Context

Pediatric mild traumatic brain injuries (mTBIs) represent an evolving field of interest in youth athletics. Although most players recover within 4 weeks, some have symptoms that last longer. Little is known about youth health-related quality of life (HRQoL) after mTBI.

Objectives

To characterize youth HRQoL after soccer-related mTBI and to identify predictors of individual differences in HRQoL recovery.

Design

Prospective cohort study.

Setting

Youth soccer.

Participants

Soccer players, aged 8 to 17 years, who sustained an mTBI (n = 23) or orthopaedic injury (OI, n = 24) or remained uninjured (n = 23) during a single season.

Main Outcome Measure(s)

We assessed HRQoL via the Pediatric Quality of Life Inventory, version 4.0, and postconcussive symptoms via the Health and Behavior Index. Serial assessments occurred at 24 to 48 hours, 7 days, 30 days, and 90 days postinjury via telephone interview.

Results

At 7 days postinjury, the mTBI and OI groups had poorer total HRQoL (F2,67 = 11.35, P < .001) than the uninjured control group. At 7 days, the mTBI group had the poorest psychosocial HRQoL, whereas the OI group had the poorest physical HRQoL. Differences between the mTBI and uninjured control groups resolved by 30 days. Within the mTBI group, players with significant postconcussive symptoms at 7 days had poorer total (F1,21 = 23.071, P ≤ .001; F1,21 = 5.798, P = .028), psychosocial (F1,21 = 16.488, P = < .001; F1,21 = 5.050, P = .039), and physical (F1,21 = 21.671, P = < .001; F1,21 = 5.119, P = .038) HRQoL at 7 and 30 days, respectively, than players with minimal symptoms; these differences resolved by 90 days.

Conclusions

As a group, youth soccer players who sustained mTBI had transient impairments in HRQoL that resolved by 30 days. A subset of players with significant postconcussive symptoms at 7 days postinjury had poorer HRQoL for at least 30 days postinjury than those whose postconcussive symptoms had resolved within a week of injury. This suggests ongoing recovery in this subset at 30 days and the potential utility of HRQoL as a measure of recovery.

Key Points
  • Most youth soccer players who experienced mild traumatic brain injury (mTBI) had transient impairments in health-related quality of life (HRQoL) that resolved by 30 days.

  • A subset of players with mTBI who had significant symptoms at 7 days postinjury displayed poorer HRQoL at 30 days postinjury, suggesting ongoing or slower recovery in this group at this time point.

  • As an additional measure of mTBI recovery, HRQoL may have utility.

Approximately 3.8 million sport-related mild traumatic brain injuries (mTBIs), also referred to as concussions, occur annually in the United States, accounting for up to 8% of pediatric emergency room visits.1  Although the vast majority of these injuries resolve within 4 weeks, a small percentage of patients experience longer-lasting symptoms.2,3  These symptoms can result in disruptions to physical, academic, social, and behavioral functioning.4  However, relatively few researchers have characterized health-related quality of life (HRQoL) after pediatric mTBI4 ; HRQoL represents a multiconstruct concept that captures the effect of disease states on a patient’s physical, mental, and social well-being.4 

The relatively small body of literature exploring HRQoL after pediatric mTBI has produced mixed results in both the acute and chronic postinjury periods. Adolescents with mTBI demonstrated poorer HRQoL at 1 week,5  3 months,6  and 12 months postinjury.69  Even asymptomatic youth have displayed poorer HRQoL post-mTBI.7  In contrast, several other authors found no difference at the time of documented clinical recovery,5  at 1 year postinjury,9  and at 2.5 years postinjury,10  with no difference in HRQoL at any point postinjury.2,11 

Impairments in HRQoL are more consistently evident among youth with prolonged recovery after mTBI. In youth with ongoing symptoms at 1 month, 3 months,7  and 6 months postinjury,12  HRQoL was consistently poorer than in those who were asymptomatic postinjury. A relationship between poorer HRQoL at 1 week postinjury and delayed recovery has also been demonstrated.5,13  Measures of HRQoL were better at predicting time lost to injury after sport-related mTBI, defined as the number of days between initial injury and clearance for return to play, than traditional mTBI assessment tools.1  Such measures may, therefore, be useful in predicting patients who will have a relatively slower recovery.

