Background: A validated clinical risk tool has been developed to identify pediatric and adolescen... more Background: A validated clinical risk tool has been developed to identify pediatric and adolescent patients at risk of developing persisting symptoms after concussion, but has not been prospectively investigated within a sample of athletes seen after concussion by primary care sports medicine physicians and/or athletic trainers. Purpose: To determine whether a validated clinical risk prediction tool for persistent postconcussive symptoms (PPCSs) predicted which patients would develop PPCSs when obtained within 14 days of concussion among a multicenter sample of adolescent athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Pediatric and adolescent patients (8-18 years of age) from 7 pediatric medical centers and 6 secondary school athletic training facilities who were diagnosed with a concussion and presented ≤14 days after concussion were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit and were followed until...
Objective: To examine patient and injury factors that may predict quality of life (QoL) and sympt... more Objective: To examine patient and injury factors that may predict quality of life (QoL) and symptom duration after concussion. Design: Prospective, longitudinal. Settings: Six children's hospital-based medical centers and 9 secondary school athletic training facilities. Patients: Pediatric patients (8-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit for a diagnosis of sport-related concussion. Interventions: Patients completed a medical history, the Postconcussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP). Main Outcome Measures: Eight predictor variables [age, sex, assessment time, loss of consciousness, amnesia and history of concussion, migraines, or attention-deficit hyperactivity disorder or (ADHD)] were assessed using regression models constructed for each dependent variable. Results: A total of 244 patients (15.1 ± 2.1 years, 41% female) were enrolled (mean = 5 ± 3 days after concussion; range = 1-14 days). Female sex, later initial assessment, and presence of amnesia were associated with lower QoL scores on several domains, whereas loss of consciousness was associated with higher QoL for fatigue. A history of migraines was associated with lower peer relationship QoL. Patients who subsequently developed persisting symptoms had lower mobility scores and higher anxiety, depressive symptom, fatigue, and pain interference scores. Conclusions: Female sex, later clinic presentation, and amnesia were associated with a lower QoL related to mobility, anxiety, depressive symptoms, fatigue, and pain interference. Interestingly, previous concussion and preinjury ADHD diagnosis did not negatively impact postinjury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later postinjury time points using a concussion-specific outcomes instrument.
Context: Sports specialization, or focused participation in a single sport, is associated with an... more Context: Sports specialization, or focused participation in a single sport, is associated with an increased rate of overuse injury and burnout. Medical associations and sport organizations have published recommendations for sport specialization aimed to reduce the negative consequences. Healthcare providers (HCPs) are often identified as individuals who can educate athletes and parents about these important recommendations. Objective: This study aimed to compare knowledge, perceptions, awareness, confidence, and use of sports specialization recommendations between HCPs who work with pediatric athletes.
Purpose To 1) describe collegiate student-athlete(SA) race and household income, and 2) evaluate ... more Purpose To 1) describe collegiate student-athlete(SA) race and household income, and 2) evaluate time to normal academic performance (i.e., return to learn[RTL]), initiation of the return to play(iRTP) protocol, RTP protocol duration, and time to unrestricted RTP(URTP) after sustaining sport-related concussion(SRC). Methods Data were collected between 2014-2020 by the Concussion Assessment, Research, and Education (CARE) Consortium. Baseline data were used to characterize participant demographics(N = 22,819) and post-SRC outcomes(n = 5485 SRCs) in time to RTL(n = 1724) and RTP outcomes(n = 2646) by race. Descriptive statistics and non-parametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox-Proportional Hazards regression assessed the effect of race on risk of RTL and RTP recovery timepoints. Results ...
International Journal of Environmental Research and Public Health
Secondary school ATs (SSATs) are uniquely positioned healthcare providers at an optimal public he... more Secondary school ATs (SSATs) are uniquely positioned healthcare providers at an optimal public health intersection where they can provide equitable healthcare to low socioeconomic status (SES) adolescents. SSATs face similar challenges to physicians in treating low SES patients, but their strategies may be different compared to other medical professions. However, the consequences of low SES population healthcare delivery by SSATs have not been explored. SSATs were asked to share what challenges, if any, they encounter with providing care for their low SES patients and what strategies they find most effective to overcome these challenges. Data were collected via semi-structured interviews and reflective field notes and analyzed using a four-step, interpretative phenomenological analysis (IPA) guided theme development. Data saturation was met, and the sample size aligned with other IPA studies. Trustworthiness was established with research triangulation and Yardley’s four principles. ...
