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

Multifaceted concussion assessment battery: sensitivity at the expense of specificity?

OBJECTIVES

A multifaceted assessment battery is recommended for testing suspected concussed athletes; however, the individual tests have limitations and potentially may lead to false positive outcomes. Therefore, the purpose of this study was to psychometrically evaluate concussion assessment tools used for intercollegiate student-athletes, with a focus on the time interval between baseline and subsequent assessments.

METHODS

Ninety-two collegiate student-athletes matched between concussion (N = 46. F32/M14) and non-concussion (N = 46, 32F/14 M) completed the standard assessment of concussion, balance error scoring system, symptom questionnaire, and computerized neurocognitive tests at baseline and acutely (<48 h) following a concussion. Test outcomes were compared between time points with three approaches: 1) vs baseline, 2) reliable change scores (RCI), and 3) vs American College of Rehabilitation Medicine (ACRM). Concussion assessment sensitivity, specificity, likelihood ratios, predictive values, and diagnostic odds ratio were calculated. A receiver operator characteristic compared area under the curve (AUC) for the overall battery as well as between academic years.

RESULTS

The sensitivity of the battery was high (78.3-95.7%), but specificity was low to moderate (6.5-52.2%) with comparison to the RCI typically performing best. The three approaches yielded AUC values between 0.51 and 0.63 which is below the discriminatory threshold (0.70) with comparison to RCI performing best. By academic year, Juniors was the only year in which the ROC exceeded the threshold (0.75). The number of tests failed did not improve any AUC values (0.51-0.69) to exceed the threshold.

CONCLUSIONS

The outcomes of this study support the premise that concussion must be evaluated using a comprehensive clinical examination including a variety of assessments to evaluate each clinical domain. Clinicians need to recognize that the multifaceted assessment battery has high sensitivity, but the overall psychometrics do not exceed the threshold for group discrimination and caution must be used in their interpretation.

A Machine Learning Model for Post-Concussion Musculoskeletal Injury Risk in Collegiate Athletes

BACKGROUND

Emerging evidence indicates an elevated risk of post-concussion musculoskeletal injuries in collegiate athletes; however, identifying athletes at highest risk remains to be elucidated.

OBJECTIVE

The purpose of this study was to model post-concussion musculoskeletal injury risk in collegiate athletes by integrating a comprehensive set of variables by machine learning.

METHODS

A risk model was developed and tested on a dataset of 194 athletes (155 in the training set and 39 in the test set) with 135 variables entered into the analysis, which included participant's heath and athletic history, concussion injury and recovery-specific criteria, and outcomes from a diverse array of concussion assessments. The machine learning approach involved transforming variables by the weight of evidence method, variable selection using L1-penalized logistic regression, model selection via the Akaike Information Criterion, and a final L2-regularized logistic regression fit.

RESULTS

A model with 48 predictive variables yielded significant predictive performance of subsequent musculoskeletal injury with an area under the curve of 0.82. Top predictors included cognitive, balance, and reaction at baseline and acute timepoints. At a specified false-positive rate of 6.67%, the model achieves a true-positive rate (sensitivity) of 79% and a precision (positive predictive value) of 95% for identifying at-risk athletes via a well-calibrated composite risk score.

CONCLUSIONS

These results support the development of a sensitive and specific injury risk model using standard data combined with a novel methodological approach that may allow clinicians to target high injury risk student athletes. The development and refinement of predictive models, incorporating machine learning and utilizing comprehensive datasets, could lead to improved identification of high-risk athletes and allow for the implementation of targeted injury risk reduction strategies by identifying student athletes most at risk for post-concussion musculoskeletal injury.

Effects of Landing Impacts and Running on Balance Error Scoring System Performance

CONTEXT

The Balance Error Scoring System (BESS) is the most commonly used balance test during concussion assessment; however, the test has known limitations related to fatigue. Jumping and landing along with running are common athletic activities that adversely affect postural control. However, the effect of neither subexertional running nor jumping and landing tasks on the BESS is known. Therefore, the purpose of this study was to investigate the effects of a brief exercise bout of running or jumping on BESS performance.

DESIGN

We recruited 52 recreationally active participants who were divided into 3 groups: (1) Drop Jump (Landing), Treadmill Running (Run), and Control.

