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Background Approximately one-third of all concussions lead to persistent postconcussion syndrome (PPCS). Repetitive transcranial magnetic stimulation (rTMS) is a form of noninvasive brain stimulation that has been extensively used to treat refractory major depressive disorder and has a strong potential to be used as a treatment for patients with PPCS. Functional near-infrared spectroscopy (fNIRS) has already been used as a tool to assess patients with PPCS and may provide insight into the pathophysiology of rTMS treatment in patients with PPCS. Objective The primary objective of this research is to determine whether rTMS treatment improves symptom burden in patients with PPCS compared to sham treatment using the Rivermead postconcussion symptom questionnaire. The secondary objective is to explore the neuropathophysiological changes that occur following rTMS in participants with PPCS using fNIRS. Exploratory objectives include determining whether rTMS treatment in participants with PPCS will also improve quality of life, anxiety, depressive symptoms, cognition, posttraumatic stress, and function secondary to headaches. Methods A total of 44 adults (18-65 years old) with PPCS (>3 months to 5 years) will participate in a double-blind, sham-controlled, concealed allocation, randomized clinical trial. The participants will engage in either a 4-week rTMS treatment protocol or sham rTMS protocol (20 treatments). The left dorsolateral prefrontal cortex will be located through Montreal Neurologic Institute coordinates. The intensity of the rTMS treatment over the left dorsolateral prefrontal cortex will be 120% of resting motor threshold, with a frequency of 10 Hz, 10 trains of 60 pulses per train (total of 600 pulses), and intertrain interval of 45 seconds. Prior to starting the rTMS treatment, participant and injury characteristics, questionnaires (symptom burden, quality of life, depression, anxiety, cognition, and headache), and fNIRS assessment will be collected. Repeat questionnaires and fNIRS will occur immediately after rTMS treatment and at 1 month and 3 months post rTMS. Outcome parameters will be analyzed by a 2-way (treatment × time) mixed analysis of variance. Results As of May 6, 2021, 5 participants have been recruited for the study, and 3 have completed the rTMS protocol. The estimated completion date of the trial is May 2022. Conclusions This trial will expand our knowledge of how rTMS can be used as a treatment option of PPCS and will explore the neuropathophysiological response of rTMS through fNIRS analysis. Trial Registration ClinicalTrials.gov NCT04568369; https://clinicaltrials.gov/ct2/show/NCT04568369 International Registered Report Identifier (IRRID) DERR1-10.2196/31308

Objective With some variability, research indicates that a high percentage (20–60%) of athletes do not report post-concussion symptoms, despite having sufficient concussion knowledge. Our study examined whether competitiveness and past reporting predicted future reporting intention in males participating in high contact sports. Method Participants included 92 male athletes (M = 19.35 years, SD = 4.35) recruited from a mid-sized Canadian city participating in high contact sports (American football, rugby, or hockey). Competitiveness was measured using the Sport Orientation Questionnaire. The Rosenbaum Concussion Knowledge and Attitudes Survey-Student Version was used to assess concussion knowledge and nondisclosure. Logistic regression was conducted to predict future intention of playing despite experiencing post-concussion symptoms. Age, knowledge, competitiveness, sport, and past history of concussion nondisclosure were included as predictors. Results Age, sport, and concussion knowledge were not significant predictors. Competitiveness was a significant predictor for the model, such that higher competitiveness predicted less likelihood to report post-concussion symptoms. Our findings also suggest that athletes who have not disclosed a concussion in the past are more likely to have higher intention to continue to play with symptoms of a concussion in the future. Over half (54%) of the athletes reported past history of concussion nondisclosure. Conclusions Interventions focusing on increasing general concussion knowledge are not adequate to prevent symptom nondisclosure. The results suggest that highly competitive athletes or athletes with a past history of nondisclosure are most vulnerable to future nondisclosure. These findings could help improve future interventions by targeting athletes at high-risk of concussion nondisclosure.

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BACKGROUND Approximately one-third of all concussions lead to persistent post-concussion syndrome (PPCS). Repetitive transcranial magnetic stimulation (rTMS) is a form of non-invasive brain stimulation that has been extensively used to treat refractory major depressive disorder and has strong potential to be used as a treatment for patients with PPCS. Functional near-infrared spectroscopy (fNIRS) has already been used as a tool to assess patients with PPCS and may provide insight into the pathophysiology of rTMS treatment in patients with PPCS. OBJECTIVE The primary objective is to determine whether rTMS treatment improves symptom burden in patients with PPCS compared to sham using the Rivermead Post-concussion Symptom questionnaire as the primary outcome measure. The secondary objective is to explore the neuropathophysiological changes that occur following rTMS in patients with PPCS using fNIRS. Exploratory objectives include determining whether rTMS treatment in patients with PPCS will also improve quality of life, anxiety, depressive symptoms, cognition, post-traumatic stress and function secondary to headaches. METHODS Forty-four adults (18-65) with PPCS (>3 months-5 years) will participate in a double-blind, sham-controlled, concealed allocation, randomized clinical trial. Patients will engage in either a four-week rTMS treatment protocol or sham rTMS protocol (20 treatments). The left DLPFC will be located through Montreal Neurologic Institute (MNI) coordinates. The intensity of the rTMS will be 120% of the resting motor threshold, with a frequency of 10 Hz, 10 trains of 60 pulses/train (total of 600 pulses), and an inter-train interval of 45 seconds. Prior to starting the rTMS treatment, patient and injury characteristics, questionnaires (symptom burden, quality of life, depression, anxiety, cognition, and headache), and fNIRS assessment will be collected. Repeat questionnaires and fNIRS will occur immediately after rTMS treatment and at 1- and 3- month post-rTMS. Outcome parameters within each specific group (rTMS, sham) will be analyzed by a one-way repeated measures analysis of variance (RM-ANOVA). RESULTS To date, 5 patients have been recruited for the study and 3 have completed the rTMS protocol. The estimated completion date of the trial is April 2022. CONCLUSIONS This trial will expand our knowledge of how rTMS can be used as a treatment option of PPCS and explore the neuropathophysiological response of rTMS though fNIRS analysis. CLINICALTRIAL ClinicalTrials.gov - NCT04568369