Introduction Concussions occur frequently in the populations athletic trainers (ATs) treat. Incorporating person-centered care (PCC) components can improve patient outcomes. Although ATs have the potential to mitigate the negative effects of social determinants of health (SDoHs), of which health literacy is a key underpinning, gaps remain among ATs regarding familiarity, comfort, and knowledge of the SDoH-related needs of patients, making educational interventions prudent. Framework Teaching PCC concepts (SDoHs; health literacy; and the International Classification of Functioning, Disability and Health [ICF] model) prepares students to provide care rooted in cultural agility and ethical practice, allowing them to adapt clinical care, make appropriate clinical decisions, and coordinate clinical care based on patient culture. Implementation We provide recommendations on how to incorporate PCC concepts into pedagogy associated with concussion using the ICF model. Specifically, course activity examples are provided for Commission on Accreditation of Athletic Training Education standards 57, 76, and 93. Importantly, the activities incorporate the components of PCC: SDoH, health literacy, and the ICF model. Implications The recommendations outlined are potential options for educators on how to incorporate the ICF model, SDoHs, and health literacy into the curriculum associated with the continuum of care for patients with concussions. It is critical to incorporate the concepts into athletic training pedagogy regarding concussion management, as concussions occur frequently in the patient populations ATs treat, and PCC can effectively improve patient outcomes. The recommendations can be modified to meet student needs and can be applied within a wide variety of educational or clinical sites as well as among diverse patient populations.

OBJECTIVE:To determine the agreement of parent and child responses to the Brain Injury Perception Scale (BIPS), a modified version of the Illness Perceptions Questionnaire-Revised, following a pediatric concussion. METHOD:This was a cross-sectional study of 88 parent-child dyads who completed the BIPS at their initial visit to a specialty concussion clinic within 30 days following pediatric (11-18 years of age) concussion. Descriptive statistics were calculated, followed by Spearman's rho (ρ), which assessed parent-child item consistency. Cross-tab tables were used to understand the direction of item consistency. RESULTS:Only five (13.2%) out of 38 BIPS items demonstrated parent-child consistency (p < .05), with both disagreeing that the brain injury is permanent (ρ = .27), will have major consequences on their life (ρ = .25), makes them upset (ρ = .22), will strongly affect the way others see them (ρ = .29), and will be with them for the rest of their life (ρ = .22). CONCLUSIONS:Parent-child agreement regarding brain injury perceptions following a pediatric concussion was low (13%), reflecting the importance of assessing and then addressing parent and child perceptions individually in pediatric concussion management.

Concussion is a commonly occurring health-related condition in childhood, especially among youth athletes, that may require school-based management. Given their background and role, school psychologists are well-positioned to support students who have experienced a head injury; however, research suggests that school psychologists lack the confidence to lead a school concussion management team. This study examined sources of school psychologists’ concussion‑related knowledge, their self‑rated competence to engage in concussion‑management activities, and factors that may predict perceived competence. Results revealed that the school psychologists surveyed in this study primarily acquired concussion knowledge through independent professional development activities (e.g., readings) followed by formal workshops. Self-ratings of perceived competence were not high across the seven concussion management activities. Depending on the concussion management activity, concussion knowledge, previous formal professional development, or years of experience emerged as the leading predictors of perceived competence. Findings underscore the need for additional training and structured protocols for school psychologists involved in concussion management.

