Concussion history associated with adolescent psychological distress but not hazardous gambling: a cross-sectional study

BACKGROUND

Sustaining multiple concussions over one's lifetime may be associated with behavioral and mood changes beyond the acute phase of injury. The present cross-sectional study examined the relationship between concussion history, the incidence of current moderate-severe psychological distress, and lifetime adolescent hazardous gambling in high school students.

METHODS

Four-hundred fifty-nine high school students from southern Sweden (age: 16.81 ± 0.83, 58.2% male) completed a survey assessing concussion history (0,1,2…>8), psychological distress using the Kessler-6 scale, and lifetime hazardous gambling using the NODS-CLiP scale.

RESULTS

Participants who self-reported three or more concussions were more likely to endorse moderate-severe symptoms of psychological distress than those with no concussion history while controlling for covariates, OR = 2.71, 95% CI [1.19, 6.18]. In contrast, concussion history was not associated with hazardous gambling after controlling for confounding variables.

CONCLUSIONS

Self-reporting three or more concussions was associated with increased current psychological distress beyond the acute phase of injury among high school students. Adolescents who have sustained multiple concussions should undergo mental health evaluations beyond the acute phase of injury to identify and treat psychological distress, but probing for hazardous gambling may not be clinically relevant in this previously concussed adolescent population.

Concussion Symptoms and Neurocognitive Performance of Children and Adolescents on Antidepressants

INTRODUCTION/PURPOSE

There is a well-established association between preexisting depression/anxiety and greater postconcussion symptom burden, but the potential impact of antidepressant medications has not been fully explored. The primary objective of this study was to compare preinjury/baseline and postinjury concussion symptom scores and neurocognitive performance of athletes on antidepressant medications, both with healthy controls and with those with depression/anxiety not on antidepressants.

METHODS

This is a cross-sectional study using data collected from 49,270 junior and high school athletes from computerized neurocognitive assessments (Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]) administered between 2009 and 2018 held by the Massachusetts Concussion Management Coalition. The main outcome measures were symptom scores and neurocognitive performance measures, all of which were assessed both at baseline and postinjury. Statistical analysis included analysis of variance and Tukey pairwise comparisons for continuous variables and Fisher's exact test for categorical variables. Multivariate regression models were used to adjust for potential confounding variables.

RESULTS

Both at baseline and postinjury, athletes with depression/anxiety had mean total symptom scores that were more than double that of healthy controls regardless of antidepressant use. Although there were no significant differences in neurocognitive performance at baseline, depression/anxiety was associated with small but significant decreases in postinjury visual memory and visual motor scores.

CONCLUSIONS

Both at baseline and after sustaining a concussion, young athletes with depression/anxiety experience significantly greater symptom burden compared with healthy controls regardless of antidepressant use.

Dual statistical models link baseline visual attention measure to risk for significant symptomatic concussion in sports

Aim

Athletic pre-season testing can establish functional baseline for comparison following concussion. Whether impacts of future concussions may be foretold by such testing is little known.

Materials & methods

Two sets of models for a significant burden of concussion were generated: a traditional approach using a series of logistic regressions, and a penalized regression approach using elastic net.

Results

3091 youth and adult athletes were baseline-assessed. 90 subsequently experienced concussion and 35 were still experiencing a significant burden of concussion when tested within two weeks. Both models associated prior history of head injury and visual attention-related metrics with a significant burden of concussion.

Conclusion

Pre-season testing of visual attention may identify athletes who are at risk for significant sports-related concussion.

Premorbid Risk Factors and Acute Injury Characteristics of Sport-Related Concussion Across the National Collegiate Athletic Association: Findings from the Concussion Assessment, Research, and Education (CARE) Consortium

BACKGROUND

Previous sport-related concussion research highlights post-injury characteristics that influence recovery trajectories; however, there is limited information regarding premorbid factors that affect sport-related concussion risk.

OBJECTIVE

We aimed to (a) compare premorbid demographic factors among a large cohort of collegiate student athletes who did or did not sustain a sport-related concussion and (b) assess differences in acute injury characteristics based on biological sex and contact level.

METHODS

We conducted a cohort study of university student athletes from 22 sports enrolled in the Concussion Assessment, Research, and Education (CARE) Consortium study from 2014 to 2021 (n = 1804 student athletes with sport-related concussions; n = 21,702 student athletes without sport-related concussions).

