Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Review: Lifetime Psychiatric Outcomes after

Pediatric Sports-Related Concussion

Kelsey A. Singh

Bon Secours Memorial College of Nursing

Christine Turner, PhD

NUR 4122: Nursing Research

April 8, 2018

“I have neither given nor received aid, other than acknowledged, on this assignment or test, nor

have I seen anyone else do so.”

INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: This integrative review looked at the relationship between sports related concussions

(SRC) sustained by pediatric patients and psychiatric outcomes over the patients’ lifetimes.

Background: Concussions are classified as a type of mild traumatic brain injury (TBI) that can

cause changes in neurologic functions and which fall into four categories: physical, cognitive,

emotional, and sleep. Psychiatric outcomes for pediatric patients in the emotional category are

the least understood by health care professionals. Improperly diagnosed and managed

concussions in pediatric patients can lead to lifetime mental health complications and even

suicide.

Method: This is an integrative literature review of research studies that were selected from

defined academic databases. The selected articles consist of quantitative studies or integrative

reviews. The findings of these studies affirmatively addressed the PICOT question.

Results: The evidence supports the theory that certain pediatric patients are at risk for lifetime

psychiatric outcomes if their SRCs are not properly diagnosed and managed. Clinical

assessments should include specific screening for mental health symptoms. Health care

professionals need extensive education in physical, cognitive, and especially mental health

concussion protocols.

Limitations: The integrative review is limited by the researcher’s experience and training level,

the assignment length and research restrictions, and the limitations identified in the selected

research.

Implications for Practice: Proper education of health care professionals including nurses, other

adults, and pediatric patients can improve mental health outcomes following SRCs.
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Recommendations for Future Research: Future research should include the role of nursing in

the diagnosis and education protocols developed for SRCs in pediatric patients.
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Integrative Review: Lifetime Psychiatric Outcomes after Pediatric Sports-Related Concussion

The purpose of this integrative review is to identify the relationship between sports related

concussions (SRC) sustained by pediatric patients and psychiatric outcomes over the patients’

lifetimes. The Centers for Disease Control and Prevention (CDC) has stated that SRCs are reaching

epidemic numbers (Kontos et al., 2013; Topolovec-Vranic et al., 2015). Recognition of this surge in

SRCs is particularly important to pediatric athletes because “younger athletes demonstrate worse

outcomes following concussion and are at a high risk of catastrophic injury if they continue to play

with a symptomatic concussion” (Kontos et al. 2015, p 717).

Concussions are classified as a type of mild traumatic brain injury (TBI) that occurs from an

external force to the head or body, causing a change in neurologic functions (Condor & Condor,

2015). These changes cause symptoms that can fall into four categories: physical, cognitive,

emotional, and sleep (Condor & Condor, 2015; Topolovec-Vranic et al., 2015). In recent years,

research has increased in concussion awareness and management, particularly for adult athletes,

and in addition, SRC impact on physical and cognitive functioning has been documented for

pediatric athletes. Until recently, however, research has not focused on the psychiatric and

emotional outcomes from a SRC on pediatric patients (Ellis et al., 2015). The goal of this

integrative literature review is to survey and discuss current data related to the researcher’s PICOT

question: Do sports related concussions influence psychiatric outcomes in pediatric patients over

their lifetime?

Design and Methods

Five research articles were used in this integrative review. The method utilized by the

researcher began with an initial search using Google Scholar and PubMed. The search words

were pediatric concussion, psychiatric, mental illness, sport-related concussion, and chronic
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traumatic encephalopathy (CTE). The results yielded over 50,000 articles. The articles were

filtered by publication year, peer-review, location and relevance to the PICOT question. Articles

were limited to publication years 2013-2018. Articles were also limited to only studies done in

the United States and Canada, published, and peer-reviewed. Full-text availability was another

limiting factor. Many articles were eliminated due to these requirements.

