{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T02:50:50Z","timestamp":1792464650120,"version":"4.5.0"},"reference-count":48,"publisher":"Scientific Scholar","license":[{"start":{"date-parts":[[2020,3,3]],"date-time":"2020-03-03T00:00:00Z","timestamp":1583193600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["ruralneuropractice.com"],"crossmark-restriction":true},"short-container-title":["JNRP"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>\n                    <jats:bold>Background<\/jats:bold>\n                    \u2003Mild-traumatic brain injury (mTBI) and concussions cause significant morbidity. To date, synthesis of specific health care disparities and gaps in care for rural mTBI\/concussion patients remains needed.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Methods<\/jats:bold>\n                    \u2003A comprehensive literature search was performed using PubMed database for English articles with keywords \u201crural\u201d and (\u201cconcussion\u201d or \u201cmild traumatic brain injury\u201d) from 1991 to 2019. Eighteen articles focusing on rural epidemiology (\n                    <jats:italic>n<\/jats:italic>\n                    = 5), management\/cost (\n                    <jats:italic>n<\/jats:italic>\n                    = 5), military (\n                    <jats:italic>n<\/jats:italic>\n                    = 2), and concussion prevention\/return to play (\n                    <jats:italic>n<\/jats:italic>\n                    = 6) were included.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Results<\/jats:bold>\n                    \u2003mTBI\/concussion incidence was higher in rural compared with urban areas. Compared with urban patients, rural patients were at increased risk for vehicular injuries, lifetime number of concussions, admissions for observation without neuroimaging, and injury-related costs. Rural patients were less likely to utilize ambulatory and mental health services following mTBI\/concussion. Rural secondary schools had decreased access to certified personnel for concussion evaluation, and decreased use of standardized assessment instruments\/neurocognitive testing. While school coaches were aware of return-to-play laws, mTBI\/concussion education rates for athletes and parents were suboptimal in both settings. Rural veterans were at increased risk for postconcussive symptoms and posttraumatic stress. Telemedicine in rural\/low-resource areas is an emerging tool for rapid evaluation, triage, and follow-up.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Conclusions<\/jats:bold>\n                    \u2003Rural patients are at unique risk for mTBI\/concussions and health care costs. Barriers to care include lower socioeconomic status, longer distances to regional medical center, and decreased availability of neuroimaging and consultants. Due to socioeconomic and distance barriers, rural schools are less able to recruit personnel certified for concussion evaluation. Telemedicine is an emerging tool for remote triage and evaluation.\n                  <\/jats:p>","DOI":"10.1055\/s-0039-3402581","type":"journal-article","created":{"date-parts":[[2020,3,3]],"date-time":"2020-03-03T19:00:08Z","timestamp":1583262008000},"page":"23-33","update-policy":"https:\/\/doi.org\/10.25259\/crossmark_policy","source":"Crossref","is-referenced-by-count":62,"title":["Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations"],"prefix":"10.25259","volume":"11","author":[{"given":"John K.","family":"Yue","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States"},{"name":"Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pavan S.","family":"Upadhyayula","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Columbia University Medical Center, New York, New York, United States"},{"name":"Department of Neurological Surgery, University of California San Diego, San Diego, California, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lauro N.","family":"Avalos","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryan R L.","family":"Phelps","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States"},{"name":"Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Catherine