American Medical Society for Sports Medicine position statement on concussion in sport

Higher Sedentary Behaviors and Lower Levels of Specific Knowledge Are Risk Factors for Physical Activity-Related Injuries in Saudi Adolescents

Encouraging physical activity (PA) for adolescents is necessary to achieve and maintain optimal health, but it may increase the risk of PA-related injuries. This study sought to assess the frequency, location, type, and severity of PA-related injuries in Saudi students aged 13 to 18 years and to identify associated risk factors. A total of 402 students, including 206 boys aged 15.87 ± 1.69 years and 196 girls aged 15.83 ± 1.70 years, were randomly assigned to participate in this study. For each participant, height, weight, body mass index, and fat percentage were measured. Responses to a specially designed four-part self-administered questionnaire were also collected. Results revealed that better specific knowledge was associated with a lower likelihood of sustaining injuries (β = -0.136; p = 0.001) but increased sedentary behaviors were associated with a greater likelihood of sustaining a PA-related injury (β = 0.358; p = 0.023). Gender, knowledge, and sedentary behaviors were the factors overall associated with a greater likelihood of suffering 1, 2, and 3 or more PA-related injuries. However, gender, fat-free mass, knowledge, and sedentary behaviors were associated overall with a greater likelihood of bruises, strains, fractures, sprains, concussions, and at least two types of PA-related injuries. Collectively, we should pay attention to the PA-related injury problem among middle and high school students, particularly when promoting a physically active lifestyle.

Psychological Contributions to Symptom Provocation Testing After Concussion

OBJECTIVE

Following concussion, symptoms such as headache, dizziness, and fatigue may transiently worsen or reemerge with increased exertion or activity. Standardized tests have been developed to assess symptom increases following aerobic, cognitive, or vestibular/oculomotor challenge. Although neurophysiological mechanisms are proposed to underlie symptom increases following exertion, psychological factors such as anxiety and misinterpretation of normal bodily sensations may also play a role. In this study, we examined the contribution of psychological factors to symptom provocation testing outcomes.

SETTING

Two outpatient concussion clinics in British Columbia, Canada.

PARTICIPANTS

Adults with persistent symptoms following concussion ( N = 79; 62% women).

DESIGN

In a single session, participants completed self-report questionnaires measuring the psychological factors of interest and underwent symptom provocation testing including aerobic (Buffalo Concussion Bike Test; BCBT), cognitive (National Institutes of Health Toolbox-Cognition Battery; NIHTB-CB), and vestibular/oculomotor (Vestibular/Ocular Motor Screening for Concussion; VOMS) challenge.

MAIN MEASURES

Psychological factors of interest included premorbid and current anxiety (Generalized Anxiety Disorder-7; GAD-7), catastrophizing (Pain Catastrophizing Scale-Adapted; PCS-A), fear avoidance behavior (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and somatization (Patient Health Questionnaire-15; PHQ-15). Our primary outcome variables were self-reported symptom change during each symptom provocation test.

RESULTS

We found that current anxiety ( B = 0.034; 95% CI = 0.003, 0.065), symptom catastrophizing ( B = 0.013; 95% CI = 0.000, 0.026), fear avoidance behavior ( B = 0.029; 95% CI = 0.008, 0.050), and somatization ( B = 0.041; 95% CI = 0.007, 0.075) were associated with increased symptoms during the VOMS in univariate models adjusted for time postinjury but not in a multivariable model that included all covariates. The psychological variables of interest were not significantly related to symptom change during the BCBT or NIHTB-CB.

CONCLUSION

Our findings suggest that symptom provocation test failure should be interpreted with caution because it might indicate psychological maladjustment rather than lingering brain injury or incomplete neurophysiological recovery.

Adjusting to Changing Environments: Virtual Preseason SCAT5 Assessment in Canadian Male Youth Football Players

OBJECTIVE

To provide preseason reference scores for Canadian youth tackle football players on the Sport Concussion Assessment Tool 5 (SCAT5) and to examine whether age, concussion history, and self-reported medical diagnoses are associated with SCAT5 subcomponent performance.

DESIGN

Cross-sectional study.

SETTING

Calgary, Alberta.

PARTICIPANTS

Five hundred one male youth football players (ages 13-18 years) participating in the 2021 season.

ASSESSMENT OF RISK FACTORS

SCAT5 subcomponents were assessed by age group (13-14, 15-16, 17-18), concussion history (0, 1, 2+, and yes/no), and self-reported diagnoses (headache disorder, attention-deficit/hyperactive disorder, learning disability/dyslexia, and depression, anxiety, or other psychiatric disorder).

MAIN OUTCOME MEASURES

Virtual video administration (vs traditional in-person testing) of the SCAT5 was completed, and subcomponent scores included total number of symptoms (/22), symptom-severity score (/132), Standardized Assessment of Concussion [orientation (/5), immediate memory (/30), concentration (/5), delayed recall (/10)], and modified Balance Error Scoring System (/30). Kruskal-Wallis, one-way analysis of variance , Mann-Whitney U , or independent t tests were used to assess possible associations depending on number of groups and data normality.

RESULTS

Virtual SCAT5 assessment scores across all outcomes did not differ by age group or concussion history. The median number of symptoms and median symptom-severity score at baseline was 2, and 173 players (34.5%) reported no symptoms. Median total number of errors on the modified Balance Error Scoring System was 3. Participants with certain self-reported diagnoses (attention-deficit/hyperactive disorder, dyslexia) demonstrated poorer performance on some SCAT5 subcomponents (symptom reporting, Standardized Assessment of Concussion).

CONCLUSIONS

Baseline SCAT5 performance did not differ by age group or concussion history in male youth football players. Diagnoses of the self-reported disorders examined may be important considerations for interpretation of the SCAT5 assessment.

Evolving the SCAT5 for Ruling Out Higher-Severity Traumatic Brain Injuries-Can Decision Rules Developed for Emergency Settings Help?

BACKGROUND: Decision rules (eg, Canadian computed tomography head rule [CCHR] for adults and Pediatric Emergency Care Applied Research Network [PECARN] rule for children/adolescents) are used in emergency settings (emergency room [ER] rules) to assess traumatic brain injuries (TBIs). The rules have a high-sensitivity and near-perfect negative predictive value that help to rule out more severe TBI. CLINICAL QUESTION: Which criteria should be added to the Sport Concussion Assessment Tool 5 (SCAT5) to reach the sensitivity of the ER rules and improve the utility of the SCAT5 for screening for higher-severity head and brain injuries? KEY RESULTS: We performed a comparative analysis of the SCAT5 with the CCHR and PECARN rules. We compared the presence (yes or no) and comparative "face value" sensitivity (lower, identical, or higher) of the SCAT5 criteria to the ER rules criteria. Loss of consciousness, vomiting, severe/increasing headache, and seizure are SCAT "red flags" with similar or higher sensitivity compared to ER rules criteria. Five criteria had lower sensitivity or were absent from the SCAT. Emergency room rules include any abnormality on the Glasgow Coma Scale (GCS<15), but only a "deterioration of the state of consciousness" is considered a "red flag" in the SCAT5. Persistent retrograde amnesia for more than 30 minutes, age>65, severity of the mechanism of injury, and signs of skull fractures are not mentioned in the SCAT5. CLINICAL APPLICATION: We identified 5 criteria that could inform the evolution the SCAT5 to improve its ability to rule out more severe TBI in a sideline assessment context. J Orthop Sports Phys Ther 2023;53(3):113-119. Epub: 9 December 2022. doi:10.2519/jospt.2022.11301.

Implementation of Return to Learn Protocols for Student Athletes with Sport and Recreation Related Concussion: An Integrative Review of Perceptions, Challenges and Successes

Concussion or mild traumatic brain injury (mTBI) is a common phenomenon in the United States, with up to 3.6 million sport-related mTBIs diagnosed annually. Return to learn protocols have been developed to facilitate the reintegration of students into school after mTBI, however, the implementation of return to learn protocols varies significantly across geographic regions and school districts. An integrative review of the literature was performed using Whittemore and Knalf's methodology. A search of published literature was conducted using the PRISMA checklist. Database searches were conducted from March 2,019 to October 2,021 using the terms "mild traumatic brain injury" and "return to learn." Twenty-eight publications were included. Three themes were derived from this review: lack of policy, poor staff education on concussion symptoms and stakeholder communication breakdown. The development of communication patterns and use of a return to learn protocol could facilitate a gradual return to full academic workload after concussion.

