Original Investigation | Neurology

Prior Concussions and Risk of Disability for Patients After a Motor Vehicle Crash
Donald A. Redelmeier, MD, MSHSR; Vidhi Bhatt, BSc; Samantha S. M. Drover, PhD

Abstract Key Points

Question Is a prior concussion
IMPORTANCE Recovery after a motor vehicle crash can be slow, frustrating, and incomplete with
associated with an increased risk of
lingering neurocognitive complications.
long-term disability following a motor
vehicle crash?
OBJECTIVE To examine whether a prior concussion is associated with increased risk of long-term
disability after a motor vehicle crash. Findings In this cohort study of
907 984 adult patients, a prior
DESIGN, SETTING, AND PARTICIPANTS This cohort study included adults surviving a motor concussion was associated with a 15%
vehicle crash treated in Ontario, Canada, from April 2003 to March 2023 with analyses to increased risk of long-term disability.
November 2025.
Meaning This finding suggests the
importance of counseling patients about
EXPOSURE Prior concussion.
the risks of motor vehicle crashes and
previous concussions, as well as the
MAIN OUTCOME AND MEASURES Long-term disability defined by official social service records,
importance of follow-up care to reduce
comparing those with a prior concussion and those with no history of a prior concussion.
the risk of subsequent disability.

RESULTS A total of 907 984 patients injured in a motor vehicle crash were included (mean [SD] age,
37 [14] years; 472 435 male [52.0%]); 19 851 patients had a prior concussion and 888 133 had no prior + Invited Commentary
concussion. A total of 54 678 patients were subsequently diagnosed with long-term disability over
9 543 505 patient-years of follow-up (mean [SD], 10.5 [5.8] years), equal to an absolute risk of 1 in 17
+ Supplemental content
Author affiliations and article information are
per decade (5.7 per 1000 patient-years). Patients with a prior concussion had a 15% higher adjusted
listed at the end of this article.
risk of long-term disability (95% CI, 9%-21%; P < .001) compared with those with no prior
concussion. The increased risk of long-term disability was independent of other measured risk
factors, applied to diverse patient groups, and included those involved as passengers or pedestrians.
The increased risk extended across a spectrum of crash severity, was accentuated for single-vehicle
events, replicated in analyses with artificial intelligence models adjusting for confounding, and
remained distinct from the risks of death, readmission, or short-term health care costs.

CONCLUSIONS AND RELEVANCE This population-based cohort study suggests a significant

increased risk of long-term disability after a motor vehicle crash, particular among patients with a
prior concussion. More efforts at concussion prevention and traffic safety counseling may be justified
for patients.

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Introduction
A concussion is an acute head injury caused by energy that compromises brain function temporarily.
Research suggests a prior concussion may contribute to subsequent motor vehicle crash risks for
patients.1,2 Whether a concussion might also limit neurocognitive reserve and lessen recovery after a
later injury is unknown, especially in comparison to other factors that influence recovery.3,4 On the
one hand, a prior concussion might lead to neurocognitive complications and residual impairments

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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 JAMA Network Open | Neurology Concussions and Disability After a Motor Vehicle Crash

that limit a patient’s health.5,6 On the other hand, a prior concussion may be a trivial factor compared
with a patient’s full profile of environment, lifestyle, and personal risks.7-9
Motor vehicle crashes are a common health threat with a 30% to 70% lifetime risk for the
average individual in the US.10 Most people do not die from a crash, yet many do not recover
completely and some have a variable course with lasting neurocognitive complications.3 In addition,
people remember a crash and may make behavioral changes to compensate afterwards. A greater
awareness of long-term prognosis might help in targeting symptomatic interventions for patient
recovery and prevention. A rigorous estimate about the future can also help reconcile mistaken
expectations, reduce conflicts about public health planning, and potentially aid in counseling
patients about traffic safety.11
However, previous studies provide little information on long-term recovery after a motor
vehicle crash. Instead, the prevailing trauma research tends to focus on a patient’s short-term
physiology rather than long-term disability.12 Risk factors contributing to a serious crash are not
always the same as prognostic factors that determine recovery.13 The purpose of this study was to
explore directly whether prior concussion is associated with how well a patient recovers from a
subsequent motor vehicle crash. We hypothesized that individuals with prior concussion might have
increased risk of disability after a motor vehicle crash occurring years later.