Articles were then chosen based on their relevance to the PICOT question. A discussion

on sport-related concussions was a requirement for each article. The articles used were

quantitative articles with the intention to analyze quantified findings. Qualified authors were

prioritized; examples of appropriate qualifications included Medical Doctor (MD), Doctor of

Philosophy (PhD), Bachelor of Science (BS) and Master of Science (MSc). The total number of

articles chosen after these limitations were applied is five, resulting in four quantitative studies

(Brown et al., 2014; Ellis et al., 2015; Kontos et al., 2013; Topolovec-Vranic et al., 2015) and

one integrative review (McCrory, Meeuwisse, Kutcher, Jordan, & Gardner, 2013). Also, one

literature review was chosen for background (Condor & Condor, 2015).

Findings

Five research articles were included in this integrative review; the articles are summarized

in the Qualitative and Quantitative Article Evaluation Table located in the Appendix. In addition,

one literature review was used for background. The articles were in accord that improperly

diagnosed and managed SRCs can lead to lifetime physical, cognitive, and emotional/mental health

deficits (Brown et al., 2014; Condor, 2015; Ellis et al., 2015; Kontos et al., 2013; McCrory et al.,

2013; Topolovec-Vranic et al., 2015). Two articles that looked at SRCs in pediatric patients

identified risk factors for severity of symptoms and best practices (Condor & Condor, 2015; Ellis et

al., 2015). Other articles looking at the emotional/psychiatric outcomes determined significant
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additional research is required to ensure appropriate interventions occur to diagnose and manage

SRCs in pediatric patients (Brown et al., 2014; McCrory et al., 2013; Topolovec-Vranic et al.,

2015). Finally, there was consensus in the research that pediatric athletes, parents, coaches, trainers,

school personnel, and medical personnel require significant training on diagnosing and managing

the physical, cognitive, and, in particular, psychiatric outcomes of SRCs. These themes are

discussed in detail below.

SRC Risk Factors and Best Practices in Pediatric Patients

Condor and Condor (2015) conducted a literature review of SRCs in pediatric patients from

the authors’ unique perspective as neuropsychologists, focusing specifically on signs and symptoms

of SRCs, and risk factors for prolonged recovery. The authors divided SRC signs into four

categories: physical, cognitive, emotional, and sleep. Under each category, they listed specific

symptoms. Some examples include: 1. physical—headache, balance impairment, 2. Cognitive—

mental fogginess, difficulty in concentration and memory; 3. Emotional—irritability, sadness,

rapidly changing emotions; and 4. Sleep—sleeping more or less than usual (Condor & Condor,

2015). The authors also identified “factors associated with increased concussion risk” (Condor &

Condor, 2015, p. 90), including athlete’s age, sport, and sex. The authors noted that current data

suggests an “inverse relationship between age/level of sport played and symptom resolution time”

so that the youngest athletes playing recreational sports need the most conservative concussion

management (Condor & Condor, 2015, p. 91). Finally, the authors reviewed the literature for best

practices to minimize the risks of SRCs. They concluded that best practices should include:

education of all people involved in pediatric sports, including the athlete; safe play rules; strength

and conditioning; and proper return to play (RTP) and return to learn (RTL) protocols (Condor &

Condor, 2015).
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In a study conducted by Ellis et al., (2015), the authors looked at psychiatric outcomes after

pediatric SRCs. The authors conducted a retrospective chart review of all patients less than 19

years of age referred within a defined time to a multidisciplinary pediatric concussion clinic,

resulting in a sample size of 174. A single neurosurgeon performed clinical assessments and Post-

Concussion Symptom Scale (PCSS) scoring. Baseline characteristics were analyzed using

proportions for multifaceted characteristics with chi-square comparisons and “means with standard

deviations for continuous characteristics” (Ellis et al. 2015, p.711) with t-test comparisons. The

study results indicated that almost half of the patients with SRC or post-concussion syndrome

(PCS) initially reported emotional symptoms.

Additional Research Recommendations for Post-Concussion Mental Health

Brown et al., (2014) used a prospective cohort study that gathered at each visit self-reported

data on cognitive activity level from concussion clinic patients with a median age of 15. The data

was collected using the PCSS. The authors used the Kaplan-Meier Product Limit method to chart

the impact of cognitive activity level on symptom duration and a Cox proportional hazard model to

adjust for other variables in concussion recovery. The sample size was 355 patients. This research

added to the body of data by documenting that the highest levels of post-concussion cognitive

activity leads to the slowest resolution of concussion symptoms, but the lowest levels of activity did

not predict the fastest resolutions. Cognitive activities to limit after a concussion include reading,

texting, gaming, and school-work. Brown et al., recommend training for the patient, parents, school

and athletic personnel regarding the importance of limiting activity.

