Consensus statement on concussion in sport--the 4th International Conference on Concussion in Sport held in Zurich, November 2012

Sport-related concussive convulsions: a systematic review

OBJECTIVES

The incidence of sport-related concussion (SRC) continues to rise. Presentations of concussed athletes vary from subtle symptoms to notable signs. Between the 4th and 5th iterations of the Concussion in Sport Group (CISG) guidelines, concussive convulsions were removed as a modifying factor, but little evidence or discussion supported this change. While considerable research exists regarding post-traumatic epilepsy in moderate to severe traumatic brain injury, convulsions following SRC are relatively understudied. There is no clear consensus on the prevalence of convulsions, seizures, or the management of these entities following SRC. The aim of this review was to assess the state of the literature, describe the management trends of concussive convulsions and post-traumatic epilepsy in the SRC population, and provide evidence and guidance for the management of these athletes.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adapted for a review of heterogeneous literature. English-language titles and abstracts published prior to June 2017 were searched systematically across four electronic databases. Primary peer-reviewed journal articles were included if they reported individuals of any age or gender who suffered a concussion or mild traumatic brain injury that was associated with seizure activity during a sports/recreational event.

RESULTS

Of 852 records screened for review, 58 full-text articles were assessed for eligibility. Eight studies with 130 athletes total met the inclusion criteria. Of these individuals suffering a SRC convulsion or a post-concussive seizure, 0.8% received antiepileptic medications, 24.6% underwent electroencephalography, and 30.8% underwent brain imaging. The mean time until the participant returned to play was 14.8 days. Only 6.9% developed long-term sequelae over a mean follow-up time of 3.3 years.

CONCLUSIONS

The current literature describing concussive convulsions and post-concussion seizure in sports is limited. A void of primary literature concerning the management of patients with concussive convulsions or seizures and the long-term sequelae among this population remains. However, the evidence available suggests that concussive convulsions do not need to be a primary modifying factor in the management of SRC.

Assessing the effects of concussion using the C3Logix Test Battery: An exploratory study

The C3Logix is a computerized concussion assessment tool that measures a wider array of symptoms (i.e., balance and oculomotor functioning) than other computerized batteries. Although the C3Logix has been used increasingly by athletic organizations at all levels of play, its utility within the concussion population has not been extensively examined. The current study aimed to determine whether the C3Logix is sensitive to the effects of concussion. A total of 54 student-athletes enrolled at a large southern university completed the C3Logix at baseline and within days following a suspected concussion (mean = 2.93, SD = 3.14). Dependent-samples t-tests revealed that relative to their baselines, following concussion, athletes both reported significantly greater postconcussive symptoms and performed more poorly on measures of reaction time and computer-measured balance. Decrements in processing speed, visual acuity, and clinician-observed errors on tests of balance also trended toward significance. Results suggest that inclusion of measures of balance and oculomotor functioning in the assessment of concussion may provide additional clinical utility above and beyond domains typically measured by computerized concussion assessments.

Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial

OBJECTIVE

To evaluate (1) systematic assessment of exercise tolerance in adolescents shortly after sport-related concussion (SRC) and (2) the prognostic utility of such assessment.

DESIGN

Prospective randomized controlled trial.

SETTING

University and community sports medicine centers.

PARTICIPANTS

Adolescents with SRC (1-9 days from injury). Sixty-five were randomized and 54 completed the study (mean age 15 years, 4 days after injury).

INTERVENTIONS

Buffalo Concussion Treadmill Test (BCTT, n = 27) or not (controls, n = 27) on visit day #1. Heart rate threshold (HRt) at symptom exacerbation represented level of exercise tolerance. Participants reported symptoms daily for 14 days and then had follow-up BCTT (n = 54). Recovery was defined as returning to normal level of symptoms and exercise tolerance, verified by independent physician examination.

MAIN OUTCOME MEASURES

Days to recovery and typical (≤21 days) versus prolonged recovery (>21 days). Mixed effects linear models and linear regression techniques examined symptom reports and time to recovery. Linear regression assessed the association of HRt with recovery time.

RESULTS

Days to recovery (P = 0.7060) and typical versus prolonged recovery (P = 0.1195) were not significantly different between groups. Symptom severity scores decreased in both groups over 14 days (P < 0.0001), were similar (P = 0.2984), and did not significantly increase the day after the BCTT (P = 0.1960). Lower HRt on visit day #1 was strongly associated with prolonged recovery time (P = 0.0032).

CONCLUSIONS

Systematic evaluation of exercise tolerance using the BCTT within 1 week after SRC did not affect recovery. The degree of early exercise intolerance after SRC was important for prognosis. This has implications for school academic and team preparation.

Why Professional Football Players Chose Not to Reveal Their Concussion Symptoms During a Practice or Game

OBJECTIVE

To determine why professional football players in Canada decided not to seek medical attention during a game or practice when they believed they had suffered a concussion.

DESIGN

Retrospective survey.

SETTING

Preseason Canadian Football League training camps.

PARTICIPANTS

Four hundred fifty-four male professional football players.

MAIN OUTCOME MEASURES

Reasons athletes did not seek medical attention for a presumed concussion during the previous season, how often this occurred and how important these reasons were in the decision process.

RESULTS

One hundred six of the 454 respondents (23.4%) believed they had suffered a concussion during their previous football season and 87 of the 106 (82.1%) did not seek medical attention for a concussion at least once during that season. The response "Did not feel the concussion was serious/severe and felt you could still continue to play with little danger to yourself" was the most commonly listed reason (49/106) for not seeking medical attention for a presumed concussion. Many players answered that they did not seek medical attention because they did not want to be removed from a game (42/106) and/or they did not want to risk missing future games (41/106) by being diagnosed with a concussion.

CONCLUSIONS

Some professional football players who believed they had suffered a concussion chose not to seek medical attention at the time of injury. Players seemed educated about the concussion evaluation process and possible treatment guidelines, but this knowledge did not necessarily translate into safe and appropriate behavior at the time of injury.

Online postconcussion return-to-play instructions

OBJECTIVE The authors of recent concussion guidelines have sought to form a consensus on injury management, but it is unclear if they have been effective in conveying this information to the public. Many parents and athletes obtain medical recommendations via the Internet. This review is aimed at evaluating consistency between online resources and published guideline statements in postconcussion return-to-play (RTP) decisions. METHODS Five websites were selected through a Google search for RTP after concussion, including a federal government institution (Centers for Disease Control and Prevention) website, a national high school association (National Federation of State High School Associations) website, a popular nationally recognized medical website for patients (WebMD), a popular parent-driven website for parents of children who participate in sports (MomsTeam), and the website of a private concussion clinic (Sports Concussion Institute), along with a university hospital website (University of Michigan Medicine). Eight specific items from the Zurich Sport Concussion Consensus Statement 2012 were used as the gold standard for RTP recommendations. Three independent reviewers graded each website for each of the 8 recommendations (A = states guideline recommendations appropriately; B = mentions guideline recommendation; C = does not mention guideline recommendation; F = makes inappropriate recommendation). RESULTS A grade of A was assigned for 45.8% of the recommendations, B for 25.0%, C for 25.0%, and F for 4.2%. All the websites were assigned an A grade for the recommendation of no RTP on the day of injury. Only 1 website (WebMD) mentioned medication usage in conjunction with the Zurich statement, and only 2 websites (Sports Concussion Institute and University of Michigan Medicine) mentioned appropriate management of persistent symptoms. None of these websites commented correctly on all 8 guideline recommendations. CONCLUSIONS Online resources are inconsistent in relaying guideline recommendations for RTP and provide a potential source of confusion in the management of concussion for athletes and their parents, which can result in inappropriate RTP decisions.