METHODS

All participants performed a preintervention BESS test and were then randomly assigned to a group. The jumping group performed 10 drop jumps from a 50 cm box, 30 seconds between trials, the running group performed a 3-minute treadmill run, and the control group sat quietly for 5 minutes. All participants then completed a second BESS test. The primary analysis was a 2 (time) by 3 (group) repeated-measure analysis of variance with sex as a covariate.

RESULTS

There was a significant interaction (F = 7.396, P = .002). On post hoc, there was a significant improvement (lower) score in the Control group (PRE: 13.9 [4.5]; POST: 10.5 [2.9]; P = .019, d = 0.89) but no significant differences in either the running (P = .579) or landing (P = .849) groups.

CONCLUSIONS

A relatively brief exercise intervention resulted in participants failing to improve a subsequent BESS assessment, whereas control participants who rested for 5 minutes committed fewer (3.4) errors. These results suggest that sports health care providers should recognize that even low- to moderate-intensity brief exercise can result in a failure to improve with repeat BESS administration.

A Machine Learning Model for Post-Concussion Musculoskeletal Injury Risk in Collegiate Athletes

Background

Emerging evidence indicates an elevated risk of post-concussion musculoskeletal (MSK) injuries in collegiate athletes; however, identifying athletes at highest risk remains to be elucidated.

Objective

The purpose of this study was to model post-concussion MSK injury risk in collegiate athletes by integrating a comprehensive set of variables by machine learning.

Methods

A risk model was developed and tested on a dataset of 194 athletes (155 in the training set and 39 in the test set) with 135 variables entered into the analysis, which included participant's heath and athletic history, concussion injury and recovery specific criteria, and outcomes from a diverse array of concussions assessments. The machine learning approach involved transforming variables by the Weight of Evidence method, variable selection using L1-penalized logistic regression, model selection via the Akaike Information Criterion, and a final L2-regularized logistic regression fit.

Results

A model with 48 predictive variables yielded significant predictive performance of subsequent MSK injury with an area under the curve of 0.82. Top predictors included cognitive, balance, and reaction at Baseline and Acute timepoints. At a specified false positive rate of 6.67%, the model achieves a true positive rate (sensitivity) of 79% and a precision (positive predictive value) of 95% for identifying at-risk athletes via a well calibrated composite risk score.

Conclusion

These results support the development of a sensitive and specific injury risk model using standard data combined with a novel methodological approach that may allow clinicians to target high injury risk student-athletes. The development and refinement of predictive models, incorporating machine learning and utilizing comprehensive datasets, could lead to improved identification of high-risk athletes and allow for the implementation of targeted injury risk reduction strategies by identifying student-athletes most at risk for post-concussion MSK injury.

Collegiate student-athletes concussion knowledge and attitudes: what a difference a decade Makes

OBJECTIVE

The purpose of this study was to assess changes in concussion knowledge and attitudes amongst incoming intercollegiate student-athletes over the course of a decade (2010-2012 vs 2021-2023).

METHODS

There were 592 student-athletes from 2 cohorts (2010-2012, 2021-2023) who completed the Rosenbaum Concussion Knowledge and Attitudes Survey (ROCKaS) questionnaire which is comprised of a concussion knowledge index (CKI, 0-24) and attitude index (CAI, 15-75) with higher scores reflecting better performance. A three factor ANOVA (Group, Sex, Concussion History) compared performance on the CKI and CAI. Individual questions were compared between groups with a Chi-Square analysis.

RESULTS

For the CKI, there was a significant main effect for Group (2010-2012: 18.5 ± 2.6, 2021-2023: 19.4 ± 2.5, p < 0.001, η 2 = 0.032 ) . For the CAI, there was also a significant main effect for group (2010-2012: 52.9 ± 6.0, 2021-2023: 62.2 ± 6.5, p < 0.001, η 2 = 0.359 ) .

CONCLUSIONS

The results of this study show a modest increase in concussion knowledge; however, large improvements in concussion attitudes were observed between groups. These results suggest a continued improvement in student-athlete concussion awareness and provide specific areas to continue addressing persistent misconceptions.

