Approximately 10-15% of patients with mild traumatic brain injury (mTBI) report persistent, chronic symptoms more than one month later. Coping behaviors after mTBI can range from fear avoidance (FA), or a reluctance to return to activity because of the fear of symptom exaggeration, to endurance (END), or an overly aggressive return to activity. We evaluated how coping strategy relates to self-reported symptoms in patients with prolonged recovery from mTBI.

Participants were 72 individuals (age 37.8 + 18.4, 65% female) who sustained a mTBI at least one month prior to assessment (median (IQR) = 5.5 (2.0-11.3) months). Participants completed the Brain Injury Recovery Disposition Scale (BIRDS) to assess FA and END behaviors, and Sport Concussion Assessment Tool (SCAT5) Symptom Inventory. A BIRDS spectrum score was calculated as the difference between FA and END scores to determine individual coping behavior on a spectrum from extreme FA (more negative) to extreme END (more positive). SCAT5 symptoms were separated into four domain scores: somatic, cognitive, sleep, and emotion. Regressions were performed for each outcome examining their potential linear and quadratic associations to coping behavior (i.e., BIRDS spectrum score). Follow-up regressions were performed covarying for age and sex to explore the potential influence of these variables on each outcome.

The linear and quadratic components of the BIRDS spectrum score were not significantly related to total number of persisting concussive symptoms. For overall total symptom severity, the quadratic component of the relationship was significant (B = .24, p = 0.04). Visualization of the overall trend line suggested that symptom severity was highest on the extreme FA side of the BIRDS spectrum (highly negative BIRDS spectrum score), decreased as coping behavior become more balanced (BIRDS spectrum score surrounding “0"), plateaued, then increased abruptly on the extreme END side (highly positive BIRDS spectrum score). For cognitive symptoms, the linear component of the BIRDS spectrum score was significant (B = -.28, p = 0.02) and the quadratic component was marginally significant (B = .22, p = 0.06). The quadratic (but not linear) component was significantly related to both the severity of sleep (B = .31, p = 0.01) and emotion symptoms (B = .25, p = 0.03). Finally, neither the linear nor quadratic components were significantly related to the somatic symptom severity. After covarying for age and sex, the quadratic component remained significant for total symptom severity (p = 0.05) as well as the linear component for cognitive severity (p = 0.02).

Both extreme “fear avoidance” and “endurance” coping styles may be related to more severe chronic mTBI symptoms, especially in domains of sleep and emotion symptoms. Patients with balance of both fear avoidance and endurance behaviors may be more likely to experience less severe symptoms even among mTBI patients with persistent complaints. Identifying coping behavior styles early after mTBI could improve prognostication and help with developing personalized treatment plans to improve patient recovery. Future research with larger sample sizes should further examine the influence of age and sex on the relationship between coping behavior and symptom severity.

There is rising concern over the potential cumulative and long-lasting effects of prior concussions in active and retired athletes. Previous studies suggest that there is an inverse relationship between concussion (or mild traumatic brain injury) and sleep, with increasing evidence of individuals reporting chronically disrupted sleep following remote concussion. The extent to which these effects are cumulative across repeat concussions is unknown. This project aimed to investigate the association between the number of prior concussions and subjective sleep quality in otherwise healthy collegiate-aged athletes. Furthermore, we investigated which aspects of sleep are most associated with prior concussion.

A total of 176 collegiate-aged athletes (Mage = 21.19, SD = 1.63; 65.9% men) completed off-season clinical visits, at least 6 months since their most recent concussion. Semi-structured interviews captured detailed sport and head injury history across the lifespan. The number of prior concussions for each participant was retrospectively assessed based on American Congress of Rehabilitation Medicine criteria. Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). A general linear model tested the relationship between number of prior concussions and global PSQI score (i.e., overall sleep quality). Logistic regression models were fit to investigate the association of the number of prior concussions with individual subcomponents of the PSQI (i.e., quality, latency, duration, efficiency, disturbances, use of sleep medications, and daily dysfunction), which were binarized based on their distribution. Sex and total number of years of exposure to contact sports were included as covariates for all models.

The number of prior concussions was significantly associated with worse overall sleep quality as assessed by the global PSQI score, F(3,172)=6.92, p= <0.001, unstandardized beta[B](standard error[SE])=0.54(0.14). Investigation of sub-components showed that the number of prior concussions was significantly associated with multiple PSQI subcomponents, including: poorer sleep quality, odds ratio [OR]=1.35, 95% CI [1.05, 1.74], p=0.02; longer sleep latency, OR=1.35, 95% CI [1.08, 1.68], p=0.008; more sleep disturbances, OR=1.56, 95% CI [1.15, 2.12], p=0.004; and more sleep-related daily dysfunction, OR=1.46, 95% CI [1.16, 1.83], p=0.001. The number of prior concussions was not significantly associated with sleep duration, sleep efficiency, or the use of sleep medication (ps>0.05). There were no years of exposure effects (ps>0.05). Select sex-related effects on sleep quality were observed. Specifically, women reported significantly worse global sleep scores, F(3,172)=6.92, p=0.048, B(SE)=-0.99(0.50), and women reported significantly more sleep disturbances, B(SE)=1.47(0.70), p=0.04, OR=4.34 (95% CI [1.11, 16.98].

These results suggest a potential dose-effect of concussion history on poorer sleep quality ratings in otherwise healthy athletes. Specific facets of sleep that were adversely associated with prior concussion included sleep quality, latency, disturbances, and daily dysfunction, highlighting potential areas for sleep-related clinical interventions. Given the adverse effects of chronic sleep disturbance on mental health, future studies are needed to determine the role of concussion-related sleep problems in the adverse psychological outcomes observed in some athletes with multiple prior concussions.

Prior research has found that a greater history of concussion is associated with subtle increases in symptom endorsement. Recent work indicates that a family history of psychiatric disorder is a potential risk factor for prolonged recovery following a single injury. While greater symptom endorsement is observed among those with a personal psychiatric history, the potential role of family psychiatric history in elevated symptom endorsement in the context of repeated concussion has not been investigated. Therefore, the objective of this work was to determine whether family psychiatric history moderates the association of concussion history and elevated symptom endorsement in active collegiate athletes.