Beyond describing changes in HRQoL, multiple researchers have examined potential predictors of HRQoL. The post-mTBI symptom burden1,8,1215  and prior number of mTBIs7,1618  have both shown relationships with poorer HRQoL. A variety of preinjury features have also been associated with poorer postinjury HRQoL. These include preinjury HRQoL,8  older age,6  female gender,7,19  mood disorders,10  school difficulties (including attention-deficit/hyperactivity disorder),7,10  and somatic complaints (eg, headache).7,8  At the professional level, career length and position have been implicated in sport-related mTBI outcomes,20  but these relationships have not yet been studied directly in youth. An improved understanding of impairments and predictors of HRQoL after youth mTBI may aid in identifying those at risk for poorer outcomes and could ultimately help optimize the timing and approach to clinical interventions for recovering athletes.

The purpose of our study was to contribute to the growing body of research characterizing HRQoL after mTBI in youth athletes. The current work was part of a larger longitudinal investigation of outcomes from youth soccer–related mTBI. Our group previously reported that after mTBI, the symptom recovery trajectory was similar in this sample to well-established findings in older high school and collegiate athletes.21  In the current research, we examined HRQoL in 3 groups of competitive soccer players aged 8 to 17 years: those who sustained an mTBI during the season, those who sustained an orthopaedic injury (OI) during the season, and uninjured control athletes. The selection of an appropriate control group for studying the effects of mTBI is a complex topic that has been the subject of both theoretical debate and empirical study. Studies that include only an uninjured control group cannot disentangle potential brain injury effects from factors that may predispose some individuals to injury or from general injury effects. For these reasons, recognition is growing of the importance of including an OI control group in pediatric TBI research.22,23  Including an OI control group in the current study provided a more rigorous test of the effect of mTBI on HRQoL than a comparison with only an uninjured control group would allow.

The aims of our study were to describe the pattern of initial HRQoL impairment and subsequent recovery in the mTBI group as compared with OI and healthy control groups, as well as to identify predictors of individual differences in HRQoL recovery within the mTBI group. Our main hypothesis was that most soccer players with mTBI would have transient impairments in HRQoL that normalized within the initial days to weeks. We expected to find worse HRQoL in the initial postinjury period among mTBI players compared with uninjured control players and that the HRQoL of the OI group would fall between these 2 groups. Our secondary hypothesis was that the subset of those with significant postconcussive symptoms at 1 week postinjury would have longer-lasting HRQoL impairment than those with minimal symptoms.

Study Design

The investigation was approved by the university-affiliated institutional review board. Information regarding study design was provided to all parents, coaches, and team managers. A prospective cohort of youth soccer players, aged 8 to 17 years, was recruited from a large competitive soccer club between 2016 and 2017. A total of 72 participants were eligible for inclusion; 2 were lost to follow-up and were therefore excluded from this study. Seventy participants had complete data and were divided into 3 groups: mTBI (n = 23), OI (n = 24), and uninjured control (n = 23). All players with mTBI or OI in this study incurred their injury during the single examined season. As in the initial study, mTBI was defined as exposure to blunt force trauma with loss of consciousness (<30 minutes) or ≥2 of the following acute signs: transient neurologic deficit, recurrent vomiting, nausea, headache, diplopia, dizziness, memory loss, disorientation, or other mental status change.21  Athletes with OI sustained injuries below the neck with no concern for concomitant mTBI and an Abbreviated Injury Scale score of <3 (scores in this range are roughly equivalent to mTBI; examples of injuries in the OI group were ankle sprain, wrist sprain, mallet finger, and radius fracture).21 