Lived Experiences of Adolescent Athletes Following Sport-Related Concussion

Background:

Previous studies have identified the effect of sport-related concussion on health-related quality of life through the use of patient-reported outcome measures. However, there has been little research exploring the underlying mechanisms that influence these perceptions of health-related quality of life among adolescent athletes who have sustained a sport-related concussion.

Purpose:

To explore the psychosocial aspects of concussion among adolescent athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 12 interscholastic athletes (4 girls, 8 boys; mean ± SD age, 15.7 ± 1.7 years; grade level, 10.2 ± 1.4) were interviewed via a semistructured interview protocol between 15 and 30 days postinjury. Data analysis was guided by the consensual qualitative research tradition. Themes and categories emerged through consensus by a 3-person research team, and bias was minimized through the use of multiple-analyst triangulation.

Results:

Participants identified numerous postconcussion symptoms that resulted in increasing difficulty with emotions (eg, irritable, easily frustrated), roles at school (eg, concentration difficulties, fatigue), and roles in their social environment (eg, letting the team down, not being able to contribute to sport). As a result, participants expressed how they tried to minimize or mask symptoms to decrease the potential of being viewed differently by their peers.

Conclusion:

Adolescent athletes perceived a significant effect of sport-related concussion on numerous areas of psychosocial and emotional health and well-being. Anticipatory guidance—with education regarding the possible signs and symptoms, risk factors, and recovery expectations following a concussion—is important to include in postinjury management. A better understanding of sport-related concussion and expected recovery could help to improve perceptions of this injury among interscholastic athletes. Additionally, best practices should be identified to assist health care professionals and school personnel in the development of temporary adjustments or formal academic adjustment policies in the secondary school setting, therefore ensuring that the patients receive the support that they need to maintain their roles as students.

GAIT DEFICITS UNDER DUAL - TASK CONDITIONS IN THE CONCUSSED ADOLESCENT AND YOUNG ATHLETE POPULATION: A SYSTEMATIC REVIEW

BACKGROUND

There are no current sport concussion assessments that capture the effects of dual-task conditions on gait. Multiple studies have evaluated changes, but none have comprehensively examined literature related to the adolescent and young adult population.Purpose: The purpose of this systematic review is to synthesize documented changes in gait under dual-task conditions in adolescents and young adults after sustaining a concussion.Study Design: Systematic Review.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was consulted to guide this systematic review. Six databases were searched: Cinahl, ProQuest, PubMed, Scopus, SPORTdiscus, and Web of Science. Concussion, gait, and dual-task, along with their synonymous terms were the search terms used. Inclusion criteria consisted of adolescent and young adult age groups, acute concussion, dual-tasking, and matched controls. Quality assessment was performed using The Joanna Briggs Institute Critical Appraisal Checklist for Case Control Studies.

RESULTS

Ten full-text articles were selected for inclusion. Concussed individuals demonstrated longer stride times with shorter stride lengths, increased mediolateral displacement with corresponding increases in sagittal and frontal plane peak velocity, and decreased sagittal plane Center of Mass (COM) and Center of Pressure (COP) displacement. The majority of included studies demonstrated moderate to large effect sizes in these gait characteristics.

CONCLUSION

Concussed individuals demonstrated decreased gait stability while ambulating with a dual-task condition. Though statistically significant differences between concussed individuals and matched controls lasted only 72 hours, concussed individuals demonstrated continued improvements in gait for up to two months post-injury, which has the potential to affect an athlete's ability to perform. Further research is needed to determine if a gait examination with a dual-task condition is a realistic, reliable, and valid measure to be included in return to sport testing.

LEVEL OF EVIDENCE

2a.

Sleep Disturbance Following Concussion Is a Risk Factor for a Prolonged Recovery

Sleep disturbance is a common problem following concussion. A retrospective chart review was conducted at a regional concussion clinic on patients 13 to 18 years of age between 2005 and 2011. Statistical analysis evaluated sleep disturbance and duration of concussion, as well as the use and effectiveness of melatonin. A total of 417 patients met inclusion criteria. One hundred twenty-three (34%) reported disturbance in sleep. There was no difference in sleep disturbance based on age, gender, or past number of concussions. Sleep disturbance was associated with a 3- to 4-fold increase in recovery time. Non-sport-related concussions were more likely to be associated with sleep disturbance compared to sport-related concussions (45% vs 29%, P = .01). Melatonin improved sleep disturbance in 67% of the patients. Evaluating sleep disorders following concussion is an important part of the assessment. These findings will help clinicians provide anticipatory guidance and treatment for adolescents recovering from concussion.

Acute Clinical Predictors of Symptom Recovery in Emergency Department Patients with Uncomplicated Mild Traumatic Brain Injury or Non-Traumatic Brain Injuries

There is a subset of patients with mild traumatic brain injury (mTBI) who report persistent symptoms that impair their functioning and quality of life. Being able to predict which patients will experience prolonged symptom recovery would help clinicians target resources for clinical follow-up to those most in need, and would facilitate research to develop precision medicine treatments for mTBI. The purpose of this study was to investigate the predictors of symptom recovery in a prospective sample of emergency department trauma patients with either mTBI or non-mTBI injuries. Subjects were examined at several time points from within 72 h to 45 days post-injury. We quantified and compared the value of a variety of demographic, injury, and clinical assessment (symptom, neurocognitive) variables for predicting self-reported symptom duration in both mTBI (n = 89) and trauma control (n = 73) patients. Several injury-related and neuropsychological variables assessed acutely (< 72 h) post-injury predicted symptom duration, particularly loss of consciousness (mTBI group), acute somatic symptom burden (both groups), and acute reaction time (both groups), with reasonably good model fit when including all of these variables (area under the receiver operating characteristic curve [AUC] = 0.76). Incorporating self-reported litigation involvement modestly increased prediction further (AUC = 0.80). The results highlight the multifactorial nature of mTBI recovery, and injury recovery more generally, and the need to incorporate a variety of variables to achieve adequate prediction. Further research to improve this model and validate it in new and more diverse trauma samples will be useful to build a neurobiopsychosocial model of recovery that informs treatment development.

Academic outcomes and accommodations following adolescent sport-related concussion: a pilot study

Aim:

The purpose of this study was to examine academic achievement, absenteeism and school accommodations following adolescent sport-related concussion (SRC).

Methods:

A case-series was conducted among grade 8–12 students who suffered an SRC. The primary outcomes were change in pre- and post-concussion overall, core report card grade point average (GPA) and absenteeism due to concussion. The most helpful school accommodations were tabulated.

Results:

Pre- and post-concussion GPA was obtained from 33 students – 16 (48%) developed persistent post-concussion symptoms (symptoms lasting >4 weeks). There was no significant difference in pre- and post-concussion grades among students with a SRC for overall (p = 0.75) or core (p = 0.56) GPA. The median number of missed school days was 4 (interquartile range [IQR]: 2–8). Allowing for physical and cognitive rest was identified as the most helpful accommodation (30%).