Methods
Study Setting
We conducted a population-based cohort analysis in Ontario, Canada’s most populated region, with
10 980 900 individuals in 2013 (study midpoint), 8 920 342 registered motor vehicles, and 60 088
motor vehicle crashes causing injury.14 Disability support programs were available for adults who
qualified for income support due to chronic disabilities (population prevalence 41 per 1000 adults,
annual incidence 3 per 1000 adults, lifetime costs averaging $200 000 per adult).15-18 Universal
health insurance guaranteed access to emergency care and electronic records were available for
authorized investigators to conduct population-based health research. The Institute for Clinical
Evaluative Sciences (ICES) is an independent, nonprofit research institute that analyzes health care
data for health system evaluation and improvement.19,20
ICES is a prescribed entity under Ontario’s Personal Health Information Protection Act (PHIPA).
Section 45 of PHIPA authorizes ICES to collect personal health information, without consent, for the
purpose of analysis or for compiling statistical information with respect to the management of,
evaluation or monitoring of, the allocation of resources to, or planning for all or part of the health
system. Projects that use data collected by ICES under section 45 of PHIPA, and use no other data,
are exempt from institutional review board approval. The use of the data in this project was
authorized under section 45 and approved by ICES’ Privacy and Legal Office. The reporting of this
study results followed the Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) reporting guideline.

Motor Vehicle Crash

We identified patients injured in a motor vehicle crash throughout the region (178 emergency
departments) during a 20-year interval (April 1, 2003, to March 31, 2023). We excluded children (age
17 years or younger), seniors (age 65 years or older), those with a home address outside Ontario, and
those with preexisting disability (to ensure each patient was eligible for subsequent disability
support). These methods (eAppendix 1 in Supplement 1) have been validated in past research.21-23
Individuals with more than 1 crash were analyzed according to first incident so that each patient was
included once in analysis. Additional crash details included timing (hour), configuration (single,
multiple vehicles), position (driver, passenger, pedestrian), need for ambulance (yes, no), triage
severity (Canadian Triage and Acuity Scale [CTAS] score), hospitalization (yes, no), and initial trauma
assessment (Injury Severity Scale).24

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Prior Concussions
We identified a prior concussion diagnosis by accessing physician billing data from earlier years using
linkage algorithms and encoded identifiers (eAppendix 2 in Supplement 1) based on the International
Classification of Diseases, Ninth Revision (ICD-9) diagnosis (code: 850).25 This diagnostic code for
concussion has been validated with excellent specificity (99%) and moderate sensitivity (46% to
76%).26,27 The look-back interval spanned 5 years prior to the crash to consistently count all patients
in accord with the time of inception of databases. Additional details included time from most recent
concussion (2 years or longer, within 2 years) and number of separate concussions (single vs
multiple). The available databases lacked information on Rivermead Post-Concussion scores, the
Sport Concussion Assessment Tool, or other measures for gauging concussion severity.28,29

Additional Characteristics
Further patient characteristics were obtained by computerized linkages to multiple health care
records using validated algorithms and unique patient identifiers (eAppendix 2 in Supplement 1).30
The demographic registry was used to determine the patient’s age (years), sex (binary),
socioeconomic status (quintile), and home location (urban, rural).31,32 The physician services
database provided data on clinic visits, emergency contacts, and hospitalizations to collect diagnoses
before the motor vehicle crash.33 Specific attention was directed to demographic factors associated
with long-term disability (eg, low socioeconomic status) and diagnoses associated with long-term
disability (eg, alcohol misuse). The available databases contained no information on social factors
that influence employment including training, salary, family supports, or work satisfaction.34,35