We measured HRQoL at 7, 30, and 90 days after injury. Seven days was chosen because many individuals with sport-related mTBI show good recovery by that point and earlier authors found symptoms at a median of 6.5 days postinjury predicted recovery and HRQoL.14  Thirty days was chosen as a second time point as expert consensus defines expected recovery as within 1 month of injury; symptoms beyond this time are considered persistent.3  Ninety days was chosen as the final time point based on evidence that the large majority of athletes will have recovered well from mTBI within that timeframe.6,24  Although some individuals do experience ongoing symptoms at 90 days, such symptoms tend to be more strongly related to noninjury than to injury factors.24 

At the start of the season, parents of potentially eligible athletes were asked to fill out an online background questionnaire that included demographic and health information. Postinjury study eligibility, retrospective baseline data, and outcome measures were obtained via telephone interviews. The data-collection protocol consisted of telephone interviews of the athlete and parent at 4 time points: 1 to 2 days postinjury (mean = 1.38 days, range = 1–3 days), 7 days postinjury (mean = 7.15 days, range = 6–9 days), 30 days postinjury (mean = 33 days, range = 29–43 days), and 90 days postinjury (mean = 96.35 days, range = 86–107 days). A significant proportion of parents had not completed the background questionnaire before the study; in these cases, missing demographic and health information were obtained during the first telephone interview.

Participants

Parental consent and child assent were obtained before participation. The average age of all athletes was 13.6 ± 2.05 years, with no difference across groups. Data obtained during the first telephone interview included age, career length, position, preexisting inattention symptoms, preexisting anxiety and somatization symptoms, preexisting developmental or school difficulties (defined as receiving special education or Section 504 accommodations, repeating a grade, prior referral to early intervention, or diagnosed learning disability), number of previous mTBIs, and history of mTBI recovery lasting >7 days. Player position was categorized as either offense or defense. Background data across groups are summarized in Table 1.

Table 1.

Background Information for the Groups With Mild Traumatic Brain Injury, Orthopaedic Injury, or No Injury

Background Information for the Groups With Mild Traumatic Brain Injury, Orthopaedic Injury, or No Injury
Background Information for the Groups With Mild Traumatic Brain Injury, Orthopaedic Injury, or No Injury

The mTBI group was divided into subgroups based on the postconcussive symptom burden at 7 days measured on the parent-reported Health and Behavior Inventory (HBI). As described in the initial study,21  postconcussive symptoms at 7 days were compared with each participant’s own retrospective baseline using reliable change indices. Those with an absolute reliable change index value exceeding z = 1.64 at 7 days postinjury were considered to have significant symptoms.25  This procedure resulted in one subgroup of 9 youth with minimal symptoms and a second subgroup of 14 youth with significant ongoing symptoms at 7 days postinjury.

Procedures

Athletes and a primary caregiver independently completed the HBI, and the caregiver completed the Pediatric Quality of Life Inventory (PedsQL), version 4.0. Parents’ and self-reported HBI scores were strongly correlated (R = 0.65, P < .001); however, we used only parents’ scores because of their higher completion rates. Health-related quality of life was assessed via the age-appropriate parent proxy version of the PedsQL questionnaire, which has demonstrated strong psychometric properties in pediatric patients with TBI and a variety of other pediatric populations.2,4,6,11,26  We opted to use the parent-reported HRQoL in this study because parent- and self-reported scores have been shown to be similar to patients’ scores in mTBI2,4,5  and because similar studies of pediatric HRQoL post-mTBI have relied on parental proxies.8,25 

During the initial telephone contact, parents were asked to rate their child’s preinjury functioning in order to provide a retrospective measure of baseline HRQoL and postconcussive symptoms. Parental ratings of current HRQoL and postconcussive symptoms were also obtained at 7, 30, and 90 days postinjury. The uninjured control group completed the PedsQL and HBI at the same data-collection points, with subsequent postinjury days defined relative to the first telephone contact.

