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Abstract Background Up to 1.9 million youth in the USA sustain a concussion each year, and up to 30% experience persistent post-concussive symptoms (PPCS) lasting 1 month or more. PPCS can substantially interfere with social, emotional, and academic functioning. Despite these concerns, few evidence-based treatments are available for youth with PPCS. We previously found effectiveness in treating youth with concussion using a collaborative care intervention that integrates mental health care into a medical model, with improvements in concussive symptoms and quality of life at 1 year. Using the multiphase optimization strategy (MOST) framework, we now aim to assess the contribution of each of the three components that were part of collaborative care: concussion-focused cognitive behavioral therapy (cf-CBT), parenting skills training (PST), and care management (CM). Methods The MOST factorial design examines all three intervention components with two levels of each (present or absent), resulting in 8 possible treatment combinations. We will recruit 368 youth with PPCS from 2 geographic locations (Seattle and Dallas), randomizing them to 1 of 8 treatment groups. Youth and/or parents will attend treatment sessions via video conferencing software over 3 months, and complete surveys regarding primary outcomes (concussive symptoms and health-related quality of life) and secondary outcomes (sleep, pain, mood, and parental distress) at 6 weeks and 3, 6, and 12 months. We will also assess potential mediators and moderators to allow for future tailoring and refinement. Discussion The overarching goal of this investigation is to determine which collaborative care components (delivered individually or in combination) are most effective in treating PPCS in concussion-exposed youth. The investigation will inform mental health screening, intervention, and referral procedures for youth and families following concussion. At the completion of this study, we will have an optimized and refined intervention for youth with PPCS ready for large-scale implementation and dissemination. Trial registration ClinicalTrials.gov NCT06036147. Registered on September 13, 2023.

AbstractPhysical contact such as tackling is a part of youth sport, but associated with concussion risk. Coach communication with athletes about how to approach contact could be a strategy to reduce concussion risk. We interviewed n = 50 adult stakeholders (coaches, referees and administrators) in youth football and soccer to identify barriers and facilitators to coach communication about contact. We framed interviews using the Theory of Planned Behavior, discussing: knowledge/experience, attitudes/beliefs, norms/values and perceived behavioral control. Stakeholders could easily describe ‘good’ contact (knowledge/experience) like keeping your head up (football) and tackling shoulder-to-shoulder (soccer), and ‘bad’ contact like spearing (football) and retaliating against an opponent (soccer). They also talked about the importance of sportsmanship and playing by the rules. Most coaches believed ‘bad’ contact was associated with greater injury (attitudes/beliefs). Coaches felt responsible for managing contact (norms/values), but also described not receiving any information indicating that this was part of their role. Coaches worried about creating a fear of injury, and felt it was important for discussions to be framed positively (perceived behavioral control). In summary, youth football and soccer coaches believe ‘bad’ contact is associated with greater injury risk and feel it is their role to provide youth guidance about contact, but describe a lack of institutional guidance regarding this role. They also are concerned about barriers, including creating fear, and describe ways to address this barrier with language. Developing programs to support coach communication about contact with youth athletes presents a potential strategy for concussion prevention.

Abstract Background Subthreshold exercise, defined as aerobic exercise below the level that causes symptoms, has been utilized as a treatment for youth with persistent postconcussive symptoms (PPCS), but there is currently little evidence to guide use. In addition, prior studies of exercise for PPCS have all required multiple in-person visits. We developed a virtual approach for delivering subthreshold exercise to youth with PPCS called the Mobile Subthreshold Exercise Program (MSTEP), and we have now been funded to conduct a large national randomized controlled trial (RCT) to test its efficacy for reducing concussive symptoms and improving health-related quality of life. Methods This investigation is an RCT comparing MSTEP to an active control. We will recruit 200 adolescents 11–18 years old with postconcussive symptoms persisting for at least 1 week but less than 1 year. Youth will be randomized to receive either 6 weeks of subthreshold exercise (MSTEP) or a stretching condition (control). Youth and parents will complete surveys of concussive symptoms at baseline, weekly during the intervention, and at 3 and 6 months. The primary outcomes will be trajectory of concussive symptoms and health-related quality of life over the 6 months of the study. Secondary outcomes will include depression, anxiety, and sleep quality. We will also assess potential mediators of treatment effects including moderate-vigorous physical activity and fear avoidance of concussive symptoms. Discussion This multisite RCT of MSTEP will provide vital information regarding the efficacy of a virtually delivered subthreshold exercise program for youth with PPCS, and insight regarding potential mediators of treatment effects, including objectively measured physical activity and fear avoidance of concussive symptoms. Trial registration ClinicalTrials.gov NCT04688255. Registered on December 29, 2020.

Abstract Background Most concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes. Methods A mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9–16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155). Results Internal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to “always” tell their coach about symptoms of a suspected concussion. Conclusions The CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.

