Digital and Paper-Based Concussion Tracking

Abstract

Self-monitoring may help individuals recovering from concussion recognize symptom patterns and adjust daily activities, but consistent engagement with tracking systems cannot be assumed. Digital and paper-based approaches differ in their practical features and demands, raising questions about how modality, usability, monitoring burden, and self-regulatory processes relate to adherence and perceived self-regulatory awareness. This proposal outlines a critical integrative literature review informed by self-regulation theory, feedback control theory, and the Technology Acceptance Model. Structured searches of PsycINFO, PubMed/MEDLINE, and Scopus will identify relevant empirical research, supplemented by foundational theoretical literature. Publications will be screened against documented eligibility criteria, appraised using design-appropriate criteria, and organized in an evidence matrix. A critical thematic synthesis will compare findings, definitions, and methodological limitations, distinguishing concussion-specific evidence from indirect evidence from other health contexts. The review will inform a provisional conceptual model examining potential supportive and demand pathways, contextual influences, and the distinction between useful self-regulatory awareness and unwanted symptom vigilance. The study will not recruit participants or test causal effects. Its intended contribution is to clarify the evidence base and generate propositions for future empirical research.

Introduction and Purpose

Concussion recovery often requires individuals to manage fluctuating symptoms while gradually resuming academic, athletic, occupational, and everyday activities. Contemporary guidance emphasizes a progressive, symptom-guided return to activity rather than prolonged inactivity (Pertab et al., 2025; U.S. Department of Veterans Affairs & U.S. Department of Defense [VA/DoD], 2021). Many decisions about pacing and participation occur outside clinical appointments, making the ability to notice patterns and adjust behavior particularly relevant.

Structured self-monitoring offers one way to document symptoms, energy, and activity demands over time. Digital tools may offer reminders, organized records, and feedback, whereas paper-based formats may reduce screen exposure and technological demands. Yet neither modality guarantees continued engagement, and monitoring may help some individuals while adding burden or unwanted attention to symptoms for others.

The purpose of this thesis is to critically evaluate published research and develop a theory-informed conceptual model explaining how and under what conditions tracking systems may relate to adherence and perceived self-regulatory awareness during concussion recovery. Rather than testing whether digital or paper tracking is more effective, the review will examine what the available literature reports, where evidence is inconsistent or limited, and which relationships warrant future investigation.

Literature Review

Self-monitoring is central to accounts of behavioral self-regulation. Bandura (1991) and Carver and Scheier (1982) describe processes through which individuals observe their circumstances, compare information with goals or standards, and adjust their behavior. Chen et al. (2017) discuss self-monitoring as a potential support for reflection and adaptive change. In concussion recovery, these ideas suggest that tracking may help individuals notice relationships between activity demands and symptom experiences, although recording information does not necessarily mean it will be interpreted or used effectively.

Awareness is also a multidimensional construct. Work in neurological rehabilitation distinguishes recognition of personal abilities and limitations from noticing difficulties as they occur in daily life (Sansonetti et al., 2025). Research on return to work after illness similarly illustrates the relevance of developing awareness of changing capabilities (Haugstvedt et al., 2011). These perspectives support examining perceived self-regulatory awareness while avoiding the assumption that increased attention to symptoms is always beneficial. Symptom vigilance is a potentially different, unwanted experience.

Engagement presents a separate challenge. Research on ecological momentary assessment identifies assessment frequency, burden, and declining compliance as practical concerns (Tonkin et al., 2023; Williams et al., 2021). Adherence can be operationalized as completed entries, responses to prompts, or sustained use, and these measures are not interchangeable. Consequently, differences in reported completion rates may reflect the design of the monitoring protocol as well as participants’ experiences.

