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ORIGINAL ARTICLE
Reducing concussion symptoms among teenage youth: Evaluation of a mobile
health app
Lise Worthen-Chaudhari
a
, Jane McGonigal
b
, Kelsey Logan
c
, Marcia A. Bockbrader
a
, Keith O. Yeates
d
,
and W. Jerry Mysiw
a
a
Department of Physical Medicine and Rehabilitation and Neurological Institute, The Ohio State University, Columbus, OH, USA;
b
Institute for the
Future, Palo Alto, CA, USA;
c
Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of
Cincinnati College of Medicine, Cincinnati, OH, USA;
d
Department of Psychology, Alberta Children’s Hospital Research Institute, and Hotchkiss Brain
Institute, University of Calgary, Calgary, AB, Canada
ABSTRACT
Objective: To evaluate whether a mobile health application that employs elements of social game design
could compliment medical care for unresolved concussion symptoms.
Design: Phase I and Phase II (open-label, non-randomized, ecological momentary assessment methodology).
Setting: Outpatient concussion clinic.
Participants: Youth, aged 13–18 years, with concussion symptoms 3+ weeks after injury; Phase I: n = 20;
Phase II: n = 19.
Interventions: Participants received standard of care for concussion. The experimental group also used a
mobile health application as a gamified symptoms journal.
Outcome measures: Phase I: feasibility and satisfaction with intervention (7-point Likert scale, 1 high).
Phase II: change in SCAT-3 concussion symptoms (primary), depression and optimism.
Results: Phase 1: A plurality of participants completed the intervention (14 of 20) with high use (110 +/−18%
play) and satisfaction (median +/−interquartile range (IQR) = 2.0+/−0.0). Phase II:Groupswereequivalenton
baseline symptoms, intervention duration, gender distribution, days since injury and medication prescription.
Symptomsandoptimismimprovedmorefortheexperimentalthanfortheactivecontrolcohort(U=18.5, p=
0.028, effect size r=0.50andU=18.5, p= 0.028, effect size r= 0.51, respectively).
Conclusions: Mobile apps incorporating social game mechanics and a heroic narrative may promote
health management among teenagers with unresolved concussion symptoms.
ARTICLE HISTORY
Received 5 January 2017
Revised 14 May 2017
Accepted 15 May 2017
KEYWORDS
Rehabilitation; intervention;
children; concussion; mobile
health; gaming
The World Health Organization task force named concussion a
public health problem in 2004 [1], yet treatment options for
concussion, or mild Traumatic Brain Injury (mTBI), remain
limited today. The American Academy of Neurology recom-
mends limiting cognitive and physical effort and prohibiting
sports involvement until a concussed individual is asymptomatic
without medication [2]; however, this level of physical, cognitive
and social inactivity represents a lifestylechangewithitsownrisk
factors, including social isolation, depression and increased inci-
dence of suicidal ideology [3]. In addition, cognitive rest often
involves limiting screen stimulation associated with popular
modes of interpersonal interaction, such as text messaging, social
networking on digital platforms (e.g. Facebook, Twitter,
Instagram) and multiplayer video gaming, thereby blocking com-
mon avenues for social connection [4]. The impact of social
connections on health has been well established within the field
of network science [5], but these findings have been slow to
change traditional health-care practices. A critical need exists for
interventions that might improve concussion symptoms faster
while mitigating risks associated with prescribed inactivity and
providing avenues for continued social connection.
Youth are especially at risk with regard to concussion [6]. The
rate of reported concussion in high school athletes has doubled
since 2005 [7], and youth demonstrate more prolonged recovery
from symptoms [8–10]. Concussion symptoms can include a
variety of complaints: headaches, confusion, depression, sleep
disturbance, fatigue, irritability, agitation, anxiety, dizziness, dif-
ficulty concentrating or thinking clearly, sensitivity to light and
noise [11], impaired cognitive function [12–14] and impaired
postural control [15,16]. These symptoms create the need to
manage academic and physical activity adjustments prescribed
to treat the injury. Lack of resolution of such symptoms poses
real-life consequences for educational progress and psychoso-
cial–behavioural development among youth.