RESULTS

Statistical analyses indicated student athletes who self-identified as Black (odds ratio [OR] = 1.61; 95% confidence interval [CI] = 1.42, 1.81) or multiracial (OR = 1.32; 95% CI 1.10, 1.59) demonstrated greater odds of experiencing sport-related concussions than White-identifying student athletes. Additional findings suggest male athletes (OR = 1.47; 95% CI 1.20, 1.81) and contact sport student athletes (OR = 1.40; 95% CI 1.16, 1.70) may be at increased odds for sport-related concussions if they were previously diagnosed with attention deficit hyperactive disorder. Notable post-injury characteristics across sexes included differences in the incident loss of consciousness (male: 5.9%, female: 2.6%; p < 0.001), post-traumatic amnesia (male: 13.6%, female: 5.1%; p < 0.001), and retrograde amnesia (male: 6.8%, female: 2.8%; p < 0.001). A greater proportion of contact-sport student athletes experienced an altered mental status (52.7%) than limited contact (36.2%) and non-contact (48.6%) [p < 0.001]. Last, student athletes participating at lower contact levels were more likely to have a longer delay in removal from activity following injury (contact: 73.6 ± 322.2 min; limited contact: 139.1 ± 560.0 min; non-contact: 461.4 ± 1870.8 min; p = 0.005).

CONCLUSIONS

The present study provides contemporary pre- and post-sport-related concussion injury characteristics using a considerably sized cohort of collegiate student athletes. These findings support previous work suggesting sport-related concussion results in complex individualized clinical presentations, which may influence management strategies.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Attention-Deficit Hyperactivity Disorder and Learning Disabilities Modify Recovery and Sport Behavior Following Sport-Related Concussion

Limited evidence exists concerning how a diagnosis of attention-deficit hyperactivity disorder and/or learning disabilities (ADHD/LD) modifies recovery and behavior following sport-related concussion (SRC). To understand how ADHD/LD modifies the post-SRC experience, we conducted a retrospective cohort study of concussed young athletes through phone interviews with patients and guardians. Outcomes included time until symptom resolution (SR) and return-to-learn (RTL), plus subjective changes in post-SRC activity and sports behavior. Multivariate Cox and logistic regression was performed, adjusting for biopsychosocial characteristics. The ADHD/LD diagnosis was independently associated with worse outcomes, including lower likelihood to achieve SR (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = [0.41-0.94]; P = .02) and RTL (HR = 0.55, 95% CI = [0.36-0.83]; P < .01) at any time following injury, and increased odds of changing sport behavior after concussion (odds ratio [OR] = 3.26, 95% CI = [1.26-8.42], P = .02), often to a safer style of play (62.5% vs 39.6%; P = .02) or retiring from the sport (37.5% vs 18.5%; P = .02). These results provide further evidence of the unique needs for athletes with ADHD/LD following SRC.

Long-term test-retest reliability of the vestibular/ocular motor screening for concussion in child athletes: A preliminary study

The Vestibular/Ocular Motor Screening (VOMS) is a sport-related concussion screening tool that assesses vestibular ocular reflex (VOR) and oculomotor symptom provocation. Long-term test-retest reliability of the VOMS over multiple athletic seasons has not yet been established in a pediatric population. Fifty-one child athletes (females = 28, 54.9%) 8-13 years of age, completed a baseline VOMS assessment at two timepoints, 18 months apart. Cronbach's alpha was used to examine the internal consistency at both time points. Two-way mixed intra-class correlation coefficients and Cohen's Kappa statistics were used to evaluate test-retest reliability. High internal consistency existed at both initial (α = 0.91) and follow-up (α = 0.95) for VOMS symptom provocation items. Strong inter-item correlations were noted between vertical VOR (r = ≥0.70) and visual motion sensitivity (VMS) (r = ≥0.70). Fair agreement was produced for convergence (κ = 0.23, vertical VOR (κ = 0.25) and VMS (κ = 0.25), as well as reliability on NPC distance (ICC2,k = 0.31). All other VOMS scores yielded poor agreement between time points. Symptom provocation was the same for 49% of athletes between timepoints, while 31.4% had a decrease in scoring at follow-up. Symptom provocation from VOMS tasks lessened with increasing age and time; therefore, clinicians should consider annual baseline testing to improve accuracy for concussion evaluation and management in pediatrics.

