Early vs. delayed evaluation and persisting concussion symptoms during recovery in adults

Risk Factors for Fall-Related Mild Traumatic Brain Injuries Among Older Adults: A Systematic Review Highlighting Research Gaps

Mild traumatic brain injury (mTBI) is commonly undiagnosed, delaying treatment and recovery. Approximately 80% of mTBIs in older adults stem from falls, yet the predictive factors remain unclear. This systematic review aimed to examine the risk factors for fall-related mTBIs among older adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed (Prospero ID: CRD42023377847). The scope included prospective studies analyzing the risk factors for fall-related mTBIs in adults ≥ 60 years. The primary outcome measure was the relative risk for fall-related mTBIs, and the secondary outcomes were fall rate, total falls, and faller/non-faller count among those with and without an mTBI. CINAHL Plus, Health Source: Nursing Academic Edition, Nursing and Allied Health Database, Medline via PubMed, SPORTDiscus, and Web of Science were searched on 4 November 2022 and 31 May 2024. Additional electronic searches were conducted. Two authors planned to screen the articles and assess the quality and risk of bias, with a third author adjudicating disagreements. Results were to be presented in a narrative synthesis. The database search yielded 434 records; 410 titles and abstracts were screened after deduplication, and 71 reports underwent a full-text review. No prospective observational studies were eligible because they did not fulfil the following: (1) focus on an mTBI (46 records); (2) exclusively assess individuals aged ≥60 (20 records); or (3) examine falls (5 records). Given the devastating consequences of fall-related mTBIs among older adults, there is an urgent need to identify the risk factors to improve screening and intervention.

Identifying the 'Miserable Minority' Among Pediatric Patients Following Concussion

OBJECTIVES

To investigate whether there are empirically-detectable subgroups of concussion severity and recovery across three consecutive concussions, as well as to define risk factor and clinical assessment differences across subgroups.

METHODS

The present study was a retrospective chart review of 202 adolescents 13.17 ± 1.99 years old who presented to a concussion specialty clinic within 30 days of injury for multiple injuries between 2019 and 2020. Participants included patients from a specialty clinic for two (n = 202) or three (n = 68) total concussions. Latent class analysis (LCA) was used to identify subgroups based upon concussion symptom severity and recovery time. Risk factors (sex, age at first injury, and histories of anxiety, depression, migraine, motion sickness, ocular dysfunction, and attention-deficit/hyperactivity disorder [ADHD] or learning disability [LD]) were compared across subgroups.

RESULTS

A two-class solution yielded one group of 163 participants characterized by lower symptoms and shorter recovery times (80.7%, "normal") and 39 participants (19.3%, "miserable minority") characterized by higher symptoms and longer recovery times. Only female sex (OR = 4.91, p = 0.005) was a significant predictor of class membership. The miserable group presented for treatment nearly 4 days later (9.41 days) compared to the normal group (5.74 days) for the first injury, and almost 2 days later for the second injury (7.33 vs 5.26 days).

CONCLUSIONS

Approximately 1 in 5 patients who presented to a concussion specialty clinic for a repeat concussion were classified in the miserable minority subgroup. This subgroup was characterized by markedly higher initial symptom burdens and over double the recovery time.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III evidence.

Quantitative pupillometry as a potential biomarker in early concussion assessment

BACKGROUND

There are limited objective methods when it comes to identifying and diagnosing concussion. Pupil assessment is performed routinely as a standard-of-care following traumatic brain injury (TBI). Unlike the highly subjective and limited reliability of pupil assessment using penlights and flashlights, Quantitative pupillometry (QP) is an established, valid, and reliable method of pupillary assessment. This study aims to investigate the use of QP values in concussion evaluation.