A total of 176 (mean age = 21.19 ± 1.63; 116 male) collegiate athletes completed this study at the Medical College of Wisconsin. Participant’s family psychiatric history was collected through a modified Family History Screen (FHS) regarding the participant’s biological parents, siblings, and children, focusing on questions relating to major depressive disorder (MDD; 3 total questions) and general psychiatric history (5 total questions). Concussion history was assessed through a semi-structured interview using American College of Rehabilitation Medicine criteria for mild traumatic brain injury. Concussion symptoms were measured via the Sport Concussion Assessment Tool (SCAT-5) and psychological distress was assessed using the Brief Symptom Inventory-18 (BSI-18). General linear models tested the association of the number of prior concussions with log-transformed SCAT-5 and BSI-18 scores. Additional general linear models were fit to assess the effects of number of prior concussions, family psychiatric history (MDD family history and general family history, each coded as Yes/No), and the interaction of prior concussion and family psychiatric history on log-transformed SCAT-5 and BSI-18 scores. Sex was included as a covariate in all models.

More prior concussions were significantly associated with greater symptom severity scores on the SCAT-5 (x2=26.87, p<0.001, unstandardized beta[B](standard error[SE])=0.25(0.05)) and BSI-18 (x2=20.94, p<0.00, B(SE)=0.19(0.04)). For the models investigating the effects of family psychiatric history, neither the main effect of MDD family history nor the MDD family history by prior concussion interaction were significant for either the SCAT-5 (ps>0.05) or BSI-18 (ps>0.05). Similarly, for the general history model, neither the main effect of general family psychiatric history nor the interaction of general family psychiatric history and number of prior concussions were significant for either the SCAT-5 (ps>0.05) or BSI-18 (ps>0.05). For both the MDD family history and general psychiatric family history models, the number of prior concussions remained positively associated with subjective symptoms on both the SCAT-5 (X2=20.10, p<0.001, and x2=23.50, p<0.001) and BSI-18 (x2=16.46, p<0.001, and x2=20.68, p<0.001).

The results of the current study provide further evidence for a relationship between elevated sub-clinical symptom endorsement and the number of prior concussions in active, collegiate athletes. The results do not, however, support the hypothesis that the association between prior concussion and an athletes’ level of symptom endorsement are moderated by the family psychiatric history. Additional research is needed to determine what factors predispose some individuals to the adverse chronic effects of repeated concussion.

Olfaction is a critical sensory function and changes in the ability to detect smells could affect quality of life by diminishing appreciation of food, drink, and other aroma-based experiences, increase danger of hazardous exposures, and cause a loss of employment. Additionally, decrements in olfaction have been related to onset of some neurodegenerative conditions. Olfactory impairments in military populations are highly prevalent and often attributed to the long-term effects of mild traumatic brain injury (mTBI) and chronic psychiatric disorders. The main goal of this investigation was to examine olfactory function in a cohort of combat veterans using a quantitative smell test.

Participants underwent a neurological examination using a revised version of the Neurological Outcome Scale for Traumatic Brain Injury. Olfactory function was examined using a set of essential oil vials with common odors. Based on the number of correctly identified odors, the following grading system was employed: no deficit; mild; moderate; severe deficit; and absence of smell detection. All study assessments were performed prior to March of 2020 (onset of COVID-19 pandemic). In addition, participants completed performance validity testing (PVT) and screening for ongoing substance misuse using the Alcohol Use Disorders Identification Test and Drug Abuse Screening Test-10. Lifetime history of brain injury, combat-related extracranial injuries, and deployment characteristics were assessed using structured interview. All available medical records were reviewed.

Participants were 38 veterans with a deployment-related mTBI who passed the PVT and did not have ongoing substance misuse issues. Olfactory examination revealed normosmia in 20 participants and various degrees of deficit in 18 (11= mild; 4=moderate; and 3=severe). The groups did not differ in demographics, post-injury interval, or current clinical (non-psychiatric) conditions. Participants with hyposmia frequently reported being exposed to a higher number of blasts and being positioned closer to the nearest primary blast, and more often endorsed a period of loss of consciousness after the most serious mTBI. In addition, they more often reported tympanic membrane perforation, extracranial injuries, and histories of both blast and blunt force mTBI. Comorbid diagnoses of posttraumatic stress disorder (PTSD), depression, chronic headaches, and pain were more common among these participants as well.

Several blast exposure and specific injury-related characteristics increase the likelihood of long-term olfactory impairments, comorbid psychiatric conditions, and chronic pain among veterans with a history of deployment-related mTBI. Notably, none of the participants with hyposmia had a clinical diagnosis of olfactory dysfunction or were receiving service-connected disability for a loss of sense of smell at the time of their assessment. Multidisciplinary rehabilitation care provided to combat veterans with history of mTBI and/or PTSD should include olfactory examination using both quantitative and qualitative smell tests, education regarding the adversities related to loss of smell, management of current psychiatric symptoms, and follow-up assessments. The lack of a comparison group without a history of mTBI and the small sample size were the main limitations of this investigation.

mTBI is trauma to the brain due to a blow or other mechanical force affecting the head. Prior research has established that common symptoms of mTBI include decreased sleep quality and onset/worsening of emotional dysregulation. However, there is little published research investigating how sleep disruption and depressive symptoms are experienced at varying stages of mTBI. We hypothesized that sleep disruption would change with differing time since injury, and that depressive symptoms should accordingly. Additionally, since females tend to have higher rates of depression, we predicted that there would be a significant difference between the sexes at different stages post-mTBI.

This study included 145 healthy adults, split into six groups, comparing healthy controls consisting of 15 males (Mage=23.67, SD=5.066) and 17 females (Mage=25.35, SD=7.035) to individuals who had mTBI, 41 males (Mage=26.88, SD=8.509) and 72 females (Mage=23.79, SD=6.898) at five points post-mTBI: 2 weeks and 1, 3, 6, and 12 months. The Pittsburgh Sleep Quality Index (PSQI) global score was used to assess individual sleep quality and disturbances; higher scores indicated poorer sleep quality. The Beck Depression Index (BDI-II) was used to assess characteristics and symptoms of depression. We adjusted the score to exclude item 16, which measures changes in sleep. Higher scores indicate more severe depressive symptoms. We conducted a multivariate analysis of variance and Pearson correlation to examine whether there were significant differences in sleep and depression at different stages of mTBI for each sex.

We discovered that sleep quality was worse at chronic stages of mTBI (i.e, 12M, p=<.001), than at acute stages (2W, p=.049), and compared to healthy controls. There were also significant differences in depression scores compared to healthy controls at 2W, p=.008, 3M, p=<.001, and 6M, p=.012, but not 12M, p=.313, suggesting that depressive symptoms resolved by 12M in those with mTBI. To explain this, we investigated sex differences, as males tend to experience fewer depressive disorders than females. However, females reported fewer depressive symptoms than males at chronic stages of mTBI. This finding was not statistically significant as females had a Mbdi_total=6.84, SD=7.98 and males had a Mbdi_total=5.38, SD=6.078; still, this could be due to the low statistical power of the study, and with a larger sample size, could produce statistically significant differences between the sexes. Despite this, there is a statistically significant difference in the depression score for females between 2W and 12M post-mTBI (p=.046; effect size of d=.99). Comparatively, males showed no significant divergence between depression and sleep scores.

