Sports-Related Concussion

Dr. Yang and her team have completed the Robert Wood Johnson Foundation -funded study that examined barriers to the implementation of state youth concussion laws within US high schools as perceived by high school athletic trainers. The study found:

• Barriers to the implementation of the concussion education tenet occurred at the school level and included (1) lack of quality education, (2) lack of buy-in to educational requirements, and (3) lack of time for and attendance at educational meetings.
• Barriers to the implementation of the removal from play tenet were from intra- and inter-personal levels and included (1) athletes underreporting concussion symptoms, (2) lack of communication, (3) resistance from parents and coaches, and (4) sport culture and “old school” mentality.
• Barriers to the implementation of the return-to-play tenet centered on intra- and interpersonal barriers as well as policy-level influences and included (1) cost of and access to medical care, (2) resistance from stakeholders, and (3) lack of understanding of concussion.

These findings provide insight into the barriers high schools encounter when implementing state youth concussion laws. Results can be used to inform the development of multilevel implementation strategies that aim to reduce these implementation barriers and promote high schools’ successful execution and application of state concussion laws, which, in turn, can help schools maximize the safety of their student-athletes. These findings also shed light on necessary updates and revisions to current state concussion laws.

Dr. Yang and her team, in collaboration with Dr. Elaine Mardis from the Institute for Genomic Medicine and Dr. James MacDonald from Sports Medicine, recently completed a pilot project, funded by The Abigail Wexner Research Institute at Nationwide Children’s Hospital and The Ohio State University Discovery Theme Initiative on Chronic Brain Injury. The project aimed to longitudinally monitor salivary expressions of a panel of microRNAs (miRNAs) over time in concussed children ages 5-17 years to identify biomarkers that can detect concussed children who are at risk for persistent post-concussion symptoms (PPCS). This project found:

• Of the 91 miRNAs expressed above background levels, 13 salivary miRNAs were significantly upregulated post-concussion in children with PPCS compared to those without PPCS, suggesting that salivary miRNAs may serve as an objective prognostic biomarker for PPCS.
• The expression levels of the 13miRNAs that were differentially expressed in the two groups were consistently higher in children with PPCS than those without PPCS across the three timepoints, except for one miRNA. 
• Among the 13 miRNAs identified, one was also identified in a prior study, with significantly different expression levels between children with and without PPCS.

Dr. Yang and her team, in collaboration with investigators from The Ohio State University (OSU), are currently conducting a study funded by the OSU Chronic Brain Injury Program addressing the need for and barriers to developing headgear use policies for girls’ lacrosse players in Ohio.

Currently, U.S. Lacrosse allows girls’ lacrosse players to wear headgear, but does not require them. While helmets will not prevent all concussions, previous research has demonstrated that headgear does provide some level of protection from concussion among girls’ lacrosse players. However, there has been much debate on whether headgear should be required in girls’ lacrosse as scientific evidence on the topic is limited.

This study aims to:

• Identify the needs of and barriers to the development of mandated helmet use policies in girls’ lacrosse in Ohio 
• Examine the current helmet use policies and practices in girls’ lacrosse across Ohio
• Develop a lacrosse injury registry prototype

Funded by the Centers for Disease Control and Prevention (CDC), Dr. Yang and her team examined the impact of Ohio’s Youth Traumatic Brain Injury (TBI) Law on changes in patterns of concussion-related healthcare utilization among youth aged 5 to 18 years old. They found that:

• Concussion-related healthcare utilization significantly increased over time
• Youth living in rural areas were treated for concussions at higher rates than urban youth
• Rural youth most commonly visited the emergency department for initial concussion-related care. For urban youth, this pattern shifted over time from the emergency department to their primary care provider for initial concussion-related care.
• Sports-related concussions and non-sports-related concussions are likely to have different patterns of healthcare utilization before and after the enactment of Ohio’s concussion law. Privately insured youth had a significantly higher rate of initial concussion visits throughout the study than publicly insured youth.
• Publicly insured youth were significantly more likely to seek initial concussion-related care at the ED and urgent care but less likely to seek initial concussion related care at a sports medicine clinic than privately insured youth.

Funded by the Robert Wood Johnson Foundation, Dr. Yang and her team evaluated the impact of state traumatic brain injury (TBI) laws on the rate of new and recurrent concussions among a nationally representative sample of high school athletes using High School RIO data. They also analyzed policy implementation at the school level. The main findings include:

• Significantly increased trends in new and recurrent concussion reporting rates. These increases were observed from pre-law, through immediate-post-law, and into the post-law period.
• Approximately two and a half years after the laws went into effect, the recurrent concussion rate showed a significant decline.
• All participating high schools developed concussion policies to guide the implementation of their respective state's youth TBI law, but these laws varied in policy enforcement, description, and implementation specifications.
• Effective implementation of the core tenets of concussion law goes beyond simply removing injured athletes from play, monitoring them for return to play, and distributing information sheets; A successful implementation of the state concussion laws and policies at the school level requires involving multiple stakeholders and using various existing resources.

Dr. Yang and her team recently completed a National Institute of Child Health and Human Development (NICHD)- funded study examining optimal levels of physical and cognitive rest after sports-related concussion among youth aged 11 to 17 years. This project found:

• Acute and sub-acute self-paced physical activity alone neither hastened nor prolonged concussion recovery in youth.
• Increased time spent in medium or high intensity cognitive activities was associated with faster symptom resolution, while delay in returning to school was associated with slower symptom resolution.
• Over 80% of concussed youth returned to school at least once for part of the day during the first week post-injury; Increased school time during the first week post-injury is associated with earlier symptom resolution.

Dr. Yang and her team, in collaboration with investigators from The Ohio State University (OSU) and University of Alabama Birmingham, are currently conducting an NIH-funded study evaluating driving among teen drivers with an mTBI from acutely post-injury to symptom resolution, and assessing the influence of increased cognitive load and underlying neurocognitive deficits on driving performance compared to matched healthy controls.

Resuming driving after a mild traumatic brain injury (mTBI) is an immediate goal for many individuals as they return to their daily activities. However, while physicians commonly prescribe physical and cognitive rest after an mTBI, evidence-based guidance about when patients can safely return to drive is lacking. This is particularly concerning for young drivers as they are already at greater risk for motor vehicle crashes, including serious and fatal crashes.

This study aims to:

• Characterize the trajectory of driving from acutely post-injury to symptom resolution among teen drivers with mTBI compared to healthy controls
• Examine the effect of cognitive load on driving performance from acutely post-injury to symptom resolution in teen drivers with mTBI compared to healthy controls
• Examine the extent to which differences in driving performance between teen drivers with and without mTBI, especially under increased cognitive load, are mediated by acute post-injury neurocognitive function

Drs. Yang and McKenzie and their teams completed a pilot study funded by a Connect and Collaborate grant that aims to develop an innovative, virtual reality (VR) mobile app to educate youth athletes about the signs and symptoms of concussion, the potential dangers of concussion, and the importance of concussion reporting. The preliminary findings show that: 

• VR concussion education mobile app was well-received and accepted by participating youth soccer athletes and their parents and coaches.
• Youth athletes enjoyed the computer-generated, immersive, three-dimensional environment that allowed them to virtually “experience” concussion events and symptoms. 
• Youth athletes showed improvements in concussion symptom recognition and reporting intentions after using the VR concussion education mobile app. 
• Drs. Yang and McKenzie, in collaboration with a multidisciplinary research team, are applying for additional funding to conduct a larger trial that aims to increase youth athletes' concussion symptom awareness and recognition before they experience an injury and improve their understanding of the importance of reporting concussion.