Evaluation of differences across age groups in the incidence, severity, and recovery of concussion in adolescent student-athletes from 2009 to 2019

OBJECTIVE

Concussion incidence is known to be highest in children and adolescents; however, there is conflicting evidence about the effect of age on concussion risk and recovery within the adolescent age range. The heterogeneity of results may be partially due to the use of age groupings based on convenience, making comparisons across studies difficult. This study evaluated the independent effect of age on concussion incidence, severity, and recovery in student-athletes aged 12-18 years using cluster analysis to define groupings.

METHODS

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores of 11,403 baseline tests and 4922 postinjury tests were used to calculate the incidence rates for adolescent student-athletes grouped into 3 age bands (12-13, 14-15, and 16-18 years of age) on the basis of clustering analysis. The recently created Severity Index was used to compare concussion severity between groups. Follow-up tests for subjects who sustained a concussion were used to evaluate recovery time. The chi-square test and 1-way ANOVA were used to compare differences in demographic characteristics and concussion incidence, severity, and recovery. Multivariable logistic and linear regressions were used to evaluate the independent effects of age on concussion incidence and severity, respectively. Multivariable Cox hazard regression was used to evaluate differences in recovery time. Further analyses were conducted to directly compare findings across studies on the basis of the age groupings used in prior studies.

RESULTS

Multivariable regression analyses demonstrated that the 14- to 15-year-old age group had a significantly higher concussion incidence than both the 12- to 13-year-old (14- to 15-year-old group vs 12- to 13-year-old group, OR 1.57, 95% CI 1.16-2.17, p = 0.005) and 16- to 18-year-old (16- to 18-year-old group vs 14- to 15-year-old group, OR 0.79, 95% CI 0.69-0.91, p = 0.0008) age groups. There was no difference in incidence between the 12- to 13-year-old and 16- to 18-year-old groups (16- to 18-year group vs 12- to 13-year group, OR 1.26, 95% CI 0.93-1.72, p = 0.15). There were also no differences in concussion severity or recovery between any groups.

CONCLUSIONS

This study found that concussion incidence was higher during mid-adolescence than early and late adolescence, suggesting a U-shaped relationship between age and concussion risk over the course of adolescence. Age had no independent effect on concussion severity or recovery in the 12- to 13-, 14- to 15-, and 16- to 18-year-old groups. Further analysis of the various age groups revealed that results may vary significantly with minor changes to groupings, which may explain the divergent results in the current literature on this topic. Thus, caution should be taken when interpreting the results of this and all similar studies, especially when groupings are based on convenience.

Epidemiology of sport-related concussion rates in female contact/collision sport: a systematic review

Objectives

To determine sport-related concussion (SRC) incidence rates in female contact/collision sport.

Design

Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Data sources

Four databases (PubMed, SportsDiscus, Web of Science, CINAHL) were searched for data from 2012 to 2021.

Eligibility criteria

Studies reporting SRC incidence rates or the number of concussions and athletic exposures (AEs) per 1000 participating events or hours in healthy female contact and collision sport athletes of any age were included.

Results

The search yielded 8438 non-duplicate articles. Following screening, 19 were included in the analysis (median quality score=70%), with 8 reporting match or training incidence rates. Studies were primarily from US high school and collegiate populations; data are reported for eight sports. Rugby union reported the highest match SRC rates (8.2-16.11 per 1000 AE hours), followed by Gaelic football (5.21 per 1000 AE hours) and soccer (2.08-4.04 per 1000 AE events). Where available, match SRC rates were substantially higher than training and overall SRC rates.

Conclusion

Female sports such as rugby union, Gaelic football and soccer present the highest risk for SRCs within the available data. Previous research indicates a potentially greater injury burden for female athletes experiencing SRCs than their male counterparts. Thus, future research should analyse concussion knowledge and return-to-play protocols in these sports. Future research should also prioritise exploration of the gap in SRC rates within amateur sports, and data should be presented specifically in the context of athletic exposures (match vs training).

Trial registration number

CRD42021281569.

