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Luszawski, C., et al. Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players. Clinical Journal of Sport Medicine 34(3):p 256-265, May 2024
B.C. Injury Research and Prevention Unit
Children's Hospital (Vancouver, B.C.)
Luszawski, Caroline A.
Plourde, Vickie
Sick, Stacy R.
Galarneau, Jean-Michel
Eliason, Paul H.
Brooks, Brian L.
Mrazik, Martin
Debert, Chantel T.
Lebrun, Constance
Babul, Shelina
Hagel, Brent E.
Dukelow, Sean P.
Schneider, Kathryn J.
Emery, Carolyn A.
Yeates, Keith Owen
Objective: To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players following sport-related concussion. Design: Prospective cohort study, Safe-to-Play (2013-2018). Setting: Youth hockey leagues in Alberta and British Columbia, Canada. Participants: 353 ice hockey players (aged 11-18 years) who sustained a total of 397 physician63 diagnosed concussions. Independent Variables: Psychosocial variables. Main Outcome Measures: Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors associated with TTR, summarized with time ratios (TR). Covariates included age, sex, body checking policy, days from concussion to initial physician visit, and symptom severity at initial physician visit. Results: Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01- 1.09]), and higher parent ratings of distress about their child’s well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]), were associated with longer recovery. Conclusions: Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors following concussion may promote recovery.
This is a non-final version of an article published in final form in Luszawski, Caroline A. MSc*,†; Plourde, Vickie PhD‡,§,¶; Sick, Stacy R. BSc, CAT(C)║; Galarneau, Jean-Michel PhD║; Eliason, Paul H. PhD║; Brooks, Brian L. PhD*,†,**,††; Mrazik, Martin PhD‡‡; Debert, Chantel T. MD, MSc§§,¶¶; Lebrun, Constance MDCM║║; Babul, Shelina PhD***; Hagel, Brent E. PhD†,║,†††; Dukelow, Sean P. MD, PhD§§,¶¶,‡‡‡; Schneider, Kathryn J. PhD†,║,¶¶,§§§; Emery, Carolyn A. PhD†,║,¶¶,†††; Yeates, Keith Owen PhD*,†,¶¶. Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players. Clinical Journal of Sport Medicine 34(3):p 256-265, May 2024. | DOI: 10.1097/JSM.0000000000001187 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 1 Ice Hockey Players 2 3 Caroline A Luszawski, MSc1,2, Vickie Plourde, PhD3-5, Stacy R Sick, BSc, CAT(C)6, Jean-Michel 4 Galarneau, PhD6, Paul H Eliason, PhD6, Brian L Brooks, PhD1,2,7,8, Martin Mrazik, PhD9, Chantel T 5 Debert, MD, MSc10,11, Constance Lebrun, MDCM12, Shelina Babul, PhD13, Brent E Hagel, 6 PhD2,6,14, Sean P Dukelow MD PhD10,11,15, Kathryn J Schneider, PhD2,6,11,16, Carolyn A Emery 7 PhD,2,6,11,17, Keith Owen Yeates, PhD1,2,11 8 9 1University of Calgary Department of Psychology, Alberta, Canada 10 2Alberta Children’s Hospital Research Institute, Alberta, Canada 11 3School of Psychology, Université de Moncton, New Brunswick, Canada 12 4Centre de formation médicale du Nouveau-Brunswick, Université de Sherbrooke, New 13 Brunswick, Canada 14 5Faculté Saint-Jean, University of Alberta, Alberta, Canada 15 6Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, 16 Canada 17 7Alberta Children’s Hospital, Neurosciences Program, Alberta, Canada 18 8University of Calgary, Departments of Pediatrics and Clinical Neurosciences 19 9Department of Educational Psychology, University of Alberta 20 10Department of Clinical Neurosciences, University of Calgary, Alberta, Canada 21 11Hotchkiss Brain Institute, University of Calgary, Alberta, Canada 22 12Glen Sather Sports Medicine Clinic, Department of Family Medicine, Faculty of Medicine & 23 Dentistry, University of Alberta, Edmonton, Alberta 24 13University of British Columbia, Department of Pediatrics, Faculty of Medicine, BC Children’s 25 Hospital, Vancouver, BC, Canada 26 14Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 27 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 28 15Cumming School of Medicine, University of Calgary, Alberta, Canada 29 16Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada 30 17Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 31 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 32 33 Correspondence: Caroline A Luszawski MSc; Department of Psychology, University of Calgary, 34 2500 University Drive NW, Calgary, AB T2N 1N4; Tel: 416-389-5664; Fax: 403-282-8249; Email: 35 caroline.luszawski@ucalgary.ca 36 37 Conflicts of Interest and Source of Funding: 38 Brian Brooks receives royalties for the sales of the Pediatric Forensic Neuropsychology textbook 39 (Oxford University Press), royalties for three pediatric neuropsychological tests [Child and 40 Adolescent Memory Profile (ChAMP, Sherman and Brooks, 2015, PAR Inc.), Memory Validity 41 Profile (MVP, Sherman and Brooks, 2015, PAR Inc.), and Multidimensional Everyday Memory 42 Ratings for Youth (MEMRY, Sherman and Brooks, 2017, PAR Inc.)], and has a private practice 43 where he evaluates youth and professional hockey players with concussion. For the remaining 44 authors no conflicts of interest were noted. 45 We acknowledge funding from the Canadian Institutes of Health Research and Hotchkiss Brain 46 Institute. 47 Acknowledgements: The Sport Injury Prevention Research Centre is one of the International 48 Research Centres for Prevention of Injury and Protection of Athlete Health supported by the 49 International Olympic Committee. We acknowledge funding from the Canadian Institutes of 50 Health Research (C Emery PI) and Hotchkiss Brain Institute for the Safe2Play project. Dr. Yeates 51 holds the Ronald and Irene Ward Chair in Pediatric Brain Injury, funded by the Alberta 52 Children’s Hospital Foundation. Dr. Emery holds a Canada Research Chair (Tier 1) in Concussion. 53 Dr. Brooks acknowledges salary funding from the Canadian Institutes for Health Research 54 Embedded Clinician Researcher Salary Award during the collection of these data. 55 Abstract Word Count: 246. Manuscript Word Count: 2999 56 Abstract 57 Objective: To investigate the association between psychosocial factors and physician clearance 58 to return to play (RTP) in youth ice hockey players following sport-related concussion. 59 Design: Prospective cohort study, Safe-to-Play (2013-2018). 60 Setting: Youth hockey leagues in Alberta and British Columbia, Canada. 61 Participants: 353 ice hockey players (aged 11-18 years) who sustained a total of 397 physician-62 diagnosed concussions. 63 Independent Variables: Psychosocial variables. 64 Main Outcome Measures: Players and parents completed psychosocial questionnaires 65 preinjury. Players with a suspected concussion were referred for a study physician visit, during 66 which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single 67 question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured 68 as days between concussion and physician clearance to RTP. Accelerated failure time models 69 estimated the association of psychosocial factors associated with TTR, summarized with time 70 ratios (TR). Covariates included age, sex, body checking policy, days from concussion to initial 71 physician visit, and symptom severity at initial physician visit. 72 Results: Self-report of increased peer-related problems on the Strengths and Difficulties 73 Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion 74 outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-75 1.09]), and higher parent ratings of distress about their child’s well-being at the time of injury 76 (TR, 1.06 [95% CI, 1.02-1.09]), were associated with longer recovery. 77 Conclusions: Greater pre-existing peer-related problems and acute distress about concussion 78 outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial 79 factors following concussion may promote recovery. 80 81 Key Words: concussion, psychosocial, recovery, child, adolescent, brain injury 82 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 83 Ice Hockey Players 84 Introduction 85 Concussion rates in children and adolescents are steadily increasing1 and can lead to 86 significant functional impairment.2 Most children recover fully within a few weeks, but up to a 87 third will experience persistent post-concussive symptoms (PCS)3 (which include a range of 88 cognitive, physical, and emotional complaints) and delayed recovery for a month or longer.4 89 Children in collision sports are at an increased risk of sustaining concussion.5 In sports 90 such as ice hockey, more elite levels of play and policy allowing body checking in games are 91 associated with higher concussion rates.6,7 92 Factors such as age3, sex3,8, and history of previous head injury8,9 have been associated 93 with recovery in studies of pediatric concussion arising in sport. In a previous study of 94 predictors of recovery from pediatric concussion in youth ice hockey players, physician 95 clearance to return to play (RTP) was prolonged for players who took longer than 7 days before 96 their initial physician assessment, had poorer tandem stance, reported moderate/severe 97 headache, or had greater symptom severity at their first physician visit.10 98 A few studies have investigated the association between psychosocial factors and time 99 to recovery (TTR) in youth athletes11–13 and outcome measures such as persistent PCS, which 100 may be associated with delayed RTP.8 Results suggest that factors such as pre-injury health 101 related quality of life (QoL)14, resilience15,16, and adjustment14 may be associated with delayed 102 recovery in youth following concussion. 103 Child and parent characteristics, such as parental support17,18 or child perfectionism19, 104 may influence a child’s risk of injury. To our knowledge, however, neither parental involvement 105 nor perfectionism have been investigated in relation to recovery from pediatric concussion. 106 However, studies of sport-related injuries more generally indicate that parental over-107 involvement may be associated with over-use injuries in childhood through pressure to 108 specialize early and spend increased time in sports.19,20 Similarly, child perfectionism has been 109 associated with increased risk of injury in youth athletes and may affect recovery from injury.21–110 24 111 In adults, perceptions of acute distress and expectations of recovery appear to play an 112 important role in the development of PCS25–28 However, these factors have rarely been 113 investigated in relationship to pediatric concussion,29,30 although negative perceptions of injury 114 have been associated with more persistent PCS and emotional distress in adolescents.30 115 Few studies have investigated whether psychosocial factors are associated with delayed 116 recovery following pediatric concussion over and above well-established predictors such as sex 117 and days to initial physician visit.31 Further study of psychosocial factors potentially associated 118 with recovery could help identify adolescents more likely to experience prolonged recovery, aid 119 in the design of interventions to prevent persistent PCS, and help adolescents return to school 120 and play faster after concussion. 121 The current study sought to investigate the association of pre-injury and post-acute 122 psychosocial factors with time to physician clearance to RTP in adolescent ice hockey players 123 with sport-related concussion. The current study also sought to investigate whether the 124 psychosocial factors added incrementally to other factors previously identified as associated 125 with RTP in the same sample (e.g., time to initial physician assessment, tandem stance errors, 126 symptom severity) at initial physician assessment. Specifically, we hypothesized that lower pre-127 injury QoL, psychological adjustment, resilience, and expectations of recovery would lead to 128 longer TTR. We also hypothesized that higher perfectionism, parental involvement and post-129 acute parent and child distress would lead to longer TTR. 130 Methods 131 Study Design 132 This is a secondary, planned analysis of data drawn from a larger prospective cohort 133 study, Safe to Play, that evaluated concussions and injuries in youth ice hockey players over 5 134 seasons (2013-2018). This cohort included only those players who sustained a suspected sport-135 related concussion and were later diagnosed by a study physician. 136 Participants 137 Sample size was determined a priori for the larger Safe to Play study.10 Participants were 138 eligible for inclusion if they participated in male or female leagues and were registered with 139 Hockey Vancouver, Calgary or Edmonton, or surrounding area leagues, were between the ages 140 of 11 and 17 years, and had written informed player consent (for those 15 and older) or assent 141 and parent consent if needed.10,32 Players were excluded if they had a previous injury or illness 142 preventing full participation in hockey at start of season. 143 Measures 144 Strengths and Difficulties Questionnaire (SDQ). The SDQ assesses psychosocial adjustment using 145 a 25-item scale.33. Both self-report and parent proxy versions were completed at preinjury 146 assessments. The SDQ has shown satisfactory reliability and validity.33–35 147 Pediatric Quality of Life Inventory (PedsQL). The PedsQL is a 23-item questionnaire that 148 measures health-related quality of life.36. Both self-rated and parent-proxy versions were 149 completed at preinjury assessments. Reliability and validity of the PedsQL are well 150 established.36–38 151 Connor Davidson Resiliency scale (CD-RISC). The CD-RISC is a 10 item questionnaire that 152 measures the ability to cope with adversity.39 Originally developed in adults, the CD-RISC has 153 shown adequate validity in children as well.39–41 154 The Sport Multidimensional Perfectionism Scale (Sport-MPS2). The Sport-MPS2 is a self-report 155 questionnaire that assesses perfectionistic tendencies within sport. The Sport MPS2 has shown 156 adequate construct validity.42,43 157 Parent involvement in sport questionnaire (PISQ). The PISQ is a 19 item questionnaire that 158 assesses parental behaviour within the sport context.44,45 The scales on the PISQ have shown 159 satisfactory internal reliability.44 160 Distress and recovery expectation questions. Three questions were asked at the initial post-161 injury physician visit regarding distress felt by the player (or parent) at the time of the injury, 162 distress felt by the player (or parent) about injury outcomes at the time of the initial physician 163 visit, and whether the player (or parent) believed the player would make a full recovery. All 164 three questions were rated on a 10-point Likert scale. The questions were modeled on items 165 from the Timeline and Emotional Representations subscales of the Revised Illness Perception 166 Questionnaire.46 These subscales are intended to assess the player’s and parent’s illness 167 representations, which are important mediators of health outcomes.47 168 Procedure 169 A previously validated injury surveillance methodology in youth ice hockey was used to 170 collect injury and participation information.47 This included a preinjury baseline questionnaire, 171 the Sport Concussion Assessment Tool48 (SCAT3 in years 1-4; SCAT 5 in year 5), weekly exposure 172 sheets, and injury report forms (IRF).47,49–51 Psychosocial and behavioural questionnaires were 173 also administered to players as part of baseline testing. In years 2 through 5 of the Safe to Play 174 study, these included the SDQ, PedsQL, CD-RISC, and Sport-MPS2. Additionally, parents 175 completed the parent/guardian version of the SDQ, PedsQL, and PISQ. 176 Teams participating in the study assigned a team designate (e.g., manager, safety coach) 177 who collected weekly exposure sheets and identified players with a suspected concussion or 178 injury occurring from participation in ice hockey. All players with a suspected concussion had 179 the opportunity to follow up with a study sports medicine physician. Study physicians used the 180 most current international consensus statement in sport to define a concussion, standardize 181 assessment procedures at initial and follow up assessments, and clear a participant to return to 182 sport following the standardized RTP protocol (year 1 to 4)51 or return to sport strategy (year 183 5).50 184 The SCAT3 or SCAT5, which contained the symptom rating scale, was completed at the 185 initial physician visit after a concussion. The symptom rating scale was the same on the SCAT3 186 and SCAT5.49,50 The three supplemental questions regarding distress and expected outcome of 187 injury were also completed by players and parents at the initial visit. 188 Study physician clearance to RTP was based on concussion related symptoms and 189 completion of the RTP protocol as defined by the most recent international consensus 190 statement on concussion in sport at the time.50,51 TTR was defined as the number of days 191 between the date of injury as reported on the IRF and study physician clearance to RTP. 192 Statistical Analyses 193 Statistical analyses were conducted using Stata 17.52 Alpha level was set at .05. 194 Participants included in analyses had at least one concussion diagnosed by a study sports 195 medicine physician and completed at least one of the psychosocial measures (SDQ, PedsQL, CD-196 RISC, Sport-MPS2, PISQ at preinjury assessments, and questions regarding distress and recovery 197 expectations at the time of the initial physician appointment). 198 Descriptive statistics (frequencies and proportions) were computed to document sample 199 characteristics. Because our interest was in time to clearance for RTP,53 accelerated failure time 200 models with loglogistic distribution (bivariate and fully adjusted multivariable models) were 201 generated using complete case analysis to examine the association between psychosocial 202 factors and TTR.10 Repeat concussions for players participating across multiple seasons were 203 handled using clustered standard errors. The date of RTP was based on IRF or weekly exposure 204 sheets if data were not available in physician records.10 The IRF was completed by study 205 personnel if a participant did not complete a final physician visit. Players who were lost to 206 follow-up were censored in the statistical models. 207 We selected covariates according to available data and previous research showing 208 associations with TTR.3,10,54 Covariates included age, sex (male, female), body checking policy 209 (permitted/not permitted), days from concussion to physician visit (7 days or less versus more 210 than 7 days55,56), and symptom severity measured at the initial physician visit (SCAT3 or SCAT5 211 total symptom severity score10). 212 Results 213 Participants 214 A total of 4419 adolescents were recruited for the larger parent study over a five-year 215 period (6584 player seasons); however, the psychosocial questionnaires of interest were only 216 introduced in the second year (season 2014-2015) of the study (see Figure 1). This yielded 4080 217 individual players and 5762 player seasons (N2014-15 = 1398, N2015-16 = 1902, N2016-17 = 1319, 218 N2017-18 = 1143) potentially eligible for analysis. During these seasons, 549 concussions were 219 diagnosed by a study physician, and 397 (72%) had data available for at least one psychosocial 220 measure (Figure 1); 159 (29%) had baseline psychosocial data only, 47 (9%) had psychosocial 221 data only at the initial physician visit, and 191 (35%) had psychosocial data at both times 222 (Supplemental materials, Table 1S). These subgroups did not differ significantly in sex, days to 223 initial physician visit, symptom severity at the initial physician visit, or TTR, but did differ in the 224 likelihood of a previous concussion and of playing in a body checking league and in average age. 225 As noted above, multivariable analyses controlled for age and body checking policy; previous 226 concussion was not controlled because it was not predictive of TTR in our previous study.10 227 A total of 353 players accounted for the 397 concussions (M age=13.90 years; SD=1.53). 228 Most concussions involved males (n=346; 87.2%) and players in a body checking league (n=269; 229 67.8%). Physicians evaluated most concussions within 7 days of injury (n=283; 71.3%) and 230 slightly less than half (n=183; 46.1%) of the concussions were not preceded by another 231 concussion that occurred before the start of the season. Median acute total symptom severity 232 score (/132) at the initial physician visit was 10.0 (IQR=3-23.5). Median time to being cleared to 233 play, for those not lost to follow-up, was 16 days (IQR=11-27). Table 1 presents descriptive data 234 for psychosocial measures. 235 Factors Associated with Time to Recovery 236 Table 2 reports bivariate accelerated failure time models for all psychosocial variables. 237 Lower levels of resilience and higher levels of inattention/hyperactivity and peer relationship 238 problems reported by adolescents at baseline were significantly associated with a longer TTR in 239 bivariate analyses. Higher ratings of distress about concussion outcomes and lower 240 expectations of a full recovery at the initial physical visit also were associated with longer TTR. 241 For parent ratings, higher ratings of distress about their child’s concussion outcomes and about 242 their child’s well-being at the time of injury (TOI) were significantly associated with longer TTR. 243 Table 3 shows fully adjusted multivariable accelerated failure time models. For self-244 ratings (Tables 2S and 3S; see Supplemental materials for full models), higher pre-injury peer-245 related problems reported at baseline (TR, 1.10 [95% CI, 1.02-1.19]) and higher ratings of 246 distress about concussion outcomes acutely post-injury (TR, 1.06 [95% CI, 1.01-1.11]) were 247 associated with longer TTR. For every 1-point increase in self-ratings of peer problems or of 248 acute distress about their concussion outcomes, TTR increased by 10% and 6%, respectively. 249 Figure 2 presents probability curves for RTP based on low (10th percentile), median (50th 250 percentile), and high (90th percentile) ratings of adolescent self-reported ratings for (a) current 251 distress at TOI and (b) peer problems at baseline. 252 Fully adjusted models for parent ratings (Tables 4S and 5S; see Supplemental materials 253 for full models) showed that only parent acute ratings of higher distress about their child’s well-254 being at the TOI (time ratio [TR], 1.06 [95% confidence interval (CI), 1.02-1.09]) and about 255 concussion outcomes (TR, 1.05 [95% CI, 1.01-1.09]) remained associated with longer recovery. 256 For every 1-point increase in distress about their child’s well-being at the TOI or about their 257 child’s concussion outcomes, TTR increased by 6% and 5%, respectively. Figure 3 presents 258 probability curves for RTP based on low (10th percentile), median (50th percentile), and high 259 (90th percentile) acute parent ratings of (a) their distress about concussion outcomes and (b) 260 their distress about their child’s wellbeing. 261 Discussion 262 This study investigated psychosocial variables associated with time to physician 263 clearance for RTP in adolescent ice hockey players with concussion. The median TTR was 16 264 days, consistent with previous research suggesting that many youth with sports-related 265 concussion recover within 2-3 weeks of their injury (median of 178 and 1810 days). After 266 controlling for relevant covariates, adolescent reports of pre-injury peer problems at baseline 267 and levels of distress about their concussion outcomes acutely post-injury, as well as parent 268 levels of distress about their child’s well-being acutely post-injury, were associated with a 269 significant increase in time to RTP. 270 Few studies have investigated parent and youth distress and expectations as associated 271 with recovery, and to our knowledge this is the first to do so in adolescent ice hockey players. 