Sleep disruption and depressive symptoms were correlated in individuals with mTBI in both acute and chronic stages; however, at 12M, there was a decrease in this correlation due to females exhibiting fewer depressive symptoms in combination with greater sleep disruption in the chronic phase of mTBI. Further research investigating the relationship between depression and sleep quality by looking at females with a much larger sample size would be helpful in clarifying these associations.

There is a wide variability in the neuropsychiatric presentation of mild traumatic brain injury (mTBI), and accurate diagnosis and treatment is complicated by within-condition heterogeneity and overlapping symptoms of common comorbidities (e.g., PTSD). Such diagnostic complexities can obfuscate clinical decision-making and lead to suboptimal treatment response. In contrast to traditional diagnostic categories, person-centered analysis methods create data-derived groupings wherein individuals within a cluster are similar and individuals across clusters are different. The current study sought to apply clustering to dimensional emotional and neuropsychological features in treatment-seeking Veterans with mTBI, with the goal of identifying more precise, homogeneous clinical profiles.

Study participants were 190 Veterans with mTBI history participating in a clinical neuropsychological assessment of cognitive complaints (Mean age: 34.38, 89.6% male, average years of education: 13.14). Participants completed a diagnostic interview, neuropsychological tests, and symptom questionnaires (NBSI, PCL, BDI, BAI, AUDIT, PSQI). To identify clusters of similar neuropsychiatric presentations, we first conducted dimension reduction on data from the cognitive tests and self-report measures using principal components analysis. Second, cluster analysis and cluster validation was performed on the resultant principal components (R: kmeans, clusterboot, clusterValid) to find homogeneous subgroups of participants.

The clinical data was best represented by principal components reflecting anxious arousal, depressive cognitions, somatic post-concussive symptoms, reexperiencing and avoidance symptoms, and objective cognitive deficits. Cluster analysis using bootstrapping and cluster validity indices (e.g., Silhouette width, Dunn index) indicated that a 6-subgroup solution was optimal (subgroups were labeled Group A-Group F). Group A was characterized by moderate levels across all dimension scores. Group B was characterized by elevated somatic post-concussive symptoms and cognitive deficits. Group C was characterized by intact cognitive performance and low somatic post concussive symptoms. Group D was characterized by elevated depressive cognitions. Group E was characterized by high anxious arousal but low depressive cognitions and reexperiencing and avoidance. Group F was characterized by elevated reexperiencing and avoidance. The subgroups did not differ statistically on any demographic items, such as years of education, age, or gender. However, there were statistically significant differences across groups in performance validity failure (x2(10) = 27.17, p=.002); Group B showed the highest rate of failure.

Results demonstrate that phenotypically similar subgroups of individuals can be identified within treatment-seeking Veterans with mTBI. Data suggest that somatic post-concussive symptoms may be linked to cognitive deficits, however the rate of validity failure indicates that neuropsychological test scores may not reflect true cognitive ability. In contrast to prior studies that treat mTBI as a unitary construct that accounts for symptoms, our data suggest that a nuanced evaluation yields vastly diverse clinical presentations. Cluster analytic frameworks hold promise for better assessment and treatment planning for Veterans, as both patients and their treating clinicians would be greatly served by the ability to use common clinical assessment tools to better identify a given individual’s clinical needs. A critical next step is to validate subgroups using novel samples and data sources (e.g., neurobiology, genetics) and to determine if these subgroupings can be effectively utilized to personalize treatment assignment.

A non-negligeable proportion of individuals who have sustained a mild traumatic brain injury (TBI) are at risk of developing persistent symptoms. The impact of persistent post-mTBI symptoms can be profound, causing significant disruptions in well-being, functioning and quality of life (Agtarap, et al., 2021). Reduced social participation often extends beyond the acute recovery period and continues to be associated with lower quality of life for many months after mTBI (Voormolen et al., 2019). Coping was found to be essential in order to decrease physical symptoms, have better psychological health, as well as increase social participation (Vos et al., 2019). The variables of perceived stress and depression were also linked directly and indirectly to mild post-TBI adjustment in terms of their return-to-work status (Strom and Kosciulek, 2007). Furthermore, a greater percentage of individuals with mTBI report chronic pain as compared to individuals with more severe TBIs (Weyer Jamora, Schroeder & Ruff, 2013). Given these implications and the growing concern for mTBI as a potentially disabling and chronic medical condition, it is important to focus on identifying the processes that can lead to persistent symptoms and related preventive interventions that can be applied. This present study aimed to investigate the association between coping and social participation according to anxiety, depression, and pain symptomatology, before and after rehabilitation in a mild TBI population benefiting from an outpatient rehabilitation program.

A prospective longitudinal cohort study design was employed, with two-time points for outcome assessment (i.e., start and end of rehabilitation). This study included 70 adults aged between 18 and 78 who experienced a mTBI between February 2016 and January 2020 and received interdisciplinary outpatient rehabilitation services at a major rehabilitation centre in the Greater Montreal region.Measures administered pre and post rehabilitation included the Rehabilitation Survey of Problems and Coping (R-SOPAC), the Mayo-Portland Adaptability Inventory-4 (MPAI-4), the Depression Anxiety Stress Scales 21 (DASS-21), and the Brief Pain Inventory-Short Form (BPI-SF). Mediation analyses were carried out via PROCESS macro for SPSS, model 4 and 6 (Hayes, 2013).

Mediation analyses indicated a partial indirect link between coping, anxiety, and pain on the level of social participation at the pre-rehabilitation time point. Post-rehabilitation, a significant partial mediating relationship regarding the impact of pain on the link between coping and social participation, was found. In addition, a statistically significant mediation relationship was found, where anxiety mediated the relationship of coping and social participation. These relationships suggest that lower levels of coping appear to be linked to a higher self-reported level of psychological distress and pain, resulting in lower social participation.

This observational rehabilitation cohort study demonstrates how anxiety and pain are associated with coping and social participation outcome following mTBI. These results are quite pertinent for clinical purposes in that paying close attention to the level of anxiety and perceived impact of pain during rehabilitation, and applying targeted interventions at these levels, in particular to increase coping, may prove particularly beneficial to improve social participation outcome.

