Context: 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. Objectives: 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. Design: Prospective cohort study. Setting: Clinical setting. Patients or Other Participants: 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. Main Outcome Measure(s): 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. Results: 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. Conclusions: 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.

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.

Context: Concussion legislation mandates that health care providers have experience in concussion management. Unfortunately, standards for current continuing and clinician education are ill defined.Objective: (1) Determine if a didactic-based educational intervention would increase knowledge and perceived expertise and (2) examine the correlations between the variables of knowledge, experience, and perceived expertise.Design: Prospective cohort study, level II.Patients or Other Participants: Novice health care providers were divided into 2 groups: college sophomore athletic training students (n = 16) and college sophomore medical dietetics students (n = 19).Setting: Classroom setting.Intervention(s): Both groups were administered a knowledge questionnaire before the intervention (Time 1) and again 30 weeks later (Time 3). The athletic training student group completed a didactic intervention and completed the questionnaire at the end of the quarter ∼15 weeks later (Time 2).Main Outcome Measure(s): The main outcome measure was a 34-item questionnaire designed to examine knowledge, experience, and perceived expertise using true-false items, scenarios, Likert-scaled items, and open-ended questions derived from existing evidence and current literature. The scores from the knowledge, perceived expertise, and experience items served as dependent variables.Results: No statistically significant interaction between groups existed on knowledge scores after the didactic intervention (P = .10). Statistically significant interactions existed between group and time for both perceived expertise (F1,33 = 86.38, P ≤ .001) and experience (F1,33 = 14.2, P ≤ .001) with the athletic training student group demonstrating significant increases in scores over time. There was a statistically significant correlation between the number of concussions evaluated and perceived expertise (r2 = 0.630, P ≤ .001).Conclusions: Educators need to implement the best educational techniques to maximize knowledge attainment and perceived expertise. While it appears that clinical experience may supersede didactic education, a combination of both will encourage higher-level thinking and implementation.

Clinical Scenario: Concussions are severely underreported, with only 47.3% of high school athletes reporting their concussion. The belief was that athletes who were better educated on the signs and symptoms and potential dangers of concussion would be more likely to report. However, literature has shown inconsistent evidence on the efficacy of concussion education, improving reporting behaviors. Factors such as an athlete’s attitude, subjective norms, and perceived behavioral control have shown promise in predicting intention to report concussions in athletes. Focused Clinical Question: Do attitudes, subjective norms, and perceived behavioral control influence adolescent athletes’ intention to report? Summary of Key Findings: Three studies (1 randomized control and 2 cross-sectional surveys) were included. Across the 3 studies, attitudes, subjective norms, and perceived behavioral control positively influenced athletes’ reporting intention. The studies found that attitude toward concussion reporting and perceived behavioral control were the most influential predictors of reporting intention. Clinical Bottom Line: There is moderate evidence to suggest that positive attitudes, supportive subjective norms, and increased perceived behavioral control influence reporting intention in secondary school athletes. Strength of Recommendation: Grade B evidence exists that positive attitudes, supportive subjective norms, and increased perceived behavioral control positively influence concussion reporting intention in secondary school athletes.

Background: Most concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes. Methods: A mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9–16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155). Results: Internal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to “always” tell their coach about symptoms of a suspected concussion. Conclusions: The CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.