Background Sport-related concussions (SRCs) affect millions of adolescents and young adults annua... more Background Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education. Objective To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery. Methods Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group's overall ratings. Results Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol. Conclusion There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders. Key Points Despite a growing interest in sport-related concussion (SRC) research, there is limited empirical support for return-to-learn (RTL) strategies. Current consensus recommendations for RTL may not be appropriate and/or feasible in higher education. The Post-Concussion Collegiate RTL Protocol provides specific recommendations to progress university students back to course-related activities after SRC.
Supplemental Material, Supplementary_Tables_11_1_2018 for Sport and Physical Activity Level Impac... more Supplemental Material, Supplementary_Tables_11_1_2018 for Sport and Physical Activity Level Impacts Health-Related Quality of Life Among Collegiate Students by Traci R. Snedden, John Scerpella, Stephanie A. Kliethermes, Rocío S. Norman, Liga Blyholder, Jen Sanfilippo, Timothy A. McGuine, and Bryan Heiderscheit in American Journal of Health Promotion
Background: Sport specialization is increasingly common in many youth sports and has been linked ... more Background: Sport specialization is increasingly common in many youth sports and has been linked to increased injury, overtraining, and burnout. Several organizations have developed safe sport recommendations in an effort to mitigate injury risk. Healthcare providers (HCPs) can be a source of education for parents and athletes on safe sports practices, but the awareness, confidence, and use of these recommendations among HCPs who work with youth athletes is limited. Hypothesis/Purpose: To evaluate the awareness, confidence, and use of sports specialization and safe sport recommendations of HCPs who work with pediatric athletes. Methods: A cross-sectional online survey was developed to assess pediatric HCP awareness of, confidence in, and clinical use of sports specialization recommendations. The survey included 1) personal demographics, 2) professional demographics, 3) knowledge and perceptions of sport specialization, 4) awareness, confidence, and use of recommendations, and 5) HCP...
OBJECTIVE To conduct a literature review about the breadth of risks for acquiring hepatitis C vir... more OBJECTIVE To conduct a literature review about the breadth of risks for acquiring hepatitis C virus (HCV) among women who are living in the United States. DESIGN A mixed research synthesis of qualitative, quantitative, and mixed-methods studies guided by the Socioecological Model and Theory of Gender and Power. SAMPLE AND ANALYTIC STRATEGY The sample consisted of 29 studies: 10 qualitative, 18 quantitative, and one mixed-methods studies. Data were analyzed using a segregated approach and integrated into a narrative synthesis of themes by components of the Socioecological Model. RESULTS Individual risks themes were drug use as a coping strategy, transition to injection drug use, and lack of awareness about HCV. Interpersonal risks themes were social norms of drug use and drug use and sexual activities. Community risks themes were community re-entry, housing instability, and community HCV resources. Societal risks themes are policies affecting drug markets and social construct of "worthlessness." CONCLUSIONS Findings highlight the need for comprehensive gender-specific HCV prevention strategies built around harm reduction. In partnership with women with lived experience, public health nurses can apply findings to build harm reduction collaborations aimed at implementing HCV risk-reduction or risk-elimination strategies.