BACKGROUND: Concussion is a critical public health issue, with approximately one in five adolescents and a substantial number of college athletes reporting a lifetime history of concussion. The impact of concussion on cognitive health may extend across the lifespan, increasing the risk of potential long-term cognitive impairments, such as dementia. Although concussion research continues to grow and incorporate athlete demographic factors, it overwhelmingly includes singular comparisons between Black or African American versus White individuals when considering race as a determinant of health. This narrow analytic lens fails to capture the increasing demographic diversity in the United States (US), where the multiracial population has risen by over 200% from 2010 to 2020, and the percentage of individuals identifying solely as White alone has declined. As a result, current research practices risk overlooking meaningful social subgroup differences that could inform equitable concussion prevention and recovery efforts. STUDY PURPOSE: We examined how race and ethnicity are inconsistently defined and underreported in concussion research. Current practices, such as collapsing diverse social identities into “non-White” or omitting them entirely, limit clinical relevance and perpetuate structural health inequities. We advocate for more inclusive representation and methodological rigor in future studies. RECOMMENDATIONS FOR FUTURE RESEARCH: We propose three key actions. First, design research questions that explicitly center inclusion, moving beyond binary racial comparisons and capturing the experiences of underrepresented groups such as American Indian or Alaska Native, Asian, Hispanic or Latino, and multiracial/ethnic populations. Second, leverage robust, publicly available and nationally representative datasets, such as the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System, the Strong Heart Study, and All of Us. Third, apply rigorous analytical approaches, such as stratification, the use of interaction terms, heterogeneity tests, and/or subgroup analyses, rather than limiting analysis to adjustment for race and ethnicity as possible confounding variables in statistical models. CONCLUSION: To advance health equity in concussion research, it is essential to improve diverse demographic representation, apply rigorous analytic methods, and acknowledge the structural determinants that shape disparate outcomes. Our recommendations aim to guide researchers, funders, and policymakers toward a more inclusive and impactful research agenda.

OBJECTIVE:Within a sample of young athletes with attention-deficit/hyperactivity disorder (ADHD), to explore the frequency of disclosed and nondisclosed concussions, identify reasons the youth did not report a suspected concussion, and learn the frequency that the youth still practiced or played in a game after a suspected concussion. METHOD:Cross-sectional surveys were completed by 448 youth athletes (ages 8-14 years) and a corresponding parent (or caregiver). As part of larger respective surveys, questions regarding ADHD status and concussion history were asked of the youth and parents. Data regarding 40 youth with ADHD were available for analyses. Due to the low frequency of concussive injuries within the total sample, descriptive statistics and qualitative techniques were used to contextualize the data. RESULTS:The youth with ADHD were not more likely to experience at least one diagnosed concussion or nondisclosed concussion as compared to non-ADHD controls. Three of 40 youth athletes with ADHD (8%) had been diagnosed with a concussion, whereas 5 (13%) self-reported a nondisclosed concussion. Not wanting to lose playing time and not wanting to miss a game were the two most endorsed reasons for concussion nondisclosure. CONCLUSIONS:More research is needed to understand the present results considering other research that puts similarly aged athletes with ADHD at greater risk for concussion. Education for youth with ADHD might help reduce the number of nondisclosed concussions that have a more complex recovery trajectory in this population.

Context:Low health literacy disproportionately affects individuals and communities that are socially disadvantaged or have geographical barriers to health care. For injuries such as concussion, preparticipation education is typically mandatory, but it is unclear if the reading level of these educational documents is suitable to meet the health literacy needs of adolescent athletes across urban and rural communities. Objective:To assess differences in health literacy among adolescent athletes in urban and rural communities and compare scores with the state-mandated concussion education handout. Design:Cross-sectional study. Setting:High school athletics. Patients or Other Participants:Participants included 270 adolescent athletes in total who attended urban (n = 157) and rural (n = 110) schools. Main Outcome Measures:The Rapid Estimate of Adolescent Literacy in Medicine-Teen (REALM-Teen) was used to assess a participant's ability to read common medical words and lay terms for body parts and illnesses. The tool consists of 66 words divided into 3 lists, and scores can range from 0 to 66. Scores are tabulated into a health literacy score for each participant, equating to a grade-specific reading level. Results:Urban adolescent athletes had a higher total REALM-Teen score than rural participants (t = 3.868, p < .001). Urban adolescents had higher mean scores than those from rural locations for each individual REALM-Teen list; score differences were statistically significant for lists 2 and 3 (t = 2.888, p = .004; t = 4.012, p < .001, respectively). Only 26% (n = 41) of urban and 12.7% (n = 14) of rural adolescent athletes scored at a reading level that aligns with the health literacy level necessary to read /comprehend the state-provided concussion education handout. Conclusions:Urban adolescent athletes had better health literacy compared with their rural peers; however, irrespective of rurality, more than half of participants had low health literacy for their appropriate age/grade in high school (≤seventh grade). Ensuring that health information is provided at an appropriate reading level for the target audience is essential to increasing health literacy.