272 Negative thinking about outcomes as reflected in distress and lower expectations of recovery 273 have not been well studied. ‘Nocebo effects’ occur when an individual has negative 274 expectations of outcomes that are associated with prolonged recovery or worsened 275 symptoms.57 Because much online information about concussion is not from reliable sources 276 and may be inaccurate,58,59 some parents and adolescents in the study may have experienced 277 ‘nocebo effects’, prolonging recovery. Parent and player distress and recovery expectations 278 likely reflect messaging by both clinicians and scientists, who should aim to provide accurate, 279 up-to-date information regarding the outcomes of concussion. Future studies should 280 investigate whether the accuracy of information that adolescents and their families have about 281 concussion is associated with their distress, expectancies of recovery, and TTR. 282 Parent-rated but not self-rated distress about the adolescent’s wellbeing at the TOI was 283 significantly associated with a longer TTR. Youth hockey players may tend to minimize their 284 vulnerability to concussion,60 and this may help explain why adolescent reports of distress 285 regarding their wellbeing at the TOI were not significantly associated with TTR. Higher parental 286 distress regarding their child’s wellbeing could be indicative of higher overall parent stress, 287 which has been shown to be associated with a decreased ability to help children cope with 288 injury and therefore may lead to prolonged recovery.61 289 In this study, self-reported peer-related problems was the pre-injury psychosocial factor 290 uniquely associated with TTR. Peer and other forms of social support have been shown to be 291 important in facilitating recovery from pediatric concussion; children identify a need to rely on 292 friends for support during recovery and adolescents who experience persistent PCS often 293 report lower levels of peer support.62,63 The adolescents in our study who reported more peer 294 problems may not have had the same access to social supports as adolescents who reported 295 fewer peer problems and may have therefore experienced a longer time to RTP. Peer-related 296 problems may also be a marker for other functional difficulties that put adolescents at risk of 297 persistent PCS.64 298 In this study, pre-injury QoL, psychological adjustment, resilience, perfectionism, and 299 parental involvement were not significantly related to TTR in multivariable models. These 300 findings could be a function of the outcome investigated in our study, clearance to RTP. Pre-301 injury QoL, adjustment, resilience, perfectionism, and parental involvement could be related to 302 symptom severity or other functional difficulties as opposed to RTP. 303 Our results have potential clinical implications. Education about appropriate 304 expectations about outcomes might assist in shortening TTR. Clinicians and scientists should 305 help to dispel concussion misinformation and aim to support more accurate expectations to aid 306 in recovery.57 Providing accurate information about recovery has been recommended for 307 pediatric concussion management,50 and future studies should investigate whether doing so 308 affects recovery expectations. Because more peer problems were associated with increased 309 time, promoting positive peer relationships also might help facilitate faster recovery. 310 Limitations 311 One study limitation is that questions regarding post-injury distress and expectations of 312 recovery were single items, which may limit their reliability and validity. Additionally, we did 313 not assess the nature or accuracy of the educational information about concussion that our 314 families received prior to or after their adolescent’s injury and that could account for potential 315 ‘nocebo’ effects. Our sample consisted of ice hockey players, which might limit generalizability 316 of the findings to athletes in other contact sports. Additionally, the participants were mostly 317 males and we could not investigate sex differences in post-acute distress and expectations of 318 recovery. Finally, our analyses of psychosocial variables collected at baseline and at TOI were 319 based on overlapping but distinct samples, which differed in history of concussion, body 320 checking policy, and age. However, we controlled for two of those variables in multivariable 321 analyses, and the groups did not differ on several other variables that are also associated with 322 TTR. Nevertheless, missing data from study participants with concussion may have introduced 323 unmeasured bias. 324 Conclusion 325 This study provides evidence that psychosocial factors are associated with 326 TTR following concussion in adolescent ice hockey players, over and above other well-studied 327 variables such as sex, body checking policy, initial symptom severity, and time to initial 328 physician visit. Specifically, parent-rated distress about their child’s wellbeing, parent and child 329 rated distress about concussion outcomes, and self-rated pre-injury peer problems were 330 associated with longer TTR, over and above other factors known to be related to recovery. 331 These results suggest potential targets for interventions to shorten recovery from concussion in 332 adolescents. 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Perspectives of adolescents and their 502 parents regarding service needs following a mild traumatic brain injury. Brain Inj. 503 2008;22(2):161-173. doi:10.1080/02699050701867381 504 59. Kollia B, Basch CH, Mouser C, Deleon AJ. Assessment of information on concussion available 505 to adolescents on social media. Int J Prev Med. 2018;9:19. 506 doi:10.4103/ijpvm.IJPVM_265_17 507 60. Mrazik M, Perra A, Brooks BL, Naidu D. Exploring minor hockey players’ knowledge and 508 attitudes toward concussion: implications for prevention. J Head Trauma Rehabil. 509 2015;30(3):219-227. doi:10.1097/HTR.0000000000000018 510 61. Teel EF, Caron JG, Gagnon IJ. Higher parental stress is significantly related to longer clinical 511 recovery times in concussed children: a mixed-methods study. J Sci Med Sport. 512 2022;25(2):108-114. doi:10.1016/j.jsams.2021.08.014 513 62. Minney MJ, Roberts RM, Mathias JL, Raftos J, Kochar A. Service and support needs following 514 pediatric brain injury: perspectives of children with mild traumatic brain injury and their 515 parents. Brain Inj. 2019;33(2):168-182. doi:10.1080/02699052.2018.1540794 516 63. Atif H, Morgan B, Tuohy K, et al. Personality traits and social supports in adolescents with 517 persistent postconcussion symptoms. J Head Trauma Rehabil. 2022;37(2):E71-E79. 518 doi:10.1097/HTR.0000000000000682 519 64. Aviv I, Shorer M, Fennig S, et al. Persistent post-concussion symptoms in children: pre-injury 520 social difficulties and acute stress reaction as risk factors. Child Neuropsychol. Published 521 online May 1, 2022:1-21. doi:10.1080/09297049.2022.2072823 522 523 Figure 1. Participant flowchart showing the denominator for a complete case analysis (i.e., 524 complete set of covariates for that outcome of interest) in each final model. 525 Figure 2. Association of varying levels of self-reported (a) distress about outcomes and (b) peer 526 problems with probability of return to play (RTP). (a) A 60% probability of RTP is achieved at 527 ~23 days for a self-rating of distress at the 10th percentile (score = 1) but at ~36 days for a rating 528 at the 90th percentile (score=8). Put differently, the probability of RTP at 30 days post-injury is 529 ~80% for a rating of distress at the 10th percentile but only ~50% for a rating at the 90th 530 percentile. (b) A 60% probability of RTP is achieved at ~20 days for a self-rating of peer 531 problems at the 10th percentile (score=0) but at ~25 days for a rating at the 90th percentile 532 (score=3). Alternatively, the probability of RTP at 30 days post-injury is ~80% for a rating of peer 533 problems at the 10th percentile but only ~65% for a rating at the 90th percentile. 534 Figure 3. Association of varying levels of parent-rated (a) distress about their child’s outcomes 535 and (b) distress about their child’s well-being at with probability of return to play (RTP). (a) A 536 60% probability of RTP is achieved at ~25 days for a rating of parent distress about outcomes at 537 the 10th percentile (score=1) but at ~38 days for a rating at the 90th percentile (score=9). 538 Alternatively, the probability of RTP at 30 days post-injury is ~70% for a rating of distress at the 539 10th percentile but only ~50% for a rating at the 90th percentile. (b) A 60% probability of RTP is 540 achieved at ~23 days for a rating of parent distress about well-being at the time of injury at the 541 10th percentile but at ~36 days for a rating at the 90th percentile (score=10). Put differently, the 542 probability of RTP at 30 days post-injury is ~75% for rating of distress at the 10th percentile but 543 only 55% probability for a rating at the 90th percentile. 544 This is a non-final version of an article published in final form in Luszawski, Caroline A. MSc*,†; Plourde, Vickie PhD‡,§,¶; Sick, Stacy R. BSc, CAT(C)║; Galarneau, Jean-Michel PhD║; Eliason, Paul H. PhD║; Brooks, Brian L. PhD*,†,**,††; Mrazik, Martin PhD‡‡; Debert, Chantel T. MD, MSc§§,¶¶; Lebrun, Constance MDCM║║; Babul, Shelina PhD***; Hagel, Brent E. PhD†,║,†††; Dukelow, Sean P. MD, PhD§§,¶¶,‡‡‡; Schneider, Kathryn J. PhD†,║,¶¶,§§§; Emery, Carolyn A. PhD†,║,¶¶,†††; Yeates, Keith Owen PhD*,†,¶¶. Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players. Clinical Journal of Sport Medicine 34(3):p 256-265, May 2024. | DOI: 10.1097/JSM.0000000000001187 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 1 Ice Hockey Players 2 3 Caroline A Luszawski, MSc1,2, Vickie Plourde, PhD3-5, Stacy R Sick, BSc, CAT(C)6, Jean-Michel 4 Galarneau, PhD6, Paul H Eliason, PhD6, Brian L Brooks, PhD1,2,7,8, Martin Mrazik, PhD9, Chantel T 5 Debert, MD, MSc10,11, Constance Lebrun, MDCM12, Shelina Babul, PhD13, Brent E Hagel, 6 PhD2,6,14, Sean P Dukelow MD PhD10,11,15, Kathryn J Schneider, PhD2,6,11,16, Carolyn A Emery 7 PhD,2,6,11,17, Keith Owen Yeates, PhD1,2,11 8 9 1University of Calgary Department of Psychology, Alberta, Canada 10 2Alberta Children’s Hospital Research Institute, Alberta, Canada 11 3School of Psychology, Université de Moncton, New Brunswick, Canada 12 4Centre de formation médicale du Nouveau-Brunswick, Université de Sherbrooke, New 13 Brunswick, Canada 14 5Faculté Saint-Jean, University of Alberta, Alberta, Canada 15 6Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, 16 Canada 17 7Alberta Children’s Hospital, Neurosciences Program, Alberta, Canada 18 8University of Calgary, Departments of Pediatrics and Clinical Neurosciences 19 9Department of Educational Psychology, University of Alberta 20 10Department of Clinical Neurosciences, University of Calgary, Alberta, Canada 21 11Hotchkiss Brain Institute, University of Calgary, Alberta, Canada 22 12Glen Sather Sports Medicine Clinic, Department of Family Medicine, Faculty of Medicine & 23 Dentistry, University of Alberta, Edmonton, Alberta 24 13University of British Columbia, Department of Pediatrics, Faculty of Medicine, BC Children’s 25 Hospital, Vancouver, BC, Canada 26 14Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 27 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 28 15Cumming School of Medicine, University of Calgary, Alberta, Canada 29 16Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada 30 17Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 31 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 32 33 Correspondence: Caroline A Luszawski MSc; Department of Psychology, University of Calgary, 34 2500 University Drive NW, Calgary, AB T2N 1N4; Tel: 416-389-5664; Fax: 403-282-8249; Email: 35 caroline.luszawski@ucalgary.ca 36 37 Conflicts of Interest and Source of Funding: 38 Brian Brooks receives royalties for the sales of the Pediatric Forensic Neuropsychology textbook 39 (Oxford University Press), royalties for three pediatric neuropsychological tests [Child and 40 Adolescent Memory Profile (ChAMP, Sherman and Brooks, 2015, PAR Inc.), Memory Validity 41 Profile (MVP, Sherman and Brooks, 2015, PAR Inc.), and Multidimensional Everyday Memory 42 Ratings for Youth (MEMRY, Sherman and Brooks, 2017, PAR Inc.)], and has a private practice 43 where he evaluates youth and professional hockey players with concussion. For the remaining 44 authors no conflicts of interest were noted. 45 We acknowledge funding from the Canadian Institutes of Health Research and Hotchkiss Brain 46 Institute. 47 Acknowledgements: The Sport Injury Prevention Research Centre is one of the International 48 Research Centres for Prevention of Injury and Protection of Athlete Health supported by the 49 International Olympic Committee. We acknowledge funding from the Canadian Institutes of 50 Health Research (C Emery PI) and Hotchkiss Brain Institute for the Safe2Play project. Dr. Yeates 51 holds the Ronald and Irene Ward Chair in Pediatric Brain Injury, funded by the Alberta 52 Children’s Hospital Foundation. Dr. Emery holds a Canada Research Chair (Tier 1) in Concussion. 53 Dr. Brooks acknowledges salary funding from the Canadian Institutes for Health Research 54 Embedded Clinician Researcher Salary Award during the collection of these data. 55 Abstract Word Count: 246. Manuscript Word Count: 2999 56 Abstract 57 Objective: To investigate the association between psychosocial factors and physician clearance 58 to return to play (RTP) in youth ice hockey players following sport-related concussion. 59 Design: Prospective cohort study, Safe-to-Play (2013-2018). 60 Setting: Youth hockey leagues in Alberta and British Columbia, Canada. 61 Participants: 353 ice hockey players (aged 11-18 years) who sustained a total of 397 physician-62 diagnosed concussions. 63 Independent Variables: Psychosocial variables. 64 Main Outcome Measures: Players and parents completed psychosocial questionnaires 65 preinjury. Players with a suspected concussion were referred for a study physician visit, during 66 which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single 67 question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured 68 as days between concussion and physician clearance to RTP. Accelerated failure time models 69 estimated the association of psychosocial factors associated with TTR, summarized with time 70 ratios (TR). Covariates included age, sex, body checking policy, days from concussion to initial 71 physician visit, and symptom severity at initial physician visit. 72 Results: Self-report of increased peer-related problems on the Strengths and Difficulties 73 Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion 74 outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-75 1.09]), and higher parent ratings of distress about their child’s well-being at the time of injury 76 (TR, 1.06 [95% CI, 1.02-1.09]), were associated with longer recovery. 77 Conclusions: Greater pre-existing peer-related problems and acute distress about concussion 78 outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial 79 factors following concussion may promote recovery. 80 81 Key Words: concussion, psychosocial, recovery, child, adolescent, brain injury 82 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 83 Ice Hockey Players 84 Introduction 85 Concussion rates in children and adolescents are steadily increasing1 and can lead to 86 significant functional impairment.2 Most children recover fully within a few weeks, but up to a 87 third will experience persistent post-concussive symptoms (PCS)3 (which include a range of 88 cognitive, physical, and emotional complaints) and delayed recovery for a month or longer.4 89 Children in collision sports are at an increased risk of sustaining concussion.5 In sports 90 such as ice hockey, more elite levels of play and policy allowing body checking in games are 91 associated with higher concussion rates.6,7 92 Factors such as age3, sex3,8, and history of previous head injury8,9 have been associated 93 with recovery in studies of pediatric concussion arising in sport. In a previous study of 94 predictors of recovery from pediatric concussion in youth ice hockey players, physician 95 clearance to return to play (RTP) was prolonged for players who took longer than 7 days before 96 their initial physician assessment, had poorer tandem stance, reported moderate/severe 97 headache, or had greater symptom severity at their first physician visit.10 98 A few studies have investigated the association between psychosocial factors and time 99 to recovery (TTR) in youth athletes11–13 and outcome measures such as persistent PCS, which 100 may be associated with delayed RTP.8 Results suggest that factors such as pre-injury health 101 related quality of life (QoL)14, resilience15,16, and adjustment14 may be associated with delayed 102 recovery in youth following concussion. 103 Child and parent characteristics, such as parental support17,18 or child perfectionism19, 104 may influence a child’s risk of injury. To our knowledge, however, neither parental involvement 105 nor perfectionism have been investigated in relation to recovery from pediatric concussion. 106 However, studies of sport-related injuries more generally indicate that parental over-107 involvement may be associated with over-use injuries in childhood through pressure to 108 specialize early and spend increased time in sports.19,20 Similarly, child perfectionism has been 109 associated with increased risk of injury in youth athletes and may affect recovery from injury.21–110 24 111 In adults, perceptions of acute distress and expectations of recovery appear to play an 112 important role in the development of PCS25–28 However, these factors have rarely been 113 investigated in relationship to pediatric concussion,29,30 although negative perceptions of injury 114 have been associated with more persistent PCS and emotional distress in adolescents.30 115 Few studies have investigated whether psychosocial factors are associated with delayed 116 recovery following pediatric concussion over and above well-established predictors such as sex 117 and days to initial physician visit.31 Further study of psychosocial factors potentially associated 118 with recovery could help identify adolescents more likely to experience prolonged recovery, aid 119 in the design of interventions to prevent persistent PCS, and help adolescents return to school 120 and play faster after concussion. 121 The current study sought to investigate the association of pre-injury and post-acute 122 psychosocial factors with time to physician clearance to RTP in adolescent ice hockey players 123 with sport-related concussion. The current study also sought to investigate whether the 124 psychosocial factors added incrementally to other factors previously identified as associated 125 with RTP in the same sample (e.g., time to initial physician assessment, tandem stance errors, 126 symptom severity) at initial physician assessment. Specifically, we hypothesized that lower pre-127 injury QoL, psychological adjustment, resilience, and expectations of recovery would lead to 128 longer TTR. We also hypothesized that higher perfectionism, parental involvement and post-129 acute parent and child distress would lead to longer TTR. 130 Methods 131 Study Design 132 This is a secondary, planned analysis of data drawn from a larger prospective cohort 133 study, Safe to Play, that evaluated concussions and injuries in youth ice hockey players over 5 134 seasons (2013-2018). This cohort included only those players who sustained a suspected sport-135 related concussion and were later diagnosed by a study physician. 136 Participants 137 Sample size was determined a priori for the larger Safe to Play study.10 Participants were 138 eligible for inclusion if they participated in male or female leagues and were registered with 139 Hockey Vancouver, Calgary or Edmonton, or surrounding area leagues, were between the ages 140 of 11 and 17 years, and had written informed player consent (for those 15 and older) or assent 141 and parent consent if needed.10,32 Players were excluded if they had a previous injury or illness 142 preventing full participation in hockey at start of season. 143 Measures 144 Strengths and Difficulties Questionnaire (SDQ). The SDQ assesses psychosocial adjustment using 145 a 25-item scale.33. Both self-report and parent proxy versions were completed at preinjury 146 assessments. The SDQ has shown satisfactory reliability and validity.33–35 147 Pediatric Quality of Life Inventory (PedsQL). The PedsQL is a 23-item questionnaire that 148 measures health-related quality of life.36. Both self-rated and parent-proxy versions were 149 completed at preinjury assessments. Reliability and validity of the PedsQL are well 150 established.36–38 151 Connor Davidson Resiliency scale (CD-RISC). The CD-RISC is a 10 item questionnaire that 152 measures the ability to cope with adversity.39 Originally developed in adults, the CD-RISC has 153 shown adequate validity in children as well.39–41 154 The Sport Multidimensional Perfectionism Scale (Sport-MPS2). The Sport-MPS2 is a self-report 155 questionnaire that assesses perfectionistic tendencies within sport. The Sport MPS2 has shown 156 adequate construct validity.42,43 157 Parent involvement in sport questionnaire (PISQ). The PISQ is a 19 item questionnaire that 158 assesses parental behaviour within the sport context.44,45 The scales on the PISQ have shown 159 satisfactory internal reliability.44 160 Distress and recovery expectation questions. Three questions were asked at the initial post-161 injury physician visit regarding distress felt by the player (or parent) at the time of the injury, 162 distress felt by the player (or parent) about injury outcomes at the time of the initial physician 163 visit, and whether the player (or parent) believed the player would make a full recovery. All 164 three questions were rated on a 10-point Likert scale. The questions were modeled on items 165 from the Timeline and Emotional Representations subscales of the Revised Illness Perception 166 Questionnaire.46 These subscales are intended to assess the player’s and parent’s illness 167 representations, which are important mediators of health outcomes.47 168 Procedure 169 A previously validated injury surveillance methodology in youth ice hockey was used to 170 collect injury and participation information.47 This included a preinjury baseline questionnaire, 171 the Sport Concussion Assessment Tool48 (SCAT3 in years 1-4; SCAT 5 in year 5), weekly exposure 172 sheets, and injury report forms (IRF).47,49–51 Psychosocial and behavioural questionnaires were 173 also administered to players as part of baseline testing. In years 2 through 5 of the Safe to Play 174 study, these included the SDQ, PedsQL, CD-RISC, and Sport-MPS2. Additionally, parents 175 completed the parent/guardian version of the SDQ, PedsQL, and PISQ. 176 Teams participating in the study assigned a team designate (e.g., manager, safety coach) 177 who collected weekly exposure sheets and identified players with a suspected concussion or 178 injury occurring from participation in ice hockey. All players with a suspected concussion had 179 the opportunity to follow up with a study sports medicine physician. Study physicians used the 180 most current international consensus statement in sport to define a concussion, standardize 181 assessment procedures at initial and follow up assessments, and clear a participant to return to 182 sport following the standardized RTP protocol (year 1 to 4)51 or return to sport strategy (year 183 5).50 184 The SCAT3 or SCAT5, which contained the symptom rating scale, was completed at the 185 initial physician visit after a concussion. The symptom rating scale was the same on the SCAT3 186 and SCAT5.49,50 The three supplemental questions regarding distress and expected outcome of 187 injury were also completed by players and parents at the initial visit. 188 Study physician clearance to RTP was based on concussion related symptoms and 189 completion of the RTP protocol as defined by the most recent international consensus 190 statement on concussion in sport at the time.50,51 TTR was defined as the number of days 191 between the date of injury as reported on the IRF and study physician clearance to RTP. 192 Statistical Analyses 193 Statistical analyses were conducted using Stata 17.52 Alpha level was set at .05. 