In the United States, defining concussion as "a complex pathophysiological process affecting the ... more In the United States, defining concussion as "a complex pathophysiological process affecting the brain, induced by traumatic biochemical forces secondary to direct or indirect forces to the head", high school athletes sustain an estimated 300,000 sportsrelated concussions annually, assumedly underreported. Among individuals 15 to 24 years of age, sports are second only to motor vehicle accidents as the leading cause of concussions. In recent years, there has been an expansion of knowledge that has led to an increased awareness and understanding that all concussions include some level of injury to the brain and that an athlete suspected of having a concussion should be immediately removed from play for further evaluation. However, the utilization of decision-making tools that aid in detecting a concussion in addition to management of this injury vary among clinicians and are fraught with mixed psychometric results. The overall goal of this study was to improve the ability to detect and manage sports-related concussion in the adolescent athlete by evaluating a measurement model that included self-reported symptoms and neurocognitive tests. These frequently utilized assessment tools are components of the Immediate Post Concussion Assessment and Cognitive Test (ImPACT), a common computer-based measure in adolescents. This iv study also sought to provide additional support to the validity of ImPACT when applied to the adolescent athlete. An existing de-identified dataset of adolescent athletes, aged 14-18, was utilized to examine the structure of various models. Using confirmatory factor analysis, a successful solution was found, contributing additional psychometric support and utility to ImPACT. An expanded understanding of psychometrically strong diagnostic tools, specific to the adolescent age group, is of utmost importance as even a single concussion can produce permanent sequelae in a developing brain with greater susceptibility to cognitive decline and slower recovery compared to older athletes.
OBJECTIVES To estimate the prevalence, characteristics, and gender differences among people aged ... more OBJECTIVES To estimate the prevalence, characteristics, and gender differences among people aged 15-44 years who are living with current HCV infections in the United States. DESIGN AND SAMPLE We conducted a cross-sectional, secondary data analysis using data from people who participated in National Health and Nutrition Examination Survey (NHANES) cycles in 2009-2018. MEASUREMENTS Sociodemographic, social behavior, and clinical factors that had been identified as related to having HCV, barriers to receiving HCV screening, care, or treatment, and health conditions that increase the risks of developing HCV-related complications were studied. A weighted-data analysis approach was used to generate descriptive statistics. RESULTS The estimated, weighted prevalence of current HCV infections was 0.3% (95% CI, 0.2-0.4), representing approximately 363,161 people (95% CI, 301,402-424, 920). Females were more likely than males to have an unknown risk factor and reported worse overall health. Males were more likely to have comorbidities such as obesity or diabetes that put them at risk for developing life-threatening complications. CONCLUSIONS Increased public health attention with gender-specific actions are needed to address the health needs of the thousands of people aged 15-44 years who are living with current HCV infections across the United States.
Background: A validated clinical risk tool has been developed to identify pediatric and adolescen... more Background: A validated clinical risk tool has been developed to identify pediatric and adolescent patients at risk of developing persisting symptoms after concussion, but has not been prospectively investigated within a sample of athletes seen after concussion by primary care sports medicine physicians and/or athletic trainers. Purpose: To determine whether a validated clinical risk prediction tool for persistent postconcussive symptoms (PPCSs) predicted which patients would develop PPCSs when obtained within 14 days of concussion among a multicenter sample of adolescent athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Pediatric and adolescent patients (8-18 years of age) from 7 pediatric medical centers and 6 secondary school athletic training facilities who were diagnosed with a concussion and presented ≤14 days after concussion were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit and were followed until...
Objective: To examine patient and injury factors that may predict quality of life (QoL) and sympt... more Objective: To examine patient and injury factors that may predict quality of life (QoL) and symptom duration after concussion. Design: Prospective, longitudinal. Settings: Six children's hospital-based medical centers and 9 secondary school athletic training facilities. Patients: Pediatric patients (8-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit for a diagnosis of sport-related concussion. Interventions: Patients completed a medical history, the Postconcussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP). Main Outcome Measures: Eight predictor variables [age, sex, assessment time, loss of consciousness, amnesia and history of concussion, migraines, or attention-deficit hyperactivity disorder or (ADHD)] were assessed using regression models constructed for each dependent variable. Results: A total of 244 patients (15.1 ± 2.1 years, 41% female) were enrolled (mean = 5 ± 3 days after concussion; range = 1-14 days). Female sex, later initial assessment, and presence of amnesia were associated with lower QoL scores on several domains, whereas loss of consciousness was associated with higher QoL for fatigue. A history of migraines was associated with lower peer relationship QoL. Patients who subsequently developed persisting symptoms had lower mobility scores and higher anxiety, depressive symptom, fatigue, and pain interference scores. Conclusions: Female sex, later clinic presentation, and amnesia were associated with a lower QoL related to mobility, anxiety, depressive symptoms, fatigue, and pain interference. Interestingly, previous concussion and preinjury ADHD diagnosis did not negatively impact postinjury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later postinjury time points using a concussion-specific outcomes instrument.