National Collegiate Athletic Association athletic trainers' response to the Arrington settlement: management, compliance, and practice patterns

The primary purpose of this study was to assess Athletic Trainers' (ATs) report of NCAA member institution compliance with the Arrington settlement, the concussion lawsuit vs. the NCAA, and to elucidate compliance predictors. A secondary purpose was to provide a contemporary concussion management clinical practice pattern description among NCAA collegiate athletic trainers. Head Athletic Trainers from NCAA Division I, II, and III completed an electronic questionnaire in August 2020 regarding their institution's response to the Arrington Settlement and their current concussion management clinical practice patterns. The 37-item questionnaire included AT and institution demographics, current concussion management policies, and response to the Arrington settlement with a specific focus on the five settlement requirements. An overall compliance score on the five requirements, compliance on the individual requirements, and concussion management practices are reported with descriptives. Regression was used to identify specific predictors of both overall and individual settlement requirements. An ANOVA compared compliance by NCAA division level. Being pressured to be non-compliant was assessed between sexes by a chi-square. There were 223 respondents (21.8%), and overall compliance was high (4.1 ± 0.7) with the five required Arrington Settlement components. Settlement requirement 1, pre-season baseline testing, and requirement 5, presence of trained personnel at all contact sport practices, had the lowest compliance rates at 44.8% and 73.3%, respectively. The number of sports the institution offered was the only significant predictor of each requirement. There was no difference in compliance between NCAA divisions. Although the overall rate of being non-compliant pressure was low (13.8%), females were 3.28x more likely report being pressured than males. NCAA institutions are generally compliant with the Arrington settlement; however, lack of clarity in the requirements, particularly requirement 1, raises potential concerns. Concussion management practices continue to incorporate multifaceted approaches and are largely consistent with current best practices.

Which psychosocial factors are associated with return to sport following concussion? A systematic review

BACKGROUND

Psychosocial factors predict recurrent injury and return to preinjury level of performance following orthopedic injury but are poorly understood following concussion. Current management protocols prioritize physical measures of recovery. Therefore, the objective of this study was to describe the psychosocial factors associated with return to sport (RTS) and how they are measured in athletes who sustained a concussion.

METHODS

MEDLINE, Embase, APA PsycINFO, CINAHL, and SPORTDiscus were searched through February 2, 2021. Eligible studies included original peer-reviewed publications describing psychosocial factors associated with RTS following a diagnosed concussion. The primary outcome was scales or measures employed and/or key thematic concepts.

RESULTS

Of the 3615 studies identified, 10 quantitative cohort studies (Oxford Centre for Evidence-Based Medicine Level-3) representing 2032 athletes (85% male; high-school and collegiate collision/contact athletes) and 4 qualitative studies representing 66 athletes (74% male; 70% American football; aged 9-28 years) were included. We identified 3 overarching themes and 10 outcome measures related to psychosocial factors associated with RTS following concussion: (a) fear (e.g, of recurrent concussion, of RTS, of losing playing status); (b) emotional factors (e.g, depression, anxiety, perceived stress, mental health, disturbance mood); and (c) contextual factors (e.g, social support, pressure, sense of identity).

CONCLUSION

Although current medical clearance decisions prioritize physical measures of recovery, evidence suggests diverse psychosocial factors influence RTS following concussion. It remains unclear which psychosocial factors contribute to a successful RTS, including the influence of sex/gender and age. Future studies should evaluate the association of psychological readiness with physical measures of recovery at medical clearance, preinjury level of performance, and risk of recurrent concussion to support RTS clinical decision-making.

Concussion is not associated with elevated rates of lower-extremity musculoskeletal injuries in National Football League Players

OBJECTIVE

Emerging evidence has identified an ~2x elevated risk of musculoskeletal (MSK) injury in the year following a concussion. Most of these studies have examined a single college/university athletic department and may lack generalizability to professional sports. Therefore, the purpose of this study was to assess the odds of post-concussion MSK injury utilizing publicly available National Football League (NFL) injury reports.

METHODS

Concussions were identified through a review of published NFL injury reports during the 2015, 2016, and 2017 regular seasons. Concussed players were matched by team and position, and injuries were tracked for both groups for the remainder of the season. A chi-square analysis compared the frequency of MSK injury in both groups and a Cox Proportional Hazard model calculated the risk of sustaining a subsequent MSK injury.

RESULTS

There were 322 concussed NFL players who met inclusion criteria and were successfully matched. From the time of concussion through the remainder of the season, 21.4% of the concussed players were injured and 26.4% of control participants were injured. There was no difference in MSK injury rates (p = 0.166), and the relative risk ratio was 0.90 for subsequent injury in the concussion group. There was no difference in the time to event for subsequent MSK between the two groups (p = 0.123).