Cross-Cultural Adaptation of the Urdu Version of Rosenbaum Concussion Knowledge and Attitude Survey—Student Version in Pakistan

Evaluating athletes’ knowledge of and attitudes toward sports-related concussions is important. However, there is limited research involving South Asian athletes, partly due to the lack of a valid and reliable tool. This study, therefore, aimed to translate and validate the Rosenbaum Concussion Knowledge and Attitude Survey—Student Version, an established tool used to measure knowledge and attitude toward concussion, into Urdu. Rosenbaum Concussion Knowledge and Attitude Survey—Student Version was translated into Urdu using the standard guidelines and then completed by 369 athletes participating in contact sports at different universities in Pakistan. Confirmatory factor analysis was performed on the Concussion Attitude Index items to examine the underlying factorial structure. Construct validity of Concussion Attitude Index factors was also investigated using convergent and discriminant validity. The results showed that the Urdu version of the Rosenbaum Concussion Knowledge and Attitude Survey—Student Version has good psychometric properties and is a valid and reliable tool for evaluating Urdu-speaking athletes’ knowledge of and attitudes toward concussions.

Sport-related concussion disclosure in women's rugby-A social identity approach

Introduction

Sport-related concussion (SRC) is a risk of collision sports such as women's rugby. To support appropriate SRC diagnosis and management, an understanding of the factors that encourage SRC disclosure is necessary. To date, research has focused on ascertaining individual player knowledge and attitudes towards SRC disclosure.

Methods

We chose to investigate the potential influence of group identification effects by examining the role of social identity on SRC disclosure in elite women's rugby. Seventeen elite players from the United Kingdom and Ireland were interviewed and their transcripts thematically analysed.

Results

The data highlighted that the players shared a very strong social identity as women in rugby and were acutely aware that their experiences were different to their male counterparts. The shared social identity had both positive and negative implications for SRC disclosure. The players interviewed did not feel comfortable disclosing their symptoms to their coach and often felt that medical staff either did not listen to them or were unavailable to them. Mediators such as communication, trust in medical teams, perceived pressure, positive injury management experience, and player role models were identified.

Discussion

This research could be utilised to inform sport psychology interventions to enhance SRC disclosure in elite women's rugby.

Electrophysiological trajectories of concussion recovery: From acute to prolonged stages in late teenagers

PURPOSE

Numerous studies have reported electrophysiological differences between concussed and non-concussed groups, but few studies have systematically explored recovery trajectories from acute concussion to symptom recovery and the transition from acute concussion to prolonged phases. Questions remain about recovery prognosis and the extent to which symptom resolution coincides with injury resolution. This study therefore investigated the electrophysiological differences in recoveries between simple and complex concussion.

METHODS

Student athletes with acute concussion from a previous study (19(2) years old) were tracked from pre-injury baseline, 24-48 hours after concussion, and through in-season recovery. The electroencephalography (EEG) with P300 evoked response trajectories from this acute study were compared to an age-matched population of 71 patients (18(2) years old) with prolonged post-concussive symptoms (PPCS), 61 (SD 31) days after concussion.

RESULTS

Acute, return-to-play, and PPCS groups all experienced a significant deficit in P300 amplitude compared to the pre-injury baseline group. The PPCS group, however, had significantly different EEG spectral and coherence patterns from every other group.

CONCLUSION

These data suggest that while the evoked response potentials deficits of simple concussion may persist in more prolonged stages, there are certain EEG measures unique to PPCS. These metrics are readily accessible to clinicians and may provide useful parameters to help predict trajectories, characterize injury (phenotype), and track the course of injury.

Understanding racial differences in computerized neurocognitive test performance and symptom-reporting to deliver culturally competent patient-centered care for sport-related concussion

OBJECTIVE

This study examined neurocognitive performance and symptoms between concussed Black and White collegiate athletes at baseline, post-injury, and change from baseline to post-injury.

METHOD

The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) was used to measure neurocognitive performance and four concussion symptom clusters for 235 concussed collegiate athletes. Between-groups differences were documented at baseline and post-injury, along with change in scores for sex/race, and sport/race groups, using ANOVAs. Baseline scores, and days-to-post-test were covariates in post-injury comparisons. Symptom endorsement by race was evaluated using chi-square analyses.

RESULTS

At baseline, group comparisons by race and sex showed that Black male/female athletes scored lower on reaction time (RT; p = .008), White females scored higher on verbal memory (VerbMem; p = .001), Black females scored lower on visual motor processing speed (VMS; p = .001), and Black football athletes scored slower/poorer on RT (p = .001) and VMS (p = .006). Post-injury, Black males scored lower on visual memory (VisMem; p = .005) and VMS (p = .002), and Black football athletes scored slower on VMS (p = .005), whereas White non-football athletes scored higher on VerbMem (p = .002) and reported fewer symptoms. Significant time-by-sport/race interactions were found for VerbMem (p < .001), VisMem (p < .001) and reported symptoms. With respect to post-injury symptom scores/endorsement, Black athletes scored significantly higher for physical (p = .01) and sleep (p = .01) symptoms.

CONCLUSION

These findings drive the conversation of how subjective measures of symptoms, and objective clinical concussion measures, may relate to the concussion recovery process and providing a culturally competent clinical management approach for diverse patients.

An Investigation of Physiological System Impairments in Individuals 4 Weeks to 6 Months Following Mild Traumatic Brain Injury

OBJECTIVE

The Buffalo Concussion Treadmill Test (BCTT) was developed to identify potential physiological system impairment (PSI) underlying persistent symptoms post-mild traumatic brain injury (mTBI). This study evaluates PSI in individuals 4 weeks to 6 months post-mTBI using the BCTT "failure" criteria, and additional exploratory measures of test duration and heart rate (HR) response.

SETTING

Tertiary hospital and university.

PARTICIPANTS

Participants included 73 individuals 4 weeks to 6 months post-mTBI and a comparison group of 39 healthy controls (HCs). The mTBI group was further subgrouped at screening into those considering themselves asymptomatic (Asymp mTBI) ( n = 35) or symptomatic (Symp mTBI) ( n = 36).

DESIGN

Observational cohort study.

MAIN MEASURES

BCTT; failure rate (%), test duration (minutes), HR responses.

RESULTS

: Thirty percent of the mTBI group (including 50% of the Symp and 9% of the Asymp subgroups) failed the BCTT. BCTT duration and associated overall HR change was significantly lower in the mTBI group and Symp subgroup compared with HCs. Compared with HCs maximal HR percentage was higher for the first 4 minutes of the test in the mTBI group, and for the first 2 minutes of the test for the Symp subgroup.

CONCLUSIONS

Individuals post-mTBI demonstrated PSI impairment subacutely. In some individuals this was despite an initially reported absence of symptoms. The study also showed some preliminary evidence that BCTT duration and HR responses may be additionally informative post-mTBI.

Relationship between anxiety and concussion symptoms among adolescents enrolled in a randomized controlled trial of aerobic exercise

BACKGROUND

Affective symptoms, specifically, anxiety, are often overlooked after sport-related concussion (SRC), and may contribute to prolonged recovery.

OBJECTIVE

To examine the impact of anxiety during clinical recovery among adolescents (13-18y) enrolled in a randomized trial of aerobic exercise for SRC.

METHODS

Patients at three sites were randomized into aerobic exercise or stretching arms, and enrolled in the 4-week intervention. The relationship between PROMIS Anxiety score at initial visit and time to symptom resolution was evaluated with survival analysis. The relationship between weekly PROMIS Anxiety score and Post-concussion Symptom Inventory (PCSI) score was evaluated with Linear Mixed Models. Analyses adjusted for study arm and baseline covariates.

RESULTS

Among 54 adolescents (median age = 15.8y, initial visit PCSI score = 32, pre-injury PROMIS Anxiety score = 2), median time to symptom resolution was 10 days (25th-75th percentiles: 6-24) in the Low-PROMIS Anxiety group and 12 days (25th-75th percentiles: 5-21) in the High-PROMIS Anxiety group (p = 0.62). Each additional unit of PROMIS Anxiety score corresponded to a 1.52-unit higher PCSI total score (p <  0.01). Neither effect varied by aerobic exercise/stretching group.

CONCLUSION

Higher initial PROMIS Anxiety score was not significantly associated with delayed symptom resolution. However, over time, PROMIS Anxiety score was significantly associated with elevated PCSI score, regardless of exercise/stretching group.

The impact of riboflavin on the duration of sport-related concussion: A randomized placebo-controlled trial

Objectives

The objective of this study was to investigate the time to recovery after an SRC comparing riboflavin 400mg daily to placebo in a group of elite level athletes from multiple sports.

Methods

The study was a double-blind randomized placebo-controlled trial with intention to treat conducted from 2016–2020 at two different academic institutions. The study enrolled varsity student-athletes (SA) at each institution. The investigators and participants were blinded to treatment allocation. The treatment group received 14 capsules of either riboflavin 400mg or placebo to take daily until completed. The team physician made the diagnosis of an SRC within 24 h of the injury.