Background: Concussion is common, and up to 30% of youth develop persistent symptoms. Preliminary data suggests treatment with rehabilitative exercise is beneficial, but most programs require frequent in-person visits, which is challenging for youth in rural areas, and has been made more difficult for all youth during the COVID-19 pandemic. We have adapted an exercise intervention to be delivered via telehealth using Zoom and personal fitness devices, which could ensure access to this type of treatment.Objective: The goal of this study was to assess feasibility and acceptability of a telehealth delivered exercise intervention for concussion, the Mobile Subthreshold Exercise Program (MSTEP), and collect pilot data regarding efficacy.Materials and Methods: All youth received the 6-week MSTEP intervention which included wearing a Fitbit and setting exercise heartrate and duration goals weekly over Zoom with the research assistant. Youth completed standardized measures of concussive symptoms (Health Behavior Inventory, HBI), fear-avoidance (Fear of Pain Questionnaire, FOPQ) and health-related quality of life (Pediatric Quality of life Assessment, PedsQL), as well as a structured qualitative exit interview. We examined change in measures over time using mixed effects modeling, controlling for age, sex, prior concussion and duration of symptoms. We coded qualitative interviews using Thematic analysis.Results: We recruited 19 subjects, 79% female with average age 14.3 (SD 2.2) and mean duration of symptoms 75.6 days (SD 33.7). Participants wore the Fitbit on 80% of days, and completed 94% of surveys and 96% of Zoom calls. Concussive symptoms (HBI) decreased significantly over the 6 week intervention (−10.6, 95%CI: −16.0 to −5.1) as did fear-avoidance (−21.6, 95%CI: −29.8 to −13.5). PedsQL improved significantly during the same time period (+15.1, 95%CI: 8.6–21.6). Approximately three-quarters (76%) of youth rated their care as “excellent.” Participants appreciated the structure of the guided exercise program and the support of the RA. They also enjoyed being able to track their progress with the Fitbit.Conclusion: This study provides evidence for the feasibility and acceptability of a telehealth delivered rehabilitative exercise intervention for youth with concussion. Further research utilizing a randomized controlled trial is needed to assess efficacy.Clinical Trial Registration:https://clinicaltrials.gov, identifier: NCT03691363. https://clinicaltrials.gov/ct2/show/NCT03691363

Objective: To evaluate feasibility and acceptability of a sub-threshold exercise program with minimal in-person visits to treat youth with persistent sport-related concussion, and explore efficacy for improving concussive symptoms, health-related quality of life, and fear-avoidance.Study design: We conducted a pilot randomized controlled trial comparing a 6 week sub-threshold exercise program requiring only two in-person visits to active control (stretching) for 12–18 year old youth with persistent sport-related concussion. We measured moderate-to-vigorous physical activity pre- and post-intervention using accelerometry, and increased goals weekly via phone contact. We examined feasibility and acceptability using qualitative interviews. We used exponential regression to model differences in trajectory of concussive symptoms by experimental group, and linear regression to model differences in trajectory of health-related quality of life and fear-avoidance of pain by experimental group.Results: Thirty-two subjects randomized, 30 completed the study (n = 11 control, n = 19 intervention), 57% female. Youth and parents reported enjoying participating in the study and appreciated the structure and support, as well as the minimal in-person visits. Exponential regression modeling indicated that concussive symptoms declined more rapidly in intervention youth than control (p = 0.02). Health-related quality of life and fear-avoidance of pain improved over time, but were not significantly different by group.Conclusions: This study indicates feasibility and potential benefit of a 6 week subthreshold exercise program with minimal in-person visits for youth with persistent concussion. Potential factors that may play a role in improvement such as fear-avoidance deserve further study.

C. elegans will orient and travel in a straight uninterrupted path directly towards the negative pole of a DC electric field. We have sought to understand the strategy worms use to navigate to the negative pole in a uniform electric field that is fixed in both direction and magnitude. We examined this behavior by quantifying three aspects of electrotaxis behavior in response to different applied field strengths: the mean approach trajectory angles of the animals' tracks, turning behavior (pirouettes) and average population speeds. We determined that C. elegans align directly to the negative pole of an electric field at sub-preferred field strength and alter approach trajectories at higher field strengths to maintain taxis within a preferred range we have calculated to be ~ 5V/cm. We sought to identify the sensory neurons responsible for the animals' tracking to a preferred field strength. eat-4 mutant animals defective in glutamatergic signaling of the amphid sensory neurons are severely electrotaxis defective and ceh-36 mutant animals, which are defective in the terminal differentiation of two types of sensory neurons, AWC and ASE, are partially defective in electrotaxis. To further elucidate the role of the AWC neurons, we examined the role of each of the pair of AWC neurons (AWCOFF and AWCON), which are functionally asymmetric and express different genes. nsy-5/inx-19 mutant animals, which express both neurons as AWCOFF, are severely impaired in electrotaxis behavior while nsy-1 mutants, which express both neurons as AWCON, are able to differentiate field strengths required for navigation to a specific field strength within an electric field. We also tested a strain with targeted genetic ablation of AWC neurons and found that these animals showed only slight disruption of directionality and turning behavior. These results suggest a role for AWC neurons in which complete loss of function is less disruptive than loss of functional asymmetry in electrotaxis behavior within a uniform fixed field.