Social Determinants of Health and Health Equity in the Treatment and Rehabilitation of Sport-Related Concussion: A Content Analysis of Intervention Research

Nathan Cook, Harvard Medical School, Boston, United States
Alicia Kissinger-Knox, Spaulding Rehabilitation Hospital, Charlestown, United States
Ila Iverson, Karolinska Institutet, Stockholm, Sweden
Brian Liu, Spaulding Rehabilitation Hospital, Charlestown, United States
Katie Stephenson, University of New England, Biddeford, United States
Grant Iverson, Harvard Medical School, Boston, United States


The most recent Concussion in Sport Group consensus statement, published in 2023, was informed by systematic reviews examining the evidence for (a) targeted interventions to facilitate concussion recovery and (b) prescribed exercise or rest following concussion. The purpose of this content analysis was to (a) examine the studies included in the two systematic reviews to determine the extent to which the clinical science on concussion treatment and rehabilitation has investigated or discussed social determinants of health (SDoH) or health equity and (b) offer recommendations to enhance the incorporation of SDoH and health equity in concussion treatment outcome research and clinical care.

Participants and Methods:
We coded 31 studies that examined prescribed or targeted treatment for sport-related concussion identified from two recent systematic reviews. Authors examined studies to determine whether SDoH domains and associated subcategories derived from the US Department of Health and Human Services Healthy People 2020 and 2030 websites were addressed. Pairs of raters coded each article independently and resolved disagreements through discussion.

The 31 studies included 2,698 participants (median=50 participants per study; range 9-456). The average sample age was reported in 27 studies (87.1%) and was 16.2 years (SD=2.5; median=15 years). Gender was reported in nearly all studies (96.8%). In contrast, racial composition (k=6; 19.4%) and ethnic composition (k=4; 12.9%) were usually not reported. The vast majority of participants were identified as White and non-Hispanic. No study explicitly mentioned “social determinants of health” by name or examined health equity or disparities directly. Only four studies (12.9%) examined an SDoH domain in an inferential/intentional manner, and typically only a single subcategory in an SDoH domain. Four additional studies (12.9%) examined a single SDoH domain in a descriptive manner and one additional study (3.2%) examined two SDoH domains in a descriptive manner. No study examined health equity or disparities directly, such as by explicitly focusing analyses on this research question or topic. Four studies (12.9%) examined ethnicity (i.e., Hispanic), but exclusively as a demographic category; no studies examined ethnicity in depth. Five studies (16.1%) examined race as a demographic category/sample descriptor and only one study (3.2%) examined race in depth. About 3 out of 5 studies (61.3%) excluded participants based on demographic, sociocultural, or health factors, primarily due to language proficiency. Most studies did not acknowledge or discuss any limitations related to SDoH or health equity (k=27; 87.9%) nor explicitly mention SDoH or health equity as important frameworks or areas of focus to guide future concussion treatment research (k=29; 93.5%).

The new consensus statement includes recommendations for sport-related concussion treatment and rehabilitation that rely on an evidence-base that has not included social determinants of health or studies addressing health equity. Clinical researchers are encouraged to design treatment and rehabilitation studies that focus specifically on under-represented groups to determine if they have specific and unique treatment and rehabilitation needs, whether certain practical modifications to treatment protocols might be necessary, and whether completion rates and treatment adherence and response are similar.
Category: Concussion/Mild TBI (Child)

Keyword 1: concussion/ mild traumatic brain injury
Keyword 2: sports-related neuropsychology
Keyword 3: treatment outcome