Results

A total of sixty participants enrolled in the study. Fifty-two participants completed the study. Subjects in the riboflavin group had a statistically significant lower number of average days to recovery of 9.92 days (CI ± 2.8) compared to placebo of 22.2 days (CI ± 11.5) (P < 0.05). Subjects matched for age, gender, history of SRCs, attention deficit hyperactivity disorder and Periodic Health Questionnaire-9 scores.

Conclusions

This is one of the first studies that documents an effective treatment option for an SRC at the time of injury. Riboflavin is safe, inexpensive, and readily available making it an ideal treatment.

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

Over the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

The Clinical Utility of the Child SCAT5 for Acute Concussion Assessment

Background

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5 and 12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion.

Methods

Our participants included 34 concussed (21 boys, 13 girls; age = 12.8 ± 0.86 years) and 44 non-concussed (31 boys, 13 girls; age = 12.4 ± 0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r=\frac{Z}{\sqrt{n}}$$\end{document}r=Zn) were calculated to assess the magnitude of difference for each comparison. The diagnostic properties (sensitivity, specificity, diagnostic accuracy, predictive values, likelihood ratios, and diagnostic odds ratio) of each Child SCAT5 score were also calculated.

Results

Concussed children endorsed more symptoms (p < 0.001, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.45), higher symptom severity (p < 0.001, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.44), and had higher double leg (p = 0.046, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.23), single leg (p = 0.035, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.24), and total scores (p = 0.022, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.26) for the mBESS than the non-concussed children. No significant differences were observed for the SAC-C scores (p’s ≥ 0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC = 0.76–0.77), negative predictive values (NPV = 0.84–0.88), and negative likelihood ratios (-LR = 0.22–0.31) of the Child SCAT5 scores.

Conclusions

Clinicians should prioritize interpretation of the symptom evaluation form of the Child SCAT5 as it was the most effective component for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion.

Traumatic brain injury: progress and challenges in prevention, clinical care, and research

Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research.

In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents.

Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery.

The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition.

Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers.

In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI.

Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation.

Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority.

This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.

Association of Concussion History and Prolonged Recovery in Youth

OBJECTIVE

To determine the number of prior concussions associated with increased incidence of persistent postconcussive symptoms (PPCS) in a cohort of acutely concussed pediatric patients.

DESIGN

Prospective observational cohort study.

SETTING

Three university-affiliated concussion clinics.

PARTICIPANTS

Two hundred seventy participants (14.9 ± 1.9 years, 62% male, 54% with prior concussion) were assessed within 14 days of concussion and followed to clinical recovery. Participants with a second head injury before clinical recovery were excluded.

MEASURES AND MAIN OUTCOME

Concussion history, current injury characteristics, recovery time, and risk for prolonged recovery from current concussion.

RESULTS

There was no statistically significant change in PPCS risk for participants with 0, 1 or 2 prior concussions; however, participants with 3 or more prior concussions had a significantly greater risk of PPCS. Twelve participants sustained a subsequent concussion after clinical recovery from their first injury and were treated as a separate cohort. Our secondary analysis found that these participants took longer to recover and had a greater incidence of PPCS during recovery from their latest concussion.

CONCLUSION

Pediatric patients with a history of 3 or more concussions are at greater risk of PPCS than those with fewer than 3 prior concussions.

Nutritional interventions to support acute mTBI recovery

When mild traumatic brain injury (mTBI) occurs following an impact on the head or body, the brain is disrupted leading to a series of metabolic events that may alter the brain's ability to function and repair itself. These changes may place increased nutritional demands on the body. Little is known on whether nutritional interventions are safe for patients to implement post mTBI and whether they may improve recovery outcomes. To address this knowledge gap, we conducted a systematic review to determine what nutritional interventions have been prescribed to humans diagnosed with mTBI during its acute period (<14 days) to support, facilitate, and result in measured recovery outcomes.

Methods

Databases CINAHL, PubMed, SPORTDiscus, Web of Science, and the Cochrane Library were searched from inception until January 6, 2021; 4,848 studies were identified. After removing duplicates and applying the inclusion and exclusion criteria, this systematic review included 11 full papers.

Results

Patients that consumed enough food to meet calorie and macronutrient (protein) needs specific to their injury severity and sex within 96 h post mTBI had a reduced length of stay in hospital. In addition, patients receiving nutrients and non-nutrient support within 24-96 h post mTBI had positive recovery outcomes. These interventions included omega-3 fatty acids (DHA and EPA), vitamin D, mineral magnesium oxide, amino acid derivative N-acetyl cysteine, hyperosmolar sodium lactate, and nootropic cerebrolysin demonstrated positive recovery outcomes, such as symptom resolution, improved cognitive function, and replenished nutrient deficiencies (vitamin D) for patients post mTBI.

Conclusion

Our findings suggest that nutrition plays a positive role during acute mTBI recovery. Following mTBI, patient needs are unique, and this review presents the potential for certain nutritional therapies to support the brain in recovery, specifically omega-3 fatty acids. However, due to the heterogenicity nature of the studies available at present, it is not possible to make definitive recommendations.

Systematic review registration

The systematic review conducted following the PRISMA guidelines protocol was registered (CRD42021226819), on Prospero.

Sex-related differences in sternocleidomastoid muscle morphology in healthy young adults: A cross-sectional magnetic resonance imaging measurement study

BACKGROUND

Changes in sternocleidomastoid (SCM) muscle cross-sectional area (CSA) and volume may contribute to neck-related concussion symptoms and whiplash-associated disorders. Magnetic resonance imaging (MRI) data on healthy SCM morphology can provide information that may lead to targeted treatment protocols.

OBJECTIVES

To examine sex-related differences in MRI-based SCM CSA, SCM volume and neck area in healthy young adults, to analyze associations between measurements and participant variables and to assess inter-rater reliability for measurement quantification.

DESIGN

Cross-sectional study.

METHODS

13 males and 14 females underwent MRI scans. Slices obtained from C3-C7 were analyzed by three raters. SCM CSA at C4, total SCM volume from C3-C7 and neck area at C4 were quantified. Measurements were calculated as absolute and normalized values by body mass. Multivariable regression was used to analyze associations between normalized measurement values and participant variables. Inter-rater reliability was determined using intraclass correlation coefficients (ICC).

RESULTS

Females had significantly lower normalized overall average SCM CSA (mean difference 1.3 mm²/kg (95% CI 0.4-2.2, p = 0.006) and total SCM volume (mean difference 140.8 mm3/kg (95% CI 66.1-215.5, p < 0.001) than males. Regression models indicated female sex was associated with lower normalized overall average SCM CSA (p = 0.004) and total SCM volume (p < 0.001). Inter-rater reliability was excellent for SCM CSA (ICC_3,3 = 0.909), SCM volume (ICC_3,3 = 0.910) and neck area (ICC_3,3 = 0.995).

CONCLUSIONS

These results enhance our understanding of sex-related differences in SCM morphology and will inform future research and clinical practice related to cervical muscle injury.

Time to expand the circle of care - General practitioners' experiences of managing concussion in the community

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

Lower post-injury psychological resilience is associated with increased recovery time and symptom burden following sport-related concussion

The purpose of this study was to compare athletes with high and low resilience scores on concussion outcomes, and identify significant predictors associated with protracted recovery (>30 days). Forty-five adolescent and young adult athletes (28 males; aged 15.13 ± 2.74; range of 11-22) were diagnosed with an SRC within 14 days of injury (M = 4.9 days) and grouped as high or low resilience based on score on the Connor-Davidson Resilience Scale-10 (CD-RISC-10). Primary dependent measures included days to full clearance, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Depression Anxiety and Stress Scale-21 (DASS-21), and Vestibular/Ocular Motor Screening (VOMS). The low resilience group (n = 22) had a longer recovery (36.0 ± 27.6 vs 17.8 ± 11.2 days), endorsed more mood symptoms (PCSS Affective cluster; 3.8 ± 0.8 vs 0.9 ± 0.7), and were more likely to have VOMS scores above cut off (p = 0.01-0.02), compared to those with high psychological resilience (n = 23). Logistic regression found low resilience scores was the only significant predictor for protracted recovery among injury characteristics and risk factors. Psychological resilience is a critical factor associated with recovery time following sport-related concussions. Low resilience was also associated with other poor clinical outcomes, greater subjective symptom report, more severe vestibular dysfunction, and elevated levels of mood symptoms following injury.

Concussion education in medical students studying in Scotland: an assessment of knowledge and future needs

BACKGROUND

Physicians play a key role in ensuring athletes with concussion safely return to sport. Research has shown deficiencies in concussion education amongst physicians and medical students. However, studies have not previously been conducted in UK medical schools.