Context: Sports specialization, or focused participation in a single sport, is associated with an... more Context: Sports specialization, or focused participation in a single sport, is associated with an increased rate of overuse injury and burnout. Medical associations and sport organizations have published recommendations for sport specialization aimed to reduce the negative consequences. Healthcare providers (HCPs) are often identified as individuals who can educate athletes and parents about these important recommendations. Objective: This study aimed to compare knowledge, perceptions, awareness, confidence, and use of sports specialization recommendations between HCPs who work with pediatric athletes.
Purpose To 1) describe collegiate student-athlete(SA) race and household income, and 2) evaluate ... more Purpose To 1) describe collegiate student-athlete(SA) race and household income, and 2) evaluate time to normal academic performance (i.e., return to learn[RTL]), initiation of the return to play(iRTP) protocol, RTP protocol duration, and time to unrestricted RTP(URTP) after sustaining sport-related concussion(SRC). Methods Data were collected between 2014-2020 by the Concussion Assessment, Research, and Education (CARE) Consortium. Baseline data were used to characterize participant demographics(N = 22,819) and post-SRC outcomes(n = 5485 SRCs) in time to RTL(n = 1724) and RTP outcomes(n = 2646) by race. Descriptive statistics and non-parametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox-Proportional Hazards regression assessed the effect of race on risk of RTL and RTP recovery timepoints. Results ...
International Journal of Environmental Research and Public Health
Secondary school ATs (SSATs) are uniquely positioned healthcare providers at an optimal public he... more Secondary school ATs (SSATs) are uniquely positioned healthcare providers at an optimal public health intersection where they can provide equitable healthcare to low socioeconomic status (SES) adolescents. SSATs face similar challenges to physicians in treating low SES patients, but their strategies may be different compared to other medical professions. However, the consequences of low SES population healthcare delivery by SSATs have not been explored. SSATs were asked to share what challenges, if any, they encounter with providing care for their low SES patients and what strategies they find most effective to overcome these challenges. Data were collected via semi-structured interviews and reflective field notes and analyzed using a four-step, interpretative phenomenological analysis (IPA) guided theme development. Data saturation was met, and the sample size aligned with other IPA studies. Trustworthiness was established with research triangulation and Yardley’s four principles. ...
Background Sport-related concussions (SRCs) affect millions of adolescents and young adults annua... more Background Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education. Objective To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery. Methods Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group's overall ratings. Results Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol. Conclusion There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders. Key Points Despite a growing interest in sport-related concussion (SRC) research, there is limited empirical support for return-to-learn (RTL) strategies. Current consensus recommendations for RTL may not be appropriate and/or feasible in higher education. The Post-Concussion Collegiate RTL Protocol provides specific recommendations to progress university students back to course-related activities after SRC.
Supplemental Material, Supplementary_Tables_11_1_2018 for Sport and Physical Activity Level Impac... more Supplemental Material, Supplementary_Tables_11_1_2018 for Sport and Physical Activity Level Impacts Health-Related Quality of Life Among Collegiate Students by Traci R. Snedden, John Scerpella, Stephanie A. Kliethermes, Rocío S. Norman, Liga Blyholder, Jen Sanfilippo, Timothy A. McGuine, and Bryan Heiderscheit in American Journal of Health Promotion
Background: Sport specialization is increasingly common in many youth sports and has been linked ... more Background: Sport specialization is increasingly common in many youth sports and has been linked to increased injury, overtraining, and burnout. Several organizations have developed safe sport recommendations in an effort to mitigate injury risk. Healthcare providers (HCPs) can be a source of education for parents and athletes on safe sports practices, but the awareness, confidence, and use of these recommendations among HCPs who work with youth athletes is limited. Hypothesis/Purpose: To evaluate the awareness, confidence, and use of sports specialization and safe sport recommendations of HCPs who work with pediatric athletes. Methods: A cross-sectional online survey was developed to assess pediatric HCP awareness of, confidence in, and clinical use of sports specialization recommendations. The survey included 1) personal demographics, 2) professional demographics, 3) knowledge and perceptions of sport specialization, 4) awareness, confidence, and use of recommendations, and 5) HCP...