CONCLUSION

The primary finding of this study was no elevated risk of post-concussion MSK in NFL football players.

What Is the Evidence on Natural Recovery Over the Year Following Sports-Related and Non-sports-Related Mild Traumatic Brain Injury: A Scoping Review

Background: Treatment approaches often differ dependent upon whether a person experiences a sports-related or a non-sports-related mild traumatic brain injury. It remains unclear if recovery from these injuries is comparable or unique to context of the injury. Objective: To identify knowledge gaps on self-reported outcomes and trajectories between sports- and non-sports-related mild traumatic brain injuries and how they are assessed in adults. Methods: This scoping review used a systematic search of key electronic databases, including PubMed, SPORTDiscus, Embase, MEDLINE, and CINAHL for articles published in 1937 until March 10, 2021. Articles were included if they were available in English; full text published in a peer-reviewed journal; had a prospective or retrospective study design; reported data on mild TBI cases >16 years of age, and included data from at least two time points on self-reported outcomes within 12 months post-injury. A standardized data extraction spreadsheet was used to determine the participant characteristics, definitions, assessment methods, outcomes, and recovery time frames. Results: Following removal of duplicates, the search strategy elicited 6,974 abstracts. Following abstract review, 174 were retained for full text review. Of the 42 articles that met inclusion criteria, 18 were sports related (15 in the USA and three in Canada) and 24 were general population studies (six in USA, three in Canada, three in Australasia, nine in Europe, two in Taiwan, and one in Morocco). Direct comparison in recovery trajectories between the sport and general population studies was difficult, given notable differences in methodology, definitions, types of outcome measures, and timing of follow-up assessments. Only one article reported on both sports-related and non-sports-related traumatic brain injuries separately at comparable timepoints. This study revealed no differences in recovery time frames or overall symptom burden. Discussion: Whilst there is a clear benefit in researching specific subpopulations in detail, standardized outcome measures and follow-up time frames are needed across contexts to facilitate understanding of similarities and differences between sports- and non-sports-related mild traumatic brain injuries to inform clinical treatment.

The Prevalence and Impact of Debilitative Psychological and Behavioral Responses to Long-Term Injury in Athletes

Injuries, and their psychological and maladaptive behavioral consequences, are an inevitable by-product of sport participation. This study sought to investigate the prevalence of maladaptive behaviors and psychological corollaries of long-term injury in order to understand if these are universal experiences of long-term injured athletes. Competitive athletes (n = 187; average time spent injured =43 weeks), across a range of sports completed an online questionnaire developed to investigate the psychological and behavioral consequences of long-term injury. Results indicated that negative symptoms after injury were a universal experience and are the “normal” response to injury, not the “exception.” The most prevalent psychological consequences were rumination (97.9%), boredom (94.7%), and fear of reinjury (93.6%). Furthermore, indicators of suicidal ideation were reported by more than 50% of participants. Factor analysis revealed a six-factor model: (a) self-sabotaging behavior, (b) daily functioning, (c) addictive behavior, (d) clinical issues, (e) fixation on injury, and (f) compromised athletic identity. All factors significantly correlated with debilitating impact. Thus, this study calls for a change to the support of long-term injured athletes to include routine psychological care.

Psychological and Social Needs: Athletes’ and Mental Performance Consultants’ Perspectives on a Gap in Concussion Protocols

While research advancements have substantially improved concussion management efforts, consideration for the psychological and social aspects of concussive injuries have remained largely absent from concussion protocols. The present study was undertaken to identify elite athletes’ psychological and social needs during the recovery process. Elite athletes with a history of concussion and mental performance consultants who work with concussed elite athletes participated in focus group interviews to shed light on these needs. A thematic analysis of these focus groups revealed six psychological and social needs: acceptance, normality, confidence, self-efficacy, trust in relationships, and social support. These themes are framed within concussion literature to help initiate a conversation on how psychological and social needs should be addressed as part of multifaceted efforts to improve concussion recovery.

Injury risk profile of amateur Irish women soccer players and players' opinions on risk factors and prevention strategies

OBJECTIVE

To explore injury profile, opinions on risk factors and injury prevention, among Irish amateur women soccer players.

