2021, Vol. 37(1) 17-27
img1
Divya Jain, BS 
, Kristy B. Arbogast, PhD, Christina L. Master, MD, and Catherine C. McDonald, PhD, RN, FAAN
Abstract
Concussion is a common injury among adolescents. It is unknown how a concussion affects driving behavior and performance in adolescents. Although there are guidelines for return to learn, exercise, and sports that school nurses can help support in school, little is known about return to driving after concussion. The goal of this integrative review was to summarize the current literature on return to driving after concussion in adolescents. Six articles published between 2016 and 2020 were included in the review. Physicians and nurse practitioners find providing driving recommendations to adolescents to be appropriate; however, they are unclear what metrics to use to determine whether a patient is fit to drive. Future studies should explore clinical predictors of readiness to return to driving in adolescents. School nurses have an opportunity to support adolescents in their resumption of typical activities after concussion including school, sports, and, as more evidence becomes available, driving.
Keywords
adolescence, concussion, return to driving, driving safety
Approximately 1.1–1.9 million children under the age of 18 in the United States are diagnosed with a concussion annually, with most occurring in 14- to 17-year-olds (Bryan et al., 2016; Centers for Disease Control and Prevention [CDC], 2007). The mainstay for concussion management is a period of physical and cognitive rest followed by a gradual return to daily activities. Practitioners have stepwise management strategies for guiding adolescents back to school and sports postinjury, but no such guidelines exist for returning to driving, a common adolescent daily activity that can be affected by concussion (Harmon et al., 2019; Zemek et al., 2015).
Concussions can affect neurological domains that are required for driving and thus may particularly influence the safety of adolescents behind the wheel (Preece et al., 2010). For example, there is a high prevalence of visual disturbances postconcussion in adolescents (Master et al., 2016). Of particular concern, a concussion may affect the cognitive processes that are required for driving. Driving is a cognitively demanding task, requiring simultaneous monitoring, updating, planning, and attention control (Romer et al., 2014). In adolescents, impairments to motor and visual integration, as well as cognition, can persist past symptom resolution (Brown et al., 2015; Field et al., 2003; Shrey et al., 2011). While it is not known how the cognitive deficits adolescents experience postinjury affect their driving performance, it is known that healthy adolescents who have greater difficulty with executive functions tend to display worse driving performance (Mäntylä et al., 2009; Pope et al., 2016).
Typically, research on adolescent driving safety has focused on risk factors such as the presence of other adolescent passengers, in-vehicle distractions, and hazard anticipation (Curry et al., 2012; Foss & Williams, 2015; Romer et al., 2014). Little is known about the risk of driving postconcussion in adolescents as most research of the effects of concussion on driving performance focuses on the adult population (Baker et al., 2015b; Hoffman et al., 2018; Preece et al., 2010; Schmidt et al., 2017). Research from the adult population indicates that deficiencies in cognitive processes such as attention and working memory that occur after a concussion or mild traumatic brain injury are associated with worse driving performance (Schmidt et al., 2017). There is also evidence to suggest that adult drivers have worse hazard perception within 48 hr postinjury (Preece et al., 2010), but few studies focus on changes in driving performance throughout recovery.
Both the Centers for Disease Control and the American Medical Society for Sports Medicine agree that adolescents should be counseled on returning to driving postconcussion (CDC, 2018; Harmon et al., 2019); however, many practitioners, patients, and families are not aware that driving could potentially be dangerous after a concussion (Preece et al., 2013; Schmidt et al., 2018, 2019). School nurses are in an optimal position to support adolescents and families after a concussion as injured youth return to school, sports, and exercise and often have many resources available given the breadth and depth of research guiding return to these cognitive and physical activities. However, the area of return to driving in adolescents is not as well known. Therefore, the purpose of this integrative review is to summarize the current literature on return to driving after concussion in adolescents.
Method
The electronic databases PubMed, Scopus, and PsycINFO were searched August 4, 2020, using the following key words, mapped to Medical Subject Headings when available: (concussion* OR concussed OR mild traumatic brain injury) AND (automobile driving OR driving OR driver’s license* OR licensure OR driving restriction*) AND (resume OR resumption OR return* OR allow* OR continue) AND (adolescen* OR teen* OR youth*).