Conclusion:

Larger studies should investigate the role that school accommodations and development of persistent post-concussion symptoms have on academic outcomes.

Normative Values of the Sport Concussion Assessment Tool 3 (SCAT3) in High School Athletes

OBJECTIVE

Establish sex, age, and concussion history-specific normative baseline sport concussion assessment tool 3 (SCAT3) values in adolescent athletes.

DESIGN

Prospective cohort.

SETTING

Seven Wisconsin high schools.

PARTICIPANTS

Seven hundred fifty-eight high school athletes participating in 19 sports.

INDEPENDENT VARIABLES

Sex, age, and concussion history.

MAIN OUTCOME MEASURES

Sport Concussion Assessment Tool 3 (SCAT3): total number of symptoms; symptom severity; total Standardized Assessment of Concussion (SAC); and each SAC component (orientation, immediate memory, concentration, delayed recall); Balance Error Scoring System (BESS) total errors (BESS, floor and foam pad).

RESULTS

Males reported a higher total number of symptoms [median (interquartile range): 0 (0-2) vs 0 (0-1), P = 0.001] and severity of symptoms [0 (0-3) vs 0 (0-2), P = 0.001] and a lower mean (SD) total SAC [26.0 (2.3) vs 26.4 (2.0), P = 0.026], and orientation [5 (4-5) vs 5 (5-5), P = 0.021]. There was no difference in baseline scores between sex for immediate memory, concentration, delayed recall or BESS total errors. No differences were found for any test domain based on age. Previously, concussed athletes reported a higher total number of symptoms [1 (0-4) vs 0 (0-2), P = 0.001] and symptom severity [2 (0-5) vs 0 (0-2), P = 0.001]. BESS total scores did not differ by concussion history.

CONCLUSION

This study represents the first published normative baseline SCAT3 values in high school athletes. Results varied by sex and history of previous concussion but not by age. The normative baseline values generated from this study will help clinicians better evaluate and interpret SCAT3 results of concussed adolescent athletes.

Comparison of Psychological Response between Concussion and Musculoskeletal Injury in Collegiate Athletes

The psychological response to musculoskeletal injuries has been well documented, however, research on the psychological response to concussion is limited. The Profile of Mood States (POMS) and the State-Trait Anxiety Inventory (STAI) have recently been used to assess the psychological recovery of concussions. Although some studies indicate that psychological response is different for musculoskeletal injuries and concussion, there is currently not enough information to indicate this difference occurs at specific clinical milestones. The purpose of this study was to compare the psychological responses of student-athletes who have been diagnosed with a concussion to those of athletes diagnosed with musculoskeletal injuries with similar recovery duration. Fifteen collegiate athletes who sustained a musculoskeletal injury were recruited and matched with 15 previously collected concussion participants. The main outcome measures were the scores of POMS constructs: tension-anxiety, anger-hostility, fatigue-inertia, depression-dejection, vigor-activity, confusion-bewilderment, and total mood disturbance and STAI (state anxiety only). Two-way MANOVAs was run to determine the effects of group and time on POMS and STAI constructs. There were no significant interactions identified, but follow-up ANOVAs identified a main effect for time for most POMS subscales, with POMS scores improving over time in both groups. Analyses also revealed that tension-anxiety, vigor-activity and the STAI were not affected by time or group. The findings of this study, that both groups' psychological response to injury improves over time and at similar clinical milestones suggests reduction in sports and team related activities may play a substantial role in the psychological response to either concussion or musculoskeletal injury.

Symptom-Guided Emergency Department Discharge Instructions for Children With Concussion

OBJECTIVES

The objective was to evaluate the use and utility of a novel set of emergency department discharge instructions (DIs) for concussion based on a child's ongoing symptoms: symptom-guided DIs (symptom DIs). Differences in clinical outcomes were also assessed.

METHODS

A convenience sample of 114 children aged 7 to 17 years presenting to an urban pediatric emergency department with a complaint of concussion was assembled. Children were randomized to standard DIs or symptom DIs. Children completed a graded symptom checklist (GSC) and completed daily the GSC for 1 week. Telephone follow-up was performed at 7 days after enrollment using a standardized survey.

RESULTS

Fifty-eight children received the symptom DIs, and 56 received the standard DIs. Rates of use were similar with reported rates of 92% for symptom DIs and 84% for standard DIs. Caregivers with symptom DIs reported that the DIs were more helpful in determining when their child could return to school and physical activity (P < 0.05) than caregivers with standard DIs. Children continued to have postconcussive symptoms days and weeks after their injury with 44% of children with symptom DIs and 51% of children with standard DIs reporting symptoms on the GSC at 1 week.

CONCLUSIONS

Both study groups reported frequent use of the DIs. Caregivers with symptom DIs found them particularly helpful in determining when their child could return to school and physical activity. Larger-scale investigations are needed to further develop instructions that are easy to use and that may decrease the postconcussive period.

Decreased Anticipatory Postural Adjustments During Gait Initiation Acutely Postconcussion

OBJECTIVE

To investigate anticipatory postural adjustments (APAs) during the transitional movement task of gait initiation (GI) in individuals acutely after a concussion.

DESIGN

Cohort study.

SETTING

University research center.

PARTICIPANTS

A population-based sample of participants (N=84) divided into 2 equal groups of acutely postconcussion and healthy student athletes.

INTERVENTION

Participants were tested on 2 occasions: a preinjury baseline test and then the concussion group was retested acutely postconcussion and the healthy student athlete group again at a similar time. All participants completed 5 trials of GI on 4 forceplates.

MAIN OUTCOME MEASURES

The dependent variables were the displacement and velocity of the center of pressure (COP) during the APA phase and initial step kinematics. Comparisons were made with a 2 (group) × 2 (time) repeated-measures analysis of variance.

RESULTS

There was a significant interaction for COP posterior displacement (P<.001) and lateral displacement (P<.001). Posteriorly, post hoc testing identified a significant reduction in the concussion group (pretest: 5.7±1.6cm; posttest: 2.6±2.1cm; P<.001), but no difference in the healthy student athlete group (pretest: 4.0±1.6cm; posttest: 4.0±2.5cm; P=.921). Laterally, post hoc testing identified a significant reduction in the concussion group (pretest: 5.8±2.1cm; posttest: 3.8±1.8cm; P<.001), but no difference in the healthy student athlete group (pretest: 5.0±2.5cm; posttest: 5.2±2.4cm; P=.485).

CONCLUSIONS

The results of this study suggest difficulty in the planning and execution of GI acutely postconcussion, and posterior APA displacement and velocity are highly effective measures of impaired postural control. Finally, the APA phase is linked to the supplementary motor area, which suggests a supraspinal contribution to postconcussion impaired postural control.

A Physiological Approach to Prolonged Recovery From Sport-Related Concussion

Management of the athlete with postconcussion syndrome (PCS) is challenging because of the nonspecificity of PCS symptoms. Ongoing symptoms reflect prolonged concussion pathophysiology or conditions such as migraine headaches, depression or anxiety, chronic pain, cervical injury, visual dysfunction, vestibular dysfunction, or some combination of these. In this paper, we focus on the physiological signs of concussion to help narrow the differential diagnosis of PCS in athletes. The physiological effects of exercise on concussion are especially important for athletes. Some athletes with PCS have exercise intolerance that may result from altered control of cerebral blood flow. Systematic evaluation of exercise tolerance combined with a physical examination of the neurologic, visual, cervical, and vestibular systems can in many cases identify one or more treatable postconcussion disorders.

