Running head: COMBINED CARE IN CONCUSSION TREATMENT The Effect of Combined Mental Health and Physical Treatment on Clinical Outcomes following Concussions in Adolescent/Young Adults A DISSERTATION Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Doctor of Health Science (DHSc) in Health Science and Exercise Leadership Patrick J. Smith Research Adviser, Dr. Ellen West California, Pennsylvania 2019 CALIFORNIA UNIVERSITY of PENNSYLVANIA CALIFORNIA, PA COMBINED CARE IN CONCUSSION TREATMENT DISSERTATION APPROVAL Health Science and Exercise Leadership We hereby approve the Dissertation of Patrick J Smith Candidate for the degree of Doctor of Health Science (DHSc) COMBINED CARE IN CONCUSSION TREATMENT Acknowledgements I’d like to thank all of those involved both directly and indirectly in my pursuit of completing the Doctor of Health Sciences program. First, I’d like to thank my dissertation committee of Dr. Tom West, Dr. Rebecca Hess, Dr. Anthony Kontos, and Dr. Ellen West. Dr. West served as both a committee member and my research advisor. She provided countless hours of revisions and advice and was accessible at all hours of the day and night. All of you have contributed significantly to my understanding of my topic, my understanding how to engage in research, and you have all supported me as I’ve grown personally and professionally. Your expertise and knowledge have been incredibly valuable and appreciated every step of the way. Next, I’d like to thank the staff at the UPMC Concussion Research Lab, especially Cyndi Holland, a Clinical Research Coordinator, Kara Viggiano who was also a Clinical Research Coordinator at UPMC, and Dr. Anthony Kontos who is both a Research Director at UPMC and a leading researcher across the world in the field of concussion study. Because of their help, I was able to visit the site several times, observe one of their doctors, and learn more about the process of concussion treatment in a cutting-edge environment. I’d also like to thank Dr. Melissa Sovak who continually provided support for the statistical analysis of my research, who answered my questions at all hours of the day, and who provided calm guidance when I was feeling overwhelmed. I am also grateful to my classmates, who provided text message check-ins and continued support throughout COMBINED CARE IN CONCUSSION TREATMENT the program. I was truly impressed with how close I felt to all of them despite being so far apart. Lastly, but certainly not least, I’d like to thank my family for all their support throughout this process. Every little thing helped, from my girlfriend Erin taking the dogs outside while I was working, to my mother bringing over a casserole dish, to my father helping me with yardwork, and to my son for watching movies on the couch with me while I worked on my laptop. You have all made sacrifices to help me complete this program that are too numerous to name. I am beyond grateful to all that you’ve done for me. COMBINED CARE IN CONCUSSION TREATMENT Table of Contents List of Figures…………………...................................................................i List of Tables………………………………………………………………ii Abstract…………………………………………………………………….iii Introduction………………………………………………………………...1 Methods…………………………………………………………………….8 Research Design……….……………………………………………8 Operational Definitions……………………………………………..9 Data…..……………….…………………………………………….11 Treatment Groups…………………………………………………..12 Clinical Profiles……………………………………………………..15 Instruments……………………………………………………….…………17 Immediate Post-Concussion Assessment and Cognitive Testing…..17 Post-Concussion Symptom Scale………………………………...…20 Vestibular/ Ocular Motor Screening (VOMS)………………………21 Chart Abstraction Form……………………………………………..22 Data Collection Form…………………….….………......………..…22 Procedures…………………………………………………………..……….22 The Research Database………….…….……….…………...….…….23 Data Collection…………………………….….………......…………24 COMBINED CARE IN CONCUSSION TREATMENT Data Analysis…………………………………….…..……...……….………25 Summary of Results……………………………….……….…....….……..27 Descriptive Data…………………………………………………...27 Treatment Group Comparisons……………………………………29 Clinical Profiles……………………………………………………30 General Discussion………………………………….………..……………35 Clinical Implications and Future Research………….……………………..42 Conclusion…………………………………………………………………44 References………………………………………………………………….46 Review of the Literature, Appendix A……………………………………..56 Assessment, Diagnosis, and Current Treatment Models…………...58 Prevalence………….…………………………………...….59 Protocols and Procedures…….…………………………….60 Population Differences……………………………..61 Assessment Tools…………………………………..62 Importance of Quick Response…………………….63 Currently Accepted Treatment Approaches………….…….64 Population Assessment in Concussion Management……………….67 Gender Differences in Concussion Recovery….……….…..68 Body Mass Index Differences……….……………...………69 COMBINED CARE IN CONCUSSION TREATMENT High School versus College Athletes……….………………70 Diagnostic Tools……….……………………………………72 Active Recovery and Prescription of Physical Activity………….....76 Visual/Vestibular Treatments Post-Concussion Symptoms……...…79 Screening and Assessment….……………………………….79 Balance and Gait Treatment….……………………………..80 Visual Therapies….…………………………………………82 Cognitive Issues in Collaborative Care……………………………..84 Prevalence and Scope of Cognitive Issues…….……………85 Explanatory Style on Recovery……….…………………….90 Cognitive Behavioral Treatments….………………………..91 Executive Functioning Training in CBT…………....95 Psychological Referrals in Concussion Treatment….………97 Physical and Mental Health Collaborative Care…….………99 Psychoeducational Interventions in Collaborative Care….…101 Conclusion…………………………………………………………...104 Problem Statement, Appendix B…………………………………………….108 Additional Methodology, Appendix C………………………………………111 Appendix C1 ImPACT® Testing….…………….…………….……..112 Appendix C2 VOMS……………………………………………...…119 Appendix C3 Chart Abstraction Form……………………………....122 Appendix C4 Data Collection Form……...………………………….124 COMBINED CARE IN CONCUSSION TREATMENT Appendix C5 Sample Consent Form...………………………………126 Appendix C6 IRB Approval of Submission…………………………136 Appendix C7 Certificates of Training……………………………….140 References……………………………………………………...……………146 i COMBINED CARE IN CONCUSSION TREATMENT List of Figures Figure 1 Title Page Days to recovery based on first visit PCSS insomnia score…..……32 ii COMBINED CARE IN CONCUSSION TREATMENT List of Tables Table Title Page 1 Descriptive statistics for sample……………………………..28 2 Gender and personal history per group..…………………….28 3 Distribution statistics for sample…………………………….29 4 Days to recovery per treatment group……………………….31 5 Clinical profile distribution per group……………………….31 6 Predictors to prolonged recovery…………………………….32 COMBINED CARE IN CONCUSSION TREATMENT iii Abstract Concussions and traumatic brain injuries (TBI) are a major health concern, with an average of 2-4 million concussions occurring in the United States each year (Langlois, Rutland-Brown, & Thomas, 2006). Among these injuries, 79.6% required emergency department care, 16.8% required admittance to a hospital, and 3.6% of these cases resulted in death (Langlois, et al., 2006). Concussions are individualized with different symptoms and impairments, which may be delayed or changing in presentation (McCrory et al., 2017). Although many concussions resolve within a few weeks some involve longterm continued physical, behavioral, cognitive, and sleep symptoms (McCrory et al., 2017). The purpose of this research was to investigate the hypothesis that a combined physical and mental health treatment would be associated with a more rapid recovery (i.e., resolution of symptoms) and improved cognitive outcomes. This causal-comparative quasi-experimental design involved data from 29 adolescents and young adults (13 females, 16 males) aged 16-25 years with a sport-related concussion (SRC) between January 2017 and December 2019. The deidentified data were accessed from an electronic health records database at a concussion specialty clinic located in the midAtlantic region. The data of 25 patients who received only a physical health intervention, consisting of dynamic or aerobic exertion therapies and sport-specific training as clinically appropriate, formed the physical health treatment control group. The data of four patients who received a combined mental health and physical health treatment formed the mental health treatment group. The mental health treatment group received both a physical and a mental health treatment consisting of dynamic or aerobic exertion COMBINED CARE IN CONCUSSION TREATMENT ii therapy or sport-specific training, and a targeted mental health treatment such as cognitive behavioral therapy or psychiatric care as clinically appropriate. Results of an ANOVA and generalized linear model indicated that subjects receiving the mental health treatment recovered in 116.50 days (SD = 39.06), whereas the physical health treatment control group recovered in 29.44 days (SD = 16.34) (p<.001, effect size [ES]= .25). Initial reports of problems sleeping in both groups, as measured on the Post-concussion Symptom Scale (PCSS) (p=.006), elevated second visit ImPACT® (p=.02) scores, VOMS total scores (p=.01), and loss of consciousness (p=.02) were all significantly correlated with a longer recovery. Other medical history and injury-related factors, such as a personal history of migraine, concussion history, disorientation at time of injury, posttraumatic amnesia, and gender, were unrelated to recovery. These findings suggest that differences in treatment groups’ symptoms and clinical presentation may indicate more complex initial injuries that could be responsible for both the referral to mental health treatment and prolonged recovery. Patients who experience mental health symptoms post-concussion may be more likely to require specialized treatment and take longer to recover. COMBINED CARE IN CONCUSSION TREATMENT 1 Concussions are brain injuries caused by direct or indirect traumatic force to the head, neck, or body that is transferred to the head that can lead to mental and physical harm over a range of clinical presentations, including impaired brain functions and disruptions in brain processes (McCrory et al., 2017). Concussions and traumatic brain injury (TBI) are prevalent in contact and non-contact sports and occur in athletes of all ages (Coleman, 2016). In the general population, the Centers for Disease Control and Prevention (CDC) estimates that concussions were involved in 2.87 million emergency room visits, hospital stays, or as a cause of death in 2014 (CDC, 2019; “TBI: Get the facts,” 2017). Specifically, for individuals under the age of 18, it is estimated that 1.1 million to 1.9 million individuals incur a concussion from sports or recreational activities (Bryan, Rowhani-Rahbar, Comstock, & Rivara, 2016). Each year, approximately 329,000 of these injured adolescents require treatment in emergency rooms for SRCs in the United States alone (“TBI: Get the facts,” 2017). In organized sports the injury rate of concussion can reach nearly one injury per 1,000 exposures to sport (Daneshvar, Nowinski, McKee, & Cantu, 2011). Because some individuals seem to recovery quickly from concussions while others have prolonged symptoms, recovery from concussions has been a topic of discussion in the news and popular culture as several high-profile cases have arisen. Concussions are unique injuries with some athletes recovering quickly and some experiencing long-lasting effects (Coleman, 2016). These differences in recovery have led researchers to investigate possible effects based on gender, body mass index (BMI), COMBINED CARE IN CONCUSSION TREATMENT 2 and age. Some differences in athletes’ recoveries from concussions have been noted across genders; these differences may be related to biological and situational factors such as increased prevalence of migraines in females, increased rates of depression in adolescent females, differences in use of coping skills, and less total neck mass to absorb impacts that may cause concussions (Kontos, Elbin, Appaneal, Covassin, & Collins 2013; Neidecker, Gealt., Luksch, & Weaver 2017). Early reports of certain symptomology may be an indicator of prolonged recovery risk. Individuals reporting impairments in the vestibular and oculomotor systems have lower scores on neurocognitive measures and experience prolonged concussion recovery (Sinnott, Elbin, Collins, Reeves, Holland, & Kontos, 2019). Other differences in recovery from concussions have been seen based on BMI. Athletes who had a BMI less than 25 were more likely to have their concussive symptoms return to baseline within two weeks from injury than those who had a BMI over 30 (Lee, Wu, Zuckerman, Stanko, LaChaud, Solomon, & Sills, 2016). Nelson et al. (2016) suggested that college athletes and high school athletes may experience similar injury patterns and recovery due to recovery times between groups only varying based on injury severity. Athletes suspected of having a concussion must be appropriately assessed and diagnosed so they may receive adequate and timely treatment. Numerous assessment and diagnostic tools, including balance testing using the Balance Error Scoring System (BESS), cognitive assessments such as the Sports Concussion Assessment Tool Third Version (SCAT-3), and vision and ocular testing such as the King-Devick Test (Hobbs et COMBINED CARE IN CONCUSSION TREATMENT 3 al., 2016) are commonly used. Additionally, to measure visual and ocular motor impairment symptoms such as dizziness, balance problems, and gait issues, the Vestibular and Ocular Motor Screening (VOMS) tool has been developed (Mucha et al., 2014). It has been shown to be a valid and reliable tool and measures dysfunction in the vestibular, vision, and somatosensory systems and can effectively distinguish between concussed and non-concussed patients (Kontos & Collins, 2018; Mucha et al., 2014; York, Smith, Babcock, & Alsalaheen, 2017). Also, the Glasgow Coma Scale (GCS) is frequently used to measure baseline symptoms and consciousness (McLernon, 2014), and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) with PostConcussion Symptom Scale (PCSS) testing procedures have been shown to effectively measure concussion symptoms in athletes (Allen & Gfeller, 2009; Elbin, Schatz, & Covassin, 2011; Merritt, Bradson, Meyer, & Arnett, 2017). Once a concussion is diagnosed, treatment referrals can be made. Evidence suggests that physical rehabilitation programs can be beneficial in reducing concussion symptoms of poor balance, poor cognitive functioning, and reduced perceived quality of life in adolescents recovering from sport concussions (Chan et al., 2018). Vestibular therapies have also been shown to reduce post-concussive symptoms, particularly dizziness, nausea, poor balance, gait problems, and sensory processing errors in adolescents and adults recovering from sport-related concussions (SRC) and non-athletic concussions (Alsalaheen et al., 2010; Kleffelgaard, Soberg, Bruusgaard, Tamber, & Langhammer, 2016; Kontos, Deitrick, Collins, & Mucha 2017). Visual therapies COMBINED CARE IN CONCUSSION TREATMENT 4 (Alsalaheen, Mucha, Morris, Furman, & Sparto, 2013; Fimreite, Willeford, & Ciuffreda, 2016) and optometry interventions (Clark et al., 2017) have been shown to reduce postconcussive symptoms such as photosensitivity in adolescents and adults recovering from concussions caused by both sport and non-sport experiences. Additionally, mental health treatments have been shown to reduce the effects of post-concussion symptoms in SRCs (Brown et al., 2014; Conder & Conder, 2015; WieseBjornstal, White, Russell, & Smith, 2015). Mental health treatments have also been shown effective in reducing symptomology for those experiencing other TBI or brain injuries not related to sports (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2009). These interventions aim to reduce post-concussive symptoms to allow individuals to be more functional in their daily lives. A link has been demonstrated between athletes experiencing concussions and an increase in negative mental health symptoms afterwards such as increased anxiety and depression (Vargas, Rabinowitz, Meyer, & Arnett, 2015). Pre-existing conditions such as a history of repeated concussions, sustained through sport or non-sport means, is a predictive factor for post-concussion depression in adolescents (Chrisman & Richardson, 2014). Other pre-existing mental health conditions, such as attention deficit hyperactivity disorder (ADHD) and depressive symptoms prior to injury, may lead to more severe mental health symptoms following an SRC (Wiese-Bjornstal et al., 2015). Additionally, adolescents with a personal history of somatization, or reporting symptoms that cannot be fully explained through testing or diagnosis, are often slower to recover from concussions (Root, et al., 2016). COMBINED CARE IN CONCUSSION TREATMENT 5 Cognitive behavioral therapy (CBT) is a therapeutic psychological treatment approach that aims to teach helpful patterns of behavior, coping skills for difficult situations, and skills for recognizing thought distortions. CBT assists subjects in reframing negative cognitions and is a treatment that can be used to treat symptoms of depression and anxiety in various populations (“What is cognitive behavioral therapy?”, 2018). CBT and skills training have been shown to treat these common effects often associated with delayed recovery from concussion; both athletes and non-athletes engaging in these interventions have reported decreased depression, anxiety, improved perceived quality of life, and increased confidence in their recoveries (Cantor et al., 2014; Conder & Conder, 2015, Silverberg et al., 2013). Collaborative care models are those that implement and coordinate treatment between physical healthcare and mental healthcare and have been shown to reduce postconcussive symptoms in various populations (Asarnow, Rozenman, Wiblin, & Zeltzer, 2015; Makdissi et al., 2017; McCarty, Zatzick, Stein, Wang, Hilt, & Rivara, 2016). The collaborative care model is not well-defined in the literature, but current research suggests defining it as embedding mental health treatment interventions, such as CBT, care management, and pharmacological consultation with physical interventions (McCarty et al., 2016) or integrating behavioral health treatments into primary care (Asarnow et al., 2015). Researchers investigated the effects of a collaborative care intervention consisting of teaching of coping skills, positive thinking skills, sleep hygiene, advocacy within the COMBINED CARE IN CONCUSSION TREATMENT 6 school, and coordination of care among mental health and physical health providers among adolescents experiencing post-concussion symptoms. These individuals receiving a collaborative care treatment showed a reduction of symptoms more quickly than those receiving physical health treatment, which consisted of consultation with a rehabilitation specialist and submaximal exercise as appropriate (McCarty et al., 2016). Collaborative care models have also shown promise in reducing high-risk behavior associated with traumatic head injuries, such as weapon carrying and substance abuse when using CBT, motivational interviewing, and educating primary care physicians (Asarnow et al., 2015). The purpose of this research was to investigate the effects of a mental health treatment intervention consisting of a combined mental health treatment and physical health treatment on post-concussive symptoms in adolescents and young adults. The hypothesis tested was that adolescents and young adults aged 16 to 25 who have experienced a concussion and have participated in a combined mental health and physical health treatment will recover more quickly from their post-concussive symptoms, as measured on the ImPACT® and time to clearance, than those who received a physical health intervention alone. Physical health treatments were referred to as “physical health treatment” and included physical interventions such as working with an athletic trainer, physical therapist, vestibular therapist, or receiving rest and gradual return to activity. The mental health treatment group received physical treatment and was combined with behavioral health interventions such as CBT, referral for psychiatric care, medication management, cognitive skill building, or case management. A secondary research COMBINED CARE IN CONCUSSION TREATMENT 7 purpose was to explore other group differences on select characteristics and clinical profiles to help determine key clinical differences between groups that may also influence time to recovery. COMBINED CARE IN CONCUSSION TREATMENT 8 Methods The following description of methodology will address details of the completed research. This section consists of subsections including specific research design and subject information. The research design subsection provides the rational for design, strengths, and weaknesses of the completed research design. Additionally, the data and treatment groups subsections discuss general characteristics and demographics of subjects, sampling of subjects’ data, and details inclusion and exclusion criteria for participation in the study. The methods section also details the instruments, procedures, and data analysis used. Research Design This study involved a causal-comparative quasi-experimental design featuring a between-subjects variable and a within-subjects variable. The independent variable, which was the between-subjects variable, was type of treatment received, “mental health treatment” or “physical health treatment.” The dependent variables, which were the within-subjects variables, consisted of the initial scores on the six ImPACT® neurocognitive tests identifying concussion symptoms and PCSS. Also included were the ImPACT® and PCSS scores at time of clearance to return to normal activity, and number of days from time from injury to clearance. Other factors included in the dependent COMBINED CARE IN CONCUSSION TREATMENT 9 variables were gender, concussion history, migraine history, and if the concussion was incurred during sports. This research design was used to establish relationships between variables whereby the type of treatment used, a combined mental health and physical health treatment or physical health treatment only, were tested for differences in time to clearance to return to normal activity as determined to be clinically appropriate by the treating clinicians, and computerized neurocognitive testing scores at initial appointment and time of clearance. For participants’ data to be included in this study, they must have been treated for an SRC between January 2017 to December 2019. Participants whose data was chosen for inclusion were between the ages of 16 to 25 years old at the time of injury. Data were excluded for individuals outside of the targeted age group, those treated outside of the specified timeframe, and for those with a psychiatric treatment history, including current or past psychiatric medication and/or therapy, as assessed at intake. Examples of preexisting psychiatric needs included being engaged in mental health therapy at the time of injury, personal history of psychiatric disorder, or previous history of using psychiatric medications. Operational Definitions Concussion was defined as an injury resulting from direct or indirect traumatic force that affects the brain and its subsequent processes, causes impairment of COMBINED CARE IN CONCUSSION TREATMENT 10 functioning, and often results in inconclusive neuroimaging scans. A concussion is a brain injury that can result in neuropathological changes that typically follows a progressive course of recovery, but in some cases can result in continued post-concussive symptoms. Common concussion symptoms include headache, mental fogginess, behavioral or emotional changes, headache, nausea, loss of consciousness, and sleep problems (McCrory et al., 2017). For this study, physical health treatment referred to treatment including dynamic or aerobic exertion therapies or sport-specific physical training. The type of physical activity was an individualized and targeted approach for each subject’s unique needs potentially including targeted vestibular or oculomotor therapy if clinically warranted. The mental health treatment referred to the application of all the treatments offered to the physical health treatment plus the addition of a targeted and appropriate mental health treatment referral. Symptoms related to depression and anxiety were treated using mental health treatment referrals to CBT, psychotherapy, psychiatric care, or psychotropic