Research and Implementation of Distributed Computing Management System for College Students' Sports Health Based on Integrated Regional Collaborative Medical Care

This paper constructs and applies a university student sports health management system through the theory of integrated regional collaborative medical care and distributed computing technology. Firstly, it analyzes the current situation and problems of cross-regional medical care, the root causes, and the corresponding business scenarios, reflecting the development trend of cross-regional medical care, in the light of the current practical needs of cross-regional medical care. In response to the strong demand for cross-regional medical care, this paper gives the overall design of the distributed computing system, for the deployment and architecture of the cross-regional platform; the registration of cross-regional patients, regional platforms, and health events and documents; and data exchange, service integration, and process integration, etc. The corresponding design is given. The research was conducted on several medical institutions to refine the functional requirements for the construction of the regional collaborative medical platform, and the requirements were analyzed to present the research results of the collaborative medical project. Based on this, requirements were made for the preparation of the project construction data center and medical institutions, and the remote consultation and two-way referral modules of the distributed collaborative medical platform were designed, which are processed and analyzed through a system composed of multiple servers. The results are returned to the user, and the design results were tested for functionality, compatibility, security, and other usability tests. The necessity and feasibility of the college physical health test data platform were analyzed. Students have various needs for physical test data management, the necessity of designing the college physical health test data platform, and the feasibility of the college physical health test data platform in terms of technical means, theoretical basis, and social environment.

Attention-Deficit/Hyperactivity Disorder-Related Self-Reported Symptoms Are Associated With Elevated Concussion Symptomatology

The aim of the present investigation was to provide insight into how postconcussion symptomatology may be altered in individuals exhibiting attention-deficit/hyperactivity disorder (ADHD)-related behaviors and examine factors that may be responsible for driving such relationships. A total of 99 individuals were assessed during the subacute phase of concussion recovery. Inattentive symptomatology, but not diagnosis of ADHD, was related to greater concussion-symptom severity and overall symptoms endorsed. Cluster and factor analyses highlighted that the relationship between ADHD symptomatology and concussion symptomatology was not a function of overlapping constructs being assessed (i.e., concussion-related symptomatology was not a proxy of ADHD-related symptomatology). These relationships were not mediated by parental observations of impairments in behaviors associated with executive functioning (i.e., executive dysfunction was not driving the greater concussion-related symptomatology associated with ADHD-related symptomatology). These findings highlight the importance of moving beyond categorical frameworks of ADHD to, instead, consider the continuum of underlying behaviors.

Thinking Otherwise: Bringing Young People into Pediatric Concussion Clinical and Research Practice

Background:

As rates of pediatric concussion have steadily risen, and concerns regarding its consequences have emerged, pediatric concussion has received increased attention in research and clinical spheres. Accordingly, there has been a commitment to determine how best to prevent and manage this injury that so commonly affects young people. Despite this increased attention, and proliferation of research, pediatric concussion as a concept has rarely, if ever, been taken up and questioned. That is, little attention has been directed toward understanding what concussion ‘is’, or how young people are regarded in relation to it. As a result, pediatric concussion is understood in decidedly narrow terms, constructed as such by a biomedical way of knowing.

Aim:

We aim to demonstrate how conceptualizing concussion, and young people, ‘otherwise’, enabled the co-production of a more nuanced and complex understanding of the experience of pediatric concussion from the perspective of young people.

Approach:

Drawing on an illustrative case example from a critical qualitative arts-based study, we demonstrate how bringing young people into research as ‘knowers’ enabled us to generate much-needed knowledge about concussion in young people.

Implications:

The critical thinking put forward in this paper suggests a different approach to pediatric concussion, which is shared in the form of implications for clinical and research practice.

Perceptual-Motor Efficiency and Concussion History Are Prospectively Associated With Injury Occurrences Among High School and Collegiate American Football Players

Background:

After a sport-related concussion (SRC), the risk for lower extremity injury is approximately 2 times greater, and the risk for another SRC may be as much as 3 to 5 times greater.

Purpose:

To assess the predictive validity of screening methods for identification of individual athletes who possess an elevated risk of SRC.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Metrics derived from a smartphone flanker test software application and self-ratings of both musculoskeletal function and overall wellness were acquired from American high school and college football players before study participation. Occurrences of core or lower extremity injury (CLEI) and SRC were documented for all practice sessions and games for 1 season. Receiver operating characteristic and logistic regression analyses were used to identify variables that provided the greatest predictive accuracy for CLEI or SRC occurrence.