Mobile health platforms have been used to track symptoms,
aid treatment and provide support among individuals with con-
cussion and other diagnoses [17–20]. Framing such mobile
health platforms as games has been proposed as a creative way
to treat health issues [4,21]. In particular, the potential to engage
social support through multiplayer interactive mechanics and
reframe the work of health recovery as a personally relevant,
heroic narrative using games has been noted as a promising new
area for exploration in health care [4,22]. We sought to evaluate
the use of one such mobile health application (app), using social,
game-like interactive mechanics, as a way to complement the
medical management of unresolved concussion symptoms.
CONTACT Lise Worthen-Chaudhari lise.worthen-chaudhari@osumc.edu Dodd Hall, Department of Physical Medicine and Rehabilitation and Neurological
Institute, Rm 1060, 480 Medical Center Drive, Columbus, OH 43220, USA.
BRAIN INJURY
https://doi.org/10.1080/02699052.2017.1332388
© 2017 Taylor & Francis Group, LLC
The app we evaluated, called SuperBetter, was designed to
apply principles of positive psychology [23,24], social interaction
and gameful design—an approach that aims to evoke the psy-
chological strengths of game play such as ‘optimism, creativity,
courage, and determination’in non-game applications and rea-
lity [21]—to personal challenges like recovery from concussion
[4,21]. Specifically, this app reframes factors that might nega-
tively or positively impact health, respectively, as ‘bad guys’(e.g.
bright lights, lack of sleep) or ‘power ups’(e.g. wearing sun-
glasses or avoiding bright lights, resting when symptoms are
mild vs. once they become severe). Furthermore, this app incor-
porates social mechanics by allowing participant to invite sup-
portive individuals as ‘allies’with the ability to view logged
activity regarding their health journey and send encouraging
prompts through the app. For instance, a player might report
that they battled the headache bad guy and did or did not
conquer this personal bad guy on a specific day; an ally viewing
this post could send an encouraging message or a virtual
‘achievement award’to the player to explicitly recognize the
work the player has committed thus far to recovery; after a few
days of play, the app enables the player to graph the time course
of their progress toward vanquishing the headache bad guy as
well as revisit supportive messages they have received through-
out their battles. Using this framework of bad guys, power ups
and allies, SuperBetter has been shown previously to improve
depression in adults [22].
The study had two aims: 1) To evaluate whether the app
would be feasible for use by youth with unresolved concussion
symptoms as a complement to standard medical care (Phase I);
and 2) To assess whether recovery profiles differed between
youth who augmented medical care with the app and those who
received medical care alone (Phase II). We hypothesized youth
with concussion could successfully use the app; success was
defined as having a plurality of participants complete the inter-
vention with better than neutral satisfaction rating and no
reported unresolvable barriers to app use. We also hypothe-
sized that symptoms would improve more for those who were
able to use the app in conjunction with medical care then for
those who received medical care alone.
Methods
Setting
Outpatient pediatric sports medicine clinic, Cincinnati
Children’sHospital Medical Center
Design
Institutional Review Board approved this trial of Phase I feasi-
bility and Phase II efficacy (non-randomized, open label, con-
trolled) using ecological momentary assessment methodologies
[20,25] for assessment and intervention.
Participants
Phase I
Clinic patients (aged 13–18 years) with physician-diagnosed con-
cussion and unresolved symptoms at 3 weeks to 12 months post
injury between 13 August 2014 and 9 December 2014 were
screened and recruited as a convenience sample. Follow-up
ended on 7 January 2015. Participants were excluded for pre-
morbid learning disabilities, concurrent illness/injury at pre-test
and complicated or atypical symptom presentation per treating
clinician (e.g. symptoms incongruent with cognitive load). Per
the funded protocol, we enrolled up to 20 participants within the
specified period of grant funding. Enrollees (14 female/6 male;
age mean 15.6+/−1.6, range 13–18 years) received standard med-
ical care plus app use. All 20 participants were included in the
Phase I analysis (see CONSORT flow diagram, Figure 1)inwhich
we assessed feasibility of combining app use with medical care as
well as satisfaction with intervention (7-point Likert scale; 1 high).