G.","family":"Suen","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States"},{"name":"Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tene A.","family":"Cage","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Stanford University School of Medicine, Stanford, California, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10894","published-online":{"date-parts":[[2020,3,3]]},"reference":[{"issue":"7","key":"10.1055\/s-0039-3402581\/ref-1","doi-asserted-by":"crossref","first-page":"1118","DOI":"10.1177\/0963689717714102","article-title":"Traumatic brain injury: current treatment strategies and future endeavors","volume":"26","author":"Galgano","year":"2017","journal-title":"Cell Transplant"},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-2","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.csm.2010.08.006","article-title":"The epidemiology of sport-related concussion","volume":"30","author":"Daneshvar","year":"2011","journal-title":"Clin Sports Med"},{"issue":"4","key":"10.1055\/s-0039-3402581\/ref-3","doi-asserted-by":"crossref","first-page":"E37","DOI":"10.1097\/HTR.0000000000000260","article-title":"Epidemiology of isolated versus nonisolated mild traumatic brain injury treated in emergency departments in the United States, 2006-2012: sociodemographic characteristics","volume":"32","author":"Cancelliere","year":"2017","journal-title":"J Head Trauma Rehabil"},{"key":"10.1055\/s-0039-3402581\/ref-4","author":"Laskowitz","year":"2016","unstructured":"Translational Research in Traumatic Brain Injury. United Kingdom: CRC Press"},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-5","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/S1474-4422(12)70262-4","article-title":"BIONIC Study Group. Incidence of traumatic brain injury in New Zealand: a population-based study","volume":"12","author":"Feigin","year":"2013","journal-title":"Lancet Neurol"},{"key":"10.1055\/s-0039-3402581\/ref-9","doi-asserted-by":"crossref","first-page":"392","DOI":"10.1017\/S0305741000040790","article-title":"Defining China\u2019s rural population","volume":"130","author":"Martin","year":"1992","journal-title":"China Q"},{"key":"10.1055\/s-0039-3402581\/ref-10","first-page":"1","article-title":"How far to the nearest physician","volume":"1","author":"Ng","year":"1999","journal-title":"Rural and Small Town Canada Analysis Bulletin."},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-11","doi-asserted-by":"crossref","first-page":"123","DOI":"10.4103\/jnrp.jnrp_273_17","article-title":"The current state of rural neurosurgical practice: an international perspective","volume":"9","author":"Upadhyayula","year":"2018","journal-title":"J Neurosci Rural Pract"},{"issue":"6","key":"10.1055\/s-0039-3402581\/ref-12","doi-asserted-by":"crossref","first-page":"611","DOI":"10.1016\/j.puhe.2015.04.001","article-title":"Exposing some important barriers to health care access in the rural USA","volume":"129","author":"Douthit","year":"2015","journal-title":"Public Health"},{"issue":"5","key":"10.1055\/s-0039-3402581\/ref-13","first-page":"994","article-title":"Lost productive work time after mild to moderate traumatic brain injury with and without hospitalization","volume":"56","author":"Boake","year":"2005","journal-title":"Neurosurgery"},{"issue":"8","key":"10.1055\/s-0039-3402581\/ref-14","doi-asserted-by":"crossref","first-page":"93","DOI":"10.3390\/brainsci7080093","article-title":"Selective serotonin reuptake inhibitors for treating neurocognitive and neuropsychiatric disorders following traumatic brain injury: an evaluation of current evidence","volume":"7","author":"Yue","year":"2017","journal-title":"Brain Sci"},{"issue":"13\/14","key":"10.1055\/s-0039-3402581\/ref-15","doi-asserted-by":"crossref","first-page":"1820","DOI":"10.1080\/02699052.2017.1351000","article-title":"the TRACK-TBI Investigators. Temporal profile of care following mild traumatic brain injury: predictors of hospital admission, follow-up referral and six-month outcome","volume":"31","author":"Yue","year":"2017","journal-title":"Brain Inj"},{"issue":"2","key":"10.1055\/s-0039-3402581\/ref-16","doi-asserted-by":"crossref","first-page":"169","DOI":"10.3233\/NRE-172375","article-title":"TRACK-TBI Investigators. Preinjury employment status as a risk factor for symptomatology and