Results:

Overall, there were 87 high school and 74 American college football players included in this study. At least 1 CLEI was sustained by 45% (39/87) of high school players and 55% (41/74) of college players. Predictors of CLEI included the flanker test conflict effect ≥69 milliseconds (odds ratio [OR], 2.12; 90% CI, 1.24-3.62) and a self-reported lifetime history of SRC (OR, 1.70; 90% CI, 0.90-3.23). Of players with neither risk factor, only 38% (29/77) sustained CLEI compared with 61% (51/84) of players with 1 or both of the risk factors (OR, 2.56; 90% CI, 1.50-4.36). SRC was sustained by 7 high school players and 3 college players. Predictors of SRC included the Overall Wellness Index score ≤78 (OR, 9.83; 90% CI, 3.17-30.50), number of postconcussion symptoms ≥4 (OR, 8.35; 90% CI, 2.71-25.72), the Sport Fitness Index score ≤78 (OR, 5.16; 90% CI, 1.70-15.65), history of SRC (OR, 4.03; 90% CI, 1.35-12.03), and the flanker test inverse efficiency ratio ≥1.7 (OR, 3.19; 90% CI, 1.08-9.47).

Conclusion:

Survey responses and smartphone flanker test metrics predicted greater injury incidence among individual football players classified as high-risk compared with that for players with a low-risk profile.

Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement

Selected Issues in Sport-Related Concussion (SRC|Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus documents written for the practicing team physician. This document provides an overview of selected medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

A Novel Approach to Assessment of Perceptual-Motor Efficiency and Training-Induced Improvement in the Performance Capabilities of Elite Athletes

Standard clinical assessments of mild traumatic brain injury are inadequate to detect subtle abnormalities that can be revealed by sophisticated diagnostic technology. An association has been observed between sport-related concussion (SRC) and subsequent musculoskeletal injury, but the underlying neurophysiological mechanism is not currently understood. A cohort of 16 elite athletes (10 male, 6 female), which included nine individuals who reported a history of SRC (5 male, 4 female) that occurred between 4 months and 8 years earlier, volunteered to participate in a 12-session program for assessment and training of perceptual-motor efficiency. Performance metrics derived from single- and dual-task whole-body lateral and diagonal reactive movements to virtual reality targets in left and right directions were analyzed separately and combined in various ways to create composite representations of global function. Intra-individual variability across performance domains demonstrated very good SRC history classification accuracy for the earliest 3-session phase of the program (Reaction Time Dispersion AUC = 0.841; Deceleration Dispersion AUC = 0.810; Reaction Time Discrepancy AUC = 0.825, Deceleration Discrepancy AUC = 0.794). Good earliest phase discrimination was also found for Composite Asymmetry between left and right movement directions (AUC = 0.778) and Excursion Average distance beyond the minimal body displacement necessary for virtual target deactivation (AUC = 0.730). Sensitivity derived from Youden's Index for the 6 global factors ranged from 67 to 89% and an identical specificity value of 86% for all of them. Median values demonstrated substantial improvement from the first 3-session phase to the last 3-session phase for Composite Asymmetry and Excursion Average. The results suggest that a Composite Asymmetry value ≥ 0.15 and an Excursion Average value ≥ 7 m, provide reasonable qualitative approximations for clinical identification of suboptimal perceptual-motor performance. Despite acknowledged study limitations, the findings support a hypothesized relationship between whole-body reactive agility performance and functional connectivity among brain networks subserving sensory perception, cognitive decision-making, and motor execution. A complex systems approach appears to perform better than traditional data analysis methods for detection of subtle perceptual-motor impairment, which has the potential to advance both clinical management of SRC and training for performance enhancement.

Preexisting conditions in older adults with mild traumatic brain injuries

OBJECTIVE

This study examined the prevalence of preexisting conditions that could affect premorbid brain health, cognition, and functional independence among older adults with mild traumatic brain injury (MTBI), and the relationship between preexisting conditions, injury characteristics, and emergency department (ED) discharge location (home versus continued care).

METHODS

Older adults (N = 1,427; 55-104 years-old; 47.4% men) who underwent head computed tomography (CT) after acute head trauma were recruited from the ED. Researchers documented preexisting medical conditions retrospectively from hospital records.