194 Participants included in analyses had at least one concussion diagnosed by a study sports 195 medicine physician and completed at least one of the psychosocial measures (SDQ, PedsQL, CD-196 RISC, Sport-MPS2, PISQ at preinjury assessments, and questions regarding distress and recovery 197 expectations at the time of the initial physician appointment). 198 Descriptive statistics (frequencies and proportions) were computed to document sample 199 characteristics. Because our interest was in time to clearance for RTP,53 accelerated failure time 200 models with loglogistic distribution (bivariate and fully adjusted multivariable models) were 201 generated using complete case analysis to examine the association between psychosocial 202 factors and TTR.10 Repeat concussions for players participating across multiple seasons were 203 handled using clustered standard errors. The date of RTP was based on IRF or weekly exposure 204 sheets if data were not available in physician records.10 The IRF was completed by study 205 personnel if a participant did not complete a final physician visit. Players who were lost to 206 follow-up were censored in the statistical models. 207 We selected covariates according to available data and previous research showing 208 associations with TTR.3,10,54 Covariates included age, sex (male, female), body checking policy 209 (permitted/not permitted), days from concussion to physician visit (7 days or less versus more 210 than 7 days55,56), and symptom severity measured at the initial physician visit (SCAT3 or SCAT5 211 total symptom severity score10). 212 Results 213 Participants 214 A total of 4419 adolescents were recruited for the larger parent study over a five-year 215 period (6584 player seasons); however, the psychosocial questionnaires of interest were only 216 introduced in the second year (season 2014-2015) of the study (see Figure 1). This yielded 4080 217 individual players and 5762 player seasons (N2014-15 = 1398, N2015-16 = 1902, N2016-17 = 1319, 218 N2017-18 = 1143) potentially eligible for analysis. During these seasons, 549 concussions were 219 diagnosed by a study physician, and 397 (72%) had data available for at least one psychosocial 220 measure (Figure 1); 159 (29%) had baseline psychosocial data only, 47 (9%) had psychosocial 221 data only at the initial physician visit, and 191 (35%) had psychosocial data at both times 222 (Supplemental materials, Table 1S). These subgroups did not differ significantly in sex, days to 223 initial physician visit, symptom severity at the initial physician visit, or TTR, but did differ in the 224 likelihood of a previous concussion and of playing in a body checking league and in average age. 225 As noted above, multivariable analyses controlled for age and body checking policy; previous 226 concussion was not controlled because it was not predictive of TTR in our previous study.10 227 A total of 353 players accounted for the 397 concussions (M age=13.90 years; SD=1.53). 228 Most concussions involved males (n=346; 87.2%) and players in a body checking league (n=269; 229 67.8%). Physicians evaluated most concussions within 7 days of injury (n=283; 71.3%) and 230 slightly less than half (n=183; 46.1%) of the concussions were not preceded by another 231 concussion that occurred before the start of the season. Median acute total symptom severity 232 score (/132) at the initial physician visit was 10.0 (IQR=3-23.5). Median time to being cleared to 233 play, for those not lost to follow-up, was 16 days (IQR=11-27). Table 1 presents descriptive data 234 for psychosocial measures. 235 Factors Associated with Time to Recovery 236 Table 2 reports bivariate accelerated failure time models for all psychosocial variables. 237 Lower levels of resilience and higher levels of inattention/hyperactivity and peer relationship 238 problems reported by adolescents at baseline were significantly associated with a longer TTR in 239 bivariate analyses. Higher ratings of distress about concussion outcomes and lower 240 expectations of a full recovery at the initial physical visit also were associated with longer TTR. 241 For parent ratings, higher ratings of distress about their child’s concussion outcomes and about 242 their child’s well-being at the time of injury (TOI) were significantly associated with longer TTR. 243 Table 3 shows fully adjusted multivariable accelerated failure time models. For self-244 ratings (Tables 2S and 3S; see Supplemental materials for full models), higher pre-injury peer-245 related problems reported at baseline (TR, 1.10 [95% CI, 1.02-1.19]) and higher ratings of 246 distress about concussion outcomes acutely post-injury (TR, 1.06 [95% CI, 1.01-1.11]) were 247 associated with longer TTR. For every 1-point increase in self-ratings of peer problems or of 248 acute distress about their concussion outcomes, TTR increased by 10% and 6%, respectively. 249 Figure 2 presents probability curves for RTP based on low (10th percentile), median (50th 250 percentile), and high (90th percentile) ratings of adolescent self-reported ratings for (a) current 251 distress at TOI and (b) peer problems at baseline. 252 Fully adjusted models for parent ratings (Tables 4S and 5S; see Supplemental materials 253 for full models) showed that only parent acute ratings of higher distress about their child’s well-254 being at the TOI (time ratio [TR], 1.06 [95% confidence interval (CI), 1.02-1.09]) and about 255 concussion outcomes (TR, 1.05 [95% CI, 1.01-1.09]) remained associated with longer recovery. 256 For every 1-point increase in distress about their child’s well-being at the TOI or about their 257 child’s concussion outcomes, TTR increased by 6% and 5%, respectively. Figure 3 presents 258 probability curves for RTP based on low (10th percentile), median (50th percentile), and high 259 (90th percentile) acute parent ratings of (a) their distress about concussion outcomes and (b) 260 their distress about their child’s wellbeing. 261 Discussion 262 This study investigated psychosocial variables associated with time to physician 263 clearance for RTP in adolescent ice hockey players with concussion. The median TTR was 16 264 days, consistent with previous research suggesting that many youth with sports-related 265 concussion recover within 2-3 weeks of their injury (median of 178 and 1810 days). After 266 controlling for relevant covariates, adolescent reports of pre-injury peer problems at baseline 267 and levels of distress about their concussion outcomes acutely post-injury, as well as parent 268 levels of distress about their child’s well-being acutely post-injury, were associated with a 269 significant increase in time to RTP. 270 Few studies have investigated parent and youth distress and expectations as associated 271 with recovery, and to our knowledge this is the first to do so in adolescent ice hockey players. 272 Negative thinking about outcomes as reflected in distress and lower expectations of recovery 273 have not been well studied. ‘Nocebo effects’ occur when an individual has negative 274 expectations of outcomes that are associated with prolonged recovery or worsened 275 symptoms.57 Because much online information about concussion is not from reliable sources 276 and may be inaccurate,58,59 some parents and adolescents in the study may have experienced 277 ‘nocebo effects’, prolonging recovery. Parent and player distress and recovery expectations 278 likely reflect messaging by both clinicians and scientists, who should aim to provide accurate, 279 up-to-date information regarding the outcomes of concussion. Future studies should 280 investigate whether the accuracy of information that adolescents and their families have about 281 concussion is associated with their distress, expectancies of recovery, and TTR. 282 Parent-rated but not self-rated distress about the adolescent’s wellbeing at the TOI was 283 significantly associated with a longer TTR. Youth hockey players may tend to minimize their 284 vulnerability to concussion,60 and this may help explain why adolescent reports of distress 285 regarding their wellbeing at the TOI were not significantly associated with TTR. Higher parental 286 distress regarding their child’s wellbeing could be indicative of higher overall parent stress, 287 which has been shown to be associated with a decreased ability to help children cope with 288 injury and therefore may lead to prolonged recovery.61 289 In this study, self-reported peer-related problems was the pre-injury psychosocial factor 290 uniquely associated with TTR. Peer and other forms of social support have been shown to be 291 important in facilitating recovery from pediatric concussion; children identify a need to rely on 292 friends for support during recovery and adolescents who experience persistent PCS often 293 report lower levels of peer support.62,63 The adolescents in our study who reported more peer 294 problems may not have had the same access to social supports as adolescents who reported 295 fewer peer problems and may have therefore experienced a longer time to RTP. Peer-related 296 problems may also be a marker for other functional difficulties that put adolescents at risk of 297 persistent PCS.64 298 In this study, pre-injury QoL, psychological adjustment, resilience, perfectionism, and 299 parental involvement were not significantly related to TTR in multivariable models. These 300 findings could be a function of the outcome investigated in our study, clearance to RTP. Pre-301 injury QoL, adjustment, resilience, perfectionism, and parental involvement could be related to 302 symptom severity or other functional difficulties as opposed to RTP. 303 Our results have potential clinical implications. Education about appropriate 304 expectations about outcomes might assist in shortening TTR. Clinicians and scientists should 305 help to dispel concussion misinformation and aim to support more accurate expectations to aid 306 in recovery.57 Providing accurate information about recovery has been recommended for 307 pediatric concussion management,50 and future studies should investigate whether doing so 308 affects recovery expectations. Because more peer problems were associated with increased 309 time, promoting positive peer relationships also might help facilitate faster recovery. 310 Limitations 311 One study limitation is that questions regarding post-injury distress and expectations of 312 recovery were single items, which may limit their reliability and validity. Additionally, we did 313 not assess the nature or accuracy of the educational information about concussion that our 314 families received prior to or after their adolescent’s injury and that could account for potential 315 ‘nocebo’ effects. Our sample consisted of ice hockey players, which might limit generalizability 316 of the findings to athletes in other contact sports. Additionally, the participants were mostly 317 males and we could not investigate sex differences in post-acute distress and expectations of 318 recovery. Finally, our analyses of psychosocial variables collected at baseline and at TOI were 319 based on overlapping but distinct samples, which differed in history of concussion, body 320 checking policy, and age. However, we controlled for two of those variables in multivariable 321 analyses, and the groups did not differ on several other variables that are also associated with 322 TTR. Nevertheless, missing data from study participants with concussion may have introduced 323 unmeasured bias. 324 Conclusion 325 This study provides evidence that psychosocial factors are associated with 326 TTR following concussion in adolescent ice hockey players, over and above other well-studied 327 variables such as sex, body checking policy, initial symptom severity, and time to initial 328 physician visit. Specifically, parent-rated distress about their child’s wellbeing, parent and child 329 rated distress about concussion outcomes, and self-rated pre-injury peer problems were 330 associated with longer TTR, over and above other factors known to be related to recovery. 331 These results suggest potential targets for interventions to shorten recovery from concussion in 332 adolescents. 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Association of varying levels of self-reported (a) distress about outcomes and (b) peer 526 problems with probability of return to play (RTP). (a) A 60% probability of RTP is achieved at 527 ~23 days for a self-rating of distress at the 10th percentile (score = 1) but at ~36 days for a rating 528 at the 90th percentile (score=8). Put differently, the probability of RTP at 30 days post-injury is 529 ~80% for a rating of distress at the 10th percentile but only ~50% for a rating at the 90th 530 percentile. (b) A 60% probability of RTP is achieved at ~20 days for a self-rating of peer 531 problems at the 10th percentile (score=0) but at ~25 days for a rating at the 90th percentile 532 (score=3). Alternatively, the probability of RTP at 30 days post-injury is ~80% for a rating of peer 533 problems at the 10th percentile but only ~65% for a rating at the 90th percentile. 534 Figure 3. Association of varying levels of parent-rated (a) distress about their child’s outcomes 535 and (b) distress about their child’s well-being at with probability of return to play (RTP). (a) A 536 60% probability of RTP is achieved at ~25 days for a rating of parent distress about outcomes at 537 the 10th percentile (score=1) but at ~38 days for a rating at the 90th percentile (score=9). 538 Alternatively, the probability of RTP at 30 days post-injury is ~70% for a rating of distress at the 539 10th percentile but only ~50% for a rating at the 90th percentile. (b) A 60% probability of RTP is 540 achieved at ~23 days for a rating of parent distress about well-being at the time of injury at the 541 10th percentile but at ~36 days for a rating at the 90th percentile (score=10). Put differently, the 542 probability of RTP at 30 days post-injury is ~75% for rating of distress at the 10th percentile but 543 only 55% probability for a rating at the 90th percentile. 544 Table 1 1 Descriptive summary of psychosocial variables 2 Adolescent ratings Parent ratings N Mean Median SD Min 25th percentile 75th percentile Max N Mean Median SD Min 25th percentile 75th percentile Max Completed at time of preinjury assessment PISQ - DB 205 22.36 21 7.77 10 17 27 50 PISQ - PU 204 16.72 17 2.45 7 15 19 20 PISQ - AI 201 17.97 18 3.40 7 16 20 25 CD-RISC 214 29.02 29 5.41 17 26 33 40 QOL - physical 213 90.02 91 9.68 50 84 97 100 201 89.52 94 12.40 28 84 100 100 QOL - emotion 213 79.11 85 18.28 15 70 95 100 200 77.43 80 17.32 25 65 95 100 QOL - social 211 86.75 90 14.66 30 80 100 100 202 86.93 93 15.51 25 75 100 100 QOL - school 212 75.73 75 16.02 30 65 90 100 201 74.88 75 17.26 35 60 90 100 SDQ - emotion 213 2.21 2 2.04 0 1 4 9 200 1.78 1 1.81 0 0 3 7 SDQ - conduct 213 1.39 1 1.40 0 0 2 6 200 1.00 1 1.30 0 0 2 7 SDQ – ina/hyp 213 3.93 4 2.33 0 2 5 9 199 3.26 3 2.42 0 1 5 10 SDQ - peer 213 1.19 1 1.41 0 0 2 7 200 1.32 1 1.39 0 0 2 6 SDQ - prosocial 213 7.92 8 1.59 3 7 9 10 200 8.29 9 1.74 2 7 10 10 MPS - stand 218 24.05 24 4.23 13 21 27 34 MPS - concern 215 19.94 19 5.57 8 17 24 37 MPS - Ppress 218 21.63 22 5.67 9 18 25 36 MPS - doubts 218 14.44 14 4.02 6 12 17 26 MPS – org. 221 20.81 22 5.48 6 17 25 30 Completed at time of initial physician visit following concussion SUP - distress 226 5.29 6 2.80 1 3 7 10 216 7.42 8 2.47 1 6 10 10 SUP - outcome 225 4.05 3 2.65 1 2 6 10 216 5.29 5 2.90 1 3 8 10 SUP - recovery 225 9.31 10 1.50 3 9 10 10 218 9.12 10 1.76 1 9 10 10 Notes. Min=Minimum, Max=Maximum, N=number of concussions; SD=standard deviation; PISQ= Parent involvement in sport 3 questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience 4 Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport 5 Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental 6 questions (distress about well-being; distress about outcomes; beliefs about recovery). 7 8 Table 2 9 Bivariate accelerated failure time models predicting time to recovery 10 Adolescent ratings Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.01 0.01 0.99 1.02 0.59 PISQ - PU 147 141 111 0.97 0.03 0.92 1.03 0.33 PISQ - AI 145 139 109 0.98 0.02 0.94 1.03 0.44 CD-RISC 154 148 119 0.98 0.01 0.95 1.00 0.03 QOL - physical 158 152 121 0.99 0.01 0.98 1.01 0.25 147 141 111 1.00 0.01 0.99 1.01 0.95 QOL - emotion 158 152 121 0.99 0.00 0.99 1.00 0.11 147 141 111 1.00 0.00 1.00 1.01 0.35 QOL - social 158 152 121 1.00 0.00 0.99 1.01 0.76 148 142 112 1.00 0.01 0.99 1.01 0.99 QOL - school 158 152 121 0.99 0.00 0.98 1.00 0.09 147 141 111 1.00 0.00 0.99 1.01 0.94 SDQ - emotion 158 152 122 1.06 0.04 0.99 1.13 0.09 147 141 112 1.03 0.04 0.95 1.10 0.50 SDQ - conduct 158 152 122 1.06 0.06 0.94 1.19 0.34 147 141 112 0.97 0.05 0.87 1.07 0.50 SDQ - ina/hyp 158 152 122 1.07 0.03 1.01 1.14 0.02 146 140 111 0.97 0.03 0.92 1.02 0.27 SDQ - peer 158 152 122 1.12 0.06 1.01 1.23 0.03 147 141 112 1.01 0.08 0.87 1.17 0.94 SDQ - prosocial 158 152 122 1.07 0.05 0.97 1.17 0.19 147 141 112 1.06 0.04 0.99 1.13 0.12 MPS - stand 157 152 120 0.98 0.02 0.95 1.01 0.27 MPS - concern 154 150 118 1.01 0.01 0.98 1.03 0.54 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.96 MPS - doubts 158 153 121 1.00 0.02 0.96 1.03 0.84 MPS - org. 160 154 123 0.98 0.01 0.96 1.01 0.16 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.07 0.39 207 193 217 1.08 0.03 1.03 1.13 0.00 SUP - outcome 216 202 133 1.12 0.03 1.06 1.18 0.00 207 193 107 1.10 0.03 1.05 1.15 0.00 SUP - recovery 216 202 133 0.81 0.05 0.71 0.92 0.00 209 195 129 0.93 0.06 0.82 1.05 0.26 Notes. CI=confidence interval, Nc=number of concussions; Ny=number of youth; Nrtp=number of youth with return to play data; 11 TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= Parent involvement in sport questionnaire; 12 DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience Scale; 13 QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional 14 Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental questions (distress 15 about well-being; distress about outcomes; beliefs about recovery). 16 17 Table 3 18 Fully adjusted multivariable accelerated failure time models predicting time to recovery* 19 Adolescent rating Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.00 0.01 0.99 1.02 0.84 PISQ - PU 147 141 111 0.97 0.03 0.92 1.02 0.25 PISQ - AI 145 139 109 0.97 0.02 0.94 1.01 0.15 CD-RISC 154 148 119 0.99 0.01 0.97 1.01 0.20 QOL - physical 158 152 121 1.00 0.01 0.98 1.01 0.41 147 141 111 1.00 0.00 0.99 1.01 0.51 QOL - emotion 158 152 121 1.00 0.00 0.99 1.01 0.62 147 141 111 1.01 0.00 1.00 1.01 0.08 QOL - social 158 152 121 1.00 0.00 0.99 1.00 0.33 148 142 112 1.00 0.00 0.99 1.01 0.55 QOL - school 158 152 121 1.00 0.00 0.99 1.00 0.27 147 141 111 1.00 0.00 1.00 1.01 0.32 SDQ - emotion 158 152 122 1.01 0.03 0.94 1.07 0.86 147 141 112 1.00 0.03 0.94 1.06 0.95 SDQ - conduct 158 152 122 1.01 0.06 0.89 1.13 0.93 147 141 112 0.95 0.04 0.87 1.04 0.25 SDQ - ina/hyp 158 152 122 1.02 0.03 0.96 1.09 0.45 146 140 111 0.97 0.02 0.93 1.02 0.27 SDQ - peer 158 152 122 1.10 0.04 1.02 1.19 0.01 147 141 112 0.94 0.06 0.82 1.07 0.34 SDQ - prosocial 158 152 122 1.06 0.05 0.98 1.15 0.16 147 141 112 1.05 0.03 0.99 1.11 0.11 MPS - stand 157 152 120 0.98 0.01 0.96 1.01 0.25 MPS - concern 154 150 118 0.99 0.01 0.97 1.02 0.50 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.68 MPS - doubts 158 153 121 0.98 0.02 0.95 1.01 0.24 MPS - org. 160 154 123 0.99 0.01 0.97 1.01 0.32 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.05 0.34 207 193 217 1.06 0.02 1.02 1.09 0.00 SUP - outcome 216 202 133 1.06 0.02 1.01 1.11 0.01 207 193 107 1.05 0.02 1.01 1.09 0.01 SUP - recovery 216 202 133 0.90 0.06 0.80 1.02 0.11 209 195 129 0.96 0.04 0.89 1.04 0.30 Notes. *Adjusted for age, sex, body checking league, symptom severity score at the time of initial physician visit, and number of days 20 between concussion and initial physician visit; CI=confidence interval, Nc=number of concussions; Ny=number of youth; 21 Nrtp=number of youth with return to play data; TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= 22 Parent involvement in sport questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-23 RISC=Connor-Davidson Resilience Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; 24 ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental 25 pressure; org=organization; SUP=supplemental questions (distress about well-being; distress about outcomes; beliefs about 26 recovery). 27 Supplemental Tables and Figures 28 29 Table 1S: Demographic and other characteristics by availability of psychosocial data No psychosocial data Baseline psychosocial data only Time of injury psychosocial data only Both baseline and time of injury psychosocial data Total N % N % N % N % N % P value Sex males 133 87.5 138 86.8 40 85.1 168 88 479 87.3 .932 females 19 12.5 21 13.2 7 14.9 23 12 70 12.8 Previous concussion yes 81 53.3 79 49.7 29 61.7 86 45 275 50.1 .005 no 45 29.6 74 46.5 13 27.7 96 50.3 228 41.5 missing 26 17.1 6 3.8 5 10.6 9 4.7 46 8.4 Body checking yes 74 48.7 111 69.8 34 72.3 124 64.9 343 62.5 .043 no 54 35.5 45 28.3 10 21.3 66 34.6 175 31.9 missing 24 15.79 3 1.9 3 6.4 1 0.5 31 5.7 Days from injury to physician visit 42 27.6 29 18.2 12 25.5 37 19.4 120 21.9 .052 <=7 days 85 55.9 94 59.1 35 74.5 154 80.6 368 67 >7 days 25 16.5 36 22.6 0 0 61 11.1 missing Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Age statistic 13.8(1.7) 14(11-17) 14.2(1.5) 14(10-17) 14.5(1.5) 15(11-17) 13.5(1.5) 14(10-17) 13.9(1.6) 14(10-17) .001 missing (N) 14 2 0 5 21 Total symptom severity statistic 17.9(18.0) 13(0-73) 16.2(15.7) 11(0-81) 18.7(17.1) 12.8(0-71) 15.2(16.6) 10(0-73) 16.5(16.8) 11(0-81) .539 missing (N) 31 60 1 8 100 Days to recovery statistic 26.1(29.8) 18(0-180) 22.1(23.2) 16(1-156) 31(52.8) 18(4-361) 24.5(26.5) 17(0-190) 24.8(29.7) 17(0-361) .574 missing (N) 1 1 0 0 2 Total 152 27.7 159 29 47 8.6 191 34.8 549 100 *P-value calculated from Fisher’s exact test for categorical measures and a Wilcoxon rank-sum test for equality of medians with Fisher’s exact p-values for continuous measures. 30 Table 2S 31 Adjusted multivariable accelerated failure time model examining preinjury peer relationship 32 problems reported by children (n=158) 33 95% CI TR SE Lower bound Upper bound p Age 1.075 0.043 0.995 1.162 0.068 Sex (female) 0.685 0.117 0.490 0.958 0.027 Body checking (no) 1.446 0.194 1.111 1.882 0.006 Time to physician visit 1.263 0.272 0.828 1.926 0.279 Symptom severity 1.023 0.004 1.014 1.031 0.000 SDQ - peer 1.103 0.042 1.024 1.189 0.010 Constant 3.989 2.313 1.280 12.432 0.017 Note. CI=confidence interval; TR=time ratio; SE=standard error; SDQ=Strengths and Difficulties 34 Questionnaire. 35 36 Table 3S 37 Adjusted multivariable accelerated failure time model examining distress about concussion 38 outcomes reported by adolescent (n=216) 39 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.016 Sex (female) 0.893 0.177 0.605 1.317 0.567 Body checking (no) 1.431 0.207 1.078 1.900 0.013 Time to physician visit 1.600 0.218 1.226 2.088 0.001 Symptom severity 1.016 0.004 1.009 1.024 0.000 SUP - outcomes 1.061 0.024 1.014 1.110 0.010 Constant 11.219 1.255 9.010 13.970 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 40 (distress about outcomes). 41 42 Table 4S 43 Adjusted multivariable accelerated failure time model examining distress about adolescent’s 44 well-being reported by parents (n=207) 45 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 0.999 1.000 0.710 Sex (female) 0.935 0.164 0.664 1.318 0.702 Body checking (no) 1.552 0.226 1.167 2.065 0.003 Time to physician visit 1.874 0.276 1.404 2.502 0.000 Symptom severity 1.020 0.004 1.013 1.028 0.000 SUP - distress 1.059 0.018 1.023 1.095 0.001 Constant 8.467 1.251 6.339 11.310 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 46 (distress about child’s well-being). 