Subsequent Disability
Subsequent long-term disability was defined by the submission of a formal disability support
application as identified by official social service records (OHIP codes: K050-K054, K057-K060).
Disability applications in this setting required medical reports from a physician (Activities of Daily
Living Index, Health Status Report, Special Necessities Benefit Form). This approach to identifying
long-term disability has been validated in past research yet may underestimate total disability.36,37
The available databases did not contain information on the nature of disability, how findings were
authenticated by a physician, or whether an application was eventually denied. Secondary analyses
considered alternative long-term outcomes including all-cause mortality, hospital readmission for
any reason, and subsequent health care costs over 1 year.

Statistical Analysis
The primary analysis examined the risk of long-term disability after a motor vehicle crash and
compared patients with a prior concussion relative to those without a prior concussion. We defined
the follow-up interval as starting on the day of hospital discharge and included only individuals who
survived acute injuries. We used unadjusted cumulative incidence curves to evaluate survivors for
death or disability during follow-up, with 2 years as the predefined landmark for estimating absolute
risks (censoring anomalous empty records after 5 years). Relative risks were estimated based on the
proportional hazards model before and after adjusting for baseline characteristics (model structured
by subdistributional hazard ratios; model fit assessed by C-index).38,39 Patients not known to be
dead or disabled were assumed alive and healthy.
Secondary analyses were conducted to further explore the robustness of results and relevance
to specific patient groups. The time profile was tested by examining alternative landmarks aside from
2 years (1, 5, 10 years). Generalizability was tested by reexamining associations after stratifying on
specific crash details (timing, position, configuration, severity). Confounding was assessed by
applying Artificial Intelligence methods (XGBoost) as well as a separate propensity score analysis as
further tests of the robustness of results (eAppendix 3 and eTable 3 in Supplement 1). A basic dose-
response association was tested by assessing risk of long-term disability for those with a single
concussion compared with multiple prior concussions. XGBoost statistical analyses were conducted

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using R software (version 3.6.1; package [Link]) (R Project for Statistical Computing) and all other
analyses using SAS Enterprise Guide version 8.3 (SAS Institute Inc). A 2-sided P < .05 was specified
as the threshold for statistical significance throughout.

Results
Baseline Characteristics
A total of 907 984 patients were injured in a motor vehicle crash and required emergency medical
care (mean [SD] age, 37 [14] years; 472 435 male [52.0%]), of whom 19 851 had a prior concussion
and 888 133 had no prior concussion (eFigure in Supplement 1). The 2 groups spanned a diverse
range of demographic characteristics, medical diagnoses, and socioeconomic status (Table 1). The
largest relative differences were that patients with a prior concussion tended to be younger (ages 18
to 39 years: prior concussion, 76.5% [15 851 of 19 851 patients] vs 57.8% [513 565 of 888 133
patients]), more likely to have a history of alcohol misuse (1.5% [303 of 19 851] vs 0.8% [6952 of
888 133]), and more likely to have a mental health diagnosis (eg, anxiety: 25.1% [4979 of 19 851] vs
15.7% [139 607 of 888 133]). Other diseases showed smaller differences or were less frequent among
patients with prior concussion, including diabetes, osteoarthritis, or hypertension. Common causes
of mortality, including heart disease and cancer, were rare and observed in fewer than 5% of patients
in both groups.

Table 1. Baseline Patient Characteristics

Patients, No. (%)