RESULTS

Multiple preexisting conditions increased in frequency with greater age, including circulatory and nervous system diseases and preexisting abnormalities on head CT. Psychiatric and substance use disorders (SUDs) decreased in frequency with greater age. Among participants with uncomplicated MTBI and GCS = 15, preexisting nervous system diseases and preexisting CT abnormalities were associated with higher odds of continued care for all participants, whereas psychiatric disorders and SUDs were only associated with higher odds of continued care among participants <70 years-old. Preexisting circulatory diseases, loss of consciousness, and amnesia were unassociated with discharge location.

CONCLUSIONS

Preexisting medical conditions that could affect brain and cognitive health occur commonly among older adults who sustain MTBIs. These conditions can confound research examining post-injury outcomes within this age group.

Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement

ABSTRACT

Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus articles written for the practicing team physician. This document provides an overview of select medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Injury Reduction Programs for Reducing the Incidence of Sport-Related Head and Neck Injuries Including Concussion: A Systematic Review

BACKGROUND

Sport-related head and neck injuries, including concussion, are a growing global public health concern with a need to explore injury risk reduction strategies such as neck exercises.

OBJECTIVES

To systematically review the literature to investigate: (1) the relationship between neck strength and sport-related head and neck injuries (including sport-related concussion (SRC); and (2) whether neck exercise programs can reduce the incidence of (a) sport-related head and neck injuries; and (b) SRC.

METHODS

Five databases (Ovid MEDLINE, CINAHL, EMBASE, SPORTDiscus, and Web of Science) and research lists of included studies were searched using a combination of medical subject headings and keywords to locate original studies which reported the association between incidence of head and/or neck injury and neck strength data, or included a neck exercise intervention either in isolation or as part of a more comprehensive exercise program.

RESULTS

From an initial search of 593 studies, six were included in this review. A narrative synthesis was performed due to the heterogeneity of the included studies. The results of two observational studies reported that higher neck strength, but not deep neck flexor endurance, is associated with a lower risk of sustaining a SRC. Four intervention studies demonstrated that injury reduction programs that included neck exercises can reduce the incidence of sport-related head and neck injuries including SRC.

CONCLUSION

Consideration should be given towards incorporating neck exercises into injury reduction exercise programs to reduce the incidence of sport-related head and neck injuries, including SRC.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (registration number: 194217).

Padded Headgear does not Reduce the Incidence of Match Concussions in Professional Men's Rugby Union: A Case-control Study of 417 Cases

Concussion is the most common match injury in rugby union. Some players wear padded headgear, but whether this protects against concussion is unclear. In professional male rugby union players, we examined: (i) the association between the use of headgear and match concussion injury incidence, and (ii) whether wearing headgear influenced time to return to play following concussion. Using a nested case-control within a cohort study, four seasons (2013-2017) of injury data from 1117 players at the highest level of rugby union in England were included. Cases were physician-diagnosed concussion injuries. Controls were other contact injuries (excluding all head injuries). We determined headgear use by viewing video footage. Sixteen percent of cases and controls wore headgear. Headgear use had no significant effect on concussion injury incidence (adjusted odds ratio=1.05, 95% CI: 0.71-1.56). Median number of days absent for concussion whilst wearing headgear was 8 days, compared with 7 days without headgear. Having sustained a concussion in the current or previous season increased the odds of concussion more than four-fold (odds ratio=4.55, 95% CI: 3.77-5.49). Wearing headgear was not associated with lower odds of concussions or a reduced number of days' absence following a concussion.

Wellness Survey Responses and Smartphone App Response Efficiency: Associations With Remote History of Sport-Related Concussion

Recent research findings have strongly suggested that sport-related concussion (SRC) increases risk for subsequent injury of any type, as well as a potential for long-term adverse effects on neurological and psychological well-being. The primary purpose of this study was to explore the reliability and discriminatory power of clinical testing procedures for detecting persisting effects of SRC. We used a cross-sectional study design to assess both self-reported symptoms commonly associated with post-concussion syndrome, and the effects of mental or physical activity on metrics derived from a smartphone app designed to test perceptual-motor responses. Among 30 physically active college students, 15 participants reported a SRC occurrence prior to testing (M time-since-injury = 4.0 years, SD = 3.1, range = 5 months to 11 years). We found good test-retest reliability for key metrics derived from the smartphone app (ICC ≥ .70); and the internal consistency for the Overall Wellness Index (OWI) for 10 categories of 82 post-concussion symptoms was ideal (Cronbach's α ≥ .80). Moderate intensity treadmill running demonstrated the strongest differential effect on perceptual-motor responses between participants with a history of SRC (HxSRC) and those with no such history (No SRC), which was best represented by the speed-accuracy trade-off quantified by the inverse efficiency index (IEI: group X trial interaction p = .055). Self-reported OWI symptoms ≥4 and post-physical activity IEI ≥ 568 ms provided the strongest discrimination between HxSRC and NoSRC participants (≥1 versus 0: OR = 9.75). Our findings suggest that persisting effects from a remote SRC occurrence can be detected by easily administered screening procedures that have the potential to identify individual athletes who might derive benefit from interventions to restore their optimal function and well-being.