47 48 Table 5S 49 Adjusted multivariable accelerated failure time model examining distress about concussion 50 outcomes reported by parents (n=207) 51 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.664 Sex (female) 0.997 0.193 0.682 1.456 0.986 Body checking (no) 1.558 0.229 1.168 2.077 0.003 Time to physician visit 1.745 0.260 1.303 2.338 0.000 Symptom severity 1.018 0.004 1.010 1.027 0.000 SUP - outcome 1.051 0.019 1.014 1.090 0.007 Constant 10.135 1.158 8.102 12.678 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 52 (distress about child’s outcomes). 53 This is a non-final version of an article published in final form in Luszawski, Caroline A. MSc*,†; Plourde, Vickie PhD‡,§,¶; Sick, Stacy R. BSc, CAT(C)║; Galarneau, Jean-Michel PhD║; Eliason, Paul H. PhD║; Brooks, Brian L. PhD*,†,**,††; Mrazik, Martin PhD‡‡; Debert, Chantel T. MD, MSc§§,¶¶; Lebrun, Constance MDCM║║; Babul, Shelina PhD***; Hagel, Brent E. PhD†,║,†††; Dukelow, Sean P. MD, PhD§§,¶¶,‡‡‡; Schneider, Kathryn J. PhD†,║,¶¶,§§§; Emery, Carolyn A. PhD†,║,¶¶,†††; Yeates, Keith Owen PhD*,†,¶¶. Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players. Clinical Journal of Sport Medicine 34(3):p 256-265, May 2024. | DOI: 10.1097/JSM.0000000000001187 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 1 Ice Hockey Players 2 3 Caroline A Luszawski, MSc1,2, Vickie Plourde, PhD3-5, Stacy R Sick, BSc, CAT(C)6, Jean-Michel 4 Galarneau, PhD6, Paul H Eliason, PhD6, Brian L Brooks, PhD1,2,7,8, Martin Mrazik, PhD9, Chantel T 5 Debert, MD, MSc10,11, Constance Lebrun, MDCM12, Shelina Babul, PhD13, Brent E Hagel, 6 PhD2,6,14, Sean P Dukelow MD PhD10,11,15, Kathryn J Schneider, PhD2,6,11,16, Carolyn A Emery 7 PhD,2,6,11,17, Keith Owen Yeates, PhD1,2,11 8 9 1University of Calgary Department of Psychology, Alberta, Canada 10 2Alberta Children’s Hospital Research Institute, Alberta, Canada 11 3School of Psychology, Université de Moncton, New Brunswick, Canada 12 4Centre de formation médicale du Nouveau-Brunswick, Université de Sherbrooke, New 13 Brunswick, Canada 14 5Faculté Saint-Jean, University of Alberta, Alberta, Canada 15 6Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, 16 Canada 17 7Alberta Children’s Hospital, Neurosciences Program, Alberta, Canada 18 8University of Calgary, Departments of Pediatrics and Clinical Neurosciences 19 9Department of Educational Psychology, University of Alberta 20 10Department of Clinical Neurosciences, University of Calgary, Alberta, Canada 21 11Hotchkiss Brain Institute, University of Calgary, Alberta, Canada 22 12Glen Sather Sports Medicine Clinic, Department of Family Medicine, Faculty of Medicine & 23 Dentistry, University of Alberta, Edmonton, Alberta 24 13University of British Columbia, Department of Pediatrics, Faculty of Medicine, BC Children’s 25 Hospital, Vancouver, BC, Canada 26 14Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 27 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 28 15Cumming School of Medicine, University of Calgary, Alberta, Canada 29 16Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada 30 17Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 31 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 32 33 Correspondence: Caroline A Luszawski MSc; Department of Psychology, University of Calgary, 34 2500 University Drive NW, Calgary, AB T2N 1N4; Tel: 416-389-5664; Fax: 403-282-8249; Email: 35 caroline.luszawski@ucalgary.ca 36 37 Conflicts of Interest and Source of Funding: 38 Brian Brooks receives royalties for the sales of the Pediatric Forensic Neuropsychology textbook 39 (Oxford University Press), royalties for three pediatric neuropsychological tests [Child and 40 Adolescent Memory Profile (ChAMP, Sherman and Brooks, 2015, PAR Inc.), Memory Validity 41 Profile (MVP, Sherman and Brooks, 2015, PAR Inc.), and Multidimensional Everyday Memory 42 Ratings for Youth (MEMRY, Sherman and Brooks, 2017, PAR Inc.)], and has a private practice 43 where he evaluates youth and professional hockey players with concussion. For the remaining 44 authors no conflicts of interest were noted. 45 We acknowledge funding from the Canadian Institutes of Health Research and Hotchkiss Brain 46 Institute. 47 Acknowledgements: The Sport Injury Prevention Research Centre is one of the International 48 Research Centres for Prevention of Injury and Protection of Athlete Health supported by the 49 International Olympic Committee. We acknowledge funding from the Canadian Institutes of 50 Health Research (C Emery PI) and Hotchkiss Brain Institute for the Safe2Play project. Dr. Yeates 51 holds the Ronald and Irene Ward Chair in Pediatric Brain Injury, funded by the Alberta 52 Children’s Hospital Foundation. Dr. Emery holds a Canada Research Chair (Tier 1) in Concussion. 53 Dr. Brooks acknowledges salary funding from the Canadian Institutes for Health Research 54 Embedded Clinician Researcher Salary Award during the collection of these data. 55 Abstract Word Count: 246. Manuscript Word Count: 2999 56 Abstract 57 Objective: To investigate the association between psychosocial factors and physician clearance 58 to return to play (RTP) in youth ice hockey players following sport-related concussion. 59 Design: Prospective cohort study, Safe-to-Play (2013-2018). 60 Setting: Youth hockey leagues in Alberta and British Columbia, Canada. 61 Participants: 353 ice hockey players (aged 11-18 years) who sustained a total of 397 physician-62 diagnosed concussions. 63 Independent Variables: Psychosocial variables. 64 Main Outcome Measures: Players and parents completed psychosocial questionnaires 65 preinjury. Players with a suspected concussion were referred for a study physician visit, during 66 which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single 67 question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured 68 as days between concussion and physician clearance to RTP. Accelerated failure time models 69 estimated the association of psychosocial factors associated with TTR, summarized with time 70 ratios (TR). Covariates included age, sex, body checking policy, days from concussion to initial 71 physician visit, and symptom severity at initial physician visit. 72 Results: Self-report of increased peer-related problems on the Strengths and Difficulties 73 Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion 74 outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-75 1.09]), and higher parent ratings of distress about their child’s well-being at the time of injury 76 (TR, 1.06 [95% CI, 1.02-1.09]), were associated with longer recovery. 77 Conclusions: Greater pre-existing peer-related problems and acute distress about concussion 78 outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial 79 factors following concussion may promote recovery. 80 81 Key Words: concussion, psychosocial, recovery, child, adolescent, brain injury 82 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 83 Ice Hockey Players 84 Introduction 85 Concussion rates in children and adolescents are steadily increasing1 and can lead to 86 significant functional impairment.2 Most children recover fully within a few weeks, but up to a 87 third will experience persistent post-concussive symptoms (PCS)3 (which include a range of 88 cognitive, physical, and emotional complaints) and delayed recovery for a month or longer.4 89 Children in collision sports are at an increased risk of sustaining concussion.5 In sports 90 such as ice hockey, more elite levels of play and policy allowing body checking in games are 91 associated with higher concussion rates.6,7 92 Factors such as age3, sex3,8, and history of previous head injury8,9 have been associated 93 with recovery in studies of pediatric concussion arising in sport. In a previous study of 94 predictors of recovery from pediatric concussion in youth ice hockey players, physician 95 clearance to return to play (RTP) was prolonged for players who took longer than 7 days before 96 their initial physician assessment, had poorer tandem stance, reported moderate/severe 97 headache, or had greater symptom severity at their first physician visit.10 98 A few studies have investigated the association between psychosocial factors and time 99 to recovery (TTR) in youth athletes11–13 and outcome measures such as persistent PCS, which 100 may be associated with delayed RTP.8 Results suggest that factors such as pre-injury health 101 related quality of life (QoL)14, resilience15,16, and adjustment14 may be associated with delayed 102 recovery in youth following concussion. 103 Child and parent characteristics, such as parental support17,18 or child perfectionism19, 104 may influence a child’s risk of injury. To our knowledge, however, neither parental involvement 105 nor perfectionism have been investigated in relation to recovery from pediatric concussion. 106 However, studies of sport-related injuries more generally indicate that parental over-107 involvement may be associated with over-use injuries in childhood through pressure to 108 specialize early and spend increased time in sports.19,20 Similarly, child perfectionism has been 109 associated with increased risk of injury in youth athletes and may affect recovery from injury.21–110 24 111 In adults, perceptions of acute distress and expectations of recovery appear to play an 112 important role in the development of PCS25–28 However, these factors have rarely been 113 investigated in relationship to pediatric concussion,29,30 although negative perceptions of injury 114 have been associated with more persistent PCS and emotional distress in adolescents.30 115 Few studies have investigated whether psychosocial factors are associated with delayed 116 recovery following pediatric concussion over and above well-established predictors such as sex 117 and days to initial physician visit.31 Further study of psychosocial factors potentially associated 118 with recovery could help identify adolescents more likely to experience prolonged recovery, aid 119 in the design of interventions to prevent persistent PCS, and help adolescents return to school 120 and play faster after concussion. 121 The current study sought to investigate the association of pre-injury and post-acute 122 psychosocial factors with time to physician clearance to RTP in adolescent ice hockey players 123 with sport-related concussion. The current study also sought to investigate whether the 124 psychosocial factors added incrementally to other factors previously identified as associated 125 with RTP in the same sample (e.g., time to initial physician assessment, tandem stance errors, 126 symptom severity) at initial physician assessment. Specifically, we hypothesized that lower pre-127 injury QoL, psychological adjustment, resilience, and expectations of recovery would lead to 128 longer TTR. We also hypothesized that higher perfectionism, parental involvement and post-129 acute parent and child distress would lead to longer TTR. 130 Methods 131 Study Design 132 This is a secondary, planned analysis of data drawn from a larger prospective cohort 133 study, Safe to Play, that evaluated concussions and injuries in youth ice hockey players over 5 134 seasons (2013-2018). This cohort included only those players who sustained a suspected sport-135 related concussion and were later diagnosed by a study physician. 136 Participants 137 Sample size was determined a priori for the larger Safe to Play study.10 Participants were 138 eligible for inclusion if they participated in male or female leagues and were registered with 139 Hockey Vancouver, Calgary or Edmonton, or surrounding area leagues, were between the ages 140 of 11 and 17 years, and had written informed player consent (for those 15 and older) or assent 141 and parent consent if needed.10,32 Players were excluded if they had a previous injury or illness 142 preventing full participation in hockey at start of season. 143 Measures 144 Strengths and Difficulties Questionnaire (SDQ). The SDQ assesses psychosocial adjustment using 145 a 25-item scale.33. Both self-report and parent proxy versions were completed at preinjury 146 assessments. The SDQ has shown satisfactory reliability and validity.33–35 147 Pediatric Quality of Life Inventory (PedsQL). The PedsQL is a 23-item questionnaire that 148 measures health-related quality of life.36. Both self-rated and parent-proxy versions were 149 completed at preinjury assessments. Reliability and validity of the PedsQL are well 150 established.36–38 151 Connor Davidson Resiliency scale (CD-RISC). The CD-RISC is a 10 item questionnaire that 152 measures the ability to cope with adversity.39 Originally developed in adults, the CD-RISC has 153 shown adequate validity in children as well.39–41 154 The Sport Multidimensional Perfectionism Scale (Sport-MPS2). The Sport-MPS2 is a self-report 155 questionnaire that assesses perfectionistic tendencies within sport. The Sport MPS2 has shown 156 adequate construct validity.42,43 157 Parent involvement in sport questionnaire (PISQ). The PISQ is a 19 item questionnaire that 158 assesses parental behaviour within the sport context.44,45 The scales on the PISQ have shown 159 satisfactory internal reliability.44 160 Distress and recovery expectation questions. Three questions were asked at the initial post-161 injury physician visit regarding distress felt by the player (or parent) at the time of the injury, 162 distress felt by the player (or parent) about injury outcomes at the time of the initial physician 163 visit, and whether the player (or parent) believed the player would make a full recovery. All 164 three questions were rated on a 10-point Likert scale. The questions were modeled on items 165 from the Timeline and Emotional Representations subscales of the Revised Illness Perception 166 Questionnaire.46 These subscales are intended to assess the player’s and parent’s illness 167 representations, which are important mediators of health outcomes.47 168 Procedure 169 A previously validated injury surveillance methodology in youth ice hockey was used to 170 collect injury and participation information.47 This included a preinjury baseline questionnaire, 171 the Sport Concussion Assessment Tool48 (SCAT3 in years 1-4; SCAT 5 in year 5), weekly exposure 172 sheets, and injury report forms (IRF).47,49–51 Psychosocial and behavioural questionnaires were 173 also administered to players as part of baseline testing. In years 2 through 5 of the Safe to Play 174 study, these included the SDQ, PedsQL, CD-RISC, and Sport-MPS2. Additionally, parents 175 completed the parent/guardian version of the SDQ, PedsQL, and PISQ. 176 Teams participating in the study assigned a team designate (e.g., manager, safety coach) 177 who collected weekly exposure sheets and identified players with a suspected concussion or 178 injury occurring from participation in ice hockey. All players with a suspected concussion had 179 the opportunity to follow up with a study sports medicine physician. Study physicians used the 180 most current international consensus statement in sport to define a concussion, standardize 181 assessment procedures at initial and follow up assessments, and clear a participant to return to 182 sport following the standardized RTP protocol (year 1 to 4)51 or return to sport strategy (year 183 5).50 184 The SCAT3 or SCAT5, which contained the symptom rating scale, was completed at the 185 initial physician visit after a concussion. The symptom rating scale was the same on the SCAT3 186 and SCAT5.49,50 The three supplemental questions regarding distress and expected outcome of 187 injury were also completed by players and parents at the initial visit. 188 Study physician clearance to RTP was based on concussion related symptoms and 189 completion of the RTP protocol as defined by the most recent international consensus 190 statement on concussion in sport at the time.50,51 TTR was defined as the number of days 191 between the date of injury as reported on the IRF and study physician clearance to RTP. 192 Statistical Analyses 193 Statistical analyses were conducted using Stata 17.52 Alpha level was set at .05. 194 Participants included in analyses had at least one concussion diagnosed by a study sports 195 medicine physician and completed at least one of the psychosocial measures (SDQ, PedsQL, CD-196 RISC, Sport-MPS2, PISQ at preinjury assessments, and questions regarding distress and recovery 197 expectations at the time of the initial physician appointment). 198 Descriptive statistics (frequencies and proportions) were computed to document sample 199 characteristics. Because our interest was in time to clearance for RTP,53 accelerated failure time 200 models with loglogistic distribution (bivariate and fully adjusted multivariable models) were 201 generated using complete case analysis to examine the association between psychosocial 202 factors and TTR.10 Repeat concussions for players participating across multiple seasons were 203 handled using clustered standard errors. The date of RTP was based on IRF or weekly exposure 204 sheets if data were not available in physician records.10 The IRF was completed by study 205 personnel if a participant did not complete a final physician visit. Players who were lost to 206 follow-up were censored in the statistical models. 207 We selected covariates according to available data and previous research showing 208 associations with TTR.3,10,54 Covariates included age, sex (male, female), body checking policy 209 (permitted/not permitted), days from concussion to physician visit (7 days or less versus more 210 than 7 days55,56), and symptom severity measured at the initial physician visit (SCAT3 or SCAT5 211 total symptom severity score10). 212 Results 213 Participants 214 A total of 4419 adolescents were recruited for the larger parent study over a five-year 215 period (6584 player seasons); however, the psychosocial questionnaires of interest were only 216 introduced in the second year (season 2014-2015) of the study (see Figure 1). This yielded 4080 217 individual players and 5762 player seasons (N2014-15 = 1398, N2015-16 = 1902, N2016-17 = 1319, 218 N2017-18 = 1143) potentially eligible for analysis. During these seasons, 549 concussions were 219 diagnosed by a study physician, and 397 (72%) had data available for at least one psychosocial 220 measure (Figure 1); 159 (29%) had baseline psychosocial data only, 47 (9%) had psychosocial 221 data only at the initial physician visit, and 191 (35%) had psychosocial data at both times 222 (Supplemental materials, Table 1S). These subgroups did not differ significantly in sex, days to 223 initial physician visit, symptom severity at the initial physician visit, or TTR, but did differ in the 224 likelihood of a previous concussion and of playing in a body checking league and in average age. 225 As noted above, multivariable analyses controlled for age and body checking policy; previous 226 concussion was not controlled because it was not predictive of TTR in our previous study.10 227 A total of 353 players accounted for the 397 concussions (M age=13.90 years; SD=1.53). 228 Most concussions involved males (n=346; 87.2%) and players in a body checking league (n=269; 229 67.8%). Physicians evaluated most concussions within 7 days of injury (n=283; 71.3%) and 230 slightly less than half (n=183; 46.1%) of the concussions were not preceded by another 231 concussion that occurred before the start of the season. Median acute total symptom severity 232 score (/132) at the initial physician visit was 10.0 (IQR=3-23.5). Median time to being cleared to 233 play, for those not lost to follow-up, was 16 days (IQR=11-27). Table 1 presents descriptive data 234 for psychosocial measures. 235 Factors Associated with Time to Recovery 236 Table 2 reports bivariate accelerated failure time models for all psychosocial variables. 237 Lower levels of resilience and higher levels of inattention/hyperactivity and peer relationship 238 problems reported by adolescents at baseline were significantly associated with a longer TTR in 239 bivariate analyses. Higher ratings of distress about concussion outcomes and lower 240 expectations of a full recovery at the initial physical visit also were associated with longer TTR. 241 For parent ratings, higher ratings of distress about their child’s concussion outcomes and about 242 their child’s well-being at the time of injury (TOI) were significantly associated with longer TTR. 243 Table 3 shows fully adjusted multivariable accelerated failure time models. For self-244 ratings (Tables 2S and 3S; see Supplemental materials for full models), higher pre-injury peer-245 related problems reported at baseline (TR, 1.10 [95% CI, 1.02-1.19]) and higher ratings of 246 distress about concussion outcomes acutely post-injury (TR, 1.06 [95% CI, 1.01-1.11]) were 247 associated with longer TTR. For every 1-point increase in self-ratings of peer problems or of 248 acute distress about their concussion outcomes, TTR increased by 10% and 6%, respectively. 249 Figure 2 presents probability curves for RTP based on low (10th percentile), median (50th 250 percentile), and high (90th percentile) ratings of adolescent self-reported ratings for (a) current 251 distress at TOI and (b) peer problems at baseline. 252 Fully adjusted models for parent ratings (Tables 4S and 5S; see Supplemental materials 253 for full models) showed that only parent acute ratings of higher distress about their child’s well-254 being at the TOI (time ratio [TR], 1.06 [95% confidence interval (CI), 1.02-1.09]) and about 255 concussion outcomes (TR, 1.05 [95% CI, 1.01-1.09]) remained associated with longer recovery. 256 For every 1-point increase in distress about their child’s well-being at the TOI or about their 257 child’s concussion outcomes, TTR increased by 6% and 5%, respectively. Figure 3 presents 258 probability curves for RTP based on low (10th percentile), median (50th percentile), and high 259 (90th percentile) acute parent ratings of (a) their distress about concussion outcomes and (b) 260 their distress about their child’s wellbeing. 261 Discussion 262 This study investigated psychosocial variables associated with time to physician 263 clearance for RTP in adolescent ice hockey players with concussion. The median TTR was 16 264 days, consistent with previous research suggesting that many youth with sports-related 265 concussion recover within 2-3 weeks of their injury (median of 178 and 1810 days). After 266 controlling for relevant covariates, adolescent reports of pre-injury peer problems at baseline 267 and levels of distress about their concussion outcomes acutely post-injury, as well as parent 268 levels of distress about their child’s well-being acutely post-injury, were associated with a 269 significant increase in time to RTP. 270 Few studies have investigated parent and youth distress and expectations as associated 271 with recovery, and to our knowledge this is the first to do so in adolescent ice hockey players. 