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Context: The Buffalo Concussion Treadmill Test (BCTT) for exercise intolerance following concussion may highlight underlying autonomic dysfunction. Autonomic function at rest and with exertion may be predictive of neurocognitive performance for individuals with sports-related concussion. The purpose of this study is to explore the feasibility and utility of combining multimodal assessments with heart rate variability (HRV) measures during the BCTT for individuals with a remote history of concussion. Design: Prospective cohort study design, pretest/posttest. Methods: Participants included 5 males and 5 females (N = 10, age: 25.2 [3.3] y old, height: 173.2 [11.2] cm, mass: 73.4 [13.7] kg, body mass index: 24.5 [3.9], time since last concussion of 6.3 [4.5] y). All participants completed the multimodal assessment battery including: Concentration Reverse Digits (6 digits), Stroop Incongruent, and King–Devick Test under single- (seated) and dual-task conditions (walking on treadmill at 2.0 mph, 0% incline). Heart rate and HRV was collected at rest, during the BCTT, and during postexercise recovery. HRV data were processed and analyzed based on established protocols. Paired t tests were performed for pre- and postmeasurements separately for single- and dual-task tests of the multimodal assessment battery and HRV indices. Results: During the BCTT, HRV indices reflective of peripheral nervous system activity demonstrated a significant reduction with concomitant increase in HRV indices of sympathetic nervous system activity (P < .05). Recovery in these HRV indices toward baseline was observed during postexercise recovery. Neurocognitive performance on the Stroop task significantly improved with exercise (P < .05). Conclusion: Implementation of multimodal assessments to evaluate physiological and neurocognitive responses to exercise in individuals with history of sports-related concussion is feasible. Addition of these objective measures may decrease reliance on self-reporting of exercise-induced symptom exacerbation, enabling clinicians to identify individuals whose neurocognitive performance or physiologic response to exercise on the BCTT deviates from the expected.

Context: Sport-related concussion management often requires referral to physical therapy (PT). Objectives: To (1) outline the role of PT in the management of sport-related concussion, (2) describe patients who underwent PT, and (3) discuss outcomes of athletes who underwent PT. Design: Retrospective cohort study. Setting: Single institution. Methods: Adolescent athletes aged 14–19 years old who sustained a sport-related concussion from November 2017 to April 2022 were evaluated. The cohort was dichotomized into 2 groups: PT versus no PT. The outcomes were days from initial PT visit to symptom resolution (SR) and return-to-play. Subgroup analyses compared recovery metrics between those initiating PT before and after 30 (1 mo) and 90 days (3 mo) of injury. A univariable and multivariable regression was used to determine predictors of recovery. Results: Of 1010 concussed athletes, 205 (20.3%) received referral for rehabilitation, and 58 (28.3%) patients received PT at the parent institution. Those who received PT had a higher number of prior concussions compared with those who did not (PT: 1.0 [1.2]; non-PT: 0.6 + 1.0; χ ² = 19.37, P = .007). A large proportion of PT recipients reported headache (n = 45, 81.0%); visual disturbances (n = 32, 65.5%); and vestibular (n = 37, 63.8%), cervical (n = 25, 43.1%), or oculomotor dysfunction (n = 25, 43.1%). Most patients received exertional therapy (n = 32, 55.1%), vestibular therapy (n = 31, 53.4%), and/or cervical therapy (n = 30, 51.7%). Those initiating PT before 1 and 3 months had significantly shorter median times to SR compared with those initiating after 1 and 3 months, respectively. Multivariable regression showed that a shorter time between injury and the initial PT visit was predictive of faster SR (β = 1.66, P = .048). Conclusions: Headache, dizziness, and visual disturbances were commonly reported symptoms by patients who received PT. Cervical, vestibular, and oculomotor deficits were common objective findings by physical therapists, and cervical, vestibular, and exertional therapy were common interventions. Delayed time to PT was independently associated with a longer time to SR.