The Topolovec-Vranic (2015) conducted a nation-wide, survey of Canadian pediatric

athletes, parents, coaches, and medical professionals to determine awareness levels of post-

concussion mental illness. The participants were contacted through sports marketing databases and
INTEGRATIVE LITERATURE REVIEW 8

opted-in to the study. The study sample size was 6,937. Most of the respondents were male

coaches or trainers with post-secondary education or household incomes above $80,000. The study

developed a questionnaire with medical and sports professionals. The questionnaire had 10

true/false and multiple-choice questions that surveyed “knowledge of concussion symptoms,

experience with concussion, attitude towards concussion and demographic information”

(Topolovec-Vranic et al., 2015, p. 3). To determine awareness, respondents were asked whether 17

symptoms categorized as physical (11 symptoms), cognitive (3 symptoms), and mental health (3

symptoms) were signs of a concussion (Topolovec-Vranic et al., 2015). The authors used SAS 9.3

to analyze the data. The authors calculated the percentage of respondents who indicated yes to each

symptom and the proportion of all symptoms identified for each category. To assess differences in

symptom identification among the three categories and across demographic variables, the authors

used ANOVA and Kruskal-Wallis H or Wilcoxon rank sum tests (Topolovec-Vranic et al., 2015).

The study found that most adults in the sports community had good awareness of physical and

cognitive symptoms, but they were not as familiar with mental health symptoms. Ellis et al., (2015)

found that clinical decision making on mental health outcomes would benefit from additional

research to determine if post-concussion psychiatric outcomes in pediatric athletes result from

unresolved TBI; such research would provide evidence to modify the risk of future injury or

prolonged symptoms.

Conversely, McCrory et al., (2013) conducted an integrative literature review that there is

an association between participation in sports and “long-term cognitive, neurobehavioral,

psychiatric problems” in retired professional athletes. The reviewed articles were retrieved from

databases, reference lists, and cited reference searches, using key words and terms. McCrory

postulates that, “The clinical characterization of the presentations of athletes with chronic post-
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concussive symptoms is poorly defined and may reflect intrinsic differences (eg. genetic) between

individuals rather than the oversimplified understanding that these syndromes are due to

concussive…trauma alone” (McCrory et al., 2013, p. 1). The authors stated that risk factors for

post-concussion complication are unclear, but acknowledge they may include repeated concussions.

The authors concluded that current research was insufficient to state a causal relationship between a

history of concussions in retired athletes and the symptoms of chronic traumatic encephalopathy

(CTE), including dementia, depression and gait problems. The authors noted that the general

population experiences these symptoms, also, and that the current research does not adequately

account for age-related changes, mental illness, alcohol and drug use as contributors to CTE-like

symptoms (McCrory et al., 2013). Thus, the authors recommend additional research is required

before it is established that participation in contact sports leads to CTE. The McCrory review is the

oldest article reviewed in this integrative review, and the McCrory conclusions do not account for

more recent research.

Concussion Training is Required for Pediatric Athletes and Supporting Adults

Kontos et al., (2013) conducted a prospective cohort study during the 2011 four-month

football season to determine the risk of concussion for football players between 8 and 12 years of

age who did not have exclusion criteria such as current or recent concussion or an existing

neurologic or psychiatric disorder. The sample consisted of 468 male football players who lived in

western Pennsylvania. Consents for participation in the study were obtained from the parents,

coaches, and leagues. Assent was obtained from the athlete. The authors conducted pre-season

concussion training with the coaches and then contacted the coaches two or three times a week

regarding any suspected concussions during games. The authors also calculated individual player

exposure to a potential concussion during practice and games. SPSS version 20 was used for all
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calculations. Out of 11,338 exposures during practice and games, 20 different players sustained

concussions, two in practice and 18 in games, even though there were twice as many exposures in

practice (Kontos et al., 2013). The authors found that the older players between 11 and 12 years of

age were almost three times more likely to sustain concussions than players between 8 and 10 years

of age. The authors also concluded that concussions occurred much more frequently in games than

in practice. This finding is particularly significant because several nationwide recreational football

organizations have reduced contact exposures in practice to limit concussions. However, the