Head-Impact-Measurement Devices: A Systematic Review

CONTEXT

With an estimated 3.8 million sport- and recreation-related concussions occurring annually, targeted prevention and diagnostic methods are needed. Biomechanical analysis of head impacts may provide quantitative information that can inform both prevention and diagnostic strategies.

OBJECTIVE

To assess available head-impact devices and their clinical utility.

DATA SOURCES

We performed a systematic search of the electronic database PubMed for peer-reviewed publications, using the following phrases: accelerometer and concussion, head impact telemetry, head impacts and concussion and sensor, head impacts and sensor, impact sensor and concussion, linear acceleration and concussion, rotational acceleration and concussion, and xpatch concussion. In addition to the literature review, a Google search for head impact monitor and concussion monitor yielded 15 more devices.

STUDY SELECTION

Included studies were performed in vivo, used commercially available devices, and focused on sport-related concussion.

DATA EXTRACTION

One author reviewed the title and abstract of each study for inclusion and exclusion criteria and then reviewed each full-text article to confirm inclusion criteria. Controversial articles were reviewed by all authors to reach consensus.

DATA SYNTHESIS

In total, 61 peer-reviewed articles involving 4 head-impact devices were included. Participants in boxing, football, ice hockey, soccer, or snow sports ranged in age from 6 to 24 years; 18% (n = 11) of the studies included female athletes. The Head Impact Telemetry System was the most widely used device (n = 53). Fourteen additional commercially available devices were presented.

CONCLUSIONS

Measurements collected by impact monitors provided real-time data to estimate player exposure but did not have the requisite sensitivity to concussion. Proper interpretation of previously reported head-impact kinematics across age, sport, and position may inform future research and enable staff clinicians working on the sidelines to monitor athletes. However, head-impact-monitoring systems have limited clinical utility due to error rates, designs, and low specificity in predicting concussive injury.

Rest and Return to Activity After Sport-Related Concussion: A Systematic Review of the Literature

OBJECTIVE

To systematically review the literature regarding rest and return to activity after sport-related concussion.

DATA SOURCES

The search was conducted in the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, physical and cognitive rest, and return to activity.

STUDY SELECTION

Studies were included if they were published in English; were original research; and evaluated the use of, compliance with, or effectiveness of physical or cognitive rest or provided empirical evidence supporting the graded return-to-activity progression.

DATA EXTRACTION

The study design, patient or participant sample, interventions used, outcome measures, main results, and conclusions were extracted, as appropriate, from each article.

DATA SYNTHESIS

Articles were categorized into groups based on their ability to address one of the primary clinical questions of interest: use of rest, rest effectiveness, compliance with recommendations, or outcome after graded return-to-activity progression. A qualitative synthesis of the results was provided, along with summary tables.

CONCLUSIONS

Our main findings suggest that rest is underused by health care providers, recommendations for rest are broad and not specific to individual patients, an initial period of moderate physical and cognitive rest (eg, limited physical activity and light mental activity) may improve outcomes during the acute postinjury phase, significant variability in the use of assessment tools and compliance with recommended return-to-activity guidelines exists, and additional research is needed to empirically evaluate the effectiveness of graded return-to-activity progressions. Furthermore, there is a significant need to translate knowledge of best practices in concussion management to primary care providers.

Neuropsychological Screening of Sport-Related Concussion

Neuropsychological assessment is a key component of the multidimensional approach recommended by international consensus guidelines for evaluation of athletes affected by sport-related concussion (SRC). Over the past 2 decades, a number of conventional and computerized neuropsychological test batteries have been developed for the assessment of SRC. Standardized neurocognitive assessment tools are now commonly used across the continuum of concussion care, ranging from the sports sideline to critical care setting and the outpatient concussion clinic. We provide a brief, high-level overview of current approaches to best practice in neuropsychological assessment of SRC.

Postconcussion Symptoms as a Marker of Delayed Recovery in Children and Youth Who Recently Sustained a Concussion: A Brief Report

OBJECTIVE

To identify predictors of delayed recovery in children who sustained a concussion and sought care in a pediatric hospital.

DESIGN

Retrospective cohort study design.

SETTING

Montreal Children's Hospital Concussion Clinic database.

PATIENTS

Children who sustained a concussion and sought care within 10 days of the injury, with complete medical history and Postconcussion Symptom Scale (PCSS) score available.

INDEPENDENT VARIABLES

Total symptom score on the PCSS, sex, age, history of concussion, sleep disturbances, anxiety, learning disabilities, attention problems, and depression.

MAIN OUTCOME MEASURE

Delayed recovery (28 days or more).

RESULTS

A total of 213 children (F = 76, M = 138) with a mean age of 13.89 ± 2.55 years were included. Only total PCSS score at 10 days postinjury was identified as a significant predictor of delayed recovery (odds ratio: 1.019, P = 0.01).

CONCLUSIONS

This study demonstrates the potential for clinicians to identify, with the sole use of the PCSS, children at risk of experiencing symptoms for longer periods of time.

Concussion Management Plan Compliance: A Study of NCAA Power 5 Conference Schools

Background:

In response to concerns over concussions and repeated head impacts that occur during sports, the National Collegiate Athletic Association (NCAA) mandated that all member institutions enact a concussion management plan (CMP). Although institutional and health care provider self-reports have been investigated, compliance with NCAA protocol recommendations has not been examined.

Purpose:

To examine the CMPs from the 65 institutions within the NCAA Power 5 conferences for compliance with the NCAA 2015 concussion guidelines.

Study Design:

Descriptive epidemiology study.

Methods:

Each institution’s publicly available CMP was obtained in 2015, reviewed, and coded for compliance with each of the required 47 components. Overall compliance rate, item-level, category-level, and institution-level compliance was assessed. Independent predictors of compliance, including each institution’s athletic training staff size, academic performance, and athletic performance, were examined with quasi-binomial regression.

Results:

CMPs varied substantially in length and level of detail. The overall compliance rate for all components across all institutions was 94.3% (2880/3055). Twelve components achieved 100% (65/65) compliance, and the lowest levels of compliance were clustered in “return to learn.” There were 22 institutions that achieved a 100% compliance rate; the lowest institutional compliance was 59.6%. There were no significant associations between the independent predictors and institutional compliance.

Conclusion:

Overall compliance with NCAA concussion management requirements was high, but there remains room for improvement. The lowest level of compliance was clustered in the return-to-learn section. There were limited details provided in the reducing head trauma component. Items with lower compliance (reducing head trauma, return to learn) tended to be outside the core competencies of the medical staff, indicating an area for improvement. Encouragingly, many institutions and specific components demonstrated full compliance.

Trends in self-reported traumatic brain injury among Canadians, 2005-2014: a repeated cross-sectional analysis

Background:

Concussion and other traumatic brain injuries (TBIs) are a form of unintentional injury that has been associated with both short- and long-term health effects, including possible disability. We investigated time trends in the incidence of all types of injury and TBIs among Canadians, and assessed characteristics of TBIs.