272 Negative thinking about outcomes as reflected in distress and lower expectations of recovery 273 have not been well studied. ‘Nocebo effects’ occur when an individual has negative 274 expectations of outcomes that are associated with prolonged recovery or worsened 275 symptoms.57 Because much online information about concussion is not from reliable sources 276 and may be inaccurate,58,59 some parents and adolescents in the study may have experienced 277 ‘nocebo effects’, prolonging recovery. Parent and player distress and recovery expectations 278 likely reflect messaging by both clinicians and scientists, who should aim to provide accurate, 279 up-to-date information regarding the outcomes of concussion. Future studies should 280 investigate whether the accuracy of information that adolescents and their families have about 281 concussion is associated with their distress, expectancies of recovery, and TTR. 282 Parent-rated but not self-rated distress about the adolescent’s wellbeing at the TOI was 283 significantly associated with a longer TTR. Youth hockey players may tend to minimize their 284 vulnerability to concussion,60 and this may help explain why adolescent reports of distress 285 regarding their wellbeing at the TOI were not significantly associated with TTR. Higher parental 286 distress regarding their child’s wellbeing could be indicative of higher overall parent stress, 287 which has been shown to be associated with a decreased ability to help children cope with 288 injury and therefore may lead to prolonged recovery.61 289 In this study, self-reported peer-related problems was the pre-injury psychosocial factor 290 uniquely associated with TTR. Peer and other forms of social support have been shown to be 291 important in facilitating recovery from pediatric concussion; children identify a need to rely on 292 friends for support during recovery and adolescents who experience persistent PCS often 293 report lower levels of peer support.62,63 The adolescents in our study who reported more peer 294 problems may not have had the same access to social supports as adolescents who reported 295 fewer peer problems and may have therefore experienced a longer time to RTP. Peer-related 296 problems may also be a marker for other functional difficulties that put adolescents at risk of 297 persistent PCS.64 298 In this study, pre-injury QoL, psychological adjustment, resilience, perfectionism, and 299 parental involvement were not significantly related to TTR in multivariable models. These 300 findings could be a function of the outcome investigated in our study, clearance to RTP. Pre-301 injury QoL, adjustment, resilience, perfectionism, and parental involvement could be related to 302 symptom severity or other functional difficulties as opposed to RTP. 303 Our results have potential clinical implications. Education about appropriate 304 expectations about outcomes might assist in shortening TTR. Clinicians and scientists should 305 help to dispel concussion misinformation and aim to support more accurate expectations to aid 306 in recovery.57 Providing accurate information about recovery has been recommended for 307 pediatric concussion management,50 and future studies should investigate whether doing so 308 affects recovery expectations. Because more peer problems were associated with increased 309 time, promoting positive peer relationships also might help facilitate faster recovery. 310 Limitations 311 One study limitation is that questions regarding post-injury distress and expectations of 312 recovery were single items, which may limit their reliability and validity. Additionally, we did 313 not assess the nature or accuracy of the educational information about concussion that our 314 families received prior to or after their adolescent’s injury and that could account for potential 315 ‘nocebo’ effects. Our sample consisted of ice hockey players, which might limit generalizability 316 of the findings to athletes in other contact sports. Additionally, the participants were mostly 317 males and we could not investigate sex differences in post-acute distress and expectations of 318 recovery. Finally, our analyses of psychosocial variables collected at baseline and at TOI were 319 based on overlapping but distinct samples, which differed in history of concussion, body 320 checking policy, and age. However, we controlled for two of those variables in multivariable 321 analyses, and the groups did not differ on several other variables that are also associated with 322 TTR. Nevertheless, missing data from study participants with concussion may have introduced 323 unmeasured bias. 324 Conclusion 325 This study provides evidence that psychosocial factors are associated with 326 TTR following concussion in adolescent ice hockey players, over and above other well-studied 327 variables such as sex, body checking policy, initial symptom severity, and time to initial 328 physician visit. Specifically, parent-rated distress about their child’s wellbeing, parent and child 329 rated distress about concussion outcomes, and self-rated pre-injury peer problems were 330 associated with longer TTR, over and above other factors known to be related to recovery. 331 These results suggest potential targets for interventions to shorten recovery from concussion in 332 adolescents. 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Association of varying levels of self-reported (a) distress about outcomes and (b) peer 526 problems with probability of return to play (RTP). (a) A 60% probability of RTP is achieved at 527 ~23 days for a self-rating of distress at the 10th percentile (score = 1) but at ~36 days for a rating 528 at the 90th percentile (score=8). Put differently, the probability of RTP at 30 days post-injury is 529 ~80% for a rating of distress at the 10th percentile but only ~50% for a rating at the 90th 530 percentile. (b) A 60% probability of RTP is achieved at ~20 days for a self-rating of peer 531 problems at the 10th percentile (score=0) but at ~25 days for a rating at the 90th percentile 532 (score=3). Alternatively, the probability of RTP at 30 days post-injury is ~80% for a rating of peer 533 problems at the 10th percentile but only ~65% for a rating at the 90th percentile. 534 Figure 3. Association of varying levels of parent-rated (a) distress about their child’s outcomes 535 and (b) distress about their child’s well-being at with probability of return to play (RTP). (a) A 536 60% probability of RTP is achieved at ~25 days for a rating of parent distress about outcomes at 537 the 10th percentile (score=1) but at ~38 days for a rating at the 90th percentile (score=9). 538 Alternatively, the probability of RTP at 30 days post-injury is ~70% for a rating of distress at the 539 10th percentile but only ~50% for a rating at the 90th percentile. (b) A 60% probability of RTP is 540 achieved at ~23 days for a rating of parent distress about well-being at the time of injury at the 541 10th percentile but at ~36 days for a rating at the 90th percentile (score=10). Put differently, the 542 probability of RTP at 30 days post-injury is ~75% for rating of distress at the 10th percentile but 543 only 55% probability for a rating at the 90th percentile. 544 Table 1 1 Descriptive summary of psychosocial variables 2 Adolescent ratings Parent ratings N Mean Median SD Min 25th percentile 75th percentile Max N Mean Median SD Min 25th percentile 75th percentile Max Completed at time of preinjury assessment PISQ - DB 205 22.36 21 7.77 10 17 27 50 PISQ - PU 204 16.72 17 2.45 7 15 19 20 PISQ - AI 201 17.97 18 3.40 7 16 20 25 CD-RISC 214 29.02 29 5.41 17 26 33 40 QOL - physical 213 90.02 91 9.68 50 84 97 100 201 89.52 94 12.40 28 84 100 100 QOL - emotion 213 79.11 85 18.28 15 70 95 100 200 77.43 80 17.32 25 65 95 100 QOL - social 211 86.75 90 14.66 30 80 100 100 202 86.93 93 15.51 25 75 100 100 QOL - school 212 75.73 75 16.02 30 65 90 100 201 74.88 75 17.26 35 60 90 100 SDQ - emotion 213 2.21 2 2.04 0 1 4 9 200 1.78 1 1.81 0 0 3 7 SDQ - conduct 213 1.39 1 1.40 0 0 2 6 200 1.00 1 1.30 0 0 2 7 SDQ – ina/hyp 213 3.93 4 2.33 0 2 5 9 199 3.26 3 2.42 0 1 5 10 SDQ - peer 213 1.19 1 1.41 0 0 2 7 200 1.32 1 1.39 0 0 2 6 SDQ - prosocial 213 7.92 8 1.59 3 7 9 10 200 8.29 9 1.74 2 7 10 10 MPS - stand 218 24.05 24 4.23 13 21 27 34 MPS - concern 215 19.94 19 5.57 8 17 24 37 MPS - Ppress 218 21.63 22 5.67 9 18 25 36 MPS - doubts 218 14.44 14 4.02 6 12 17 26 MPS – org. 221 20.81 22 5.48 6 17 25 30 Completed at time of initial physician visit following concussion SUP - distress 226 5.29 6 2.80 1 3 7 10 216 7.42 8 2.47 1 6 10 10 SUP - outcome 225 4.05 3 2.65 1 2 6 10 216 5.29 5 2.90 1 3 8 10 SUP - recovery 225 9.31 10 1.50 3 9 10 10 218 9.12 10 1.76 1 9 10 10 Notes. Min=Minimum, Max=Maximum, N=number of concussions; SD=standard deviation; PISQ= Parent involvement in sport 3 questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience 4 Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport 5 Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental 6 questions (distress about well-being; distress about outcomes; beliefs about recovery). 7 8 Table 2 9 Bivariate accelerated failure time models predicting time to recovery 10 Adolescent ratings Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.01 0.01 0.99 1.02 0.59 PISQ - PU 147 141 111 0.97 0.03 0.92 1.03 0.33 PISQ - AI 145 139 109 0.98 0.02 0.94 1.03 0.44 CD-RISC 154 148 119 0.98 0.01 0.95 1.00 0.03 QOL - physical 158 152 121 0.99 0.01 0.98 1.01 0.25 147 141 111 1.00 0.01 0.99 1.01 0.95 QOL - emotion 158 152 121 0.99 0.00 0.99 1.00 0.11 147 141 111 1.00 0.00 1.00 1.01 0.35 QOL - social 158 152 121 1.00 0.00 0.99 1.01 0.76 148 142 112 1.00 0.01 0.99 1.01 0.99 QOL - school 158 152 121 0.99 0.00 0.98 1.00 0.09 147 141 111 1.00 0.00 0.99 1.01 0.94 SDQ - emotion 158 152 122 1.06 0.04 0.99 1.13 0.09 147 141 112 1.03 0.04 0.95 1.10 0.50 SDQ - conduct 158 152 122 1.06 0.06 0.94 1.19 0.34 147 141 112 0.97 0.05 0.87 1.07 0.50 SDQ - ina/hyp 158 152 122 1.07 0.03 1.01 1.14 0.02 146 140 111 0.97 0.03 0.92 1.02 0.27 SDQ - peer 158 152 122 1.12 0.06 1.01 1.23 0.03 147 141 112 1.01 0.08 0.87 1.17 0.94 SDQ - prosocial 158 152 122 1.07 0.05 0.97 1.17 0.19 147 141 112 1.06 0.04 0.99 1.13 0.12 MPS - stand 157 152 120 0.98 0.02 0.95 1.01 0.27 MPS - concern 154 150 118 1.01 0.01 0.98 1.03 0.54 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.96 MPS - doubts 158 153 121 1.00 0.02 0.96 1.03 0.84 MPS - org. 160 154 123 0.98 0.01 0.96 1.01 0.16 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.07 0.39 207 193 217 1.08 0.03 1.03 1.13 0.00 SUP - outcome 216 202 133 1.12 0.03 1.06 1.18 0.00 207 193 107 1.10 0.03 1.05 1.15 0.00 SUP - recovery 216 202 133 0.81 0.05 0.71 0.92 0.00 209 195 129 0.93 0.06 0.82 1.05 0.26 Notes. CI=confidence interval, Nc=number of concussions; Ny=number of youth; Nrtp=number of youth with return to play data; 11 TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= Parent involvement in sport questionnaire; 12 DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience Scale; 13 QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional 14 Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental questions (distress 15 about well-being; distress about outcomes; beliefs about recovery). 16 17 Table 3 18 Fully adjusted multivariable accelerated failure time models predicting time to recovery* 19 Adolescent rating Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.00 0.01 0.99 1.02 0.84 PISQ - PU 147 141 111 0.97 0.03 0.92 1.02 0.25 PISQ - AI 145 139 109 0.97 0.02 0.94 1.01 0.15 CD-RISC 154 148 119 0.99 0.01 0.97 1.01 0.20 QOL - physical 158 152 121 1.00 0.01 0.98 1.01 0.41 147 141 111 1.00 0.00 0.99 1.01 0.51 QOL - emotion 158 152 121 1.00 0.00 0.99 1.01 0.62 147 141 111 1.01 0.00 1.00 1.01 0.08 QOL - social 158 152 121 1.00 0.00 0.99 1.00 0.33 148 142 112 1.00 0.00 0.99 1.01 0.55 QOL - school 158 152 121 1.00 0.00 0.99 1.00 0.27 147 141 111 1.00 0.00 1.00 1.01 0.32 SDQ - emotion 158 152 122 1.01 0.03 0.94 1.07 0.86 147 141 112 1.00 0.03 0.94 1.06 0.95 SDQ - conduct 158 152 122 1.01 0.06 0.89 1.13 0.93 147 141 112 0.95 0.04 0.87 1.04 0.25 SDQ - ina/hyp 158 152 122 1.02 0.03 0.96 1.09 0.45 146 140 111 0.97 0.02 0.93 1.02 0.27 SDQ - peer 158 152 122 1.10 0.04 1.02 1.19 0.01 147 141 112 0.94 0.06 0.82 1.07 0.34 SDQ - prosocial 158 152 122 1.06 0.05 0.98 1.15 0.16 147 141 112 1.05 0.03 0.99 1.11 0.11 MPS - stand 157 152 120 0.98 0.01 0.96 1.01 0.25 MPS - concern 154 150 118 0.99 0.01 0.97 1.02 0.50 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.68 MPS - doubts 158 153 121 0.98 0.02 0.95 1.01 0.24 MPS - org. 160 154 123 0.99 0.01 0.97 1.01 0.32 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.05 0.34 207 193 217 1.06 0.02 1.02 1.09 0.00 SUP - outcome 216 202 133 1.06 0.02 1.01 1.11 0.01 207 193 107 1.05 0.02 1.01 1.09 0.01 SUP - recovery 216 202 133 0.90 0.06 0.80 1.02 0.11 209 195 129 0.96 0.04 0.89 1.04 0.30 Notes. *Adjusted for age, sex, body checking league, symptom severity score at the time of initial physician visit, and number of days 20 between concussion and initial physician visit; CI=confidence interval, Nc=number of concussions; Ny=number of youth; 21 Nrtp=number of youth with return to play data; TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= 22 Parent involvement in sport questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-23 RISC=Connor-Davidson Resilience Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; 24 ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental 25 pressure; org=organization; SUP=supplemental questions (distress about well-being; distress about outcomes; beliefs about 26 recovery). 27 Supplemental Tables and Figures 28 29 Table 1S: Demographic and other characteristics by availability of psychosocial data No psychosocial data Baseline psychosocial data only Time of injury psychosocial data only Both baseline and time of injury psychosocial data Total N % N % N % N % N % P value Sex males 133 87.5 138 86.8 40 85.1 168 88 479 87.3 .932 females 19 12.5 21 13.2 7 14.9 23 12 70 12.8 Previous concussion yes 81 53.3 79 49.7 29 61.7 86 45 275 50.1 .005 no 45 29.6 74 46.5 13 27.7 96 50.3 228 41.5 missing 26 17.1 6 3.8 5 10.6 9 4.7 46 8.4 Body checking yes 74 48.7 111 69.8 34 72.3 124 64.9 343 62.5 .043 no 54 35.5 45 28.3 10 21.3 66 34.6 175 31.9 missing 24 15.79 3 1.9 3 6.4 1 0.5 31 5.7 Days from injury to physician visit 42 27.6 29 18.2 12 25.5 37 19.4 120 21.9 .052 <=7 days 85 55.9 94 59.1 35 74.5 154 80.6 368 67 >7 days 25 16.5 36 22.6 0 0 61 11.1 missing Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Age statistic 13.8(1.7) 14(11-17) 14.2(1.5) 14(10-17) 14.5(1.5) 15(11-17) 13.5(1.5) 14(10-17) 13.9(1.6) 14(10-17) .001 missing (N) 14 2 0 5 21 Total symptom severity statistic 17.9(18.0) 13(0-73) 16.2(15.7) 11(0-81) 18.7(17.1) 12.8(0-71) 15.2(16.6) 10(0-73) 16.5(16.8) 11(0-81) .539 missing (N) 31 60 1 8 100 Days to recovery statistic 26.1(29.8) 18(0-180) 22.1(23.2) 16(1-156) 31(52.8) 18(4-361) 24.5(26.5) 17(0-190) 24.8(29.7) 17(0-361) .574 missing (N) 1 1 0 0 2 Total 152 27.7 159 29 47 8.6 191 34.8 549 100 *P-value calculated from Fisher’s exact test for categorical measures and a Wilcoxon rank-sum test for equality of medians with Fisher’s exact p-values for continuous measures. 30 Table 2S 31 Adjusted multivariable accelerated failure time model examining preinjury peer relationship 32 problems reported by children (n=158) 33 95% CI TR SE Lower bound Upper bound p Age 1.075 0.043 0.995 1.162 0.068 Sex (female) 0.685 0.117 0.490 0.958 0.027 Body checking (no) 1.446 0.194 1.111 1.882 0.006 Time to physician visit 1.263 0.272 0.828 1.926 0.279 Symptom severity 1.023 0.004 1.014 1.031 0.000 SDQ - peer 1.103 0.042 1.024 1.189 0.010 Constant 3.989 2.313 1.280 12.432 0.017 Note. CI=confidence interval; TR=time ratio; SE=standard error; SDQ=Strengths and Difficulties 34 Questionnaire. 35 36 Table 3S 37 Adjusted multivariable accelerated failure time model examining distress about concussion 38 outcomes reported by adolescent (n=216) 39 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.016 Sex (female) 0.893 0.177 0.605 1.317 0.567 Body checking (no) 1.431 0.207 1.078 1.900 0.013 Time to physician visit 1.600 0.218 1.226 2.088 0.001 Symptom severity 1.016 0.004 1.009 1.024 0.000 SUP - outcomes 1.061 0.024 1.014 1.110 0.010 Constant 11.219 1.255 9.010 13.970 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 40 (distress about outcomes). 41 42 Table 4S 43 Adjusted multivariable accelerated failure time model examining distress about adolescent’s 44 well-being reported by parents (n=207) 45 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 0.999 1.000 0.710 Sex (female) 0.935 0.164 0.664 1.318 0.702 Body checking (no) 1.552 0.226 1.167 2.065 0.003 Time to physician visit 1.874 0.276 1.404 2.502 0.000 Symptom severity 1.020 0.004 1.013 1.028 0.000 SUP - distress 1.059 0.018 1.023 1.095 0.001 Constant 8.467 1.251 6.339 11.310 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 46 (distress about child’s well-being). 47 48 Table 5S 49 Adjusted multivariable accelerated failure time model examining distress about concussion 50 outcomes reported by parents (n=207) 51 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.664 Sex (female) 0.997 0.193 0.682 1.456 0.986 Body checking (no) 1.558 0.229 1.168 2.077 0.003 Time to physician visit 1.745 0.260 1.303 2.338 0.000 Symptom severity 1.018 0.004 1.010 1.027 0.000 SUP - outcome 1.051 0.019 1.014 1.090 0.007 Constant 10.135 1.158 8.102 12.678 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 52 (distress about child’s outcomes). 53 This is a non-final version of an article published in final form in Luszawski, Caroline A. MSc*,†; Plourde, Vickie PhD‡,§,¶; Sick, Stacy R. BSc, CAT(C)║; Galarneau, Jean-Michel PhD║; Eliason, Paul H. PhD║; Brooks, Brian L. PhD*,†,**,††; Mrazik, Martin PhD‡‡; Debert, Chantel T. MD, MSc§§,¶¶; Lebrun, Constance MDCM║║; Babul, Shelina PhD***; Hagel, Brent E. PhD†,║,†††; Dukelow, Sean P. MD, PhD§§,¶¶,‡‡‡; Schneider, Kathryn J. PhD†,║,¶¶,§§§; Emery, Carolyn A. PhD†,║,¶¶,†††; Yeates, Keith Owen PhD*,†,¶¶. Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players. Clinical Journal of Sport Medicine 34(3):p 256-265, May 2024. | DOI: 10.1097/JSM.0000000000001187 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 1 Ice Hockey Players 2 3 Caroline A Luszawski, MSc1,2, Vickie Plourde, PhD3-5, Stacy R Sick, BSc, CAT(C)6, Jean-Michel 4 Galarneau, PhD6, Paul H Eliason, PhD6, Brian L Brooks, PhD1,2,7,8, Martin Mrazik, PhD9, Chantel T 5 Debert, MD, MSc10,11, Constance Lebrun, MDCM12, Shelina Babul, PhD13, Brent E Hagel, 6 PhD2,6,14, Sean P Dukelow MD PhD10,11,15, Kathryn J Schneider, PhD2,6,11,16, Carolyn A Emery 7 PhD,2,6,11,17, Keith Owen Yeates, PhD1,2,11 8 9 1University of Calgary Department of Psychology, Alberta, Canada 10 2Alberta Children’s Hospital Research Institute, Alberta, Canada 11 3School of Psychology, Université de Moncton, New Brunswick, Canada 12 4Centre de formation médicale du Nouveau-Brunswick, Université de Sherbrooke, New 13 Brunswick, Canada 14 5Faculté Saint-Jean, University of Alberta, Alberta, Canada 15 6Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, 16 Canada 17 7Alberta Children’s Hospital, Neurosciences Program, Alberta, Canada 18 8University of Calgary, Departments of Pediatrics and Clinical Neurosciences 19 9Department of Educational Psychology, University of Alberta 20 10Department of Clinical Neurosciences, University of Calgary, Alberta, Canada 21 11Hotchkiss Brain Institute, University of Calgary, Alberta, Canada 22 12Glen Sather Sports Medicine Clinic, Department of Family Medicine, Faculty of Medicine & 23 Dentistry, University of Alberta, Edmonton, Alberta 24 13University of British Columbia, Department of Pediatrics, Faculty of Medicine, BC Children’s 25 Hospital, Vancouver, BC, Canada 26 14Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 27 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 28 15Cumming School of Medicine, University of Calgary, Alberta, Canada 29 16Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada 30 17Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 31 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 32 33 Correspondence: Caroline A Luszawski MSc; Department of Psychology, University of Calgary, 34 2500 University Drive NW, Calgary, AB T2N 1N4; Tel: 416-389-5664; Fax: 403-282-8249; Email: 35 caroline.luszawski@ucalgary.ca 36 37 Conflicts of Interest and Source of Funding: 38 Brian Brooks receives royalties for the sales of the Pediatric Forensic Neuropsychology textbook 39 (Oxford University Press), royalties for three pediatric neuropsychological tests [Child and 40 Adolescent Memory Profile (ChAMP, Sherman and Brooks, 2015, PAR Inc.), Memory Validity 41 Profile (MVP, Sherman and Brooks, 2015, PAR Inc.), and Multidimensional Everyday Memory 42 Ratings for Youth (MEMRY, Sherman and Brooks, 2017, PAR Inc.)], and has a private practice 43 where he evaluates youth and professional hockey players with concussion. For the remaining 44 authors no conflicts of interest were noted. 45 We acknowledge funding from the Canadian Institutes of Health Research and Hotchkiss Brain 46 Institute. 47 Acknowledgements: The Sport Injury Prevention Research Centre is one of the International 48 Research Centres for Prevention of Injury and Protection of Athlete Health supported by the 49 International Olympic Committee. We acknowledge funding from the Canadian Institutes of 50 Health Research (C Emery PI) and Hotchkiss Brain Institute for the Safe2Play project. Dr. Yeates 51 holds the Ronald and Irene Ward Chair in Pediatric Brain Injury, funded by the Alberta 52 Children’s Hospital Foundation. Dr. Emery holds a Canada Research Chair (Tier 1) in Concussion. 53 Dr. Brooks acknowledges salary funding from the Canadian Institutes for Health Research 54 Embedded Clinician Researcher Salary Award during the collection of these data. 55 Abstract Word Count: 246. Manuscript Word Count: 2999 56 Abstract 57 Objective: To investigate the association between psychosocial factors and physician clearance 58 to return to play (RTP) in youth ice hockey players following sport-related concussion. 59 Design: Prospective cohort study, Safe-to-Play (2013-2018). 60 Setting: Youth hockey leagues in Alberta and British Columbia, Canada. 61 Participants: 353 ice hockey players (aged 11-18 years) who sustained a total of 397 physician-62 diagnosed concussions. 63 Independent Variables: Psychosocial variables. 64 Main Outcome Measures: Players and parents completed psychosocial questionnaires 65 preinjury. Players with a suspected concussion were referred for a study physician visit, during 66 which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single 67 question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured 68 as days between concussion and physician clearance to RTP. Accelerated failure time models 69 estimated the association of psychosocial factors associated with TTR, summarized with time 70 ratios (TR). Covariates included age, sex, body checking policy, days from concussion to initial 71 physician visit, and symptom severity at initial physician visit. 72 Results: Self-report of increased peer-related problems on the Strengths and Difficulties 73 Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion 74 outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-75 1.09]), and higher parent ratings of distress about their child’s well-being at the time of injury 76 (TR, 1.06 [95% CI, 1.02-1.09]), were associated with longer recovery. 77 Conclusions: Greater pre-existing peer-related problems and acute distress about concussion 78 outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial 79 factors following concussion may promote recovery. 80 81 Key Words: concussion, psychosocial, recovery, child, adolescent, brain injury 82 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 83 Ice Hockey Players 84 Introduction 85 Concussion rates in children and adolescents are steadily increasing1 and can lead to 86 significant functional impairment.2 Most children recover fully within a few weeks, but up to a 87 third will experience persistent post-concussive symptoms (PCS)3 (which include a range of 88 cognitive, physical, and emotional complaints) and delayed recovery for a month or longer.4 89 Children in collision sports are at an increased risk of sustaining concussion.5 In sports 90 such as ice hockey, more elite levels of play and policy allowing body checking in games are 91 associated with higher concussion rates.6,7 92 Factors such as age3, sex3,8, and history of previous head injury8,9 have been associated 93 with recovery in studies of pediatric concussion arising in sport. In a previous study of 94 predictors of recovery from pediatric concussion in youth ice hockey players, physician 95 clearance to return to play (RTP) was prolonged for players who took longer than 7 days before 96 their initial physician assessment, had poorer tandem stance, reported moderate/severe 97 headache, or had greater symptom severity at their first physician visit.10 98 A few studies have investigated the association between psychosocial factors and time 99 to recovery (TTR) in youth athletes11–13 and outcome measures such as persistent PCS, which 100 may be associated with delayed RTP.8 Results suggest that factors such as pre-injury health 101 related quality of life (QoL)14, resilience15,16, and adjustment14 may be associated with delayed 102 recovery in youth following concussion. 103 Child and parent characteristics, such as parental support17,18 or child perfectionism19, 104 may influence a child’s risk of injury. To our knowledge, however, neither parental involvement 105 nor perfectionism have been investigated in relation to recovery from pediatric concussion. 