Objective To evaluate parental emotions and perceptions of long-term implications of concussion, and determine the association between gender and these beliefs. Design Cross-sectional survey. Setting Youth sports. Participants Parents (n=467; males=185, females=282) of youth contact sport athletes (8–14 years). Interventions A 15-minute concussion-specific Illness Perception Questionnaire was administered after practices/games. Outcome Measures Frequencies of Likert items (1-'strongly disagree'; 5-'strongly agree') for emotions and perceptions about the long-term implications of concussion were calculated. The association between concussion perceptions and gender were assessed using chi-square analyses, and Fisher's exact tests. Significance was set at p≤.05. Main Results Overall, 75.1% (n=341/454) of parents were worried, 72.5% (n=330/455) were upset, 61.3% (n=279/455) were fearful, and 45.3% (n=205/453) were anxious at the thought of their child sustaining a concussion. Females had significantly higher negative emotional concussion perceptions than males (p's≤.001). Additionally, 87.4% (n=396/453) of parents felt that concussions could have major consequences on their child's life. Approximately half of parents (42.66%, n=211/457) believed that the effects of concussion would last a long time; however, 53.3% (n=240/450) did not think that the effects would last their child's whole life. A greater proportion of females believed that the effects of concussion would last their child's whole life (p=.001). Conclusions The majority of youth athlete parents have negative emotions associated with concussion, and females may have more psychological distress compared to males. Parents believe that concussions can have long-term implications on their child's life, but are unclear if the injury has permanent effects.

Objective Investigate diagnosis and recovery timelines of concussions in relation to racial identity concordance and discordance between the injured collegiate athlete and treating Athletic Trainer (AT). Design Retrospective chart review of medical records. Setting Six National Collegiate Athletic Association (NCAA) institutions. Participants Of 774 cases recorded, 534 (69.0%) diagnosed concussions from sports with full-time sports medicine coverage were included in this study. Racial demographic frequencies for athletes and treating ATs were: White (Athlete: n=358; AT: n=513), Black (Athlete: n=154; AT: n=8), Hispanic/Latino (Athlete: n=12; AT: n=0), Native Hawaiian/Pacific Islander (Athlete: n=8; AT: n=11), American Indian/Alaska Native (Athlete: n=1; AT: n=0), and Asian (Athlete: n=1; AT: n=0). Interventions (or Assessment of Risk Factors) Concussion cases were coded into two groups; racial concordance (i.e., racial identities were the same; n=345) and racial discordance (i.e., racial identities were different; n=189). Sex (male; female) was included as a covariate. Outcome Measures Three multivariable Cox proportional hazard regression models were used to assess days from date-of-injury to 1) diagnosis, 2) symptom resolution, and 3) return to participation. Main Results Racially discordant concussion cases were diagnosed sooner than racially concordant cases (HR: 1.22, 95%CI: 1.01–1.47, p=0.04). There were no differences by racial identity concordance and discordance for time to symptom resolution (HR: 1.04, 95%CI: 0.86–1.26, p=0.68) or return to participation (HR: 1.10, 95%CI: 0.85–1.41, p=0.48). Conclusions While racial identity concordance/discordance among collegiate athletes and ATs may play a role in concussion diagnosis, this factor may not influence concussion recovery times. Diversification of sports medicine healthcare providers is needed.

