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OBJECTIVE The avoidance-endurance model (AEM) proposes multiple pathways from acute to chronic pain, with distinct cognitive and behavioral components in each pathway. The AEM may also be applicable to persistent symptoms after concussion. In this study, we tested the AEM as an explanatory framework for concussion outcomes, by using mediation analyses through the proposed psychological mechanisms. Based on the AEM, we hypothesized that postconcussion symptoms would significantly predict avoidance behavior through catastrophizing, and endurance behavior through thought suppression and self-distraction. PARTICIPANTS AND METHODS We recruited 84 adults seeking treatment at 2 outpatient concussion clinics (M = 41.8 years old, 63% female) who completed measures of postconcussion symptoms, catastrophizing, thought suppression, "self-distraction" (Five Factor Mindfulness Questionnaire "Act with Awareness" Scale reverse-scored), avoidance behavior, and endurance behavior at an average of 17.8 weeks postconcussion. We conducted 3 mediation analyses to assess each of the AEM pathways. RESULTS We found a significant indirect effect of postconcussion symptoms on avoidance behavior through catastrophizing (ab = .113 (.036), 95% CI [.053, .195]). The indirect effects of postconcussion symptoms on endurance behavior through thought suppression (ab = .011 (.012), 90% CI [.002, .035]) and "self-distraction" (ab = .003 (.009), 90% CI [.008, .022]) were not statistically significant. CONCLUSIONS Results supported the catastrophizing-avoidance pathway in concussion, but not the thought-suppression-endurance or self-distraction-endurance pathways. Therefore, catastrophic thinking about concussion symptoms may be an appropriate treatment target for individuals who exhibit fear-avoidance behavior. Further research is needed to establish whether thought suppression and self-distraction are relevant for interventions aimed at reducing excessive endurance behavior. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

OBJECTIVE Fear avoidance behavior after a concussion or mild traumatic brain injury (mTBI) is associated with a number of adverse outcomes, such as higher symptom burden, emotional distress, and disability. The Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) is a recently developed and validated self-report measure of fear avoidance after mTBI. The objective of this study was to derive clinical normative data for the FAB-TBI. To determine whether demographic stratification was necessary and to further support clinical interpretation, we also explored associations between fear avoidance behavior and demographic and injury variables. SETTING Five concussion clinics in Canada. PARTICIPANTS Adults who sustained an mTBI (N = 563). DESIGN Cross-sectional. MAIN MEASURES Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) and measures of postconcussion symptom burden (Rivermead Postconcussion Symptoms Questionnaire, Sport Concussion Assessment Tool-5) at clinic intake. RESULTS Generalized linear modeling revealed that females reported more fear avoidance than males (95% CI = 0.66 to 2.75), indicating that FAB-TBI normative data should be stratified by sex. Differences between recruitment sites on FAB-TBI scores were reduced but not eliminated by controlling for potential confounds. Loss of consciousness (95% CI =0.61 to 2.76) and higher postconcussion symptom burden (95% CI = 0.79 to 1.03) were also associated with higher FAB-TBI scores, but time since injury was not (95% = CI -0.4 to 0.03). Tables to convert FAB-TBI raw scores to Rasch scores to percentiles are presented. CONCLUSION These findings support clinical interpretation of the FAB-TBI and further study of fear avoidance after mTBI.