medication management as clinically appropriate. Both treatment groups also received a behavioral regulation treatment as clinically appropriate. This intervention included tools for managing stress, sleep regulation, nutritional and hydration support, and physical activity to improve knowledge. The goal for this treatment was to increase awareness and individual ability to cope with concussion symptoms (Kontos & Collins, 2018). COMBINED CARE IN CONCUSSION TREATMENT 11 To properly compare the treatment groups through time, recovery from concussion must be defined. Concussion recovery will be defined as the ability to return to full athletic or academic demands based on a lack of symptomology or impairment and measured by the return to baseline, or near baseline, on neurocognitive assessments (McCrory et al., 2017). During this study, clinicians used the additional guidelines discussed by Kontos and Collins (2018) in that patients must show improved assessment scores immediately after exertion, and be able to show improvements following a progressive, moderate cardiovascular activity and dynamic exercise treatment. Lastly, patients must show improvements when considering their clinical profile assignment and their daily tasks in which they must be functional before they received clearance to return to normal activities. Data Data were selected from an existing database of those who received treatment at a specialty concussion clinic in the mid-Atlantic region. Data for those who received a physical health treatment at the clinic were referred to as the physical health treatment group. Data for those who received a physical health treatment combined with a mental health treatment after receiving a referral to a participating mental health provider site were referred to as the mental health treatment group. When diagnosed at the clinic, patients’ groupings were identified by six clinical profiles depending on clinical presentation: vestibular impairment, oculomotor, cognitive COMBINED CARE IN CONCUSSION TREATMENT 12 fatigue symptoms, post-traumatic migraine, cervical injury, and anxiety and mood impairment (Collins et al., 2016, Kontos & Collins, 2018). At the time of diagnosis, patients were assigned by their treating clinician to a primary, secondary, and tertiary clinical profile depending on their symptomology and reported impairments. Because of differences in symptoms, patients could also fall into multiple clinical profiles equally or have more prominent profiles (Kontos & Collins, 2018). Clinical profiles were prioritized by completing a thorough assessment of symptoms across multiple areas of impairment. Although this presents a complex clinical challenge, it allows clinicians to document symptoms and risk factors relevant to providing treatment (Kontos, Sufrinko, Sandel, Amami, & Collins, 2019). Treatment Groups The following sections provide detail about two groups of data studied in this research; included is how data were selected for each group, common symptomology, and the types of treatments typically provided in each group. Physical health treatment. A physical health treatment group, consisting of data from individuals receiving physical rehabilitation only or rest and gradual return to activity as clinically indicated was chosen from the database. All patients whose data were collected in the database were prescribed targeted and individualized therapies to assist with their specific symptoms and clinical presentation. These individualized COMBINED CARE IN CONCUSSION TREATMENT 13 therapies used an interdisciplinary approach and could have included vestibular treatment, oculomotor treatments, dynamic and aerobic exertion therapies, or sportspecific trainings depending on symptomology and clinical presentation. Additionally, all patients were expected to participate in a physical intervention as part of the treatment for their concussion symptoms regardless of their clinical profile assignment. This could have included, depending on clinical presentation of the athlete, aerobic exertion therapy or dynamic exertion therapy. Clinicians assigned treatment based on what is most relevant to the athlete’s goals and safety needs. The aerobic exertion therapy was individualized for each patient based on his or her fitness level and ability to tolerate exercise, and could include activities such as running, cycling, or using an elliptical (Kontos & Collins, 2018). The dynamic exertion training treatment was designed to mimic the demands athletes will experience during competition and prepare them for return to sport as their symptoms allow. Dynamic exertion training was performed with a licensed physical therapist and consisted of 30 minutes of moderately intense cardiovascular exercise, such as cycling, and progressed to whole body exercises including lunges and medicine ball rotations. If patients progressed through these tasks, they began functional dynamic exertion training designed to simulate sport-specific demands and to tax the cardiovascular, vestibular, and visual systems of the patient (Kontos & Collins, 2018). In addition to aerobic or dynamic exertion treatment, all patients at the concussion specialty clinic received behavioral regulation treatment. The components of the COMBINED CARE IN CONCUSSION TREATMENT 14 behavioral regulation treatment are stress management, sleep regulation, nutritional and hydration support, and physical activity (Kontos & Collins, 2018). This aspect of concussion treatment is aimed at delivering education, improving awareness, and improving positive coping skills to help patients and their families manage concussions and symptoms in a healthy manner. Mental health treatment. The data for those diagnosed with a psychological issue were identified for inclusion to the mental health treatment group due to being referred to a mental health treatment for treatment of their symptoms. The presenting mental health issues, along with a referral to a mental health treatment, are the primary differences between groups; however, groups may vary in their predisposition to mental health symptomology or coping response (Sandel, Reynolds, Cohen, Gillie, & Kontos, 2017). Therefore, the presentations of symptomology of those in the mental health treatment group were likely more complex and clinically acute than those in the physical health treatment only group. All primary clinical profiles were considered for inclusion if the patient was referred to a mental health treatment by a psychiatrist or other mental health professional including CBT and related therapies. Those who were selected for the mental health treatment group were also expected to participate in a physical health intervention as described above. COMBINED CARE IN CONCUSSION TREATMENT 15 Clinical Profiles The following sections provide specific detail regarding the clinical profiles assigned at the concussion specialty clinic which includes common symptomology and clinical approaches. Assignment to treatment groups, physical health treatment or mental health treatment, was determined based on clinical profiles and treatment referrals. Of note, more than one clinical profile could be assigned for each person of either treatment group. Vestibular impairment. Physical interventions were completed with patients of all clinical profiles; however, the clinical profile assignment influenced what specialized treatments were performed. The vestibular impairment profile often consisted of symptoms involving visual motion sensitivities, problems maintaining gaze, dizziness, and slowed reaction speed. Treatments for those in the vestibular profile included aerobic or dynamic exertion therapy, dual task attention exercises, sensory orientation training, and practice processing visually demanded environments as clinically appropriate (Kontos & Collins, 2018). Oculomotor impairment. Common symptoms in the oculomotor profile were visual convergence problems, blurry vision, and trouble reading. Typical treatments for the oculomotor profile included aerobic or dynamic exertion therapy, visual therapies COMBINED CARE IN CONCUSSION TREATMENT 16 such as visual convergence training, shifting visual focus from near objects to far objects, and saccadic eye movements (Kontos & Collins, 2018). Cognitive fatigue. The cognitive fatigue profile is characterized by fatigue and drowsiness, headache, and symptoms that worsen with employment or academic tasks. Concentration and attentional problems also occur with this profile. Common treatments for the cognitive fatigue profile included aerobic or dynamic exertion training and neurostimulant prescription (Kontos & Collins, 2018). Post-traumatic migraine. Symptoms typical of the post-traumatic migraine profile included headache, nausea, sensitivity to light or sound, and sometimes dizziness or vision problems. Common treatments for the post-traumatic migraine profile included aerobic or dynamic exertion therapy, prescription of psychotropic medications specifically tricyclics, selective serotonin reuptake inhibitors, and anticonvulsants (Kontos & Collins, 2018). Cervical injury. The cervical injury profile typically presents with injury to the neck area because of the force associated with the concussion injury. Patients experienced pain in the neck and head, numbness, or tingling. Patients in this profile often experienced less functional impairment that the other clinical profiles. Typical treatments included aerobic or dynamic exertion therapy, acupuncture, biofeedback, medications, or potentially surgery as deemed clinically appropriate (Kontos & Collins, 2018). COMBINED CARE IN CONCUSSION TREATMENT 17 Anxiety and mood. The anxiety and mood clinical profile typically presented with anxiety and depression as evidenced by excessive worry, intrusive thoughts, sleep problems, racing thoughts, loss of energy, feeling overwhelmed or hopeless, and irritability. Patients in this profile were often treated with aerobic or dynamic exertion therapy, CBT, psychotherapy, psychiatric referral and medications, mindfulness training, or art and music therapies (Kontos & Collins, 2018). Instruments Four instruments were used for this research, the ImPACT® test and it’s PCSS subscale (Appendix C1), the VOMS (Appendix C2), a Chart Extraction Form (Appendix C3) used by the concussion specialty clinic to extract the blinded subject data, and a Data Collection Form (Appendix C4) for the secondary analysis of data for this research. The ImPACT® test, PCSS subscale, and VOMS were used to collect data. The demographic data were captured on the ImPACT® initial visit. Immediate Post-Concussion Assessment and Cognitive Testing®. At the concussion specialty clinic, concussion symptoms were assessed and scored using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) which included six subscales and the Post-Concussion Symptom Scale (PCSS). The ImPACT® was delivered in an electronic format which was used at initial contact with subjects upon COMBINED CARE IN CONCUSSION TREATMENT 18 each visit to the concussion specialty clinic. This computerized neurocognitive test takes about 30 minutes to complete and collects demographic and medical histories before moving on to the six neurocognitive tests that generate the clinical profile (Appendix C1) (Solomon, 2011). It is common practice for these tools to be used by athletic training and/or sports medicine staff to gather baseline data and at periodic intervals during treatment of a concussion to determine when an athlete is ready to return to play (Covassin, Elbin, Stiller-Ostrowski, & Kontos, 2009). The demographic data collected included height, weight, age, name, organization, dominant hand of the participant, gender, and education history including history of special educational needs (Solomon, 2011). Next, a medical history was gathered by the treating clinicians. Medical data gathered included history of seizures, epilepsy, surgery on the brain, history of brain infections such as meningitis, previous psychiatric care, and previous treatment history for substance use disorders (Solomon, 2011). The first neurocognitive test involves word discrimination. Each participant rapidly viewed five sets of words and identified the target word. This test evaluated attention and verbal recognition in short-term memory (Solomon, 2011). The second test followed a similar format but asked subjects to remember shapes instead of words to test visual recognition and attention (Solomon, 2011). The third test examined visual working memory, visual processing, and performance when faced with distraction tasks. The test involved four trials of randomly placed x and o letters that the participant must recall, and then a reaction speed test (Solomon, 2011). The fourth test evaluated short-term memory COMBINED CARE IN CONCUSSION TREATMENT 19 and processing speed using symbol matching (Solomon, 2011). The fifth test, consisting of matching colors and color words, tested impulse control and reaction speed in the participant (Solomon, 2011). The sixth and final test focused on working memory and processing speed by asking the participant to click on the numbers in reverse order, followed by a letter recollection exercise (Solomon, 2011). Composite scores are generated for verbal memory, visual memory, reaction time, processing speed, and impulse control scores as well as a total symptoms score. Test results show the number of scores correctly answered and increase or decrease in percentage of correctly answered questions in the composite scores (ImPACT® Applications, Inc, 2007). The cognitive efficiency index is also generated, which compares speed of response to percentage of correct answers to determine if the participant is trying to work quickly or is focusing on accuracy (ImPACT® Applications, Inc, 2007). The scores are generated at each visit to the concussion specialty clinic and are used to help inform assignment to clinical profiles. These clinical profiles are used by clinicians to provide targeted treatment for specific symptomology. To demonstrate reliability of the ImPACT® scale, researchers have assessed high school student athletes scores to determine test and retest reliability (Elbin et al., 2011). A total of 369 high school varsity athletes were given the ImPACT® scale as a preseason testing protocol over a two-year period. The researchers compared the results of the preseason testing and found moderate to high reliability (ICC.569-.851 for scores) for the COMBINED CARE IN CONCUSSION TREATMENT 20 ImPACT® scale (Elbin et al., 2011). Highest reliability was reported for motor processing speed, reaction time, and visual and verbal memory (Elbin et al., 2011 The validity of the ImPACT® scale has also been tested against another commonly used tool, the National Football League’s (NFL) neuropsychological testing battery (Allen & Gfeller, 2009). One hundred subjects completed both testing methods, with half of the group completing the ImPACT® first and the other half completing the NFL battery first. The researchers found correlations across tests for verbal memory components, visual motor speed, and reaction time (Allen & Gfeller, 2009). These findings suggest that the ImPACT® scale presented in an electronic format demonstrates validity similar to accepted pencil and paper assessments like those used in the NFL battery (Allen & Gfeller, 2009). Post-Concussion Symptom Scale (PCSS). The PCSS is a 22-item selfreported symptoms scale that is included as part of the ImPACT® test. The PCSS is used to track concussion symptoms such as dizziness, trouble sleeping, nausea, difficulty remembering, drowsiness, and sensitivity to light and sound. The PCSS asks participants to rank their symptoms experienced in the past 24 hours on a scale of 0 (none) to 6 (severe) (Solomon, 2011). The PCSS is also administered in an electronic format at initial contact and with subjects each time they visited the specialty concussion clinic for treatment. The measures within the PCSS, such as cognitive symptom cluster, physical symptom cluster, and affective system cluster showed moderate to low reliability (ICC .765, .441, .494) (Merritt et al., 2017). The ImPACT® and PCSS subscale used together COMBINED CARE IN CONCUSSION TREATMENT 21 have been shown to have high test-retest reliability when used at different testing points across time (p<.01) (Merritt et al., 2017). The ImPACT® scale and PCSS subscale together have also demonstrated validity in its ability to differentiate between those athletes who have been diagnosed with a concussion and those who have not with 81.9% sensitivity and 89.4% specificity (Schatz, Pardini, Lovell, Collins, & Podell, 2006). Vestibular/Ocular Motor Screening (VOMS). The VOMS tool was developed to assess vestibular and oculomotor symptoms and impairment following a concussion (Appendix C2) (Mucha et al., 2014; York et al., 2017). The VOMS measure includes 1) smooth pursuits, 2) saccades (horizontal, vertical), 3) near point convergence (NPC) distance, 4) vestibulo-ocular reflex (VOR) (horizontal, vertical), and 5) visual motion sensitivity (VMS). The tool takes between five and seven minutes to administer and assesses symptom provocation following each item on headache, dizziness, nausea, and fogginess using a 0-10 Likert-type scale following each item (Mucha et al., 2014). The VOMS generates seven item symptom provocation scores and includes an average measure of NPC across three trials. VOMS clinical cut-offs are greater than or equal to two on any symptom provocation item and greater than or equal to 5cm on average NPC distance (Mucha et al., 2014). York et al. (2017) showed that the VOMS has a high level of test-retest reliability when completed in a within-subjects design (ICC = .95, p<.001). The VOMS can accurately identify concussion from controls in 89% of cases (95% CI, p<.001) (Mucha et al., 2014). COMBINED CARE IN CONCUSSION TREATMENT 22 Chart abstraction form. The chart abstraction form is a paper document created by the concussion specialty clinic (Appendix C3). This form is completed by a worker at the lab when a researcher wishes to obtain data from the patient database. One form is completed per patient dataset within the database. This form prevents external researchers from accessing patient-identifying information such as name, date of birth, address, etc. The form allows the concussion specialty clinic worker to document ImPACT® and PCSS scores, VOMS scores, mental health and concussion history, visit number, clinical profiles, treatment referrals, and time to clearance to be transferred to researchers. Data collection form. The data collection form was developed by the researcher to organize data gathered from the concussion specialty clinic into a meaningful and workable format (Appendix C4). The data collection form compiled all data gathered across the numerous chart abstraction forms into one password-protected Excel workbook which was entered into data analysis software. Procedures The researcher attended meetings at the concussion specialty clinic with the research director and clinical research coordinator to discuss feasibility and opportunities for research. These meetings and verbal discussion resulted in the development of a research proposal that outlined the steps taken to gather data and ensured proper analysis would be conducted to test the hypothesis. Once the proposal was reviewed, an COMBINED CARE IN CONCUSSION TREATMENT 23 Institutional Review Board (IRB) request was submitted to the university associated with the concussion specialty clinic. After approval by the IRB and the California University of Pennsylvania IRB (Appendix C6), the data for this study were collected via a database at the concussion specialty clinic located in the mid-Atlantic region. Following approval of the IRB requests, a formal request for records, which described the information to be collected including details of the inclusion and exclusion criteria for patient records, was completed and submitted to the concussion specialty clinic. The data for this secondary analysis were collected onto Chart Abstraction Forms (Appendix C3) for each set of subjects’ data by a researcher at the concussion specialty clinic. The dataset was then sent electronically to the researcher via the Data Collection Form (Appendix C4) in a Microsoft Excel format for analysis. The research database. The database contained the subjects’ entire medical records, including demographic information, past relevant medical history, treatment plan, referral information, and computerized neurocognitive testing scores. The ImPACT® and PCSS subscale were performed via an electronic testing format taking approximately 30 minutes that provided an electronic memory, motor speed, reaction control, impulse control, total symptom score, and delivered a clinical profile to the treating clinician (ImPACT® Applications, Inc., 2007). The tests were automatically scored in the electronic format and produced a detailed clinical report of demographic information and neurocognitive data points (ImPACT® Applications, Inc., 2007). Information and scores contained in the database were censored of any identifying COMBINED CARE IN CONCUSSION TREATMENT 24 information to the researcher. Information that was removed included name, date of birth, address, insurance and billing information, and any recurrences of this information throughout the record. This task was completed by a concussion specialty clinic researcher using the chart abstraction forms. Data collection. A convenience sample of subjects’ data was selected by a researcher from the database center for patients who received treatment for SRC from calendar year 2017 to 2019 for individuals between the ages of 16-25 years old at the time of initial concussion injury. Exclusion criteria was individuals outside of the target age group or with pre-existing psychiatric needs identified during intake, such as being prescribed psychiatric or behavioral health medication, or being in mental health therapy at the time of injury. Only 4 sets of data matched the criteria for the intervention group and were included in the sample. The convenience sample of those meeting criteria for the physical health treatment group was generated by a researcher at the concussion specialty clinic and resulted in 25 sets of data being included. Subjects had already completed consent to engage in research (Appendix C5) upon beginning treatment at the facility. Subjects’ data were deidentified by a researcher at the concussion specialty clinic of any patient identifying information. Data were then recorded onto a Chart Abstraction Form (Appendix C4) by a team member and uploaded electronically into the Data Collection Form (Appendix C5), which was a secure Microsoft Excel spreadsheet. In this manner, patient-identifying information was not viewed and did not leave the facility as COMBINED CARE IN CONCUSSION TREATMENT 25 per the facility’s policies and procedures. Data collected consisted of computerized neurocognitive testing scores and VOMS scores at the initial appointment and at time of clearance, number of days to return to play, and referrals as outlined on the Chart Abstraction Form (Appendix C4). The Chart Abstraction Form also recorded loss of consciousness, disorientation, confusion, ADHD symptoms, personal and family histories of migraine, motion sickness, ocular disorders, personal and family histories of anxiety and depression, and previous concussion history. The form also detailed the clinical profiles assigned to each data set. Data Analysis The following subsection is an outline of the metrics and techniques used to analyze the data collected. This research aimed to investigate the overriding hypothesis that adolescent and young adults aged 16-25 receiving a combined treatment consisting of a mental health and physical health care would have a faster resolution of postconcussion symptoms as measured by time to clearance to return to normal activity and scores on computerized neurocognitive testing tools. The independent variable was type of treatment received, mental health treatment or physical health treatment, was not be manipulated by the researcher. The dependent variables were the within-subjects variable, which included repeated measure scores on the computerized neurocognitive COMBINED CARE IN CONCUSSION TREATMENT 26 testing for total composite and six subscales, PCSS, VOMS, and time to recovery as measured by the number of days until the individual was cleared to return to normal activity. Data were represented and summarized using standard techniques, including descriptive statistics. Analysis of data using a repeated measures ANOVA was completed to compare the within-subjects’ data, including total composite scores on the computerized neurocognitive tool to compare improvements within subjects over time and between-subjects’ data, including differences in scores seen across interventions as well as number of days until clearance to return to activity. A significance level of α = p ≤ 0.05 was used for all quantitative analyses. Effect sizes were calculated for any differences found between groups to gain perspective on differences seen across groups and to limit Type I and Type II errors. Effect sizes were used in conjunction with significance testing to help determine the power of this study. In doing so, data were properly analyzed to identify potential changes over time across groups. COMBINED CARE IN CONCUSSION TREATMENT 27 Summary of Results Descriptive Data A convenience sample was extracted from the database which resulted in 29 records being included. The physical health treatment group, consisting of 25 patients’ data, represented an age range of 16-19 years old, with a mean age of 16.96 (SD = .98) years, and included 10 (40%) females and 15 (60%) males. All participants were being treated for SRC. The physical health treatment group attended a mean of 2.6 neuropsychiatric visits (SD = .86), with a minimum amount of 2 visits, and a maximum number of 5 visits (Table 1). The mental health treatment group (four total) consisted of three females’ data and one male’s data with subjects aged 16-18 years old, with a mean age of 17 (Table 2). The mental health treatment group attended a mean number of 4.5 neuropsychiatric appointments (SD = 2.38) with a minimum of 2, and a maximum of 7 visits. The mental health treatment group and physical health treatment group did not significant differ in distribution of traits for age (p=.93), gender (p=.26), or days from injury to first visit (p=.51, Table 3). 