Kontos study recommended not reducing practice time because that is when proper techniques are

taught, which may limit the concussions that occur in games. The authors’ recommended best

practice was education of concussion awareness for players, parents, coaches, and school personnel

(Kontos et al., 2013).

This is a consensus position taken by each of the other studies that looked at pediatric

athletes. Condor and Condor (2015) identified evidence-based best practices that included

education of pediatric athletes and supporting adults on rest protocols for RTP and RRL activities,

including on appropriate educational plans and accommodations. The Brown et al., (2014) study

supports the Condor recommendation, with a special emphasis on training involved adults on

cognitive rest, educational accommodations, and RTL protocols. Similarly, the Ellis et al., (2015)

study recommended concussion education and training, with a particular focus on training health

care professionals on the need to include screening for mental health issues and suicide ideation.

The authors of the Topolovec-Vranic et al., (2015) study concluded that concussion awareness is

critical for pediatric athletes and their supporting adults in all areas, but particularly regarding

mental health.

Discussion/Implications
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Three themes emerged from the articles selected for review, each of which relates to the

researcher’s PICOT question. The following discussion is organized by the three themes: risk

factors and best practices, additional research recommendations, and concussion training. The

discussion examines the implication of the articles on the PICOT question.

SRC Risk Factors and Best Practices in Pediatric Patients

Multiple articles looked at risk factors that impact concussion severity (Condor & Condor,

2015; Ellis et al., 2015). Condor and Ellis characterized SRC outcomes as physical, cognitive,

sleep, and emotional. Both studies concluded that a large proportion of pediatric SRC patients

report emotional symptoms, the symptoms often fluctuate and resolve, and some patients

experience persistent emotional symptoms. The Condor and Ellis study also identified risk factors

for persistent emotional or psychiatric outcomes, including preinjury symptoms, family history,

severity of concussion, low socioeconomic status, and gender (Ellis et al., 2015). Each of the

articles emphasized the importance of conservative concussion management for all athletes, but

particularly for pediatric athletes. In addition, Ellis et al., (2015) stressed the need for health care

professionals to expand clinical screenings of pediatric patients to include mental health

assessments for depression and suicidal ideation (Ellis et al., 2015). These articles relate to the

PICOT question by discussing the current state of evidence that indicates improperly diagnosed and

managed concussions are predictors for prolonged recoveries or lifetime symptoms. Ellis et al.,

focused especially on the potential lifetime mental health and psychiatric impairments that can

result if best practices are not followed.

Condor and Condor (2015) provided interventions to minimize the incidence and severity of

SRC, each of which involve education of all persons involved in sports. These authors’ suggestions

include statutory requirements for education, use of safe play guidelines, and RTP and RTL
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guidelines. The Ellis et al., (2015) study concluded with recommendations for interventions with

pediatric patients with SRC and PCS, such as in-depth clinical histories that explore symptoms of

depression and suicide ideation, mental health training for health care professionals who treat these

patients, and additional research, especially to develop evidence-based guidelines for RTP and

RTL. This researcher notes that neither of these studies specifically examined the role of nurses in

the care of these athletes. As a result, this researcher suggests additional research should be

conducted on effective training for nurses so clarify their role in clinical assessments and in

education of the public.

Additional Research Recommendations for Post-Concussion Mental Health

Several studies made research recommendations to produce additional evidence-based

knowledge to improve mental health outcomes in pediatric patients with SRCs. Brown et al.,

(2014) recommended additional research to determine optimal levels of post-concussion cognitive

rest to reduce the negative outcomes from SRCs. Topolovec-Vranic et al., (2015) recommended

additional research to evaluate why concussion awareness may fluctuate among geographical

regions, whether media is an appropriate vehicle to impart information to improve concussion

symptom awareness, and whether greater awareness translates into better concussion prevention

and management strategies. Ellis et al., (2015) found that clinical decision making on mental health

outcomes would benefit from additional research to determine if post-concussion psychiatric

outcomes in pediatric athletes result from unresolved TBI; such research would provide evidence to

modify the risk of future injury or prolonged symptoms.