DESIGN

A cross-sectional online survey.

SETTING

Irish amateur winter league.

PARTICIPANTS

Active players ≤18 years of age.

MAIN OUTCOMES

Differences were found between injured and uninjured groups, and risk factors that significantly predict soccer injury were identified.

RESULTS

168 injuries were reported by 83 respondents during the winter season. An increased prevalence of competition anxiety was observed in (53.8%:n = 85 of respondents) compared to other risk factors. There was a negative association between injuries and players' general health state (OR = 0.820, 95% CI 0.7-0.9, p = 0.007). Players' knowledge about some risk factors including playing position, joint hypermobility, and playing during menses contradicts current evidence. 50%; n = 67 of the respondents had not received any education on injury risk or prevention.

CONCLUSION

This study identified that Irish amateur women soccer players that responded have different characteristics, prevalence of risk factors and injury profiles to women players from different levels and countries. The findings suggest that some players may not be aware of the existing evidence base pertaining to common risk factors for injury. Further research is required to confirm the findings and explore the implementation of injury prevention strategies.

Mood, Psychological, and Behavioral Factors of Health-Related Quality of Life Throughout Recovery From Sport Concussion

OBJECTIVE

To measure alterations in mood, psychological, and behavioral factors in collegiate athletes throughout recovery from sport concussion (SC) compared with matched controls.

SETTING

University research laboratory.

PARTICIPANTS

Twenty (55% female) division I collegiate athletes with SC (19.3 ± 1.08 years old, 1.77 ± 0.11 m, 79.6 ± 23.37 kg) and 20 (55% female) uninjured matched controls (20.8 ± 2.17 years old, 1.77 ± 0.10 m, 81.9 ± 23.45 kg).

DESIGN

Longitudinal case control.

MAIN MEASURES

Self-reported concussion-related symptoms, anxiety, resilience, stigma, sleep disturbance, fatigue, and appetite were assessed at 3 time points in the SC group: T1 (≤72 hours of SC), T2 (7 days after T1), and TF (after symptom resolution). Control participants were evaluated at similar intervals. Group and group-by-sex differences were assessed using repeated-measures analyses of variance. Post hoc analyses were performed with Tukey's honestly significant difference (HSD) and paired-sample t tests.

RESULTS

The SC group had greater sleep disturbance than controls at T1 (P = .001; d = 1.21) and endorsed greater stigma at all time points (P ≤ .03; d ≥ 0.80). Stigma (F(2) = 3.68; P = 0.03; η2p = 0.12), sleep disturbance (F(2) = 5.27; P = .008; η2p = 0.15), and fatigue (F(2) = 3.46; P = .04; η2p = 0.11) improved throughout recovery in those with SC only. No differences were observed between males and females (P > .05).

CONCLUSION

Sleep disturbance and stigma were negatively affected by SC, highlighting potential areas for clinical interventions to maximize recovery in males and females.

The Comparative Mental Health Responses Between Post-Musculoskeletal Injury and Post-Concussive Injury Among Collegiate Athletes: A Systematic Review

BACKGROUND

The average annual national estimate of injuries sustained by collegiate athletes is 210,674, which encompasses both those of a musculoskeletal and a concussive nature. Although athletic injuries are sustained through physical means and produce physical symptoms, sports-related injuries may be a stressor among athletes that is related to mental health.

PURPOSE

The purpose of this systematic review is to summarize existing literature describing mental health responses in collegiate athletes with a concussion compared to those with a musculoskeletal injury.

STUDY DESIGN

Systematic Review.

METHODS

Systematic searches of PubMed, CINAHL, Scopus, ProQuest, and SportDiscus were completed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized. Methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tool. Data extracted from the included articles included the study design, number of participants, type of injury, sex, age, sport participation, outcome measures, and time to return to play.

RESULTS

A total of six articles were included. Peak depressive symptoms in athletes who sustain a concussion or musculoskeletal injury occur within one-week post-injury. No significant differences between the concussive and musculoskeletal groups anxiety scores were found at baseline or at each follow-up session. Athletes from both groups were found to be returning to their respective sports with anxiety scores representative of clinical anxiety.

CONCLUSION

Similar trends in depressive and anxiety symptoms at various time points post-injury were observed in athletes with both musculoskeletal and concussive injuries. This study identified that athletes were returning to play before their psychological symptoms had returned to their baseline.