Inclusion criteria for the integrative review were databased, peer-reviewed publications written in English that examined driving after concussion as an independent or dependent variable; focused on the adolescent age-group, 13–18 years of age; and published between 2000 and 2020. Research studies, case reports, and quality improvement articles were included. Exclusion criteria included review articles, dissertations, theses, and editorials.
Results
A total of 70 articles were identified in the search strategy. After removing duplicates, 53 articles remained. Of these, 46 articles were excluded based on title and abstract review, leaving seven articles. After full-text review, one article was excluded because the focus was not on changes to driving behavior in adolescents after concussion. Six articles published between 2016 and 2020 were included in the integrative review. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram (Moher et al., 2009) illustrates search results (Figure 1), and a summary of results is presented in Table 1. The level of evidence was determined using the Johns Hopkins Nursing Evidence-Based Practice Research Appraisal Tool (Dang & Dearholt, 2017). Of the six studies, one case study and one survey reported on data collected from adolescents. Four studies focused on data from clinicians and their use of the electronic health record with adolescent patients and/or their clinical guidance/recommendations. Two themes emerged through the studies: changes to adolescent driving performance and behavior after concussion and the current state of clinician recommendations with respect to driving.
Changes to Driving Behaviors and Performance Postconcussion
Two studies examined changes in driving behavior and performance in adolescents after concussion. One case study of an 18-year-old collegiate athlete who sustained a concussion during ice hockey practice showed a decline in executive function, via the Trail Making Test–Part B, and increased infractions on a driving simulation assessment 48-hr postinjury as compared to a preseason baseline (Raukar et al., 2018). These results suggest that cognitive deficits that arise after a concussion may impact driving performance in adolescents.
Another study leveraged the Youth Risk Behavior Survey, a survey administered biannually by the CDC that has two questions related to risky driving behavior: How often the high school student has driven drunk and how often they have been a passenger in a car of a driver who has been drinking (Knell et al., 2020). While these survey items do not encompass all kinds of risky driving behaviors, female participants who had sustained a sports- or recreation-related concussion in the last 12 months were more likely to ride in a vehicle with a driver who had been drinking than female participants who had no history of concussion. No such association was found for male participants, and neither male nor female participants had an association between driving drunk and prior history of concussion.
Clinician Recommendations for Driving in Adolescents After Concussion
Two different quality improvement projects at children’s hospital systems in Ohio and Texas amended the electronic medical record (EMR) to prompt sports medicine physicians to provide adolescent concussion patients with driving recommendations (Santana et al., 2020; Stuart et al., 2016). Both projects were successful, with over 97% of patients receiving driving recommendations without significantly lengthening the visit after changes to the EMR were adopted. However, a common challenge for physicians at both locations was objectively determining whether a patient was fit to return to driving. So while most patients were given time-based or behavior-based (i.e., driving at night) driving recommendations during their visit, physicians highlighted the fact there is no single test, time frame, or published guideline for health care providers to follow.
Fig1
Objectively measured data also served as an important indicator for provider recommendations for driving status. One of the quality improvement projects captured reasons why a sports medicine physician recommended restrictions or limitations to driving. The most common reason was vestibular dysfunction (46%) determined by a validated vestibular-ocular-motor screening assessment (Santana et al., 2020). In addition, a retrospective chart review of 183 patients seen at one sports medicine clinic showed that the administration of a computerized neurocognitive assessment increased the odds of a patient being cleared to drive by nearly 6-fold (MacDonald et al., 2018). These two studies indicate that objectively measured data, rather than subjectively reported symptoms, were associated with a physician’s recommendation for driving status. In contrast, a survey of nurse practitioners licensed in Washington and Oregon found that most recommended restrictions or limitations to driving for an adolescent patient are based on symptoms, most commonly the presence of headache, nausea, and other visual symptoms (Klein et al., 2017). Only 1% of these survey respondents recommended the use of a standardized tool or protocol to guide driving recommendations.
Discussion
This integrative review has shown a scarcity of published studies with respect to returning to driving after concussion in the adolescent population. All studies were either of Level III (nonexperimental studies) or Level V (quality improvement projects and case reports) evidence (Dang & Dearholt, 2017). The majority focused on clinician recommendations. Physicians and nurse practitioners alike find providing driving recommendations to adolescents after a concussion to be appropriate; however, they are unclear what metrics to use to determine whether a patient is fit to drive. Two studies examined changes in driving behavior and performance in adolescents after concussion. Both studies suggest that some adolescents may engage in riskier driving behaviors and display worse driving performance after a concussion.