disability in mild traumatic brain injury: A TRACK-TBI analysis","volume":"43","author":"Yue","year":"2018","journal-title":"NeuroRehabilitation"},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-17","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1089\/neu.2015.4158","article-title":"Screening for post-traumatic stress disorder in a civilian emergency department population with traumatic brain injury","volume":"34","author":"Haarbauer-Krupa","year":"2017","journal-title":"J Neurotrauma"},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-18","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1089\/neu.2013.2984","article-title":"TRACK-TBI Investigators. Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study","volume":"31","author":"McMahon","year":"2014","journal-title":"J Neurotrauma"},{"key":"10.1055\/s-0039-3402581\/ref-19","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1016\/j.jocn.2017.07.022","article-title":"Emergency department blood alcohol level associates with injury factors and six-month outcome after uncomplicated mild traumatic brain injury","volume":"45","author":"Yue","year":"2017","journal-title":"J Clin Neurosci"},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-20","doi-asserted-by":"crossref","first-page":"e180210","DOI":"10.1001\/jamanetworkopen.2018.0210","article-title":"Assessment of follow-up care after emergency department presentation for mild traumatic brain injury and concussion: results from the TRACK-TBI Study","volume":"1","author":"Seabury","year":"2018","journal-title":"JAMA Netw Open"},{"issue":"3","key":"10.1055\/s-0039-3402581\/ref-21","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1001\/jamapsychiatry.2018.4288","article-title":"and the TRACK-TBI Investigators. Risk of posttraumatic stress disorder and major depression in civilian patients after mild traumatic brain injury: a TRACK-TBI study","volume":"76","author":"Stein","year":"2019","journal-title":"JAMA Psychiatry"},{"issue":"3","key":"10.1055\/s-0039-3402581\/ref-22","doi-asserted-by":"crossref","first-page":"E10","DOI":"10.1097\/HTR.0000000000000457","article-title":"A comparison of satisfaction with life and the glasgow outcome scale-extended after traumatic brain injury: an analysis of the TRACK-TBI pilot study","volume":"34","author":"Kreitzer","year":"2019","journal-title":"J Head Trauma Rehabil"},{"issue":"5","key":"10.1055\/s-0039-3402581\/ref-23","first-page":"715","article-title":"The association between rurality and return to work for workers\u2019 compensation claimants with work-related musculoskeletal injuries: An analysis of workers who failed to return to work within typical healing time frames","volume":"30","author":"Lavoie","year":"2017","journal-title":"Int J Occup Med Environ Health"},{"issue":"3","key":"10.1055\/s-0039-3402581\/ref-24","doi-asserted-by":"crossref","first-page":"197","DOI":"10.3233\/NRE-2003-18303","article-title":"Rural\/urban differences in vocational outcomes for state vocational rehabilitation clients with TBI","volume":"18","author":"Johnstone","year":"2003","journal-title":"NeuroRehabilitation"},{"issue":"3","key":"10.1055\/s-0039-3402581\/ref-25","doi-asserted-by":"crossref","first-page":"736","DOI":"10.1097\/TA.0b013e3182aafdf5","article-title":"An epidemiologic profile of pediatric concussions: identifying urban and rural differences","volume":"76","author":"Stewart","year":"2014","journal-title":"J Trauma Acute Care Surg"},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-26","first-page":"23","article-title":"Causes and consequences of head injuries among rural inhabitants hospitalised in a multi-organ injury Ward. II. Circumstances, types and consequences of head injuries","volume":"16","author":"Karwat","year":"2009","journal-title":"Ann Agric Environ Med"},{"issue":"3","key":"10.1055\/s-0039-3402581\/ref-27","doi-asserted-by":"crossref","first-page":"262","DOI":"10.4103\/0976-3147.118764","article-title":"Bicycle accident-related head injuries in India","volume":"4","author":"Munivenkatappa","year":"2013","journal-title":"J Neurosci Rural Pract"},{"issue":"9","key":"10.1055\/s-0039-3402581\/ref-28","doi-asserted-by":"crossref","first-page":"1202","DOI":"10.1007\/s00268-001-0082-8","article-title":"Neurosurgical