Background:Involving stakeholders has been acknowledged as a way to improve quality and relevance in health research. The mechanisms that support effective research engagement with stakeholders have not been studied in the area of concussion. Concussion is a large public health concern worldwide with billions of dollars spent on health care services and research with improvements in care and service delivery not moving forward as quickly as desired. Enabling effective stakeholder engagement could improve concussion research and care.Objective:The aim of the study was to identify potential benefits, challenges, and motivators to engaging in research by gathering the perspectives of adults with lived experience of concussion.Methods:A thematic analysis of qualitative responses collected from a convenience sample attending a provincial brain injury conference (n = 60) was undertaken using open coding followed by axial coding.Results:Four themes regarding benefits to engagement emerged: first-hand account, meaningful recovery, research relevance, and better understanding of gaps. Three forces inhibited engagement: environmental barriers, injury-related constraints, and personal deterrents. Four enablers supported engagement: focus on positive impact, build connections, create a supportive environment, and provide financial assistance.Conclusions:Understanding stakeholder’s perspectives on research engagement is an important issue that may serve to improve research quality. There may be unique nuances at play with injury-specific stakeholders that require researchers to consider a balance between reducing inhibitors while supporting enablers. These findings are preliminary and limited. Nevertheless, they provide needed insight and guidance for ongoing investigation regarding improvement of stakeholder engagement in concussion research.

Objective:Indigenous youth are vulnerable to concussion when playing hockey. A clear characterisation of sex differences among Indigenous youth could assist in tailoring future education programmes for prevention and management of concussion. The purpose of this study was to compare and contrast concussion knowledge, attitudes and resources in First Nations girls and boys playing recreational hockey.Method:The cross-sectional survey was conducted in partnership with a First Nations’ chief, other Indigenous community leaders and a tertiary care head injury clinic. In Canada, researchers engaging with Indigenous peoples are expected to adhere to principles of Ownership, Control, Access and Possessions. The study included Indigenous boys and girls between the ages of 10 and 18 years of age.Results:More girls attending the hockey tournament participated in the study as compared to boys (girlsn= 46, boysn= 29). More girls reported they had never experienced a concussion (73.9%), as compared to boys (58.6%) self-reports. Less than half of all study participants were able to identify some signs and symptoms of concussion such as vomiting/nausea, memory problems, fatigue and blurred vision and recognition of several concussion symptoms varied by sex.Conclusions:We created a unique partnership between Indigenous leaders and tertiary care clinic staff. Among Indigenous youth reasons for not reporting concussion symptoms to the coach varied by sex (although not reaching statistical significance), suggesting concussion education warrants tailoring for girls and boys.

OBJECTIVE The purpose of this pilot study was twofold: (1) to begin to understand concussion in youth hockey in a First Nations community in Canada and (2) to determine the impact of a novel concussion education workshop. DESIGN A one-group quasiexperimental time series study was undertaken. SAMPLE A total of 41 participants consented, with 71% (n = 29) completing data collection at all three study time points. MEASUREMENT AND INTERVENTIONS Two nurses one from the First Nations community and one from the tertiary care center collaborated to develop and deliver the intervention on concussion specifically general, hockey and symptom knowledge. The primary outcome was Total Knowledge Score (TKS), whereby correct responses to a self-reported questionnaire were summed and then converted to a percentage. RESULTS The TKS were similar across study time points; preworkshop 71.7%, postworkshop 71.8%, and 6-month follow-up 72%. CONCLUSIONS Nurses worked collaboratively with cultural experts from a First Nations community to integrate Indigenous ways of knowing into concussion awareness and safety for First Nations youth playing hockey.

Background:Standardized data collection for traumatic brain injury (TBI) (including concussion) using common data elements (CDEs) has strengthened clinical care and research capacity in the United States and Europe. Currently, Ontario healthcare providers do not collect uniform data on adult patients diagnosed with concussion.Objective:The Ontario Concussion Care Strategy (OCCS) is a collaborative network of multidisciplinary healthcare providers, brain injury advocacy groups, patient representatives, and researchers with a shared vision to improve concussion care across the province, starting with the collection of standardized data.Methods:The International Framework of Functioning Disability and Health was selected as the conceptual framework to inform the selection of CDEs. The CDEs recommended by the OCCS were identified using key literature, including the National Institute of Neurological Disorders and Stroke–Zurich Consensus Statements for concussion in sport and the Ontario Neurotrauma Foundation Concussion/mTBI clinical guidelines.Results:The OCCS has recommended and piloted CDEs for Ontario that are readily available at no cost, clinically relevant, patient friendly, easy to interpret, and recognized by the international scientific community.Conclusions:The implementation of CDEs can help to shift Ontario toward internationally recognized standard data collection, and in so doing yield a more comprehensive evidence-based approach to care while also supporting rigorous research.