METHODS

This observational study analyzed data collected by the North Texas Concussion Registry (ConTex). ConTex enrolls subjects who are >5-years of age and clinically diagnosed with concussion. Subjects are excluded if they had moderate or severe traumatic brain injury, spinal cord injury with an American Spinal Injury Association score of C or worse, or if the injury occurred > 6 months from enrollment. Data included demographics, medical history, time since concussion, the Sport Concussion Assessment Tool (SCAT5©) post-concussion symptom scale (PCSS), and QP assessment using the PLR3000® (Neuroptics Inc.) hand-held pupillometer. This study identified all subjects clinically diagnosed with concussion who had completed QP assessment, totaling 162. We created tertiles to describe the lowest (0-20), middle (21-43), and the highest (44-113) symptom score groupings to examine QP data.

RESULTS

Of 162 subjects, 88 were female (54.3%), with a mean age of 15.8 (SD=6.9) years. Most (49.4%) occurrences were sport-related injuries. The mean time since injury was 21 (SD=28.6) days. The mean SCAT5 PCSS score was 37.3 (SD=25.6). A significant difference within average and maximum constriction velocities (p=.041 and 0.034, respectively) was found between subjects seen early (<2weeks) versus late (>2weeks) after injury. Pupillometry values were statistically different across SCAT5 PCSS tertiles for anisocoria after light exposure (p=.046).

CONCLUSIONS

This exploratory study is among the first to show that certain QP values - latency of constriction, constriction velocity, and average dilation velocity - may be useful in providing objective metrics when evaluating more symptomatic concussion.

Recovery, interrupted: persisting symptoms after concussion and the power of iatrogenesis

Persisting symptoms after concussion (PSaC) affect up to 30% of children, adolescents, and young adults beyond 1 month post-injury, posing challenges in clinical care. This retrospective study examined 54 patients referred for neuropsychological evaluation due to PSaC, exploring factors contributing to symptom persistence. Results showed that 75.9% of patients experienced symptoms attributable to non-concussion factors, with 90.7% lacking evidence-based care post-injury. Pre-existing conditions, including migraines, anxiety, depression, and other psychiatric disorders, correlated with symptom burden. Linear regression models indicated that these psychiatric factors and the absence of evidence-based recommendations predicted symptom severity [R2 = .314, p = .002], with other psychiatric disorders showing a significant effect [β = 2.28, p = .008]. History of any psychiatric disorder predicted current symptom count [R2 = .121, p = .010]. Logistic regression identified migraines (Nagelkerke R2 = .389, p = .000) and depression (Nagelkerke R2 = .124, p = .033) as predictors of non-concussion etiology. Anxiety, depression, migraines, psychiatric disorders, and lack of evidence-based care predicted non-concussion symptoms (Nagelkerke R2 = .575, p = .000). These findings highlight the importance of holistic, individualized care in concussion. Early neuropsychological involvement may improve diagnosis, reduce iatrogenic effects, and optimize recovery through tailored evidence-based interventions.

Introduction of the 'Blue Card' Concussion Policy to Semi-Elite Australian Football: Medical Staff Experiences and Perceptions

Background

The Western Australian Football League (WAFL) introduced a new umpire driven 'blue-card rule' for concussion, but its benefit to the sports medicine team is unknown.

Purpose

To determine the experiences and perceptions of medical staff within the 2022-2023 Men's and Women's WAFL competitions following the introduction of the 'blue-card rule'.

Study Design

Cross-sectional study.

Method

An online survey was delivered through Qualtrics to all WAFL medical staff (doctors, physiotherapists, head trainers). The survey contained four sections (demographics, concussion knowledge, concussion exposure and blue-card perceptions) with closed and multiple-answer questions. Standard methods for reporting descriptive data were applied, including mean ± standard deviation (SD) and proportions (%). Between-group differences were assessed using chi-square tests, and significance was accepted at p <0.05.

Results

Response rate was 48% (n=7 doctors, n=12 physiotherapists, n=12 head trainers). Most staff (70%) did not agree that the 'blue-card rule' was a helpful concussion policy or should remain within the WAFL. Staff also felt umpires are not qualified to identify suspected concussions on-field (67%). Over two-thirds of medical staff feel the Football Commission needs to provide education about concussion policies before the commencement of each season. Only 33% of medical staff felt completely confident in delivering a sideline assessment, and 17% felt completely confident in their diagnostic capabilities. Relationships between medical and other staff were not substantially impacted by the 'blue-card rule'.