The PedsQL assesses HRQoL in 4 domains: physical, school, emotional, and social functioning, and the scores are summed for a total measure. The school, emotional, and social functioning scores also contribute to a psychosocial subscale.26  The primary scales used in this study were the total HRQoL as well as the psychosocial and physical subscales. All domain and total scores are measured on a linear scale ranging from 0 to 100, with 0 representing the poorest HRQoL and 100 representing the best possible HRQoL.26 

Symptom severity was rated via the HBI, a questionnaire that measures common postconcussive symptoms and has been validated for use in pediatric patients with TBI.21,25  The HBI measures the frequency of 20 common postconcussive symptoms. Each symptom is rated on a scale from 0 to 3 based on its frequency, with higher HBI scores indicating a greater symptom burden. If >50% of the HBI scale items were missing, participants were excluded from all subsequent analyses. If <50% were missing, absent values were replaced with the group’s mean for the scale at that time point. Values were replaced in 5 instances for the mTBI group, 8 for the OI group, and once for the control group. No included participants were missing data at multiple time points.

To measure retrospective preinjury emotional functioning, parents also completed the Anxiety and Somatization subscales of the Behavior Assessment System for Children, third edition, at the first postinjury telephone interview. The Behavior Assessment System for Children measures emotional and behavioral status via rating scales and established normative values. It is both highly reliable and well validated.20  Preinjury attention-deficit/hyperactivity disorder symptoms were also assessed retrospectively via parental report during the first telephone interview using the National Institute for Children’s Health Quality Vanderbilt Assessment.27 

Statistical Analyses

All statistical analyses were performed via JMP statistical processing software (version 14.3.0; JMP Statistical Discovery LLC). An a priori α level of .05 (2 tailed) was used for all analyses. We examined the variables for extreme outliers and extreme departures from normality by group. Any outliers beyond 3 SDs were trimmed to 3 SDs. One-way analyses of variance (ANOVAs) were calculated to compare the PedsQL scores across groups and time points. Significant ANOVAs were further investigated post hoc via Tukey-Kramer analysis. In the mTBI group, we computed 1-way ANOVAs and analyses of covariance to explore predictors of total HRQoL at each time point. Categorical predictor variables were mTBI subgroup (minimal versus significant symptoms at 7 days postinjury), sex, player position, history of school difficulty, and history of prolonged mTBI recovery. Continuous predictor variables were parents’ retrospective ratings of participants’ preinjury symptoms of inattention, anxiety, and somatization. Significant relationships were further evaluated with post hoc ANOVAs or analyses of covariance of PedsQL subdomains at those time points.

Trajectory of HRQoL Across Groups

Total HRQoL

Retrospective baseline total HRQoL scores were not different across groups (F2,67 = 0.24, P = .786, ηp2 = 0.001). At 7 days postinjury, differences were present in total HRQoL (F2,67 = 11.35, P < .001, ηp2 = 0.253), and players with mTBI or OI had poorer total HRQoL than control players. At 30 days postinjury, group differences persisted (F2,67 = 4.63, P = .013, ηp2 = 0.121), and players with OI had poorer total HRQoL than the control group; however, players with mTBI were not different from either group. At 90 days postinjury, no group differences were noted in total HRQoL (F2,67 = 1.78, P = .177, ηp2 = 0.05, Figure 1).

Figure 1

Parent-reported total health-related quality of life in the 3 groups at baseline and 3 postinjury time points. a Indicates a difference from the control group.

Figure 1

Parent-reported total health-related quality of life in the 3 groups at baseline and 3 postinjury time points. a Indicates a difference from the control group.

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Psychosocial HRQoL

Retrospective baseline psychosocial HRQoL scores were not different across groups (F2,67 = 0.29, P = .750, ηp2 = 0.009). Yet at 7 days postinjury, differences occurred among groups (F2,67 = 5.74, P = .005, ηp2 = 0.146). The players with mTBI had poorer psychosocial HRQoL than control players, but those with OI were not different from either group. No group differences were seen in psychosocial HRQoL at 30 days (F2,67 = 1.78, P = .177, ηp2 = 0.050) or 90 days (F2,67 = 0.02, P = .983, ηp2 < 0.001, Figure 2) postinjury.