Characteristics Prior concussion (n = 19 851) No prior concussion (n = 888 133)
Demographic data
Age, y
18-39 15 185 (76.5) 513 565 (57.8)
40-65 4666 (23.5) 374 568 (42.2)
Sex
Male 9889 (49.8) 462 546 (52.1)
Female 9962 (50.2) 425 587 (47.9)
Home location
Urban 16 891 (85.1) 781 009 (87.9)
Rural 2960 (14.9) 107 124 (12.1)
Past diagnosesa
Alcohol misuse 303 (1.5) 6952 (0.8)
Diabetes 578 (2.9) 42 350 (4.8)
Hypertension 764 (3.8) 59 760 (6.7)
Heart disease 668 (3.4) 30 433 (3.4)
Syncope 2350 (11.8) 54 459 (6.1)
Sleep apnea 1232 (6.2) 42 525 (4.8)
Osteoarthritis 525 (2.6) 28 904 (3.3)
Depression 1395 (7.0) 31 288 (3.5)
Anxiety 4979 (25.1) 139 607 (15.7)
Cancer 464 (2.3) 23 544 (2.7)
Socioeconomic status quintileb
Highest 4072 (20.5) 156 359 (17.6)
Next highest 4142 (20.9) 177 179 (19.9)
Middle 3920 (19.7) 182 936 (20.6)
a
Based on previous year.
Next lowest 3842 (19.4) 184 650 (20.8)
b
Based on home neighborhood, missing data coded
Lowest 3875 (19.5) 187 009 (21.1)
as lowest.

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Acute Care
Motor vehicle crash patterns were comparable for the 2 groups as characterized by incident time,
vehicle configuration, and individual position (Table 2). Initial mean (SD) injury severity scores were
similar for patients with a prior concussion (2.65 [3.84]) compared with those without a prior
concussion (2.35 [3.75]). Initial triage severity also showed no significant imbalance between the 2
groups. Over a third required emergency ambulance transport, with a significantly lower frequency
for patients with a prior concussion relative to those without a prior concussion (38.9% [7724 of
19 851] vs 43.9% [390 189 of 888 133]). Rates of hospital admission were significantly lower for
patients with a prior concussion (3.0% [603 of 19 851] vs 4.2% [36 991 of 888 133]). In addition,
mean (SD) length of stay among those admitted was shorter for patients with a prior concussion
(7.83 [10.43] days) than those without a prior concussion (9.49 [18.91] days).

Subsequent Disability
A total of 54 678 individuals developed a disability during follow-up, equivalent to an average rate of
5.7 per 1000 person-years. Patients with a prior concussion accounted for 1311 cases of disability over
160 787 patient-years, equal to an absolute rate of 8.2 per 1000 annually. Patients without a prior
concussion accounted for 53 367 cases of disability over 9 382 718 patient-years, equal to an absolute
rate of 5.7 per 1000 annually. The difference corresponded to a 34% relative increased risk of long-
term disability associated with a prior concussion (95% CI, 27%-41%; P < .001). The increased risk
became apparent a few months after injury, persisted over extended years of follow-up, and equaled
1 case of long-term disability for every 180 survivors at the 2-year landmark (Figure 1).

Table 2. Traffic Crash Patterns

Prior concussion
Yes No
Characteristics (n = 19 851) (n = 888 133)
Crash features
Timea
Dawn 871 (4.4) 42 819 (4.8)
Morning 3490 (17.6) 167 386 (18.8)
Afternoon 4739 (23.9) 211 897 (23.9)
Evening 5568 (28.0) 249 577 (28.1)
Night 3732 (18.8) 161 488 (18.2)
Late night 1451 (7.3) 54 966 (6.2)
b
Configuration
Single vehicle 5883 (29.6) 237 119 (26.7)
Multivehicle 10 218 (51.5) 479 682 (54.0)
Not motorized 2720 (13.7) 126 273 (14.2)
Unlisted 1030 (5.2) 45 059 (5.1)
c
Position
a
Boundaries for time period were 4:00 am, 8:00 am,
Driver 10 478 (52.8) 474 066 (53.4)
12:00 pm, 4:00 pm, 8:00 pm, and 12:00 am.
Passenger 4736 (23.9) 200 314 (22.6) b
International Statistical Classification of Diseases
Pedestrian 4637 (23.4) 213 753 (24.1) and Related Health Problems, Tenth Revision (ICD-10)
Emergency cared codes single and multiple vehicle events.
c
Ambulance 7724 (38.9) 390 189 (43.9) Pedestrian includes bicycles, scooters, and other
nonprotected road users.
High triage severity 4630 (23.3) 188 287 (21.2)
d
Assessed in emergency department for traffic crash.
Hospital admission 603 (3.0) 36 991 (4.2)
e
ICD-10 algorithm; range, 0 to 75; higher indicates
Injury Severity, mean (SD)e 2.65 (3.84) 2.35 (3.75)
worse injury.
Days in Hospital, mean (SD)f 7.83 (10.43) 9.49 (18.91) f
Based on cases admitted.