Significant advances in the research of sport-related concussion (SRC) and repetitive head impacts (RHI) over the previous decade have translated to improved injury identification, diagnosis, and management. However, an objective gold standard for SRC/RHI treatment has remained elusive. SRC often result in heterogenous clinical outcomes, and the accumulation of RHI over time is associated with long-term declines in neurocognitive functioning. Medical management typically entails an amalgamation of outpatient medical treatment and psychiatric and/or behavioral interventions for specific symptoms rather than treatment of the underlying functional and/or structural brain injury. Transcranial photobiomodulation (tPBM), a form of light therapy, has been proposed as a non-invasive treatment for individuals with traumatic brain injuries (TBI), possibly including SRC/RHI. With the present proof-of-concept pilot study, we sought to address important gaps in the neurorehabilitation of former athletes with a history of SRC and RHI by examining the effects of tPBM on neurocognitive functioning.

The current study included 49 participants (45 male) with a history of SRC and/or RHI. Study inclusion criteria included: age 18-65 years and a self-reported history of SRC and/or RHI. Exclusion criteria included: a history of neurologic disease a history of psychiatric disorder, and MRI contraindication. We utilized a non-randomized proof-of-concept design of active treatment over the course of 8-10 weeks, and neurocognitive functioning was assessed at pre- and post-treatment. A Vielight Neuro Gamma at-home brain tPBM device was distributed to each participant following baseline assessment.

Participants completed standardized measures of neurocognitive functioning, including the California Verbal Learning Test (CVLT-3), Delis Kaplan Executive Function System (D-KEFS), Continuous Performance Test (CPT-3), and The NIH Toolbox Cognition Battery. Neurocognitive assessments were collected prior to and following tPBM treatment. Paired t-tests and Wilcoxon’s signed-rank tests were used to evaluate change in performance on measures of neurocognitive functioning for normal and nonnormal variables, respectively, and estimates of effect size were obtained.

Study participants’ ability for adapting to novel stimuli and task requirements (i.e., fluid cognition; t=5.96; p<.001; d=.90), verbal learning/encoding (t=3.20; p=.003; d=.48) and delayed recall (z=3.32; p=.002; d=.50), processing speed (t=3.13; p=.003; d=.47), sustained attention (t=-4.39; p<.001; d=-.71), working memory (t=3.61; p=.001; d=.54), and aspects of executive functioning improved significantly following tPBM treatment. No significant improvements in phonemic and semantic verbal fluencies, reading ability, and vocabulary were shown following tPBM treatment.

The results of this pilot study demonstrate that following 8-10 weeks of active tPBM treatment, retired athletes with a history of SRC and/or RHI experienced significant improvements in fluid cognition, learning and memory, processing speed, attention, working memory, and aspects of executive functioning. Importantly, the majority of effect sizes ranged from moderate to large, suggesting that tPBM has clinically meaningful improvements on neurocognitive functioning across various cognitive domains. These results offer support for future research employing more rigorous study designs on the potential neurorehabilitative effects of tPBM in athletes with SRC/RHI.

Blast-related traumatic brain injury (bTBI) is one of the most common injuries among Veterans who have served in recent wars in Iraq and Afghanistan. Despite representing a distinct mechanism of injury, long-term clinical and functional outcomes of bTBI are generally comparable with non-blast-related traumatic brain injury (TBI). However, controversy remains over whether bTBI etiology differentially impacts emotional regulation and neurocognition - particularly with respect to post-traumatic stress disorder (PTSD) and verbal and visual memory. Through diffusion tensor imaging (DTI), the present study investigates the microstructural pathophysiology of bTBI, compared to non-blast TBI, in neural pathways involved in emotional regulation and cognitive control.

Participants included 36 Veterans (25% female; age M = 36.33, SD = 10.11; years of education M = 15.67, SD = 2.34). Axial diffusivity (AD) in networks of emotional and cognitive control was acquired using magnetic resonance imaging (MRI) with a DTI protocol. Analyses of variance (ANOVA) were used to compare Veterans with self-reported bTBI (n = 23) to those with non-blast-related TBI (n = 13).

In the left hemisphere, Veterans with bTBI exhibited significantly smaller AD in axonal projections from the caudate nucleus (CN) to the orbitofrontal cortex (OFC), as well as in projections from the putamen to the OFC (p < 0.05). In the right hemisphere, Veterans with bTBI also exhibited significantly smaller AD in networks connecting the hippocampus to the amygdala (p < 0.05).

Compared to Veterans with non-blast-related TBI, Veterans with bTBI exhibited decreased AD in neural pathways from the CN to the OFC, the putamen to the OFC, and the hippocampus to the amygdala - indicative of increased axonal injury in these areas. Our results suggest that, on a microstructural level, emotional and cognitive networks are susceptible to longitudinal blast-related white matter damage. This is consistent with the literature in post-concussion syndrome (PCS) and provides a potential mechanism underlying results previously reported from this sample, describing subjective cognitive complaints in the absence of objective clinical deficits. As such, therapies that target networks of emotional and cognitive control may be particularly beneficial for Veterans with bTBI.

Concussion patients frequently report increased distractibility, with more than half endorsing “concentration difficulty”. Previous studies have demonstrated impairments in maintaining attention and voluntary attentional allocation in concussion patients. However, involuntary attentional allocation (distraction) is not well understood in the context of concussion. The goal of this study was to examine distraction in acute pediatric concussion patients, monitoring frontal lobe activity using functional near-infrared spectroscopy (fNIRS) - a noninvasive measure of local hemodynamic activity - to elucidate whether post-concussion distractibility is associated with the availability of attentional control resources.

Participants included concussion patients (cases; n=19) presenting to specialty care within 28 days of injury (M=8.05, SD=5.55) and controls (n=16) presenting for reasons other than concussion. Participants were 13-17 years old (M=14.83, SD=1.10) and 57.1% female. Participants completed a computerized measure of behavioral distraction (the additional singleton paradigm) while frontal lobe activity was recorded using fNIRS 4-channel split sensor. On each trial, an array of shapes (five squares and one circle) was presented, and participants reported the orientation of a line segment inside a target shape (circle). The search array included a distractor (a square that differed in color) on 50% of trials. For each participant, the fNIR signal for epochs of each trial type (distractor present/absent) were averaged and subjected to a linear regression in which the data were fitted to a hemodynamic response function (HRF).

34 participants (19 cases, 15 controls) were included in our behavioral analysis. Reaction time (RT) was significantly slower on distractor present compared to distractor absent trials; F(1,32)=17.151, p<.001. There was no significant effect of group (case/control) on RT (F(1,32)=1.24, p=.273) or interaction between group and trial type (F(1,32)=1.05, p=.313). 29 participants (15 cases, 14 controls) were included in fNIRS analyses. The effect of group and distractor presence/absence on oxygenated hemoglobin (HbO2) was examined for each channel. A significant effect of distractor presence/absence was observed in channel 3; F(1,27)=8.510, p=.007. There were no significant effects of group or interactions between group and distractor presence/absence.