Phase II
Following completion of the Phase I study, we recruited 22
additional youth (17 female/5 male; age mean 15.6 +/−1.7,
range 13–18 years) from the concussion clinic as a convenience
sample into an active control cohort to receive standard medical
care. Enrollment occurred from 7 January 7 to 10 June 2015 and
from 16 September 16 to 7 October 2015 (Note: no recruitment
during summer 2015 due to school vacation). Follow-up lasted
through 4 November 2015. Recruitment ended when we
achieved a number of active control enrollees comparable to
the number of previously enrolled experimental participants
from Phase I. Using the following inclusion/exclusion criteria,
nine active control participants from the active control cohort
and 10 experimental participants from the Phase I cohort were
included in an open-label, non-randomized Phase II analysis
(see CONSORT flow diagram, Figure 1):
●Symptom score of at least four points on Sports
Concussion Assessment Tool-3 (SCAT-3 [26]) pre-test.
Post-test occurred 3–8 weeks after pre-test. Both pre-
and post-tests occurred while school was in session.
●No pre-existing attention-deficit/hyperactivity disorder
(ADHD), which has been shown to influence concus-
sion symptom recovery [27].
●No additional injury (e.g. ankle sprain) or illness (e.g. pneu-
monia) occurring between pre- and post-test that resulted in
parallel medical care for an issue other than concussion.
●Experimental group: no self-reported barriers to
compliance.
Interventions
All participants received standard of care for unresolved con-
cussion symptoms and were treated by one physician (KL).
Experimental intervention
The app was loaded onto the mobile devices of experimental
participants and set to display concussion-specific content that
the research team had developed, entitled the Battle Royal Power
Pack, which guided participants to track the frequency and
severity of 22 concussion symptoms [26]. Using the app for
symptoms tracking was similar to documenting symptoms by
hand in a journal but translated the symptoms journal concept
into a: a) mobile device format, b) personally relevant, heroic
2L. WORTHEN-CHAUDHARI ET AL.
narrative and c) platform within which support givers could
provide structured support.
Players interacted with in-app content as follows:
(1) Symptoms were represented as bad guys (e.g. headaches,
dizziness, feeling confused) and medical recommenda-
tions were represented as power ups (e.g.sleep,sun-
glasses, academic concussion management plan).
(2) Participants invited allies to join their personal net-
work in the app. Our research coordinator was always
an ally. The participant had the choice to invite friends
and/or family as additional allies who could view their
in-app activity and could send resilience points,
achievements, comments and personalized emails in
response to activity.
(3) Logged activity consisted of any in-app action
(Figure 2), such as reporting that a bad guy was
battled and how severe the battle was, reporting
that a power up was completed, ‘liking’acomment
from an ally or posting a status update in the
activity feed.
Allocated to active control (n= 22)
Received allocated intervention (n= 10)
Did not receive allocated intervention (n= 12)
·n=3 discontinued concussion care
·n=3 out of school at post-test
·n=6 did not return for concussion care within
window of interest (3-8 weeks bet baseline
and post-test)
Excluded (n=3) due to:
·Symptoms resolved (n= 2)
·Learning disability (n=1)
Declined to participate (n=0)
Analysed (n= 10)
·Excluded from analysis (n=1)
·n=1 ADHD
Enrolled (n= 22)
Lost to follow-up (n= 0)
Assessed for
eligibility (n=25)
Assessed for
eligibility (n=24)
Analyzed (n= 10)
·Excluded from analysis (n= 4)
·n=4 ADHD
Excluded (n=4) due to:
·Symptoms resolved (n=2)
·Complicated presentation (n=2)
Declined to participate (n=0)
Allocated to intervention (n= 20)
·Received allocated intervention (n= 14)
·Did not receive allocated intervention
(n= 6)
·n=3 discontinued concussion care
·n=1 unanticipated difficulties with
home internet connection
·n=1 competing extra-curricular
commitments (e.g. cheerleading)
·n=1 concurrent, unrelated illness
Analysed (n = 14)
·Excluded from analysis (n= 0)
Enrolled (n= 20)
Lost to follow-up (n= 0)
Discontinued intervention (n= 0)
Figure 1. CONSORT flow diagram.
