Fear-Avoidant Adults Have Worse Clinical Outcomes and Recovery Time Following Concussion.

Objective: To compare initial multidomain clinical outcomes and recovery time between fear-avoidant (FA) and non-fear-avoidant (NFA) adults following concussion.

Setting: Specialty concussion clinic.

Participants: Adults aged 18-50 years within 30 days of a diagnosed concussion. Based on clinical cutoffs for the Fear Avoidance Components Scale (FACS) at the initial clinic visit, participants were categorized into FA (41-100; moderate to severe) and NFA (0-40; none to mild) groups.

Design: Prospective cohort study.

Main measures: 1) Clinical intake and interview, 2) FACS, 3) Concussion Clinical Profiles Screening Tool (CP-Screen), 4) Post-Concussion Symptom Scale (PCSS), 5) Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), 6) Vestibular/Ocular Motor Screening (VOMS), 7) Generalized Anxiety Disorder 7-Item Assessment (GAD-7), 8) Patient Health Questionnaire (PHQ-9), 9) Patient Health Questionnaire (PHQ-15), 10) Recovery Time (days to medical clearance).

Results: 74 participants (M=28.7 ± 8.4 years, 68.9% female) were included, 37 (50.0%) in the FA and 37 (50.0%) in the NFA group. There were no differences in demographics, medical history, or injury characteristics between groups. The FA group had worse CP Screen anxiety/mood (p=0.04), cognitive (p=0.04), and total (p=0.04); ImPACT reaction time (p=0.01); VOMS visual motion sensitivity (p=0.03) and total (p=0.04); GAD-7 (p<0.01); and PHQ-9 (p<0.01) scores than the NFA group. Results from a Cox proportional hazards model demonstrated that the FA group had a 62% lower instantaneous recovery likelihood on any given day than the NFA group (HR=0.38, 95% CI: 0.15-0.96, p=0.04) while controlling for CP Screen total.

Conclusions: Fear-avoidant adults demonstrated worse concussion symptoms, reaction time, and vestibular impairments compared to non-fear-avoidant adults following concussion. Moreover, after controlling for initial symptom severity, fear-avoidant adults took significantly longer to recover than non-fear-avoidant adults. Future research should explore potential mechanisms underlying the relationship between fear avoidance and poor outcomes, including reduced adherence to treatment recommendations.