Lastly, a capture index was calculated for each participant by subtracting average RT on distractor absent trials from distractor present trials and correlated with HbO2 (beta weights averaged across trial type) for each group at each channel. No significant correlations were observed. There was a trend towards a negative correlation for case participants, particularly in channel 1, which strengthened when an outlier was removed (r=-.407, p=.149).

Reaction time and frontal lobe activity - which serves as a proxy for attentional control resources - were significantly higher when a distractor was present. Although there were no significant differences in behavioral distraction between groups, concussion patients trended towards higher levels of frontal lobe activity. Likewise, although not statistically significant, there was a trend towards a negative correlation for cases such that more attentional control resources (i.e., higher frontal lobe activity) was associated with less behavioral distraction (i.e., smaller capture index). This suggests that concussion patients may recruit more neural resources to produce comparable behavioral responses to healthy controls.

Recent conceptualizations of concussion symptoms have begun to shift from a latent perspective (which suggests a common cause; i.e., head injury), to a network perspective (where symptoms influence and interact with each other throughout injury and recovery). Recent research has examined the network structure of the Post-Concussion Symptom Scale (PCSS) cross-sectionally at pre-and post-concussion, with the most important symptoms including dizziness, sadness, and feeling more emotional. However, within-subject comparisons between network structures at pre-and post-concussion have yet to be made. These analyses can provide invaluable information on whether concussion alters symptom interactions. This study examined within-athlete changes in PCSS network connectivity and centrality (the importance of different symptoms within the networks) from baseline to post-concussion.

Participants were selected from a larger longitudinal database of high school athletes who completed the PCSS in English as part of their standard athletic training protocol (N=1,561). The PCSS is a 22-item self-report measure of common concussion symptoms (i.e., headache, vomiting, dizziness, etc.) in which individuals rate symptom severity on a 7-point Likert scale. Participants were excluded if they endorsed history of brain surgery, neurodevelopmental disorder, or treatment history for epilepsy, migraines, psychiatric disorders, or alcohol/substance use. Network analysis was conducted on PCSS ratings from a baseline and acute post-concussion (within 72-hours post-injury) assessment. In each network, the nodes represented individual symptoms, and the edges connecting them their partial correlations. Estimations of the regularized partial correlation networks were completed using the Gaussian graphical model, and the GLASSO algorithm was used for regularization. Each symptom’s expected influence (the sum of its partial correlations with other symptoms) was calculated to identify the most central symptoms in each network. Recommended techniques from Epskamp et al. (2018) were completed for assessing the accuracy of the estimated symptom importance and relationships. Network Comparison Tests were conducted to observe changes in network connectivity, structure, and node influence.

Both baseline and acute post-concussion networks contained negative and positive relationships. The expected influence of symptoms was stable in both networks, with difficulty concentrating having the greatest expected influence in both. The strongest edges in the networks were between symptoms within similar domains of functioning (e.g., sleeping less was associated with trouble falling asleep). Network connectivity was not significantly different between networks (S=0.43), suggesting the overall degree to which symptoms are related was not different at acute post-concussion. Network structure significantly differed at acute post-concussion (M=0.305), suggesting specific relationships in the acute post-concussion network were different than they were at baseline. In the acute post concussion network, vomiting was less central and sensitivity to noise and mentally foggy more central.

PCSS network structure at acute post-concussion is altered, suggesting concussion may disrupt symptom networks and certain symptoms’ associations with the experience of others after sustaining a concussive injury. Future research should compare PCSS networks later in recovery to examine if similar structural changes remain or return to baseline structure, with the potential that observing PCSS network structure changes post-concussion could inform symptom resolution trajectories.

The increasing incidence rates of concussive injuries, specifically among the youth age demographic, has led to the Center for Disease Control and Prevention to classify these injuries as a “silent epidemic.” While symptoms from concussion typically remit within four weeks, many experience symptoms that persist beyond what is typically expected. For children, the persistence of symptoms can have damaging side-effects that impact daily functioning and the progression through developmental and educational milestones. Recent research highlights factors that modify the nature of outcomes after a concussive injury. For youth-aged individuals, one such factor is the presence of premorbid conditions. A growing body of research suggests children with learning disorders (LDs) may be more susceptible to negative symptom outcomes across neuropsychological domains. Therefore, the purpose of this study is to further examine the influence of developmental learning disorders on concussion outcomes among youths.

Youths between 7 and 19 years of age that sought care at a concussion specialty clinic were screened for inclusion in the current study. The final sample of included 54 patients who reported having a neurodevelopmental LD between the ages of 8 and 17 and 54 patients without LDs matched on age, race/ethnicity, and gender to serve as paired case-controls. Measures of post-concussive physical symptoms (Modified Balance Error Scoring System; Quality of Life in Neurological Disorders: Neuro-QoL-SD, Neuro-QoL-F), emotional state (BAI, BDI), parent report measure of behavioral manifestations of cognitive functioning (Behavioral Rating Inventory of Executive Function), and select measures from the CogState automated test battery (i.e., One-Back, Two-Back, Groton Maze Learning, and Groton Maze Recall) were administered during the patient’s first examination at the clinic. Patients were instructed by the provider to follow-up at the clinic between two-three weeks for a repeat examination. The current study examined concussion outcome variables via two (group: LD, control) by two (time: initial examination, follow-up examination) repeated measures ANCOVAs where time between injury and the first examination was included as a covariate to control for the duration of elapsed days since injury.

Regarding cognitive symptoms, parent reported behaviors associated with executive functioning symptoms increased over time to reach clinically significant levels for the LD group, while symptoms decreased and remained within normal limits for the control group. Performance-based measures of cognition revealed no significant interactions or group/time differences. Additionally, the LD group showed more intense balance problems compared to the control group and symptom trends suggest LD participants may be more susceptible to prolonged, clinically significant, balance problems. With respect to sleep disturbances and fatigue, symptoms remained within normal limits across groups and time. Depression and anxiety symptoms remained within normal limits across groups and time as well.

Results highlight more intense balance problems and parent-reported executive dysfunction following concussion for youths with LDs compared to those without LDs. Additionally, though not significantly different

than the control group, results reveal several symptom domains in which the level of dysfunction meets clinical significance for the LD group participants only. As such, this study highlights the continued need for the scientific study of risk factors for vulnerable populations to aid in assessment and prevention efforts, especially for youths with LD.