trauma in People\u2019s Republic of China","volume":"25","author":"Zhao","year":"2001","journal-title":"World J Surg"},{"issue":"8","key":"10.1055\/s-0039-3402581\/ref-29","doi-asserted-by":"crossref","first-page":"664","DOI":"10.1136\/bjsm.2007.040923","article-title":"Hospitalisations for sport-related concussions in US children aged 5 to 18 years during 2000-2004","volume":"42","author":"Yang","year":"2008","journal-title":"Br J Sports Med"},{"issue":"8","key":"10.1055\/s-0039-3402581\/ref-30","doi-asserted-by":"crossref","first-page":"793","DOI":"10.1017\/S1355617716000709","article-title":"Predictors of post-concussive symptoms in young children: injury versus non-injury related factors","volume":"22","author":"Bernard","year":"2016","journal-title":"J Int Neuropsychol Soc"},{"issue":"5","key":"10.1055\/s-0039-3402581\/ref-31","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1136\/injuryprev-2018-042865","article-title":"Evaluating mild traumatic brain injury management at a regional emergency department","volume":"24","author":"Brown","year":"2018","journal-title":"Inj Prev"},{"key":"10.1055\/s-0039-3402581\/ref-32","doi-asserted-by":"crossref","first-page":"e319","DOI":"10.1016\/j.wneu.2013.11.008","article-title":"Outcomes of a nontransfer protocol for mild traumatic brain injury with abnormal head computed tomography in a rural hospital setting","volume":"82","author":"Levy","year":"2014","journal-title":"World Neurosurg"},{"issue":"4","key":"10.1055\/s-0039-3402581\/ref-33","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1080\/026990500120664","article-title":"Ambulatory care for traumatic brain injuries in the US, 1995-1997","volume":"14","author":"Schootman","year":"2000","journal-title":"Brain Inj"},{"issue":"2","key":"10.1055\/s-0039-3402581\/ref-34","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1111\/1475-6773.13096","article-title":"Rural-urban disparities in health care costs and health service utilization following pediatric mild traumatic brain injury","volume":"54","author":"Graves","year":"2019","journal-title":"Health Serv Res"},{"key":"10.1055\/s-0039-3402581\/ref-35","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1186\/s12913-016-1743-5","article-title":"Adoption of routine telemedicine in Norwegian hospitals: progress over 5\u00a0years","volume":"16","author":"Zanaboni","year":"2016","journal-title":"BMC Health Serv Res"},{"issue":"10","key":"10.1055\/s-0039-3402581\/ref-36","doi-asserted-by":"crossref","first-page":"803","DOI":"10.1089\/tmj.2012.0118","article-title":"Teleconcussion: an innovative approach to screening, diagnosis, and management of mild traumatic brain injury","volume":"18","author":"Vargas","year":"2012","journal-title":"Telemed J E Health"},{"issue":"8","key":"10.1055\/s-0039-3402581\/ref-37","doi-asserted-by":"crossref","first-page":"1110","DOI":"10.4088\/JCP.11m07587","article-title":"Examining the relation between combat-related concussion, a novel 5-factor model of posttraumatic stress symptoms, and health-related quality of life in Iraq and Afghanistan veterans","volume":"73","author":"Tsai","year":"2012","journal-title":"J Clin Psychiatry"},{"issue":"1","key":"10.1055\/s-0039-3402581\/ref-38","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1037\/a0032782","article-title":"Deployment-related sequelae and treatment utilization in rural and urban war veterans in Hawaii","volume":"11","author":"Whealin","year":"2014","journal-title":"Psychol Serv"},{"issue":"4","key":"10.1055\/s-0039-3402581\/ref-39","doi-asserted-by":"crossref","first-page":"546","DOI":"10.4085\/1062-6050-48.4.12","article-title":"The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations","volume":"48","author":"Casa","year":"2013","journal-title":"J Athl Train"},{"issue":"5","key":"10.1055\/s-0039-3402581\/ref-40","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1097\/PEC.0b013e31828e9cea","article-title":"A substantial proportion of life-threatening injuries are sport-related","volume":"29","author":"Meehan","year":"2013","journal-title":"Pediatr Emerg Care"},{"issue":"2","key":"10.1055\/s-0039-3402581\/ref-41","doi-asserted-by":"crossref","first-page":"156","DOI":"10.4085\/1062-6050-50.2.03","article-title":"Athletic