BRAIN INJURY 3
Participants were asked to log activity at the frequency of one
logged activity per day for 5 days each week, for a target dose of 15
logged activities over the first 3 weeks between pre- and post-test.
To identify non-compliance and associated barriers, we assessed
the number of days the app was used and contacted participants
whodidnotusetheappfor4consecutivedaysinany7-dayperiod
to ask if they were experiencing any barriers to play. If a barrier
was named, our research coordinator reviewed potential strategies
to overcome the barrier (e.g. for the stated barrier of ‘having
trouble remembering to play’, the strategy to overcome the barrier
wastolookforthedailymessagefrom the app displayed on their
mobile device and to take that moment to log activity). If partici-
pants showed no additional lapse in app use, then barriers to play
were considered resolved. However, if participants showed an
additional lapse in app use, defined as an additional 4-day gap
in any 7-day period, they were considered to have not completed
the intervention and their barriers to compliance were noted.
Outcome measures
Phase I
Primary outcome measure:
Number of participants completing the intervention relative
to all enrolled.
Secondary measures:
●App use (%Play), expressed as per cent of target dose in
first 3 weeks of intervention;
●Satisfaction with intervention, rated on a seven-point
Likert scale (1 = high, 4 = neutral, 7 = low);
●Barriers to compliance.
Phase II
Primary outcome measure:
Concussion symptom severity on the SCAT-3 symptom check-
list score. The SCAT-3 is commonly used for concussion assess-
ment on the field and in the clinic [28], as self-reported symptoms
are a key component of concussion assessment [29]. The symptom
checklist score is a sum across 22 self-report symptom ratings, each
ranging in severity from absent (0) to severe (6). Test–retest
reliability and receiver operating characteristic (ROC) measures
have been established for adolescents (Intraclass Correlation =
0.62, 7-day interval and ROC area under curve = 0.83) [29].
Secondary outcome measures:
●Optimism, as measured by the Life Orientation Test–
Revised (LOT-R) [30]. LOT-R scores are a sum across 10
self-rated items, with higher scores (max = 24) indicating
higher optimism. The LOT-R is reliable (Cronbach’salpha
coefficient = 0.70) with marginal gender differences and no
linear age trend [31].
●Depression, as measured by the Center for Epidemiological
Studies–Depression Child (CES-DC) [32]. The CES-DC
score ranges from 0 (none) to 60 (severe) and is a sum
across 20 self-report items, which are rated in terms of
frequency over the past week. The CES-DC is a reliable
measure of depression (Cronbach’s alpha coefficient =
0.89) among youth [33].
Analysis
Analyses were completed in IBM SPSS Statistics v24.0 (Armonk,
NY: IBM Corp) and Microsoft Excel 2013 (Redmond, WA:
Microsoft Corporation). Due to small sample sizes with non-
normal distributions, non-parametric statistics were used. Phase
I analyses consisted of descriptive statistics for feasibility, utiliza-
tion and satisfaction. The criterion for feasibility was defined as
having a plurality of enrolled participants complete the interven-
tion.Utilization,or%Play,wascalculated as actual logged activity
in the first 3 weeks divided by target dose (15 logged events). The
criterion for satisfaction with the app was defined as median
satisfaction rating better than neutral (4) on the Likert scale. Chi-
squared tests were used to test satisfaction ratings, compare group
differences in categorical baseline variables and evaluate group
Figure 2. Screenshots from three screens encountered during SuperBetter mobile application play (clockwise from top middle): ‘My Challenge’,‘Superhero To-Do
Today’and ‘Epic Win’.