Concussion-specific studies illustrate these difficulties. In a five-week digital intervention feasibility study, d’Offay et al. (2023) reported 28.23% average daily symptom diary completion. Storvig et al. (2025) reported 89% median adherence among 19 participants included in an adherence analysis during 28 days of home testing of a symptom-mapping application for persistent postconcussion symptoms. Elbin et al. (2025) reported 71% median compliance with four daily assessments over seven days among adolescents and young adults following concussion. These percentages should not be ranked as competing estimates of modality effectiveness: the studies differ in population, recovery stage, schedule, system design, and adherence denominator.

The studies also raise questions beyond completion. Elbin et al. (2025) observed variation in compliance by assessment timing and study day, while Storvig et al. (2025) reported two adverse events involving increased symptom awareness. The latter observation supports considering unwanted vigilance as a possible outcome, not concluding that tracking generally causes it. None of these three studies directly compared equivalent digital and paper-based tracking conditions.

Technology and diary research offers further perspectives on how usability and perceived value may shape engagement (Broderick, 2008; Schretzlmaier et al., 2022). The distinction between a tracking format and the features bundled with it is important: reminders, interface complexity, recording schedules, and access requirements may affect completion independently of whether entries are recorded digitally or on paper. Likewise, self-reported completion and objectively documented responses may represent different adherence constructs. The available concussion studies justify broader examination, but they do not establish that comparative evidence is absent across the field.

The proposed review will therefore evaluate and integrate research from concussion management, neurological rehabilitation, self-regulation, and technology acceptance. It will examine where findings converge or differ, whether methodological features help explain those differences, and which potential relationships are sufficiently supported to inform a conceptual model.

Theoretical Framework

Three complementary perspectives will guide the review. Bandura’s (1991) social cognitive account describes self-regulation through self-observation, judgment, and self-reaction. Tracking may provide information for these processes, but its potential contribution depends on how that information is interpreted and used. Carver and Scheier’s (1982) feedback control theory adds the idea of comparing a current state with a desired state and adjusting behavior in response to perceived discrepancies.

Davis’s (1989) Technology Acceptance Model identifies perceived usefulness and perceived ease of use as factors relevant to acceptance of information technology. Although developed for technology, these concepts help frame questions about how manageable and worthwhile different tracking systems feel. I-O psychology research also treats self-regulation as a process shaped by individual and contextual factors (Vancouver & Day, 2005). Paper systems may reduce screen-related demands while introducing others, such as remembering entries or retrieving prior records. These possibilities require examination rather than assumption.

Together, these theories suggest provisional supportive and demand pathways. Useful feedback, accessibility, and manageable recording procedures may support continued tracking and opportunities for reflection. Conversely, cognitive effort, frequent prompts, or screen-related burden may interfere with engagement; repeated symptom attention may also be experienced as unwanted vigilance. Recovery stage, symptom burden, screen tolerance, and prior technology experience may condition these relationships. The review will assess which proposed links have direct empirical support, which rely on indirect evidence, and which remain theoretical.

Research Questions

The overarching research question is: How might tracking modality, cognitive demands, usability, and self-regulatory processes influence adherence and perceived self-regulatory awareness during concussion recovery?

• What has been reported about completion and continued use of digital or paper-based symptom-monitoring systems following concussion?
• How do researchers define and measure adherence, usability, tracking burden, and symptom awareness?
• Which findings are consistent or inconsistent across studies, and how might differences relate to population characteristics, recovery stage, tracking schedules, or system design?
• Which mechanisms from self-regulation, feedback control, and technology acceptance theories may help explain the reported patterns?
• What theory-informed propositions can be developed into a conceptual model for future empirical investigation?

Methods

Research Design

The study will use a critical integrative literature review informed by Whittemore and Knafl (2005), Snyder (2019), and Jaakkola (2020). This approach permits critical consideration of quantitative, qualitative, mixed-methods, and conceptual contributions without treating them as equivalent forms of evidence. No original participant data will be collected. A written review protocol will be finalized before the full search, and any later changes will be documented.