training services in public secondary schools: a benchmark study","volume":"50","author":"Pryor","year":"2015","journal-title":"J Athl Train"},{"issue":"6","key":"10.1055\/s-0039-3402581\/ref-42","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1097\/JSM.0000000000000409","article-title":"Disparities in athletic trainer staffing in secondary school sport: implications for concussion identification","volume":"27","author":"Kroshus","year":"2017","journal-title":"Clin J Sport Med"},{"key":"10.1055\/s-0039-3402581\/ref-43","first-page":"1282","article-title":"Developing a concussion assessment mHealth app for certified Athletic Trainers","volume":"2017","author":"McGrath","year":"2018","journal-title":"AMIA Annu Symp Proc"},{"issue":"6","key":"10.1055\/s-0039-3402581\/ref-44","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1016\/j.pmrj.2012.03.013","article-title":"Concussion evaluation methods among Washington State high school football coaches and athletic trainers","volume":"4","author":"Murphy","year":"2012","journal-title":"PM R"},{"issue":"5","key":"10.1055\/s-0039-3402581\/ref-45","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1177\/0363546514521774","article-title":"The effect of coach education on reporting of concussions among high school athletes after passage of a concussion law","volume":"42","author":"Rivara","year":"2014","journal-title":"Am J Sports Med"},{"issue":"5","key":"10.1055\/s-0039-3402581\/ref-46","doi-asserted-by":"crossref","first-page":"1190","DOI":"10.1177\/0363546513519073","article-title":"Implementation of concussion legislation and extent of concussion education for athletes, parents, and coaches in Washington State","volume":"42","author":"Chrisman","year":"2014","journal-title":"Am J Sports Med"},{"issue":"6","key":"10.1055\/s-0039-3402581\/ref-47","doi-asserted-by":"crossref","first-page":"416","DOI":"10.1111\/josh.12510","article-title":"Strategies to address unmet needs and facilitate return to learn guideline adoption following concussion","volume":"87","author":"Lyons","year":"2017","journal-title":"J Sch Health"},{"issue":"2","key":"10.1055\/s-0039-3402581\/ref-48","doi-asserted-by":"crossref","first-page":"e5","DOI":"10.1016\/j.jen.2008.12.010","article-title":"Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting","volume":"35","author":"Jagoda","year":"2009","journal-title":"J Emerg Nurs"},{"key":"10.1055\/s-0039-3402581\/ref-49","doi-asserted-by":"crossref","first-page":"1391","DOI":"10.1016\/S0140-6736(00)04561-X","article-title":"The Canadian CT head rule for patients with minor head injury","volume":"357(9266)","author":"Stiell","year":"2001","journal-title":"Lancet"},{"key":"10.1055\/s-0039-3402581\/ref-50","doi-asserted-by":"crossref","first-page":"k3527","DOI":"10.1136\/bmj.k3527","article-title":"External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands","volume":"362","author":"Foks","year":"2018","journal-title":"BMJ"},{"issue":"3","key":"10.1055\/s-0039-3402581\/ref-51","first-page":"613","article-title":"The occupational health status of hired farm workers","volume":"14","author":"Villarejo","year":"1999","journal-title":"Occup Med"}],"container-title":["Journal of Neurosciences in Rural Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/ruralneuropractice.com\/concussion-and-mild-traumatic-brain-injury-in-rural-settings-epidemiology-and-specific-health-care-considerations\/","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/ruralneuropractice.com\/concussion-and-mild-traumatic-brain-injury-in-rural-settings-epidemiology-and-specific-health-care-considerations\/","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,8,5]],"date-time":"2023-08-05T00:41:31Z","timestamp":1691196091000},"score":1,"resource":{"primary":{"URL":"https:\/\/ruralneuropractice.com\/concussion-and-mild-traumatic-brain-injury-in-rural-settings-epidemiology-and-specific-health-care-considerations\/"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,3,3]]},"references-count":48,"alternative-id":["10.1055\/s-0039-3402581"],"URL":"https:\/\/doi.org\/10.1055\/s-0039-3402581","relation":{},"ISSN":["0976-3147"],"issn-type":[{"value":"0976-3147","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,3,3]]},"article-number":"23"}}