28 COMBINED CARE IN CONCUSSION TREATMENT Table 1. Descriptive statistics for sample Physical Health Treatment Variable Mean SD Min Max Visits 2.6 .86 2 5 Days to recovery 29.4 16.34 10 Age 16.9 1.01 Days from injury to 7.9 4.16 Mental Health Treatment n Mean SD Min Max n 25 4.5 2.38 2 7 4 85 25 116.5 39.06 72 164 4 16 19 25 17 .81 16 18 4 2 18 25 11 8.16 5 23 4 First visit Table 2. Gender and personal history per group Physical Health Treatment Mental Health Treatment Variable N=25 N=4___________ Gender 10 female, 15 male 3 female, 1 male Concussion history 6 yes, 19 no (24% prevalence) 2 yes, 2 no (50% prevalence) Migraine history 7 yes, 18 no (28% prevalence) 1 yes, 3 no (25% prevalence) 29 COMBINED CARE IN CONCUSSION TREATMENT Table 3. Distribution statistics for sample Physical Health Treatment Mental Health Treatment p = .93 Physical Health Treatment Mental Health Treatment p=.26 Physical Health Treatment Mental Health Treatment p=.51 Treatment Group Comparisons A one-way between subject’s ANOVA was conducted to compare the effects of a mental health treatment on the amount of days to recovery. There was a significant effect of treatment received on the days to recovery [F (1,27)=64.23, p=<.001]. The results showed that the group receiving mental health treatment recovered in 116.50 days (SD = 39.06) and required an average of 4.5 visits (SD = 2.38). The physical health treatment group recovered in 29.44 days (SD = 16.34) and attended a mean of 2.6 appointments (SD = .86). The physical health treatment group attended the first treatment appointment COMBINED CARE IN CONCUSSION TREATMENT 30 an average of 7.9 days after a concussion (SD = .416), and the mental health treatment group attended the first treatment appointment an average of 11 days after a concussion (SD = 8.16). These findings were not statistically significant towards days to recovery (p=19). These findings do not support the hypothesis that those receiving a mental health treatment would recover more quickly than those receiving physical health treatment. Effect sizes were calculated using a difference of means between groups. The finding supported a small effect size of .25 (Table 4). Clinical Profiles The physical health treatment group had a primary assignment to the posttraumatic migraine clinical profile (14), with the vestibular profile receiving the second most frequent assignment (6). The most common secondary profile assignment for the physical health treatment group was vestibular (4). The mental health treatment group had a primary assignment to the vestibular profile (3), with a secondary profile of posttraumatic migraine being the most common (3, Table 5). This highlights differences seen across groups regarding clinical presentation and assignment of treatment. 31 COMBINED CARE IN CONCUSSION TREATMENT Table 4. Days to recovery per treatment group Group n Mean SD Min Max n Physical health treatment 25 29.4 16.34 10 85 25 Mental health treatment 4 116.5 39.06 72 164 4 Table 5. Clinical profile distribution per group Physical Health Treatment (n=25) Primary Profile (n) Secondary Profile (n) Mental Health Treatment (n=4) Primary Profile (n) Secondary Profile (n) PTM (3) PTM (14) Vestibular (4) Vestibular (3) Vestibular (6) Ocular (2) Anxiety/Mood (1) Additional findings. A generalized linear model was completed to analyze if other items were related to time to recovery. Sleep issues were investigated first, specifically trouble falling asleep, hypersomnia, and insomnia for both groups across the first and second visit. Those in either treatment group who reported trouble sleeping on the PCSS at the initial visit experienced a longer recovery time (Figure 1) than those who did not (p=.006), but insomnia symptoms were not significant if reported at the second visit (p=.162). COMBINED CARE IN CONCUSSION TREATMENT 32 COLLABORATIVE CARE IN CONCUSSION TREATMENT i Figure 1. Days to recovery based on first visit PCSS insomnia score The model demonstrated that the second visit PCSS total score was significantly related to days to recovery (p = .02), and the second visit VOMS total score was significantly related to a longer recovery (p = .01). These details align with the research supporting the VOMS tool and its ability to differentiate between concussed and nonconcussed patients (Kontos & Collins, 2018; Mucha et al., 2014; York, Smith, Babcock, & Alsalaheen, 2017). Continued symptom reporting on the VOMS may be indicative of underlying neurological issues that may prolong concussion recovery (Clark et al., 2017). Loss of consciousness was significantly related to time to recovery (p=.02) and may be indicative of more severe concussion injuries. Disorientation was not significantly related to days to recovery (p=.95), and neither was personal history of migraine (p=.42), motion sickness history (p=.32), post-traumatic amnesia (p=.91), nor personal concussion history COMBINED CARE IN CONCUSSION TREATMENT 33 (p=.56). Reports of confusion were also not significantly related to recovery (p=.77), and neither was age (p=.52) nor gender (p=.22, Table 6). In addition, a stepwise linear model was completed to determine if the order of variable entry influenced the relationships seen above. The stepwise regression was calculated to review relationships between the type of treatment received, computerized neurocognitive testing total scores, and VOMS total scores across visit one and two to see which variables were most directly related to prolonged recovery. A significant regression equation was found for the type of treatment only (R2= .704, F(4,29) =64.23, p<.0001) suggesting type of treatment received was biggest predictor of recovery. This analysis was completed to minimize Type I and Type II errors. COMBINED CARE IN CONCUSSION TREATMENT Table 6. Predictors to prolonged recovery. Variable Wald’s 95% Confidence P_Value Migraine history .17 .42 Concussion history .34 .56 Disorientation .00 .95 Confusion .08 .77 Motion sickness history .98 .32 Age .08 .52 Gender .05 .22 Visit 1 PCSS total .004 .85 Visit 1 VOMS total .003 .76 Visit 2 PCSS total .23 .02* Visit 2 VOMS total .27 .01* Post-Traumatic Amnesia .01 .91 Loss of Consciousness 5.33 .02* *Those indicated with an asterisk are significant correlations 34 COMBINED CARE IN CONCUSSION TREATMENT 35 General Discussion The research conducted showed that on average the adolescents and young adults who were clinically appropriate to receive mental health treatment as part of their concussion treatment experienced prolonged recovery. These findings may highlight a clinical difference between the two groups. Those who were deemed appropriate for an additional mental health treatment likely experienced worse or more complex symptoms and may have required more time to return to baseline measurements than the group who did not have mental health needs. It is likely that in comparing these two treatment groups, two distinct patient groups were identified that had differing needs, and this key difference is what drove recovery time. The primary finding supported a statistically significant group difference that did not support the proposed hypothesis (i.e. patients referred to mental health treatment combined with a physical health treatment modality would experience a quicker recovery as evidenced by fewer days reported to recovery). The small effect size, uneven group design, and underpowered sample size were limiting factors in this study, which must be considered when reviewing results. Each treatment group was clinically appropriate for the treatment referral they received as assessed by their treating clinicians, which demonstrates a difference in group symptom presentation. Because of this, it is likely that the mental health treatment group presented with more severe concussion symptoms and required the extra mental health treatment. This difference in the groups’ symptoms is COMBINED CARE IN CONCUSSION TREATMENT 36 also responsible for a lack of support of the hypothesis because those with more severe symptoms, and those requiring more treatment, are likely to take longer to recover from their symptoms. The statistical evaluations showed that common influencers of concussion recovery, such as reported symptoms of disorientation, post-traumatic amnesia, confusion, history of migraine, and concussion history, did not significantly influence results. Concussions that presented with a loss of consciousness, elevated secondary total scores on the computerized neurocognitive testing, and elevated VOMS scores were related to prolonged recovery from concussion and are to be expected as they likely indicate more severe injuries and that some individuals are continuing to experience symptoms impacting their functioning. High initial symptom reporting after a concussion has been linked to prolonged recovery (McCrory et al., 2017) and without a significant improvement these symptoms are likely to be reported on follow up testing. Additionally, Kontos et al. (2019) suggested that clinical profiles have complex interactions with each other, and those patients experiencing mental health symptoms can be challenging to treat because they lack awareness of psychological symptoms and how they influence perception and presentation of symptoms. Similarly, distribution of clinical profiles aligned in that post-traumatic migraine was the most common clinical profile and the vestibular impairment profiles also occurred frequently. This study also aligns with research completed regarding symptom reporting. Other researchers have found that subjects reporting continued symptoms on the VOMS COMBINED CARE IN CONCUSSION TREATMENT 37 between 10-20 days after initiating treatment were more likely to have prolonged concussion recoveries (Sinnott, Elbin, Collins, Reeves, Holland, & Kontos, 2019). This implies that additional neurological factors may be contributing to prolonged recovery. Clark et al. (2017) suggested that those with persistent sensory problems may have damage to the neurological pathways or other complex sensory processing issues. The VOMS may have identified these issues common in prolonged recovery. Because these symptoms were directly addressed in treatment, some symptoms of vestibular and oculomotor problems may have been exacerbated during treatment, especially early in treatment as seen by Kleffelgaard et al. (2016). Insomnia reported on the PCSS at the initial visit was also linked to prolonged recovery from concussion and may be related to high initial symptom presentation. This is important to note as Kontos and Collins (2018) reported that sleep issues can improve with concussion symptoms, or can become problematic and persist throughout treatment, thus inhibiting recovery from concussion. Because of this, it is important to identify and treat sleep issues early. Additionally, individuals who have a history of somatization have been shown to have prolonged concussion recoveries (Root et al., 2016). This factor may have been more common in patients experiencing mental health symptoms, as subjects could have potentially misinterpreted or experienced their mental health symptoms in a physical manner. This interaction was reflected in the findings, as mental health symptoms were present in patients with a vestibular clinical profile in the mental health treatment group. COMBINED CARE IN CONCUSSION TREATMENT 38 The data may provide additional validation to the Clinical Profiles Treatment Model suggested by Kontos and Collins (2018). These researchers suggested conducting a comprehensive assessment following injury and accurate assignment of clinical profiles most closely matching symptoms. In their model, those who are not experiencing nervousness, anxiety, sadness, depression, or other mood disturbances would not be referred to receive a mental health intervention. The researchers noted the difficulty treating mental health symptoms and that many of the medications discussed for treatment require weeks or months to demonstrate efficacy (Kontos & Collins, 2018). Because of the prolonged recovery of those in the mental health treatment group, it is possible that these subjects experienced this issue related to recovery. This research may provide additional support for the assignment to mental health treatment based on increased needs. Similarly, it appears that those who did not require additional mental health treatments were accurately identified and assigned to the proper group as evidenced by their quicker recoveries. Additionally, this research suggests that underlying neurological problems may exist in those assigned to mental health treatment as evidenced by continued symptom reporting and higher scores on the VOMS. This finding aligns with problems identified by Sandel et al. (2017) that suggest neurological changes following SRC may overlap with mood disorders and can lead to longer recoveries. Limitations/strengths. The use of pre-existing healthcare data is often used in research due to available data and ethical concerns regarding assignment of treatment. A COMBINED CARE IN CONCUSSION TREATMENT 39 strength of this type of research included that when there are existing databases, with consent, researchers can use this data to observe and analyze relationships among variables without intervention. An additional strength of the research design is that it allowed this researcher to look at longer time periods without having to wait for the duration of treatment to occur for those whom have already completed treatment. There were several limitations to this research. This causal-comparative quasiexperimental design did not feature a random assignment to treatment types, and therefore cannot be used to determine cause and effect but can simply highlight correlations in the existing data. Additionally, the target sample size was 25 for the physical health treatment group and 25 for the mental health treatment group. However, although the goal of 25 for the physical health treatment group was achieved, only four patients fitting inclusion criteria were located for the mental health treatment group. Additionally, the specific types of treatment received by the two groups were not measured. The research database only captured neuropsychological visits at the concussion specialty clinic and did not track compliance with physical health or mental health treatments. Also, differences in types of treatment received were not measured (i.e. CBT compared to psychotropic medications in the mental health treatment group). Despite finding a significant relationship, the small effect size and small sample was insufficient to power this research. As such, any results should be viewed cautiously. Therefore, the hypothesis cannot be confidently unsupported; however, evidence has COMBINED CARE IN CONCUSSION TREATMENT 40 been gathered supporting differences in the treatment groups that may lead to prolong recoveries. Also, the possibility of confounding variables is present in this type of study, because only correlations are observed. It is possible that there could be unidentified outside variables that impacted the results of this study that were not considered. For example, it was not evident how severe each concussion was and how this may have impacted recovery. It is possible that those who experienced more severe concussions were referred to more intensive treatment services, such as additional mental health treatment. These highly acute clinical presentations would likely take more time to resolve symptoms. There were also limitations with the database used. The database reflected the amount of neuropsychiatric appointments attended but did not document the amount of physical therapy appointments attended. It is possible that the combined mental health treatment group attended more neuropsychiatric appointments due to the nature of their injuries, but there may have been a similar number of physical therapy appointments attended between groups. Subjects may have been noncompliant with treatment recommendations made by the clinicians at the concussion specialty clinic, and a lack of participation in treatment would likely cause longer recovery. Referrals to outside treatment services were documented in the database but because of the nature of the existing database and the use of separate medical records the level of compliance was unclear. It was also unclear if subjects attended these additional service appointments, COMBINED CARE IN CONCUSSION TREATMENT how frequently, or the level of progress attained in these services. This may have impacted results because if those receiving referrals outside of the clinic, or to participating departments within the clinic, did not comply with treatment recommendations, their recoveries were likely prolonged. The mental health treatment group would have likely been disproportionately affected by this potential issue as they were referred to more services. 41 COMBINED CARE IN CONCUSSION TREATMENT 42 Clinical Implications and Future Research In diagnosing and treating concussions, clinicians must be aware of the importance of proper assessment for pre-existing factors that may influence concussion recoveries. Clinicians must also be aware of the importance of appropriate clinical referral and types of treatment that are evidence-based for concussion care. Many treatment centers may not have the resources available to treat all symptoms of concussion and must be able to make appropriate treatment referrals to outside agencies. Sports programs in lower level sports, such as high school, and rural areas may not have easy access to neuropsychiatrists or physical therapists in specialty concussion treatments like vestibular or oculomotor therapies. These clinicians must be invested in forming a treatment team using outside referral sources and work to ensure proper coordination of care, communication, and continuity of treatment. Future research should be conducted to provide further support for treatment interventions in concussion recovery. Specifically, similar research should be conducted on a larger sample size so that findings may generalize more to the population studied. Also, researchers should follow patients for a longer period as they recover from concussions to help identify and address any differences between patients who experience prolonged symptoms beyond six months or longer from those who do not. Other methodology, such as using randomized controlled trials, can be used to gather stronger evidence for the support of combined mental health and physical health COMBINED CARE IN CONCUSSION TREATMENT 43 treatment. Researchers should also compare patients who receive a physical health treatment only to those who receive mental health treatment within the anxiety and mood clinical profile. Lastly, further study should also be done across the concussion clinical profiles to provide support for the assessment, assignment of clinical profiles, unique problems seen across groups, and individualized treatment applied to all groups. COMBINED CARE IN CONCUSSION TREATMENT 44 Conclusion The initial findings of this research did not support the hypothesis that individuals referred to a combined mental health treatment and physical health treatment would experience a quicker recovery from concussion as evidenced by the computerized neurocognitive testing scores and by requiring fewer days to clearance. However, the effect size was small (.25), and the study was low in power. The intervention group who received mental health treatment required more days to recover than the physical health treatment group. This finding is likely due to those patients receiving the mental health treatment having additional needs and symptoms outside of a physical health only intervention that further compounds their symptoms. The review of data also showed that reported symptoms of disorientation, confusion, migraine history, and concussion history did not significantly impact the findings. Initial reports of insomnia, along with prolonged symptom reporting, appears to be an influencer on recovery, especially higher scores on the computerized neurocognitive testing. This research provides support for the idea that there are differences in groups receiving physical health treatment and mental health treatment. Those patients who are clinically appropriate for a referral to mental health treatment likely presented with increased symptomology at time of treatment, and those with continued symptom reporting may be experiencing more advanced neurological issues. This highlights the importance of appropriate clinical assessment, referral, and treatment based on patient COMBINED CARE IN CONCUSSION TREATMENT 45 history and presenting symptoms. The appropriate clinical application of these results will lead to more accurate identification and tracking of symptoms using targeted and specific treatment approaches. These findings also support the clinical profile treatment approach initially proposed by Kontos and Collins (2018) and may provide validation for their assessment and prescribing practices. If they accurate assessed an individual with higher recovery needs, they may have appropriately referred to more types of treatment, and this type of individual may be slower to recover due to the complexity of the injury. Mental health symptoms presenting after a concussion are typically challenging to treat, and medication interventions may take weeks or months to show benefits (Kontos & Collins, 2018). Kontos et al. (2019) also suggested that these individuals may lack insight into how their mental health symptoms influence their perceptions, behavior, and symptoms. This highlights the importance of the development of an adequate treatment team to assess and diagnose concussions, and work to develop a treatment team that can manage patients’ needs. In many settings and communities, barriers may exist to treatment. In these scenarios, it is important for clinicians to make outside referrals and maintain appropriate coordination of care to ensure that all concussion needs are addressed. These findings help clarify the underlying issues related with concussion recovery and highlights the unique mental health and neurological needs exhibited by those requiring mental health treatment. COMBINED CARE IN CONCUSSION TREATMENT 46 References Allen, B.J., & Gfeller, J.D. (2010). The immediate post-concussion assessment and cognitive testing battery and traditional neuropsychological measures: A construct and concurrent validity study. Brain Injury, 25(2), 179-191. https://doi.org/10.3109/02699052.2010.541897 Alsalaheen, B.A., Mucha, A., Morris, L.O., Whitney, S.L., Furman, J.M., CamioloReddy, C.E…Sparto, P.J. (2010). Vestibular rehabilitation for dizziness and balance disorders after concussion. 