OBJECTIVES

To assess students' concussion knowledge and learning in Scottish Medical Schools.

DESIGN

A survey with 23 questions was distributed to Year 3-6 medical students studying in Scotland in October 2020. The survey included the following: (1) demographics, (2) concussion knowledge, e.g. 'What is the role of headgear in preventing concussion?' (3) concussion learning, 'In which part of the curriculum should concussion be taught?.' Frequencies of responses were calculated for each question.

RESULTS

200 students responded (response rate 8%). The average symptoms and management score were 87.3% and 31% respectively. 15% of participants knew that headgear has no role in preventing concussions and one participant identified the minimum "return to sport" timeframes for adults and children. 15% had learnt about concussion at medical school with 92.5% interested in receiving concussion teaching at medical school.

CONCLUSION

Knowledge gaps exist in managing and preventing sports-related concussion. There is a discrepancy between levels of concussion teaching and the desire and importance placed on concussion education.

Test-retest reliability of the neurotracker compared to the impact test for the management of mild traumatic brain injuries during two consecutive university sport seasons

INTRODUCTION

Neurocognitive assessment tools such as the Neurotracker and ImPACT have been proposed to optimize sports-related mild traumatic brain injury (mTBI) management. Baseline testing is recommended with such assessments to individualize monitoring of athletes' remission. While the ideal timeframe between baseline updates has been studied for the ImPACT, these data are missing for the Neurotracker.

OBJECTIVE

The current study aimed to compare the test-retest reliability of the ImPACT and Neurotracker for two consecutive seasons in university athletes participating in sports at risk for mTBI.

METHODS

At the start of two consecutive seasons, 30 athletes with no recent history of mTBI completed a baseline assessment including the Neurotracker and the ImPACT. The test-retest reliability of the results was analyzed by considering intra-class correlation (ICC), Becker's standardized mean difference (d_B) and Bland-Altman' plot of each outcome.

RESULTS

The Neurotracker and the Visual Motor Speed composite score of the ImPAC were the only outcomes with significative ICCs and acceptable d_B between the two seasons. Neurotracker was the only outcome with a significative bias (+0.179).

CONCLUSION

Our research suggests that the Neurotracker has an acceptable level of test-retest reliability after one year in comparison to the ImPACT.

Sensory Phenotypes for Balance Dysfunction After Mild Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

Recent team-based models of care use symptom subtypes to guide treatments of individuals with chronic effects of mild traumatic brain injury (mTBI). However, these subtypes, or phenotypes, may be too broad, particularly for balance (e.g., vestibular subtype). To gain insight into mTBI-related imbalance, we (1) explored whether a dominant sensory phenotype (e.g., vestibular impaired) exists in the chronic mTBI population, (2) determined the clinical characteristics, symptomatic clusters, functional measures, and injury mechanisms that associate with sensory phenotypes for balance control in this population, and (3) compared the presentations of sensory phenotypes between individuals with and without previous mTBI.

METHODS

A secondary analysis was conducted on the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium. Sensory ratios were calculated from the sensory organization test, and individuals were categorized into 1 of the 8 possible sensory phenotypes. Demographic, clinical, and injury characteristics were compared across phenotypes. Symptoms, cognition, and physical function were compared across phenotypes, groups, and their interaction.

RESULTS

Data from 758 Service Members and Veterans with mTBI and 172 individuals with no lifetime history of mTBI were included. Abnormal visual, vestibular, and proprioception ratios were observed in 29%, 36%, and 38% of people with mTBI, respectively, with 32% exhibiting more than 1 abnormal sensory ratio. Within the mTBI group, global outcomes (p < 0.001), self-reported symptom severity (p < 0.027), and nearly all physical and cognitive functioning tests (p < 0.027) differed across sensory phenotypes. Individuals with mTBI generally reported worse symptoms than their non-mTBI counterparts within the same phenotype (p = 0.026), but participants with mTBI in the vestibular-deficient phenotype reported lower symptom burdens than their non-mTBI counterparts (e.g., mean [SD] Dizziness Handicap Inventory = 4.9 [8.1] for mTBI vs 12.8 [12.4] for non-mTBI, group × phenotype interaction p < 0.001). Physical and cognitive functioning did not differ between the groups after accounting for phenotype.

DISCUSSION

Individuals with mTBI exhibit a variety of chronic balance deficits involving heterogeneous sensory integration problems. While imbalance when relying on vestibular information is common, it is inaccurate to label all mTBI-related balance dysfunction under the vestibular umbrella. Future work should consider specific classification of balance deficits, including specific sensory phenotypes for balance control.

The Incidence, Cost, and Burden of Concussion in Women's Rugby League and Rugby Union: A Systematic Review and Pooled Analysis

BACKGROUND

The extent of concussion injury in the rugby codes for women is unclear.

OBJECTIVE

Our aim was to review all published studies reporting concussion injuries from match and training participation in rugby codes and report the pooled data estimates for rugby league and union concussion injury epidemiology.

METHODS

We conducted a systematic literature analysis of concussion in rugby league and rugby union for published studies from January 1990 to July 2021. Data from 16 studies meeting the inclusion criteria were extracted for women's concussion injuries and were subsequently pooled. Costs from Accident Compensation Corporation (ACC) data were attributed to the results to provide cost estimates.

RESULTS

The pooled analysis match injury incidence of women's concussion was higher for rugby league (10.3 per 1000 match hours) than rugby 15 s (2.8 per 1000 match hours) or rugby 7 s (8.9 per 1000 match hours). There was a fourfold difference in the pooled incidence of concussion in women's rugby league (risk ratio [RR] 4.53, 95% confidence interval [CI] 1.8-11.3]; p = 0.0001) when compared with rugby 15 s. There was also a ninefold higher risk of a concussion during match participation compared with training participation for women's rugby 15 s (RR 9.3, 95% CI 1.29-66.78; p = 0.0070). The total estimated costs for the concussions reported were NZ$1,235,101. For rugby 7 s, the pooled concussive injury burden was 33.2 days.

CONCLUSIONS

Our pooled analysis clarified the extent of concussion injury and the possible associated costs at several levels of the game for women's rugby codes. The pooled mean days lost because of concussions was 33 days. As this was considerably longer than the 7- to 10-day expected timeframe outlined in the Concussion in Sport Consensus statement, these guidelines need to be updated to include sex-specific differences.

Personality Predictors of Sports-Related Concussion Incidence: Analysis of Data From a Large, Heterogeneous Undergraduate Sample

OBJECTIVE

Studies investigating the associations between personality and sports-related concussion are limited. The current study aimed to address this gap by examining whether specific personality dimensions predicted self-reported sports-related concussion outcomes.

DESIGN

This study included 1141 undergraduate students ( Mage = 19.47, SD = 2.14, female = 64.5%) who completed a battery of online personality measures and self-reported sports-related concussion items. The self-reported sports-related concussion outcomes included a single diagnosed sports-related concussion incident (i.e., "diagnosed sports-related concussion incidence") and incidents of multiple diagnosed sports-related concussions (i.e., "multiple diagnosed sports-related concussion incidents"). Analyses included splitting data randomly into training and validation data sets. Multivariate logistic regression models were then fit to each data set to determine predictors of sports-related concussion.

RESULTS

In both training and validation data sets, extraversion and experience seeking were found to be positively and most strongly associated with both sports-related concussion outcomes, whereas motor inhibition was found to be negatively associated with both outcomes. Additional personality dimensions showed differential relations with each sports-related concussion outcome.

CONCLUSIONS

The current study highlights the importance of considering personality dimensions in the context of self-reported sports-related concussion outcomes, as there are differential relations between personality dimensions and these outcomes. Thus, prevention efforts for sports-related concussion may benefit from evaluating additional athlete factors, like personality traits.

The Effect of Physical Exertional Testing on Postconcussion Symptom Scale Scores in Male and Female High School Students

PURPOSE

Symptom scores commonly measured following concussion were compared between male and female adolescents with (Hx+) and without (Hx-) a history of concussion, pre and post physical exertion testing.

METHODS

Eighty (males [n = 60; Hx+ = 19], female [n = 20; Hx+ = 5]) high school students (ages 15-17 y) completed the Buffalo Concussion Treadmill Test once and the modified shuttle run test twice. Symptom scores were collected using the 22-point Symptom Evaluation Scale on the Sport Concussion Assessment Tool (version 5) immediately pre and post physical exertion testing.

RESULTS

The symptoms most reported during preexertional testing were fatigue/low energy, feeling slowed down, and nervous/anxious, whereas feeling slowed down, fatigue/low energy, "pressure in head" (males only), and headache (females only) were most frequently reported during postexertion testing.