4L. WORTHEN-CHAUDHARI ET AL.
differences for number of responders on outcome measures.
Responders were defined as participants who improved numeri-
cally from pre- to post-test. Mann–Whitney U two-sample rank-
sum tests were used to compare group differences in non-catego-
rical baseline variables and evaluate group differences on pre- to
post-test change scores. Effect size (r) for change scores was
calculated by dividing Wilcoxon Zby square root of the combined
sample size (n = 19).
Results
Phase I
The app met criterion for feasibility, with a plurality of enrollees
(14 of 20, or 70%) completing the intervention. These 14 partici-
pants had a median age of 17.0 (interquartile range (IQR) 2.0)
years; demonstrated high app utilization (Table I,median%Play=
110%, IQR 22% of target dose) and reported high satisfaction
(Figure 3, median Likert scale rating of 2.0, IQR 0.0). Satisfaction
criteria were met, indicating the ratings observed were significantly
different from what would be expected given a normal distribution
with a neutral mean, Chi
2
(6) = 183.3, p < 0.0001. Barriers to
compliance reported by the six enrollees who did not complete the
study included: discontinuation of medical care (n = 3), unantici-
pated difficulties with home Internet access (n = 1), competing
extracurricular activity schedule (n = 1) and concomitant illness
during enrollment (n = 1).
Phase II
Groups were not significantly different at baseline across all
factors considered (Table II). App users reported high satisfaction
(median 2.0, IQR 0.3) and %Play (median 113%, IQR 18%).
Table III summarizes outcome measures. There were significantly
more intervention ‘responders’for SCAT-3 symptoms (p= 0.006)
and optimism (p= 0.012) in the experimental group (100% and
80%, respectively) than the control cohort (44% and 22%,
respectively). Furthermore, symptoms and optimism improved
more for the experimental than for the active control cohort (U=
18.5, p= 0.028, effect size r=0.50andU=18.5, p= 0.028, effect
size r= 0.51, respectively). Experimental vs. control group med-
ians (IQR) for symptom change were 16.0 (32.0) and −2.0 (24.0),
respectively. Experimental vs. control group medians (IQR) for
optimism change were 3.0 (5.0) and 0.0 (1.0), respectively. No
significant differences were found between cohorts for depression
responders or change in depression scores.
Finally, post hoc, Spearman correlations between SCAT-3
change and optimism change were calculated and revealed no
significant correlations within cohorts (app use: rho =0.078,p=
0.830; control: rho = 0.248, p=0.521) or across groups (rho =
0.386, p=0.102). Furthermore, we found no significant correla-
tion between baseline optimism and SCAT-3 change either
within groups (app users: rho = 0.202, p=0.576; control: rho =
0.298, p=0.0.436) or across groups (rho = 0.211, p=0.386).
Discussion
Youth were able to use the SuperBetter app in conjunction with
traditional medical care for post-concussive symptoms and were
satisfied with use of the app as experienced within this study
(hypothesis 1). Additionally, participants who used the app to
complement medical care saw more relief from concussion
symptoms than those experiencing traditional medical care
alone (hypothesis 2). These findings suggest that tapping into
existing habits, such as mobile device and social network activity,
with a gamified app is a feasible and potentially effective way to
facilitate medical care among youth with concussion. To our
knowledge, this is the first evidence that a mobile app, designed
to reframe the concussion challenge as a personal heroic narra-
tive and leverage social interaction mechanics, can augment
concussion care for teens.
Use of the app in combination with standard care also
appeared to promote optimism more than standard care alone,
regardless of optimism levels at start of the study. We propose that
the gameful [21] and/or social interactive design of SuperBetter
were effective to improve optimism among users without requir-
ing high optimism at the start of the intervention to ensure
Table I. Use, described as median (IQR) percentage of target dose (%Play) and
median satisfaction ratings for the SuperBetter intervention (7-point Likert
rating, 1 high) during each study phase.