Each of these recommendations starts with an acknowledgement that improperly diagnosed

and managed SRCs in pediatric patients can influence psychiatric outcomes over the patients’

lifetimes, which directly addresses the researcher’s PICOT question. Again, there is a research gap
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in the role of nursing in SRC diagnosis and management, particularly in mental health. While

evidence requires better training of the broad group labeled health professionals to increase the

effectiveness of clinical assessments and treatment of mental health issues, nurses are not

specifically mentioned in the literature, and future research should focus on this area.

Concussion Training is Required for Pediatric Athletes and Supporting Adults

Although one study found that coaches and other supporting adults are familiar with the

physical and cognitive symptoms of SRCs (Topolovec-Vranic et al., 2015), all the articles that

looked at SRCs in pediatric patients concluded that the first best practice to limit the mental health

outcomes of SRCs is to educate the athlete, parents, coaches, trainers, and school personnel (Brown

et al., 2014; Condor & Condor, 2015; Ellis et al., 2015; Kontos et al., 2013; McCrory et al., 2013;

Topolovec-Vranic et al., 2015). The education should focus on risk factors for concussion (Condor

& Condor, 2015; Ellis et al., 2015), the importance of cognitive rest (Brown et al., 2014), RTP and

RTL protocols (Condor & Condor, 2015; Kontos et al., 2013), and improved protocols for mental

health screening for use by health care professionals. Again, the nursing role is not clearly defined

in the existing research, but in the perspective of this researcher, nurses are uniquely positioned to

educate wide swaths of the public, from the office patient to the athletic staff and educators in

schools to public service announcements over the media. Additional research is needed in this area.

Limitations

This integrative literature review has several limitations, starting with the difficulty of the

topic reviewed and the researcher’s inexperience with the integrative review format, the statistical

tools used to analyze date in the majority of the reviewed studies, and many of the medical terms

used. In addition, the integrative review is not exhaustive because it includes a limited number of
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articles that are no older than five years, rather than an historical review. Also, relevant full-text

articles were often unavailable to the researcher.

In addition, the articles reviewed had limitations that impacted the quality of the research.

The limitations ranged from reliance on self-reported data, evaluation at group rather than

individual levels, samples pulled from patients already diagnosed with concussions rather than the

general population, young age of study subjects, and use of data collection tools that pulled

subjective information that could be influenced by the researcher and the subject. As with all

research, the limitations should inform the reader as to the quality and usefulness of the research

results.

Conclusions

This integrative literature review compiled evidence that affirmatively answers the PICOT

question: Do sports-related concussions influence psychiatric outcomes in pediatric patients over

their lifetime? McCrory et al. (2015, p.4) was skeptical of the role of SRCs in psychiatric outcomes

in retired professional athletes acknowledged that “scientific research might establish that

participation in contact sports leads to [CTE]” that causes physical, cognitive, and mental health

issues over the athletes’ lifetime. All the reviewed studies indicated that additional research is

needed to develop the most effective protocols to assess and manage SRCs, particularly to reduce

impacts on mental health outcomes (Brown et al., 2014; Condor & Condor, 2015; Ellis et al., 2015;

Kontos et al., 2013; McCrory et al., 2013; Topolovec-Vranic et al., 2015). Regardless of the focus

of the reviewed studies, they each recommended education of all stakeholders using current best

practice protocols, noting that in particular, mental health outcomes are the least understood by

athletes, supporting adults, and health care professionals. The role of nursing in implementing

these protocols should be developed in future research.

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References

Brown, N. J., Mannix, R. C., O’Brien, M. J., Gostine, D., Collins, M. W., & Meehan, W. P.

(2014). Effect of cognitive activity level on duration of post-concussion symptoms.