Objective Compare Child SCAT5 baseline assessment scores among uninjured middle school athletes that predominantly speak Spanish to matched controls that predominantly speak English. Design A nested case-control study was conducted on baseline Child SCAT5 assessments. Setting Middle school sports within a large public-school division in Virginia, USA. Participants 144 middle school athletes (ages 12.3±0.7; 36.1% girls, 63.9% boys, Spanish-speaking n=72, English-speaking n=72). Interventions (or Assessment of Risk Factors) Athletes reported their predominant language (i.e., 'language spoken at home'). Athletes that predominantly spoke Spanish were individually matched to athletes that predominantly spoke English on age, gender, sport, school, and comorbidities (e.g., ADHD, concussion history, etc.). Outcome Measures Child SCAT5 scores of: Total Symptoms; Symptom Severity; Standardized Assessment of Concussion-Child Version (SAC-C; immediate memory, digits backwards, concentration, delayed recall); and the Modified Balance Error Scoring System (mBESS). Main Results Mann Whitney U tests revealed no differences in symptom endorsements between predominantly English- and Spanish-speakers. Predominantly English-speakers performed slightly better on SAC-C (English M=21.97, 95%CI 21.54–22.41; Spanish M=21.11, 95%CI 20.62–21.60, p<.01, r=-.25), Immediate Memory (English M=14.22, 95%CI 14.01–14.44; Spanish M=13.29, 95%CI 12.93–13.65, p<.01, r=-0.45) and mBESS scores (English M=4.11, 95%CI 3.31–4.92; Spanish M=5.31, 95%CI 4.43–6.18, p<.01, r=-0.25) than the predominantly Spanish-speakers. Conclusions There were small differences in scores between predominantly English- and Spanish-speaking middle school athletes on baseline Child SCAT5 assessments. This suggests that language may not impact Child SCAT5 performance in a clinically meaningful way. Further research on concussion assessment tools across diverse pediatric populations is essential to ensure equitable health care.

Objective To investigate concussion diagnosis and recovery timelines of White and Black collegiate athletes. Design Retrospective cohort study. Setting Six National Collegiate Athletic Association (NCAA) institutions. Participants Of 774 documented concussions, 521 (67.3%) cases were analyzed that reported the racial identity of the athlete as being White or Black, had at least one recovery outcome available, and occurred in a sport with an athletic trainer present at practices and competitions. There were 220 (42.2%) concussions sustained by White males, 146 (28.0%) by White females, 128 (24.6%) by Black males, and 27 (5.2%) by Black females. Interventions (or Assessment of Risk Factors) Data for diagnosed concussions sustained from 2015–2020 were obtained from each participating sites' medical records. The independent variable was race (White; Black) with sex (Male; Female) as a covariate. Outcome Measures Dependent variables included days from 1) the date of injury to diagnosis, 2) symptom resolution, and 3) return to participation. Three separate multivariable Cox proportional hazard regression (HR) models were calculated and extreme outliers were censored. Main Results When adjusting for sex, Black athletes were diagnosed with a concussion sooner than White athletes (HR 1.27, 95% CI 1.04–1.55, p=0.02) by a median of 1 day. No racial differences were observed for the time intervals between concussion occurrence and symptom resolution (HR 1.15, 95% CI .94–1.41, p=0.19) or return to participation (HR 1.07, 95% CI .83–1.39, p=0.60). Conclusions There may be racial differences at initial concussion diagnosis that do not persist throughout the recovery timeline in US collegiate athletes.

Objective To determine the impact of having a dedicated certified athletic trainer (AT) on sex-differences in reporting or recovery from sport concussion. Design Retrospective chart review. Setting Six National Collegiate Athletic Association institutions. Participants Two hundred and sixty-eight (n=108 female, n=160 male; age 19.9±1.46 years) collegiate athletes diagnosed with a concussion. Female and male athletes were compared separately within the conditions of having an AT present or not for competitions and practices for their sport (n=98,91% females, n=157, 98% males). Interventions (or Assessment of Risk Factors) Data were collected between 2015 and 2020. Sex (Female/Male) and AT access (Yes/No) were the independent variables. Outcome Measures Chi-Squared (χ2) tests compared dedicated AT access by sex. Dependent variables were days from date of injury to: diagnosis (iDx), symptom-free (iSF), and return-to-participation (iRTP). Separate Mann-Whitney U tests compared iDx, iSF, and iRTP for male and female athletes with or without a dedicated AT. Main Results Significantly fewer (χ2(1)=7.62,p=0.006,Φ=0.17) female athletes had dedicated AT access compared to male athletes. Female athletes had similar days to iDx(U=417.00¸z=0.79,p=0.43,r=0.08), iSF(U=377.00¸z=-1.20, p=0.23, r=0.12), and iRTP(U=395.00¸z=-1.01,p=0.31,r=-0.10) regardless of if they had a dedicated AT. Male athletes with or without a dedicated AT also had a similar number of days to iDx(U=240.00¸z=0.06,p=0.95,r=0.01), iSF(U=193.00¸z=-0.54,p=0.59,r=-0.04), or iRTP(U=182.50¸z=-0.67,p=0.50,r=-0.05). Conclusions The absence of a dedicated AT did not delay reporting or recovery from concussion in collegiate athletes regardless of sex. Notably, however, males were more likely to have a dedicated AT. Future research is needed to confirm and extend our findings in athletes with varying exposure to ATs.