106 However, studies of sport-related injuries more generally indicate that parental over-107 involvement may be associated with over-use injuries in childhood through pressure to 108 specialize early and spend increased time in sports.19,20 Similarly, child perfectionism has been 109 associated with increased risk of injury in youth athletes and may affect recovery from injury.21–110 24 111 In adults, perceptions of acute distress and expectations of recovery appear to play an 112 important role in the development of PCS25–28 However, these factors have rarely been 113 investigated in relationship to pediatric concussion,29,30 although negative perceptions of injury 114 have been associated with more persistent PCS and emotional distress in adolescents.30 115 Few studies have investigated whether psychosocial factors are associated with delayed 116 recovery following pediatric concussion over and above well-established predictors such as sex 117 and days to initial physician visit.31 Further study of psychosocial factors potentially associated 118 with recovery could help identify adolescents more likely to experience prolonged recovery, aid 119 in the design of interventions to prevent persistent PCS, and help adolescents return to school 120 and play faster after concussion. 121 The current study sought to investigate the association of pre-injury and post-acute 122 psychosocial factors with time to physician clearance to RTP in adolescent ice hockey players 123 with sport-related concussion. The current study also sought to investigate whether the 124 psychosocial factors added incrementally to other factors previously identified as associated 125 with RTP in the same sample (e.g., time to initial physician assessment, tandem stance errors, 126 symptom severity) at initial physician assessment. Specifically, we hypothesized that lower pre-127 injury QoL, psychological adjustment, resilience, and expectations of recovery would lead to 128 longer TTR. We also hypothesized that higher perfectionism, parental involvement and post-129 acute parent and child distress would lead to longer TTR. 130 Methods 131 Study Design 132 This is a secondary, planned analysis of data drawn from a larger prospective cohort 133 study, Safe to Play, that evaluated concussions and injuries in youth ice hockey players over 5 134 seasons (2013-2018). This cohort included only those players who sustained a suspected sport-135 related concussion and were later diagnosed by a study physician. 136 Participants 137 Sample size was determined a priori for the larger Safe to Play study.10 Participants were 138 eligible for inclusion if they participated in male or female leagues and were registered with 139 Hockey Vancouver, Calgary or Edmonton, or surrounding area leagues, were between the ages 140 of 11 and 17 years, and had written informed player consent (for those 15 and older) or assent 141 and parent consent if needed.10,32 Players were excluded if they had a previous injury or illness 142 preventing full participation in hockey at start of season. 143 Measures 144 Strengths and Difficulties Questionnaire (SDQ). The SDQ assesses psychosocial adjustment using 145 a 25-item scale.33. Both self-report and parent proxy versions were completed at preinjury 146 assessments. The SDQ has shown satisfactory reliability and validity.33–35 147 Pediatric Quality of Life Inventory (PedsQL). The PedsQL is a 23-item questionnaire that 148 measures health-related quality of life.36. Both self-rated and parent-proxy versions were 149 completed at preinjury assessments. Reliability and validity of the PedsQL are well 150 established.36–38 151 Connor Davidson Resiliency scale (CD-RISC). The CD-RISC is a 10 item questionnaire that 152 measures the ability to cope with adversity.39 Originally developed in adults, the CD-RISC has 153 shown adequate validity in children as well.39–41 154 The Sport Multidimensional Perfectionism Scale (Sport-MPS2). The Sport-MPS2 is a self-report 155 questionnaire that assesses perfectionistic tendencies within sport. The Sport MPS2 has shown 156 adequate construct validity.42,43 157 Parent involvement in sport questionnaire (PISQ). The PISQ is a 19 item questionnaire that 158 assesses parental behaviour within the sport context.44,45 The scales on the PISQ have shown 159 satisfactory internal reliability.44 160 Distress and recovery expectation questions. Three questions were asked at the initial post-161 injury physician visit regarding distress felt by the player (or parent) at the time of the injury, 162 distress felt by the player (or parent) about injury outcomes at the time of the initial physician 163 visit, and whether the player (or parent) believed the player would make a full recovery. All 164 three questions were rated on a 10-point Likert scale. The questions were modeled on items 165 from the Timeline and Emotional Representations subscales of the Revised Illness Perception 166 Questionnaire.46 These subscales are intended to assess the player’s and parent’s illness 167 representations, which are important mediators of health outcomes.47 168 Procedure 169 A previously validated injury surveillance methodology in youth ice hockey was used to 170 collect injury and participation information.47 This included a preinjury baseline questionnaire, 171 the Sport Concussion Assessment Tool48 (SCAT3 in years 1-4; SCAT 5 in year 5), weekly exposure 172 sheets, and injury report forms (IRF).47,49–51 Psychosocial and behavioural questionnaires were 173 also administered to players as part of baseline testing. In years 2 through 5 of the Safe to Play 174 study, these included the SDQ, PedsQL, CD-RISC, and Sport-MPS2. Additionally, parents 175 completed the parent/guardian version of the SDQ, PedsQL, and PISQ. 176 Teams participating in the study assigned a team designate (e.g., manager, safety coach) 177 who collected weekly exposure sheets and identified players with a suspected concussion or 178 injury occurring from participation in ice hockey. All players with a suspected concussion had 179 the opportunity to follow up with a study sports medicine physician. Study physicians used the 180 most current international consensus statement in sport to define a concussion, standardize 181 assessment procedures at initial and follow up assessments, and clear a participant to return to 182 sport following the standardized RTP protocol (year 1 to 4)51 or return to sport strategy (year 183 5).50 184 The SCAT3 or SCAT5, which contained the symptom rating scale, was completed at the 185 initial physician visit after a concussion. The symptom rating scale was the same on the SCAT3 186 and SCAT5.49,50 The three supplemental questions regarding distress and expected outcome of 187 injury were also completed by players and parents at the initial visit. 188 Study physician clearance to RTP was based on concussion related symptoms and 189 completion of the RTP protocol as defined by the most recent international consensus 190 statement on concussion in sport at the time.50,51 TTR was defined as the number of days 191 between the date of injury as reported on the IRF and study physician clearance to RTP. 192 Statistical Analyses 193 Statistical analyses were conducted using Stata 17.52 Alpha level was set at .05. 194 Participants included in analyses had at least one concussion diagnosed by a study sports 195 medicine physician and completed at least one of the psychosocial measures (SDQ, PedsQL, CD-196 RISC, Sport-MPS2, PISQ at preinjury assessments, and questions regarding distress and recovery 197 expectations at the time of the initial physician appointment). 198 Descriptive statistics (frequencies and proportions) were computed to document sample 199 characteristics. Because our interest was in time to clearance for RTP,53 accelerated failure time 200 models with loglogistic distribution (bivariate and fully adjusted multivariable models) were 201 generated using complete case analysis to examine the association between psychosocial 202 factors and TTR.10 Repeat concussions for players participating across multiple seasons were 203 handled using clustered standard errors. The date of RTP was based on IRF or weekly exposure 204 sheets if data were not available in physician records.10 The IRF was completed by study 205 personnel if a participant did not complete a final physician visit. Players who were lost to 206 follow-up were censored in the statistical models. 207 We selected covariates according to available data and previous research showing 208 associations with TTR.3,10,54 Covariates included age, sex (male, female), body checking policy 209 (permitted/not permitted), days from concussion to physician visit (7 days or less versus more 210 than 7 days55,56), and symptom severity measured at the initial physician visit (SCAT3 or SCAT5 211 total symptom severity score10). 212 Results 213 Participants 214 A total of 4419 adolescents were recruited for the larger parent study over a five-year 215 period (6584 player seasons); however, the psychosocial questionnaires of interest were only 216 introduced in the second year (season 2014-2015) of the study (see Figure 1). This yielded 4080 217 individual players and 5762 player seasons (N2014-15 = 1398, N2015-16 = 1902, N2016-17 = 1319, 218 N2017-18 = 1143) potentially eligible for analysis. During these seasons, 549 concussions were 219 diagnosed by a study physician, and 397 (72%) had data available for at least one psychosocial 220 measure (Figure 1); 159 (29%) had baseline psychosocial data only, 47 (9%) had psychosocial 221 data only at the initial physician visit, and 191 (35%) had psychosocial data at both times 222 (Supplemental materials, Table 1S). These subgroups did not differ significantly in sex, days to 223 initial physician visit, symptom severity at the initial physician visit, or TTR, but did differ in the 224 likelihood of a previous concussion and of playing in a body checking league and in average age. 225 As noted above, multivariable analyses controlled for age and body checking policy; previous 226 concussion was not controlled because it was not predictive of TTR in our previous study.10 227 A total of 353 players accounted for the 397 concussions (M age=13.90 years; SD=1.53). 228 Most concussions involved males (n=346; 87.2%) and players in a body checking league (n=269; 229 67.8%). Physicians evaluated most concussions within 7 days of injury (n=283; 71.3%) and 230 slightly less than half (n=183; 46.1%) of the concussions were not preceded by another 231 concussion that occurred before the start of the season. Median acute total symptom severity 232 score (/132) at the initial physician visit was 10.0 (IQR=3-23.5). Median time to being cleared to 233 play, for those not lost to follow-up, was 16 days (IQR=11-27). Table 1 presents descriptive data 234 for psychosocial measures. 235 Factors Associated with Time to Recovery 236 Table 2 reports bivariate accelerated failure time models for all psychosocial variables. 237 Lower levels of resilience and higher levels of inattention/hyperactivity and peer relationship 238 problems reported by adolescents at baseline were significantly associated with a longer TTR in 239 bivariate analyses. Higher ratings of distress about concussion outcomes and lower 240 expectations of a full recovery at the initial physical visit also were associated with longer TTR. 241 For parent ratings, higher ratings of distress about their child’s concussion outcomes and about 242 their child’s well-being at the time of injury (TOI) were significantly associated with longer TTR. 243 Table 3 shows fully adjusted multivariable accelerated failure time models. For self-244 ratings (Tables 2S and 3S; see Supplemental materials for full models), higher pre-injury peer-245 related problems reported at baseline (TR, 1.10 [95% CI, 1.02-1.19]) and higher ratings of 246 distress about concussion outcomes acutely post-injury (TR, 1.06 [95% CI, 1.01-1.11]) were 247 associated with longer TTR. For every 1-point increase in self-ratings of peer problems or of 248 acute distress about their concussion outcomes, TTR increased by 10% and 6%, respectively. 249 Figure 2 presents probability curves for RTP based on low (10th percentile), median (50th 250 percentile), and high (90th percentile) ratings of adolescent self-reported ratings for (a) current 251 distress at TOI and (b) peer problems at baseline. 252 Fully adjusted models for parent ratings (Tables 4S and 5S; see Supplemental materials 253 for full models) showed that only parent acute ratings of higher distress about their child’s well-254 being at the TOI (time ratio [TR], 1.06 [95% confidence interval (CI), 1.02-1.09]) and about 255 concussion outcomes (TR, 1.05 [95% CI, 1.01-1.09]) remained associated with longer recovery. 256 For every 1-point increase in distress about their child’s well-being at the TOI or about their 257 child’s concussion outcomes, TTR increased by 6% and 5%, respectively. Figure 3 presents 258 probability curves for RTP based on low (10th percentile), median (50th percentile), and high 259 (90th percentile) acute parent ratings of (a) their distress about concussion outcomes and (b) 260 their distress about their child’s wellbeing. 261 Discussion 262 This study investigated psychosocial variables associated with time to physician 263 clearance for RTP in adolescent ice hockey players with concussion. The median TTR was 16 264 days, consistent with previous research suggesting that many youth with sports-related 265 concussion recover within 2-3 weeks of their injury (median of 178 and 1810 days). After 266 controlling for relevant covariates, adolescent reports of pre-injury peer problems at baseline 267 and levels of distress about their concussion outcomes acutely post-injury, as well as parent 268 levels of distress about their child’s well-being acutely post-injury, were associated with a 269 significant increase in time to RTP. 270 Few studies have investigated parent and youth distress and expectations as associated 271 with recovery, and to our knowledge this is the first to do so in adolescent ice hockey players. 272 Negative thinking about outcomes as reflected in distress and lower expectations of recovery 273 have not been well studied. ‘Nocebo effects’ occur when an individual has negative 274 expectations of outcomes that are associated with prolonged recovery or worsened 275 symptoms.57 Because much online information about concussion is not from reliable sources 276 and may be inaccurate,58,59 some parents and adolescents in the study may have experienced 277 ‘nocebo effects’, prolonging recovery. Parent and player distress and recovery expectations 278 likely reflect messaging by both clinicians and scientists, who should aim to provide accurate, 279 up-to-date information regarding the outcomes of concussion. Future studies should 280 investigate whether the accuracy of information that adolescents and their families have about 281 concussion is associated with their distress, expectancies of recovery, and TTR. 282 Parent-rated but not self-rated distress about the adolescent’s wellbeing at the TOI was 283 significantly associated with a longer TTR. Youth hockey players may tend to minimize their 284 vulnerability to concussion,60 and this may help explain why adolescent reports of distress 285 regarding their wellbeing at the TOI were not significantly associated with TTR. Higher parental 286 distress regarding their child’s wellbeing could be indicative of higher overall parent stress, 287 which has been shown to be associated with a decreased ability to help children cope with 288 injury and therefore may lead to prolonged recovery.61 289 In this study, self-reported peer-related problems was the pre-injury psychosocial factor 290 uniquely associated with TTR. Peer and other forms of social support have been shown to be 291 important in facilitating recovery from pediatric concussion; children identify a need to rely on 292 friends for support during recovery and adolescents who experience persistent PCS often 293 report lower levels of peer support.62,63 The adolescents in our study who reported more peer 294 problems may not have had the same access to social supports as adolescents who reported 295 fewer peer problems and may have therefore experienced a longer time to RTP. Peer-related 296 problems may also be a marker for other functional difficulties that put adolescents at risk of 297 persistent PCS.64 298 In this study, pre-injury QoL, psychological adjustment, resilience, perfectionism, and 299 parental involvement were not significantly related to TTR in multivariable models. These 300 findings could be a function of the outcome investigated in our study, clearance to RTP. Pre-301 injury QoL, adjustment, resilience, perfectionism, and parental involvement could be related to 302 symptom severity or other functional difficulties as opposed to RTP. 303 Our results have potential clinical implications. Education about appropriate 304 expectations about outcomes might assist in shortening TTR. Clinicians and scientists should 305 help to dispel concussion misinformation and aim to support more accurate expectations to aid 306 in recovery.57 Providing accurate information about recovery has been recommended for 307 pediatric concussion management,50 and future studies should investigate whether doing so 308 affects recovery expectations. Because more peer problems were associated with increased 309 time, promoting positive peer relationships also might help facilitate faster recovery. 310 Limitations 311 One study limitation is that questions regarding post-injury distress and expectations of 312 recovery were single items, which may limit their reliability and validity. Additionally, we did 313 not assess the nature or accuracy of the educational information about concussion that our 314 families received prior to or after their adolescent’s injury and that could account for potential 315 ‘nocebo’ effects. Our sample consisted of ice hockey players, which might limit generalizability 316 of the findings to athletes in other contact sports. Additionally, the participants were mostly 317 males and we could not investigate sex differences in post-acute distress and expectations of 318 recovery. Finally, our analyses of psychosocial variables collected at baseline and at TOI were 319 based on overlapping but distinct samples, which differed in history of concussion, body 320 checking policy, and age. However, we controlled for two of those variables in multivariable 321 analyses, and the groups did not differ on several other variables that are also associated with 322 TTR. Nevertheless, missing data from study participants with concussion may have introduced 323 unmeasured bias. 324 Conclusion 325 This study provides evidence that psychosocial factors are associated with 326 TTR following concussion in adolescent ice hockey players, over and above other well-studied 327 variables such as sex, body checking policy, initial symptom severity, and time to initial 328 physician visit. Specifically, parent-rated distress about their child’s wellbeing, parent and child 329 rated distress about concussion outcomes, and self-rated pre-injury peer problems were 330 associated with longer TTR, over and above other factors known to be related to recovery. 331 These results suggest potential targets for interventions to shorten recovery from concussion in 332 adolescents. 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Association of varying levels of self-reported (a) distress about outcomes and (b) peer 526 problems with probability of return to play (RTP). (a) A 60% probability of RTP is achieved at 527 ~23 days for a self-rating of distress at the 10th percentile (score = 1) but at ~36 days for a rating 528 at the 90th percentile (score=8). Put differently, the probability of RTP at 30 days post-injury is 529 ~80% for a rating of distress at the 10th percentile but only ~50% for a rating at the 90th 530 percentile. (b) A 60% probability of RTP is achieved at ~20 days for a self-rating of peer 531 problems at the 10th percentile (score=0) but at ~25 days for a rating at the 90th percentile 532 (score=3). Alternatively, the probability of RTP at 30 days post-injury is ~80% for a rating of peer 533 problems at the 10th percentile but only ~65% for a rating at the 90th percentile. 534 Figure 3. Association of varying levels of parent-rated (a) distress about their child’s outcomes 535 and (b) distress about their child’s well-being at with probability of return to play (RTP). (a) A 536 60% probability of RTP is achieved at ~25 days for a rating of parent distress about outcomes at 537 the 10th percentile (score=1) but at ~38 days for a rating at the 90th percentile (score=9). 538 Alternatively, the probability of RTP at 30 days post-injury is ~70% for a rating of distress at the 539 10th percentile but only ~50% for a rating at the 90th percentile. (b) A 60% probability of RTP is 540 achieved at ~23 days for a rating of parent distress about well-being at the time of injury at the 541 10th percentile but at ~36 days for a rating at the 90th percentile (score=10). Put differently, the 542 probability of RTP at 30 days post-injury is ~75% for rating of distress at the 10th percentile but 543 only 55% probability for a rating at the 90th percentile. 544 Table 1 1 Descriptive summary of psychosocial variables 2 Adolescent ratings Parent ratings N Mean Median SD Min 25th percentile 75th percentile Max N Mean Median SD Min 25th percentile 75th percentile Max Completed at time of preinjury assessment PISQ - DB 205 22.36 21 7.77 10 17 27 50 PISQ - PU 204 16.72 17 2.45 7 15 19 20 PISQ - AI 201 17.97 18 3.40 7 16 20 25 CD-RISC 214 29.02 29 5.41 17 26 33 40 QOL - physical 213 90.02 91 9.68 50 84 97 100 201 89.52 94 12.40 28 84 100 100 QOL - emotion 213 79.11 85 18.28 15 70 95 100 200 77.43 80 17.32 25 65 95 100 QOL - social 211 86.75 90 14.66 30 80 100 100 202 86.93 93 15.51 25 75 100 100 QOL - school 212 75.73 75 16.02 30 65 90 100 201 74.88 75 17.26 35 60 90 100 SDQ - emotion 213 2.21 2 2.04 0 1 4 9 200 1.78 1 1.81 0 0 3 7 SDQ - conduct 213 1.39 1 1.40 0 0 2 6 200 1.00 1 1.30 0 0 2 7 SDQ – ina/hyp 213 3.93 4 2.33 0 2 5 9 199 3.26 3 2.42 0 1 5 10 SDQ - peer 213 1.19 1 1.41 0 0 2 7 200 1.32 1 1.39 0 0 2 6 SDQ - prosocial 213 7.92 8 1.59 3 7 9 10 200 8.29 9 1.74 2 7 10 10 MPS - stand 218 24.05 24 4.23 13 21 27 34 MPS - concern 215 19.94 19 5.57 8 17 24 37 MPS - Ppress 218 21.63 22 5.67 9 18 25 36 MPS - doubts 218 14.44 14 4.02 6 12 17 26 MPS – org. 221 20.81 22 5.48 6 17 25 30 Completed at time of initial physician visit following concussion SUP - distress 226 5.29 6 2.80 1 3 7 10 216 7.42 8 2.47 1 6 10 10 SUP - outcome 225 4.05 3 2.65 1 2 6 10 216 5.29 5 2.90 1 3 8 10 SUP - recovery 225 9.31 10 1.50 3 9 10 10 218 9.12 10 1.76 1 9 10 10 Notes. Min=Minimum, Max=Maximum, N=number of concussions; SD=standard deviation; PISQ= Parent involvement in sport 3 questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience 4 Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport 5 Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental 6 questions (distress about well-being; distress about outcomes; beliefs about recovery). 