External validation of symptom severity classification levels for the PostConcussion Symptom Inventory (PCSI).

Two distinct samples of parents and children, ages 8-18, participated from a: (1) prospective multicenter cohort study (Predicting Persistent Post-concussive Problems in Pediatrics, 5P) (Zemek et al., 2016), including parents (n=2,852), adolescents (n=1,087; mean age=15.13; 54% male), and children (n=1,271; mean age=10.70; 65% male) and (2) published clinic sample at Children’s National Hospital (CN) including parents (n=1,197; adolescents, n=835; children, n=326) (Gioia et al., 2019). Participants completed the age-specific Post-Concussion Symptom Inventory (PCSI): Mean time postinjury = 8 hours (5P), 6 days (PCSI2), generating a post-pre-injury difference (RAPID) score. The distribution of the RAPID scores for the Total Symptom and 4 subscales (physical, emotional, cognitive, sleep/fatigue) were examined to define 4 symptom severity classification levels (minimal - within the CI for recovered, low <20th %tile, moderate 21-79th %tile, high >80th %tile) for the respective samples. These severity distributions were compared between the two distinct datasets.

ANOVAs were performed to examine group differences in the mean scores for each of the 4 classification levels. No significant differences were found for all the RAPID score distributions with minimal effect sizes (<.1% variance) for the parents, adolescents and children. PCSI RAPID Total Score ranges for the severity classifications were as follows: Minimal-Parent and adolescent groups 5P<=5, Clinic <=5; Children: 5P<=3, Clinic<=3; Low- Parents 5P 6-15, Clinic 6-13; Adolescents 5P 6-19, Clinic 6-16; Children: 5P 4-7, Clinic: 4-7; Moderate-Parents 5P 16-49, Clinic 14-47; Adolescents 5P 20-56, Clinic 17-51; Children 5P 8-17, Clinic: 818; High- Parents: 5P>=50, Clinic >=48; Adolescents 5P >=57, Clinic >=52; Children 5P >=18, Clinic >=19).

Our findings reveal a parallel distribution of RAPID scores in the two distinct 5P and Clinic patient populations, yielding nearly identical severity classification level parameters across all five PCSI symptom domains (total score, physical, cognitive, emotional, and sleep/fatigue). The present investigation provides evidence of validity for the use of these severity classification levels across the ED and specialty clinic settings.

Patients with persistent post-concussion symptoms (PPCS) experience prolonged recovery (e.g., headache, fatigue, or dizziness) lasting >2 months post injury. These symptoms are thought to be maintained by several biopsychosocial factors including dysregulated stress responses, such as pain catastrophizing, that may drive behavioral avoidance and contribute to mood symptoms and cognitive difficulties. Conditions with similar symptomatology to PPCS (e.g., anxiety disorders, somatosensory disorders, chronic pain, etc.) also exhibit maladaptive thought patterns like pain catastrophizing as well as decrements in certain aspects of cognitive performance; however little is known about how pain catastrophizing might relate to neuropsychological performance in youth with PPCS. Therefore, the purpose of this study was to examine the relationship between pain catastrophizing and neuropsychological performance in youth participants with PPCS.

A prospective case-control study design was used to examine 29 participants between the ages of 13 to 23. Participants were divided into two groups: 1) patients with PPCS (2-16 months post-injury; n = 15) and 2) age-matched, non-injured controls (n = 14). Participants completed the Pain Catastrophizing Scale (PCS) to determine degree of catastrophic thinking related to pain experience and the Beck Depression Inventory (BDI). Neuropsychological performance was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and a modified version of the Paced Auditory Serial Addition Test (PASAT) where performance was evaluated by total correct and error type (i.e., commission and omission) across 5 trials. ANCOVA was used to compare group differences in pain catastrophizing and neuropsychological tests scores while controlling for age and linear regressions examined the relationship between PCS total score and each neuropsychological test score while controlling for level of depression.

Overall, the PPCS group reported significantly higher levels of pain catastrophizing on the PCS compared to the control group (p < 0.01). For neuropsychological performance, the PPCS group scored significantly lower than the control group on List Learning (p < 0.01), Semantic Fluency (p < 0.05), and List Recall (p < 0.01) on the RBANS and made significantly higher omission errors (but not commission) on the PASAT(p <.01). Higher pain catastrophizing was also associated with poorer neuropsychological performance on the exact same tasks the PPCS group performed worse than controls. There was no significant interaction by group in the impact of PCS scores on neurocognitive performance.

Compared to controls, youth PPCS patients reported higher levels of pain catastrophizing. Additionally, pain catastrophizing was associated with poorer neuropsychological performance. These findings suggest that increased pain catastrophizing after head injury could contribute to poorer cognitive performance in youth. As such, interventions that target maladaptive cognitive coping styles like pain catastrophizing may be especially helpful for patients with PPCS.

When neuropsychologists serve as consultants to schools, concussion management programs are associated with fewer referrals, faster cognitive recovery, and reduced incidence of protracted recovery compared to programs with physician consultants. However, accessing neuropsychological services can be challenging due to geographical and financial barriers. Particularly in rural areas, travel associated with post-concussion management can represent as a significant financial and time burden. Increasing accessibility to neuropsychologists has the potential to address these concerns, while also providing quality care to more

individuals. The current study aims to assess the cost-effectiveness and clinical outcomes of a remote, neuropsychologist-led consultation model of concussion management. We hypothesized that this remote model would save patients both money and time, while also improving patient outcomes.

604 high school concussion cases occurring between May 2019 and May 2022 were reviewed; 571 were included in the current analysis. The sample was 51% male with a mean age of 15.8 years (SD=1.32). All students took ImPACT tests following suspected concussions, with tests administered at the school by certified athletic trainers or nurses. Test results were electronically reviewed by the consulting neuropsychologist. Interpretations and recommendations were then sent via email to the school official. Cognitive recovery, defined as the days from the injury to the final ImPACT test, and incidence of repeat concussions, or concussions occurring within 3 months of a previous concussion, were used as indicators of patient outcomes. Financial burden was determined by calculating the round-trip distance in miles from the patient’s school to the neuropsychologist’s medical center, then multiplying this number by the 2022 standard mileage reimbursement rate of $0.63/mile to determine the travel cost for a single consultation.

The sample consisted of 571 individual concussion cases and 1,285 total ImPACT tests. An average of 2.25 tests were administered for each concussion case (SD=0.90), with an average of 18.47 days to the final test (SD=16.59). 8 concussions (1.4% of total concussions) occurred within 3 months of a previous injury. The distance from schools to the closest available neuropsychologist ranged from 2.4 to 102 miles. The remote nature of the consultation model allowed for patients to avoid up to 204 miles, or up to 4.5 hours, of driving for each consultation. Thus, patients saved anywhere from $3.00 to $127.50 in travel costs per consultation.

