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The concussion literature has increasingly shown that preinjury factors influence the course of concussion recovery. In a recent Annals of the Child Neurology Society article, neuropsychology fellow Laura Winstone-Weide, PhD, with colleagues Kelly Gettig, DNP, APRN, and Cynthia Austin, PhD, ABPP, used structural equation modeling (SEM) to examine the contribution of preinjury factors, baseline symptoms, and first-visit symptoms to the time required to return to baseline following injury.

SEM is an advanced statistical technique that allows simultaneous consideration of multiple variables as well as mediation analysis to test direct and indirect effects. The study analyzed prospectively collected data from 642 adolescents who were assessed in the Dell Children’s concussion clinic. Preinjury variables included a history of headache, anxiety, depression, attention-deficit/hyperactivity disorder, learning disability, previous concussions, and female gender. A particular strength of the study was the diversity in patient ethnicity (54% Hispanic), insurance status (41% Medicaid), and mechanism of injury (54% sports-related concussion), facilitating broader generalization across adolescent concussion populations.

Preinjury headaches, depression, and anxiety had the strongest direct effects on baseline symptoms. Adolescents with preinjury depression and/or anxiety took an average of four to six additional days to clearance for high-risk activities. Notably, a history of prior concussions or learning disability did not influence symptom reporting or recovery when considered simultaneously with other risk factors. The study emphasizes the unique, additive effects of preinjury factors on symptom reporting and concussion recovery. The authors concluded that preinjury risk factors should be viewed as a constellation, with particular attention to mental health factors in concussion management.

The Traumatic Brain Injury and Concussion Program at Dell Children’s Medical Center was established in 2018 and has evaluated over 2,000 patients. Its complex concussion clinic focuses on children and adolescents with risk factors for prolonged recovery time. In addition to collecting data to support evidence-based guidance on concussion management and recovery expectations, clinic staff members provide annual concussion management education to hundreds of school nurses, athletic trainers, and coaches. Their work recently led to modification of the Texas High School Coaches Association’s required return-to-play education to include active rehabilitation.

Winstone-Weide LK, Gettig K, Austin CA. Postconcussive symptom severity, risk factors for prolonged recovery, and mental health history: pathways of influence in a diverse pediatric sample. Ann Child Neurol Soc. 2024;2:281-289, doi.org/10.1002/cns3.20094.