Variable
Phase I
(n=14)
Phase II
(n=10)
%Play 110% (22%) 113% (18%)
Satisfaction with intervention 2.0 (0.0) 2.0 (0.3)
Chi
2
statistic, comparison with normally
distributed responses around a ‘neutral’mean
183.3
(df = 6)
171.5
(df = 6)
pvalue <0.0001 <0.0001
0
2
4
6
8
10
Very
Satisfied
Satisfied Slightly
Satisfied
Neutral Slightly
Unsatisfied
Unsatified Ver
Unsatisfied
y
Frequency
Phase I
Phase II
Figure 3. Satisfaction with app was high for both Phase I and Phase II experimental cohorts.
BRAIN INJURY 5
participant adoption. These data provide evidence that gameful,
social design is possible for use in health care, is successful
deployed in this particular mobile app, and is impactful even
among those who do not start out optimistic at the commence-
ment of an intervention. Further study is needed to understand
the interplay between optimism and recovery in neurorehabilita-
tion for youth, as well as for the general population.
Several potential mechanisms may explain how app use
reduces symptom severity and increases optimism. The app
may serve to remind participants of concussion management
recommendations during intervals between clinic visits. The
inclusion of our clinical coordinator as an ally provided a con-
nection to the medical team that may improve patient ‘buy-in’to
medical care and/or compliance with medical recommenda-
tions. The encouragement to recruit a small number of high-
quality allies may help the participant cope with their illness by
guiding them to tap into their social network for support. The
cognitive reframing of their concussion recovery journey as a
heroic narrative, and the specific constructive actions of game
play, may increase optimism and reduce learned helplessness
[21] by returning a locus of control to the individual coping with
illness. Whether app use increases medical compliance or
improves optimism by enhancing social support, positive self-
thinking or other constructive coping strategies require further
study. However, qualitative feedback from app users provides
support for the theories, specifically that: 1) Reframing recovery
as a heroic narrative helped them cope with the symptoms of
their injury; and 2) Recruiting close allies, combined with posi-
tive messaging within the app, helped them feel less isolated in
their recovery journey. An early play-tester of the app noted: ‘It’s
HARD to ask forhelp when you’re sick, especially if you are used
to being able to take care of yourself. You fear becoming a
burden, of sounding like you are constantly complaining, of
running out of goodwill from your friends and family. The
SuperBetter game provides a framework, through missions,
that allows friends and family to have concrete, actionable
ways to help me, and provides me with a way to focus on what
I CAN do, instead of what I CAN’T. It lets me see, and lets loved
ones see, exactly what I go through on a daily basis, and to
recognize that those are, in fact, epic wins. It allows me to
participate in my life and healing instead of just sitting around
waiting to get better’.
Because app use and game play inherently involve active
repetition of some mental or physical task, they provide an
opportunity, as McGonigal (2011 & 2015) has said, to harness
the work and attention thatplayers willingly devote to interactive
play in order to improve health [4,21]. The implementation of
the SuperBetter app as a youth concussion intervention is a
concrete demonstration of this principle. Specifically, pairing
the social, mobile app SuperBetter with traditional medical
care appears to improve outcomes and optimism for youth
with unresolved concussion symptoms. More study is needed
Table II. Baseline characteristics for Phase II participants expressed as percent of individuals in group with characteristic or median value plus interquartile range (in
parentheses) and mean rank (MR).