CONCLUSION

An understanding of the common exertion-related symptoms at baseline in a laboratory or field-based setting in adolescents may be advantageous for clinicians as they manage individual recovery postconcussion. This is particularly important during an adolescent's recovery and return to play when exertional testing may be implemented, especially since symptoms were reported pre and post exertional testing in both males and females regardless of concussion history.

Static and Dynamic Balance Assessment in Healthy and Concussed Adolescent Athletes

OBJECTIVE

The purpose of this study was to explore the utilization of the Y Balance Test (YBT) alongside the Balance Error Scoring System (BESS) during examination of healthy adolescent athletes (14-18 year old) as well as those with acute and chronic concussion.

DESIGN

A repeated-measures study of balance in a cross-sectional convenience sample of adolescents participating in high-school athletics.

SETTING

Data were collected on healthy athletes in their school setting for comparison purposes and on concussed athletes in the physical therapy rehabilitation center at the hospital.

PARTICIPANTS

Participants were a convenience sample of male and female athletes between the ages of 14 to 18 year old [180 healthy (111 male, 69 female) and 44 (28 male, 16 female) with concussion].

ASSESSMENT OF RISK FACTORS

All participants were cleared for participation by preparticipation examination or by the treating sport medicine physician.

MAIN OUTCOME MEASURES

Healthy athletes performed the YBT, a dynamic assessment of balance. Athletes with concussion also performed the BESS, a static assessment of balance.

RESULTS

Means for each YBT reach direction were statistically different for both healthy males and females ( P < 0.05). Within both the acute and chronic subsets of the concussed sample, some participants performed over the median value for the BESS but not the YBT.

CONCLUSIONS

These data may suggest that dynamic balance testing in conjunction with static balance testing could be valuable in both the acute and chronic phases of concussion to ensure a comprehensive assessment of the necessary balance skills for athletic play.

Characteristics of concussion subtypes from a multidomain assessment

OBJECTIVE

The aim of this study was to analyze the best combination of clinical variables associated with concussion subtypes using a multidomain assessment comprising medical history; symptoms; and cognitive, ocular, and vestibular impairment in a cohort of patients presenting to a concussion specialty clinic.

METHODS

Adolescent patients (n = 293) completed demographics and medical history, Concussion Clinical Profiles Screening, Immediate Post-Concussion Assessment and Cognitive Testing, and vestibular ocular motor screening at their first visit (mean 7.6 ± 7.8 days postinjury) to a concussion specialty clinic. Each participant was adjudicated to have one or more subtype (anxiety/mood, cognitive, migraine, ocular, and vestibular) by a healthcare professional based on previously published criteria. A series of backward, stepwise logistic regressions were used to identify significant predictors of concussion subtypes, and predictive probabilities from the logistic regression models were entered into area under the receiver operating characteristic curve (AUC) models.

RESULTS

Each of 5 logistic regression models predicting primary subtypes accounted for 28%-50% of the variance (R2 = 0.28-0.50, p < 0.001) and included 2-8 significant predictors per model. Each of the models significantly differentiated the primary subtype from all other subtypes (AUC = 0.76-0.94, p < 0.001).

CONCLUSIONS

These findings suggest that each concussion subtype can be identified using specific outcomes from a multidomain assessment. Clinicians can employ such an approach to better identify and monitor recovery from subtypes as well as guide interventions.

Exploration of Race and Ethnicity, Sex, Sport-Related Concussion, Depression History, and Suicide Attempts in US Youth

IMPORTANCE

Racial, ethnic, and sex disparities for concussion incidence and suicide attempts in youth have been reported, but data on the interaction of these variables in a large national data set are lacking. Understanding how race and ethnicity interact with sex and concussion to influence suicide attempts could yield critical information on the sociocultural impact of brain injury and mental health in US youth.

OBJECTIVE

To examine the associations of concussion history, race and ethnicity, and sex with reported suicide attempts among adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional cohort study used data from US Youth Risk Behavior Surveillance System (YRBSS) survey respondents between 2017 and 2019. Data were analyzed from May 2021 to January 2022.

EXPOSURES

Respondents reported sport- or recreation-related concussion (yes or no), depression (yes or no), and suicide attempt (yes or no) over the previous 12 months, along with race and ethnicity (categorized as American Indian or Alaska Native, Asian, Black, Hispanic/Latino, multiracial, Native Hawaiian or other Pacific Islander, and White), and sex (male or female).

MAIN OUTCOMES AND MEASURES

Two Chi-Square Automatic Interaction Detection (CHAID) decision tree models were built. The first was suicide attempt with depression history (SA-DEP), the second was suicide attempt without depression history (SA-NO DEP). CHAID uses risk factors (eg, number of concussions, race and ethnicity, sex) to divide the study sample into a series of subgroups that are nested within each other. Risk ratios (RRs) and 95% CIs were calculated for each subgroup to provide effect estimates.

RESULTS

A total of 28 442 youths aged up to 18 years (mean [SD] age, 14.6 [3.0] years; 14 411 [50.7%] female) responded to the survey. The CHAID decision trees revealed a complex interaction between race, sex, and concussion history for attempting suicide, which differed by depression history (overall accuracy, 84.4%-97.9%). Overall, depression history was the variable most strongly associated with SA (adjusted odds ratio, 11.24; 95% CI, 10.27-12.29). Concussion was the variable most strongly associated with SA-DEP (RR, 1.31; 95% CI, 1.20-1.51; P < .001). Black, Hispanic/Latino, or multiracial race and ethnicity were associated with increased risk for SA-DEP compared with others (RR, 1.59; 95% CI, 1.38-1.84; P < .001). American Indian or Alaska Native, Black, and Hispanic/Latino race and ethnicity were associated with increased risk for SA-NO DEP (RR, 1.89; 95% CI, 1.54-2.32; P < .001) compared with the remaining population.

CONCLUSIONS AND RELEVANCE

These findings suggest that clinicians should consider race, ethnicity, and sex when evaluating the role of sport- or recreation-related concussion on suicide risk among US youth.

Association Between Fear of Pain and Sports-Related Concussion Recovery in a Pediatric Population

OBJECTIVE

To determine whether an association exists between fear of pain and recovery time from sports-related concussion in a pediatric population.

DESIGN

Prospective observational study.

SETTING

Primary outpatient sports medicine clinic of a large pediatric hospital.

PATIENTS

One hundred twenty-eight pediatric patients aged 8 to 18 years who presented to clinic with a primary diagnosis of concussion from September 2018 to March 2020. Inclusion criteria included presentation within 2 weeks of injury and symptomatic on initial visit. Patients who sustained a concussion because of motor vehicle collisions or assault were excluded.

INDEPENDENT VARIABLES

There was no intervention. Study participants who met inclusion criteria were administered the Fear of Pain Questionnaire (FOPQ) at their initial visit.

MAIN OUTCOME MEASURES

Time to clinical recovery was the main outcome measure and was determined by the fellowship-trained sports medicine physician based on resolution of concussion symptoms, resumption of normal physical and cognitive daily activities, no use of accommodations or medications, and normalization of physical exam.

RESULTS

There was a significant difference in FOPQ scores for those with prolonged recovery (M = 33.12, SD = 18.36) compared with those recovering in fewer than 28 days (M = 26.16, SD = 18.44; t [126] = -2.18, P = 0.036).

CONCLUSIONS

Consistent with the adult literature, we found that pediatric patients are more likely to have a prolonged recovery from concussion when they have higher fear of pain.

Defining Biological Phenotypes of Mild Traumatic Brain Injury Using Saliva MicroRNA Profiles

Concussion is a heterogeneous injury that relies predominantly on subjective symptom reports for patient assessment and treatment. Developing an objective, biological test could aid phenotypic categorization of concussion patients, leading to advances in personalized treatment. This prospective multi-center study employed saliva micro-ribonucleic acid (miRNA) levels to stratify 251 individuals with concussion into biological subgroups. Using miRNA biological clusters, our objective was to assess for differences in medical/demographic characteristics, symptoms, and functional measures of balance and cognition. The miRNAs that best defined each cluster were used to identify physiological pathways that characterized each cluster. The 251 participants (mean age: 18 ± 7 years; 57% male) were optimally grouped into 10 clusters based on 22 miRNA levels. The clusters differed in age (χ2 = 19.1, p = 0.024), days post-injury at the time of saliva collection (χ2 = 22.6; p = 0.007), and number of prior concussions (χ2 = 17.6, p = 0.040). The clusters also differed in symptom reports for fatigue (χ2 = 17.7; p = 0.039), confusion (χ2 = 22.3; p = 0.008), difficulty remembering (χ2 = 22.0; p = 0.009), and trouble falling asleep (χ2 = 17.2; p = 0.046), but not objective balance or cognitive performance (p > 0.05). The miRNAs that defined concussion clusters regulate 16 physiological pathways, including adrenergic signaling, estrogen signaling, fatty acid metabolism, GABAergic signaling, synaptic vesicle cycling, and transforming growth factor (TGF)-β signaling. These results show that saliva miRNA levels may stratify individuals with concussion based on underlying biological perturbations that are relevant to both symptomology and pharmacological targets. If validated in a larger cohort, miRNA assessment could aid individualized, biology-driven concussion treatment.