Figure 2

Psychosocial health-related quality of life in the 3 groups at baseline and 3 postinjury time points. a Indicates a difference from the control group.

Figure 2

Psychosocial health-related quality of life in the 3 groups at baseline and 3 postinjury time points. a Indicates a difference from the control group.

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Physical HRQoL

Retrospective baseline physical HRQoL scores were not different across groups (F2,67 = 0.35, P = .704, ηp2 = 0.10). However, at 7 days postinjury, the groups differed (F2,67 = 20.35, P < .001, ηp2 = 0.378). Players with OI had poorer physical HRQoL scores than players with mTBI or control players, and those with mTBI scored worse than control players. At 30 days postinjury, group differences were again present (F2,67 = 7.17, P = .002, ηp2 = 0.176): physical HRQoL scores were poorer in players with OI than those in either the mTBI or control group. Group differences persisted at 90 days postinjury (F2,67 = 4.97, P = .010, ηp2 = 0.129): players with OI scored worse than control players, whereas those with mTBI did not diff from either group (Figure 3).

Figure 3

Physical health-related quality of lifein the 3 groups at baseline and 3 postinjury time points. a Indicates a difference from the control group. b Indicates a difference from the mild traumatic brain injury group.

Figure 3

Physical health-related quality of lifein the 3 groups at baseline and 3 postinjury time points. a Indicates a difference from the control group. b Indicates a difference from the mild traumatic brain injury group.

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Predictors of Quality of Life in Players With mTBI

Total HRQoL

At 7 days postinjury, retrospective baseline anxiety (F1,21 = 9.290, P = .008, ηp2 = 0.367) and somatization (F1,21 = 5.455, P = .033, ηp2 = 0.254) displayed significant effects on total HRQoL across all players with mTBI. Greater baseline anxiety and somatization were both associated with poorer postinjury HRQoL. No other significant effects of baseline anxiety or somatization on total HRQoL were evident at any other time point (Table 2). Furthermore, among all players with mTBI, HRQoL did not differ by parent-reported sex, player position, a history of developmental or school difficulty, or a history of prolonged mTBI recovery. The relationship between the previous number of mTBIs and HRQoL was also not significant at any time point.

Table 2.

Predictors of Total Health-Related Quality of Life in the Mild Traumatic Brain Injury Group by Time (Analysis of Covariance)

Predictors of Total Health-Related Quality of Life in the Mild Traumatic Brain Injury Group by Time (Analysis of Covariance)
Predictors of Total Health-Related Quality of Life in the Mild Traumatic Brain Injury Group by Time (Analysis of Covariance)

Psychosocial HRQoL

Across all players with mTBI, anxiety had a significant effect on retrospective baseline psychosocial HRQoL at 7 days (F1,21 = 9.805, P = .006, ηp2 = 0.380) but not at 30 days postinjury (F1,21 = 0.019, P = .892, ηp2 = 0.001), such that those with more baseline anxiety had poorer postinjury HRQoL. No other variable had a significant effect on psychosocial HRQoL at 7 or 30 days postinjury (Table 3). To limit multiple comparisons, we did not examine associations with psychosocial HRQoL beyond 30 days, as no predictors of total HRQoL were significant at 30 days or later.

Table 3.