Pediatrics, 133(2), e299-e304. doi:10.1542/peds.2013-2125

Conder, R. L., & Conder, A. A. (2015). Sports-related concussions. North Carolina medical

journal, 76(2), 89-95. doi:10.18043/ncm.76.2.89 (DON’T USE)

Ellis, M. J., Ritchie, L. J., Koltek, M., Hosain, S., Cordingley, D., Chu, S., & Russell, K. (2015).

Psychiatric outcomes after pediatric sports-related concussion. Journal of Neurosurgery:

Pediatrics, 16(6), 709-718. doi: 10.3171/2015.5.PEDS15220.

Kontos, A. P., Elbin, R. J., Fazio-Sumrock, V. C., Burkhart, S., Swindell, H., Maroon, J., &

Collins, M. W. (2013). Incidence of sports-related concussion among youth football

players aged 8-12 years. The Journal of pediatrics, 163(3), 717-720. doi:

10.1016/j.jpeds.2013.04.011

McCrory, P., Meeuwisse, W. H., Kutcher, J. S., Jordan, B. D., & Gardner, A. (2013). What is the

evidence for chronic concussion-related changes in retired athletes: behavioural,

pathological and clinical outcomes?. Br J Sports Med, 47(5), 327-330.

doi:10.1136/bjsports-2013-092248

Topolovec-Vranic, J., Zhang, S., Wong, H., Lam, E., Jing, R., Russell, K., & Violence Research

Team. (2015). Recognizing the symptoms of mental illness following concussions in the

sports community: need for improvement. PLoS one, 10(11), e0141699.

doi:10.1371/journal.pone.0141699
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First Author Topolovec-Vranic, J., Zhang, S., Wong, H., Lam, E., Jing, R., Russell, K., & Violence Research
Team. (2015). Recognizing the symptoms of mental illness following concussions in the sports
(Year)/Qualifications community: a need for improvement. PLoS one, 10(11), e0141699.
doi:10.1371/journal.pone.0141699

Background/Problem  Sports-related concussion is the most common type of TBI in youth and sports account for over
Statement half the concussions sustained by youth each year.
 In North America more than half million youth under the age of 15 who sustain a concussion
require hospital-based care each year – problematic for young people because of the potential
cumulative or longer term deleterious effects of concussion.
Conceptual/theoretical  No theoretical framework
Framework  Researchers evaluated awareness of concussion-related symptoms amongst members of the
sports community
Design/  Cross-sectional national electronic survey
 Youth athletes, parents, coaches and medical professionals across Canada were recruited
Method/Philosophical through mailing lists from sports-related opt-in marketing databases.
 The proportion of identified symptoms (categorized as physical, cognitive, mental health-related
Underpinnings and overall) as well as participant factors associated with symptom recognition were analyzed.

Sample/ Setting/Ethical  Ethics was approved by St. Michael’s Hospital Research Ethics Board
Considerations  Survey was ten true/false and multiple choice items which were designed to assess awareness
and understanding of concussion amongst general Canadian public and within the sports
community

Major Variables Studied (and  Patients understanding of concussion

their definition), if
appropriate

Measurement Tool/Data  Survey comprised ten true/false and multiple choice items which were designed to assess
INTEGRATIVE LITERATURE REVIEW
Collection Method
Data Analysis
Findings/Discussion –
Appraisal/Worth to practice
18
awareness and understanding of concussion
 Conducted online by an independent Canadian agency, Field Day Inc., and was hosted by
surveymonkey.com

 Data Analysis was performed using SAS 9.3. Respondents were instructed to check off yes or
no for each of the 17 listed symptoms of a concussion such as physical, cognitive, mental health
or overall.
 Stress the need for educational initiatives to increase awareness regarding mental-health related
symptoms associated with concussion
 Diagnosis of concussion is almost completely relying on its symptoms; some concussions
resolve quickly and others leave devastating consequences which as disability, chronic traumatic
encephalopathy, or even death
 Study included large national sample and the concurrent assessment of various groups including
athletes, parents, coaches and medical professionals.
 Findings help to shed light on areas in which concussion awareness and knowledge initiative
need to be targeted to enhance the prevention and recovery from sport-related concussion.
INTEGRATIVE LITERATURE REVIEW 19