The remote nature of this consultation model yielded a similar cognitive recovery time to previous literature, indicating that it may be as effective as in-person consultation. Repeat concussions represented less than 1.5% of concussion cases, indicating that care was successful enough to prevent second concussions in the majority of the sample. The remote nature of the model also saved patients time (up to 4.5 hours of driving) and money (up to $127.50 in travel costs). Thus, a remote consultation model has the potential to increase access to first-rate concussion care in rural settings, while also being cost- and time-effective for patients.

Neuropsychological assessment is the cornerstone of concussion management, and the nature of its delivery can vary widely. While literature concerning post-concussion care typically revolves around in-person evaluation, the proliferation of computerized neuropsychological tests (CNTs) has allowed for some distance between concussion patients and the neuropsychologist. In the wake of a global pandemic, several papers describing the use of telehealth for concussion care have emerged; however, the small samples found in these studies may suggest that access to care remains an issue. Additionally, telehealth may not be a sustainable fee-for-service approach as CMS aims to curtail telehealth reimbursement for behavioral health clinicians. The objective of the present study is to describe a remote neuropsychological consultation model of concussion management and evaluate its productivity and impact in a rural setting.

In this model, a neuropsychologist based at an academic medical center in the northeastern United States consulted to middle school, high school, and collegiate concussion management programs. Students typically were administered baseline ImPACT tests prior to participation in sports, and all students in the current sample completed post-injury ImPACT tests as part of return to play protocols. The neuropsychologist read test results through the test’s online portal, then communicated interpretation and recommendations via email or phone to the school’s representative (e.g., athletic trainer, athletic director, or school nurse). 837 unique concussions were recorded between 2019 and 2022. After removing abnormal cases (e.g., COVID-19 school closures, extended college breaks, non-concussions, and non-return to play decisions), 790 unique concussions (51.4% male) were included for analysis, with a mean age of 16.84 years (SD=2.17). Descriptive statistics were used to characterize the sample.

Across 790 unique concussions, 7 were middle school, 571 were high school, and 212 were college students. 1,750 total postinjury ImPACT tests were administered over the three-year period. Per concussion, an average of 2.22 (SD=0.90) tests were used. Average time to the last ImPACT given was 18.47 days (SD=16.59), with a median of 15 days. Ten concussions (1.27% of total concussions) occurred within 3 months of a previous injury. The distance between schools and the medical center ranged from 2.4 to 102 miles (M=60.29; SD=34.34).

The current study suggests that there is value in a remote model of neuropsychological consultation for concussion management. While telehealth offers a promising method of evaluation for concussion, it may be inaccessible and present reimbursement challenges. The remote consultation model described here increases access to care by eliminating in-person visits, which decreases demand for physical space at medical centers and increases access to rural populations with seemingly no negative effect on care. This consultation model also allows neuropsychologists working in concussion management more flexibility, potentially increasing the volume of cases they can assess. This program evaluation suggests remote models have merit, but replication studies in different regions of the country are needed.

Youth athletes with concussion are at an increased risk of sustaining new concussions and orthopedic injuries after clearance for return-to-play. There are training programs, extensively studied in other patient populations, which can improve performance in cognitive domains that have been implicated in sport-related injury and re-injury after concussion (i.e., visual attention/processing speed). The Useful Field of View (UFOV) is one such training program, accompanied by a computerized adaptive assessment for evaluating response to training and maintenance in clinical trials. Remote UFOV assessment administration may help improve adherence, particularly in assessing long-term training effects. The current study explores the feasibility of virtual UFOV assessment and equivalence with in-person administration in youth clinically recovered from concussion and healthy controls.

Participants included youth ages 10-18 enrolled in a longitudinal study examining neural recovery following medical clearance from concussion. UFOV was attempted in 61 participants (Mage=15.06; SD=2.00; n=19 in-person; n=42). Of these, 7 virtual administrations were discontinued due to computer limitations, and 1 in-person administration was excluded due to overall performance validity concerns. This resulted in a total sample of 53 participants (Mage=15.02, SD=2.00, 58.5% male; n=14 concussion, Mdays_since_injury=272.64, SD=185.35; n=39 controls). UFOV was administered either in-person (n=18) using manual guidelines or virtually (n=35) on the participant’s computer using video-conference screen-share and a secondary device for an additional view of the participant and their keyboard/mouse. For virtual visits, the examiner recorded concerns about the remote testing environment (e.g., screen glare, viewing distance not measured appropriately), and analyses were conducted with and without cases with concerns. Between-group (in-person vs virtual administration) demographic differences were examined using chi-square tests/t-tests. Mann-Whitney U tests were used to examine for differences in UFOV scores (ms; higher scores are worse) by administration context (in-person vs. virtual) given threats to normality.

For virtual administrations, the most commonly reported concerns about the remote testing environment were related to lighting (n=12) and viewing distance (n=3). There were no significant differences in age, sex, concussion history, sport participation history, or IQ by administration context (in-person vs. virtual). UFOV performance did not vary significantly by administration context for processing speed or divided attention subtests, but performance on the selective attention subtest was significantly better in the virtual administration group (Median in-person =93.33; Medianvirtual=63.33; U=203.00, p=0.035). This trend persisted after removing an outlier (>2SD; p=0.065) and after removing cases where lighting (p=0.060) and screen-viewing distance (p=0.085) were not adequately controlled.

Though preliminary, results suggest that UFOV can be administered virtually, in youth with and without a history of concussion, but that those assessed virtually using their home computer may have an advantage, particularly for the selective attention subtest. This may be due to comfort level within the home environment or subtle differences in viewing distance that were not appreciated by the examiner remotely. Importantly, not all participants were able to complete the assessment virtually due to computer limitations. Future work with larger samples size should examine the extent to which completers vary from non-completers in terms of sociodemographic variables.

Much of the pediatric concussion literature focuses on sports and recreation related injuries, while there is a relative paucity of research on the cognitive and psychological sequelae associated with assault. However, it is understood that children with assault-related injuries demonstrate a longer recovery time. This case series reviews the data of four teenagers who were administered cognitive, emotional, and behavioral screeners after sustaining an assault related concussion.

Four pediatric female patients (ages 13,14,15,15) with a recent history of concussion due to physical assault presented for evaluation at a hospital-based concussion clinic. All four patients were administered a computerized cognitive screener as well as self-report measures for mood, anxiety, post-traumatic stress disorder (PTSD), and sleep disturbance.