7 8 Table 2 9 Bivariate accelerated failure time models predicting time to recovery 10 Adolescent ratings Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.01 0.01 0.99 1.02 0.59 PISQ - PU 147 141 111 0.97 0.03 0.92 1.03 0.33 PISQ - AI 145 139 109 0.98 0.02 0.94 1.03 0.44 CD-RISC 154 148 119 0.98 0.01 0.95 1.00 0.03 QOL - physical 158 152 121 0.99 0.01 0.98 1.01 0.25 147 141 111 1.00 0.01 0.99 1.01 0.95 QOL - emotion 158 152 121 0.99 0.00 0.99 1.00 0.11 147 141 111 1.00 0.00 1.00 1.01 0.35 QOL - social 158 152 121 1.00 0.00 0.99 1.01 0.76 148 142 112 1.00 0.01 0.99 1.01 0.99 QOL - school 158 152 121 0.99 0.00 0.98 1.00 0.09 147 141 111 1.00 0.00 0.99 1.01 0.94 SDQ - emotion 158 152 122 1.06 0.04 0.99 1.13 0.09 147 141 112 1.03 0.04 0.95 1.10 0.50 SDQ - conduct 158 152 122 1.06 0.06 0.94 1.19 0.34 147 141 112 0.97 0.05 0.87 1.07 0.50 SDQ - ina/hyp 158 152 122 1.07 0.03 1.01 1.14 0.02 146 140 111 0.97 0.03 0.92 1.02 0.27 SDQ - peer 158 152 122 1.12 0.06 1.01 1.23 0.03 147 141 112 1.01 0.08 0.87 1.17 0.94 SDQ - prosocial 158 152 122 1.07 0.05 0.97 1.17 0.19 147 141 112 1.06 0.04 0.99 1.13 0.12 MPS - stand 157 152 120 0.98 0.02 0.95 1.01 0.27 MPS - concern 154 150 118 1.01 0.01 0.98 1.03 0.54 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.96 MPS - doubts 158 153 121 1.00 0.02 0.96 1.03 0.84 MPS - org. 160 154 123 0.98 0.01 0.96 1.01 0.16 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.07 0.39 207 193 217 1.08 0.03 1.03 1.13 0.00 SUP - outcome 216 202 133 1.12 0.03 1.06 1.18 0.00 207 193 107 1.10 0.03 1.05 1.15 0.00 SUP - recovery 216 202 133 0.81 0.05 0.71 0.92 0.00 209 195 129 0.93 0.06 0.82 1.05 0.26 Notes. CI=confidence interval, Nc=number of concussions; Ny=number of youth; Nrtp=number of youth with return to play data; 11 TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= Parent involvement in sport questionnaire; 12 DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience Scale; 13 QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional 14 Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental questions (distress 15 about well-being; distress about outcomes; beliefs about recovery). 16 17 Table 3 18 Fully adjusted multivariable accelerated failure time models predicting time to recovery* 19 Adolescent rating Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.00 0.01 0.99 1.02 0.84 PISQ - PU 147 141 111 0.97 0.03 0.92 1.02 0.25 PISQ - AI 145 139 109 0.97 0.02 0.94 1.01 0.15 CD-RISC 154 148 119 0.99 0.01 0.97 1.01 0.20 QOL - physical 158 152 121 1.00 0.01 0.98 1.01 0.41 147 141 111 1.00 0.00 0.99 1.01 0.51 QOL - emotion 158 152 121 1.00 0.00 0.99 1.01 0.62 147 141 111 1.01 0.00 1.00 1.01 0.08 QOL - social 158 152 121 1.00 0.00 0.99 1.00 0.33 148 142 112 1.00 0.00 0.99 1.01 0.55 QOL - school 158 152 121 1.00 0.00 0.99 1.00 0.27 147 141 111 1.00 0.00 1.00 1.01 0.32 SDQ - emotion 158 152 122 1.01 0.03 0.94 1.07 0.86 147 141 112 1.00 0.03 0.94 1.06 0.95 SDQ - conduct 158 152 122 1.01 0.06 0.89 1.13 0.93 147 141 112 0.95 0.04 0.87 1.04 0.25 SDQ - ina/hyp 158 152 122 1.02 0.03 0.96 1.09 0.45 146 140 111 0.97 0.02 0.93 1.02 0.27 SDQ - peer 158 152 122 1.10 0.04 1.02 1.19 0.01 147 141 112 0.94 0.06 0.82 1.07 0.34 SDQ - prosocial 158 152 122 1.06 0.05 0.98 1.15 0.16 147 141 112 1.05 0.03 0.99 1.11 0.11 MPS - stand 157 152 120 0.98 0.01 0.96 1.01 0.25 MPS - concern 154 150 118 0.99 0.01 0.97 1.02 0.50 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.68 MPS - doubts 158 153 121 0.98 0.02 0.95 1.01 0.24 MPS - org. 160 154 123 0.99 0.01 0.97 1.01 0.32 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.05 0.34 207 193 217 1.06 0.02 1.02 1.09 0.00 SUP - outcome 216 202 133 1.06 0.02 1.01 1.11 0.01 207 193 107 1.05 0.02 1.01 1.09 0.01 SUP - recovery 216 202 133 0.90 0.06 0.80 1.02 0.11 209 195 129 0.96 0.04 0.89 1.04 0.30 Notes. *Adjusted for age, sex, body checking league, symptom severity score at the time of initial physician visit, and number of days 20 between concussion and initial physician visit; CI=confidence interval, Nc=number of concussions; Ny=number of youth; 21 Nrtp=number of youth with return to play data; TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= 22 Parent involvement in sport questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-23 RISC=Connor-Davidson Resilience Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; 24 ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental 25 pressure; org=organization; SUP=supplemental questions (distress about well-being; distress about outcomes; beliefs about 26 recovery). 27 Supplemental Tables and Figures 28 29 Table 1S: Demographic and other characteristics by availability of psychosocial data No psychosocial data Baseline psychosocial data only Time of injury psychosocial data only Both baseline and time of injury psychosocial data Total N % N % N % N % N % P value Sex males 133 87.5 138 86.8 40 85.1 168 88 479 87.3 .932 females 19 12.5 21 13.2 7 14.9 23 12 70 12.8 Previous concussion yes 81 53.3 79 49.7 29 61.7 86 45 275 50.1 .005 no 45 29.6 74 46.5 13 27.7 96 50.3 228 41.5 missing 26 17.1 6 3.8 5 10.6 9 4.7 46 8.4 Body checking yes 74 48.7 111 69.8 34 72.3 124 64.9 343 62.5 .043 no 54 35.5 45 28.3 10 21.3 66 34.6 175 31.9 missing 24 15.79 3 1.9 3 6.4 1 0.5 31 5.7 Days from injury to physician visit 42 27.6 29 18.2 12 25.5 37 19.4 120 21.9 .052 <=7 days 85 55.9 94 59.1 35 74.5 154 80.6 368 67 >7 days 25 16.5 36 22.6 0 0 61 11.1 missing Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Age statistic 13.8(1.7) 14(11-17) 14.2(1.5) 14(10-17) 14.5(1.5) 15(11-17) 13.5(1.5) 14(10-17) 13.9(1.6) 14(10-17) .001 missing (N) 14 2 0 5 21 Total symptom severity statistic 17.9(18.0) 13(0-73) 16.2(15.7) 11(0-81) 18.7(17.1) 12.8(0-71) 15.2(16.6) 10(0-73) 16.5(16.8) 11(0-81) .539 missing (N) 31 60 1 8 100 Days to recovery statistic 26.1(29.8) 18(0-180) 22.1(23.2) 16(1-156) 31(52.8) 18(4-361) 24.5(26.5) 17(0-190) 24.8(29.7) 17(0-361) .574 missing (N) 1 1 0 0 2 Total 152 27.7 159 29 47 8.6 191 34.8 549 100 *P-value calculated from Fisher’s exact test for categorical measures and a Wilcoxon rank-sum test for equality of medians with Fisher’s exact p-values for continuous measures. 30 Table 2S 31 Adjusted multivariable accelerated failure time model examining preinjury peer relationship 32 problems reported by children (n=158) 33 95% CI TR SE Lower bound Upper bound p Age 1.075 0.043 0.995 1.162 0.068 Sex (female) 0.685 0.117 0.490 0.958 0.027 Body checking (no) 1.446 0.194 1.111 1.882 0.006 Time to physician visit 1.263 0.272 0.828 1.926 0.279 Symptom severity 1.023 0.004 1.014 1.031 0.000 SDQ - peer 1.103 0.042 1.024 1.189 0.010 Constant 3.989 2.313 1.280 12.432 0.017 Note. CI=confidence interval; TR=time ratio; SE=standard error; SDQ=Strengths and Difficulties 34 Questionnaire. 35 36 Table 3S 37 Adjusted multivariable accelerated failure time model examining distress about concussion 38 outcomes reported by adolescent (n=216) 39 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.016 Sex (female) 0.893 0.177 0.605 1.317 0.567 Body checking (no) 1.431 0.207 1.078 1.900 0.013 Time to physician visit 1.600 0.218 1.226 2.088 0.001 Symptom severity 1.016 0.004 1.009 1.024 0.000 SUP - outcomes 1.061 0.024 1.014 1.110 0.010 Constant 11.219 1.255 9.010 13.970 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 40 (distress about outcomes). 41 42 Table 4S 43 Adjusted multivariable accelerated failure time model examining distress about adolescent’s 44 well-being reported by parents (n=207) 45 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 0.999 1.000 0.710 Sex (female) 0.935 0.164 0.664 1.318 0.702 Body checking (no) 1.552 0.226 1.167 2.065 0.003 Time to physician visit 1.874 0.276 1.404 2.502 0.000 Symptom severity 1.020 0.004 1.013 1.028 0.000 SUP - distress 1.059 0.018 1.023 1.095 0.001 Constant 8.467 1.251 6.339 11.310 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 46 (distress about child’s well-being). 47 48 Table 5S 49 Adjusted multivariable accelerated failure time model examining distress about concussion 50 outcomes reported by parents (n=207) 51 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.664 Sex (female) 0.997 0.193 0.682 1.456 0.986 Body checking (no) 1.558 0.229 1.168 2.077 0.003 Time to physician visit 1.745 0.260 1.303 2.338 0.000 Symptom severity 1.018 0.004 1.010 1.027 0.000 SUP - outcome 1.051 0.019 1.014 1.090 0.007 Constant 10.135 1.158 8.102 12.678 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 52 (distress about child’s outcomes). 53 This is a non-final version of an article published in final form in Luszawski, Caroline A. MSc*,†; Plourde, Vickie PhD‡,§,¶; Sick, Stacy R. BSc, CAT(C)║; Galarneau, Jean-Michel PhD║; Eliason, Paul H. PhD║; Brooks, Brian L. PhD*,†,**,††; Mrazik, Martin PhD‡‡; Debert, Chantel T. MD, MSc§§,¶¶; Lebrun, Constance MDCM║║; Babul, Shelina PhD***; Hagel, Brent E. PhD†,║,†††; Dukelow, Sean P. MD, PhD§§,¶¶,‡‡‡; Schneider, Kathryn J. PhD†,║,¶¶,§§§; Emery, Carolyn A. PhD†,║,¶¶,†††; Yeates, Keith Owen PhD*,†,¶¶. Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players. Clinical Journal of Sport Medicine 34(3):p 256-265, May 2024. | DOI: 10.1097/JSM.0000000000001187 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 1 Ice Hockey Players 2 3 Caroline A Luszawski, MSc1,2, Vickie Plourde, PhD3-5, Stacy R Sick, BSc, CAT(C)6, Jean-Michel 4 Galarneau, PhD6, Paul H Eliason, PhD6, Brian L Brooks, PhD1,2,7,8, Martin Mrazik, PhD9, Chantel T 5 Debert, MD, MSc10,11, Constance Lebrun, MDCM12, Shelina Babul, PhD13, Brent E Hagel, 6 PhD2,6,14, Sean P Dukelow MD PhD10,11,15, Kathryn J Schneider, PhD2,6,11,16, Carolyn A Emery 7 PhD,2,6,11,17, Keith Owen Yeates, PhD1,2,11 8 9 1University of Calgary Department of Psychology, Alberta, Canada 10 2Alberta Children’s Hospital Research Institute, Alberta, Canada 11 3School of Psychology, Université de Moncton, New Brunswick, Canada 12 4Centre de formation médicale du Nouveau-Brunswick, Université de Sherbrooke, New 13 Brunswick, Canada 14 5Faculté Saint-Jean, University of Alberta, Alberta, Canada 15 6Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, 16 Canada 17 7Alberta Children’s Hospital, Neurosciences Program, Alberta, Canada 18 8University of Calgary, Departments of Pediatrics and Clinical Neurosciences 19 9Department of Educational Psychology, University of Alberta 20 10Department of Clinical Neurosciences, University of Calgary, Alberta, Canada 21 11Hotchkiss Brain Institute, University of Calgary, Alberta, Canada 22 12Glen Sather Sports Medicine Clinic, Department of Family Medicine, Faculty of Medicine & 23 Dentistry, University of Alberta, Edmonton, Alberta 24 13University of British Columbia, Department of Pediatrics, Faculty of Medicine, BC Children’s 25 Hospital, Vancouver, BC, Canada 26 14Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 27 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 28 15Cumming School of Medicine, University of Calgary, Alberta, Canada 29 16Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada 30 17Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, 31 O’Brien Institute for Public Health, University of Calgary, Alberta, Canada 32 33 Correspondence: Caroline A Luszawski MSc; Department of Psychology, University of Calgary, 34 2500 University Drive NW, Calgary, AB T2N 1N4; Tel: 416-389-5664; Fax: 403-282-8249; Email: 35 caroline.luszawski@ucalgary.ca 36 37 Conflicts of Interest and Source of Funding: 38 Brian Brooks receives royalties for the sales of the Pediatric Forensic Neuropsychology textbook 39 (Oxford University Press), royalties for three pediatric neuropsychological tests [Child and 40 Adolescent Memory Profile (ChAMP, Sherman and Brooks, 2015, PAR Inc.), Memory Validity 41 Profile (MVP, Sherman and Brooks, 2015, PAR Inc.), and Multidimensional Everyday Memory 42 Ratings for Youth (MEMRY, Sherman and Brooks, 2017, PAR Inc.)], and has a private practice 43 where he evaluates youth and professional hockey players with concussion. For the remaining 44 authors no conflicts of interest were noted. 45 We acknowledge funding from the Canadian Institutes of Health Research and Hotchkiss Brain 46 Institute. 47 Acknowledgements: The Sport Injury Prevention Research Centre is one of the International 48 Research Centres for Prevention of Injury and Protection of Athlete Health supported by the 49 International Olympic Committee. We acknowledge funding from the Canadian Institutes of 50 Health Research (C Emery PI) and Hotchkiss Brain Institute for the Safe2Play project. Dr. Yeates 51 holds the Ronald and Irene Ward Chair in Pediatric Brain Injury, funded by the Alberta 52 Children’s Hospital Foundation. Dr. Emery holds a Canada Research Chair (Tier 1) in Concussion. 53 Dr. Brooks acknowledges salary funding from the Canadian Institutes for Health Research 54 Embedded Clinician Researcher Salary Award during the collection of these data. 55 Abstract Word Count: 246. Manuscript Word Count: 2999 56 Abstract 57 Objective: To investigate the association between psychosocial factors and physician clearance 58 to return to play (RTP) in youth ice hockey players following sport-related concussion. 59 Design: Prospective cohort study, Safe-to-Play (2013-2018). 60 Setting: Youth hockey leagues in Alberta and British Columbia, Canada. 61 Participants: 353 ice hockey players (aged 11-18 years) who sustained a total of 397 physician-62 diagnosed concussions. 63 Independent Variables: Psychosocial variables. 64 Main Outcome Measures: Players and parents completed psychosocial questionnaires 65 preinjury. Players with a suspected concussion were referred for a study physician visit, during 66 which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single 67 question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured 68 as days between concussion and physician clearance to RTP. Accelerated failure time models 69 estimated the association of psychosocial factors associated with TTR, summarized with time 70 ratios (TR). Covariates included age, sex, body checking policy, days from concussion to initial 71 physician visit, and symptom severity at initial physician visit. 72 Results: Self-report of increased peer-related problems on the Strengths and Difficulties 73 Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion 74 outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-75 1.09]), and higher parent ratings of distress about their child’s well-being at the time of injury 76 (TR, 1.06 [95% CI, 1.02-1.09]), were associated with longer recovery. 77 Conclusions: Greater pre-existing peer-related problems and acute distress about concussion 78 outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial 79 factors following concussion may promote recovery. 80 81 Key Words: concussion, psychosocial, recovery, child, adolescent, brain injury 82 Psychosocial Factors Associated with Time to Recovery Following Concussion in Adolescent 83 Ice Hockey Players 84 Introduction 85 Concussion rates in children and adolescents are steadily increasing1 and can lead to 86 significant functional impairment.2 Most children recover fully within a few weeks, but up to a 87 third will experience persistent post-concussive symptoms (PCS)3 (which include a range of 88 cognitive, physical, and emotional complaints) and delayed recovery for a month or longer.4 89 Children in collision sports are at an increased risk of sustaining concussion.5 In sports 90 such as ice hockey, more elite levels of play and policy allowing body checking in games are 91 associated with higher concussion rates.6,7 92 Factors such as age3, sex3,8, and history of previous head injury8,9 have been associated 93 with recovery in studies of pediatric concussion arising in sport. In a previous study of 94 predictors of recovery from pediatric concussion in youth ice hockey players, physician 95 clearance to return to play (RTP) was prolonged for players who took longer than 7 days before 96 their initial physician assessment, had poorer tandem stance, reported moderate/severe 97 headache, or had greater symptom severity at their first physician visit.10 98 A few studies have investigated the association between psychosocial factors and time 99 to recovery (TTR) in youth athletes11–13 and outcome measures such as persistent PCS, which 100 may be associated with delayed RTP.8 Results suggest that factors such as pre-injury health 101 related quality of life (QoL)14, resilience15,16, and adjustment14 may be associated with delayed 102 recovery in youth following concussion. 103 Child and parent characteristics, such as parental support17,18 or child perfectionism19, 104 may influence a child’s risk of injury. To our knowledge, however, neither parental involvement 105 nor perfectionism have been investigated in relation to recovery from pediatric concussion. 106 However, studies of sport-related injuries more generally indicate that parental over-107 involvement may be associated with over-use injuries in childhood through pressure to 108 specialize early and spend increased time in sports.19,20 Similarly, child perfectionism has been 109 associated with increased risk of injury in youth athletes and may affect recovery from injury.21–110 24 111 In adults, perceptions of acute distress and expectations of recovery appear to play an 112 important role in the development of PCS25–28 However, these factors have rarely been 113 investigated in relationship to pediatric concussion,29,30 although negative perceptions of injury 114 have been associated with more persistent PCS and emotional distress in adolescents.30 115 Few studies have investigated whether psychosocial factors are associated with delayed 116 recovery following pediatric concussion over and above well-established predictors such as sex 117 and days to initial physician visit.31 Further study of psychosocial factors potentially associated 118 with recovery could help identify adolescents more likely to experience prolonged recovery, aid 119 in the design of interventions to prevent persistent PCS, and help adolescents return to school 120 and play faster after concussion. 121 The current study sought to investigate the association of pre-injury and post-acute 122 psychosocial factors with time to physician clearance to RTP in adolescent ice hockey players 123 with sport-related concussion. The current study also sought to investigate whether the 124 psychosocial factors added incrementally to other factors previously identified as associated 125 with RTP in the same sample (e.g., time to initial physician assessment, tandem stance errors, 126 symptom severity) at initial physician assessment. Specifically, we hypothesized that lower pre-127 injury QoL, psychological adjustment, resilience, and expectations of recovery would lead to 128 longer TTR. We also hypothesized that higher perfectionism, parental involvement and post-129 acute parent and child distress would lead to longer TTR. 130 Methods 131 Study Design 132 This is a secondary, planned analysis of data drawn from a larger prospective cohort 133 study, Safe to Play, that evaluated concussions and injuries in youth ice hockey players over 5 134 seasons (2013-2018). This cohort included only those players who sustained a suspected sport-135 related concussion and were later diagnosed by a study physician. 136 Participants 137 Sample size was determined a priori for the larger Safe to Play study.10 Participants were 138 eligible for inclusion if they participated in male or female leagues and were registered with 139 Hockey Vancouver, Calgary or Edmonton, or surrounding area leagues, were between the ages 140 of 11 and 17 years, and had written informed player consent (for those 15 and older) or assent 141 and parent consent if needed.10,32 Players were excluded if they had a previous injury or illness 142 preventing full participation in hockey at start of season. 143 Measures 144 Strengths and Difficulties Questionnaire (SDQ). The SDQ assesses psychosocial adjustment using 145 a 25-item scale.33. Both self-report and parent proxy versions were completed at preinjury 146 assessments. The SDQ has shown satisfactory reliability and validity.33–35 147 Pediatric Quality of Life Inventory (PedsQL). The PedsQL is a 23-item questionnaire that 148 measures health-related quality of life.36. Both self-rated and parent-proxy versions were 149 completed at preinjury assessments. Reliability and validity of the PedsQL are well 150 established.36–38 151 Connor Davidson Resiliency scale (CD-RISC). The CD-RISC is a 10 item questionnaire that 152 measures the ability to cope with adversity.39 Originally developed in adults, the CD-RISC has 153 shown adequate validity in children as well.39–41 154 The Sport Multidimensional Perfectionism Scale (Sport-MPS2). The Sport-MPS2 is a self-report 155 questionnaire that assesses perfectionistic tendencies within sport. The Sport MPS2 has shown 156 adequate construct validity.42,43 157 Parent involvement in sport questionnaire (PISQ). The PISQ is a 19 item questionnaire that 158 assesses parental behaviour within the sport context.44,45 The scales on the PISQ have shown 159 satisfactory internal reliability.44 160 Distress and recovery expectation questions. Three questions were asked at the initial post-161 injury physician visit regarding distress felt by the player (or parent) at the time of the injury, 162 distress felt by the player (or parent) about injury outcomes at the time of the initial physician 163 visit, and whether the player (or parent) believed the player would make a full recovery. All 164 three questions were rated on a 10-point Likert scale. The questions were modeled on items 165 from the Timeline and Emotional Representations subscales of the Revised Illness Perception 166 Questionnaire.46 These subscales are intended to assess the player’s and parent’s illness 167 representations, which are important mediators of health outcomes.47 168 Procedure 169 A previously validated injury surveillance methodology in youth ice hockey was used to 170 collect injury and participation information.47 This included a preinjury baseline questionnaire, 171 the Sport Concussion Assessment Tool48 (SCAT3 in years 1-4; SCAT 5 in year 5), weekly exposure 172 sheets, and injury report forms (IRF).47,49–51 Psychosocial and behavioural questionnaires were 173 also administered to players as part of baseline testing. In years 2 through 5 of the Safe to Play 174 study, these included the SDQ, PedsQL, CD-RISC, and Sport-MPS2. Additionally, parents 175 completed the parent/guardian version of the SDQ, PedsQL, and PISQ. 176 Teams participating in the study assigned a team designate (e.g., manager, safety coach) 177 who collected weekly exposure sheets and identified players with a suspected concussion or 178 injury occurring from participation in ice hockey. All players with a suspected concussion had 179 the opportunity to follow up with a study sports medicine physician. Study physicians used the 180 most current international consensus statement in sport to define a concussion, standardize 181 assessment procedures at initial and follow up assessments, and clear a participant to return to 182 sport following the standardized RTP protocol (year 1 to 4)51 or return to sport strategy (year 183 5).50 184 The SCAT3 or SCAT5, which contained the symptom rating scale, was completed at the 185 initial physician visit after a concussion. The symptom rating scale was the same on the SCAT3 186 and SCAT5.49,50 The three supplemental questions regarding distress and expected outcome of 187 injury were also completed by players and parents at the initial visit. 188 Study physician clearance to RTP was based on concussion related symptoms and 189 completion of the RTP protocol as defined by the most recent international consensus 190 statement on concussion in sport at the time.50,51 TTR was defined as the number of days 191 between the date of injury as reported on the IRF and study physician clearance to RTP. 192 Statistical Analyses 193 Statistical analyses were conducted using Stata 17.52 Alpha level was set at .05. 194 Participants included in analyses had at least one concussion diagnosed by a study sports 195 medicine physician and completed at least one of the psychosocial measures (SDQ, PedsQL, CD-196 RISC, Sport-MPS2, PISQ at preinjury assessments, and questions regarding distress and recovery 197 expectations at the time of the initial physician appointment). 198 Descriptive statistics (frequencies and proportions) were computed to document sample 199 characteristics. Because our interest was in time to clearance for RTP,53 accelerated failure time 200 models with loglogistic distribution (bivariate and fully adjusted multivariable models) were 201 generated using complete case analysis to examine the association between psychosocial 202 factors and TTR.10 Repeat concussions for players participating across multiple seasons were 203 handled using clustered standard errors. The date of RTP was based on IRF or weekly exposure 204 sheets if data were not available in physician records.10 The IRF was completed by study 205 personnel if a participant did not complete a final physician visit. Players who were lost to 206 follow-up were censored in the statistical models. 