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Retrieved from: http://aann.org/publications/journal Merritt, V.C., Bradson, M.L., Meyer, J.E., & Arnett, P.A. (2017). Evaluating the testretest reliability of symptom indices associated with the ImPACT® postconcussion symptom scale (PCSS). Journal of Clinical and Experimental Neuropsychology, 40(4), 377-388. https://doi.org/10.1080/12803395.2017.1353590 Mucha, A., Colling, M.W., Elbin, R.J., Furman, J.M., Troutman-Eneski, C., DeWolf, R.M., …& Kontos, A.P. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions. The American Journal of Sports Medicine, 42(10), 2479-2486. https://doi.org/10.1177/0363546514543775 COMBINED CARE IN CONCUSSION TREATMENT 53 Neidecker, J.M., Gealt., D.B., Luksch, J.R., & Weaver, M.D. (2017). First-time sportsrelated concussion recovery: The role of sex, age, and sport. The Journal of the American Osteopathic Association, 117(10). 635-642. https://doi.org/10.7556jaoa.2017.120 Nelson, L.D., Guskiewicz, K.M., Barr, W.B., Hammeke, T.A., Randolph, C., Ahn, K.W., …McCrea, M.A. (2016). Age differences in recovery after sport-related concussion: A comparison of high school and collegiate athletes. Journal of Athletic Training, 51(2), 142-152. https://doi.org/10.4085/1062-6050-51.4.04 Root, J.M., Zuckerbraun, N.S., Wang, L., Winger, D.G., Brent, D., Kontos, A., & Hickey, R.W. (2016). History of somatization is associated with prolonged recovery from concussion. The Journal of Pediatrics, 174, 39-44. https://doi.org/10.1016/j.jpeds.2016.03.020 Sandel, N., Reynolds, E., Cohen, P.E., Gillie, B.L., & Kontos, A.P. (2017). Anxiety and mood clinical profile following sport-related concussion: From risk factors to treatment. 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Journal of Science and Medicine in Sport, 22(2019), 1292-1297. https://doi.org/10.1016/j.sams.2019.08.004 Spikman, J.M., Boelen, D.H.E., Lamberts, K.F., Brouwer, W.H., & Fasotti, L. (2009). Effects of a Multifaceted treatment programme for executive dysfunction after acquired brain injury on indications of executive functioning in daily life. Journal of the International Neuropsychological Society, 16(1),118-129. https://doi.org/10.1017/S1355617709991020 Solomon, G. (2011). Introduction to ImPACT® [PowerPoint presentation]. Retrieved from: https://www.vumc.org/vscc-research/files/vsccresearch/public_files/IntroductiontoImPACT®Vanderbilt20131115.pdf TBI: Get the facts. (4/27/2017). Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/traumaticbraininjury/get_the_facts.html COMBINED CARE IN CONCUSSION TREATMENT 55 Vargas, G., Rabinowitz, A., Meyer, J., & Arnett, P.A. (2015). Predictors and prevalence of postconcussion depression symptoms in collegiate athletes. Journal of Athletic Training, 50(3), 250-255. https://doi.org/10.4085/1062-6050-50.3.02 Wiese-Bjornstal, D., White, A.C., Russell, H.C., & Smith, A.M. (2015). Psychology of sport concussions. Kinesiology Review, 4, 169-189. https://doi.org/10.1123/kr.2015-0012 What Is Cognitive Behavioral Therapy? (2018). The American Psychological Association. Retrieved from: http://www.apa.org/ptsd-guideline/patients-andfamilies/cognitive-behavioral.aspx York, A.M., Smith, L., Babcock, M., & Alsalaheen, B. (2017). Validity and reliability of the vestibular/ocular motor screening and associations with common concussion screening tools. Sports Health, 9(42), 174-180. https://doi.org/10.1177/1941738116678411 COMBINED CARE IN CONCUSSION TREATMENT Appendix A Review of the Literature 56 COMBINED CARE IN CONCUSSION TREATMENT 57 Recovery from concussions has been a topic of discussion in the news and popular culture as several high-profile cases have arisen. These cases were highlighted by compromised neurological function and other poor outcomes. Concussions and traumatic brain injury (TBI) are prevalent in contact and non-contact sports and occurs in athletes of all ages. The Centers for Disease Control and Prevention (CDC) estimates that in the general population for all ages, concussions were present in 2.87 million emergency room visits, hospital stays, or as a cause of death in 2014 (CDC, 2019; “TBI: Get the facts,” 2017). For those under the age of 18, it is estimated that 1.1 million to 1.9 million individuals incur a concussion from sports or recreational activities (Bryan, RowhaniRahbar, Comstock, & Rivara, 2016). These injuries are subjective experiences, with some athletes recovering quickly and some experiencing long-lasting effects (Coleman, 2016). Despite the health risks and potential consequences of concussions incurred by athletes, there has been little agreement among clinicians about optimal programs of recovery. Additionally, subjective experiences of concussions have led to differentiated treatment approaches per individual (Coleman, 2016; Hobbs, Young, & Bailes 2016). Currently, there are numerous recommendations following concussion with little consensus among professionals. Physical activity and gradual return to activity is commonly prescribed (Chan, Iverson, Purtzki, Wong, Kwan, Gangnon, & Silverberg 2018; Coleman, 2016). Vestibular problems can be treated with posture control work, physical therapy interventions, and visual therapies (Kontos, Deitrick, Collins, & Mucha, COMBINED CARE IN CONCUSSION TREATMENT 58 2017). Mental health symptoms can be intensified following concussion, especially depression (Chrisman, & Richardson, 2014), and cognitive behavioral therapy has been used to teach effective coping skills for managing symptoms (Silverberg et al., 2013). The purpose of this review was to investigate the effects of physical health interventions, mental health interventions, and collaborative care treatment methods for sport-related concussions in adolescent and young-adult athletes aged 16 to 25. The review will cover the theoretical framework of the issue as well as the empirical evidence. The population specifics of adolescents and adults will be reviewed as well as active recovery programs, cognitive problems, treatment approaches, and balance and vestibular treatments. Lastly, the benefits of applying a collaborative care model incorporating aspects of both physical health and mental health treatment will be reviewed. Concussion Assessment, Diagnosis, and Current Treatment Models Researchers have struggled to develop a focused and agreed upon definition of concussions due to the varied experiences and recovery times associated with head injuries. Recently, a consortium of experts defined a concussion as an injury resulting from a traumatic force that affects the brain and its subsequent processes; causes impairment of functioning, and often neuroimaging scans fail to show specific injury COMBINED CARE IN CONCUSSION TREATMENT 59 (McCrory et al., 2017). These injuries may occur as a direct force to the head or to other parts of the body which results in a secondary ImPACT® such as a helmet hitting the ground. Concussions can occur from sport contact as well as through non-sport means. It is essential that researchers agree upon this definition of concussions so that a proper diagnosis can be rendered. Prevalence of Concussions To effectively treat a concussion in the sports population, athletes must first have their injuries identified, be appropriately assessed, and diagnosed to be selected for treatment (Coleman, 2016). Most often, the goals of concussion assessment, diagnosis, and treatment are to remove the athlete from any unsafe conditions, reduce the possibility of negative symptoms, and allow the athlete to return to play as quickly as possible. The National Collegiate Athletic Association (NCAA) tracks data regarding their athletes and injuries they sustain, including injuries such as broken bones, torn ligaments, sprains, and concussions. This information is available via the NCAA Injury Surveillance Program database (Zuckerman et al., 2016). Using the NCAA database in a retrospective cohort study, Zuckerman et al. (2016) used the NCAA Injury Surveillance Program to investigate the prevalence of concussions in athletics, determine correlational factors related to prolonged recovery from concussion, and to identify trends in athletes across sports, age, and sex. This COMBINED CARE IN CONCUSSION TREATMENT 60 foundational study investigated the 2009-2010 and 2014-2015 athletic seasons and found that there were a total of 1866 reported unique NCAA athletes who experienced concussions. Out of these athletes, 7.4% went on to experience post-concussion symptoms such as prolonged headache, dizziness, depression or anxiety, exercise intolerance, and fatigue (Zuckerman et al, 2016). The most common sport for athletes to receive a concussion was men’s American football which made up 38.6% of all concussions. The rate of concussion in organized sports can reach as high as 1 diagnosed injury per 1,000 exposures to sport (Daneshvar et al., 2011). Additionally, negative outcomes as well as increased risk for repeated concussions were most associated with symptoms of amnesia, dizziness, loss of balance, nausea, concentration problems, and sensitivity to light and sound. Protocols and Procedures Problems with diagnosing. When an individual is suspected of having a concussion, it is imperative that he or she be assessed and properly diagnosed. Hobbs et al. (2016) noted the importance of early detection of concussions and potential complications from concussions in athletes. The researchers reported that difficulties in diagnosis arise due to the lack of visual evidence of concussion on traditional brain scans, whereby athletic trainers and physicians must then rely on subjective reports. There is a COMBINED CARE IN CONCUSSION TREATMENT 61 wide use of various concussion diagnostic tools, which can add to confusion when multiple professionals are treating an individual. Further complicating that matter, historically clinicians have struggled to agree on the definition of a concussion (McCrory et al., 2017). The course of injury may be different for everyone, and treating clinicians need to be aware of the warning signs and symptoms that may present with a concussion (Coleman, 2016; Hobbs et al., 2016). Researchers note that there are also other areas impacted by concussions, including academic problems for students or student athletes, financial problems, emotional and mental health symptoms, and peer relations issues; these symptoms may be less apparent to the treatment team than physical symptoms (Coleman, 2016; Hobbs et al., 2016). Population differences. Additionally, there has been discussion about differences in population regarding concussion symptoms, treatment, and potential outcomes. Research has supported the idea that high school and college athlete populations respond similarly when faced with similar injuries (Kontos et al., 2013; Nelson et al., 2016; Williams, Puetz, Giza, & Broglio, 2016). The authors found that college and high school athletes’ injuries and recoveries followed similar trajectories. Also, noted differences among gender for coping skills were identified. Those athletes who experience concussive injuries are less likely than their peers who experience orthopedic injuries to use active coping skills, and male athletes are even less COMBINED CARE IN CONCUSSION TREATMENT 62 likely than female peers to use coping skills. Female athletes are more likely when injured to use support systems, humor, and distraction to cope with their injuries (Kontos et al., 2013). Researchers noted that despite these differences, athletes reported similar levels of cognitive performance (Nelson et al., 2016). Other predictors of prolonged concussion recovery have been noted in a review of the literature by Brent and Max, 2017. These authors found that children who are slow to recover from concussions are more likely to have had a prior concussion. Depression or psychiatric illness prior to a concussion may also increase time to recovery, as well as a history of migraine headaches (Brent & Max, 2017). Adolescents who have a prior history of somatization may also recovery more slowly from concussions (Root et al., 2016). Assessment tools. When a concussion is suspected, certified athletic trainers and sports medicine staff play a vital initial role in early detection and are usually the first to encounter an athlete who possibly has a concussion (Coleman, 2016). Balance testing using the Balance Error Scoring System (BESS), cognitive assessments such as the Sports Concussion Assessment Tool Third Version (SCAT-3), and vision and ocular testing such as the King-Devick test and VOMS are all useful tools that can be administered immediately after a suspected injury to increase the likelihood of early detection of concussions in athletes (Hobbs et al., 2016; Mucha et al., 2014; York et al., 2017). COMBINED CARE IN CONCUSSION TREATMENT 63 The ImPACT® tool is a commonly used concussion assessment that consists of six neurocognitive tests to generate composite scores regarding word discrimination, attention and verbal memory, visual working memory, working memory, processing speed, impulse and reaction speed, and processing speed (Solomon, 2011). The PostConcussion Symptom Scale (PCSS) is a multi-faceted subscale of the ImPACT® and has been shown to have high test-retest reliability (Merritt et al., 2017). The measures within the PCSS, such as cognitive symptom cluster, physical symptom cluster, and affective system cluster also showed moderate to high reliability (Merritt et al., 2017). The affective system cluster has also been shown to influence the responses to testing protocols and is correlated with higher depressive symptom reporting, suggesting that clinicians must be cognizant of observable affective symptoms (Ramanathan, Rabinowitz, Barwick, & Arnett, 2011). Importance of quick response. Quick and accurate assessment and diagnosis of a concussion is important for reducing risks to athletes and delayed recovery (Hobbs et al., 2016). It has been noted that athletes who return to play too quickly risk increased symptomology, potential for increased time away from sport, as well as potential for brain damage. Guskiewicz et al. (2003) noted that experiencing a concussion is a predictive variable for future concussions and reported that ten out of eleven athletes who experienced multiple concussions in the same sports season did so within ten days of the initial injury. The National Collegiate Athletic Association’s (NCAA) best practices for concussion management (Coleman, 2016) reported that athletes must immediately be COMBINED CARE IN CONCUSSION TREATMENT 64 removed from play and other sports activities such as practice for at least the current day when a concussion or brain injury is suspected to reduce likelihood of negative complications. Currently Accepted Treatment Approaches Once a concussion has been diagnosed, team athletic trainers and physicians often refer athletes to treatment. The NCAA best practices for concussion management (Coleman, 2016) states that athletes will typically return to normal activities once they return to their baseline measurements prior to the concussive injury. Athletes are recommended to make a gradual return to normal activities as tolerated based on symptomology. These steps are taken as a progressive series of achievements towards physical and cognitive normalcy for each individual, with athletes beginning light activity with return to regular activity as intolerance decreases. Researchers note that many athletes will experience symptom complications and require further treatment (Hobbs et al., 2016). Rest and light activity are often the most prescribed form of treatment for those experiencing a concussion (Thomas, Apps, Hoffman, McCrea, & Hammeke, 2018). Upon initial diagnosis of concussion, most athletes are provided with instructions to only engage in light activity until their symptoms begin to subside and they become more capable of engaging in routine activities. This is a commonly accepted practice in the COMBINED CARE IN CONCUSSION TREATMENT 65 medical and athletic field. However, research has shown that those participating in an active rehabilitation program consisting of submaximal aerobic activity show little differences in improvements for several major concussive symptoms such as balance, cognition, and parental anxiety about progress post-concussion (Gagnon, Grilli, Friedman, & Iverson, 2016). Little difference was also seen in Maerlender, Rieman, Lichtenstein, and Condiracci’s (2015) work comparing athletes receiving active recovery against those prescribed rest. These authors noted that both groups showed improvements in their symptoms at a similar rate. Because of this, evidence supporting active recovery only prescriptions are contradictory at this time. Mental health symptoms are common after concussion and may be worsened by prior history of concussion or family history of mental health symptoms (Chrisman & Richardson, 2014; Conder & Conder, 2015). Cognitive behavioral therapy (CBT), cognitive reframing, and biofeedback for concussions and brain injuries has shown promise in the foundational literature (Conder & Conder, 2015; Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996, Silverberg et al., 2013). Although Mittenberg et al. (1996) studied older adults (mean age of 43 in the treatment group and mean age of 49 in the control group), the results may be applicable to other populations. Those who participated in the treatment group received detailed directions from a therapist about implementing CBT principles such as stress reduction, tips for symptom improvement, biased thinking awareness, and tips for scheduling activities to reinforce positive thoughts and actions. The treatment group showed COMBINED CARE IN CONCUSSION TREATMENT 66 improvements over the treatment as usual group in terms of days to recovery, frequency of symptoms six months later, days per week of symptomology, and severity of reported symptoms (Mittenberg, et al. 1996). While research remains somewhat limited and sometimes contradictory regarding treatment of concussions, some schools have begun to act through utilizing the resources available to them. The Sahuarita United School District 30 identified that at times, athletes who experienced concussions had difficulty transitioning back into their academic routine and school workloads. The district formed a collaborative team utilizing their registered nurse (RN), parents, school board members, superintendent, community healthcare providers, coaches, school psychologists, health assistants, and parents to address this issue creatively (Dachtyl & Morales, 2017). The team initially suggested using the Rehabilitation Act of 1973’s Section 504 plan to make accommodations for the injured students but reported that this was unsatisfactory due to the 504 plan’s intent to assist those with more permanent disabilities (Dachtyl & Morales, 2017). They developed the Cognitive Return to Exertion (CoRTEx) concussion management protocol that utilizes interventions with a speech-language pathologist as well as an athletic trainer. The resulting developed program consisted of a multi-phased program beginning with diagnosis, coordination with educational systems and physical health clinicians, incorporation of testing of symptoms, modification to educational demands as COMBINED CARE IN CONCUSSION TREATMENT 67 appropriate, and appropriate follow up. If a student’s concussive symptoms continue after the intervention, then referrals are made for the appropriate 504 plan or Individualized Educational Plan (IEP). An important part of the program is communication among educators, treating clinicians, healthcare workers, team members, and family (Dachtyl & Morales, 2017). The researchers reported case studies of students who have completed the program and note adequate support was provided. This initial research provides evidence that changes can be made at the school level to help athletes recover from concussion symptoms and reintegrate into their academic work. This program may be an example of how school districts can utilize existing resources and services to create replicable programs across school districts and may represent the beginning of a commonly accepted practice. Population Assessment in Concussion Management In treating concussions and post-concussive symptoms, it is important that clinicians provided targeted treatment towards the individual he or she is treating. Some differences in recovery may exist based on gender (Kontos et al., 2013; Neidecker et al., 2017), body mass index (Lee et al., 2016), as well as high school athlete or college athlete COMBINED CARE IN CONCUSSION TREATMENT 68 status (Williams, Puetz, Giza, & Broglio, 2015). In addition to accurately understanding individual needs, diagnostic tools must be selected that show valid and reliable results. Evidence-based tools include the Glasgow Coma Scale (McLernon, 2014), the ImPACT® and PCSS (Merritt et al., 2017), and the Beck Depression Inventory (Steer, Cavalieri, Leonard, & Beck, 1999). Gender Differences in Concussion Recovery Other differences have been noticed across genders. Kontos et al. (2013), in a study using high school and college-aged student athletes, observed that female student athletes were more likely than male student athletes to use coping skills for recovery across all injury types. Examples of more commonly used coping skills include utilization of social supports, self-distraction, and humor. Differences have been noted across injury types (Kontos et al., 2013). Those athletes who experienced orthopedic injury were more likely than those who experienced concussion to utilize coping skills. The concussion group reported lower acceptance, less coping for distraction, higher substance use, more self-blame, and more denial than those experiencing orthopedic injuries (Kontos et al., 2013). Other gender differences have been noted in the literature (Neidecker et al., 2017). These researchers compared medical records for male and female athletes aged 11-18 who experienced a first-time concussion to clarify any differences between sexes COMBINED CARE IN CONCUSSION TREATMENT 69 for duration of symptoms and types of symptoms expressed. Athletes were considered recovered from their concussion symptoms when their ImPACT® scores were similar to their baseline scores. Most male athletes (75%) recovered from their symptoms within 3 weeks of injury, whereas only 42% of female athletes reported recovery from symptoms within 3 weeks (Neidecker et al., 2017). The researchers noted that there were differences in recovery from concussions based on gender and hypothesized that these differences may be related to biological factors such as increased prevalence of migraines in females, increased rates of depression in adolescent females, and less total neck mass to absorb impacts that may cause concussions (Neidecker et al., 2017). Body Mass Index Differences Other differences in concussion recovery have been noted based on body mass index (BMI). Lee et al. (2016) noted that among adolescent and young adult athletes who experienced a sports concussion, obese individuals took longer to return to baseline in numerous measures, including reaction time and PCSS scores. In this study, athletes were matched based on age, gender, type of sport, and amount of previously diagnosed concussions. Obese athletes who incurred a concussion experienced longer delays in visual and verbal memory functions, reaction time, motor speed, and higher scores on the PCSS than those who were within a normal weight according to the CDC standards. COMBINED CARE IN CONCUSSION TREATMENT 70 Those athletes who had a BMI less than 25 were more likely to have their concussive symptoms return to baseline in two weeks than those who had a BMI over 30 (Lee et al., 2016). High School versus College Athletes There are numerous changes that occur physiologically among adolescents and young adults. Because of this, it is worth investigating possible differences across adolescent and young adult populations. Potential differences in expression of symptoms, if any, may impact potential treatment recommendations or paths of recovery. Some additional differences in concussion recovery have been noted in the literature between high school athletes and collegiate athletes (Williams et al., 2015). Adolescent and young adult athletes may recover similarly for cognitive symptoms, at 5 days and 7 days respectively. Despite this similarity, high school and collegiate athletes