Predictors of Psychosocial and Physical Health-Related Quality of Life at 7 and 30 Days Postinjury in the Mild Traumatic Brain Injury Group (Analysis of Covariance)a

Predictors of Psychosocial and Physical Health-Related Quality of Life at 7 and 30 Days Postinjury in the Mild Traumatic Brain Injury Group (Analysis of Covariance)a
Predictors of Psychosocial and Physical Health-Related Quality of Life at 7 and 30 Days Postinjury in the Mild Traumatic Brain Injury Group (Analysis of Covariance)a

Physical HRQoL

Across all players with mTBI, baseline somatization affected physical HRQoL at 7 (F1,21 = 6.125, P = .025, ηp2 = 0.277) but not 30 (F1,21 = 0.350, P = .563, ηp2 = 0.021) days postinjury. A higher level of preinjury somatization was associated with poorer postinjury physical HRQoL. No other variable had a significant effect on psychosocial HRQoL at 7 or 30 days postinjury (Table 3). To limit multiple comparisons, we did not evaluate associations with physical HRQoL beyond 30 days as no significant predictors of total HRQoL at 30 days or later were identified.

Players With mTBI Who Had Minimal Versus Significant Symptoms at 7 Days Postinjury: HRQoL

Retrospective baseline total HRQoL was not different in players with mTBI who had minimal versus significant symptoms at 7 days postinjury (F1,21 = 0.013, P = .912, ηp2 = 0.001). Total HRQOL was poorer among those with significant compared with minimal symptoms at 7 (F1,21 = 23.071, P < .001, ηp2 = 0.590) and 30 (F1,21 = 5.798, P = .028, ηp2 = 0.266) days postinjury, but this difference resolved by 90 days postinjury (F1,21 = 0.617, P = .444, ηp2 = 0.037). Similarly, participants with significant symptoms had poorer psychosocial HRQoL than those with minimal symptoms at both 7 (F1,21 = 16.488, P = < .001, ηp2 = 0.508) and 30 (F1,21 = 5.050, P = .039, ηp2 = 0.240) days postinjury. Participants with significant symptoms also had poorer physical HRQoL than those with minimal symptoms at 7 (F1,21 = 21.671, P < .001, ηp2 = 0.575) and 30 (F1,21 = 5.119, P = .038, ηp2 = 0.242) days postinjury. Given the lack of group differences in total HRQoL at 90 days and to limit multiple comparisons, we did not examine subgroup differences in psychosocial or physical HRQoL at 90 days.

Pediatric HRQoL after mTBI is a growing area of study, and previous researchers have produced conflicting results. The purpose of our study was to further characterize patterns of pediatric HRQoL after mTBI through comparison with athletes who experienced OI and uninjured control athletes. We also sought to identify predictors of HRQoL after mTBI in youth athletes.

Youth soccer players who sustained an mTBI or OI during the season displayed poorer parent-reported HRQoL than control players at 7 days postinjury, with the mTBI group having the poorest psychosocial HRQoL and the OI group having the poorest physical HRQoL. By 30 days postinjury, HRQoL for players who sustained mTBI no longer differed from that of uninjured control players; however, physical HRQoL remained poor in those with OI at 30 and 90 days, likely reflecting the natural course of the OI group’s injuries.2  These results are consistent with those of 2 earlier studies in which physical HRQoL was poorer in youth with OI than those with mTBI at 30 days postinjury.2 

Overall, the finding of initial HRQoL impairment in the mTBI group at 7 days postinjury with improvement by 30 days aligns with our primary hypothesis predicting the transient nature of mTBI-induced HRQoL impairments in youth competitive athletes. This is consistent with prior literature demonstrating poorer HRQoL in athletes with mTBI than control athletes at 7 days postinjury,5,13  with improvement or resolution by 30 days5  and 90 days postinjury.28  In contrast to our outcomes, other researchers found persistently worse HRQoL at 30 days7,15  and 90 days postinjury.6,19  Furthermore, 2 studies failed to reveal any difference between players with mTBI and control players at any time point.2,11  This variability was likely due to a variety of factors, which may have included recruitment strategies. Authors who noted prolonged differences in HRQoL often assessed patients recruited from an emergency department7,15  or from specialty medical consultations. Both of these may represent a relatively more severe or atypical injury population.19  One such population may be a subset of participants experiencing more subacute symptoms after mTBI, who are likely overrepresented in studies recruiting from these locations.

