outcomes via the Concussion Learning Assessment & School Survey (CLASS) and constructed a multivariable predictive model evaluating patient factors associated with school time loss., Results: 167 patients participated (mean age = 14.5 ± 2.2 years; 46% female). Patients were assessed initially at 5.0 ± 3.0 days post-injury and had a final follow-up assessment 24.5 ± 20.0 days post-concussion. Participants missed a median of 2 days of school (IQR = 0.5-4), and 21% reported their grades dropped after concussion. Higher initial symptom severity rating (β = 0.06, 95% CI = 0.03-0.08, p  < 0.001) and perception of grades dropping after concussion (β = 1.37, 95% CI = 0.28-2.45, p  = 0.01) were significantly associated with more days of school time missed after concussion. Those who reported their grades dropping reported missing significantly more school (mean = 5.0, SD = 4.7 days missed of school) than those who reported their grades did not drop (mean = 2.2, SD = 2.6 days missed of school; p  < 0.001; Cohen's d = 0.87)., Conclusions: Children and adolescents reported missing a median of 2 days of school following concussion, and more missed school time after a concussion was associated with more severe concussion symptoms and perception of grades dropping. These findings may support recommendations for minimal delays in return-to-learn after concussion.