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Additional Risk Factors

The increased risk of long-term disability after a motor vehicle crash was associated with many other
individual characteristics. In particular, younger age (relative risk [RR], 1.18; 95% CI, 1.16-1.21), male
sex (RR, 1.13; 95% CI, 1.11-1.15), a rural home location (RR, 1.09; 95% CI, 1.07-1.12), and lower
socioeconomic status (lowest quartile: RR, 1.94; 95% CI, 1.89-1.99) were each associated with an
increased risk of long-term disability in adjusted analyses (Table 3). As expected, a diagnosis of
alcohol misuse was a substantial risk factor (RR, 2.70; 95% CI, 2.56-2.84). A diagnosis of depression
(RR, 1.78; 95% CI, 1.72-1.84), anxiety (RR, 2.00; 95% CI, 1.96-2.04), diabetes (RR, 1.48; 95% CI,
1.42-1.53), and hospital admission (RR, 1.10; 95% CI, 1.06-1.15) were additional risk factors to lesser
degrees. Conversely, diagnoses of treated hypertension or cancer were not significant risks. The
model fit was mediocre (C statistic = 0.684 overall, 0.722 at 2-year landmark). Adjusting for all
measured characteristics showed a 15% relative increased risk of long-term disability for patients
with a prior concussion (95% CI, 9%-21%; P < .001).

Adjusting for Confounding

Further artificial intelligence techniques were applied to check robustness by adjusting for
interactions, nonlinear relationships, and latent associations with unmeasured variables. Gradient
boosting was tuned with a 0.03 learning rate, total of 750 iterations, weight of 3 for minimum child
count, maximum tree depth of 4 levels, and typical run times of 15 minutes per model. The model fit
was marginally improved (C statistic = 0.701 overall, 0.741 at 2-year landmark) and calibration was
uneven (Figure 2). The model applied to patients who had a prior concussion estimated 409
expected cases of long-term disability (in contrast to 453 cases observed at 2 years). This contrast
suggested a 28% relative increased risk of long-term disability for patients with a prior concussion
(95% CI, 4%-52%; P = .02).

Clinical Distinctions
The increased risk of long-term disability after a concussion applied to diverse groups. Patients with
lower socioeconomic status had a higher subsequent risk of long-term disability, yet the relative risk
associated with a concussion applied at all levels of income (eTable 1 in Supplement 1). Similarly, those
with higher crash severity had a higher subsequent risk of long-term disability, yet the relative risk
associated with a concussion applied across the spectrum. Those with a relatively remote prior
concussion and those with a relatively recent prior concussion each showed a significant increase in
relative risk. Comparing patients with a single identified prior concussion to patients with multiple
identified prior concussions showed no significant dose-response gradient. No subgroup analysis
showed a significant opposite finding of reduced relative risk.

Figure 1. Risk of Long-Term Disability

150
Unadjusted RR, 1.34; 95% CI, 1.27-1.41; P < .001
cumulative risk/1000 patients
Risk of long-term disability,

Prior concusssion

100

No prior concusssion
50

Cumulative incidence plots of unadjusted absolute risk

of long-term disability after a traffic crash. Results
0 show increased risk of long-term disability for patients
0 5 10 15 20
with a prior concussion. For context, population norm
Time, y
is 3 per 1000 patients annually (equal to 6 per 1000
No. at risk
Prior concussion 19 851 12 710 6056 3045 260 patients after 2 years and 60 per 1000 patients after
No prior concussion 888 133 698 187 456 235 242 488 39 821 20 years).