Concussion History and Neuromechanical Responsiveness Asymmetry

CONTEXT

Detection of subtle changes in brain sensorimotor processes may enable clinicians to identify athletes who would derive the greatest benefit from interventions designed to reduce the risk for future injury and progressive neurologic or musculoskeletal dysfunction.

OBJECTIVE

To develop a generalizable statistical model for identifying athletes who possess subtle alterations in sensorimotor processes that may be due to previous concussion.

DESIGN

Cross-sectional study.

SETTING

Residential Olympic Training Center sports medicine clinic.

PATIENTS OR OTHER PARTICIPANTS

A primary cohort of 35 elite athletes and a secondary cohort of 40 elite athletes who performed identical tests the preceding year.

INTERVENTION(S)

Two upper extremity tests of visual-motor reaction time and 2 tests of whole-body reactive agility were administered. The whole-body tests required lateral or diagonal responses to virtual-reality targets, which provided measures of reaction time, speed, acceleration, and deceleration.

MAIN OUTCOME MEASURE(S)

Sport-related concussion history, which was reported by 54% (n = 19) of the athletes in the primary cohort and 45% (n = 18) of the athletes in the secondary cohort.

RESULTS

Univariable analyses identified 12 strong predictors of sport-related concussion history, which we combined to create a composite metric with maximum predictive value. Composite lateral asymmetry for whole-body reactive movements and persisting effects of previous musculoskeletal injury yielded a logistic regression model with exceptionally good discrimination (area under the curve = 0.845) and calibration (predicted-observed probabilities within 7 subgroups: r = 0.959, P = .001). Application of the derived model to compatible data acquired from another cohort of elite athletes demonstrated very good discrimination (area under the curve = 0.772) and calibration (within 8 subgroups: r = 0.849, P = .008).

CONCLUSIONS

Asymmetry in whole-body reactive movement capabilities may be a manifestation of a subtle abnormality in the functional connectivity of brain networks that might be relevant to previously reported associations between sport-related concussion history and musculoskeletal injury occurrence.

Normal variability within a collegiate athlete sample: A rationale for comprehensive baseline testing

OBJECTIVE

Sport-related concussions continue to garner attention as research emerges about the effects of these injuries. Many have advocated for cognitive baselines; however, there is no uniform practice of neuropsychological baseline testing at the collegiate level leading to variance in administration and interpretation. Continuing clarification on best practices is essential for the field, especially considering previous research highlighting normal variability on cognitive tests in other populations, but also the need for separate normative sources for those with attention and learning problems. This study aimed to evaluate the range of normal variability in a diverse sample of collegiate athletes administered a traditional neuropsychological baseline.

METHOD

Neuropsychological baseline measures were collected on 236 Division 1 University student athletes over 4 years. Frequency of scores that fell at 1, 1.5, and 2 or greater standard deviations were reviewed. Student athletes were further evaluated for likelihood of factors which could impact results (i.e. Attention-Deficit/Hyperactivity Disorder [ADHD], Specific Learning Disorder [SLD], and psychiatric distress).

RESULTS

The results demonstrated high rates of variability in most test scores for the collective sample. Student athletes at risk for ADHD, SLD, and/or psychiatric distress appeared to demonstrate a higher degree of variability relative to individuals with minimal risk.

CONCLUSION

Baseline evaluation data revealed the presence of normal variability in a student athlete population. Left unrecognized, this can lead to errors in clinical recommendations given the nature of concussion. Certain individuals have risk factors which may increase the range of variability, and this should be explored further in future research.