All four of the pediatric cases reported significant symptoms of PTSD, depression, anxiety, and sleep disturbance. For all four patients, the most notable problems across cognitive performance measures were observed in the areas of simple and complex attention.

Results of this case series revealed clinically significant anxiety, depression, PTSD-symptoms, and sleep disturbance in conjunction with poor simple and complex attention. These pediatric cases illustrate the potential link between assault-related concussions, emotional and behavioral symptoms, and cognitive functioning. Furthermore, assault-related concussions may elevate risk toward attentional problems associated with psychological distress. Early evaluation of PTSD and mood related symptomatology is suggested to best support treatment planning and recovery in this population. Future studies are needed to explore the nature of the relationship between cognitive and emotional sequelae in patients who present with assault-related concussions.

Consideration of individual differences in recovery after concussion has become a focus of concussion research. Sex and racial/ethnic identity as they may affect reporting of concussion symptoms have been studied at single time points but not over time. Our objective was to investigate the factors of self-defined sex and race/ethnicity in reporting of lingering concussion symptoms in a large sample of adolescents.

Concussed, symptomatic adolescents (n=849; Female=464, Male=385) aged 13-18 years were evaluated within 30 days of injury at a North Texas Concussion Registry (ConTex) clinic. Participants were grouped by self-defined race/ethnicity into three groups: Non-Hispanic Caucasian (n=570), Hispanic Caucasian (n=157), and African American (n=122). Measures collected at the initial visit included medical history, injury related information, and the Sport Concussion Assessment Tool-5 Symptom Evaluation (SCAT-5SE). At a three-month follow-up, participants completed the SCAT-5SE. Pearson’s Chi-Square analyses examined differences in categorical measures of demographics, medical history, and injury characteristics. Prior to analysis, statistical assumptions were examined, and log base 10 transformations were performed to address issues of unequal group variances and nonnormal distributions. A three-way repeated measures ANOVA (Sex x Race/Ethnicity x Time) was conducted to examine total severity scores on the SCAT-5SE. Bonferroni post-hoc tests were performed to determine specific group differences. SPSS V28 was used for analysis with p<0.05 for significance. Data reported below has been back transformed.

A significant interaction of Time by Race/Ethnicity was found for SCAT-5SE scores reported at initial visit and three-month follow-up (F(2, 843)=7.362, p<0.001). To understand this interaction, at initial visit, Race/Ethnicity groups reported similar levels of severity for concussion symptoms. At three month follow-up, African Americans reported the highest level of severity of lingering symptoms (M= 3.925, 95% CIs [2.938-5.158]) followed by Hispanic Caucasians(M= 2.978, 95% CIs [2.2663.845]) and Non-Hispanic Caucasians who were the lowest(M= 1.915, 95% CIs [1.6262.237]). There were significant main effects for Time, Sex, and Race/Ethnicity. Average symptom levels were higher at initial visit compared to three-month follow-up (F(1, 843)=1531.526, p<0.001). Females had higher average symptom levels compared to males (F(1, 843)=35.58, p<0.001). For Race/Ethnicity (F(2, 843)=9.236, p<0.001), Non-Hispanic Caucasians were significantly different than African Americans (p<0.001) and Hispanic Caucasians (p=0.021) in reported levels of concussion symptom severity.

Data from a large sample of concussed adolescents supported a higher level of reported symptoms by females, but there were no significant differences in symptom reporting between sexes across racial/ethnic groups. Overall, at three-months, the African American and Hispanic Caucasians participants reported a higher level of lingering symptoms than Non-Hispanic Caucasians. In order to improve care, the difference between specific racial/ethnic groups during recovery merits exploration into the factors that may influence symptom reporting.

Children who sustain a mild traumatic brain injury (mTBI) are at increased odds of additive injury and continue to show altered motor performance relative to never-injured peers after being medically cleared (MC) to return to normal activities. There is a critical need to determine when children can return to activities without risk of short and long-term adverse effects, with research showing high reinjury rates for 3-12 months after RTP. The Physical and Neurological Examination for Subtle Signs (PANESS) measures subtle signs of motor impairment during gait, balance, and timed motor functions. Recent literature has demonstrated that PANESS timed motor function can distinguish between children medically cleared post-mTBI compared to never-injured controls. The present study examined performance on timed motor tasks in youth medically cleared from mTBI following medical clearance and 3-months later, compared to never-injured peers.

25 children (Mage=14.16, SD=2.46; Male=68%) were enrolled within 6 weeks of medical clearance from mTBI (Mdays post MC=33, SD=13.4, Range=2-59) along with 66 typically developing, never-injured controls (Mage=13.9, SD=2.22; Male=50%). Group differences were evaluated for the Timed Motor section of the PANESS at enrollment and at a 3-month follow-up (Mdays from enrollment to follow-up=95.90, SD=12.69, Range=62-129). This 3-month follow-up occurred on average 4 months after medical clearance (Mdays from MC to follow-up=130.08, SD=17.58, Range=92 - 164). The Timed Motor section includes Repetitive (foot tapping, hand patting, and finger tapping) and Sequential (heel-toe rocking, hand pronate/supinate, finger sequencing) raw time scores, measured in seconds. The Total Timed Motor Speed score is the combination of Repetitive and Sequential Movement and the side-to-side tongue item.

At 3-month follow-up, mTBI participants (M=67.55, SD=8.26, Range=53.66-83.88) performed worse than controls (M=63.09, SD=10.23, Range=39.86-100.51) on Total Timed Motor Speed, t(89)= 1.95, p<0.05), including when controlling for age and sex, F(1, 87)=4.67, p<0.05. At the same time point, mTBI participants (M=36.54, SD=5.47, Range=28.74-49.17) performed worse on Sequential Speed than controls (M=32.93, SD=6.1, Range=21.49-56.76), t(89)=2.59, p<0.01, including when controlling for age and sex, F(1, 87)=7.687, p<0.01). Although groups performed similarly on Sequential Speed at the initial time point, mTBI participants exhibited a trend of less improvement from initial to follow-up (MmTBI=-1.69, Mcontrol=-3.68, t(90)=1.445, p=0.076).

Although groups did not significantly differ on Timed Motor Speed items at the initial time point, the mTBI group showed consistently lower scores than controls at both time points and less improvement over time. Results indicate that Total Timed Motor Speed, specifically Sequential Speed, may be a sensitive marker of persisting differences in high-level motor and cognitive learning/control in children who have been medically cleared after mTBI. More data are needed to evaluate these findings over a longer time period, and future studies should examine behavioral markers concurrently with physiologic brain recovery over time.