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Additional Outcomes
The increased risk of long-term disability after a concussion was distinct from other outcomes
(eTable 2 in Supplement 1). A total of 37 385 patients died during follow-up, with no significant
difference in risk per 1000 annually for patients with a prior concussion compared with patients with
no prior concussion (3.25 per 1000 person-years vs 3.75 per 1000 person-years; P = .051). Similarly,
a total of 322 290 patients were subsequently readmitted for any reason during follow-up, with no
significant difference in risk per 1000 annually for those with a prior concussion (45.94 per 1000
person-years vs 43.25 per 1000 person-years; P = .13). Average short-term health care costs over the
first year after the crash were also similar for those with and without a prior concussion ($4925 vs
$4815; P = .41). In accord with past research, the annual risk of another future motor vehicle crash
was increased for those with a prior concussion (21.74 per 1000 person-years vs 13.10 per 1000
person-years; P < .001).

Table 3. Factors Associated With Long-Term Disability

Relative risk (95% CI)a

Characteristics Basic analysisb Adjusted analysisc
Factor
Prior concussion 1.34 (1.27-1.41) 1.15 (1.09-1.21)
Younger age (<40 y) 1.18 (1.16-1.20) 1.18 (1.16-1.21)
Male sex 1.10 (1.08-1.12) 1.13 (1.11-1.15)
Rural home 1.02 (0.99-1.04) 1.09 (1.07-1.12)
Diagnosis
Alcohol misuse 4.68 (4.45-4.92) 2.70 (2.56-2.84)
Diabetes 1.42 (1.37-1.47) 1.48 (1.42-1.53)
Hypertension 0.95 (0.92-0.98) 0.93 (0.89-0.96)
Heart disease 1.12 (1.07-1.18) 1.02 (0.97-1.06)
Syncope 1.61 (1.57-1.66) 1.41 (1.37-1.45)
Sleep apnea 1.26 (1.21-1.30) 1.14 (1.10-1.18)
Osteoarthritis 1.26 (1.21-1.32) 1.24 (1.19-1.30)
Depression 2.54 (2.46-2.62) 1.78 (1.72-1.84)
Anxiety 2.21 (2.17-2.25) 2.00 (1.96-2.04)
Cancer 0.84 (0.79-0.89) 0.85 (0.80-0.90)
Socioeconomicd
Highest 0.67 (0.65-0.69) 0.67 (0.65-0.70)
Next to highest 0.82 (0.79-0.84) 0.83 (0.81-0.86)
Next to lowest 1.36 (1.32-1.39) 1.33 (1.30-1.37)
Lowest 2.04 (1.99-2.09) 1.94 (1.89-1.99)
Crash timee
Dawn 1.14 (1.09-1.18) 1.05 (1.01-1.10)
Morning 0.91 (0.89-0.93) 0.94 (0.92-0.97)
Afternoon 1.04 (1.02-1.07) 1.05 (1.03-1.08)
Night 1.13 (1.10-1.15) 1.09 (1.07-1.12)
Late night 1.46 (1.41-1.51) 1.29 (1.25-1.33)
Configurationf
Single vehicle 1.35 (1.33-1.38) 1.06 (1.03-1.08)
Nonmotorized 1.16 (1.13-1.19) 0.78 (0.75-0.81) a
Estimates based on hazard ratio from Cox
Unlisted 1.21 (1.17-1.26) 0.89 (0.85-0.93) survival model.
Positiong b
No adjustments for baseline differences.
Passenger 1.32 (1.29-1.34) 1.30 (1.28-1.33) c
Adjusted for all other characteristics by regression
Pedestrian 1.50 (1.47-1.53) 1.67 (1.62-1.72) model (Table 1, Table 2).
Acute care d
Referant is middle socioeconomic status.
Ambulance 1.17 (1.15-1.19) 1.09 (1.07-1.11) e
Referant is evening interval.
Triage severity 1.33 (1.30-1.35) 1.16 (1.14-1.19) f
Referant is multivehicle incident.
Injury severityh 1.03 (1.03-1.04) 1.02 (1.02-1.02) g
Referant is driver position.
Hospital admission 1.63 (1.57-1.68) 1.10 (1.06-1.15) h
Referent per unit increase in Injury Severity Score.