Context: Clinical concussion assessments do not typically simulate the speed or complexity of sport. Performance changes arising from combined physical, cognitive, and sensory demands of sport may thus remain undetected during rehabilitation. We developed R2Play, a multidomain return-to-play assessment tool for youth with concussions. R2Play involves levels and conditions that vary in physical, cognitive, and sensory load to simulate the multidomain demands of sport. Objectives: To explore cross-site feasibility, face validity, and content validity of R2Play by integrating quantitative and qualitative data. Methods: Convergent mixed-methods feasibility study. Five sites will each recruit 5 clinicians (total n_c = 25) and 10 youth sport participants (ages 10–25 y) with a history of concussion in the previous year (total n_y = 50). Feasibility will be evaluated using quantitative criteria for acceptability, demand, implementation, practicality, and integration, and qualitative investigated data from content analysis of postassessment interviews with youth and clinician participants. Face validity will be investigated in postassessment interviews. Content validity will be established through (1) changes in performance metrics (time to completion, errors, and heart rate) across R2Play levels, (2) youth-perceived physical and cognitive exertion for each level, and (3) overall clinician perceptions determined through postassessment interviews. Qualitative and quantitative data will be merged through joint display to identify areas of convergence, divergence, and complementarity, and to establish meta-inferences about feasibility, face validity, and content validity. Discussion: This study aims to demonstrate the face and content validity of R2Play, and its feasibility for cross-site implementation. Findings will guide further iteration of R2Play and establish the foundation for a larger multicenter validation study to establish the psychometric properties of R2Play. This work represents an important first step toward the implementation of an ecologically valid multidomain assessment tool designed to support a safe and efficient return-to-play after concussion, ultimately reducing the risk of recurrent concussion and subsequent injury.

Context: Social support is an important consideration during athletes’ rehabilitation following a concussion. Yet, its influence during the return-to-sport (RTS) strategy has been underexplored. Design: Concussed athletes’ experiences with social support during RTS were explored prospectively using an explanatory sequential mixed methods design. Methods: University rugby, basketball, and track and field athletes (N = 8) from a single Canadian institution, 19–23 years of age (mean = 20.63, SD = 1.51), completed concentric circles maps, the Perceived Available Support in Sport Questionnaire, and 2 semistructured interviews during their RTS. We analyzed concentric circles maps and questionnaire data descriptively and interview data using codebook thematic analysis. Results: Athletes identified 16 different social support agents. The 5 most important agents during RTS were athletic therapists, student therapists, head coaches, significant others, and teammates/friends. Significant others provided the most emotional (mean = 2.82, SD = 1.85) and esteem (mean = 2.63, SD = 1.85) support, and the athletic therapist (mean = 1.82, SD = 1.35) and head coaches (mean = 0.93, SD = 1.19) provided the most informational and tangible support. We generated 4 themes from athletes’ interviews: social support behaviors, contextual factors, concussion and RTS factors, and psychological readiness factors. Conclusions: The number of social support agents present, frequency of support types, and demonstration of support behaviors decreased across the concussion RTS strategy. Contextual (ie, toughness), concussion (ie, visibility), and RTS (ie, prognosis uncertainty) factors influenced athletes’ perceptions of social support agents’ support behaviors. Results add to our limited understanding of athletes’ social support during RTS following a concussion and suggest exploring the integration of behavior-specific (eg, checking in, providing reassurance, and demonstrating compassion) social support strategies to promote concussion rehabilitation and readiness to RTS.