LEVEL OF EVIDENCE

2a.

Participation in pre-injury level sport one-year following sport-related concussion: A prospective, matched cohort study

OBJECTIVES

To estimate the times taken to receive clearance to return to sporting activity and to return to pre-injury level of sport competition following sport-related concussion, and to estimate the proportion of athletes who were participating at their pre-injury level of sport competition six months and one-year following sport-related concussion.

DESIGN

Prospective cohort study.

METHODS

Amateur, adult athletes (16-38 years old) were diagnosed with sport-related concussion at a university-affiliated hospital emergency department. Participants were assessed within one-week, upon medical clearance to return to sporting activity, two weeks following return to sporting activity, six months, and 12 months following sport-related concussion. We assessed sex-, age-, and activity-matched non-injured, control participants at matched time-points. Participants were asked during each study assessment whether they were participating in any sport, in a different sport than before their sport-related concussion, in the same sport but at a lower level of competition than before their sport-related concussion, or in the same sport at the same level of competition than before their sport-related concussion.

RESULTS

Fifty concussed participants and 50 non-injured, control participants completed the study. The median times taken to receive clearance to return to sporting activity and to return to pre-injury level of sport competition following sport-related concussion were 13 days (95%CI=12,16) and 31 days (95%CI=28,32), respectively. One-year following sport-related concussion, 52% of participants reported that they were no longer participating in the same sport and at the same level of competition as they were before their sport-related concussion, compared with only 24% of participants in the non-injured, control group (p=0.003).

CONCLUSIONS

A greater percentage of athletes in the concussion group were not participating at their perceived pre-injury level of sport competition one-year following sport-related concussion compared with a non-injured control group. Factors that explain the lower proportion of amateur athletes participating at their pre-injury level of sport competition one-year after sport-related concussion are likely multifaceted and should be considered in future investigations.

Impairments in Dynamic Postural Control across Concussion Clinical Milestones

The aim of this study was to assess gait initiation (GI) performance longitudinally across clinical concussion recovery milestones through return to participation (RTP). We recruited 54 collegiate student-athletes, 27 with concussions and 27 matched controls (15 female and 12 male per group). Participants performed five trials of GI at baseline and again at five post-concussion clinical milestones: 1) Acute, the day clinical tests achieved baseline values on the 2) Balance Error Scoring System (BESS), 3) Immediate Post-Concussion Assessment and Cognitive Test ImPACT, 4) Asymptomatic, and 5) RTP Day. GI performance on six outcome measures (anterior/posterior and medial/lateral center of pressure displacements and velocities during the anticipatory postural adjustment [APA] phase and initial step length and velocity) with repeated-measures mixed model and pair-wise post hoc. A reliable change index (RCI) was calculated, and post-concussion participant's performance was compared to the RCI at milestones. There were significant interactions for APA posterior and lateral displacement, APA posterior velocity, step length, and step velocity. The post-hoc tests identified significant deficits across clinical milestones and at RTP for APA posterior and lateral displacement, step length, and step velocity. There were no post-hoc differences for any outcome measure in the control group. At RTP, 85.2-88.9% of concussion participants had at least one outcome measure which exceeded the 80% or 95% RCI. The primary finding of this study was persistent impairments in dynamic postural control, suggesting ongoing neurophysiological impairment despite clinical recovery. These results suggest that collegiate student-athletes may be RTP before neurophysiological recovery and potentially exposing themselves to elevated risk of recurrent concussion or subsequent musculoskeletal injury.

No Clinical Predictors of Postconcussion Musculoskeletal Injury in College Athletes

PURPOSE

This study aimed to identify clinical predictors of postconcussion subsequent musculoskeletal (MSK) injuries.

METHODS

We recruited 66 National Collegiate Athletic Association intercollegiate student-athletes with a diagnosed concussion as well as 36 National Collegiate Athletic Association student-athletes without a concussion. All participants completed a multifaceted concussion baseline consisting of 1) 22-item 0-6 self-reported symptom checklist with outcomes including both the number of symptoms endorsed (0-22) and 2) total symptom score (0-132), 3) Standard Assessment of Concussion, 4) Balance Error Scoring System, 5) Immediate Post-Concussion Assessment and Cognitive Testing, 6) clinical reaction time, and 7) the King-Devick as well as demographic and injury characteristics. The concussion participants completed the same examination acutely postconcussion, and binary logistic regression was used to identify predictors of subsequent MSK from the change scores (acute minus baseline). From the 66 concussed student-athletes, a subset 36, matched with the healthy athletes, compared the risk of subsequent MSK in the year before and year after their concussion.