Objective: Hockey is a popular sport played by many First Nation youth. Concussion frequently goes unrecognized and unreported in youth hockey. Unintentional injuries among Indigenous youth occur at rates three to four times the national Canadian average. The study sought to examine knowledge, attitudes and sources of concussion information among First Nations people attending a provincial hockey tournament. Methods: A cross-sectional survey was undertaken. The survey by Mzazik et al. were modified to use in this study. Participants included youth (6-18 years) hockey players (n=75), parents (n=248) and coaches (n=68). The main outcome measure was total knowledge index (TKI) which consisted of the sum of correct responses to 15 multiple choice questions. Additional data gathered included demographics, concussion history, attitudes toward concussion and sources of information. Descriptive statistics included proportion comparisons. Variables were tested using χ2 and analysis of variance. Results: Overall TKI scores (out of a total of 15) were low; players (5.9±2.8), parents (7.5±2.6) and coaches (7.9±2.6). Participants with higher knowledge scores reported more appreciation of the seriousness of concussion. Sources of information about concussion differed by study group, suggesting the need for multiple knowledge translation strategies to reach youth, parents and coaches. Conclusions: Future initiatives are urgently needed to improve education and prevention of concussion in First Nations youth hockey. Collaborating and engaging with communities can help to ensure an Indigenous lens for culturally safe interventions.

Background: Mild traumatic brain injury (mTBI) is a significant public health concern. Research has shown that mTBI is associated with persistent physical, cognitive, and behavioural symptoms, leading to significant direct and indirect medical costs. Our objective was to determine if age impacts the type and severity of post-mTBI symptoms experienced. Methods: Retrospective analysis of prospectively collected data at a level 1 tertiary care outpatient head injury clinic. Participants (N=167) were patients seen at the clinic following an mTBI. The Rivermead Post-Concussion Symptoms Questionnaire was used to assess symptom severity. Results: In our sample, the mean age was 44±16 years with 51% males. Compared with other age groups, patients >66 years of age were significantly more likely to report an mTBI between 6 AM to 12 PM (69%). Middle-aged patients (36-55 years) were more likely to report higher severity of certain post-mTBI symptoms (headache, nausea and vomiting, irritability, poor concentration, sleep disturbance, blurry vision, light sensitivity, and taking longer to think) compared with patients >66 years of age. Conclusions: In general, middle-aged patients reported higher severity of post-mTBI symptoms compared with the oldest patients. Thus, there was a significant association between age and the severity of specific mTBI symptoms, which highlights the need for targeted management. Additional research is needed to understand the mechanisms that could be contributing to the higher symptom severity experienced by the middle-aged group.

Aim: The cognitive, emotional, behavioral and physical impairments experienced by adults after mild traumatic brain injury (mTBI) can produce substantial disability, with 15–20% requiring referral to tertiary care (TC) for persistent symptoms. Methods: A convenience sample of 201 adult patients referred to TC as a result of mTBI was studied. Self-reported data were collected at first TC visit, on average 10 months postinjury. Patients reported the type and intensity of healthcare provider visit(s) undertaken while awaiting TC. Results: On average males reported 37 and females 30 healthcare provider visits, resulting in over $500,000 Canadian dollars spent on potentially excess mTBI care over 1 year. Discussion: Based on conservative estimate of 15% of mTBI patients receiving TC, this finding identifies a possible excess in care of $110 million for Ontario. Accurate diagnosis of mTBI and early coordination of follow-up care for those needing TC could increase cost–effectiveness.