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Discussion
We studied thousands of patients over many years and found a high risk of long-term disability after
a motor vehicle crash, double the population norm. The major risk factors were demographic
characteristics, alcohol misuse, psychiatric illnesses, and selected medical diseases. We also
identified that a prior concussion in patients was associated with a worse risk of long-term disability
after a motor vehicle crash. The overall effect size associated with a prior concussion was substantial,
comparable with a diagnosis of sleep apnea, and greater than a diagnosis of heart disease. Together
these findings suggest that recovery after a prior concussion can sometimes be incomplete and
contributes to a possible loss of long-term resilience that impairs a person’s ability to return to full
function after a motor vehicle crash occurring years later.
Our results support past research on long-term prognosis after a motor vehicle crash. A cohort
analysis of 2019 adults after a noncatastrophic crash identified 23% were unable to resume full
duties after 6 months.9 A cross-sectional survey of 442 adults following an earlier crash found
multiple persisting health conditions limiting an individual’s ability to work.40 A cohort survey of 590
adults injured in a crash identified ongoing deficits due to pain, anxiety, mobility, and restricted
activity more than 1 year later.41 Another prospective cohort study (64 007 patients) found 8% had
a permanent medical impairment when assessed after 2 years.42 In addition, clinical studies often
identify a high frequency of depression, social isolation, and reduced workforce participation among
adults with a prior traumatic brain injury.43

Limitations
An important limitation of our research is that each concussion is different, thereby making an exact
prognosis hard to estimate due to lingering uncertainties.44 A randomized trial of concussions would
be unthinkable, which means confounding can include genetics, lifestyle, personality, and many
other unknowns. In our patients, for example, the available data lack specifics on how each prior
concussion occurred, the severity of injury, pattern of symptoms, extent of comorbidities, and
precise time for recovery.45,46 The data also lack records of childhood concussions; therefore, some
patients in the control group may be misclassified and may have experienced head injuries decades

Figure 2. Risk at Different Predicted Probabilities

70

No prior concussion
60
Observed risk/1000 patients (2-y landmark)

Prior concussion

50

40

30

20

10

0
0 10 20 30 40 50 60 70
Estimated risk/1000 patients (2-y landmark)

The diagonal line represents the line of equivalence (ie, observed

risk = predicted risk). Results show a wide range of estimated risk and generally
higher relative risk for patients with a prior concussion; for example, top decile
shows observed risk of 70.1 per 1000 for patients with a concussion and 59.6
per 1000 for patients with no prior concussion.

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earlier.47 Together, these uncertainties imply that clinical care needs to be personalized because
aggregate statistics may underestimate the risk of long-term disability in some patients.48
A related set of limitations reflects the distinction between correlation and causality.
Specifically, the observed data do not prove that a prior concussion directly contributed to the future
disability or that preventing the concussion could have avoided the subsequent disability. In addition,
the data do not identify whether a strategy of directly treating concussions symptoms would be
more effective for patients than a general approach of encouraging greater traffic safety overall for
reducing long-term disability.49 Moreover, a statistical model that adjusts for confounding by
attributing risk to baseline characteristics may lead to overadjustment bias if a concussion can
synergistically worsen a comorbidity (eg, a concussion exacerbating an underlying substance misuse
disorder in a patient). These limitations are directions for future science.
Additional limitations relate to the amount of other information available and many further
unknowns. We have no direct information on living circumstances, communication abilities, and
other social determinants of disability.50 The unmeasured uncertainties also include details of the
vehicle speed, reasons for travel, and total trips for each patient.51 We lack many clinical details about
the initial treatment of the patient after the crash including subsequent outpatient services for
community integration.52,53 Similarly, we lack engineering details about the conditions of the road,
specifics of the vehicle, prevailing traffic enforcement, systems for safe transportation, and
surrounding weather conditions.54,55 Collectively, these limitations might introduce substantial noise
that generally bias analyses toward the null.