Temporal Differences in Concussion Symptom Factors in Adolescents following Sports-Related Concussion

OBJECTIVE

To evaluate temporal differences in concussion symptoms up to 30 days following a sports-related concussion.

STUDY DESIGN

Adolescent and young adult athletes (n = 782) were separated based on time since injury at presentation as Early (0-7 days; n = 321, age: 15.4 ± 1.9 years, 51.7% female), Middle (8-14 days; n = 281, age: 15.8 ± 2.2 years, 54.8% female), and Late (15-30 days; n = 180, age: 15.6 ± 1.8 years, 52.8% female). All participants completed the 22-item Post-Concussion Symptom Scale at first visit. A confirmatory factor analysis was completed separately for each time since injury cohort using a 4-component model reported previously.

RESULTS

The confirmatory factor analysis model fit was acceptable for Early, Middle, and Late (using cognitive-migraine-fatigue, affective, sleep, and somatic factors). Both affective (change = 0.30; P = .01; Cohen d = 0.30) and sleep (change = 0.51; P ≤ .001; Cohen d = 0.47) factors were significantly greater in the Late group compared with the Early, but not Middle, groups. The previously reported 4-factor symptom model, including cognitive-migraine-fatigue, affective, somatic, and sleep factors, was appropriate for adolescents up to 30 days' postinjury. However, adolescents who presented between 15 and 30 days' postinjury reported greater affective and sleep symptoms than those who presented within 1 week.

CONCLUSIONS

Clinicians should consider these temporal differences when evaluating concussion symptoms in adolescents, as greater affective and sleep symptoms can be predictive of prolonged recovery/persistent complications.

What is the effect of personalized cognitive strategy instruction on facilitating return-to-learn for individuals experiencing prolonged concussion symptoms?

The purpose of this study was to evaluate the degree to which personalized cognitive strategy instruction (PCSI) assisted students with prolonged concussion symptoms (PCS) to achieve functional and academic-related goals. It was hypothesized that goal attainment on collaboratively developed functional goals and selected scores on the pre/post outcome measurements would improve following the delivery of PCSI. A non-concurrent multiple baseline design was utilized across three female participants ages 13-16. The weekly status tracking measurement of participant performance served as the primary measurement analysed to determine the existence of a functional relation between the addition of PCSI to psychoeducation and the achievement of participant outcome. Although visual analysis of the plotted status tracking data did not support the existence of a functional relation, all three participants met or exceeded functional goals on their goal attainment scales. A Tau-U analysis supported a small treatment effect. The positive response to the intervention from two of the three participants in addition to goal attainment for all three participants suggests PCSI has potential to mitigate cognitive challenges in adolescents with PCS. Implications for future research and methods to promote ecological measurement of intervention effects are discussed.

Head Impact Exposure in Youth and Collegiate American Football

The relationship between head impact and subsequent brain injury for American football players is not well-defined, especially for youth. The objective of this study is to quantify and assess Head Impact Exposure (HIE) metrics among youth and collegiate football players. This multi-season study enrolled 639 unique athletes (354 collegiate; 285 youth, ages 9-14), recording 476,209 head impacts (367,337 collegiate; 108,872 youth) over 971 sessions (480 collegiate; 491 youth). Youth players experienced 43 and 65% fewer impacts per competition and practice, respectively, and lower impact magnitudes compared to collegiate players (95th percentile peak linear acceleration (PLA, g) competition: 45.6 vs 61.9; 95th percentile PLA practice: 42.6 vs 58.8; 95th percentile peak rotational acceleration (PRA, rad·s^-2) competition: 2262 vs 4422; 95th percentile PRA practice: 2081 vs 4052; 95th percentile HITsp competition: 25.4 vs 32.8; 95th percentile HITsp practice: 23.9 vs 30.2). Impacts during competition were more frequent and of greater magnitude than during practice at both levels. Quantified comparisons of head impact frequency and magnitude between youth and collegiate athletes reveal HIE differences as a function of age, and expanded insight better informs the development of age-appropriate guidelines for helmet design, prevention measures, standardized testing, brain injury diagnosis, and recovery management.

Factors Associated With a Prolonged Time to Return to Play After a Concussion

BACKGROUND

Prognosticating recovery times for individual athletes with a concussion remains a challenge for health care providers. Several preinjury and postinjury factors have been proposed to be predictive of prolonged return-to-play (RTP) times, but the data in this area are still sparse.

PURPOSES

This study aimed to identify risk factors associated with prolonged recovery times and determine which are most predictive of prolonged recovery times in a head-to-head comparison.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All concussions occurring between September 2017 and August 2020 at a single National Collegiate Athletic Association Division I institution were reviewed and included in this study. Preinjury modifiers including age, sex, sport, concussion history, and past medical problems were collected from the electronic medical records. Postinjury modifiers analyzed included initial and follow-up Sport Concussion Assessment Tool 5th Edition scores, vestibular evaluation findings, and eye tracking results.

RESULTS

A total of 159 athletes and 187 concussion cases were included. Preinjury factors that were correlated with prolonged RTP times included a history of concussions (P = .015), a history of migraines (P = .013), and whether an athlete participated in an individual sport (P = .009). Postinjury factors correlated with prolonged RTP times included the total number (P = .020) and severity (P = .023) of symptoms as well as abnormal Vestibular Ocular Motor Screening findings (P = .002). Overall, 6 different symptoms (balance problems, difficulty concentrating, light sensitivity, drowsiness, fatigue/low energy, and difficulty remembering) were significantly correlated with prolonged RTP times. The study also found that the number and severity of symptoms were additive in a dose-dependent fashion. On multivariable analysis of all these factors, a history of concussions was found to be the most predictive of prolonged RTP times, while participation in an individual sport had the largest effect on recovery times.

CONCLUSION

Several preinjury and postinjury risk factors were identified as being correlated with prolonged recovery times. Many of these risk factors were also found to be additive in nature. This information provides clinicians with a valuable tool in prognosticating and estimating recovery times for athletes. The study also revealed that athletes participating in individual sports had longer RTP times compared with athletes in team sports, which is a novel finding that requires further research.

Should We Lose Sleep Over Sleep Disturbances After Sports-Related Concussion? A Scoping Review of the Literature

OBJECTIVE

A single, severe traumatic brain injury can result in chronic sleep disturbances that can persist several years after the incident. In contrast, it is unclear whether there are sleep disturbances after a sports-related concussion (SRC). Considering growing evidence of links between sleep disturbance and neurodegeneration, this review examined the potential links between diagnosed SRCs and sleep disturbances to provide guidance for future studies.

METHODS

The scoping review undertook a systematic search of key online databases (Scopus, MEDLINE, SportDiscus, and Web of Science) using predetermined search terms for any articles that examined sleep after concussion. A screening criterion using agreed inclusion and exclusion criteria was utilized to ensure inclusion of relevant articles.

DESIGN

This scoping review is guided by the PRSIMA Scoping Review report.

RESULTS

Ten studies met the inclusion criteria, reporting on 896 adults who had experienced an SRC. Comparison with 1327 non-SRC adults occurred in 8 studies. Nine studies subjectively examined sleep, of which all but one study reported sleep disturbances after an SRC. Three studies objectively measured sleep, with 2 studies indicating large coefficients of variation of sleep duration, suggesting a range of sleep responses after an SRC. The only study to examine overnight polysomnography showed no differences in sleep metrics between those with and without an SRC. No studies examined interventions to improve sleep outcomes in people with concussion.

CONCLUSIONS

This scoping review indicates preliminary evidence of sleep disturbances following an SRC. The heterogeneity of methodology used in the included studies makes consensus on the results difficult. Given the mediating role of sleep in neurodegenerative disorders, further research is needed to identify physiological correlates and pathological mechanisms of sleep disturbances in SRC-related neurodegeneration and whether interventions for sleep problems improve recovery from concussion and reduce the risk of SRC-related neurodegeneration.

Overview of Traumatic Brain Injury in American Football Athletes

OBJECTIVE

The aim of this review is to provide a summary of the epidemiology, clinical presentation, pathophysiology, and treatment of traumatic brain injury in collision athletes, particularly those participating in American football.