Tab1
Tab1a
Tab1b
Tab1c
Guidance for clinicians on determining recommendations was challenging given the lack of current evidence. Some rely on objective assessments of neurological domains highly implicated in driving to give driving recommendations like the cognitive and visual domains. Others rely primarily on the presence of specific symptoms like headache or nausea. Because there are no standardized guidelines for health care providers to follow, clinicians not only rely on a range of criteria to determine readiness to return to driving, but they also provide a range of driving restrictions and limitations—time-based (e.g., no driving for 7 days), symptom-based (e.g., no driving until headache resolves), or assessment-based. This is in contrast to return-to-learn protocols that begin with a period of both physical and cognitive rest, followed by a gradual, controlled reintroduction of cognitive activity (Grady et al., 2012). Ramp-up of cognitive activity is generally determined by a standardized symptom monitoring tool, with patients advancing only when a given cognitive activity is tolerated without exacerbation of symptoms (Master et al., 2012). For example, a patient would advance to returning to school for a partial day once they can tolerate homework or school work at home without symptoms. Similar guidance in return to driving may be warranted.
While the addition of driving recommendations provides important guidance to adolescent patients and their families and rarely lengthens the duration of their visit, this review highlights that there is not enough evidence to support the development of standardized return-to-driving recommendations similar to return-to-learn protocols. Only two primary research articles related to the changes in driving behavior postconcussion in adolescents were found. One article suggested that adolescents may be more likely to engage in risky driving behaviors postinjury but only assessed alcohol-based driving risks. One case report found decrements on a simulated driving assessment in one collegiate athlete 48 hr postinjury. It is important to note that these studies did not assess the relationship between changes in driving behavior or performance and the criteria commonly used by practitioners to determine readiness to return to driving like vestibular dysfunction. In the adult driver population, standardized neuropsychological assessments have been used to predict return to driving after moderate and severe traumatic brain injury, but few studies exist to support the use of these assessments to determine readiness to return to driving in the adult concussion population (Baker et al., 2015a). The identification of standard clinical assessments that can predict driving performance in concussed adolescents is particularly necessary as even healthy adolescent novice drivers have difficulty with cognitively demanding driving skills like hazard recognition and focusing on the forward roadway (Curry et al., 2011; McDonald et al., 2014; McKnight & McKnight, 2003). The neurocognitive effects of a concussion could further impair their ability to complete cognitively demanding aspects of driving safely and successfully. Therefore, future studies should directly explore changes in driving behavior and performance after concussion and determine clinical predictors of readiness to return to driving.
This integrative review highlights the fact that the consequences of returning to driving too quickly after concussion in adolescents are not fully understood. While return-to-learn practices recommend gradual reintroduction of cognitive activities to mitigate the risk of symptom exacerbation, the risks of returning to driving are unknown (Master et al., 2012). Early return to driving not only may exacerbate symptoms, but the neurocognitive sequelae of concussion may put adolescent drivers, and the road users around them, at an increased risk of motor vehicle crash. A survey of collegiate student-athletes found that, while most believed that driving immediately following a concussion is unsafe, many did not refrain from driving after sustaining a concussion. The student-athletes who did refrain from driving postinjury most commonly did so based on advice from a health care provider (Schmidt et al., 2018). A better understanding of how driving performance and risk of motor vehicle crashes change after concussion in adolescents is needed to provide health care providers with evidence-based driving recommendation guidelines.
Implications for School Nursing and School Health Services
School nurses are part of the front line of helping adolescents recover from concussion and resume normal activities as during the school year, they have an opportunity for almost daily interaction with injured youth (National Association of School Nurses, 2016). Although school nurses have access to return-to-learn and -sport guidelines, no such guidelines exist for return to driving. Being at the interface between health and education, school nurses can deliver pertinent information to both adolescents and their parents/guardians. School nurses also can work with the primary health care provider, athletic trainer, and/or other school staff to support return to physical and cognitive activities (Weber et al., 2019; Welch Bacon et al., 2017). While evidence in the adolescent population is limited, school nurses are uniquely situated to monitor symptoms and administer standard clinical assessments throughout recovery to better assess readiness to return to the cognitively demanding task of driving. As more information about the types of clinical assessments that can predict the driving performance of adolescents after a concussion becomes available, school nurses may be able to administer and monitor performance on these assessments regularly and relay that information to the adolescent’s health care team and family to develop individualized steps for gradual return to driving.