First Author McCrory, P., Meeuwisse, W. H., Kutcher, J. S., Jordan, B. D., & Gardner, A. (2013). What is the
(Year)/Qualifications evidence for chronic concussion-related changes in retired athletes: behavioural, pathological and
clinical outcomes? Br J Sports Med, 47(5), 327-330. doi:10.1136/bjsports-2013-092248

Background/Problem  Chronic traumatic Encephalopathy (CTE) in retired athletes and to consider the potential
Statement differential diagnoses that require consideration when retired athletes present with cognitive and
psychiatric problems
Conceptual/theoretical  There is no theoretical framework
Framework

Design/ Method/  Integrative Review

Philosophical Underpinnings

Sample/ Setting/Ethical  Study of retired National Football League (NFL) players, revealed that 269 of 2434 respondents
Considerations reported pervious diagnosis of clinical depression

Major Variables Studied (and  n/a

their definition), if
appropriate

Measurement Tool/Data  Articles were found on online database such as Mosby’s Index, MEDLINE, CINAHL and
Collection Method EMBASE
 Used key words such as CTE, repetitive head injury, sports concussion, and sports-related
traumatic brain injury

Data Analysis  n/a

Findings/Discussion –  Speculation that repeated concussion or subconcussive impacts cause CTE remains unproven
 Causation in modern CTE case studies should proceed cautiously
INTEGRATIVE LITERATURE REVIEW 20

Appraisal/Worth to practice  Further prospective or longitudinal studies are needed

INTEGRATIVE LITERATURE REVIEW 21

First Author Kontos, A. P., Elbin, R. J., Fazio-Sumrock, V. C., Burkhart, S., Swindell, H., Maroon, J., & Collins,
(Year)/Qualifications M. W. (2013). Incidence of sports-related concussion among youth football players aged 8-12 years.
The Journal of pediatrics, 163(3), 717-720. doi: 10.1016/j.jpeds.2013.04.011

Background/Problem  Determine the risk of concussion among youth football players (ages 8-12years)
Statement

Conceptual/theoretical  There is no theoretical framework provided

Framework

Design/  Prospective cohort study was conducted between August 2011 and December 2012 on 468 of a
total 571 participants aged 8-12 years old
Method/Philosophical

Underpinnings

Sample/ Setting/Ethical  Included 468 male youth football players in western Pennsylvania during 2011 youth football
Considerations season
 Written informed consent (parent) and assent (child), players participating only in the sport of
football (during the study period), and league and coach agreement to participate
 Exclusion criteria included a history of any of the following: brain surgery, TBI, or neurologic
or psychiatric disorder and/or current concussion or concussion in past 6 months
 University of Pittsburgh institutional review board approved the protocol and consent forms
before data collection
Major Variables Studied (and  Patients and parents understanding of concussions
their definition), if
appropriate

Measurement Tool/Data  Prospective cohort study was conducted between August 2011 and December 2012 on 468 of a
total 571 participants aged 8-12 years old
INTEGRATIVE LITERATURE REVIEW
Collection Method
Data Analysis
Findings/Discussion –
Appraisal/Worth to practice
22
 Gathered information by structured phone and in-person interviews from all participants (and
their parents) and recorded additional information regarding the mechanism of injury (helmet-
to-helmet contact, helmet-to-ground)
 Data Analysis was preformed by Incidence Rates (IRs) and Incidence Density Ratios (IDRs) of
concussion were calculated for games and practices and for age groups
 Participation in games was associated with an increase in risk of concussion compared with
practices, which was higher than rates previously reported for high school and collegiate athletes
 Younger players were less likely to incur a concussion than were older players
 Study was limited by several factors – sample size was small for an epidemiologic study,
surveillance period was composed of only a single competitive season, and sample was
delimited to youth football players in western Pennsylvania and may not reflect trends in other
geographic areas
 Athletes aged 11-12 years old were about 2.5 times more likely to have a concussion compared
to the 8-10 year olds – not surprising given older players are bigger, faster, and stronger
 This article is appraisal worthy
INTEGRATIVE LITERATURE REVIEW 23

