Implication of Socio-Demographics on Cognitive-Related Symptoms in Sports Concussion Among Children

This study was performed to characterize concussion sustained among children who play sports and were seen in our pediatric institution. We postulated that patients who sustained concussion present with substantial CRS and that differences in outcome may be observed by race, ethnicity, and other health disparities indicators. Using an explanatory multivariable binomial regression (predictive) model, we obtained some relevant findings. (1) The occurrence of CRS is relatively high among children who play sports and sustained concussion. (2) CRS is associated with sex, with more girls reporting impairment relative to boys. (3) There is a substantial relationship between age and CRS. (4) After controlling for potential confounding, such as insurance, age, sex, and length of hospitalization, Black/African American children were more likely to develop CRS following sports-related concussion.

Racial variances in CRS were not observed in our crude (unadjusted) model. This observation may be due to the use of a binary variable in the measurement of CRS. In our data, we observed several indicators of CRS that required the use of ordinal scale to rank this variable. Therefore, the application of ordered category might result in the observation of a significant difference in CRS by race. We built a multivariable model using log binomial regression for possible explanation, adjusting for biologic and known confounding factors for racial association with disease and health conditions. The multivariable explanatory model clearly indicated racial variance in CRS following sports-related concussion. These data consequently support a previous studies in comparable settings. While a prospective case-control study did not observe a significant difference between African and Whites on baseline or post-concussion verbal memory, visual memory, reaction time, and total reported symptoms, however, African Americans were almost 2.5 times as likely to have at least one clinically significant cognitive decline on ImPACT at 7 days post-concussion, as well as scored lower at 7 days post-concussion relative to baseline on processing speed [17]. In another study, relative to Whites, African Americans that constituted 36.8 % of the total study sample scored lower on all seven neuropsychological tests (verbal memory—total and delayed, working memory—WAIS-3 DS and WAIS 3 LNS, perceptual reasoning, visual memory, processing speed) used for the assessment of cognitive function. These racial variances were attributed by authors attributed to unequal access to educational opportunities and cultural differences as well as lack of equivalence in cognitive measures [22].

The observed racial variation in CRS following concussion may be due to the delay in diagnosing and treating concussion, which correlates with poor prognosis. Our finding is supported by a few studies in prior research [17] that examined post-concussion ImPact composite score. The differences in these scores with Blacks/AA performing poorer relative to Whites may be attributed to several factors including baseline variance, stop socioeconomic status that may impact on timely access to care. While concussion has been shown in literature to vary in prevalence and incidence by race, its sequelae has not been fully described using health disparities indicators. Our study therefore represents a preliminary finding in this vein.

Whereas sports-related concussion has been previously described with respect to sex, however, this study described the prevalence of CRS following mTBI by sex. We have demonstrated that, following concussion, girls have increased risk of sustaining cognitive impairment. While this finding is interesting, we are unable to provide any biologic or psychosocial explanation to justify our observation. However, it is plausible to suggest that it may require longer duration for girls to be seen if sports activities are not very well developed in their institutions, implying lack of resources and timely intervention. Despite these difficulties in arriving at a specific explanation, studies have indicated the magnitude and severity of concussion among males relative to females [23]. Differences are suggested to be attributable to differences in head mass and acceleration, as well as other biologic determinants of altered mentation and visual acuity [24]. Furthermore, the increased prevalence in CRS among girls may be attributable to their increasing willingness to disclose their symptoms compared to boys. At this particular competitive level, boys may not like to disclose their symptoms, since doing so may limit their participation in sports [16]. Additionally, a study on sex differences in outcome after mTBI observed significant odds of poorer outcomes following mTBI in girls relative to boys based on the post-concussion symptoms (PCS) score [11]. In effect, we caution the interpretation of increased prevalence in CRS among girls without a careful assessment of other factors related to pain perception and expression.

Insurance has been reported in previous literature to facilitate access and utilization of care. Our studies showed that Blacks/African Americans were less likely to have private insurance compared to their White counterparts, aligning with previous findings illustrating poor outcomes for children with public insurance as well as those who are uninsured [25]. The observed association between insurance coverage and CRS in our sample may be due to decreased access to care as well as decreased care utilization by Blacks/African Americans.

The age at injury was shown in our data to significantly influence CRS. Indeed, we observed a significant association between age and CRS, with older children presenting more with CRS following concussion. The observed association may be due to participation in high-energy contact sports by older children. Willer et al. observed that older children were more likely to sustain head injuries and symptoms of concussion from sports activities, while primary cause of injury for young children was fall [26]. These sports are available to older children and are conducive to an increase in the degree of trauma, which in turn compromises cognitive functions, such as attention, memory, and orientation. It is also worthwhile to consider the changing plasticity of the brain as the child grows, implying the greater ability of the young brain to adjust to change during injury compared to older children with increased vulnerability to mTBI. McKinlay and Anderson examined age at injury as one of the issues associated with preschool child traumatic brain injury. Firstly, this study acknowledged the communication difficulties that may complicate deficits assessment in younger children. Secondly, that the absence of deficit should be cautiously interpreted since the problem or deficit may become apparent over time as the age-dependent skills fail to emerge [27, 28]. Subsequently, our data the association between age at injury and mTBI supports the observation that neuroplasticity should not be interpreted as the capability of the young child brain to return to pre-injury function [27].

This study is not without limitations. (1) This is a retrospective design that may be influenced by information and selection biases, as well as the lack of temporality, implying cause and effect association. (2) The use of preexisting data from our electronic medical records precluded data collection of known variables that could provide further explanation regarding the relationship between cognitive impairment and race. As a result of this limitation, it is possible to suspect unmeasured confounding to influence the result in this study. (3) In addition, like in most epidemiologic studies, residual confounding may influence the findings in this sample, since no matter how sophisticated a model used for adjusting for confounding, residual confounding persists [29].