OBJECTIVE To conduct a literature review about the breadth of risks for acquiring hepatitis C vir... more OBJECTIVE To conduct a literature review about the breadth of risks for acquiring hepatitis C virus (HCV) among women who are living in the United States. DESIGN A mixed research synthesis of qualitative, quantitative, and mixed-methods studies guided by the Socioecological Model and Theory of Gender and Power. SAMPLE AND ANALYTIC STRATEGY The sample consisted of 29 studies: 10 qualitative, 18 quantitative, and one mixed-methods studies. Data were analyzed using a segregated approach and integrated into a narrative synthesis of themes by components of the Socioecological Model. RESULTS Individual risks themes were drug use as a coping strategy, transition to injection drug use, and lack of awareness about HCV. Interpersonal risks themes were social norms of drug use and drug use and sexual activities. Community risks themes were community re-entry, housing instability, and community HCV resources. Societal risks themes are policies affecting drug markets and social construct of "worthlessness." CONCLUSIONS Findings highlight the need for comprehensive gender-specific HCV prevention strategies built around harm reduction. In partnership with women with lived experience, public health nurses can apply findings to build harm reduction collaborations aimed at implementing HCV risk-reduction or risk-elimination strategies.
In the United States, defining concussion as "a complex pathophysiological process affecting the ... more In the United States, defining concussion as "a complex pathophysiological process affecting the brain, induced by traumatic biochemical forces secondary to direct or indirect forces to the head", high school athletes sustain an estimated 300,000 sportsrelated concussions annually, assumedly underreported. Among individuals 15 to 24 years of age, sports are second only to motor vehicle accidents as the leading cause of concussions. In recent years, there has been an expansion of knowledge that has led to an increased awareness and understanding that all concussions include some level of injury to the brain and that an athlete suspected of having a concussion should be immediately removed from play for further evaluation. However, the utilization of decision-making tools that aid in detecting a concussion in addition to management of this injury vary among clinicians and are fraught with mixed psychometric results. The overall goal of this study was to improve the ability to detect and manage sports-related concussion in the adolescent athlete by evaluating a measurement model that included self-reported symptoms and neurocognitive tests. These frequently utilized assessment tools are components of the Immediate Post Concussion Assessment and Cognitive Test (ImPACT), a common computer-based measure in adolescents. This iv study also sought to provide additional support to the validity of ImPACT when applied to the adolescent athlete. An existing de-identified dataset of adolescent athletes, aged 14-18, was utilized to examine the structure of various models. Using confirmatory factor analysis, a successful solution was found, contributing additional psychometric support and utility to ImPACT. An expanded understanding of psychometrically strong diagnostic tools, specific to the adolescent age group, is of utmost importance as even a single concussion can produce permanent sequelae in a developing brain with greater susceptibility to cognitive decline and slower recovery compared to older athletes.
OBJECTIVES To estimate the prevalence, characteristics, and gender differences among people aged ... more OBJECTIVES To estimate the prevalence, characteristics, and gender differences among people aged 15-44 years who are living with current HCV infections in the United States. DESIGN AND SAMPLE We conducted a cross-sectional, secondary data analysis using data from people who participated in National Health and Nutrition Examination Survey (NHANES) cycles in 2009-2018. MEASUREMENTS Sociodemographic, social behavior, and clinical factors that had been identified as related to having HCV, barriers to receiving HCV screening, care, or treatment, and health conditions that increase the risks of developing HCV-related complications were studied. A weighted-data analysis approach was used to generate descriptive statistics. RESULTS The estimated, weighted prevalence of current HCV infections was 0.3% (95% CI, 0.2-0.4), representing approximately 363,161 people (95% CI, 301,402-424, 920). Females were more likely than males to have an unknown risk factor and reported worse overall health. Males were more likely to have comorbidities such as obesity or diabetes that put them at risk for developing life-threatening complications. CONCLUSIONS Increased public health attention with gender-specific actions are needed to address the health needs of the thousands of people aged 15-44 years who are living with current HCV infections across the United States.
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