may vary in their perceptions of required time needed to return to an asymptomatic state at 15 days versus 6 days respectively (Williams et al., 2015). Despite this identified difference, there may be a confounding variable present in that collegiate athletes may feel more social pressures to return to play sooner, and therefore may underreport symptoms when self-report is relied upon. As previously mentioned, recovery from cognitive symptoms appears similar in highs school and college athletes. Other symptomology following concussion in high COMBINED CARE IN CONCUSSION TREATMENT 71 school and collegiate student athlete populations appear to be similar as well (Lee, Odom, Zuckerman, Solomon, & Sills, 2013). Student athletes across both populations report similar symptoms at both baseline and post-concussion when measured with the Total Symptom Scale (TSS). Examples of symptoms measured include nausea, dizziness, insomnia, irritability, emotional problems, visual problems, and problems with memory. Both high school and college athletes also reported a similar return to baseline symptomology in those who experienced symptom resolution. Athletes who experienced symptom resolution in high school recovered within 5.5 days, and college athletes recovered within 5.7 days (Lee et al., 2013). Further research has been conducted comparing the high school athlete and collegiate student athlete population (Nelson et al., 2016). In this research, athletes who experienced a concussion were monitored on day 1, 2, 3, 5, 45, and 90 post-injury using cognitive assessments and balance assessments. It was noted that high school student athletes took approximately one to two days longer to recover than their collegiate counterparts, but they also experienced more severe injuries and these differences in recovery were not statistically significant. These findings suggest that similar injury patterns may occur in these populations, and similar treatments may be appropriate for high school and college athletes who sustain a sports-related concussion (Nelson et al., 2016). COMBINED CARE IN CONCUSSION TREATMENT 72 Diagnostic Tools The Glasgow Coma Scale (GCS) is a frequently used assessment and diagnostic tool designed to test impairment from head trauma or neurological injury (McLernon, 2014). The GCS is often used as an initial indicator in medical treatment centers to communicate state of consciousness and potential level of injury experienced. This tool measures a patient’s responsiveness with his or her eyes, verbal responsiveness, and motor responsiveness and assesses several subcategories within each to develop a total score. McLernon (2014) reported that the measure produces moderately reliable ratings in conscious patients but can lose inter-rater reliability when patients experience loss of consciousness. Additionally, it has been found that training and education increase the accuracy of administering the tool. In this sense, intra-rater reliability is enhanced with proper training protocols. The researcher recommends that the assessment be completed early after the injury, and then periodically to track changes in condition (McLernon, 2014). It is noted that despite these limitations, the GCS remains an appropriate clinical tool for assessing those experiencing head traumas due to its maintained reliability and ability to predict continuing symptoms (McLernon, 2014). This makes the scale appropriate to use for those experiencing concussion symptoms and is most valid with COMBINED CARE IN CONCUSSION TREATMENT 73 individuals experiencing only short-term loss of consciousness as often seen in sportsrelated concussions. Using testing measures that have demonstrated reliability is an important aspect of an effective concussion testing and monitoring plan. Many tools to monitor concussions are completed prior to injury for baseline reporting, immediately after a concussion, and throughout the recovery period. Because of this, research reviewed the test-retest reliability of commonly used tools including the ImPACT® Total Symptom Score and the Post-Concussion Symptom Scale (PCSS) (Merritt et al., 2017). Researchers reported that the ImPACT® scale is used to document subjects’ difficulties with verbal and visual memories, reaction time, and impulse control, while the PCSS is a specific component of the ImPACT® assessment. The PCSS used a Likert scale across 22 questions to measure severity of symptoms (Merritt et al., 2017). The PCSS showed highest test-retest reliability for the cognitive symptom scale, but only showed moderate reliability for the ImPACT® total symptom scale (Merritt et al., 2017). This research demonstrates the need for the use of additional and specific measures to be used with the ImPACT® Total Symptom Score and PCSS. To further document the ImPACT® and PCSS’s effectiveness, a study of athletes’ affective states was conducted by researchers at the Pennsylvania State University who proposed that athlete’s observable affective state may be indicative of their likelihood to report positive or negative symptoms on their baseline assessments (Ramanathan et al., 2011). The researchers’ purpose was to provide validation or critique to these tools so COMBINED CARE IN CONCUSSION TREATMENT 74 that researchers understand their effectiveness, scope, and limitations. In doing so, it allows researchers to understand their results within an affective context. The researchers studied 256 Division I NCAA athletes who had sustained a concussion during sport. The researchers used the Beck Depression Inventory Fast Screen (BDI-FS), which has been demonstrated to be a reliable and valid measurement tool (Steer, Cavalieri, Leonard, & Beck, 1999). The ImPACT® Total Symptom Score and PCSS were additionally used for data collection. Also completed was an observational rating tool designed for the researchers to rank the subjects’ affective states as they completed the test battery. The researchers found that those experiencing an observable negative affective state were more likely to score higher for depression on the BDS-FS and suggested that those athletes who received a more positive affect rating report fewer depressive symptoms. The researchers argue that it is imperative that clinicians document athletes’ affects and understand the bias that observable affect may have when reporting baseline or post-concussive measures (Ramanathan, Rabinowitz, Barwick, & Arnett, 2011). Other symptoms of concussion may also be present following an injury to the head. Adolescents and young adults who have been diagnosed with a concussion sometimes experience symptoms such as dizziness, difficulties with balance, gait, sensory processing problems, and difficulty with eye focus (Alsalahenn et al., 2010; Kleffelgaard, et al., 2016; Kontos et al., 2017). The VOMS tool has been developed to track these symptoms by assessing dysfunction of the vestibular, vision, and COMBINED CARE IN CONCUSSION TREATMENT 75 somatosensory systems using assessments in five domains (Mucha et al., 2014; York et al., 2017). The tool relies on verbal report of headache symptoms, dizziness, nausea, and fogginess on a Likert scale of 0-10 when compared to their last assessment’s symptoms (Mucha et al, 2014). The VOMS has also shown to have a high level of test-retest validity when compared through repeated tests within subjects (York et al., 2017). When compared to other evidence-based tools that measure symptomology, such as the PCSS, the VOMS scores were positively correlated with higher PCSS scores, suggesting its ability to accurate identify concussion symptoms (Mucha et al., 2014). Researchers have also suggested that the VOMS is a reliable and internally consistent tool (Mucha et al., 2014). Using peer-reviewed tools and assessments, such as the GCS, ImPACT®, BDSFS, VOMS, and PCSS with athletes who potentially have a concussion, is an important part of accurate and appropriate injury assessment. In using these tools, clinicians can accurately diagnose a concussion, track and manage symptoms, and make appropriate treatment referrals. When clinicians can efficiently diagnose a concussion and identify symptomology, an appropriate referral to treatment can be made. One of the commonly prescribed forms of treatment is active recovery and gradual return to activities as tolerated (Chan et al., 2018). COMBINED CARE IN CONCUSSION TREATMENT 76 Active Recovery and Prescription of Physical Activity Gradual return to activity as tolerated is a common recommendation for athletes who sustain a sports-related concussion, but little research exists to support the safety and effectiveness of these recommendations. Chan et al. (2018), in their randomizedcontrolled trial, compared the effects of an active rehabilitation program on nineteen adolescents aged 12-18. Of those 19 subjects 14 were female. Those participating in the control group received treatment as usual consisting of an educational session about symptom management, a psychiatric consultation, and information regarding return to school. Adolescents randomized to the experimental group engaged in submaximal aerobic exercise, visualization training, coordination training, and a home exercise program. The intervention lasted for six weeks. The researchers found that those receiving active rehabilitation experienced negative symptoms no more frequently than those receiving treatment as usual, and showed greater improvements in balance, error scoring, cognitive functioning, and quality of life measurements (Chan et al., 2018). They hypothesized that the intervention may have supported cerebrovascular changes that assisted recovery. They reported that the placebo effect may have occurred, in that those receiving active rehabilitation believed they were recovery faster. The researchers also reported that by giving athletes COMBINED CARE IN CONCUSSION TREATMENT 77 permission to exercise they may have resolved maladaptive beliefs about their situations (Chan et al, 2018). Maerlender, Rieman, Lichtenstein, and Condiracci (2015) showed no significant improvements in post-concussion symptoms following an active recovery protocol consisting of 20 minutes of moderate cycling in college athletes diagnosed with a sportsrelated concussion. The study included more females than males, and females may take longer to recover from concussions which may have affected outcomes (Neidecker et al., 2017). Also, the researchers may have failed to demonstrate a significant difference between intervention and control group because 13 subjects experienced continued symptoms and did not recover within the two-week period, which may have been tied to a short intervention or the inability of female athletes to recover quickly. The intervention group initially experienced increased post-concussive symptoms at the onset of the physical activity intervention. Athletes who experience a concussion may also show no more favorable outcomes when offered an early intervention treatment with a rehabilitation medicine specialist than those who receive a treatment as usual (Matuseviciene, Eriksson, & DeBoussard, 2016). However, this study involved high-risk and low-risk populations and their quality of life three months post-intervention. It is possible that high-risk populations may need a more comprehensive treatment approach, and they may not recover in similar ways or timeframes as low-risk concussion populations. COMBINED CARE IN CONCUSSION TREATMENT 78 Conversely, in specifically investigating the effects of a prescription for strict rest, Thomas, Apps, Hoffman, McCrea, and Hammeke (2018) randomly assigned children and adolescents diagnosed with a concussion from any cause to either receive strict rest or to treatment as usual. The treatment group was instructed to maintain five days of strict rest, where the control group was recommended to rest for one or two days, then begin returning to activity as usual. These researchers failed to show significant differences between groups in neurocognitive function, balance, and self-reported symptoms in their treatment periods. This may be due to the follow up occurring just ten days after intervention, when the primary subjects of the research were female youth, and subjects had other high-risk factors such as history of previous concussions and migraines (Thomas, Apps, Hoffman, McCrea, & Hammeke, 2018). Rest and gradual return to physical activity are common prescriptions following sports-related concussion (Chan et al., 2018). Although there appears to be some empirical support, some individuals continue to experience post-concussion symptoms and may require further interventions to address persistent symptoms. These continued symptoms may need additional treatments (such as visual or vestibular treatments) to resolve. COMBINED CARE IN CONCUSSION TREATMENT 79 Visual and Vestibular Treatments for Post-Concussion Symptoms Many athletes who experience concussions experience problems including dizziness, vertigo, balance problems, and difficulty with eye function such as focusing and reading (Kleffelgaard, Soberg, Bruusgaard, Tamber, & Langhammer, 2016). Other commonly experienced problems associated with concussions include nausea, balance problems, unsteady gait, sensory processing difficulties (Alsalaheen et al., 2010). Kontos et al. (2017) reported that to optimize outcomes of sports-related concussions, clinicians must assess for, and adequately treat, vestibular and oculomotor dysfunction. Screening and Assessment for Post-Concussion Symptoms It is noted that screening and assessment tools currently accepted as valid and reliable include the Vestibular/Oculomotor Screening Tool (VOMS), Dizziness Handicap Inventory, Sports Concussion Assessment Tool 2, King-Devick testing (Hecimovich, King, Dempsey, & Murphy, 2018; Mucha et al., 2014), ImPACT®, as well as the PCSS (Merritt et al., 2017). Researchers report that dizziness and visual motion sensitivity are common dysfunctions that can be treated with postural control, specialized work with a physical therapist, and visual therapy programs. Although research is somewhat limited in this area, current research has shown reductions in vestibular symptoms in athletes in as little as eight weeks (Kontos et al., 2017). COMBINED CARE IN CONCUSSION TREATMENT 80 Balance and Gait Treatment Researchers performed a retrospective review to assess for the effectiveness of treating commonly reported vestibular conditions following concussion in children and adults including dizziness, nausea, confidence in balance, gait, and sensory processing (Alsalaheen et al., 2010). Vestibular treatments and exercises were customized due to participant complaint, with common exercises provided such as gaze maintenance, walking, practicing balance, and traversing unstable surfaces such as walking on foam. Improvements were seen in all subjects, especially children in the study (mean age = 16) in areas such as dizziness, balance, and gait. However, with the mean intervention lasting four sessions and 33 days, the researchers report that they cannot rule out spontaneous remission of symptoms (Alsalaheen et al., 2010). Other researchers have validated the efficacy of vestibular treatment for postconcussive symptoms. Kleffelgaard, Soberg, Bruusgaard, Tamber, and Langhammer (2016) recruited adult subjects from the outpatient clinic at the Oslo University Hospital who were diagnosed with a mTBI according to the Glasgow Coma Scale following a fall or accident. All subjects reported experiencing dizziness, lack of range of motion, and experienced reduced vestibular-ocular reflexes. The subjects engaged in a group and home-based vestibular rehab program for 8 weeks. The program incorporated balance, head and eye coordination exercises, sitting and standing exercises, light walking, COMBINED CARE IN CONCUSSION TREATMENT 81 jogging, or swimming, and progressive relaxation. The researchers found that all patients experienced some negative symptoms during the initiation of the program, but no serious negative experiences were noted. Kleffelgaard et al. (2016) reported that as a result of the intervention, subjects reported improvements in balance, reduced dizziness, and improved quality of life which supports the inclusion of vestibular treatment as part of concussion recovery protocol. Alsalaheen et al. (2013) documented common vestibular prescriptions to provide a foundation for clinicians who encounter concussion patients experiencing symptoms such as dizziness, imbalance, and gait problems. The researchers reviewed 114 files at a vestibular rehabilitation clinic to collect data on a sample of children and adults with a mean age of 24 years old. They found that exercise to improve eye-head coordination, standing balance exercises, and ambulatory exercises were most frequently prescribed to patients to alleviate post-concussion symptoms. Because these are the most frequently prescribed exercises for concussive symptoms, it can reasonably be inferred to be routine practice for young adults (Alsalaheen et al., 2013). Additionally, vestibular therapies are recommended to be active, dynamic treatments that engage athletes in addressing specific symptoms and complaints involving the head and eyes (Kontos et al., 2017). COMBINED CARE IN CONCUSSION TREATMENT 82 Visual Therapies Vestibular symptoms of concussions can also include eye problems, such as perceived eye strain, trouble focusing, and sensitivity to light. The effects of using various chromatic filters have been investigated in attempts to identify potential benefit to post-concussion patients experiencing visual problems (Fimreite, Willeford, & Ciuffreda, 2016). They investigated the preferences of 12 adults recovering from a sports-related concussion or accident and injury concussion who were experiencing photosensitivity post-concussion and compared their preferences with 12 controls. The researchers used a Visograph to track eye movements and reading speed while subjects engaged in five trials of different tinted lenses as well as no lens trial. No differences between groups across trials for fixations, or regressions were found, but a significant difference in reading rate was found. The control group read faster than the trial group using the red and blue lenses while the intervention group reported increased comfort using the colored lenses. This led the researchers to suggest that future research could be conducted on colored lenses affecting the later stages of visual processing as part of a comprehensive post-concussive symptom treatment regimen and suggested that colored lenses could be used therapeutically to reduce perceived strain and discomfort following concussions (Fimreite, Willeford, & Ciuffreda, 2016). COMBINED CARE IN CONCUSSION TREATMENT 83 Additionally, further research has validated the positive effects of using chromatic filters on those experiencing visual symptoms post-concussion (Clark, Hasselfeld, Bigsby, & Divine, 2017). Subjects were adolescents and adults who were presenting with continued concussion symptoms at least three weeks post-injury and who reported continued photosensitivity as a primary symptom. The researchers in this cross-sectional study used an LED penlight commonly used in visual assessments to determine subjects’ levels of photosensitivity for a baseline measurement. Then, subjects were presented with thirteen different colored lenses, and asked if the lenses made the light better, worse, or the same. Lenses that were helpful were worn for longer periods of time to retest their effects, and then these preferred lenses were compared together. Subjects who reported spending most of their days using screens, either for work or for academics, were also tested using screens for their trials. After trying the lenses, researchers concluded that 85% of those who experienced visual problems noted improvements with colored lenses (Clark et al., 2017). These researchers hypothesize that those athletes who experience photosensitivity postconcussion may have encountered retinal damage, damage to neurological pathways, or damage to the visuosensory pathways regarding color processing. These symptoms may be both indicatory of brain injury and may help dictate treatment. These studies suggest that a variety of treatment approaches may be most beneficial to address symptoms of concussion. Balance, gait, motor control, and other physical challenges often present with post-concussive symptoms. Additionally, many COMBINED CARE IN CONCUSSION TREATMENT 84 patients experience visual problems including sensitivity, discomfort, and difficulty managing eye control. This research suggests that many factors should be considered when assessing, diagnosing, and treating individuals who experience a concussion injury, and comprehensive treatment may be needed to address the spectrum of patient concerns including mental health symptoms. Cognitive Issues and Collaborative Care Adolescents and adults who are slow to recover from concussion may be at risk of experiencing cognitive and mental health symptoms (Brent & Max, 2017; WieseBjornstal et al., 2015). Brown et al. (2014) identified that athletes may be at continued risk for depression, memory problems, concentration problems, and may benefit from mental health treatment. Additionally, research has supported the idea of executive function training (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2009). Resources such as the Concussion Care Manual: A Practice Guide (Brody, 2015) state that an initial prescription for exercise and psychological treatment may be helpful. Furthermore, additional support has been found for taking a collaborative care approach between physical and mental health for adolescents and adults recovering from sports-related concussions (McCarty, 2016; Makdissi et al., 2017). COMBINED CARE IN CONCUSSION TREATMENT 85 Prevalence and Scope of Cognitive Issues Another issue associated with concussions is the effect of injuries on cognitive function and mental health symptoms, and the relationship between cognitive activity and delayed recovery from post-concussive symptoms (Brown et al., 2014; Chrisman, & Richardson, 2014; Mrazik, Brooks, Jubinville, Meeuwisse, & Emery, 2016; Rees & Bellon, 2017; Vargas, Rabinowitz, Meyer, & Arnett, 2015). Researchers completed a literature review regarding the prevalence of cognitive problems following concussions and the treatment process for cognitive issues in concussions (Brown et al., 2014). Further topics of the review included admission and initial interview, as well as specific intervention strategies like education, skills training, cognitive behavioral therapy (CBT), and others, as well as special population considerations. The researchers reported that it is important to complete a thorough mental health status exam, including mental health testing. Other tests important to conduct include executive dysfunction, learning, memory, concentration, and sports-specific tests (Brown et al., 2014). This research helps to form consensus on the presence of mental and cognitive impairments associated with post-concussive symptoms. Similarly, other authors have noted effects of psychological risk factors on the outcome of concussions, as well as potential effects of concussions on mental health (Wiese-Bjornstal et al., 2015). The authors described the integrated model of psychological response to sport injury to understand the psychological factors relating to concussion. This research focused on factors that make athletes at risk for injury or at risk COMBINED CARE IN CONCUSSION TREATMENT 86 for delayed recovery. Further support was found by Root et al. (2016) for psychological factors influencing concussion, specifically somatization. In their prospective cohort study, the researchers completed the Children’s Somatization Inventory with patients to gather clinical information regarding somatization history. Then, they compared the PCSS and time to recovery across groups of high and low somatization history at two weeks and four weeks post-injury. The researchers found that there was a significant correlation between somatization and higher reported post-concussion symptoms at two and four weeks into their recoveries. Other psychological factors may influence the severity of concussions and prolonged recovery. Several authors reviewed research conducted in the fields of concussions and mental health and discovered that Attention Deficit Hyperactivity Disorder (ADHD) and depression prior to and after an injury can be risk factors for poor concussion recovery (Brent & Max, 2017; Wiese-Bjornstal et al., 2015). Researchers