Context: Social determinants of health including insurance type, income, race, and ethnicity have been shown to influence the utilization of physical therapy and recovery after an orthopedic injury. The influence of social determinants of health on the utilization of physical therapy and recovery from concussion is not well understood. Design: Prospective observational registry study in a specialty concussion program. Methods: Patients diagnosed with a concussion using the Postconcussion Symptom Inventory and the visio-vestibular examination (VVE) who were also referred to physical therapy were included. The main outcomes of interest were the number of days from referral to initial physical therapy evaluation and the number of physical therapy visits completed. Information related to patients’ age, race, ethnicity, sex, insurance type, and Child Opportunity Index was extracted from the registry. Multivariate and univariate regressions were used to assess the associations of each sociodemographic characteristic with the outcomes. Results: A total of 341 patients diagnosed with concussion between January 2017 and December 2023 met inclusion criteria. The average age was 14.77, and 64% were female. Patients’ age, race, ethnicity, insurance type, and Child Opportunity Index were not associated with days to evaluation or length of care in physical therapy. Higher PCSI scores in children under 12 years (coefficient: 0.17, 95% CI, 0.06–0.29) and female sex (coefficient: 1.2, 95% CI, 0.26–2.1) were associated with a longer course of care in physical therapy. Patients with an abnormal VVE score had on average 2.1 more physical therapy visits than those with a normal VVE score (coefficient: 2.1, 95% CI, 0.73–3.5). Conclusions: Higher PCSI scores in children, female sex, and higher VVE scores in general predicted a longer course of care in physical therapy. Implementation of a clinical care pathway for concussion care using the PCSI and the VVE may be one strategy to help mitigate systemic factors that might otherwise negatively influence access to physical therapy.

Context: Evidence indicates a 2 to 3 times increased risk of musculoskeletal injury after return to play from concussion. Undetected neuromuscular control deficits at return to play may relate to increased musculoskeletal injury risk. Rehabilitation to improve neuromuscular control may benefit patients with concussion, but access to rehabilitation professionals and/or poor adherence may limit efficacy. Our purpose was to determine the feasibility of an 8-week virtual neuromuscular training (NMT) program administered through a novel smartphone application among physically active, uninjured adults. Design: Feasibility trial. Methods: Participants were instructed to complete an NMT program administered via a smartphone application and returned for follow-up questionnaires 8 weeks later. They were instructed to complete 3 asynchronous self-guided workouts per week during the 8-week intervention period. Workouts included balance, plyometrics, strengthening, and dual-task exercises. The application provided instructions for each exercise using video, text, and audio descriptions. Our primary feasibility measure was participant adherence, calculated as the percentage of workouts completed out of the total possible 24 workouts. We recorded the average duration of each workout using start/stop/advance features within the application. Results: Twenty participants were enrolled, of which 15 (age = 26.3 [2.7] y, 67% female) returned for follow-up (75% retention). Participant adherence was 57.2% (25.0%; range: 16.7%–91.7%). Participants spent 17.3 (8.0) minutes per workout (range: 7.4–37.9 min). There were no adverse reactions or injuries. Most participants (60%) reported time availability as a primary barrier to intervention completion. Conclusions: Participants were moderately (>50%) adherent to a virtual NMT program, without any reported injuries. We identified several barriers to participation and pathways for improved adherence in the future. The virtual NMT program completed by uninjured adults provides evidence of its feasibility and future scalability to those with a recent concussion to address neuromuscular control deficits and reduce future injury risk.

Context: The sequelae of concussion may have psychological consequences that affect an athlete’s ability to return to play (RTP). However, confidence of RTP readiness is rarely monitored after a concussion. Design: This study examined the acute and longitudinal implications of concussion on an athlete’s confidence to RTP, the relationship between self-reported symptoms and athlete confidence to RTP, and interactions between concussion symptoms, sex, sport type (contact vs noncontact), and confidence to RTP. Methods: Forty-six college athletes (65% female) sustained a concussion and completed the Injury Psychological Readiness to Return to Sport (I-PRRS) scale at 3 timepoints: within 72 hours of injury (acute), within 72 hours of beginning the RTP protocol (pre-RTP), and within 72 hours of being fully cleared to RTP (post-RTP). Results: Athletes reported acute low confidence after concussion (I-PRRS mean [SD] = 32.59 [18.45]), which improved over time (pre-RTP mean [SD] = 52.11 [9.60]; post-RTP mean [SD] = 57.45 [5.96]). Some athletes returned to competition (post-RTP) with lingering confidence concerns (ie, I-PRRS < 50; 95% CI = 0.03–0.26). Acute symptom severity was associated with worse confidence (P < .001). Sex and sport type (contact vs noncontact) had no relationship with confidence (P = .406, P = .3314, respectively). These results indicate that athletes lack confidence acutely (within 72 h) following concussion. Conclusions: Although confidence improves over time, those who report greater acute symptoms also exhibit decreased confidence, and some athletes are returning to play with lingering concerns about their confidence (I-PRRS < 50). This preliminary evidence of heterogeneous confidence following concussion encourages the assessment and monitoring of confidence throughout concussion rehabilitation.