Limitations
It is acknowledged that this review has some limitations that are likely to affect the external validity and implications of the findings. There were only six studies, and many focused on a single-center, in particular, specialty care clinics. However, adolescents can be treated for a concussion in a variety of settings by a variety of providers, such as the emergency department, urgent care, or their primary care physician or athletic trainer. Further assessment of driving recommendations given by different clinicians in different settings is required. Some studies did not include asymptomatic adolescents even though cognitive deficits can persist past symptom resolution. Only one case report assessed deficits in driving performance in the acute phase of injury. Studies determining deficits in driving performance in a larger sample and throughout recovery are needed to develop an evidence base for driving recommendations. No studies explored the relationship between driving performance and patient factors used by clinicians to determine readiness to return to driving. This research is needed to standardize the guidelines for providing recommendations on driving to adolescents and their families.
Conclusion
This integrative review demonstrated that clinicians believe counseling adolescent patients and their families on driving after concussion is important, but there is a lack of evidence to guide recommendations, restrictions, or limitations to driving postinjury. While there is growing research evidence for return-to-driving outcomes in adults with concussion, there is a dearth of information with respect to adolescents. Additional research is required to provide school nurses with evidence-based directives for returning adolescents to driving. This evidence will also be of value to patients, their families, and other clinicians. As this evidence grows, school nurses have an opportunity to support adolescents in their resumption of driving.
Authors’ Note
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Contribution
Divya Jain contributed to conception, design, acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Kristy B. Arbogast, Christina L. Master, and Catherine McDonald contributed to conception, design, acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number R01NR018425.
ORCID iDs
Divya Jain, BS https://orcid.org/0000-0002-2255-8764 Catherine C. McDonald, PhD, RN, FAAN https://orcid.org/0000-0003-3856-8542
References
Baker, A., Unsworth, C. A., & Lannin, N. A. (2015a). Determining fitness to drive: A systematic review of the methods and assessments used after mild traumatic brain injury. British Journal of Occupational Therapy, 78(2), 73–84.
Baker, A., Unsworth, C. A., & Lannin, N. A. (2015b). Fitness-todrive after mild traumatic brain injury: Mapping the time trajectory of recovery in the acute stages post injury. Accident Analysis & Prevention, 79, 50–55. http://doi.org/10.1016/j.aap.2015.03.014
Brown,J.A.,Dalecki,M.,Hughes,C.,Macpherson,A.K.,& Sergio, L. E. (2015). Cognitive-motor integration deficits in young adult athletes following concussion. BMC Sports Science, Medicine and Rehabilitation, 7(1). http://doi.org/10.1186/s13102-015-0019-4
Bryan, M. A., Rowhani-Rahbar, A., Comstock, R. D., & Rivara, F. (2016). Sports- and recreation-related concussions in US youth. Pediatrics, 138(1). http://doi.org/10.1542/peds.2015-4635
Centers for Disease Control and Prevention. (2007). Nonfatal traumatic brain injuries from sports and recreation activities—United States, 2001–2005. MMWR. Morbidity and Mortality Weekly Report, 56(29), 733–737. http://www.ncbi.nlm.nih.gov/pubmed/17657206
Centers for Disease Control and Prevention. (2018). Heads up to health care providers: Managing return to activities. https://www.cdc.gov/headsup/providers/return_to_activities.html
Curry, A. E., Hafetz, J., Kallan, M. J., Winston, F. K., & Durbin, D. R. (2011). Prevalence of teen driver errors leading to serious motor vehicle crashes. Accident Analysis & Prevention, 43(4), 1285–1290. http://doi.org/10.1016/J.AAP.2010.10.019
Curry,A.E.,Mirman,J.H.,Kallan,M.J.,Winston,F.K.,& Durbin, D. R. (2012). Peer passengers: How do they affect teen crashes? Journal of Adolescent Health, 50(6), 588–594. http://doi.org/10.1016/j.jadohealth.2011.10.016
Dang, D., & Dearholt, S. (2017). Johns Hopkins nursing evidencebased practice: Model and guidelines (3rd ed.). Sigma Theta Tau International.