Conclusions

Medical staff within the WAFL reported the 'blue-card rule' as an ineffective concussion identification tool and did not support its continued use for future WAFL seasons. Staff suggested that the Football Commission needs to provide more education on concussion policies before the commencement of each season.

Level of Evidence

3.

Concussion management and concussion recovery in Gaelic games: a qualitative analysis

Background

The purpose of this qualitative research study was to interview current and retired Gaelic games athletes to understand the current landscape of concussion recovery in Gaelic sports from the athlete perspective.

Methods

A grounded theory methodology was employed to explore the experiences of a cohort of Gaelic games athletes (n = 22) regarding recovery from concussion, the levels of concussion awareness in Gaelic sports and their opinions on current concussion identification protocols. The study's data were gathered through semi-structured interviews.

Results

Two major themes were identified, (1) Male and female athletes experience a range of acute and chronic symptoms post-SRC and (2) Gaelic sports athletes are expected to demonstrate constant allegiance and commitment to the GAA. These themes were further divided into categories and subcategories.

Conclusion

Based on the experiences of the cohort of Gaelic sports athletes, there exists a wide variation of SRC symptomology in the acute, and chronic (post-concussion syndrome) phases. In many cases, there are reports of long-term side effects associated with the perceived mismanagement or misdiagnosis of SRC in Gaelic sports. Gaelic sports athletes require a more robust SRC management system to support and manage SRC in the acute, chronic and long-term phases.

Posttraumatic stress symptoms in recovery from concussion

BACKGROUND

Previous literature suggests that lingering concussion symptoms may be influenced by psychological factors. The relationship of posttraumatic stress symptoms (PTSS) during recovery with pre-existing/injury related factors and concussion symptomology is not fully understood. Identification of factors contributing to symptoms of posttraumatic stress may provide guidance to improve treatment following concussion.

METHOD

This study included 287 participants (Male 40.42%, n = 116; Female 59.58%, n = 171) aged 13-75 years diagnosed with a recent concussion at one of the North Texas Concussion Registry (ConTex) specialty concussion clinic sites. Preinjury emotional history, injury related factors, and emotional state at time of initial evaluation were analyzed as predictors of post-traumatic stress symptoms (PCL-5) during recovery.

RESULTS

Sixty-one percent of participants endorsed at least one PTSS. Correlations were found between initial Sport Concussion Assessment Tool 5Ⓡ (SCAT5) total emotional symptom severity and screening measures for anxiety (GAD-7; r = .453, p < .001) and depression (PHQ-8; r = .550, p < .001) symptom scores. Of the measures from the initial visit included in the multiple regression model predicting severity of PTSS at follow-up (R2 = 0.554, β < .001), three measures predicted PTSS severity: initial SCAT5 total emotional symptom severity (β = 0.565, p < .001), PHQ-8 score (β =.166, p = .009), and GAD-7 score (β = 0.119, p = .044).

CONCLUSIONS

Symptoms of anxiety and depression along with specific SCAT5 emotional symptoms present at the time of initial evaluation may serve to predict overall level of PTSS and increased risk for PTSS during recovery. PTSS may be another dimension of response to injury and concussion recovery, with a large percentage of individuals endorsing at least one PTSS. Clinicians can utilize brief assessments such as the SCAT5 at the time of initial clinical evaluation to identify those at risk for PTSS following concussion.

Stunt performers' reluctance to self-report head trauma: a qualitative study

BACKGROUND

Mild traumatic brain injuries receive voluminous attention in the research literature, but this is confined almost entirely to sports and military contexts. As an occupation, performing stunts in film, television, and entertainment places the head at high risk of repetitive impact and whiplash, but stunt performers do not enjoy the same level of healthcare supervision and access as that provided to sports participants. Therefore, the aim of this study was to evaluate stunt performers' qualitative perceptions of reporting and management of head trauma in their industry.

