Abstract
Occupational therapy has a role in facilitating college students' return to occupational performance during concussion recovery.
Concussion, a type of traumatic brain injury, is a growing health concern in the United States. Symptoms that follow concussion can occur in cognitive, physical, emotional/mood, and sleep domains (Centers for Disease Control and Prevention, 2019), with full symptom resolution occurring for 90% of high school and college athletes within 1 mo (Zuckerman et al., 2012). The signs and symptoms associated with concussion can directly affect a person’s ability to engage in occupational performance (Sang et al., 2019). Occupational performance is the “accomplishment of the selected occupation resulting from the dynamic transaction among the client, their contexts, and the occupation” (American Occupational Therapy Association [AOTA], 2020, p. 8). The degree to which concussion symptoms affect occupational performance has not been established in the literature (Sang et al., 2019). How concussion affects college students and adults in terms of specific occupational performance limitations (OPLs) they may experience, or the frequency with which they experience OPLs, is unclear.
In recent years, research has focused on developing best practice guidelines for the management of concussion and the person’s resumption of activities, including engaging in sports, learning, and work (Marshall et al., 2015). The goal of these guidelines is to provide structure for a gradual return to activity with the use of accommodations to improve performance while limiting the exacerbation of postconcussion symptoms. Many sources have indicated that the best practice is for a multidisciplinary team to manage the person’s postconcussion rehabilitation, including OPLs (Finn, 2019; Knollman-Porter et al., 2019). Occupational therapy practitioners have extensive training in grading and adapting activities to facilitate occupational performance (AOTA, 2020). However, there is only limited research regarding occupational therapy’s involvement in multidisciplinary teams (Finn, 2019) that provide services to college-age students with a diagnosis of concussion.
The three research goals for this study, in which we used cross-sectional descriptive survey results, included (1) describing the types and frequency of OPLs for college students who have sustained a concussion, (2) assessing whether the number of concussion symptoms and the recovery time are associated with OPLs after controlling for demographics, and (3) establishing the need for occupational therapy and supporting the profession’s role on multidisciplinary teams.
Method
The data for this study came from a larger project aimed at assessing currently enrolled college students’ knowledge about concussion. After approval of the project was received from the institutional review board, invitation emails were sent to the student affairs departments of 500 randomly selected universities and colleges in the United States, asking them to forward a web-based Qualtrics survey solicitation (https://www.qualtrics.com) to their students. Recruitment was also completed by means of social media solicitation. After the initial solicitation, the survey link remained live for 2 mo.
Participants
Participants were included if they reported that they had sustained a concussion while they were enrolled in college. Exclusion criteria included not reporting a concussion, having sustained a concussion while not enrolled in college, or not currently being enrolled in college.
Instruments
The survey instrument included demographic questions (e.g., gender, age, ethnicity, class designation), concussion-specific questions (e.g., mechanism, number of total concussions), symptoms experienced, recovery time (length of time symptoms were experienced), and OPLs. The number of symptoms was the sum of symptoms experienced after the most recent concussion and included a checklist of 22 common concussion symptoms (e.g., headache, dizziness) that was adapted from the Post-Concussion Symptom Scale (Lovell & Collins, 1998). The recovery time was assessed with a single item that asked how long they had experienced signs or symptoms associated with the most recent concussion. Answer response options included <3 days, 3–7 days, 1–2 wk, 3–4 wk, and >1 mo. For some analyses, this was dichotomized to <3 days and ≥3 days.
OPLs were assessed by providing participants a list of occupational performance areas. The instructions were as follows:
Please indicate on a scale of 0 to 10 how your MOST RECENT concussion affected each of the following aspects of your daily life, with 0 = not at all and 10 = negatively affected my life so bad I could not do the activity.
This survey included 16 items appropriate to university students (Table 1), and those with scores >0 were reported as endorsing the item. An OPL score was generated for each participant who endorsed at least one item (n = 46). Similar to the performance scoring method for the Canadian Occupational Performance Measure (COPM; Law et al., 2019), the five items with the highest scores for each participant were averaged together to come up with an average OPL score, with higher average scores indicating poorer occupational performance. The standardized Cronbach’s α across all items was .92.
OPL Items
Note. N = 52. OPL = occupational performance limitation.
Data Analysis
We used SAS statistical software (Version 9.4) for all analyses. Basic descriptive statistics, including means and standard deviations, are reported for continuous variables, and frequencies and valid percentages are reported for categorical variables. Bivariate associations with the primary dependent variable of interest, OPLs, were tested using a series of Pearson correlations with other continuous variables (e.g., age); t tests with binary variables (e.g., gender); and nonparametric tests, including Mann–Whitney and Kruskal–Wallis tests, with categorical variables (e.g., race). Once we had tested bivariate associations, we examined the primary hypothesis using multiple ordinary least squares linear regression with standard selection; a conservative α level of .10 decided covariate inclusion. Otherwise, α was set to .05.
Results
A total of 220 participants completed the initial survey; of those, 52 (23.6%) self-identified as having experienced a concussion while enrolled in college and completed the section of the survey that asked about occupational performance after the concussion.