Methods:

We used data from annual cycles of the Canadian Community Health Survey, 2005 to 2014, to examine all types of injury and TBI among Canadians aged 12 years or more. We estimated TBI incidence among respondents who reported any type of injury in the previous year. We used descriptive methods to describe key characteristics (sex, age, season, activity and venue) and 5- and 10-year trends, and generalized linear models to estimate annual percent change in the incidence of all types of injury and TBI.

Results:

The incidence of all types of injury and of TBIs increased between 2005 and 2014, with an annual percent change of 1.4 (95% confidence interval [CI] 0.9-1.9) and 9.6 (95% CI 8.2-11.0), respectively. Sport venues (39.9% [95% CI 32.7-47.1)] and sports-related activities (49.7% [95% CI 42.4-57.0]) were commonly associated with TBIs, and falls were the most frequent mechanism of injury (53.9% [95% CI 46.7-61.0]) leading to a TBI.

Interpretation:

Our findings highlight the increasing trends in all types of injury and TBIs in Canada, and underscore the need for ongoing population level surveillance and targeted prevention efforts to mitigate risk.

A Retrospective Cross-Sectional and Longitudinal Study of the Effects of Age on CNS Vital Signs Scores in High-School Athletes

INTRODUCTION

Current recommendations for concussion management acknowledge the importance of objective assessments of neuropsychological (NP) ability, and computerized NP assessments have been widely integrated into the concussion management protocols of high schools. The optimal intervals for baseline test administration in high-school athletes are currently uncertain. The ability to accurately detect subtle NP deficits is particularly important for high-school athletes, in which concussions are increasingly recognized for adverse effects to the developing brain.

PURPOSE

The aim of this study was to assess the pattern of change in neurocognitive test performance, as well as changes in different domains of NP functioning over time.

METHODS

Baseline computerized NP assessments were conducted at six high schools over 4 academic years using CNS Vital Signs, a battery consisting of seven well-established NP tests. Data were retrospectively examined for age differences in both cross-sectional (n = 3015) and longitudinal (n = 1221) analyses.

RESULTS

Moderate changes were observed across several NP domains over time (Cohen's d = 0.39-0.61), with the largest improvements observed in executive functioning (mean improvement 5.78, 95% confidence interval [CI] 5.41-6.14, p < 0.001), psychomotor speed (mean improvement 4.59, 95% CI 3.97-5.22, p < 0.001), cognitive flexibility (mean improvement 5.11, 95% CI 4.76-5.45, p < 0.001), and reaction time (mean improvement -12.44 ms, 95% CI -10.10 to -14.78, p < 0.001). Improvements in NP performance were most pronounced between the freshman and senior years.

CONCLUSIONS

There is an appreciable change that occurs each year of high school in one or more domains of an NP battery, with executive functioning indicating the greatest magnitude of change. Females performed better relative to males across all time points though males exhibited more substantial improvement over time.

Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial

The purpose of this study was to (a) assess the feasibility of recruitment/retention of participants, protocol/resource management, and participant safety, and (b) estimate the size of the effect between the experimental and control groups. This was a feasibility study conducted as a prospective pilot double-blind randomized clinical trial. Subjects aged 10-23 years old with acute concussion and dizziness were enrolled from sports medicine centers. Forty-one participants were randomized into treatment and were seen for physical therapy beginning at 10 days post-concussion. Subjects in the experimental group received individually tailored, pragmatically delivered progressive interventions. Subjects in the control received prescriptive sham to minimally progressive interventions. The two primary outcomes were medical clearance for return-to-play and symptomatic recovery. The median number of days to medical clearance for the experimental group was 15.5 and for the control was 26. The median number of days to symptomatic recovery was 13.5 for the experimental group and was 17 for the control. According to Cox proportional hazards regression for time to medical release for return-to-play, the experimental group demonstrated a hazard ratio of 2.91 (95% CI: 1.01, 8.43) compared to the control. For time-to-symptomatic recovery, those in the experimental group demonstrated a hazard ratio of 1.99 (95% CI: 0.95, 4.15) compared to the control. The results indicate that it is feasible and safe to complete this type of intervention study. The results provide strong support for the allocation of resources to conduct well-powered randomized clinical trials of this intervention.

Youth Football Injuries: A Prospective Cohort

Background:

There are approximately 2.8 million youth football players between the ages of 7 and 14 years in the United States. Rates of injury in this population are poorly described. Recent studies have reported injury rates between 2.3% and 30.4% per season and between 8.5 and 43 per 1000 exposures.

Hypothesis:

Youth flag football has a lower injury rate than youth tackle football. The concussion rates in flag football are lower than in tackle football.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Three large youth (grades 2-7) football leagues with a total of 3794 players were enrolled. Research personnel partnered with the leagues to provide electronic attendance and injury reporting systems. Researchers had access to deidentified player data and injury information. Injury rates for both the tackle and flag leagues were calculated and compared using Poisson regression with a log link. The probability an injury was severe and an injury resulted in a concussion were modeled using logistic regression. For these 2 responses, best subset model selection was performed, and the model with the minimum Akaike information criterion value was chosen as best. Kaplan-Meier curves were examined to compare time loss due to injury for various subgroups of the population. Finally, time loss was modeled using Cox proportional hazards regression models.

Results:

A total of 46,416 exposures and 128 injuries were reported. The mean age at injury was 10.64 years. The hazard ratio for tackle football (compared with flag football) was 0.45 (95% CI, 0.25-0.80; P = .0065). The rate of severe injuries per exposure for tackle football was 1.1 (95% CI, 0.33-3.4; P = .93) times that of the flag league. The rate for concussions in tackle football per exposure was 0.51 (95% CI, 0.16-1.7; P = .27) times that of the flag league.

Conclusion:

Injury is more likely to occur in youth flag football than in youth tackle football. Severe injuries and concussions were not significantly different between leagues. Concussion was more likely to occur during games than during practice. Players in the sixth or seventh grade were more likely to suffer a concussion than were younger players.

Uncoupling between cerebral perfusion and oxygenation during incremental exercise in an athlete with postconcussion syndrome: a case report

High-intensity exercise may pose a risk to patients with postconcussion syndrome (PCS) when symptomatic during exertion. The case of a paralympic athlete with PCS who experienced a succession of convulsion-awakening periods and reported a marked increase in postconcussion symptoms after undergoing a graded symptom-limited aerobic exercise protocol is presented. Potential mechanisms of cerebrovascular function failure are then discussed.

School Nurses on the Front Lines of Medicine

Head trauma is a common chief complaint encountered by school nurses. This article describes the initial assessment and management of head trauma in children and adolescents, delineates reasons that may prompt the school nurse to transfer a student to a local emergency department, and discusses the role of the school nurse when a student is diagnosed with a concussion.

Efficiency of an Active Rehabilitation Intervention in a Slow-to-Recover Paediatric Population following Mild Traumatic Brain Injury: A Pilot Study

Objective. The aim of this study was to identify whether the addition of an individualised Active Rehabilitation Intervention to standard care influences recovery of young patients who are slow-to-recover following a mTBI. Methods. Fifteen participants aged 15 ± 2 years received standard care and an individualised Active Rehabilitation Intervention which included (1) low- to high-intensity aerobic training; (2) sport-specific coordination exercises; and (3) therapeutic balance exercises. The following criteria were used to measure the resolution of signs and symptoms of mTBI: (1) absence of postconcussion symptoms for more than 7 consecutive days; (2) cognitive function corresponding to normative data; and (3) absence of deficits in coordination and balance. Results. The Active Rehabilitation Intervention lasted 49 ± 17 days. The duration of the intervention was correlated with self-reported participation ([Formula: see text]%, r = -0.792, p < 0.001). The average postconcussion symptom inventory (PCSI) score went from a total of 36.85 ± 23.21 points to 4.31 ± 5.04 points after the intervention (Z = -3.18, p = 0.001). Conclusion. A progressive submaximal Active Rehabilitation Intervention may represent an important asset in the recovery of young patients who are slow-to-recover following a mTBI.