First Author Brown, N. J., Mannix, R. C., O’Brien, M. J., Gostine, D., Collins, M. W., & Meehan, W. P. (2014).
(Year)/Qualifications Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics, 133(2),
e299-e304. doi:10.1542/peds.2013-2125

Background/Problem  Determine the effect of cognitive activity level on duration of post-concussion symptoms
Statement

Conceptual/theoretical  There is no theoretical framework provided

Framework

Design/Method/Philosophical  Single-center prospective cohort study of patients

Underpinnings

Sample/ Setting/Ethical  Included patients who were diagnosed with a sports-related concussion or concussion resulting
Considerations from a similar mechanism, such as a fall at a playground
 Excluded those who had incomplete medical records, patients in whom alternate diagnoses were
being considered, and patients who had more severe injury mechanisms, such as motor vehicle
accidents or falls
Major Variables Studied (and  Symptom burden at initial visit and cognitive activity level were independently associated with
their definition), if duration of symptoms
appropriate

Measurement Tool/Data  Patients completed intake form, and completed all follow-up forms
Collection Method  Patients completed scale that recorded their average level of cognitive activity
 Kaplan-Meier Product Limit method was used to generate curves of symptom duration based on
cognitive activity level
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Data Analysis
Findings/Discussion –
Appraisal/Worth to practice
24
 Main predictor variable was cognitive activity-days
 Divided cognitive activity-days into quartiles, using Kaplan-Meier analysis with log-rank test of
significance to evaluate the effects of cognitive activity-days on time to symptom resolution
 First few days after an injury, its important to tell the athlete that physical and cognitive rest is
required
 Activities that require concentration and attention may exacerbate symptoms and delay recovery
 Academic accommodations can speed the recovery process
 Increased cognitive activity is associated with longer recovery from concussion
 Study supports the use of cognitive rest
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First Author Ellis, M. J., Ritchie, L. J., Koltek, M., Hosain, S., Cordingley, D., Chu, S., & Russell, K. (2015).
(Year)/Qualifications Psychiatric outcomes after pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics,
16(6), 709-718. doi: 10.3171/2015.5.PEDS15220.

Background/Problem  Examine the prevalence of emotional symptoms among children and adolecents with sports-
Statement related concussions (SRC) who were referred to an multidisciplinary pediatric concussion
program
 Examine the prevalence, clinical features, risk factors, and managements of postinjury
psychiatric outcomes among those in the clinical population

Conceptual/theoretical  There is theoretical framework

Framework  Researchers examined patient who developed an novel psychiatric disorder, developed
subjective worsening symptoms of preinjury psychiatric disorder, or developed a new and
isolated suicidal ideation

Design/  Retrospective chart review of all patients with SRC referred to multidisciplinary pediatric
concussion program
Method/Philosophical  Clinical assessments carried out by a single neurosurgeon included clinical history, physical
examination, and Post-Concussion Symptom Scale (PCSS) scoring
Underpinnings

Sample/ Setting/Ethical  Study was approved by the institutional ethics review board at the University of Manitoba
Considerations  174 patients (mean age 14.2 years, 61.5% male) were included in the study

Major Variables Studied (and  Psychiatric outcomes after a sports-related concussion

their definition), if
appropriate
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Measurement Tool/Data  Clinical assessments carried out by a single neurosurgeon included clinical history, physical
Collection Method examination, and Post-Concussion Symptom Scale (PCSS) scoring

Data Analysis  Patients with SRC with and those without post-injury psychiatric disorders were summarized
using proportions for dichotomous/polytomous characteristics and means with standard
deviations for continuous characteristics

Findings/Discussion –  Did not standardized psychiatric interview to provide comprehensive assessment of both
preinjury and postinjury emotional symptoms and psychiatric disorders in all patients
 Emotional symptoms are commonly reported at initial consultation among pediatric patients
with SRC who are referred to a multidisciplinary pediatric concussion program

Appraisal/Worth to practice  Future research is needed to clarify the prevalence, risk factors and evidence-based management
of postinjury psychiatric outcomes after pediatric sports-related concussions
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