Field, M., Collins, M. W., & Lovell, M. R. (2003). Does age play a role in recovery from sports related concussions? A comparison of high school and collegiate athletes. American Journal of Pediatrics, 142, 546–553. http://doi.org/10.1067/mpd.2003.190
Foss, R. D., & Williams, A. F. (2015). Adolescent drivers: Finetuning our understanding. Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 57(1), s1–s5. http://doi.org/10.1016/j.jadohealth.2015.04.024
Grady, M. F., Master, C. L., & Gioia, G. A. (2012). Concussion pathophysiology: Rationale for physical and cognitive rest. Pediatric Annals, 41(9), 377–382. http://doi.org/10.3928/00904481-20120827-12
Harmon, K. G., Clugston, J. R., Dec, K., Hainline, B., Herring, S. A., Kane, S., Kontos, A. P., Leddy, J. J., McCrea, M. A., Poddar, S. K., Putukian, M., Wilson, J. C., & Roberts, W. O. (2019). American medical society for sports medicine position statement on concussion in sport. Clinical Journal of Sport Medicine, 29(2), 87–100. http://doi.org/10.1097/JSM.0000000000000720
Hoffman, N. L., Devos, H., & Schmidt, J. D. (2018). Driving performance deficits despite concussion symptom resolution: A case report. International Journal of Athletic Therapy & Training, 23(Suppl. 1), 21–26.
Klein, T. A., Graves, J. M., & Graham, J. Y. (2017). Driving after adolescent concussion: Advice from nurse practitioners in the absence of standardized recommendations. Journal of Pediatric Health Care, 31(4), 441–451. http://doi.org/10.1016/j.pedhc.2016.11.004
Knell, G., Burkhart, S. O., Caze, T. J., Polousky, J. D., Kohl, H. W., & Messiah, S. E. (2020). Association between concussion history and factors relating to cognitive, behavioral, and emotional health among American high school athletes: A crosssectional analysis. The American Journal of Sports Medicine, 48(10), 2534–2543. http://doi.org/10.1177/0363546520938776
MacDonald, J., Patel, N., Young, J., & Stuart, E. (2018). Returning adolescents to driving after sports-related concussions: What influences physician decision-making. The Journal of Pediatrics, 194, 177–181. http://doi.org/10.1016/j.jpeds.2017.10.032
Mäntylä, T., Karlsson, M. J., & Marklund, M. (2009). Executive control functions in simulated driving. Applied Neuropsychology, 16(1), 11–18. http://doi.org/10.1080/09084280802644086
Master, C. L., Gioia, G. A., Leddy, J. J., & Grady, M. F. (2012). Importance of “return-to-learn” in pediatric and adolescent concussion. Pediatric Annals, 41(9), 1–6. http://doi.org/10.3928/00904481-20120827-09
Master, C. L., Scheiman, M., Gallaway, M., Goodman, A., Robinson, R. L., Master, S. R., & Grady, M. F. (2016). Vision diagnoses are common after concussion in adolescents. Clinical Pediatrics, 55(3), 260–267. http://doi.org/10.1177/0009922815594367
McDonald, C. C., Curry, A. E., Kandadai, V., Sommers, M. S., & Winston, F. K. (2014). Comparison of teen and adult driver crash scenarios in a nationally representative sample of serious crashes. Accident Analysis & Prevention, 72, 302–308. http://doi.org/10.1016/j.aap.2014.07.016
McKnight, A. J., & McKnight, A. S. (2003). Young novice drivers: Careless or clueless? Accident; Analysis and Prevention, 35(6), 921–925. http://www.ncbi.nlm.nih.gov/pubmed/12971927
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and metaanalyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. http://doi.org/10.1371/journal.pmed.1000097
National Association of School Nurses. (2016). Concussions—The role of the school nurse. https://www.nasn.org/nasn/advocacy/professional-practice-documents/position-statements/psconcussions
Pope, C. N., Ross, L. A., & Stavrinos, D. (2016). Association between executive function and problematic adolescent driving. Journal of Developmental and Behavioral Pediatrics, 37(9), 702–711. http://doi.org/10.1097/DBP.0000000000000353
Preece, M. H. W., Geffen, G. M., & Horswill, M. S. (2013). Returnto-driving expectations following mild traumatic brain injury. Brain Injury, 27(1), 83–91. http://doi.org/10.3109/02699052.2012.722260
Preece, M. H. W., Horswill, M. S., & Geffen, G. M. (2010). Driving after concussion: The acute effect of mild traumatic brain injury on drivers’ hazard perception. Neuropsychology, 24(4), 493–503. http://doi.org/10.1037/a0018903
Raukar, N., Palms, D., Boyle, M., & Baird, J. (2018). A case report of impaired driving performance after a concussion. Rhode Island Medical Journal, 101(10) 56–57.