also reported in their psychological response to sport injury model that the use of maladaptive coping mechanisms can prolong recovery time, and concussion education is effective at reducing risk of concussion (Wiese-Bjornstal et al., 2015). Numerous factors influence recovery from concussion and can include behavioral symptoms, communication difficulties, social context, and affective symptoms such as nervousness and frustration can impair recovery. Other deficits are often seen such as memory, cognitive, and processing problems frequently occur; rest, social support, CBT, concussion education, and goal-setting interventions have all been demonstrated to improve concussion COMBINED CARE IN CONCUSSION TREATMENT 87 outcomes (Brent & Max, 2017; Wiese-Bjornstal et al., 2015). These findings suggest that there are numerous influential factors, both pre-injury and post-injury, that can delay recovery from concussion. Additionally, athletes’ mental health concerns following concussions can be addressed using specific interventions as part of the recovery process. Other research has been conducted to help verify a link between concussions and mental health problems. Chrisman and Richardson (2014) reviewed data collected from the National Survey of Children’s Health that was completed in the United States via telephone in 2007. This survey collected household health data from subjects across the United States about medical insurance, physical and mental health histories of children in the home, performance in the academic setting, and description of their local neighborhoods. Subjects were asked about their children’s histories of concussion, as well as mental health symptomology in the past and present. Upon review of the data, the authors found a correlation between a previous clinical diagnosis of concussion and current symptomology or diagnosis of depression. The researchers discovered that children who had a prior clinical concussion diagnosis were 3.3 times more likely to experience depression that those who did not experience concussion, and children who reported that their parents had poor or fair mental health were more likely to experience depression. The older the participant, the more likely he or she was to experience depression after concussion. These results were independent from gender (Chrisman & Richardson, 2014). This research suggests that depression may be one of the long-lasting effects of concussions, and these effects may be more common COMBINED CARE IN CONCUSSION TREATMENT 88 than realized. These results make a strong clinical case for the appropriate assessment, diagnosis, and treatment of depression after an athlete experiences a concussion diagnosis. Other researchers have validated the increased risk of depression following concussive injuries (Vargas et al., 2015). College athletes were given baseline assessments at the beginning of the sport season consisting of the BDI-FS assessment, and then were completed again for data comparison following concussion. Of the 84 athletes who experienced a concussion, the majority (71%) were retested within 48 hours, and all subjects were retested within one week of concussion. The researchers found that individuals who experienced a concussion were more likely to report depressive symptoms post-injury than the non-injury group, and those who began sports at an older age were more likely to experience depression after concussion (Vargas et al., 2015). They also found that people of color were more likely to experience depression postconcussion than Caucasian athletes, and those with higher estimated IQ experienced fewer symptoms post-concussion (Vargas et al., 2015). This research verifies the risk of depression following concussion and highlights some of the potential population differences in mental health following concussions. When concussion symptoms persist for extended periods of time, mental health symptoms are present in nearly all patients (Rees & Bellon, 2017). Researchers investigating common symptoms and modalities of treatment found that nearly all adults who experienced long-term post-concussion symptoms lasting two or more years COMBINED CARE IN CONCUSSION TREATMENT 89 reported anxiety and depression as their two leading cognitive symptoms (Rees & Bellon, 2017). The researchers reported that long-term recurring affective and cognitive difficulties may leave concussion patients feeling helpless, indecisive, and unable to cope with their lives and may contribute to prolonged recovery from concussion (Rees & Bellon, 2017). Additionally, other differences may exist for populations not only based on history of previous concussions, but for history of concussion combined with musculoskeletal injuries as well (Mrazik, et al., 2016). Subjects chosen for this study were 743 Canadian youth hockey players between the ages of 13-17. Athletes in this study completed a Pre-Season Questionnaire (PSQ) as well as a Behavior Assessment System for Children, 2nd Edition (BASC2) to gather data prior to the start of the athletic season. Information regarding demographics, previous mental health symptoms, head injuries, physical health injury histories, sports participation history, and medical conditions was gathered. The collected data were organized into subgroups of youth athletes, groups of no prior injury, previous concussion history, previous musculoskeletal injury, and those athletes who had experienced both musculoskeletal injuries as well as concussions. Upon evaluating the data, it was discovered that athletes in the combined injuries group showed numerous differences to the other groups such as more emotional symptoms, anxiety, and attention problems than the musculoskeletal injury only group. The combined injury group also experienced an increased sense of inadequacy, more loss of internal locus of COMBINED CARE IN CONCUSSION TREATMENT 90 control, and increased somatization of symptoms when compared to the other groups (Mrazik et al., 2016). Explanatory Style on Recovery Additionally, it appears that the internal explanatory style of athletes has an impact on recovery times from concussions as well (Shapcott, Bloom, Johnston, Loughead, & Delaney, 2007). The researchers define explanatory style as the patterns individuals use to explain either positive or negative situations in their lives and often form patterns in thought (Shapcott et al., 2007). In terms of analyzing one’s own status post-concussion, individuals use an optimistic or pessimistic explanatory style for their circumstances. Optimistic explanatory style communicates the message that the injury was external of an individual’s control, was not related to constant or unchanging circumstances, and was caused due to a specific event. Conversely, pessimistic explanatory styles convey that injury causes are internal, somewhat unchanging, and do not have specific causal factors. Data were collected using the Attributional Styles Questionnaire (ASQ) to quantify information regarding personal explanatory styles and the Sports History Questionnaire (SHQ) to collect information regarding sports participation history, number of concussions, and duration of symptoms in college aged athletes. The researchers found that explanatory style did not influence symptom duration for single COMBINED CARE IN CONCUSSION TREATMENT 91 concussion events, but those who experienced multiple concussions and who had an optimistic internal explanatory style experienced significantly longer time to return to baseline symptomology than those with a pessimistic explanatory style (Shapcott et al., 2007). This research suggests that there are numerous psychological factors that influence recovery from concussion that must be considered when treating athletes. There are unique challenges facing student athletes in their attempts to recovery from both physical health injuries and brain injuries. Special considerations may need to be taken in addressing their physical and psychological symptoms. Additionally, these confounding issues may include psychological factors, age of first sports participation, and racial factors. These additional factors may also influence recovery from complex concussions, and treatment needs to reflect these individualized concerns. Cognitive Behavioral Treatments To treat concussions, clinicians may consider referrals to cognitive behavioral therapy (CBT) or other mental health services to more adequately manage mental health symptoms. It is noted that CBT can be useful in reducing symptoms. Other techniques such as reframing, biofeedback, and neurofeedback can be used to regain bodily control. Furthermore, cognitive rehabilitation training can teach athletes skills to manage symptoms and injuries by teaching appropriate expectations, coping skills, goal setting, and others (Conder & Conder, 2015). COMBINED CARE IN CONCUSSION TREATMENT 92 Researchers studied patients at the Boston Sports Concussion Clinic who presented within three weeks of a sports concussion. Data were collected using the PCSS tool in addition to a cognitive activity scale that was developed for concussion patients. The authors found that subjects who reported the most cognitive activity, experienced the slowest self-reported time to recover from post-concussive symptoms. This issue may present challenges especially for the high school or collegiate athlete who may be pressured to return to school and complete tasks at the same rate as peers. Brown et al. (2014) reported that cognitive rest following a concussion may help athletes return to a symptom-free state more quickly than those who are more cognitively active. Because of this, it may be necessary for clinicians to prescribe specific cognitive rehabilitation therapy to address these symptoms. Researchers at the Icahn School of Medicine in New York, New York investigated the effects of cognitive rehabilitation programs on post-concussion symptoms (Cantor et al., 2014). Subjects received twice weekly group therapies, and individual therapy over twelve weeks. The intervention focused on teaching problemsolving skills, emotional regulation training, attention skills training, and use of personal aides such as daily planners or to-do lists. Therapists specifically taught skill application and generalization of techniques to current life stressors to improve use of coping skills. After twelve weeks, those subjects receiving the short-term cognitive rehabilitation program reported improved problem-solving skills and reported their behavior to be more goal-directed than the control group. Subjects who received this COMBINED CARE IN CONCUSSION TREATMENT 93 intervention also reported specific improvements in emotional regulation, self-awareness, distress tolerance, ability to pay attention, participation in activities, and improved quality of life. These results suggest that skill training is an important part of cognitive rehabilitation for those experiencing post-concussive symptoms (Cantor et al., 2014). Because of the positive effects of mental health skills training, additional research has been conducted reviewing the specific CBT interventions and skill teaching for individuals experiencing post-concussive symptoms. Thomas, Alves, Vaska, and Magalhaes, (2017), in their review of the literature, noted that effective CBT skills teaching programs prioritized improving performance on tasks and improving individual’s sense of well-being, particularly when delivered early in concussion recovery. Specific skills taught during these interventions included mental health skills such as reasoning and cognition skills, addressing maladaptive thoughts, reducing overly critical thoughts, improving attention, use of personal electronics or scheduling systems, and relaxation techniques. Physical skills were also taught during these interventions, including breathing techniques, sleep hygiene improvements, and tips to reduce headaches. Those individuals participating in these interventions showed reduced anxiety, depression, and task performance (Thomas et al., 2017). Some research has also suggested that targeted CBT treatment may reduce the potential for developing post-concussion symptoms in high-risk populations (Silverberg COMBINED CARE IN CONCUSSION TREATMENT 94 et al., 2013). In this randomized controlled pilot study, individuals who experienced a head injury within the previous six weeks and reported at least one subjective symptom of concussion were assigned to either treatment as usual, which involved a meeting with an occupational therapist for a three-hour session, or to the intervention group consisting of treatment as usual as well as a six-week CBT intervention. The CBT intervention focused on reducing health anxiety, improving self-efficacy, improve coping skills and their use, and reduction of a maladaptive negative thinking processes (Silverberg et al., 2013). Subjects in the study completed the Rivermead PostConcussion Symptoms Questionnaire and HADS Depression and Anxiety assessment at baseline and at three months after intervention to investigate the effects of the CBT intervention. The researchers found that those receiving CBT scored lower for depression on their follow up reporting and noted improved perceptions about themselves and their rehabilitations (Silverberg et al., 2013). Members of the intervention group tended to rate their level of disability as lower than those of the treatment as usual group and rated their satisfaction with concussion treatment higher. Because of the increased belief in recovery, reduction of symptoms, and potential for reduced change of chronic post-concussion syndrome, early and targeted CBT approaches may reduce mental health symptoms commonly associated with concussions (Silverberg et al., 2013). The research presented clarifies several clinical issues for those treating student athletes who have histories of concussive injury. Researchers note that it is important to COMBINED CARE IN CONCUSSION TREATMENT 95 properly assess student athletes for their physical health history, concussion history, and to be aware of athletes who have experienced both as they may experience unique challenges in their recoveries. A comprehensive concussion treatment program needs to also properly identify previous mental health history and current mental health history to most appropriately recommend treatment. This also provides support for the idea of collaborative care across physical and mental health realms to optimize benefit to student athletes as they recovery. Executive functioning training in CBT. For those recovering from a concussion, a priority of treatment is typically to return to normalcy as quickly as possible. To return to normalcy in their lives, patients who have experienced a concussion need to use their executive functioning skills in an effective way; they need to be able to plan effectively, exhibit goal-directed behavior, initiated desired tasks, and incorporate these skills into their environments (Spikman et al., 2009). The researchers investigated the ImPACT®s of an executive functioning training on executive decision-making in patients experiencing brain injury. Spikman et al. (2009) developed a randomized controlled trial featuring an executive function intervention lasting up to 24 sessions. The intervention focused on providing specific skills training on goal setting, task planning, and regulation skills while the control group received cognitive-functioning skills training via computer featuring repetitive exercises consisting of training for improved reaction time, memory, attention, and ability to plan. COMBINED CARE IN CONCUSSION TREATMENT 96 There were 75 subjects in this randomized controlled trial (RCT) who were randomized to either the intervention group or control group. Data collection occurred via The Role Resumption List, Treatment Goal Attainment, and Executive Serial Task measurements which were used at baseline, after treatment, and six months following intervention. The researchers found that the experimental group made significant progress in the assessment tools in areas such as return to work, participation in hobbies and activities, and level of social participation (Spikman et al., 2009). Also shown to improve were skills associated with daily life functioning such as organizing, planning tasks, initiating actions, and self-monitoring. Similarly, a 12-week skills training program enhanced executive functioning skills in patients with a history of TBI and executive functioning problems in areas such as emotional regulation, attention skills, and ability to use personal aides such as planners or to-do lists. Skills were taught using group therapy twice weekly and individual therapy once weekly over a period of twelve weeks. Subjects were taught executive skills during the treatment period with the intent of generalizing skills to reduce difficulties in educational, employment, or social functioning. Post-intervention, subjects showed increased ability in problem-solving, planning and purposeful behavior, and scores on the composite executive function measure (Cantor et al., 2014). These findings suggest that it is possible to treat disabling mental and cognitive symptoms of concussions. Executive dysfunction can make those experiencing concussions dependent on others, unable to work or attend school, and be unable to make COMBINED CARE IN CONCUSSION TREATMENT 97 skillful decisions and actions in their personal lives. Treatment of these symptoms through specific skills teaching during mental health treatment may be a fundamental aspect of concussion recovery, because injured athletes wish to return to baseline symptomology and resume previous activities. Psychiatric Referrals in Concussion Treatment Researchers report that research is currently lacking regarding the efficacy and best practice guidelines for prescribing psychotropic medications for athletes following a brain injury (Reardon & Factor, 2010; Warden et al., 2006). Despite these limitations, some general recommendations have been developed regarding prescribing psychotropic medications specifically to athletes. (Reardon & Factor, 2010). To treat depression after brain injury, the use of selective serotonin reuptake inhibitors (SSRIs) has been shown to improve symptoms in 87% of patients studied (Warden et al., 2006). Also of benefit, preliminary studies report that SSRIs most likely do not negatively impact muscle strength, power output, or athletic capacity (Reardon & Factor, 2010). Tricyclic antidepressants, such as amitriptyline, have been shown to be somewhat less effective in studies reviewed by Warden et al. (2006), but more research needs conducted in this area due to small sample size and lack of supporting evidence. To treat anxiety symptoms after brain injuries, some research validates the use of serotonin norepinephrine reuptake inhibitors (SNRIs) (Warden et al., 2006). COMBINED CARE IN CONCUSSION TREATMENT 98 The researchers reported that despite a lack of studies completed on brain injury patients regarding psychotropic medication’s effectiveness in reducing mental health symptoms, the demonstrated effectiveness of these interventions in other populations provides some evidence of their benefit across populations (Warden et al., 2006). When treating concussion patients with psychotropic medications, prescribers must consider the unique needs of the athlete, including compliance with anti-doping regulations in sport, potential impacts on athletic performance, and potential physiological differences between concussion patients and uninjured patients (Reardon & Factor, 2010; Warden et al., 2006). Another resource for clinicians treating concussions is the Concussion Care Manual: A Practical Guide (Brody, 2015). The manual reports that along with a thorough assessment and clinical history, care has to be given when scheduling appointments. The manual states that if individuals present with major safety issues or active suicidal ideation, then an admission into the hospital may be the most effective treatment. Other factors that may require more immediate follow up include severe anxiety or depression, professional status such as professional athlete or military staff, and prescription of new psychoactive medications may require more immediate return to the clinic. These more urgent needs may require a visit within one week or up to every three weeks, and less urgent needs such as treating mood instability, moderate issues, and more easily tolerated medications may need appointments scheduled between six weeks and six months, depending on clinical presentation (Brody, 2015). COMBINED CARE IN CONCUSSION TREATMENT 99 Physical and Mental Health Collaborative Care Research has been conducted to support the combination of physical health and mental health treatment. This approach is referred to as collaborative care. Makdissi et al. (2017) used Medline, Sportdiscus, Cinahi, Cochrane Library, and Proquest to collect a series of base studies investigating collaborative care and appropriate treatments for postconcussive symptoms. Studies were included if they included sports-related concussions and focused on either assessment or treatment of concussion symptoms lasting longer than 10 days. The researchers identified 25 eligible studies, 11 of which focused on assessment, and 14 studies that were treatment focused. The authors found support for detailed clinical assessments, limited aerobic exercise, physical therapy, and collaborative treatment that has integrated cognitive behavioral therapy (Makdissi et al., 2017). Further validation can be found via a randomized controlled trial conducted by McCarty et al. (2016). These authors investigated the effects of a collaborative care intervention compared to treatment as usual in a group of adolescents who were slow to recover from concussion. Those adolescents randomized to the intervention group received care management, CBT aimed at reducing depressive and anxious symptoms through teaching of coping skills, positive thinking skills, sleep hygiene, advocacy within the school, and coordination of care among mental health and physical health providers. COMBINED CARE IN CONCUSSION TREATMENT 100 Those receiving treatment as usual received consultation with a rehabilitation specialist including submaximal exercise as appropriate (McCarty et al., 2016). The youth, as well as their participating parents, both reported statistically significant improvements in post concussive symptoms at one month, three months, and six months following implementation of collaborative care (McCarty et al., 2016). Adolescents receiving collaborative care noted higher quality of life during and after treatment when compared to those not receiving collaborative care. This research suggests that adolescents and young adults who experience post-concussive symptoms may recover more quickly when they receive physical health care as well as mental health treatment simultaneously. Behavioral health symptoms, such as disruptive behavior, attention-deficit disorder (ADD), and substance use problems are often difficult behaviors to treat but appear to benefit from collaborative care approaches as well (Asarnow et al., 2015). The studies included in these authors’ review utilized evidence-based CBT for mental health symptoms or behavioral health problems as well as an evidence-based medication algorithm to manage symptoms. Other tactics that showed positive effects included primary care physician (PCP) communication training for mental and physical health care providers, motivational interviewing, phone coaching, and peer support services (Asarnow et al., 2015). COMBINED CARE IN CONCUSSION TREATMENT 101 Positive effects, though small to moderate, were seen in the collaborative care interventions for substance use disorders. Other mental health symptoms, such as depression and anxiety, showed larger effect sizes and suggest the efficacy of these programs in reducing symptoms than can often be related to post-concussive symptoms. The researchers suggest that the positive outcomes of integrating mental and physical healthcare can be particularly beneficial for adolescents and young adults at reducing a variety of mental health and behavioral health symptoms (Asarnow et al., 2015; McCarty et al., 2006). Psychoeducational Interventions in Collaborative Care Further evidence has suggested the efficacy of mental health treatment in concurrent treatment for those experiencing chronic symptoms (Belanger et al., 2015). Researchers investigated the effects of a web-based psychoeducational program on postconcussive