DATA SOURCES

A literature search was conducted using the PubMed/MEDLINE and Google Scholar databases for publications between 1990 and 2019. The following search phrases were used: "concussion," "professional athletes," "collision athletes," "mild traumatic brain injury," "severe traumatic brain injury," "management of concussion," "management of severe traumatic brain injury," and "chronic traumatic encephalopathy." Publications that did not present epidemiology, clinical presentation, pathophysiology, radiological evaluation, or management were omitted. Classic articles as per senior author recommendations were retrieved through reference review.

RESULTS

The results of the literature review yielded 147 references: 21 articles discussing epidemiology, 16 discussing clinical presentation, 34 discussing etiology and pathophysiology, 10 discussing radiological evaluation, 34 articles for on-field management, and 32 articles for medical and surgical management.

CONCLUSION

Traumatic brain injuries are frequent in professional collision athletes, and more severe injuries can have devastating and lasting consequences. Although sport-related concussions are well studied in professional American football, there is limited literature on the epidemiology and management of severe traumatic brain injuries. This article reviews the epidemiology, as well as the current practices in sideline evaluation, acute management, and surgical treatment of concussions and severe traumatic brain injury in professional collision athletes. Return-to-play decisions should be based on individual patient symptoms and recovery.

Use of the Independent Medical Spotter in Identifying Head Injuries in Division I Football Players

OBJECTIVE

Sport-related concussion (SRC) is a known risk of contact sports and strategies to minimize risk have been used. We aimed to determine if an independent medical spotter (IMS) identified more SRCs than would otherwise be detected by trained sideline medical staff (SMS).

DESIGN

Prospective review of SRCs during competition in the 2019 season and retrospective review of SRCs in the 2015 to 2018 seasons, which also used an IMS.

SETTING

Division I football games (home and away) of a Big 10 Conference institution.

PARTICIPANTS

All football team members who participated in competition.

INDEPENDENT VARIABLES

Occurrence of SRC during competition and whether the IMS or SMS directly visualized the injury.

MAIN OUTCOME MEASURES

The total number of SRCs that occurred during competition in the 2015 to 2019 football seasons and whom observed the SRC-SMS or IMS-or if a student athlete reported symptoms after competition.

RESULTS

Over the 5-year study period, 24 SRCs occurred during competition. Of those, 19 (79.2%) were observed by SMS, 2 (8.3%) by the IMS, and 3 (12.5%) were reported to SMS after competition ended.

CONCLUSIONS

Most SRCs are accurately identified by SMS, but a small number were apparent only to the IMS who seemed to add sensitivity in detecting a SRC. Instances remain in which SRC recognition and diagnosis were delayed despite trained SMS and IMS.

CLINICAL RELEVANCE

An IMS allows for a small-added player protection benefit using different vantage points to identify potential SRCs during competition.

Incidence of Neck Pain in Patients With Concussion in a Pediatric Emergency Department

OBJECTIVES

The aims of the study were (1) to determine the frequency of neck pain in patients diagnosed with mild traumatic brain injury (mTBI) or concussion in a pediatric level 1 trauma center emergency department (ED), (2) to identify variables associated with neck pain in this population, and (3) to report on aspects of care received in the ED including imaging and medication use.

METHODS

This is a retrospective chart review of 652 patients presenting to a pediatric ED with diagnosis of concussion/mTBI. Charts were reviewed for the following information: baseline demographic information, mechanism of injury, cause of mTBI, presence or absence of neck pain, point tenderness in the neck on physical examination, and whether the patient followed up within our health system in the 6 months after injury. Charts were also reviewed for other concussion-related symptoms, medication given in the ED, imaging performed in the ED, cervical spine clearance in the ED, and referrals made. For those patients who did have follow-up appointments within our system, additional chart review was performed to determine whether they sought follow-up treatment for symptoms related to concussion/neck pain and the duration of follow-up. Statistical analyses focused on the prevalence of neck pain in the sample. We subsequently explored the degree to which neck pain was associated with other collected variables.

RESULTS

Of 652 patients, 90 (13.8%) reported neck pain. Acceleration/deceleration injury and motor vehicle accident were predictive of neck pain. Neck pain was less common in those reporting nausea and vomiting. Direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables, this was no longer statistically significant. Patients with neck pain were older than those without neck pain. Patients with neck pain were more likely to receive ibuprofen or morphine and undergo imaging of the spine. They were also more likely to receive a referral and follow-up with neurosurgery. There was no significant difference between groups with respect to concussion-related follow-up visits or follow-up visits to a dedicated concussion clinic.

CONCLUSIONS

Neck pain is a common symptom in pediatric patients with mTBI, although it was more likely in older patients and those presenting with acceleration/deceleration mechanisms. Although patients with neck pain were more likely to receive a referral and follow-up with neurosurgery, they were not more likely to have concussion-related follow-up visits. Indeed, most patients had no follow-up visits related to their concussion, which supports the notion that concussion is a self-limiting condition.

Need for resuming sports and physical activity for children and adolescents following COVID-19 infection

Introduction

A decline in sports activities among children and adolescents was noted during the stay-at-home restrictions imposed by COVID-19. With the easing of restrictions, physical activities are being resumed.

Evidence acquisition

A data search was conducted to identify the role of parents in resuming sporting activities, the risks and benefits of doing so, the physical examination to be conducted prior to physical activity, the existence of guidelines/protocols for return to sports and physical activity, the role of comorbidities in influencing the restart of the same.

Evidence synthesis

Parents should consult the child's physician prior to allowing he/she to resume physical exercise. In preparation for this, a careful physical examination should be performed. Children with COVID-19, even if asymptomatic, should not resume any physical activity until at least 10 days after testing positive. Those with moderate or severe COVID-19 should be referred for cardiological evaluation. The level of activity should be resumed gradually, as per the GRTP protocol. Athletes with a positive COVID-19 test in the presence of concomitant medical conditions (diabetes, cardiovascular or respiratory or renal disease) should undergo medical evaluation prior to adhering to a GRTP. Those with complicated COVID19 infection or long Covid may need additional investigations.

Conclusions

While there is no doubt that it will bring multiple benefits in terms of general health, returning to play sport should be gradual and preceded by an accurate physical examination in those young subjects previously affected by the coronavirus disease, especially when their heart and/or lungs and/or kidneys were affected.

The acute, systemic effects of aerobic exercise in recently concussed adolescent student-athletes: preliminary findings

OBJECTIVES

Examine the acute effects (pre-, during, post-intervention) of two different intensities of aerobic exercise or rest on autonomic, oculomotor, and vestibular function and symptom burden in patients with a recent sport-related concussion (SRC) and compare their responses to sex-matched, age-stratified, non-concussed (HEALTHY) student-athletes.

METHODS

Student-athletes between the ages of 13 and 18 that presented to the sports medicine clinic within Day 3-7 post-SRC and from local schools were recruited for a randomized controlled trial (RCT). The participants were administered the Vestibular/Ocular Motor Screening (VOMS), King-Devick (K-D), and Post-Concussion Symptom Scale (PCSS) before and after the intervention. Heart rate variability (HRV) and mean arterial pressure (MAP) were collected before, during, and after the intervention. The intervention was either a single, 20-min session of treadmill walking at 40% (40HR) or 60% of age-predicted max heart rate (60HR), or seated, rest (NOEX).

RESULTS

30 participants completed the intervention with the SRC group treated 4.5 ± 1.3 days post-injury. Pre-exercise HRV and MAP were significantly different (p's < 0.001) during treatment but returned to pre-exercise values within 5 min of recovery in both the SRC and HEALTHY groups. Both the SRC and HEALTHY groups exhibited similar reductions pre- to post-intervention for symptom severity and count (p's < 0.05), three VOMS items (p's < 0.05) but not K-D time.

CONCLUSIONS

To date, this is the first adolescent RCT to report the acute, systemic effects of aerobic exercise on recently concussed adolescent athletes. The interventions appeared safe in SRC participants, were well-tolerated, and provided brief therapeutic benefit.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT03575455.

Concussion Management Guidelines Neglect Auditory Symptoms

Tinnitus, noise sensitivity, and hearing difficulties are commonly reported secondary to head injury. These auditory deficits have been shown to negatively impact daily functioning, and yet, often go unnoticed by health care professionals. The purpose of this editorial is to explain why it is essential for clinical practice guidelines that address the management of patients who have experienced a head injury to incorporate assessment and rehabilitation of auditory symptoms.