Context: Translating new evidence into clinical practice is a dynamic and iterative process. Research is ever evolving specific to concussion rehabilitation and requires a systematic approach rooted in science for translation into clinical practice. The knowledge-to-action (KTA) cycle framework is an effective strategy to ensure optimal outcomes and sustainability. The objective of this study was to investigate changes in clinical outcomes and clinician self-efficacy specific to concussion management in a suburban health care system utilizing the KTA framework. Design: Pretraining and posttraining intervention study. Methods: Rehabilitation professionals were electronically surveyed pre–post targeted concussion educational intervention. Questions were adapted from the General Self-Efficacy scale and tailored specifically to confidence in current concussion management. Retrospective chart reviews were also completed pre–post knowledge translation educational intervention to examine practice patterns. Data from the presurvey and retrospective chart review were utilized to identify the know–do gap and design intentional educational interventions. Statistical analysis was performed utilizing SPSS (version 28). Results: Within-group differences revealed an increase in confidence with evaluation (P = .01), intervention (P = .01), and consultation (P = .01) in concussion management. When comparing physical therapists who participated in the intervention with those who did not, there was significantly higher self-confidence in all areas (P ≤ .001) for those who engaged in the educational intervention. Pre–post chart reviews revealed improvement in clinical practice patterns in the following constructs: use of patient-reported outcome measures (P ≤ .001), objective outcome measures (P = .002), exertional testing (P ≤ .001), completion of comprehensive evaluation (P ≤ .001), and use of evidence-based practice (P ≤ .001). Conclusions: Utilizing the KTA framework resulted in improved self-efficacy of clinicians as well as improved clinical practice patterns in concussion management in an outpatient hospital-based practice. The KTA framework is a potential tool for translating current evidence related to concussion management for improved clinical outcomes.

Context: Athletes who do not follow proper concussion recovery protocols are likely to experience their symptoms for longer while putting themselves at risk of further health issues. It is, therefore, critical to identify the types of athletes who may be more or less likely to follow the guidance of medical professionals following concussions. In this research, we tested the hypothesis that athletes with higher levels of self-compassion would be more willing to follow concussion recovery protocols. Design: Cross-sectional study. Methods: We collected data from 2 samples of combat sport athletes (sample 1, N = 173 and sample 2, N = 172). All participants completed online surveys assessing self-compassion, the likelihood that they would follow 10 recovery recommendations if they were to experience a concussion in their sport, and scales assessing 3 covariates: self-esteem, conscientiousness, and sport competitiveness. Results: After controlling for self-esteem, conscientiousness, and sport competitiveness, the results of multiple regression analyses in both samples showed that self-compassion was positively associated with willingness to follow concussion recovery recommendations (sample 1: β = 0.19, 1-tailed P = .039; sample 2: β = 0.20, 1-tailed P = .025). The results of a mini meta-analysis of these effects supported this positive association, Mean r = .144, Z = 2.666, 1-tailed P = .004. Conclusions: Athletes who are highly self-compassionate reported a greater willingness to follow the advice of medical professionals and adhere to return-to-play protocol. This finding has implications for the rehabilitation of sport concussions; it may be advantageous to encourage athletes to be kind and compassionate toward themselves throughout the concussion recovery process.