Characteristic Experimental cohort (n=10) Active control cohort (n=9) Statistic pvalue
Gender Female: 7 (70%) Female: 7 (78%) Chi
2
= 0.148 0.701
Male: 3 (30%) Male: 2 (22%)
Medication use Yes: 3 (30%) Yes: 3 (33%) Chi
2
= 0.024 0.876
-Amitriptyline: 2 -Amitriptyline: 1
-Topiramate: 1 -Topiramate: 1
No: 7 (70%) -Ondansetron:1
No: 6 (67%)
Prior concussions Yes: 2 (20%) Yes: 1 (11%) Chi
2
= 0.281 0.596
-1 prior: 1 -1 prior: 1
-3 prior: 1
No: 8 (80%) No: 8 (89%)
Age 17.0 (2.0); MR: 12.0 15.0 (2.0): MR: 7.8 U= 25.0 0.096
Social network use prior to intervention Every day: 10 (100%) Every day: 7 (78%) Chi
2
= 2.484 0.115
Never: 0 Never: 2 (22%)
Game play prior to intervention Every day: 0 (0%) Every day: 2 (22%) Chi
2
=3.758 0.289
Sometimes: 4 (40%) Sometimes: 1 (11%)
Rarely: 4 (40%) Rarely: 4 (44%)
Never: 2 (20%) Never: 2 (22%)
Symptoms (SCAT-3 baseline) 19.0 (59.0); MR: 11.3 17.0 (29.5); MR: 8.6 U= 32.0 0.288
Optimism (LOT-R baseline) 17.0 (8.8); MR: 9.7 17.0 (3.5); MR: 10.4 U= 41.5 0.773
Depression (CES-DC baseline) 18.0 (15.5); MR: 12.3 13.0 (7.0): MR: 7.5 U= 22.5 0.065
Days elapsed bet baseline and post-test 30.5 (11.8); MR: 9.9 28.0 (19.5); MR: 10.2 U= 43.5 0.902
Days since injury 30.0 (74.0); MR: 8.2 42.0 (12.5); MR: 12.0 U= 27.0 0.141
Table III. Outcome measures by group: median change with interquartile range (IQR) and mean rank (MR) or responder frequency (percentage) in cohort. Group
comparison statistics are Mann-Whitney Uwith effect size rfor pre- to post-test change scores and Chi
2
for responder frequency.
Outcome measure
Experimental
(n=10)
Active control
(n=9) Statistic pvalue
Symptoms change (SCAT-3) 16.0 (32.0); MR:12.7 -2.0 (24.5); MR: 7.1 U= 18.5; r= 0.50 0.028
Optimism change (LOT-R) 3.0 (5.0); MR: 12.7 0.0 (1.0); MR: 7.1 U= 18.5; r= 0.51 0.028
Depression change (CES-DC) 8.0 (17.0): MR: 11.8 4.0 (7.5); MR: 8.0 U= 27.0; r= 0.34 0.156
Responders: Symptoms 10 (100%) 4 (44%) Chi
2
= 7.540 0.006
Responders: Optimism 8 (80%) 2 (22%) Chi
2
= 6.343 0.012
Responders: Depression 8 (80%) 7 (78%) Chi
2
= 0.014 0.906
6L. WORTHEN-CHAUDHARI ET AL.
to investigate ways that leveraging interactive media may com-
plement medical care and promote health outcomes among
youth with concussion and the general population.
Study limitations
Study limitations include small sample size, single testing site
and lack of blinding or random assignment to treatment groups.
In addition, we did not address technical barriers to participation
or potentially clinically important qualitative differences
between cohorts (e.g. mechanism of injury, types of concussion
symptoms). Finally, findings may not be generalizable to youth
with ADHD or adults with concussion, as representatives of
these populations were not studied.
Conclusions
SuperBetter improved symptoms and optimism relative to stan-
dard medical care alone in a non-randomized, open-label trial.
Mobile apps that employ social game mechanics, and that
reframe health recommendations as steps within a patient’s
personal, heroic narrative, may promote health management
among teenagers with unresolved concussion symptoms.
Declaration of interest
Funding was provided by NIH-NICHD SBIR grant 1R43HD075638-01A1.
(Clinicaltrials.gov Identifier: NCT01398566). SuperBetter was developed
under the auspices of SuperBetter, LLC and is now owned by Cherry
Street Innovation, both for-profit organizations. JM founded SuperBetter
LLC and is Chief Scientific Officer of Cherry Street Innovation. LWC has
served as a Science Advisor to SuperBetter Labs, LLC, on a pro bono basis.
No other authors have any conflict to report.
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