Table 1 includes all descriptive and demographic information. There were 16 (30.8%) male and 36 (69.2%) female participants in the concussion group. The mean age of the students was 22.8 yr. Of the total 52 participants with concussion, 46 (88.5%) reported an OPL in at least one area. The most frequently reported areas of limitation were paying attention to the instructor (43; 82.7%), engaging in exercise (41; 78.8%), reading required material in courses (39; 75.0%), and completing course assignments (37; 71.2%). Less frequently reported areas of difficulty included maintaining relationships with the following: peers (28; 53.8%), boss/coach/supervisor (25; 48.1%), family (25; 48.1%), and significant other (24; 46.2%). The least frequently reported OPL was attending faith-based or spiritual activities (reported by only 15 participants [28.8%]; Table 2).
Participant Descriptive and Demographic Characteristics
Note. N = 51. ATV = all-terrain vehicle; MVA = motor vehicle accident.
n = 43. b n = 46.
Average OPL scores were available for 46 of the 52 participants. The average OPL score on the 0-to-10 scale was 6.51 (SD = 5.30). The highest average OPL items included exercise (n = 41, M = 6.41), social activities (n = 37, M = 6.05), and sleep (n = 37, M = 5.92).
Out of the 22 symptoms, the average number was 9.25 (SD = 5.30). The most frequently endorsed symptoms included headache (n = 42; 80.8%), light sensitivity (n = 38; 73.1%), and dizziness (n = 33; 63.5%), with the lowest endorsed symptoms being sleeping less than usual and vomiting (both ns = 6; 11.5%).
Table 3 includes all the bivariate associations with OPLs. As hypothesized, number of symptoms (p = .02) and recovery time (p = .006) were significantly associated with higher OPL means. Only age reached covariate inclusion significance (p = .10), although the association showed that younger college students had higher OPL scores.
Bivariate Associations With Mean OPLs
Note. N = 46. MVA = motor vehicle accident; M-W = Mann–Whitney U test; OPL = occupational performance limitations.
Unequal.
Table 4 includes the regression results for the three variables that met a priori inclusion criteria. Although slightly underpowered, after controlling for age, number of symptoms (p = .058) and recovery time (p = .054) maintained a small to moderate association with OPL scores.
OLS Regression Results for Mean OPLs and Significant Predictors
Note. N = 39. Adj. = adjusted; OLS = ordinary least squares; OPL = occupational performance limitations; ref. = reference category.
Discussion
College students who sustain concussions generally do not have access to occupational therapy as part of their concussion management. The results of our survey indicate that college students reporting concussions with more symptoms that persist for longer periods are more likely to experience OPLs; this finding is consistent with those of other authors (Finn, 2019; Meehan et al., 2014). Difficulty with or avoidance of the performance of life roles and meaningful occupations in conjunction with the lack of physical conditioning can affect psychosocial health (DiFazio et al., 2016).
In this study, college students who experienced more symptoms reported OPLs as soon as 2 days after the injury. Identifying these people earlier, and initiating clinical care and therapies, can facilitate a faster recovery (Kontos et al., 2020, Meehan et al., 2014). Maintenance of occupational performance while experiencing concussion symptoms requires careful grading of activities and environments and the use of adaptations (e.g., wearing sunglasses, taking notes, using noise-canceling headphones). Occupational therapists are specially trained to complete comprehensive evaluations, establish individualized intervention plans (Jaber et al., 2019) that include grading of activity and adaptations, and set reasonable measurable goals to return to previous levels of occupational performance.
Frequent OPLs were reported in occupations associated with the participants’ primary role of student. Eighty-three percent of participants reported difficulty paying attention to class instruction, 75% had difficulty reading the required material, and 71% had difficulty completing assignments. This is consistent with previous literature regarding the presence of increased academic dysfunction after concussion (Wasserman et al., 2016).
These results indicate a unique need for occupational therapy intervention with students who have sustained a concussion to facilitate their continued success in academic pursuits. Students enrolled in educational activities often experience arbitrary deadlines for completion of work to achieve sufficient grades that allow them to pursue future life goals. Failure or less-than-desirable performance triggered by a short-term difficulty can have a deleterious effect on future life plans. Occupational therapists working in conjunction with the student, university offices of accessibility services, and faculty can facilitate a successful return to the classroom while avoiding exacerbation of concussion symptoms.
Limitations
Limitations of this study include that the sample was small and recruited from a large number of university settings, and therefore generalization to the larger population of people with concussion, even among college students, is limited. To better understand the full prevalence of OPLs, future studies should use recruitment techniques that enroll a more diverse population and use a more comprehensive exploration. Additional research is also necessary to identify the most effective occupational therapy interventions in this population.
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice:
Occupational therapy practitioners should be included on postconcussive care teams and protocols.
College students could benefit from occupational therapy intervention to address occupational performance limitations after concussion.
Conclusion
In this study, we aimed to establish the need for occupational therapy and to support the profession’s role on multidisciplinary teams. Most published concussion recovery protocols do not include an occupational therapist as a team member. As this study demonstrates, people who have sustained a concussion experience OPLs. Occupational therapy has a role in facilitating these people’s return to occupational performance during recovery, especially in helping college students return to the classroom.
Footnotes
Acknowledgments
We thank the following West Virginia University MOT students who assisted in data gathering for this project: Katie Blatt, Taylor Fisher, Leah Jeffrey, Taylor Lusk, Kelley Norton, Shannon O’Connor, Marina Stascak, and Madeline Waight.