207 We selected covariates according to available data and previous research showing 208 associations with TTR.3,10,54 Covariates included age, sex (male, female), body checking policy 209 (permitted/not permitted), days from concussion to physician visit (7 days or less versus more 210 than 7 days55,56), and symptom severity measured at the initial physician visit (SCAT3 or SCAT5 211 total symptom severity score10). 212 Results 213 Participants 214 A total of 4419 adolescents were recruited for the larger parent study over a five-year 215 period (6584 player seasons); however, the psychosocial questionnaires of interest were only 216 introduced in the second year (season 2014-2015) of the study (see Figure 1). This yielded 4080 217 individual players and 5762 player seasons (N2014-15 = 1398, N2015-16 = 1902, N2016-17 = 1319, 218 N2017-18 = 1143) potentially eligible for analysis. During these seasons, 549 concussions were 219 diagnosed by a study physician, and 397 (72%) had data available for at least one psychosocial 220 measure (Figure 1); 159 (29%) had baseline psychosocial data only, 47 (9%) had psychosocial 221 data only at the initial physician visit, and 191 (35%) had psychosocial data at both times 222 (Supplemental materials, Table 1S). These subgroups did not differ significantly in sex, days to 223 initial physician visit, symptom severity at the initial physician visit, or TTR, but did differ in the 224 likelihood of a previous concussion and of playing in a body checking league and in average age. 225 As noted above, multivariable analyses controlled for age and body checking policy; previous 226 concussion was not controlled because it was not predictive of TTR in our previous study.10 227 A total of 353 players accounted for the 397 concussions (M age=13.90 years; SD=1.53). 228 Most concussions involved males (n=346; 87.2%) and players in a body checking league (n=269; 229 67.8%). Physicians evaluated most concussions within 7 days of injury (n=283; 71.3%) and 230 slightly less than half (n=183; 46.1%) of the concussions were not preceded by another 231 concussion that occurred before the start of the season. Median acute total symptom severity 232 score (/132) at the initial physician visit was 10.0 (IQR=3-23.5). Median time to being cleared to 233 play, for those not lost to follow-up, was 16 days (IQR=11-27). Table 1 presents descriptive data 234 for psychosocial measures. 235 Factors Associated with Time to Recovery 236 Table 2 reports bivariate accelerated failure time models for all psychosocial variables. 237 Lower levels of resilience and higher levels of inattention/hyperactivity and peer relationship 238 problems reported by adolescents at baseline were significantly associated with a longer TTR in 239 bivariate analyses. Higher ratings of distress about concussion outcomes and lower 240 expectations of a full recovery at the initial physical visit also were associated with longer TTR. 241 For parent ratings, higher ratings of distress about their child’s concussion outcomes and about 242 their child’s well-being at the time of injury (TOI) were significantly associated with longer TTR. 243 Table 3 shows fully adjusted multivariable accelerated failure time models. For self-244 ratings (Tables 2S and 3S; see Supplemental materials for full models), higher pre-injury peer-245 related problems reported at baseline (TR, 1.10 [95% CI, 1.02-1.19]) and higher ratings of 246 distress about concussion outcomes acutely post-injury (TR, 1.06 [95% CI, 1.01-1.11]) were 247 associated with longer TTR. For every 1-point increase in self-ratings of peer problems or of 248 acute distress about their concussion outcomes, TTR increased by 10% and 6%, respectively. 249 Figure 2 presents probability curves for RTP based on low (10th percentile), median (50th 250 percentile), and high (90th percentile) ratings of adolescent self-reported ratings for (a) current 251 distress at TOI and (b) peer problems at baseline. 252 Fully adjusted models for parent ratings (Tables 4S and 5S; see Supplemental materials 253 for full models) showed that only parent acute ratings of higher distress about their child’s well-254 being at the TOI (time ratio [TR], 1.06 [95% confidence interval (CI), 1.02-1.09]) and about 255 concussion outcomes (TR, 1.05 [95% CI, 1.01-1.09]) remained associated with longer recovery. 256 For every 1-point increase in distress about their child’s well-being at the TOI or about their 257 child’s concussion outcomes, TTR increased by 6% and 5%, respectively. Figure 3 presents 258 probability curves for RTP based on low (10th percentile), median (50th percentile), and high 259 (90th percentile) acute parent ratings of (a) their distress about concussion outcomes and (b) 260 their distress about their child’s wellbeing. 261 Discussion 262 This study investigated psychosocial variables associated with time to physician 263 clearance for RTP in adolescent ice hockey players with concussion. The median TTR was 16 264 days, consistent with previous research suggesting that many youth with sports-related 265 concussion recover within 2-3 weeks of their injury (median of 178 and 1810 days). After 266 controlling for relevant covariates, adolescent reports of pre-injury peer problems at baseline 267 and levels of distress about their concussion outcomes acutely post-injury, as well as parent 268 levels of distress about their child’s well-being acutely post-injury, were associated with a 269 significant increase in time to RTP. 270 Few studies have investigated parent and youth distress and expectations as associated 271 with recovery, and to our knowledge this is the first to do so in adolescent ice hockey players. 272 Negative thinking about outcomes as reflected in distress and lower expectations of recovery 273 have not been well studied. ‘Nocebo effects’ occur when an individual has negative 274 expectations of outcomes that are associated with prolonged recovery or worsened 275 symptoms.57 Because much online information about concussion is not from reliable sources 276 and may be inaccurate,58,59 some parents and adolescents in the study may have experienced 277 ‘nocebo effects’, prolonging recovery. Parent and player distress and recovery expectations 278 likely reflect messaging by both clinicians and scientists, who should aim to provide accurate, 279 up-to-date information regarding the outcomes of concussion. Future studies should 280 investigate whether the accuracy of information that adolescents and their families have about 281 concussion is associated with their distress, expectancies of recovery, and TTR. 282 Parent-rated but not self-rated distress about the adolescent’s wellbeing at the TOI was 283 significantly associated with a longer TTR. Youth hockey players may tend to minimize their 284 vulnerability to concussion,60 and this may help explain why adolescent reports of distress 285 regarding their wellbeing at the TOI were not significantly associated with TTR. Higher parental 286 distress regarding their child’s wellbeing could be indicative of higher overall parent stress, 287 which has been shown to be associated with a decreased ability to help children cope with 288 injury and therefore may lead to prolonged recovery.61 289 In this study, self-reported peer-related problems was the pre-injury psychosocial factor 290 uniquely associated with TTR. Peer and other forms of social support have been shown to be 291 important in facilitating recovery from pediatric concussion; children identify a need to rely on 292 friends for support during recovery and adolescents who experience persistent PCS often 293 report lower levels of peer support.62,63 The adolescents in our study who reported more peer 294 problems may not have had the same access to social supports as adolescents who reported 295 fewer peer problems and may have therefore experienced a longer time to RTP. Peer-related 296 problems may also be a marker for other functional difficulties that put adolescents at risk of 297 persistent PCS.64 298 In this study, pre-injury QoL, psychological adjustment, resilience, perfectionism, and 299 parental involvement were not significantly related to TTR in multivariable models. These 300 findings could be a function of the outcome investigated in our study, clearance to RTP. Pre-301 injury QoL, adjustment, resilience, perfectionism, and parental involvement could be related to 302 symptom severity or other functional difficulties as opposed to RTP. 303 Our results have potential clinical implications. Education about appropriate 304 expectations about outcomes might assist in shortening TTR. Clinicians and scientists should 305 help to dispel concussion misinformation and aim to support more accurate expectations to aid 306 in recovery.57 Providing accurate information about recovery has been recommended for 307 pediatric concussion management,50 and future studies should investigate whether doing so 308 affects recovery expectations. Because more peer problems were associated with increased 309 time, promoting positive peer relationships also might help facilitate faster recovery. 310 Limitations 311 One study limitation is that questions regarding post-injury distress and expectations of 312 recovery were single items, which may limit their reliability and validity. Additionally, we did 313 not assess the nature or accuracy of the educational information about concussion that our 314 families received prior to or after their adolescent’s injury and that could account for potential 315 ‘nocebo’ effects. Our sample consisted of ice hockey players, which might limit generalizability 316 of the findings to athletes in other contact sports. Additionally, the participants were mostly 317 males and we could not investigate sex differences in post-acute distress and expectations of 318 recovery. Finally, our analyses of psychosocial variables collected at baseline and at TOI were 319 based on overlapping but distinct samples, which differed in history of concussion, body 320 checking policy, and age. However, we controlled for two of those variables in multivariable 321 analyses, and the groups did not differ on several other variables that are also associated with 322 TTR. Nevertheless, missing data from study participants with concussion may have introduced 323 unmeasured bias. 324 Conclusion 325 This study provides evidence that psychosocial factors are associated with 326 TTR following concussion in adolescent ice hockey players, over and above other well-studied 327 variables such as sex, body checking policy, initial symptom severity, and time to initial 328 physician visit. Specifically, parent-rated distress about their child’s wellbeing, parent and child 329 rated distress about concussion outcomes, and self-rated pre-injury peer problems were 330 associated with longer TTR, over and above other factors known to be related to recovery. 331 These results suggest potential targets for interventions to shorten recovery from concussion in 332 adolescents. 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Association of varying levels of self-reported (a) distress about outcomes and (b) peer 526 problems with probability of return to play (RTP). (a) A 60% probability of RTP is achieved at 527 ~23 days for a self-rating of distress at the 10th percentile (score = 1) but at ~36 days for a rating 528 at the 90th percentile (score=8). Put differently, the probability of RTP at 30 days post-injury is 529 ~80% for a rating of distress at the 10th percentile but only ~50% for a rating at the 90th 530 percentile. (b) A 60% probability of RTP is achieved at ~20 days for a self-rating of peer 531 problems at the 10th percentile (score=0) but at ~25 days for a rating at the 90th percentile 532 (score=3). Alternatively, the probability of RTP at 30 days post-injury is ~80% for a rating of peer 533 problems at the 10th percentile but only ~65% for a rating at the 90th percentile. 534 Figure 3. Association of varying levels of parent-rated (a) distress about their child’s outcomes 535 and (b) distress about their child’s well-being at with probability of return to play (RTP). (a) A 536 60% probability of RTP is achieved at ~25 days for a rating of parent distress about outcomes at 537 the 10th percentile (score=1) but at ~38 days for a rating at the 90th percentile (score=9). 538 Alternatively, the probability of RTP at 30 days post-injury is ~70% for a rating of distress at the 539 10th percentile but only ~50% for a rating at the 90th percentile. (b) A 60% probability of RTP is 540 achieved at ~23 days for a rating of parent distress about well-being at the time of injury at the 541 10th percentile but at ~36 days for a rating at the 90th percentile (score=10). Put differently, the 542 probability of RTP at 30 days post-injury is ~75% for rating of distress at the 10th percentile but 543 only 55% probability for a rating at the 90th percentile. 544 Table 1 1 Descriptive summary of psychosocial variables 2 Adolescent ratings Parent ratings N Mean Median SD Min 25th percentile 75th percentile Max N Mean Median SD Min 25th percentile 75th percentile Max Completed at time of preinjury assessment PISQ - DB 205 22.36 21 7.77 10 17 27 50 PISQ - PU 204 16.72 17 2.45 7 15 19 20 PISQ - AI 201 17.97 18 3.40 7 16 20 25 CD-RISC 214 29.02 29 5.41 17 26 33 40 QOL - physical 213 90.02 91 9.68 50 84 97 100 201 89.52 94 12.40 28 84 100 100 QOL - emotion 213 79.11 85 18.28 15 70 95 100 200 77.43 80 17.32 25 65 95 100 QOL - social 211 86.75 90 14.66 30 80 100 100 202 86.93 93 15.51 25 75 100 100 QOL - school 212 75.73 75 16.02 30 65 90 100 201 74.88 75 17.26 35 60 90 100 SDQ - emotion 213 2.21 2 2.04 0 1 4 9 200 1.78 1 1.81 0 0 3 7 SDQ - conduct 213 1.39 1 1.40 0 0 2 6 200 1.00 1 1.30 0 0 2 7 SDQ – ina/hyp 213 3.93 4 2.33 0 2 5 9 199 3.26 3 2.42 0 1 5 10 SDQ - peer 213 1.19 1 1.41 0 0 2 7 200 1.32 1 1.39 0 0 2 6 SDQ - prosocial 213 7.92 8 1.59 3 7 9 10 200 8.29 9 1.74 2 7 10 10 MPS - stand 218 24.05 24 4.23 13 21 27 34 MPS - concern 215 19.94 19 5.57 8 17 24 37 MPS - Ppress 218 21.63 22 5.67 9 18 25 36 MPS - doubts 218 14.44 14 4.02 6 12 17 26 MPS – org. 221 20.81 22 5.48 6 17 25 30 Completed at time of initial physician visit following concussion SUP - distress 226 5.29 6 2.80 1 3 7 10 216 7.42 8 2.47 1 6 10 10 SUP - outcome 225 4.05 3 2.65 1 2 6 10 216 5.29 5 2.90 1 3 8 10 SUP - recovery 225 9.31 10 1.50 3 9 10 10 218 9.12 10 1.76 1 9 10 10 Notes. Min=Minimum, Max=Maximum, N=number of concussions; SD=standard deviation; PISQ= Parent involvement in sport 3 questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience 4 Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport 5 Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental 6 questions (distress about well-being; distress about outcomes; beliefs about recovery). 7 8 Table 2 9 Bivariate accelerated failure time models predicting time to recovery 10 Adolescent ratings Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.01 0.01 0.99 1.02 0.59 PISQ - PU 147 141 111 0.97 0.03 0.92 1.03 0.33 PISQ - AI 145 139 109 0.98 0.02 0.94 1.03 0.44 CD-RISC 154 148 119 0.98 0.01 0.95 1.00 0.03 QOL - physical 158 152 121 0.99 0.01 0.98 1.01 0.25 147 141 111 1.00 0.01 0.99 1.01 0.95 QOL - emotion 158 152 121 0.99 0.00 0.99 1.00 0.11 147 141 111 1.00 0.00 1.00 1.01 0.35 QOL - social 158 152 121 1.00 0.00 0.99 1.01 0.76 148 142 112 1.00 0.01 0.99 1.01 0.99 QOL - school 158 152 121 0.99 0.00 0.98 1.00 0.09 147 141 111 1.00 0.00 0.99 1.01 0.94 SDQ - emotion 158 152 122 1.06 0.04 0.99 1.13 0.09 147 141 112 1.03 0.04 0.95 1.10 0.50 SDQ - conduct 158 152 122 1.06 0.06 0.94 1.19 0.34 147 141 112 0.97 0.05 0.87 1.07 0.50 SDQ - ina/hyp 158 152 122 1.07 0.03 1.01 1.14 0.02 146 140 111 0.97 0.03 0.92 1.02 0.27 SDQ - peer 158 152 122 1.12 0.06 1.01 1.23 0.03 147 141 112 1.01 0.08 0.87 1.17 0.94 SDQ - prosocial 158 152 122 1.07 0.05 0.97 1.17 0.19 147 141 112 1.06 0.04 0.99 1.13 0.12 MPS - stand 157 152 120 0.98 0.02 0.95 1.01 0.27 MPS - concern 154 150 118 1.01 0.01 0.98 1.03 0.54 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.96 MPS - doubts 158 153 121 1.00 0.02 0.96 1.03 0.84 MPS - org. 160 154 123 0.98 0.01 0.96 1.01 0.16 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.07 0.39 207 193 217 1.08 0.03 1.03 1.13 0.00 SUP - outcome 216 202 133 1.12 0.03 1.06 1.18 0.00 207 193 107 1.10 0.03 1.05 1.15 0.00 SUP - recovery 216 202 133 0.81 0.05 0.71 0.92 0.00 209 195 129 0.93 0.06 0.82 1.05 0.26 Notes. CI=confidence interval, Nc=number of concussions; Ny=number of youth; Nrtp=number of youth with return to play data; 11 TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= Parent involvement in sport questionnaire; 12 DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-RISC=Connor-Davidson Resilience Scale; 13 QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional 14 Perfectionism Scale-2; stand=personal standards; Ppress=parental pressure; org=organization; SUP=supplemental questions (distress 15 about well-being; distress about outcomes; beliefs about recovery). 16 17 Table 3 18 Fully adjusted multivariable accelerated failure time models predicting time to recovery* 19 Adolescent rating Parent ratings 95% CI 95% CI Nc Ny Nrtp Time ratio SE Lower Upper p Nc Ny Nrtp Time ratio SE Lower Upper p Completed at time of preinjury baseline assessment PISQ - DB 148 142 112 1.00 0.01 0.99 1.02 0.84 PISQ - PU 147 141 111 0.97 0.03 0.92 1.02 0.25 PISQ - AI 145 139 109 0.97 0.02 0.94 1.01 0.15 CD-RISC 154 148 119 0.99 0.01 0.97 1.01 0.20 QOL - physical 158 152 121 1.00 0.01 0.98 1.01 0.41 147 141 111 1.00 0.00 0.99 1.01 0.51 QOL - emotion 158 152 121 1.00 0.00 0.99 1.01 0.62 147 141 111 1.01 0.00 1.00 1.01 0.08 QOL - social 158 152 121 1.00 0.00 0.99 1.00 0.33 148 142 112 1.00 0.00 0.99 1.01 0.55 QOL - school 158 152 121 1.00 0.00 0.99 1.00 0.27 147 141 111 1.00 0.00 1.00 1.01 0.32 SDQ - emotion 158 152 122 1.01 0.03 0.94 1.07 0.86 147 141 112 1.00 0.03 0.94 1.06 0.95 SDQ - conduct 158 152 122 1.01 0.06 0.89 1.13 0.93 147 141 112 0.95 0.04 0.87 1.04 0.25 SDQ - ina/hyp 158 152 122 1.02 0.03 0.96 1.09 0.45 146 140 111 0.97 0.02 0.93 1.02 0.27 SDQ - peer 158 152 122 1.10 0.04 1.02 1.19 0.01 147 141 112 0.94 0.06 0.82 1.07 0.34 SDQ - prosocial 158 152 122 1.06 0.05 0.98 1.15 0.16 147 141 112 1.05 0.03 0.99 1.11 0.11 MPS - stand 157 152 120 0.98 0.01 0.96 1.01 0.25 MPS - concern 154 150 118 0.99 0.01 0.97 1.02 0.50 MPS - Ppress 158 153 121 1.00 0.01 0.98 1.02 0.68 MPS - doubts 158 153 121 0.98 0.02 0.95 1.01 0.24 MPS - org. 160 154 123 0.99 0.01 0.97 1.01 0.32 Completed at time of initial physician visit following concussion SUP - distress 217 202 134 1.02 0.02 0.98 1.05 0.34 207 193 217 1.06 0.02 1.02 1.09 0.00 SUP - outcome 216 202 133 1.06 0.02 1.01 1.11 0.01 207 193 107 1.05 0.02 1.01 1.09 0.01 SUP - recovery 216 202 133 0.90 0.06 0.80 1.02 0.11 209 195 129 0.96 0.04 0.89 1.04 0.30 Notes. *Adjusted for age, sex, body checking league, symptom severity score at the time of initial physician visit, and number of days 20 between concussion and initial physician visit; CI=confidence interval, Nc=number of concussions; Ny=number of youth; 21 Nrtp=number of youth with return to play data; TR=time ratio; SE=standard error; lower and upper= 95% confidence interval; PISQ= 22 Parent involvement in sport questionnaire; DB=directive behaviour; PU=praise and understanding; AI=active involvement; CD-23 RISC=Connor-Davidson Resilience Scale; QOL=quality of life; SDQ= Strengths and Difficulties Questionnaire; 24 ina/hyp=inattention/hyperactivity; MPS= Sport Multidimensional Perfectionism Scale-2; stand=personal standards; Ppress=parental 25 pressure; org=organization; SUP=supplemental questions (distress about well-being; distress about outcomes; beliefs about 26 recovery). 27 Supplemental Tables and Figures 28 29 Table 1S: Demographic and other characteristics by availability of psychosocial data No psychosocial data Baseline psychosocial data only Time of injury psychosocial data only Both baseline and time of injury psychosocial data Total N % N % N % N % N % P value Sex males 133 87.5 138 86.8 40 85.1 168 88 479 87.3 .932 females 19 12.5 21 13.2 7 14.9 23 12 70 12.8 Previous concussion yes 81 53.3 79 49.7 29 61.7 86 45 275 50.1 .005 no 45 29.6 74 46.5 13 27.7 96 50.3 228 41.5 missing 26 17.1 6 3.8 5 10.6 9 4.7 46 8.4 Body checking yes 74 48.7 111 69.8 34 72.3 124 64.9 343 62.5 .043 no 54 35.5 45 28.3 10 21.3 66 34.6 175 31.9 missing 24 15.79 3 1.9 3 6.4 1 0.5 31 5.7 Days from injury to physician visit 42 27.6 29 18.2 12 25.5 37 19.4 120 21.9 .052 <=7 days 85 55.9 94 59.1 35 74.5 154 80.6 368 67 >7 days 25 16.5 36 22.6 0 0 61 11.1 missing Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Mean(SD) Median (Range) Age statistic 13.8(1.7) 14(11-17) 14.2(1.5) 14(10-17) 14.5(1.5) 15(11-17) 13.5(1.5) 14(10-17) 13.9(1.6) 14(10-17) .001 missing (N) 14 2 0 5 21 Total symptom severity statistic 17.9(18.0) 13(0-73) 16.2(15.7) 11(0-81) 18.7(17.1) 12.8(0-71) 15.2(16.6) 10(0-73) 16.5(16.8) 11(0-81) .539 missing (N) 31 60 1 8 100 Days to recovery statistic 26.1(29.8) 18(0-180) 22.1(23.2) 16(1-156) 31(52.8) 18(4-361) 24.5(26.5) 17(0-190) 24.8(29.7) 17(0-361) .574 missing (N) 1 1 0 0 2 Total 152 27.7 159 29 47 8.6 191 34.8 549 100 *P-value calculated from Fisher’s exact test for categorical measures and a Wilcoxon rank-sum test for equality of medians with Fisher’s exact p-values for continuous measures. 30 Table 2S 31 Adjusted multivariable accelerated failure time model examining preinjury peer relationship 32 problems reported by children (n=158) 33 95% CI TR SE Lower bound Upper bound p Age 1.075 0.043 0.995 1.162 0.068 Sex (female) 0.685 0.117 0.490 0.958 0.027 Body checking (no) 1.446 0.194 1.111 1.882 0.006 Time to physician visit 1.263 0.272 0.828 1.926 0.279 Symptom severity 1.023 0.004 1.014 1.031 0.000 SDQ - peer 1.103 0.042 1.024 1.189 0.010 Constant 3.989 2.313 1.280 12.432 0.017 Note. CI=confidence interval; TR=time ratio; SE=standard error; SDQ=Strengths and Difficulties 34 Questionnaire. 35 36 Table 3S 37 Adjusted multivariable accelerated failure time model examining distress about concussion 38 outcomes reported by adolescent (n=216) 39 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.016 Sex (female) 0.893 0.177 0.605 1.317 0.567 Body checking (no) 1.431 0.207 1.078 1.900 0.013 Time to physician visit 1.600 0.218 1.226 2.088 0.001 Symptom severity 1.016 0.004 1.009 1.024 0.000 SUP - outcomes 1.061 0.024 1.014 1.110 0.010 Constant 11.219 1.255 9.010 13.970 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 40 (distress about outcomes). 41 42 Table 4S 43 Adjusted multivariable accelerated failure time model examining distress about adolescent’s 44 well-being reported by parents (n=207) 45 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 0.999 1.000 0.710 Sex (female) 0.935 0.164 0.664 1.318 0.702 Body checking (no) 1.552 0.226 1.167 2.065 0.003 Time to physician visit 1.874 0.276 1.404 2.502 0.000 Symptom severity 1.020 0.004 1.013 1.028 0.000 SUP - distress 1.059 0.018 1.023 1.095 0.001 Constant 8.467 1.251 6.339 11.310 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 46 (distress about child’s well-being). 47 48 Table 5S 49 Adjusted multivariable accelerated failure time model examining distress about concussion 50 outcomes reported by parents (n=207) 51 95% CI TR SE Lower bound Upper bound p Age 1.000 0.000 1.000 1.001 0.664 Sex (female) 0.997 0.193 0.682 1.456 0.986 Body checking (no) 1.558 0.229 1.168 2.077 0.003 Time to physician visit 1.745 0.260 1.303 2.338 0.000 Symptom severity 1.018 0.004 1.010 1.027 0.000 SUP - outcome 1.051 0.019 1.014 1.090 0.007 Constant 10.135 1.158 8.102 12.678 0.000 Note. CI=confidence interval; TR=time ratio; SE=standard error; SUP=supplemental question 52 (distress about child’s outcomes). 53
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concussion
psychosocial
recovery
child
adolescent
brain injury
Children and youth (0-19)
Concussion/traumatic brain injury
Psychosocial factors associated with time to recovery following concussion in adolescent ice hockey players
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