Conclusions
This population-based cohort study suggests an increased patient risk of long-term disability when a
prior concussion is followed later by a motor vehicle crash. This finding highlights the importance of
counseling patients to reduce the risk of a motor vehicle crash.43,49,56 The finding also underlines the
need to prevent head injuries in the first place by protective gear (eg, safety helmets) and preventive
behaviors (eg, wearing seatbelts).57,58 The results might also encourage more concussion prevention
for children and seniors even though these groups were not included in our study.59,60 A medication
that could treat concussions and prevent disability, of course, is a topic for future research.61-63 In the
interim, physicians caring for patients after a concussion should stress the importance of motor
vehicle safety to reduce the risk of long-term disability.

ARTICLE INFORMATION
Accepted for Publication: November 13, 2025.
Published: January 21, 2026. doi:10.1001/jamanetworkopen.2025.54831
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2026 Redelmeier
DA et al. JAMA Network Open.
Corresponding Author: Donald A. Redelmeier, MD, FRCPC, MSHSR, FACP, Sunnybrook Health Sciences Centre,
V-151, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada (dar@[Link]).
Author Affiliations: Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Ontario
(Redelmeier, Bhatt); Institute for Clinical Evaluative Sciences, Toronto, Ontario (Redelmeier, Bhatt, Drover);
Department of Medicine, University of Toronto, Toronto, Ontario (Redelmeier, Bhatt); Division of General Internal
Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario (Redelmeier); Center for Leading Injury
Prevention Practice Education & Research, Toronto, Ontario (Redelmeier).
Author Contributions: Drs Redelmeier and Drover had full access to all of the data in the study and take
responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Redelmeier, Bhatt.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Redelmeier.

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 JAMA Network Open | Neurology Concussions and Disability After a Motor Vehicle Crash

Critical review of the manuscript for important intellectual content: All authors.
Statistical analysis: Redelmeier, Drover.
Obtained funding: Redelmeier.
Administrative, technical, or material support: All authors.
Supervision: Redelmeier.
Conflict of Interest Disclosures: Dr Drover reported consulting fees from CERobs Consulting LLC outside the
submitted work. No other disclosures were reported.
Funding/Support: This project was supported by a Canada Research Chair in Medical Decision Sciences, the
Canadian Institutes of Health Research, the PSI Foundation of Ontario, the Graduate Diploma Program in Health
Research at the University of Toronto, and the Kimel-Schatzky Traumatic Brain Injury Research Fund. This study
was supported by Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario
Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). This analysis used data adapted from the
Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation,
and adapted from the MOH Postal Code Conversion File, which contains data copied under license from Canada
Post Corporation and Statistics Canada. Parts of this material are based on data and/or information compiled and
provided by MOH, Ontario Health, and Canadian Institute for Health Information.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Disclaimer: The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors
and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.
Data Sharing Statement: See Supplement 2.
Additional Contributions: We thank Matthew Burke, MD; Fizza Manzoor, MD; Larry Robinson, MD; Husain Shakil,
MD; and Charles Tator, MD (all at the University of Toronto) for helpful suggestions on specific points. None were
compensated.
Additional Information: Patients were not directly involved in setting the research agenda, designing the study
approach, or conducting the analysis. Patients were involved in manuscript review and suggestions for improving
exposition.

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SUPPLEMENT 1.
eAppendix 1. Traffic crash code categorization
eAppendix 2. Variable definitions and data sources
eAppendix 3. Technical XGBoost details
eFigure. Cohort selection
eTable 1. Stratified analysis of long-term disability
eTable 2. Other outcomes
eTable 3. Propensity score test of robustness
eTable 4. Estimates of standardized mean differences

SUPPLEMENT 2.
Data Sharing Statement

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