symptoms. A web-based psychoeducational program is a computer-delivered educational program aimed towards helping those experiencing mental health symptoms that provided information on different severity levels of head injuries, expected symptoms during treatment and recovery, tips and tactics to alleviate post-concussive symptoms, and attempted to normalize problems (Belanger et al., 2015). COMBINED CARE IN CONCUSSION TREATMENT 102 The Neurobehavioral Symptom Inventory (NBI) was used to track symptoms in the patients. The researchers failed to find significant interaction between the two groups. However, upon subgroup analysis they found a positive effect on symptoms for those receiving the intervention and participating in concurrent mental health treatment. At six months post-intervention, the group receiving the psychoeducational intervention and concurrent mental health treatment expressed symptomology similar to the control group’s measure at baseline. This evidence suggests that psychoeducational interventions and concurrent mental health treatment may more quickly reduce post-concussive symptoms to baseline more effectively than either intervention alone, but the researchers report there were not enough subjects to accurately assess whether concurrent treatment varies based on time since injury (Belanger et al., 2015). Collaborative care models may be effective in reducing high-risk behaviors such as violent behaviors, weapon carrying, substance use, and symptoms of Post-Traumatic Stress Disorder (PTSD) in individuals who have experienced physical injury or head injury (Zatzick et al., 2014). Adolescents at a Level 1 Trauma Center who experienced a traumatic injury, 47.5% of whom experienced head injuries, were randomized to either a usual care group or a stepped collaborative care intervention group. The stepped collaborative care group received case management, motivational interviewing techniques, pharmacotherapy, and CBT to address PTSD symptoms, depression, and high-risk behaviors for the 12 months following injury. The usual care group received primary care physician treatment, any outpatient surgery needed to COMBINED CARE IN CONCUSSION TREATMENT 103 recover from the injuries, and any specialty mental health services frequently offered to injury patients. The GSC was used to assess patients, the National Longitudinal Study of Adolescent Health was used to determine high-risk behaviors, and the Composite International Diagnostic Index was used to determine alcohol use behaviors. Additionally, the PTSD Reaction Index (PTSD-RI) was used to identify subjects who experienced elevated levels of symptoms related to PTSD (Zatzick et al., 2014). The researchers found the most support for reduced weapon carrying in the group receiving stepped collaborative care. Analysis of the data showed consistently lower follow up reports in depressive symptoms, PTSD, and substance use, though the effects were not large enough in this study to be considered statistically significant (Zatzick et al., 2014). However, this data suggests the possibility that collaborative care interventions may be implemented to illicit improvements in difficult, high-risk behavior. These benefits may be more readily seen in a population with a higher percentage of concussion or head injury patients. COMBINED CARE IN CONCUSSION TREATMENT 104 Conclusion Concussions are injuries that affect numerous internal mental and physical processes within an individual. As such, they are subjective experiences that researchers and clinicians have struggled to adequately define, research, and treat. Researchers now agree, however; that concussive events are the result of traumatic force to the head, resulting in impaired brain functions and processes (McCrory et al., 2017). Despite the subjective nature of concussions, is imperative that athletes be appropriately assessed and diagnosed so they may receive adequate and timely treatment. Numerous assessment and diagnostic tools, including balance testing using the Balance Error Scoring System (BESS), visual and vestibular impairment assessment tools such as the VOMS (Mucha et al., 2014; York et al., 2017), and cognitive assessments such as the Sports Concussion Assessment Tool Third Version (SCAT-3) are commonly used. Also, the Glasgow Coma Scale is frequently used to measure baseline symptoms and consciousness (McLernon, 2014), and ImPACT® and PCSS testing procedures have been shown to effectively measure concussion symptoms (Merritt et al., 2017). Once a concussion is diagnosed, treatment referrals can be made. Evidence suggests that physical rehabilitation programs can be beneficial in reducing concussion symptoms of poor balance, poor cognitive functioning, and reduced perceived quality of life (Chan et al., 2018). Vestibular therapies and treatments have also been shown to COMBINED CARE IN CONCUSSION TREATMENT 105 reduce post-concussive symptoms, particularly dizziness, nausea, poor confidence in balance, gait problems, and sensory processing errors (Alsalaheen et al., 2010; Kleffelgaard, 2016; Kontos et al., 2017). Visual therapies have also been shown to reduce post-concussive symptoms (Alsalaheen et al., 2013; Fimreite, Willeford, & Ciuffreda, 2016) as well as optometry interventions such as implementing chromatic filters and colored lenses to reduce photosensitivity (Clark et al., 2017). Additionally, mental health treatments have been shown to reduce the effects of post-concussion symptoms and allow individuals to be more functional in their daily lives (Brown et al., 2014). Chrisman and Richardson (2014) and Vargas et al. (2015) have demonstrated a link between athletes experiencing concussion and an increase in mental health symptoms afterwards such as increased anxiety and depressive symptoms. CBT and skills training have been shown to treat several of these common effects associated with delayed recovery from concussion (Cantor et al., 2014; Conder & Conder, 2015). Collaborative care models are those that implement and co-facilitate treatment between physical healthcare and mental healthcare. These models have been shown to be effective at reducing post-concussive symptoms (Makdissi et al., 2017; McCarty et al., 2016). Collaborative care models have also shown promise in reducing high-risk behavior such as weapon carrying and substance abuse (Asarnow et al., 2015). These research findings provide direction for application in treating athletes who experience concussions. Initial assessment and diagnosis is an important step to gauge COMBINED CARE IN CONCUSSION TREATMENT 106 symptoms as well to collect baseline data. Clinicians can provide treatment comprised of physical rehabilitation, vestibular and visual rehabilitation programs if symptoms are present (Alsalaheen et al., 2013; Chan et al., 2018; Kleffelgaard et al., 2016) and concurrent mental health treatment consisting of specific skills training for noted deficits (Asarnow et al., 2015; Makdissi, 2017; McCarty et al., 2016). Treatment should be monitored for effectiveness and for potential negative interactions such as increased symptomology. Treatment should be routinely monitored and adjusted to meet the client’s needs, and collaborative consultation with both physical health and mental health providers is recommended for the most effective treatment. If symptoms do not improve, physical and cognitive rest may be prescribed to reduce the cognitive and physical strain on the individual. Careful counseling and support are necessary during the recovery to allow patients to understand ways to cope with their stressors and to understand realistic expectations for recovery. Despite the strengths of the research and recommendations that are derived from it, there is still a need for future research in concussion management. Areas of consideration for future research include the application of collaborative therapy, including CBT, skills training for improvements in executive functioning, and physical treatment such as vestibular therapies and physical therapy to the high school and college-age student population. Also, an identified barrier to implementation of programs may be time of injury to time of initiation of treatment. This may be due to recruiting requirements for subjects in the research, procedural barriers of research, failure of COMBINED CARE IN CONCUSSION TREATMENT 107 injured athletes to report to treatment within the timeframe, lack of follow through on treatment recommendations, or lack of knowledge about the importance of concussion care. Despite the barriers, additional research can be conducted on implementation of interventions within 72 hours of injury. Many of the interventions reviewed were implemented several days, weeks, or even months post-injury. Additionally, many research studies investigated the effects of brief treatment interventions lasting six to eight weeks, where these programs may demonstrate more effect over a longer period. Lastly, these programs can be studied for individuals who experience multiple concussions, because each population may experience different symptom clusters with continued injury. By further investigating these areas, researchers can continue to develop and recommend the most recent and relevant evidence-based practices to support those recovering from concussions and head injuries. COMBINED CARE IN CONCUSSION TREATMENT Appendix B Problem Statement 108 COMBINED CARE IN CONCUSSION TREATMENT 109 In treating concussions and post-concussion symptoms, research has supported that physical rehabilitation programs (Chan et al., 2018) and visual and vestibular rehabilitation programs (Kontos et al., 2017) can be effective in reducing common symptoms such as cognitive problems, poor balance, and lowered quality of life. However, rest and gradual return to activity is one of the most commonly prescribed approaches (Thomas et al., 2018) but has shown little improvements in frequently experienced symptoms such as cognitive function and balance (Gagnon et al., 2016; Maerlender et al., 2015). Mental health symptoms can be frequently seen in those recovering from concussion injuries, including depression, memory problems, and problems concentrating (Brown et al., 2014; Vargas et al., 2015; Wiese-Bjornstal et al., 2015). Additionally, concussion symptoms may be more serious following repetitive concussions; children who experienced multiple concussions may be 3.3 times more likely to experience depression than those who experienced their first concussion (Chrisman et al., 2014). Research also supports the efficacy of mental health treatment in reducing symptoms associated with concussions and post-concussion using a specific psychotherapy called CBT to manage symptoms (Cantor et al., 2014; Conder & Conder, 2015). Collaborative care treatment integrates collaborative cares and have been shown to reduce concussion symptoms (McCarty et al., 2016). Adolescents receiving collaborative care noted higher quality of life during and after treatment when compared to those not receiving collaborative care, suggesting post-concussive symptoms may resolve more COMBINED CARE IN CONCUSSION TREATMENT 110 quickly when they receive physical health care as well as mental health treatment simultaneously (McCarty et al., 2016). The purpose of this research was to investigate the effects of a collaborative care intervention consisting of mental health treatment and physical health treatment on postconcussive symptoms in adolescents and young adult athletes aged 16 to 25 as measured on ImPACT® and time to clearance to return to normal activity. The goal for this research was to test the hypothesis that adolescent and young adult student athletes experiencing concussion symptoms, as identified on ImPACT® and who have participated in a collaborative care intervention, will experience improvement or resolution of symptoms more quickly than those receiving a physical health intervention as measured by time to clearance to return to normal activity. COMBINED CARE IN CONCUSSION TREATMENT Appendix C Additional Methods 111 COMBINED CARE IN CONCUSSION TREATMENT Appendix C1 ImPACT® 112 113 COMBINED CARE IN CONCUSSION TREATMENT ImPACT®Clinical Report JANE DOE JANE DOE Passport ID: X2M2-LQVS-076K Organizat ion: Episcopal Acade m y Age: Dat e of Birt h: 08/01/1999 Height : 19 Gender: Fe m ale Weight : Nat ive count ry/region: Skippe d Second language: Skippe d Nat ive language: Skippe d Years of educat ion complet ed excluding kindergart en: Skippe d Repeat ed one or more years of school: Skippe d Received speech t herapy: Skippe d Diagnosed learning disabilit y: No At t ended special educat ion classes: Skippe d Problems wit h ADD/hyperact ivit y: No Current sport : Skippe d Current level of part icipat ion: Skippe d Primary posit ion/event /class: Skippe d Years of experience at t his level: Skippe d Handedness: Number of t imes diagnosed wit h a concussion (excluding current injury): Skippe d Concussions t hat result ed in loss of consciousness: Skippe d Concussions t hat result ed in conf usion: Skippe d Concussions t hat result ed in dif f icult y remembering event s t hat occurred immediat ely af t er injury: Skippe d Concussions t hat result ed in dif f icult y remembering event s t hat occurred: Skippe d T ot al games missed as a result of all concussions combined: Skippe d Concussion hist ory: T reat ment f or headaches by physician: Skippe d Hist ory of meningit is: Skippe d T reat ment f or migraine headaches by physician: Skippe d T reat ment f or subst ance/alcohol abuse: Skippe d T reat ment f or epilepsy/seizures: Skippe d T reat ment f or psychiat ric condit ion (depression, anxiet y): Skippe d Hist ory of brain surgery: Skippe d Diagnosed wit h ADD/ADHD: Diagnosed wit h Aut ism: Skippe d Diagnosed wit h Dyslexia: Skippe d St renuous exercise in t he last 3 hours: Skippe d Page 1 10/07/2018 114 COMBINED CARE IN CONCUSSION TREATMENT ® ImPACT Clinical Report Exam T ype Base line Dat e T est ed 09/26/2018 JANE DOE Last Concussion Exam Language English T est Version 3.4.0 Composit e S cores Me m ory com posite (ve rbal) 81 Me m ory com posite (visual) 43 Visual m otor spe e d com posite 41.20 Re action tim e com posite 0.63 Im pulse control com posite 2 T ot al S ympt om S core 0 Cognit ive Ef f iciency Index * 0.19 The Cognitive Efficiency Index meas ures the interaction between accuracy (percentage correct) and s peed (reaction time) in s econds on the Symbol Match tes t. This s core was not developed to make return to play decis ions but can be helpful in determining the extent to which the athlete tried to work very fas t on s ymbol match (decreas ing accuracy) or attempted to improve their accuracy by taking a more deliberate and s low approach (jeopardizing s peed). Low s cores (0 to .20) may in s ome cas es s ugges t a very poor performance on this s ubtes t. Scores in bold RED type exceed the Reliable Change Index (RCI) when compared to the bas eline s core. However, s cores that do not exceed to RCI index may s till be clinically s ignificant. Percentile s cores if available are lis ted in s mall type. Hours slept last night Skippe d Medicat ion Skippe d ImPACT is not intended to provide a diagnos is or decis ion about the Tes t Taker. ImPACT res ults s hould be interpreted only by qualified healthcare profes s ionals . Page 2 10/07/2018 COMBINED CARE IN CONCUSSION TREATMENT ImPACT®Clinical Report 115 JANE DOE Word Memory Hit s (Immediat e) 11 Correct dist ract ors (immed.) 12 Learning percent correct 96% Hit s (delay) 12 Correct dist ract ors (delay) 12 Delayed memory % correct 100% T ot al percent correct 98% Design Memory Hit s (Immediat e) 10 Correct dist ract ors (immed.) 2 Learning percent correct 50% Hit s (delay) 9 Correct dist ract ors (delay) 4 Delayed memory % correct 54% T ot al percent correct 52% X's and O's T ot al correct (memory) 4 T ot al correct (int erf erence) 116 Average correct RT (int erf erence) 0.54 T ot al incorrect (int erf erence) 1 Average incorrect RT (int erf erence) 0.34 S ymbol Mat ch T ot al correct (visible) 27 Average correct RT (visible) 1.70 T ot al correct (hidden) 4 Average correct RT (hidden) 1.71 Color Mat ch T ot al correct (visible) 9 Average correct RT (visible) 0.78 T ot al commissions 1 Average commissions RT 0.46 T hree Let t ers T ot al sequence correct 5 T ot al let t ers correct 15 % of t ot al let t ers correct 100% Average t ime t o f irst click 1.95 Average count ed 17.8 Average count ed correct ly 17.8 Page 3 10/07/2018 COMBINED CARE IN CONCUSSION TREATMENT ® ImPACT Clinical Report S ympt oms S cores Headache 0 Nausea 0 Vomit ing 0 Balance Problems 0 Dizziness 0 Fat igue 0 T rouble f alling asleep 0 S leeping more t han usual 0 S leeping less t han usual 0 Drowsiness 0 S ensit ivit y t o light 0 S ensit ivit y t o noise 0 Irrit abilit y 0 S adness 0 Nervousness 0 Feeling more emot ional 0 Numbness or t ingling 0 Feeling slowed down 0 Feeling ment ally f oggy 0 Dif f icult y concent rat ing 0 Dif f icult y remembering 0 Visual problems 0 T ot al S ympt om S core 0 Page 4 10/07/2018 116 JANE DOE 117 COMBINED CARE IN CONCUSSION TREATMENT ® ImPACT Clinical Report Memory Composit e (Visual) Memory Composit e (Verbal) 100 100 80 80 60 60 40 40 20 20 0 81 0 React ion T ime Composit e Visual Mot or Composit e 60 1.0 48 0.8 36 0.6 24 0.4 12 0.2 41.20 09/26/18 Page 5 43 09/26/18 09/26/18 0 JANE DOE 0 0.63 09/26/18 10/07/2018 118 COMBINED CARE IN CONCUSSION TREATMENT ® ImPACT Clinical Report JANE DOE Sympt om Score Impulse Cont rol Composit e 25 125 20 100 15 75 10 50 5 25 0 2 09/26/18 Page 6 0 0 09/26/18 10/07/2018 COMBINED CARE IN CONCUSSION TREATMENT Appendix C2 VOMS 119 120 COMBINED CARE IN CONCUSSION TREATMENT Vestibular/Ocular-Motor Screening (VOMS) for Concussion Vestibular/Ocular Motor Test: BASELINE SYMPTOMS: Not Tested Headache 0-­­10 Dizziness 0-­­10 Nausea 0-­­10 Fogginess 0-­­10 Comments N/A Smooth Pursuits Saccades – Horizontal Saccades – Vertical Convergence (Near Point) VOR – Horizontal VOR – Vertical Visual Motion Sensitivity Test Instructions: Interpretation: This test is designed for use with subjects ages 9-40. When used with patients outside this age range, interpretation may vary. Abnormal findings or provocation of symptoms with any test may indicate dysfunction – and should trigger a referral to the appropriate health care professional for more detailed assessment and management. Equipment: Tape measure (cm); Metronome; Target w/ 14 point font print. Baseline Symptoms – Record: Headache, Dizziness, Nausea & Fogginess on 0-10 scale prior to beginning screening  Smooth Pursuits - Test the ability to follow a slowly moving target. The patient and the examiner are seated. The examiner holds a fingertip at a distance of 3 ft. from the patient. The patient is instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction 1.5 ft. to the right and 1.5 ft. to the left of midline. One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed. The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go fully from right to left. The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.5 ft. above and 1.5 ft. below midline for 2 complete repetitions up and down. Again, the target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 seconds to move fully downward. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 1)  Saccades – Test the ability of the eyes to move quickly between targets. The patient and the examiner are seated.  Horizontal Saccades: The examiner holds two single points (fingertips) horizontally at a distance of 3 ft. from the patient, and 1.5 ft. to the right and 1.5 ft. to the left of midline so that the patient must gaze 30 degrees to left and 30 degrees to the right. Instruct the (Near Point in cm): Measure 1: ______ Measure 2:______ Measure 3:______ COMBINED CARE IN CONCUSSION TREATMENT  121 Vertical Saccades: Repeat the test with 2 points held vertically at a distance of 3 ft. from the patient, and 1.5 feet above and 1.5 feet below midline so that the patient must gaze 30 degrees upward and 30 degrees downward. Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move up and down to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 3)  Convergence – Measure the ability to view a near target without double vision. The patient is seated and wearing corrective lenses (if needed). The examiner is seated front of the patient and observes their eye movement during this test. The patient focuses on a small target (approximately 14 point font size) at arm’s length and slowly brings it toward the tip of their nose. The patient is instructed to stop moving the target when they see two distinct images or when the examiner observes an outward deviation of one eye. Blurring of the image is ignored. The distance in cm. between target and the tip of nose is measured and recorded. This is repeated a total of 3 times with measures recorded each time. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. Abnormal: Near Point of convergence ≥ 6 cm from the tip of the nose. (Figure 4)  Vestibular-Ocular Reflex (VOR) Test – Assess the ability to stabilize vision as the head moves. The patient and the examiner are seated. The examiner holds a target of approximately 14 point font size in front of the patient in midline at a distance of 3 ft.  Horizontal VOR Test: The patient is asked to rotate their head horizontally while maintaining focus on the target. The head is moved at an amplitude of 20 degrees to each side and a metronome is used to ensure the speed of rotation is maintained at 180 beats/minute (one beat in each direction). One repetition is complete when the head moves back and forth to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea and Fogginess ratings 10 sec after the test is completed. (Figure 5)  Vertical VOR Test: The test is repeated with the patient moving their head vertically. The head is moved in an amplitude of 20 degrees up and 20 degrees down and a metronome is used to ensure the speed of movement is maintained at 180 beats/minute (one beat in each direction). One repetition is complete when the head moves up and down to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea and Fogginess ratings after the test. (Figure 6)  Visual Motion Sensitivity (VMS) Test – Test visual motion sensitivity and the ability to inhibit vestibular-induced eye movements using vision. The patient stands with feet shoulder width apart, facing a busy area of the clinic. The examiner stands next to and slightly behind the patient, so that the patient is guarded but the movement can be performed freely. The patient holds arm outstretched and focuses on their thumb. Maintaining focus on their thumb, the patient rotates, together as a unit, their head, eyes and trunk at an amplitude of 80 degrees to the right and 80 degrees to the left. A metronome is used to ensure the speed of rotation is maintained at 50 beats/min (one beat in each direction). One repetition is complete when the trunk rotates back and forth to the starting position, and 5 repetitions are performed. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 7) COMBINED CARE IN CONCUSSION TREATMENT Appendix C3 Chart Abstraction Form 122 123 COMBINED CARE IN CONCUSSION TREATMENT ID# ID#__________ __________ Staff:_________ Staff:_________ Date:________ Date:________ Chart Abstraction Form DOI: Date of Visit: MOI: LOC Yes No Hx of Migraine Yes No Anxiety hx Yes No PTA Yes No Hx undiagnosed migraine Yes No Fam hx anxiety Yes No Disorientation Yes No Hx family migraine Yes No Depression hx Yes No Confusion Yes No Motion Sickness Yes No Fam hx depression Yes No Yes No Ocular disorder/dys Yes No Concussion hx # previous: Yes Date: No ADHD/LD Current Grade: _________ Returned to school (Y/N):_______ VOMS Headache Dizziness Nausea Fogginess Baseline Smooth Pursuits HOR Saccades VER Saccades Measure 1: Measure 2: Measure 3: Convergence Horizontal VOR Vertical VOR Visual Motor Sensitivity TOTALS Date of next visit: __________________________________ Referred to vestibular: ______ Date of clearance: ___________ Clinical profile(s): ________________________ Treatment referrals: Comments _____________________ COMBINED CARE IN CONCUSSION TREATMENT Appendix C4 Data Collection Form 124 Baseline 1/10/2018 1 1/1/2018 Total Symptom Score PCSS Total Treatment Type 19 m 43 81 41 0.63 2 0 8 Intervention Reaction Time Comp Vis. Motor Speed Comp Verb. Memory Comp Vis. Memory Comp. Sex Impulse Control Comp N/A Age Date of clearance Date of Concussion Exam # Date of Exam Exam Type COMBINED CARE IN CONCUSSION TREATMENT 125 COMBINED CARE IN CONCUSSION TREATMENT Appendix C5 Sample Consent Forms 126 COMBINED CARE IN CONCUSSION TREATMENT 127 CONSENT TO PARTICIPATE IN A RESEARCH STUDY TITLE: Emotional functioning and post-concussion outcomes among youths PRINCIPAL INVESTIGATOR: Anthony Kontos, Ph.D. Assistant Research Director Telephone: (412) 432-3725 3200 South Water Street Pittsburgh, PA 15203 UPMC Sports Medicine Concussion Program CO-INVESTIGATORS: Nathan Kegel, PhD Clinical Neuropsychologist UPMC Sports Medicine Concussion Program 3858 South Water Street Pittsburgh, PA 15203 Telephone: (412) 904-1298 Natalie Sandel, PsyD Neuropsychology Fellow UPMC Sports Medicine Concussion Program 3858 South Water Street Pittsburgh, PA 15203 Telephone: (412) 904-1298 Alicia Sufrinko, PhD Clinical Neuropsychologist UPMC Sports Medicine Concussion Program 3858 South Water Street Pittsburgh, PA 15203 Telephone: (412) 904-1298 Daniel Charek, PhD Neuropsychology Fellow UPMC Sports Medicine Concussion Program 3858 South Water Street Pittsburgh, PA 15203 Telephone: (412) 904-1298 Brandon Gillie, PhD Neuropsychology Fellow UPMC Sports Medicine Concussion Program 3858 South Water Street Pittsburgh, PA 15203 Telephone: (412) 904-1298 Michael W. Collins, PhD Clinical Neuropsychology UPMC Sports Medicine Concussion Program 3858 South Water Street Pittsburgh, PA 15203 Telephone: (412) 904-1298 Johnathan French, PsyD Neuropsychology Fellow UPMC Sports Medicine Concussion Program 3858 South Water Street Pittsburgh, PA 15203 Telephone: (412) 904-1298 Concussion Program Research Staff: UPMC Sports Medicine Concussion Program 3858 South Water Street, Pittsburgh, PA 15203 Telephone: (412) 904-1298 COMBINED CARE IN CONCUSSION TREATMENT • • • • • 128 Cynthia Holland, MPH, Project Coordinator Valerie Reeves, PhD, Research Coordinator Hannah Bitzer, B.S., Research Assistant Andrew Rosse, B.S., Research Assistant Nick Blaney, B.S., Research Assistant SOURCE: UPMC Rooney Sports Medicine Concussion Program Why is this research being done? This research study will examine the relationships among pre-injury and concurrent emotional functioning and several post-concussion outcomes including neurocognitive performance, symptom report, vestibular-ocular functioning, and recovery time among concussed patients. We will examine gender differences, differences among subjects with and without history of concussion, recovery trajectories for neurocognitive data/symptom report/vestibular dysfunction. 140 people will participate in this study. Who is being asked to take part in this research study? Subjects eligible for participation in this study must be between the ages of 10-18 years of age. You/your child must have been diagnosed with a concussion within the past 30 days as determined by The University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program. What procedures will be performed for research purposes? The following measures will be completed at your/your child’s first visit: • SCARED – Child Version (Screening for Child Anxiety Related Disorders): Questionnaire designed to rate degree of anxiety symptoms experienced with the past three months, prior to injury. • SCARED – Parent Version (Screening for Child Anxiety Related Disorders): Questionnaire designed to quantify a parent’s perception of their child’s anxiety symptoms experienced with the past three months, prior to injury. • Generalized Anxiety Disorder Screen – 7 Item: Questionnaire designed to rate degree of anxiety/worry experienced with the past two weeks. • Mood and Feelings Questionnaire – Short Version: Questionnaire designed to rate degree of depression symptoms experienced with the past three months, prior to injury. The following measures will be completed at your/your child’s follow-up visits: • Generalized Anxiety Disorder Screen – 7 Item: Questionnaire designed to rate degree of anxiety/worry experienced with the past two weeks. • Mood and Feelings Questionnaire – Short Version: Questionnaire designed to rate degree of depression symptoms experienced with the past three months, prior to injury. We will also request your authorization to collect information from your/your child’s clinical medical record. Study staff will only access your medical records until your/your child’s clinical clearance visit This may include ImPACT® (Immediate Post-Concussion Assessment and COMBINED CARE IN CONCUSSION TREATMENT 129 Cognitive Testing), PCSS (Post-Concussion Symptom Scale) scores, VOMS (Vestibular and Ocular Motor Screening), Medical History information and other information regarding injury, treatment and clearance. This information will allow research study staff to gain a better understanding of the link between pre and post injury emotional functioning and injury/recovery outcomes. What are the possible risks, side effects, and discomforts of this research study? Some people feel uncomfortable answering questions of a personal nature or become fatigued or frustrated. Study subjects can refuse to answer any questions or questionnaires that make them uncomfortable or take breaks at any time. While all information about subjects and their participation in this research study will be handled in a confidential (private) manner, a breach of confidentiality is a potential risk. To minimize this risk, you/your child will be identified using a coded ID number on all documentation for the study. The master list of coded numbers will be kept in locked file cabinets accessible only to the researchers. All study data and information will be kept on a secure password protected database, in a locked office. What are possible benefits from taking part in this study? There are no direct benefits for being in this study. However, the study will enhance our understanding of concussion and may provide a better measure of concussion outcomes. Will my/my child’s insurance provider or I be charged for the costs of any procedures performed as part of this research study? No, study subjects will not be billed for study measures. However, all study measures will be completed at clinical visits which will be billed to you/your child’s health insurance company and you will be responsible for paying any deductibles, co-payments or co-insurance that are a normal part of the health insurance plan. If the child does not have health insurance, you will be responsible for all clinic costs. Will study subjects be paid to take part in this research study? Study subjects will not be compensated for participation in this study. How long will this study take? This study should take 10-15 minutes of your time. Who will know about my/my child’s participation in this research study? Any information about you/your child obtained from this research will be kept as confidential (private) as possible. All records related to your/your child’s involvement in this research study will be stored in a locked file cabinet. Your/your child’s identity on these records will be indicated by a coded ID number rather than by name, and the information linking these ID numbers with participant identity will be kept separate from the research records in a locked file cabinet. All electronic study records will be kept on secure, password protected computers, behind the UPMC COMBINED CARE IN CONCUSSION TREATMENT 130 firewalls, in locked offices. You/Your child will not be identified by name in any publication of the research results. Any study data or information shared with other investigators will be de-identified and no linking information will be provided. Will this research study involve the use or disclosure of identifiable medical information? If you/your child completed ImPACT®, PCSS, and VOMS during standard clinical care, it is possible that the data could be retrieved from the medical file. The research staff may also obtain information regarding medical history or information about this injury. Information may be obtained from your medical records and used by this research team until completion of the study. Will information from this research study be placed in the medical record? No, information from study participation will not be included into your/your child’s clinical medical record. Who will have access to identifiable medical record information related to participation in this research study? Authorized representatives of the University of Pittsburgh Research Conduct and Compliance Office may review your/your child’s identifiable research information for the purpose of monitoring the appropriate conduct of this research study. In unusual cases, the investigators may be required to release identifiable information related to your/your child’s participation in this research study in response to an order from a court of law. If the investigators learn that you/your child or someone with whom they are involved is in serious danger or potential harm, they will need to inform, as required by Pennsylvania law, the appropriate agencies. Authorized representatives of the UPMC hospitals or other affiliated health care providers may have access to identifiable information related to your/your child’s participation in this research study for the purpose of (1) fulfilling orders, made by the investigators, for hospital and health care services (e.g., laboratory tests, diagnostic procedures) associated with research study participation; (2) addressing correct payment for tests and procedures ordered by the investigators; and/or (3) for internal hospital operations (i.e., quality assurance). We will protect you/your child’s privacy and the confidentiality of your records, as described in this document, but cannot guarantee the confidentiality of your research records, including information obtained from your medical records, once your personal information is disclosed to others outside UPMC For how long will the investigators be permitted to use and disclose identifiable information related to participation in this research study? COMBINED CARE IN CONCUSSION TREATMENT 131 The investigators may continue to use and disclose, for the purposes described above, identifiable information related to your/your child’s participation in this research all research records must be maintained for at least 7 years following final reporting or publication of a project. For projects involving children, records must be maintained for 5 years past age of majority (age 23 per PA State law) after study participation ends. You/your child’s participation in this research study, to include the use and disclosure of identifiable information for the purposes described above, is completely voluntary. (Note, however, that if you do not provide your consent for the use and disclosure of your/your child’s identifiable information for the purposes described above, your child will not be allowed to participate in the research study.) Whether or not you provide your consent for your/your child’s participation in this research study will have no effect on your and your child’s current or future relationship with the University of Pittsburgh. Whether or not you provide your consent for your/your child’s participation in this research study will have no effect on current or future medical care at a UPMC hospital or affiliated health care provider or his/her current or future relationship with a health care insurance provider. Your/Your child’s doctor may be involved as an investigator in this research study. As both your/your child’s doctor and a research investigator, s/he is interested both in your/your child’s medical care and the conduct of this research study. Before agreeing to participate in this research study, or at any time during study participation, you may discuss your/your child’s care with another doctor who is not associated with this research study. You are not under any obligation to participate in any research study offered by your/your child’s doctor Is participation in this research study voluntary? Your/your child’s participation in this research study, to include the use and disclosure of their identifiable information for the purposes described above, is completely voluntary. (Note, however, that if you do not provide your assent for the use and disclosure of your/your child’s identifiable information for the purposes described above, they will not be allowed to participate in the research study.) Whether or not you provide your assent for participation in this research study will have no effect on your you/your child’s current or future medical care at a UPMC hospital or affiliated health care provider or current or future relationship with a health care insurance provider. May I withdraw, at a future date, consent for participation in this research study? You/your child may withdraw, at any time, consent for participation in this research study, to include the use and disclosure of your/your child’s identifiable information for the purposes described above. (Note, however, that if you withdraw your/your child’s consent for the use and disclosure of your/your child’s identifiable medical record information for the purposes described above, you/your child will also be withdrawn, in general, from further participation in this research study.) Any identifiable research or medical information recorded for, or resulting from, your/your child’s participation in this research study prior to the date that you formally withdrew your consent may continue to be used and disclosed by the investigators for the purposes described above. COMBINED CARE IN CONCUSSION TREATMENT 132 To formally withdraw your/your child’s consent for participation in this research study you should provide a written and dated notice of this decision to the principal investigator of this research study at the address listed on the first page of this form Your decision to withdraw your/your child’s consent for participation in this research study will have no effect on current or future relationship with the University of Pittsburgh. Your decision to withdraw your/your child’s consent for participation in this research study will have no effect on your/your child’s current or future medical care at a UPMC hospital or affiliated health care provider or current or future relationship with a health care insurance provider. ***************************************************************************** * VOLUNTARY CONSENT (For subjects 18 years old and older) The above information has been explained to me and all of my current questions have been answered. I understand that I am encouraged to ask questions about any aspect of this research study during the course of this study, and that such future questions will be answered by a qualified individual or by the investigator(s) listed on the first page of this consent document at the telephone number(s) given. I understand that I may always request that my questions, concerns or complaints be addressed by a listed investigator. I understand that I may contact the Human Subjects Protection Advocate of the IRB Office, University of Pittsburgh (1-866-212-2668) to discuss problems, concerns, and questions; obtain information; offer input; or discuss situations in the event that the research team is unavailable. A copy of this consent form will be given to me. By signing this form, I give my consent for participation in this research study and I authorize the use of my medical records as indicated in this consent form. ______________________________ Participant’s Name (Print) _____________________________ Participant’s Signature ___________________________ Date CERTIFICATION of INFORMED CONSENT I certify that I have explained the nature and purpose of this research study to the above-named individual(s), and I have discussed the potential benefits and possible risks of study participation. I further certify that no research component of this protocol was begun until after this consent form was signed. Any questions the individual(s) have about this study have been answered, and we will always be available to address future questions as they arise. COMBINED CARE IN CONCUSSION TREATMENT ___________________________________ Printed Name of Person Obtaining Consent ________________________ Role in Research Study _________________________________ Signature of Person Obtaining Consent _______________________ Date 133 ****************************************************************************** ******* PARENTAL PERMISSION (For subjects under 18 years old) The above information has been explained to me and all of my current questions have been answered. I understand that I am encouraged to ask questions about any aspect of this research study during the course of this study, and that such future questions will be answered by a qualified individual or by the investigator(s) listed on the first page of this consent document at the telephone number(s) given. I understand that I may always request that my questions, concerns or complaints be addressed by a listed investigator. I understand that I may contact the Human Subjects Protection Advocate of the IRB Office, University of Pittsburgh (1-866-212-2668) to discuss problems, concerns, and questions; obtain information; offer input; or discuss situations in the event that the research team is unavailable. A copy of this consent form will be given to me. ____________________________ Participant’s Name I understand that, as a minor (age less than 18 years), the above-named child is not permitted to participate in this research study without my consent. Therefore, by signing this form, I give my consent for his/her participation in this research study and I authorize the use of his/her medical records as indicated in this consent form. ______________________________ Parent’s Name (Print) ____________________________ Relationship to Participant (Child) _____________________________ Parent’s Signature ___________________________ Date 134 COMBINED CARE IN CONCUSSION TREATMENT CHILD ASSENT By signing this form, I agree to participate in this research study. ____________________________ ____________________________ ___________ Child’s Signature Printed Name of Child Date VERIFICATION of EXPLANATION I certify that I have carefully explained the purpose and nature of this research study to the above-named participant in appropriate language. He/she has had an opportunity to discuss it with me in detail. I have answered all his/her questions and he/she has provided affirmative agreement (i.e., assent) to participate in this study. ___________________________________ Printed Name of Person Obtaining Assent ________________________ Role in Research Study _________________________________ Signature of Person Obtaining Assent _______________________ Date CONSENT FOR CONTINUED RESEARCH PARTICIPATION I understand that I am currently participating in a research study. I further understand that consent for my participation in this research study was initially obtained from my parent or legal guardian because I was a minor (under 18 years of age). I have now reached age 18, and I am able to provide my own direct consent for participation and I authorize the use of my medical records as indicated in this consent form.". All of the above has been explained to me and all of my current questions have been answered. I understand that I am encouraged to ask questions about any aspect of this research study during the continuation of this study, and that such future questions will be answered by the researchers listed on the first page of this form. I also understand that any questions I have about my rights as a research participant will be answered by the Human Subject Protection Advocate of the IRB Office, University of Pittsburgh (1-866-212-2668). By signing below, I agree to continue my participation in this research study and I authorize the use of my medical records as indicated in this consent form. A copy of this consent form will be given to me. COMBINED CARE IN CONCUSSION TREATMENT ______________________________ Participant’s Signature 135 ____________ Date CERTIFICATION of INFORMED CONSENT I certify that I have explained the nature and purpose of this research study to the above-named individual(s), and I have discussed the potential benefits and possible risks of study participation. Any questions the individual(s) have about this study have been answered, and we will always be available to address future questions as they arise.” ___________________________________ Printed Name of Person Obtaining Consent ________________________ Role in Research Study _________________________________ Signature of Person Obtaining Consent ____________ Date COMBINED CARE IN CONCUSSION TREATMENT Appendix C6 IRB Approval of Submission 136 COMBINED CARE IN CONCUSSION TREATMENT 137 Institutional Review Board California University of Pennsylvania Morgan Hall, 310 250 University Avenue California, PA 15419 instreviewboard@calu.edu Melissa Sovak, Ph.D. Dear Patrick, Please consider this email as official notification that your proposal titled “The Effect of Collaborative Care in Concussion Treatment with Adolescents and Young Adults as Measured on the ImPACT®” (Proposal #18-069) has been approved by the California University of Pennsylvania Institutional Review Board as amended. The effective date of approval is 6/18/19 and the expiration date is 6/17/20. These dates must appear on the consent form. Please note that Federal Policy requires that you notify the IRB promptly regarding any of the following: COMBINED CARE IN CONCUSSION TREATMENT 138 (1) Any additions or changes in procedures you might wish for your study (additions or changes must be approved by the IRB before they are implemented) (2) Any events that affect the safety or well-being of subjects (3) Any modifications of your study or other responses that are necessitated by any events reported in (2). (4) To continue your research beyond the approval expiration date of 6/17/20 you must file additional information to be considered for continuing review. Please contact instreviewboard@calu.edu Please notify the Board when data collection is complete. Regards, Melissa Sovak, PhD. Chair, Institutional Review Board 139 COMBINED CARE IN CONCUSSION TREATMENT University of Pittsburgh Institutional Review Board Avenue Human Research Protection Office 3500 Fifth Suite 106 Pittsburgh, PA 15213 Tel (412) 383-1480 www.hrpo@pitt.edu APPROVAL OF SUBMISSION (Exempt) IRB: PI: Title: STUDY19030400 Anthony Kontos The Effect of Collaborative Care in Concussion Treatment with Adolescents And Young Adults as Measured on the IMPACT® Funding: Date: None May 22, 2019 On 5/22/2019, the Institutional Review Board reviewed and approved the above referenced application through the administrative review process. The study may begin as outlined in the University of Pittsburgh approved application and documents. Approval Documentation Review type: Approval Date: Initial Study 5/22/2019 Exempt Category: Determinations: (4) Secondary research on data or specimens (no consent required) • Waiver of HIPAA authorization Approved Documents: • Chart Abstraction Form As the Principal Investigator, you are responsible for the conduct of the research and to ensure accurate documentation, protocol compliance, reporting of possibly study-related adverse events and unanticipated problems involving risk to subjects or others. The HRPO Reportable Events policy, Chapter 17, is available at http://www.hrpo.pitt.edu/. Research being conducted in an UPMC facility cannot begin until fiscal approval is received from the UPMC Office of Sponsored Programs and Research Support (OSPARS). Contact OSPARS@upmc.edu with questions. If you have any questions, please contact the University of Pittsburgh IRB Coordinator, Amy Fuhrman. COMBINED CARE IN CONCUSSION TREATMENT Appendix C7 Certificates of IRB Training 140 COMBINED CARE IN CONCUSSION TREATMENT 141 COMBINED CARE IN CONCUSSION TREATMENT 142 COMBINED CARE IN CONCUSSION TREATMENT 143 COMBINED CARE IN CONCUSSION TREATMENT 144 COMBINED CARE IN CONCUSSION TREATMENT 145 COMBINED CARE IN CONCUSSION TREATMENT 146 References Allen, B.J., & Gfeller, J.D. (2010). The immediate post-concussion assessment and cognitive testing battery and traditional neuropsychological measures: A construct and concurrent validity study. Brain Injury, 25(2), 179-191. https://doi.org/10.3109/02699052.2010.541897 Alsalaheen, B., Stockdale, K., Pcchumer, D., &Broglio, S.P. (2016). Validity of the immediate post concussion assessment and cognitive testing (ImPACT®). Sports Med, 46, 1487-1501. https://doi.org/10.1007/s40279-016-0532-y Alsalaheen, B.A., Mucha, A., Morris, L.O., Whitney, S.L., Furman, J.M., CamioloReddy, C.E…Sparto, P.J. (2010). 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