The financial toll of career-ending concussions in professional hockey

AIM

Several high-profile professional hockey players have retired due to career-ending concussions sustained in the National Hockey League (NHL). We sought to determine the salary cost of career-ending concussions in the NHL.

METHODS

Concussion-induced retirements from 1995 to 2015 were identified using public media sources. The number of missed games due to a player's final concussion was multiplied by per game salary to determine cost.

RESULTS

In total, 35 players were identified: the total cost to teams and insurers of career-ending concussions was US$135,476,777. Half of the total consisted of salaries owing three players with contracts still active in 2015.

CONCLUSION

The financial impact of concussion-induced retirements provides another reason for professional leagues to take measures to better protect their players from concussion.

A Preliminary Study of the Effectiveness of an Allostatic, Closed-Loop, Acoustic Stimulation Neurotechnology in the Treatment of Athletes with Persisting Post-concussion Symptoms

BACKGROUND

Effective interventions are needed for individuals with persisting post-concussion symptoms. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is an allostatic, closed-loop, acoustic stimulation neurotechnology, designed to facilitate relaxation and self-optimization of neural oscillations.

METHODS

Fifteen athletes (seven females, mean age 18.1 years, SD 2.6) with persisting post-concussion symptoms received 18.7 (SD 6.0) HIRREM sessions over a mean of 29.6 (SD 23.2) days, including 11.3 (SD 4.6) in office days. Pre- and post-HIRREM measures included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ, n = 12), the Insomnia Severity Index (ISI, n = 15), the Center for Epidemiologic Studies Depression Scale (CES-D, n = 10), short-term blood pressure and heart rate recordings for measures of autonomic cardiovascular regulation (n = 15), and reaction time by the drop-stick method (n = 7). All participants were asked about their physical activity level and sports participation status at their post-HIRREM data collection visit and 1 to 3 months afterward.

RESULTS

At the post-HIRREM visit, subjects reported improvements in all three inventories (RPQ mean change 19.7, SD 11.4, Wilcoxon p = 0.001; ISI mean change -4.1, SD 4.1, Wilcoxon p = 0.003; CES-D mean change -12.0, SD 10.0, Wilcoxon p = 0.004), including statistically significant reductions in 14 of the 16 individual items of the RPQ. There were also statistically significant improvements in baroreflex sensitivity, heart rate variability in the time domain (SDNN), and drop-stick reaction testing (baseline mean distance of 23.8 cm, SD 5.6, decreased to 19.8 cm, SD 4.6, Wilcoxon p = 0.016). Within 3 months of the post-HIRREM data collection, all 15 had returned to full exercise and workouts, and ten had returned to full participation in their athletic activity.

CONCLUSIONS

The use of HIRREM by a series of athletes with persisting post-concussion symptoms was associated with a range of improvements including, for the majority, return to full participation in their sport. The findings do not appear to be consistent with constituents of the placebo effect. A larger controlled trial is warranted.

Return to Drive Counseling After Sports-Related Concussion: A Quality Improvement Project

Introduction

Concussion is a common injury in adolescent athletes, many of whom also drive. Counseling athletes and their families about driving risks post concussion is a potentially significant intervention. The aim of this quality improvement project was to increase driving recommendations for concussed athletes in a pediatric sports medicine clinic.

Methods

Patients in this quality improvement project were seen in the sports medicine concussion clinic between February 2014 and August 2015. We determined how often driving recommendations were documented through a retrospective chart review. Once the "return to drive" project was introduced to the sports medicine staff, multiple interventions were completed including handing out flyers to remind families about driving and creating changes to the electronic medical record.

Results

At baseline, 9.3% of visits had driving recommendations documented. After an intervention requiring clinical documentation in the electronic medical record, 97% of patients received driving recommendations.

Conclusions

The quality improvement effort was successful at increasing the frequency of delivery of appropriate driving recommendations provided to concussed athletes.

Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment

OBJECTIVE

To examine the influence of age, sex, attention-deficit hyperactivity disorder (ADHD) status, previous history of concussion, and days since injury on postconcussion postural control assessment in adolescents who have suffered a concussion.

DESIGN

Prospective cohort study.

SETTING

Hospital-based outpatient clinic.

PARTICIPANTS

Seventy-one participants (42 males; 29 females) with mean age 14.14 ± 2.44.

INDEPENDENT VARIABLES

Age, sex, previous concussion history, ADHD status, total and severity of postconcussion symptoms, and days since injury.

MAIN OUTCOME MEASURES

Total Balance Error Scoring System score, path length, center-of-pressure (COP) area, sample entropy, and Romberg quotient.

RESULTS

Pearson product-moment correlation coefficients were calculated to test for potential associations between the continuous participant characteristics and the postural control variables. Spearman correlation was used to test the association between symptom severity and the postural control variables. Standard multiple regression was used to model the extent to which participant characteristics accounted for the variance in the postural sway variables. Age was significantly associated with all of the postural sway variables except COP area for the eyes open condition and sample entropy in the anterior-posterior direction for the eyes closed condition. Sex, ADHD status, and previous concussion history did not significantly predict postural control scores.

CONCLUSIONS

Age significantly influences scores on common postconcussion postural control assessments.

CLINICAL RELEVANCE

This study demonstrates that age is a critical factor that needs to be accounted for to improve the clinical appropriateness and utility of current postconcussion postural control assessments.

A Normative Dataset of the Balance Error Scoring System in Children Aged Between 5 and 14

OBJECTIVE

Pediatric head injuries occur commonly and are being reported in increasing numbers. Balance testing is a key component in the evaluation of suspected concussion, and the balance error scoring system (BESS) is likely the most well-known and widely used measure. To date, normative BESS scores for adults have been reported but not for children.

DESIGN

Normative data for BESS scores and modified BESS scores were created in a cohort of healthy children. Potential variables were analyzed as predictors of BESS performance.

SETTING

Local elementary and junior high schools.

PARTICIPANTS

A total of 373 healthy children between the ages of 5 and 14.

INTERVENTIONS

The BESS was performed on all children.

ASSESSMENT OF RISK FACTORS

Gender, body mass index percentile, previous concussions, athletic participation, age, and the parental opinion of child's balance ability were examined as factors associated with the BESS score.

MAIN OUTCOME MEASURES

BESS scores.

RESULTS

Normative data are reported, stratified by age groups of 5 to 7 years, 8 to 10 years, and 11 to 14 years of age, for both BESS and modified BESS. Median BESS scores are 23 for children aged 5 to 7, 18 for children aged 8 to 10, and 16 for children aged 11 to 14. Median modified BESS scores are 8 for children age 5 to 7, 5 for children age 8 to 10, and 4 for children age 11 to 14. Increasing age and positive parental opinion regarding their child's balance ability were independently correlated with decreasing BESS scores (P < 0.01).