Search Strategy

Searches will be conducted in PsycINFO, PubMed/MEDLINE, and Scopus. Search concepts will combine concussion or mild traumatic brain injury with symptom monitoring, diaries, self-tracking, adherence, engagement, usability, burden, awareness, and digital or paper formats. Database-specific controlled vocabulary, keywords, truncation, and Boolean operators will be adapted and recorded. Reference lists of included studies will be checked, and targeted searches will identify foundational theoretical work. Search dates and complete search strings will be retained. A preliminary search framework and protocol decisions are provided in Appendix A.

Eligibility and Study Selection

The primary evidence set will include peer-reviewed empirical studies of structured symptom monitoring in concussion or mild traumatic brain injury reporting a relevant engagement, usability, burden, or awareness outcome. Quantitative, qualitative, and mixed-methods designs will be eligible. Relevant reviews will be used to locate primary studies and contextualize findings, but their summaries will not be counted as independent primary-study observations. A supplementary, explicitly labeled evidence set may include research in related health populations addressing mechanisms insufficiently examined in concussion studies. Foundational theoretical publications will be evaluated separately. Studies without a relevant monitoring process or sufficient information for appraisal will be excluded. To avoid excluding foundational or earlier monitoring research, no publication-year cutoff is proposed. Searches will be restricted to English-language full texts for feasibility; this restriction and its potential language bias will be reported. These eligibility decisions will be documented in the protocol before the final search.

Records will be deduplicated and screened by title and abstract, followed by full-text assessment. The researcher will document inclusion decisions, full-text exclusions and reasons, and counts at each stage. Because this is a single-researcher master’s thesis, screening will not be described as independently duplicated. Uncertain decisions will be reviewed against the protocol and discussed with the advisor as needed.

Data Extraction and Quality Appraisal

An evidence matrix will capture citation details, design, population, recovery stage, monitoring modality and features, prompting schedule, adherence definitions and denominators, awareness measures, findings, and limitations. Empirical studies will be appraised using the Mixed Methods Appraisal Tool (MMAT; 2018 version) where applicable to their design; other designs will receive a documented, design-appropriate appraisal rather than an inappropriate MMAT score. The reviewer will record criterion-level judgments and how study limitations affect confidence in each proposed relationship. Theoretical and conceptual publications will be evaluated for relevance, conceptual clarity, and evidentiary grounding, without empirical-study scores. A preliminary five-source matrix is included in Appendix D; it is not the completed evidence synthesis.

Analysis, Synthesis, and Model Development

The review will use a structured critical thematic synthesis organized around adherence, perceived self-regulatory awareness, usability, monitoring burden, modality, and contextual factors. Comparisons will attend to definitions, measurement denominators, study duration, assessment frequency, population, and recovery stage. Concussion-specific evidence will be distinguished from indirect health-context evidence and theoretical arguments. Contradictory findings and plausible methodological explanations will be reported rather than averaged into a single adherence estimate.

Following synthesis, findings will be integrated with the three theoretical perspectives to develop a provisional conceptual model. Candidate relationships will be traced to direct concussion evidence, indirect health-context evidence, or theoretical reasoning; contradictory findings will be recorded explicitly. The review will not conduct participant-level statistical analyses, meta-analysis, or causal hypothesis testing. Appendix C provides a preliminary conceptual structure and construct definitions for refinement, not a validated model.

Anticipated Conceptual Model

The anticipated product is a theory-informed model of how tracking system characteristics and individual circumstances may relate to adherence and perceived self-regulatory awareness. Potential supportive mechanisms include manageable recording, perceived usefulness, reminders, and feedback. Potential demands include cognitive effort, prompt frequency, and screen exposure. Recovery stage, symptom burden, screen tolerance, and technology experience may shape these processes.

The model will distinguish tracking completion from awareness that may inform behavioral adjustment and will treat unwanted symptom vigilance as conceptually separate from beneficial awareness. Appendix C sketches the candidate pathways and definitions. The final figure and testable propositions will be refined after evidence synthesis, with each relationship labeled according to direct, indirect, mixed, or currently insufficient support. No pathway will be presented as an established causal effect.