Consistent with our secondary hypothesis, after mTBI, a subgroup of players with significant subacute symptoms (defined as an elevated HBI score at 7 days) had worse total, psychosocial, and physical HRQoL at both 7 and 30 days postinjury versus those with minimal subacute symptoms. As expected recovery typically occurs by 28 days post-mTBI,3  the presence of reduced HRQoL at 30 days could suggest ongoing or slower recovery in this subgroup. This indicates that measures of HRQoL may be useful in predicting and identifying ongoing or slower mTBI recovery. This possibility agrees with the findings of investigators who observed that HRQoL measured acutely after mTBI accurately predicted those who would go on to develop ongoing symptoms in the following weeks to months.1,5,13  Additionally, this is a better predictor, at times, than traditional performance-based measures of mTBI such as the Standardized Assessment of Concussion and the Balance Error Scoring System.1,5,13  Our results suggest that adding measures of HRQoL to mTBI assessment batteries could help athletic trainers and health care providers better quantify recovery and identify those at risk for longer-lasting problems.

Along with characterizing HRQoL after mTBI, several groups have investigated predictors of HRQoL itself. Preinjury factors such as age, gender, player position, career length, history of school difficulty, and anxiety have all been proposed as predictors of recovery time and HRQoL.4,6,7,10,29  We evaluated all of these predictors, yet only baseline anxiety and somatization were significantly related to HRQoL, and they predicted poorer HRQoL only at 7 days postinjury. Baseline anxiety was associated with poorer psychosocial HRQoL and somatization with poorer physical HRQoL. These outcomes make intuitive sense given the category of each affected HRQoL and are supported by current literature.8,10  An examination of adolescents with mTBI showed that preinjury anxiety was a significant predictor of prolonged recovery,10  and greater somatization has also predicted poorer physical HRQoL.8  As well as non-mTBI factors, the number of previous mTBIs and a history of prolonged mTBI recovery have also been suggested as predictors of HRQoL.1,10,21,25,26  We did not find a relationship between prior mTBI and poorer HRQoL at any time point. One possible explanation for these differences may be the small number of participants with mTBI who had a history of prior mTBI (n = 7).

Our study was limited by the relatively small sample size and the retrospective nature of some measures. Although the absence of group differences in retrospective baseline measures is reassuring against the possibility of recollection bias, its effect cannot be fully excluded. We assessed competitive club soccer athletes; different results could be seen in samples of recreational athletes or athletes in different sports. These data were collected several years ago, during the 2016–2017 season, and more recent cohorts of athletes might show different recovery patterns. We attempted to limit selection bias via prospective enrollment, but this may still have been a factor. Furthermore, the nature of telephone interviews and the desire of athletes to return to sport may have resulted in some degree of response bias. Finally, we relied primarily on parents’ report scores; the pattern of results might have varied for self-reported HRQoL. Future researchers should enroll large cohorts prospectively, and preinjury factors should be measured at the start of seasons to avoid retrospective biases postinjury. Additionally, given our reliance on parental measures, future authors should include both parent- and child-reported measures to provide a more detailed characterization of HRQoL impairments.

Pediatric soccer players with mTBI or OI had poorer HRQoL than uninjured control players at 7 days postinjury, but, with the exception of physical HRQoL for players with OI, these differences resolved by 30 days. A subset of soccer players with mTBI who had significant subacute symptoms displayed poorer HRQoL at 7 and 30 days postinjury than those with minimal symptoms. Thus, HRQoL may help predict those who are more likely to experience ongoing or slower recovery after mTBI. Moreover, HRQoL represents a unique component of mTBI recovery that is not adequately captured by traditional mTBI assessments. As an additional marker, HRQoL could alert athletic trainers and other health care providers to children at risk for ongoing problems after mTBI who may benefit from increased earlier monitoring and interventions. Finally, some of the heterogeneous findings in the existing pediatric mTBI and HRQoL literature may reflect a subgroup with more subacute symptoms, who may be overrepresented in studies recruited from hospitals rather than athletic settings.

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