Romer, D., Lee, Y. C., McDonald, C. C., & Winston, F. K. (2014). Adolescence, attention allocation, and driving safety. Journal of Adolescent Health, 54(Suppl. 5), S6–S15. http://doi.org/10.1016/j.jadohealth.2013.10.202
Santana, J. A., Martinie, R., & Gomez, J. (2020). Improving concussion management by including driving recommendations for adolescents with concussions: A quality improvement project. Pediatric Quality & Safety, 5(3), e307. http://doi.org/10.1097/pq9.0000000000000307
Schmidt, J. D., Hoffman, N. L., Ranchet, M., Miller, L. S., Tomporowski, P. D., Akinwuntan, A. E., & Devos, H. (2017). Driving after concussion: Is it safe to drive after symptoms resolve? Journal of Neurotrauma, 34(8), 1571–1578. http://doi.org/10.1089/neu.2016.4668
Schmidt, J. D., Lempke, L. B., Devos, H., & Lynall, R. C. (2019). Postconcussion driving management among athletic trainers. Brain Injury, 1–8. http://doi.org/10.1080/02699052.2019.1664765
Schmidt, J. D., Lynall, R. C., Lempke, L. B., Weber, M. L., & Devos, H. (2018). Post-concussion driving behaviors and opinions: A survey of collegiate student-athletes. Journal of Neurotrauma, 35(20), 2418–2424. http://doi.org/10.1089/neu.2018.5707
Shrey, D. W., Griesbach, G. S., & Giza, C. C. (2011). The pathophysiology of concussions in youth. Physical Medicine and Rehabilitation Clinics of North America, 22(4), 577–602, vii. https://doi.org/10.1016/j.pmr.2011.08.002
Stuart, E. A., Duerson, D. H., Rodenberg, R. E., Ravindran, R., & MacDonald, J. P. (2016). Individual QI projects from single institutions return to drive counseling after sportsrelated concussion: A quality improvement project. Pediatric Quality & Safety, 1(2), e006. https://doi.org/10.1097/pq9.0000000000000006
Weber, M. L., Welch Bacon, C. E., & McLeod, T. V. (2019). School nurses’ management and collaborative practices for student-athletes following sport-related concussion. Journal of School Nursing, 35(5), 378–387. http://doi.org/10.1177/1059840518774391
WelchBacon,C.E.,Erickson,C.D.,Kay,M.C.,Weber,M.L.,& Valovich McLeod, T. C. (2017). School nurses’ perceptions and experiences with an interprofessional concussion management team in the secondary school setting. Journal of Interprofessional Care, 31(6), 725–733. http://doi.org/10.1080/13561820.2017.1345873
Zemek, R., Eady, K., Moreau, K., Farion, K. J., Solomon, B., Weiser, M., & Dematteo, C. (2015). Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management. Canadian Journal of Emergency Medicine, 17(2), 115–122. http://doi.org/10.1017/cem.2014.38
Author Biographies
Divya Jain, BS, is a PhD candidate in the Department of Bioengineering, University of Pennsylvania.
Kristy B. Arbogast, PhD, is Co-Scientific Director of the Center for Injury Research and Prevention at the Children’s Hospital of Philadelphia and Professor, Department of Pediatrics, University of Pennsylvania.
Christina L. Master, MD, is a pediatric sports medicine physician and Co-Director of the Minds Matter Concussion Program at the Children’s Hospital of Philadelphia and Professor of Clinical Pediatrics, Department of Pediatrics, University of Pennsylvania.
Catherine C. McDonald, PhD, RN, FAAN, is an Associate Professor at the University of Pennsylvania School of Nursing.
1 Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
2 Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, PA, USA
3 Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
4 Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
5 Division of Orthopedics, Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, PA, USA
6 School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
Corresponding Author:
Divya Jain, BS, Center for Injury Research and Prevention, Roberts Center for Pediatric Research, The Children’s Hospital of Philadelphia, 2716 South Street, Floor 13, Philadelphia, PA 19146, USA.
Email: jdivya@seas.upenn.edu