Objective Investigate whether an athlete's biological sex and exposure to a dedicated athletic trainer (AT) were related to clinical milestones after a sports-related concussion (SRC). Design Retrospective chart review. Methods Medical charts of collegiate athletes (n = 196 [70.9% female]) diagnosed with SRC were reviewed to extract: biological sex, dedicated AT exposure for their sport (yes/no), and time (days) to reaching clinical milestones (diagnosis, symptom resolution, unrestricted return to sport [RTS]). Mann-Whitney U tests were used to determine whether time to clinical milestones differed by sex, AT exposure, or their interaction. Proportions of same-day diagnoses and times to diagnosis, symptom resolution, and unrestricted RTS were evaluated with chi-squared and spearman's rank correlations, respectively. Results There were no significant differences in times to reaching any clinical milestone by sex, AT exposure, or their interaction (ps > 0.05). Forty-three percent of participants were diagnosed on the day of their SRC. This did not differ by sex or AT exposure (ps > 0.29). Longer times to SRC diagnosis were associated with more days to symptom resolution (rho = 0.236, p = 0.001) and unrestricted RTS (rho = 0.223, p < 0.001). Conclusions Athlete sex and AT exposure were not associated with times to reach any clinical milestone; however, delayed diagnosis was associated with longer times to reach clinical recovery.

ObjectiveThe purpose of this study was to characterize the associations of international student status and native language on time (in days) with the date of injury to (i) diagnosis, (ii) symptom resolution, and (iii) return to sport.MethodsUtilizing data from a cross-sectional cohort of 1,044 concussion cases from LIMBIC MATARS member institutions (n = 11) in the US, we conducted two, matched case-control designs. Cases were divided into two groups: (i) international (n = 32) or domestic students (n = 32) and (ii) English as an Additional Language (EAL) speakers (n = 18) or Native English language speakers (n = 18). Both groups were individually matched to their respective controls based on gender, age, sport, and preexisting health conditions.ResultsThere were no significant differences in days from injury to diagnosis (p = 0.94), symptom resolution (p = 0.64), or return to sport (p = 0.15) between international and domestic athletes. EAL speakers experienced symptom resolution approximately 7.5 days sooner (Md = 4.50; IQR = 4.00, 8.00) than Native English language speakers (Md = 12.00; IQR = 7.00, 21.00, p = 0.01).ConclusionsOur findings suggest that native language is associated with symptom resolution in collegiate athletes. Healthcare professionals should consider barriers related to native language that may impact symptom reporting and the overall injury experience of diverse collegiate athletes.

Objective: Changes in sleep quality and quantity are commonly endorsed by individuals following a concussion. Limited data exists examining the role of sleep disturbances within 72 hours, and throughout recovery, from concussion. The objective of this study was to determine if the number of days to symptom resolution varied between collegiate athletes with or without sleep-related symptoms following a concussion. Design: Retrospective chart review. Methods: Collegiate athletes (n = 539) who were diagnosed with a concussion between the 2015-2020 sport seasons participated in this retrospective chart review. Participants were divided into groups based on the presence or absence of sleep symptoms within 72 hours of a diagnosed concussion. A Mann-Whitney U test was used to compare days to symptom resolution between groups with alpha = 0.05. Results: Of the 539 participants, 250 (46.3%) reported sleep-related symptoms. Participants with sleep-related symptoms took significantly longer (U = 30656, p = 0.002) to report symptom resolution at rest (median [full range] = 8.00[0-423]) as compared to participants who did not report sleep-related symptoms (6.00[0-243] days). Conclusion: Collegiate athletes that report sleep-related symptoms immediately following concussion (<72 hours) were observed to take, on median, two days longer to achieve symptom resolution at rest when compared to athletes who did not endorse the same symptoms.