Neurodevelopmental Disorders and Risk of Concussion: Findings from the National Collegiate Athletic Association Department of Defense Grand Alliance Concussion Assessment, Research, and Education (NCAA-DOD CARE) Consortium (2014-2017)

Evidence suggests neurodevelopmental disorders (NDs) may be associated with an increased incidence of concussion, but no studies have cross-sectionally and longitudinally assessed the associations of NDs and sex with concussion in collegiate athletes. We sought to assess the odds and relative risk (RR) of concussion in athletes self-reporting a diagnosis of attention deficit/hyperactivity disorder (ADHD), learning disability (LD), and ADHD+LD. Data from the Concussion Assessment, Research and Education (CARE) Consortium (2014-2017) were used to evaluate the likelihood of concussion for male and female athletes with ADHD, LD, and ADHD+LD, relative to controls. Odds ratios (ORs) of concussion history prior to enrollment and relative risk ratios for incurring a concussion following enrollment, with and without concussion history were calculated for all groups. Athletes with self-reported diagnosis of ADHD, LD, and ADHD+LD were more likely to report a single concussion (OR range = 1.528 to 1.828) and multiple concussions (OR range = 1.849 to 2.365) prior to enrollment in the CARE Consortium, irrespective of sex compared with control athletes. While enrolled in CARE, male athletes with ADHD, LD, and ADHD+LD had greater risk of incurring a concussion (RR range = 1.369 to 2.243) than controls, irrespective of concussion history. Male athletes with ADHD+LD with concussion history (RR = 2.221) and without concussion history (RR = 1.835) had greater risk of incurring a concussion than controls. These results suggest NDs may be associated with increased odds of single and multiple concussions, irrespective of sex. However, when we accounted for concussion history, it appears only male athletes with ADHD+LD had greater risk than respective controls. There were no significant differences between females and males with ADHD, LD, or ADHD+LD for either odds of concussion history or risk for incurring concussion.

Quantitative Assessment of Balance for Accurate Prediction of Return to Sport From Sport-Related Concussion

BACKGROUND

Determining when athletes are able to return to sport after sports-related concussion (SRC) can be difficult.

HYPOTHESIS

A multimodal algorithm using cognitive testing, postural stability, and clinical assessment can predict return to sports after SRC.

STUDY DESIGN

Prospective cohort.

LEVEL OF EVIDENCE

Level 2b.

METHODS

Athletes were evaluated within 2 to 3 weeks of SRC. Clinical assessment, Immediate Post Concussion and Cognitive Testing (ImPACT), and postural stability (Equilibrate) were conducted. Resulting data and machine learning techniques were used to optimize an algorithm discriminating between patients ready to return to sports versus those who are not yet recovered. A Fisher discriminant analysis with leave-one-out cross-validation assessed every combination of 2 to 5 factors to optimize the algorithm with lowest combination of type I and type II errors.

RESULTS

A total of 193 athletes returned to contact sports after SRC at a mean 84.6 days (±88.8). Twelve subjects (6.2%) sustained repeat SRC within 12 months after return to sport. The combination of (1) days since injury, (2) total symptom score, and (3) nondominant foot tandem eyes closed postural stability score created the best algorithm for discriminating those ready to return to sports after SRC with lowest type I error (13.85%) and type II error (11.25%). The model was able to discriminate between patients who were ready to successfully return to sports versus those who were not with area under the receiver operating characteristic (ROC) curve of 0.82.

CONCLUSION

The algorithm predicts successful return to sports with an acceptable sensitivity and specificity. Tandem balance with eyes closed measured with a video-force plate discriminated athletes ready to return to sports from SRC when combined in multivariate analysis with symptom score and time since injury. The combination of these factors may pose advantages over computerized neuropsychological testing when evaluating young athletes with SRC for return to contact sports.

CLINICAL RELEVANCE

When assessing young athletes sustaining an SRC in a concussion clinic, measuring postural stability in tandem stance with eyes closed combined with clinical assessment and cognitive recovery is effective to determine who is ready to successfully return to sports.

Risk of Concussion After a Targeting Foul in Collegiate American Football

Background:

The targeting rule was adopted by the National Collegiate Athletic Association (NCAA) in 2008 to discourage dangerous contact during collegiate American football competition. Although targeting rules have been emphasized as a means to reduce concussion rates, there is currently no evidence that targeting plays are higher risk for concussion than other plays in American football.

Purpose:

To compare the rate of concussion occurring during targeting versus nontargeting plays in American collegiate football.

Study Design:

Cross-sectional study.

Methods:

Concussions occurring in games in the 2016-2019 Pac-12 Conference were classified as having occurred during either (1) a play where a targeting penalty was called or (2) all other plays. Targeting plays were further categorized to either those in which the call was upheld or those overturned by the on-field official after replay review. The number of targeting plays and the total number of plays during games were also recorded. Concussion incidence (per 1000 plays) and risk ratios were calculated.

Results:

Overall, 538 games with 68,670 plays were reviewed, during which 213 concussions occurred (15 during plays where targeting was called and 198 on other plays) and 141 targeting penalties were called. The incidence of concussion was 106.4/1000 plays for targeting plays (including 141.2/1000 upheld targeting fouls and 53.6/1000 overturned targeting fouls) and 2.9/1000 plays for nontargeting plays. The risk of concussion during targeting plays was 36.9 (95% CI, 22.4-60.7) times greater than that for all other plays. The risk of concussion during targeting plays upheld was 49.0 (95% CI, 28.5-84.2) times greater than that for all other plays.

Conclusion:

Concussion risk was significantly higher during plays in which targeting was called, especially those in which targeting fouls were upheld.

Clinical Relevance:

This study supports eliminating or reducing targeting from American football. The results of this study suggest that players should be screened for concussion after targeting plays are called.

Cervical musculoskeletal and sensorimotor impairments 4 weeks to 6 months following mild traumatic brain injury: An observational cohort study

BACKGROUND

Clinically relevant scores of neck disability have been observed in adults post mild traumatic brain injury (mTBI), even in those who initially report to be recovered. Potentially cervical musculoskeletal and/or cervical sensorimotor impairments may underlie these persistent symptoms post mTBI.

OBJECTIVE

To determine whether cervical impairments exist beyond expected recovery times following concussion compared to healthy controls (HC).

STUDY DESIGN

Observational cohort study.

METHODS

Participants aged 18-60 years consisting of 39 HC, and 72 individuals, 4 weeks to 6 months post mTBI of which 35 considered themselves asymptomatic (Asymp), and 37 symptomatic (Symp). Cervical outcome measures included range and velocity of motion, flexor muscle endurance, presence of at least one dysfunctional cervical joint, joint position error -neutral and torsion, movement accuracy, smooth pursuit neck torsion test (SPNT) and balance.

RESULTS

Individuals in the Symp mTBI group demonstrated significantly reduced: flexion and rotation range, rotation velocity, flexor endurance and movement accuracy as well as increased postural sway and a higher percentage had positive cervical joint dysfunction (p < 0.01]. The mTBI group who considered themselves recovered (Asymp)demonstrated significantly lower rotation range, flexor endurance, and a higher percentage had positive cervical joint dysfunction and positive SPNT (p < 0.05) compared to HCs.

CONCLUSION

Individuals reporting symptoms post mTBI demonstrated cervical spine musculoskeletal and sensorimotor impairments beyond expected recovery times. Those not reporting symptoms had fewer but some cervical impairments. The need for a comprehensive neck assessment should be considered, perhaps even in those not reporting symptoms.

An intervention to improve knowledge and increase comfort of concussion management among school medical staff

BACKGROUND

Concussion can negatively impact a child's ability to learn. School-based health professional staff have a unique opportunity to monitor students during recovery and mitigate the potential negative impact. Little is known about school health professional staff's knowledge and comfort with concussion diagnosis and management.

OBJECTIVES

We aimed to evaluate whether a tailored concussion education session could improve school health professional staff's knowledge about pediatric concussions. A secondary aim was to determine their knowledge retention and comfort with concussion management over the following year, including the impact of periodic follow-up education. We hypothesized that there would be sustained improvement in concussion knowledge and self-reported comfort in concussion management.

STUDY DESIGN

This study was a pre/post-intervention assessment with longitudinal follow-up. The study investigators provided a three-hour educational presentation about concussions in school-aged children. A survey on knowledge and management of pediatric concussions was administered immediately before and after this educational intervention. Knowledge retention and comfort with management was assessed at six months and at one year post-intervention.

PARTICIPANTS AND SETTING

Participants included Cincinnati Health Department school health professional staff in attendance at their Back to School in-service, prior to the start of the 2017-2018 school year.

RESULTS

Sixty school health professional staff from thirty-three schools completed the baseline knowledge survey, and forty completed all four assessments. Among the 40 participants with complete data, on average, the correct response rate (mean number correct, SD) was 82.3% (18.1/22, 11.0) pre-education, 91.8% (20.2/22, 10.3) immediate post-education, 86.4% (19.0/22, 10.8) 6-month follow-up, and 87.3% (19.2/22, 10.9) one-year follow-up.

CONCLUSIONS

A brief didactic educational intervention improved pediatric concussion knowledge and management skills among school health care providers. Periodic and in-person education is likely necessary to optimize knowledge retention.