RESULTS

The concussion participants were 1.78 times (95% confidence interval, 1.12-2.84; P = 0.015) more likely to suffer a lower extremity MSK in the year after their concussion than the control participants. The participant demographics and injury characteristics (P = 0.318) and concussion clinical outcomes (P = 0.461) did not predict subsequent MSK.

CONCLUSION

The concussion participants were 1.78 times more likely to sustain a subsequent MSK; however, no demographic, injury characteristic, or concussion assessments predicted the MSK. Thus, clinicians are not able to utilize common neurological measures or participant demographics to identify those at risk for subsequent lower extremity MSK. Injury prevention strategies should be considered for collegiate student-athletes upon premature return to participation after a concussion to reduce the subsequent MSK.

Gait Performance Is Associated with Subsequent Lower Extremity Injury following Concussion

PURPOSE

The purpose was to examine gait characteristics between collegiate athletes who did and did not sustain a lower-extremity musculoskeletal (LEMSK) injury in the year after concussion.

METHODS

Thirty-four NCAA collegiate athletes with diagnosed concussions were divided into two groups based on if they did (n = 16) or did not (n = 18) sustain a LEMSK in the year after concussion. Participants completed baseline testing before the start of the season and again at return to play postconcussion. Injuries were tracked using an electronic medical database. Participants were instrumented with three APDM Opal triaxial accelerometers and performed five single-task (ST) and five dual-task (DT) gait trials. Participants traversed a 10-meter walkway, turned around a specified endpoint, and returned to the original line. During DT, participants simultaneously walked and answered mini-mental style questions. A linear mixed-effects model assessed interactions and/or main effects between groups for gait speed, double support time, cadence, stride length, and cognitive accuracy.

RESULTS

The LEMSK group walked slower (ST, 1.15 ± 0.10 m·s; DT, 1.01 ± 0.10 m·s) than the uninjured group (ST, 1.23 ± 0.11 m·s; DT, 1.10 ± 0.11 m·s) during both ST (P = 0.04) and DT (P = 0.03). The injury group spent longer in double support (ST, 20.19% ± 2.34%; DT, 21.92% ± 2.13%) than the uninjured group (ST, 18.16% ± 2.60%; DT, 20.00% ± 2.32%) during both ST (P = 0.02) and DT (P = 0.02). The injury group had a significantly lower cognitive accuracy (89.56% ± 6.48%) than the uninjured group (95.40% ± 7.08%) across time points (P = 0.02).

CONCLUSIONS

There were significant differences in gait characteristics and cognitive accuracy between those who did and did not sustain a LEMSK injury after concussion. The LEMSK group demonstrated a conservative gait strategy both before and after their concussive injury.

Comparison Between Classic and Light Touch Massage on Psychological and Physical Functional Variables in Athletes: a Randomized Pilot Trial

BACKGROUND

Despite the general belief of the benefits and the widespread use of massage in sport field, there are limited empirical data on possible effectiveness of massage on psychological and physical functional variables.

PURPOSE

The main objective of the present study was to compare the effectiveness of classical and light touch massage on psychological and physical functional variables in athletes.

SETTING

Athletic club of Valencia.

PARTICIPANTS

20 amateur athletes were recruited from two athletic clubs.

RESEARCH DESIGN

A single-blind, randomized, pilot-placebo trial.

INTERVENTION

The subjects were randomly allocated to two different groups: a) Massage group (MG) (n=10); b) Control group (CG) (n=10). The intervention period lasted one month (one session per week).

MAIN OUTCOME MEASURES

Assessment of the participants was performed at baseline and 24 hours following the completion of the intervention. Outcome measures included hip flexion, knee extension, and mood state.

RESULTS

The results suggest that MG obtained better results on physical variables (p < .05). However, for both groups, trends suggest significant improvements in the overall mood state of the participants (p < .05).

CONCLUSION

Our results suggest that classic massage could be an effective intervention to improve functional physical variables in athletes. However, trends suggest that a light touch intervention could provoke improvements in physiological measures.