CONCLUSIONS

The normative data on BESS scores for healthy children reported here provide age-stratified reference values for suspected balance alterations.

Academic Outcomes in High-School Students after a Concussion: A Retrospective Population-Based Analysis

BACKGROUND

Many concussion symptoms, such as headaches, vision problems, or difficulty remembering or concentrating may deleteriously affect school functioning. Our objective was to determine if academic performance was lower in the academic calendar year that students sustain a concussion compared to the previous year when they did not sustain a concussion.

METHODS

Using Manitoba Health and Manitoba Education data, we conducted a population-based, controlled before-after study from 2005-2006 to 2010-2011 academic years. Grade 9-12 students with an ICD9/10 code for concussion were matched to non-concussed controls. Overall changes in grade point average (GPA) were compared for the academic year prior to the concussion to the academic year the concussion occurred (or could have occurred among non-concussed matched students).

RESULTS

Overall, 8240 students (1709 concussed, 6531 non-concussed students) were included. Both concussed and non-concussed students exhibited a lower overall GPA from one year to the next. Having sustained a concussion resulted in a -0.90% (95% CI: -1.88, 0.08) reduction in GPA. Over the same period, non-concussed matched students' GPA reduced by -0.57% (95% CI: -1.32, 0.19). Students who sustained a concussion during high school were just as likely to graduate within four years as their non-concussed peers (ORadj: 0.84; 95% CI: 0.73, 1.02).

CONCLUSIONS

We found that, at a population level, a concussion had minimal long-term effects on academic performance during high school. While academic accommodations and Return-to-Learn programs are an important component of pediatric concussion management, research is needed to identify risk factors for poor academic performance after a concussion and who should receive these programs.

The effects of a state concussion law on the frequency of sport-related concussions as seen in two emergency departments

BACKGROUND

Connecticut (CT) passed its original sport-related concussion (SRC) law (PA 10-62) in 2010. The law requires that a health-care professional evaluate high school athletes with concussion symptoms. The purpose of this study was to evaluate two level 1 Trauma Center Emergency Department (ED) records for SRC before and after the Connecticut Public Act (CT PA) 10-62 to determine if the law had an effect on the presentation to the ED of SRCs.

METHODS

A retrospective analysis of two level 1 Trauma Center Emergency Departments database was performed. Monthly data on SRCs treated in the study EDs from July 2003 through June 2012 were collected and analyzed using the autoregressive integrated moving average model. The number of SRCs in the youth (under age 14 years), high school (age 14 to 18 years), and adult (age >18 years) populations prior to CT PA 10-62 was compared to the number of SRCs post implementation of CT PA 10-62 for each academic school year, fall sports season, and summertime.

RESULTS

Monthly SRCs in high school students treated in the study EDs increased from 2.5 cases to 5.9 cases between pre and post implementation of CT PA 10-62 (p < 0.001). Statistical modeling revealed that implementation of CT PA 10-62 was associated with significantly increased SRCs treated in the study EDs and that the increase was limited to the high school students in the fall season and during the school year.

CONCLUSIONS

There has been a marked increase in the frequency of SRCs treated in the emergency departments in the high school population in Connecticut after the implementation of the sport-related concussion law. The results suggest that the sport-related concussion law in Connecticut is effective in improving the evaluation and detection of SRCs in high school students.

Young Athletes' Concerns About Sport-Related Concussion: The Patient's Perspective

OBJECTIVE

Few studies have examined the experience and concerns of the concussed athlete. The purpose of this study was to identify the most pressing concerns of athletes with concussion.

DESIGN

Cross-sectional survey of athletes who presented for evaluation of a new sport-related concussion during an 8-month period.

SETTING

Tertiary-level sports medicine division of a large academic pediatric medical center.

PARTICIPANTS

One hundred twenty one patients (67 male, 54 female) aged 8 to 18 years who had sustained a sport-related concussion participated in the study by responding to "What is the worst thing for you about having a concussion?" on the study questionnaire. Questionnaires were completed in the clinic waiting room before the visit with a provider.

INTERVENTION

Inductive content analysis was used to identify themes in the responses to the study question.

MAIN OUTCOME MEASURES

Age, sex, sport played at the time of the current injury, history of previous concussion, known contacts with concussion, and subjective report of worst aspect of concussion.

RESULTS

Seventy respondents (57.9%) cited symptoms, and 68 (56.2%) reported loss of activity as the worst part of concussion, including 17 (14.0%) who listed both symptoms and loss of activity.

CONCLUSIONS

Over half of concussed athletes indicate that the most distressing part of the injury is loss of activities, which may result from symptoms of the injury itself and/or the prescribed treatment.

CLINICAL RELEVANCE

Health care providers should not underestimate the degree to which symptoms and loss of activities affect young athletes' general well-being. In addition to the negative impact of concussion symptoms, there is an obvious cost of physical, cognitive, and social activity restrictions for patients recovering from sport-related concussions that should be explicitly addressed.

Does Game Participation Impact Cognition and Symptoms in Elite Football Players?

OBJECTIVE

To measure neurocognitive functioning in college and professional football players after game participation.

STUDY DESIGN

Retrospective, cross-sectional cohort design.

PARTICIPANTS

Ninety-four male university and professional football players.

INTERVENTION

All participants completed Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) testing at baseline, and either at postconcussion (group 1) or postgame (group 2) participation.

MAIN OUTCOME MEASURES

Results from the 5 ImPACT composite scores (Verbal Memory, Visual Memory, Visual Motor Speed, Reaction Time and Impulse Control) and Total Symptom Score.

RESULTS

Repeated-measures analysis of variance demonstrated a significant main effect for time (improvements) in 3 of 5 domains for the postconcussion group, but no improvements in the postgame group. The postconcussion group presented with significantly improved results on 4 of 5 ImPACT domains compared with the postgame group at the follow-up time interval.

CONCLUSIONS

Participation in a football game with potential cumulative head contacts did not yield increased symptoms or cognitive impairment. However, the absence of improvement in cognitive functioning in noninjured football players, which was found in those players who were returned to play after an injury, may suggest that there is a measureable impact as a result of playing football.

Concussion Management Practice Patterns Among Sports Medicine Physicians

OBJECTIVE

The primary purpose of this study was to examine concussion management practice patterns among sports medicine physicians in the United States.

DESIGN

Cross-sectional study using a web-based survey.

PARTICIPANTS

Members of the American Medical Society for Sports Medicine (AMSSM).

MAIN OUTCOME MEASURES

We distributed a questionnaire to physician members of the AMSSM assessing the current practices for evaluating and managing concussions sustained during sports. Specifically, we asked respondents about their use of management guidelines, medications, balance assessments, neuropsychological tests, and return-to-play strategies.

RESULTS

Of the 3591 members emailed, 425 (11.8%) respondents responded. Ninety-seven percent of respondents reported basing current management of sport-related concussion on a published set of criteria, with a majority (91.9%) following the guidelines provided by the Fourth International Conference on Concussion in Sport. Seventy-six percent of respondents reported using medication beyond 48 hours postinjury. Acetaminophen was reported as the most commonly administered medication, although tricyclic antidepressants and amantadine were also commonly administered. Vitamins, minerals, and dietary supplements were also reported as commonly administered. Most respondents reported using a form of neuropsychological testing (87.1%). A majority of respondents (88.6%) reported allowing athletes to return to competition after concussion only once the athlete becomes symptom free and completes a return-to-play protocol.