METHODS

After giving their informed consent, 87 motion picture and television stunt performers responded to a query about their views of ways to improve how stunt performers' occupational head trauma-specifically head impacts and head whips that could cause a concussion-are reported and managed. We analyzed their responses via content and thematic analyses. Two researchers independently marked and categorized key words, phrases, and texts to identify codes that described participants' comments. They then revised, discussed, and resolved coding discrepancies through consensus to establish inter-coder reliability. Next, we identified thematic patterns that described participants' understanding of the stunt performer industry and what must change to facilitate reporting of head trauma. We derived themes from data that occurred multiple times, both within and across short answer responses.

RESULTS

We identified three primary themes cited by the stunt performers as needs in their industry: (1) Need to Reduce the Stigma of Reporting a Stunt-Related Injury, (2) Need to Eliminate the "Cowboy Culture," and (3) Need to Improve the Quality of the Work Environment.

CONCLUSIONS

Stunt performers are crucial members of a global entertainment industry valued at approximately US$100 billion annually. A large segment of the world's population consumes their work in motion pictures, television, and live entertainment. When they are given an anonymous opportunity to speak, stunt performers offer insight into and recommendations for industry changes-primarily cultural and educational in nature-that could improve their physical and mental health, career longevity, and employability when they are confronted with head trauma.

Specialist healthcare services for concussion/mild traumatic brain injury in England: a consensus statement using modified Delphi methodology

OBJECTIVE

To establish a consensus on the structure and process of healthcare services for patients with concussion in England to facilitate better healthcare quality and patient outcome.

DESIGN

This consensus study followed the modified Delphi methodology with five phases: participant identification, item development, two rounds of voting and a meeting to finalise the consensus statements. The predefined threshold for agreement was set at ≥70%.

SETTING

Specialist outpatient services.

PARTICIPANTS

Members of the UK Head Injury Network were invited to participate. The network consists of clinical specialists in head injury practising in emergency medicine, neurology, neuropsychology, neurosurgery, paediatric medicine, rehabilitation medicine and sports and exercise medicine in England.

PRIMARY OUTCOME MEASURE

A consensus statement on the structure and process of specialist outpatient care for patients with concussion in England.

RESULTS

55 items were voted on in the first round. 29 items were removed following the first voting round and 3 items were removed following the second voting round. Items were modified where appropriate. A final 18 statements reached consensus covering 3 main topics in specialist healthcare services for concussion; care pathway to structured follow-up, prognosis and measures of recovery, and provision of outpatient clinics.

CONCLUSIONS

This work presents statements on how the healthcare services for patients with concussion in England could be redesigned to meet their health needs. Future work will seek to implement these into the clinical pathway.

Concussion Rehabilitation and the Application of Ten Movement Training Principles

Concussion awareness continues to grow in all aspects of healthcare, including the areas of prevention, acute care, and ongoing rehabilitation. Most of the concussion research to date has focussed on the challenges around screening and diagnosing what can be a complex mix of brain impairments that overlay with additional pre-existing comorbidities. While we expect further progress in concussion diagnosis, progress also continues to be made around proactive rehabilitation, with the emergence of interventions that can enhance the recovery process, maximise function and independence with a return to study, work, and play. Traditionally, optimal multimodal assessments of concussion have treated the physical, cognitive, and psychological domains of brain injury separately, which supports diagnosis, and informs appropriate follow-up care. Due to the complex nature of brain injury, multimodal assessments direct care toward professionals from many different disciplines including medicine, physiotherapy, psychology, neuropsychology, ophthalmology, and exercise physiology. In addition, these professionals may work in different fields such as sports, neurorehabilitation, vestibular, musculoskeletal, community, vocational, and general practice clinical settings. Rehabilitation interventions for concussions employed in practice are also likely to use a blend of theoretical principles from motor control, cognitive, and psychological sciences. This scale of diversity can make information dissemination, collaboration, and innovation challenging. The Ten Movement Training Principles (MTPs) have been proposed as a usable and relevant concept to guide and support clinical reasoning in neurorehabilitation. When applied to concussion rehabilitation, these same 10 principles provide a comprehensive overview of key rehabilitation strategies for current and future practice. Future collaborations can use these training principles to support clinical and research innovations including the rapid rise of technologies in this growing field of rehabilitation practice.