Differential Effects of Acute and Multiple Concussions on Gait Initiation Performance

OBJECTIVE

To identify the effect of acute and multiple concussions on gait initiation performance.

DESIGN

Cohort study.

SETTING

University research center.

PARTICIPANTS

A population-based sample of participants (N=45) divided into 3 groups: No Prior Concussion, ≥3 Prior Concussions, and Acute Concussion. The Acute Concussion participants were assessed within 24 hours of their concussion. Participants were matched based on (1) sport, (2) position, and (3) anthropometric measures.

INTERVENTIONS

Participants were tested on a single occasion and performed 5 trials of gait initiation on 4 force plates. The No Prior Concussion and ≥3 Prior Concussions groups were tested out of their primary athletic season.

MAIN OUTCOME MEASURES

The dependent variables were the posterior and lateral displacement and velocity of the center of pressure (COP) during the anticipatory postural adjustment phase and initial step kinematics (step length and step velocity). Comparisons between groups used a 1-way analysis of variance with Tukey post hoc when significant effects were identified and effect sizes were calculated.

RESULTS

There were significant effects for group for all 6 outcome measures with large effect sizes. Post hoc tests identified differences between Acute Concussion and No Prior Concussion groups for all measures. The ≥3 Prior Concussions group and No Prior Concussion group were different for COP posterior displacement (4.91±1.09 and 4.91±1.09cm, respectively, P=.032, d=0.91) and velocity (0.18±0.06 and 0.27±0.08m/s, respectively, P=.002, d=1.27).

CONCLUSION

There was continuum of performance identified whereby the Acute Concussion participants performed worse and the No Prior Concussion participants performed the best. The ≥3 Prior Concussions generally fell between these 2 groups, but only statistical significance on COP posterior displacement and velocity. These results suggest there may be subtle neurophysiological deficits present in collegiate student-athletes with ≥3 Prior Concussions group, and further investigation over the lifespan is warranted.

Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment

The risk factors of concussion may be categorized as intrinsic (internal factors specific to the individual) or extrinsic (external factors related to the environment or sport). Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. In most cases, the symptoms of concussion resolve in the initial few days following the injury, and a strategy involving a gradual return to sport and school is recommended. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. J Orthop Sports Phys Ther 2019;49(11):799-810. doi:10.2519/jospt.2019.8926.

Sport-Related Concussion Evaluation and Management

Concussion is a challenging and controversial medical diagnosis that can test even the most seasoned practitioner. Knowledge on this topic is ever evolving. It was not so long ago that grading guidelines were based on loss of consciousness and amnesia. Medicine has seen a renaissance of discovery over the past 20 years in concussion evaluation and management. A PubMed search for "concussion" between 1990 and 2000 produced just over 1000 articles and that same search including the last 18 years expands to over 10,000 publications. The most recent knowledge and recommendations are discussed based on the published evidence.

Health-Related Quality of Life Following Concussion in Collegiate Student-Athletes With and Without Concussion History

The purpose of this study was to compare global and specific health-related quality of life (HRQOL) throughout concussion recovery between those with and without concussion history. Student-athletes diagnosed with concussion completed global (Short Form-12v2; SF-12) and specific (Hospital Anxiety and Depression Scale: HADS) HRQOL assessments at baseline, 24-48 h, asymptomatic, return-to-play, and 6-months post-injury. Baseline scores were compared to post-injury time points for SF-12 subscores (physical and mental; PCS-12, MCS-12) and HADS subscores (depression and anxiety; HADS-D, HADS-A). We conducted a 2 × 5 mixed model ANOVA for group (with and without concussion history) and time (four post-injury assessments compared to baseline). We did not observe interaction or main effects for group, except those with concussion history had worse HADS-D subscores than those without concussion history. PCS-12 subscores were worse at 24-48 h, asymptomatic, and return-to-play compared to baseline, but returned to baseline 6-months post-injury. MCS-12 subscores did not differ at any time points. HADS-D subscores worsened 24-48 h post-injury, but improved for additional assessments compared to baseline. HADS-A improved post-injury compared to baseline at asymptomatic, return-to-play, and 6-month assessments, but was similar to baseline 24-48 h post-injury. HRQOL physical aspects slightly worsened post-injury and restored to baseline after returning to play.