CONCLUSIONS

Most sports medicine physicians seem to use recently developed guidelines for concussion management, regularly use medications and neuropsychological testing in management strategies, and follow established return-to-play guidelines.

CLINICAL RELEVANCE

Sports medicine physicians seem to have clinical expertise in the management of sport-related concussion.

Long-Term Anesthetic-Dependent Hypoactivity after Repetitive Mild Traumatic Brain Injuries in Adolescent Mice

Recent evidence supports the hypothesis that repetitive mild traumatic brain injuries (rmTBIs) culminate in neurological impairments and chronic neurodegeneration, which have wide-ranging implications for patient management and return-to-play decisions for athletes. Adolescents show a high prevalence of sports-related head injuries and may be particularly vulnerable to rmTBIs due to ongoing brain maturation. However, it remains unclear whether rmTBIs, below the threshold for acute neuronal injury or symptomology, influence long-term outcomes. To address this issue, we first defined a very mild injury in adolescent mice (postnatal day 35) as evidenced by an increase in Iba-1- labeled microglia in white matter in the acutely injured brain, in the absence of indices of cell death, axonal injury, and vasogenic edema. Using this level of injury severity and Avertin (2,2,2-tribromoethanol) as the anesthetic, we compared mice subjected to either a single mTBI or 2 rmTBIs, each separated by 48 h. Neurobehavioral assessments were conducted at 1 week and at 1 and 3 months postimpact. Mice subjected to rmTBIs showed transient anxiety and persistent and pronounced hypoactivity compared to sham control mice, alongside normal sensorimotor, cognitive, social, and emotional function. As isoflurane is more commonly used than Avertin in animal models of TBI, we next examined long-term outcomes after rmTBIs in mice that were anesthetized with this agent. However, there was no evidence of abnormal behaviors even with the addition of a third rmTBI. To determine whether isoflurane may be neuroprotective, we compared the acute pathology after a single mTBI in mice anesthetized with either Avertin or isoflurane. Pathological findings were more pronounced in the group exposed to Avertin compared to the isoflurane group. These collective findings reveal distinct behavioral phenotypes (transient anxiety and prolonged hypoactivity) that emerge in response to rmTBIs. Our findings further suggest that selected anesthetics may confer early neuroprotection after rmTBIs, and as such mask long-term abnormal phenotypes that may otherwise emerge as a consequence of acute pathogenesis.

The Rise of Concussions in the Adolescent Population

Background:

Concussion injuries have been highlighted to the American public through media and research. While recent studies have shown increased traumatic brain injuries (TBIs) diagnosed in emergency departments across the United States, no studies have evaluated trends in concussion diagnoses across the general US population in various age groups.

Purpose:

To evaluate the current incidence and trends in concussions diagnosed across varying age groups and health care settings in a large cross-sectional population.

Study Design:

Descriptive epidemiological study.

Methods:

Administrative health records of 8,828,248 members of a large private-payer insurance group in the United States were queried. Patients diagnosed with concussion from years 2007 through 2014 were stratified by year of diagnosis, age group, sex, classification of concussion, and health care setting of diagnosis (eg, emergency department vs physician’s office). Chi-square testing was used for statistical analysis.

Results:

From a cohort of 8,828,248 patients, 43,884 patients were diagnosed with a concussion. Of these patients, 55% were male and over 32% were in the adolescent age group (10-19 years old). The highest incidence of concussion was seen in patients aged 15 to 19 years (16.5/1000 patients), followed by those aged 10 to 14 years (10.5/1000 patients), 20 to 24 years (5.2/1000 patients), and 5 to 9 years (3.5/1000 patients). Overall, there was a 60% increase in concussion incidence from 2007 to 2014. The largest increases were in the 10- to 14-year (143%) and 15- to 19-year (87%) age groups. Based on International Classification of Disease–9th Revision classification, 29% of concussions were associated with some form of loss of consciousness. Finally, 56% of concussions were diagnosed in the emergency department and 29% in a physician’s office, with the remainder in urgent care clinics or inpatient settings.

Conclusion:

The incidence of concussion diagnosed in the general US population is increasing, driven largely by a substantial rise in the adolescent age group. The youth population should be prioritized for ongoing work in concussion education, diagnosis, treatment, and prevention.

Clinical Relevance:

The rise of concussions in the adolescent age group across the general population is concerning, and clinical efforts to prevent these injuries are needed.

Medical Care for Swimmers

Swimming is one of the most popular sports worldwide. Competitive swimming is one of the most watched sports during the Olympic Games. Swimming has unique medical challenges as a result of a variety of environmental and chemical exposures. Musculoskeletal overuse injuries, overtraining, respiratory problems, and dermatologic conditions are among the most common problems swimmers encounter. Although not unique to swimming, overtraining is a serious condition which can have significant negative impact on swimmers' health and performance. This review article is an attempt to discuss various issues that a medical team should consider when caring for swimmers.

The Clinical Utility of a Concussion Rebaseline Protocol After Concussion Recovery

OBJECTIVE

To evaluate the clinical utility of "rebaseline" testing (ie, new baseline) before the season after an athlete's concussion recovery by (1) determining differences between baseline and rebaseline scores, and (2) comparing differences to clinical reliable change indices (RCIs).

DESIGN

Retrospective cohort.

SETTING

Clinical research center.

PATIENTS

Thirty-four Division I collegiate athletes (16 females, 18 males; baseline age = 18.38 ± 0.78 years).

INTERVENTIONS

Neurocognitive, balance, and symptom testing was conducted at 3 times: (1) original baseline, (2) final postinjury before return-to-play, and (3) rebaseline completed before the next competitive season. Physicians diagnosed concussions, and all concussed athletes' returned-to-play during the same season.

MAIN OUTCOME MEASURES

Dependent variables included all neurocognitive domains, balance composite, and total symptom scores. Mean differences between sessions were compared with 80% RCIs to clinically interpret statistical findings.

RESULTS

Statistically significant improvements in neurocognitive performance were observed between baseline and rebaseline sessions: psychomotor speed (F1,33 = 13.79, P = 0.001), cognitive flexibility (F1,33 = 7.99, P = 0.008), processing speed (F1,32 = 15.93, P < 0.001), executive functioning (F1,33 = 9.61, P = 0.004), and reasoning (F1,32 = 7.63, P = 0.009). We observed significant improvement in balance (F1,29 = 22.26, P < 0.001), but no difference in total symptom score (P = 0.719). Participants performed statistically better at last postinjury compared with rebaseline in visual memory (F1,29 = 5.64, P = 0.024) and complex attention (F1,31 = 11.38, P = 0.002), but worse in processing speed (F1,30 = 8.92, P = 0.006). Participants reported more symptoms (F1.28 = 10.83, P = 0.003) at rebaseline than last postinjury. No observed mean differences exceeded RCIs.

CONCLUSIONS

All between-session improvements were within RCIs and therefore within expected test-retest variation. Our results suggest limited clinical utility for rebaseline assessments in the collegiate setting.

CLINICAL RELEVANCE

Despite statistically significant differences between test sessions, no differences exceeded RCIs, suggesting the differences were of little clinical utility in the interpretation of neurocognitive, balance, and symptom scoring.