ObjectiveWhile recovery from concussion is variable, women are more likely to report symptoms, experience worse outcomes, and have longer recovery trajectories following concussion than men. Preliminary data suggest that hormonal fluctuations, specifically progesterone, may be associated with this variability. This study aimed to understand the effect of contraceptive medication on concussion recovery.MethodsA retrospective chart review using consensus-based common data elements was conducted at 11 NCAA institutions as part of the LIMBIC MATARS consortium. Participants included female collegiate athletes diagnosed with a concussion who did (n = 117) or did not report (n = 339) contraceptive medication use. Number of days between diagnosis and symptom resolution were compared using Mann-Whitney U tests. Self-reported diagnosis of attention deficit hyperactivity disorder, concussion history, anxiety, and depression was compared using Chi-squared tests.ResultsThe proportions of participants who did or did not take contraceptive medication were similar across covariates. Female athletes regardless of contraceptive medication use recovered similarly following a concussion.ConclusionsOur findings suggest that contraceptive medication use did not significantly impact concussion recovery. Future prospective investigations should examine documentation practices and operationalize terminology for hormonal contraceptive medication to better understand their role on recovery from sport-related concussion in female collegiate athletes.

OBJECTIVE:The LIMBIC Military and Tactical Athletic Research Study (MATARS) framework was established to confirm and extend understanding of concussion with initial studies driven by clinical data collected between 2015 and 2020 in a collegiate sports setting. The LIMBIC MATARS framework will be leveraged to apply gold-standard and innovative research designs to advance the science of concussion. This manuscript provides the background, methodology, and initial demographic data associated with the LIMBIC MATARS.METHODS:Consensus-based common data elements were used to conduct a retrospective chart review, specific to collegiate athletes diagnosed with concussions between 2015 and 2020 at 11 universities.RESULTS:A final sample of 1,311 (47.8% female) concussions were diagnosed during the five-year study period from athletes participating in a variety of National Collegiate Athlete Association (NCAA) sports. The LIMBIC MATARS demographic data, align with the NCAA and other pioneering multi-site concussion-related studies in terms of biological sex, race and ethnicity, and sport participation.CONCLUSION:This pragmatic, methodological approach was used to address several a priori hypotheses related to concussion, align with other multi-site studies of concussion, and establish a consortium for future investigations.

Objective To investigate the relationship between post-concussion activity and subsequent injury risk. Design Retrospective chart review. Setting National Collegiate Athletic Association (NCAA) athletic programs (n=6) in the United States. Participants 219 NCAA collegiate athletes (age:20.1±1.4 years; height:179.3±11.0 cm; mass: 78.0±12.0 kg). Interventions (or Assessment of Risk Factors) The independent variable was level of exercise: routine daily activities (RDA) or light, non-prescribed exercise (LightEx). Outcome Measures We used a Cox proportional hazard model to assess the risk of subsequent injury between the activity groups. The study end point was six months from return-to-sport clearance or the number of days to the first new injury. Main Results Approximately 29% (63/219) of participants sustained a subsequent acute injury (47% lower extremity, 37% upper extremity, 16% concussion) within six months post-concussion. Most athletes (87% [190/219]) participated solely in RDAs following concussion; only 13% [28/219]) reported engaging in LightEx. No significant risk between groups was observed for all acute subsequent injuries combined (p=0.09). More specifically, no differences were observed for upper extremity musculoskeletal injuries (p=0.91) or concussions (p=0.81). However, the LightEx group had a significantly higher risk (HR:2.69, p=0.02, 95% CI:1.14–6.32) of an acute lower extremity musculoskeletal injury in the six months following a diagnosed concussion compared to the RDA group. Conclusions Collegiate athletes who participated in LightEx following concussion were at greater risk for sustaining a subsequent lower extremity musculoskeletal injury compared to the RDA group. Future studies should examine whether certain post-concussion activities increase the risk of subsequent injury.