Ethical Considerations and Institutional Review

This study will use published scholarly sources and will not recruit participants, administer interventions, or access identifiable private participant information. It is therefore not expected to constitute human-subjects research, but the researcher will obtain the appropriate institutional determination or documentation from Marian University before proceeding in accordance with university requirements. An IRB approval number will not be presumed.

Ethical practice will emphasize accurate attribution, transparent selection and appraisal, faithful reporting of limitations, and clear separation of empirical findings from interpretation. Search records, evidence matrices, and decision logs will be retained in university-approved storage in accordance with applicable requirements.

Limitations and Delimitations

The review will depend on the scope, quality, and reporting of existing studies. Differences in populations, monitoring schedules, tracking features, and operational definitions may limit comparisons. Evidence from related conditions may offer useful mechanisms but cannot be assumed to generalize to concussion. A single-reviewer process also introduces the possibility of selection and interpretive bias. The resulting conceptual model will not be empirically validated within this thesis.

The review will focus on structured symptom monitoring, adherence, perceived self-regulatory awareness, and closely related usability and burden factors during concussion recovery. It will not assess treatment effectiveness, predict recovery duration, or establish readiness for return to sport, school, or work. Its objective is explanatory synthesis and theory development, not a universal ranking of digital versus paper tracking.

Proposed Research Timeline

Following proposal and protocol approval, the researcher will finalize and log database-specific searches; conduct screening and record exclusions; extract and appraise evidence; compare agreement, conflict, and uncertainty; revise the conceptual diagram and propositions; and prepare the thesis for advisor review and defense. The preliminary five-source matrix will be expanded into the full evidence matrix during the review. Specific dates will be established with the advisor in accordance with Marian University deadlines.

Appendix A: Preliminary Review Protocol and Search Framework

This appendix documents the proposed search and selection framework. It is a planning document, not a record of searches already conducted. Final limits and database-specific search syntax will be approved and recorded before the full search.

Illustrative keyword structure (not yet validated or run):

(concussion OR "mild traumatic brain injury" OR mTBI) AND ("symptom tracking" OR "self-monitoring" OR "symptom diary" OR "electronic diary" OR "paper diary" OR mHealth) AND (adherence OR compliance OR engagement OR usability OR burden OR awareness)

Database-specific controlled vocabulary, synonyms, field tags, and syntax will be adapted and documented before execution. Targeted searches for self-regulation, feedback control, and technology acceptance theory will be logged separately.

Appendix B: Evidence Extraction and Appraisal Template

This blank template will be completed for each eligible empirical study. It does not present findings or quality ratings from a completed review. Supplementary health-context evidence will be labeled separately from concussion-specific evidence.

For theoretical or conceptual sources, use a separate narrative note recording the source’s theoretical contribution, conceptual clarity, relevance to the research questions, and evidentiary grounding. Do not assign an empirical-study appraisal score to these sources.

Appendix C: Preliminary Conceptual Structure and Construct Definitions

This is a provisional organizing framework based on the advisor’s planning guide. It will be evaluated and revised after the critical synthesis; the arrows below do not represent demonstrated causal effects.

Candidate propositions for evaluation: (1) usability/usefulness and adherence; (2) monitoring burden and adherence; (3) recovery context as a possible moderator; (4) adherence and useful awareness; (5) monitoring and unwanted vigilance; and (6) the role of system features beyond modality. Each will be retained, revised, or rejected according to the evidence.

Appendix D: Preliminary Five-Source Evidence Matrix

This preliminary matrix uses five sources already cited in the proposal. It records initial observations rather than a completed search or quality appraisal. The fifth source provides indirect evidence from another health context; it does not claim to measure concussion adherence.

Source classification note: The matrix includes three concussion-specific empirical studies and two indirect empirical studies. These are illustrative sources, not the final included sample; no appraisal judgments are assigned here.

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