Interaction between Age, Sex, and Mental Health Status as Precipitating Factors for Symptom Presentation in Concussed Individuals

Concussions are among the most common neurological conditions, with emergency departments and sports injury clinics seeing hundreds of patients each year. The consideration of risk factors such as age, sex, and comorbid conditions are very important when looking at individual physiological and psychological outcomes after a concussion. The purpose of this study was to look at four comorbid conditions (depression, anxiety, behavioural disorder, or learning disability) and identify any interactions with age and sex in symptom presentation after suffering a concussion. A total of 4,865 participants from the CCMI (Complete Concussion Management Inc.) dataset were used with 1,577 self-identified with a diagnosis of anxiety, depression, a behavioural disorder, or a learning disability. Fixed-factor analyses of variance were used with age and sex as fixed, grouping factors and symptom total and severity as dependent measures. For the individuals who did not have one of the 4 mental health conditions (3,288 control participants), symptom total and symptom severity increased with age (p < 0.05), and females showed more symptoms and a higher symptom severity than males across all ages (p < 0.05). A diagnosis of anxiety or depression exacerbated total symptoms and symptom severity from 25–50% above control levels in the 19 and under age groups, while depression or anxiety exacerbated total symptoms and severity by 10–15% in males more than females over 20. A diagnosis of a behavioural disorder or a learning disability exacerbated symptom severity by approximately 50% above control levels in 13–19–year-old females and in males of 30 years and older. This study highlights how the presence of a mental health condition may alter concussion symptom presentation dependent on age and sex. The identification of risk factors and how they may interact can be of great value to health care providers who manage concussion symptoms and recovery.

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.

Attention Deficit Hyperactivity Disorder in Athletes

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in difficulties with sustaining attention in tasks and/or hyperactivity/impulsivity. Prevalence rates vary and difficulties in objectively diagnosing ADHD may lead to overdiagnosis or underdiagnosis. Assessment should include a comprehensive evaluation, including history, physical, psychological evaluation, and questionnaires for ADHD. Stimulant medications are effective for treatment, but their use, side effects, and potential for misuse and abuse are a concern, particularly in athletes. Athletes and physicians also need to be aware of the governing body's drug policy for the sport.

Concussion Incidence, Duration, and Return to School and Sport in 5- to 14-Year-Old American Football Athletes

OBJECTIVE

To collect prospective data on concussion incidence, risk factors, duration of symptoms, and return to school and sport in 5- to 14-year-old American football participants.

STUDY DESIGN

We conducted a prospective cohort study over 2 years collecting data during two 10-week fall seasons. Youth with concussion were followed to determine time to return to school, sport, and baseline level of symptoms. Logistic regression was used to estimate the risk of sustaining a concussion associated with baseline demographic factors. Time to return to school, sport, and baseline symptoms were analyzed using Kaplan-Meier survival curves.

RESULTS

Of 863 youth followed (996 player-seasons), 51 sustained a football-related concussion, for an athlete-level incidence of 5.1% per season. Youth with history of concussion had a 2-fold increased risk for sustaining an incident concussion (OR, 2.2; 95% CI, 1.1-4.8). Youth with depression had a 5-fold increased risk of concussion (OR, 5.6; 95% CI, 1.7-18.8). After a concussion, 50% of athletes returned to school by 3 days, 50% returned to sport by 13 days, and 50% returned to a baseline level of symptoms by 3 weeks.

CONCLUSIONS

Concussion rates in this study were slightly higher than previously reported, with 5 of every 100 youth sustaining a football-related concussion each season. One-half of youth were still symptomatic 3 weeks after injury. Further research is needed to address the risk of concussion in youth football.

Insomnia and daytime sleepiness: risk factors for sports-related concussion

OBJECTIVE/BACKGROUND

Poor quality and inadequate sleep are associated with impaired cognitive, motor, and behavioral components of sport performance and increased injury risk. While prior work identifies sports-related concussions as predisposing factors for poor sleep, the role of sleep as a sports-related concussion risk factor is unknown. The purpose of this study was to quantify the effect of poor sleep quality and insomnia symptoms on future sports-related concussion risk.

PATIENTS/METHODS

In this study, 190 NCAA Division-1 athletes completed a survey battery, including the Insomnia Severity Index (ISI) and National Health and Nutrition Examination Survey (NHANES) Sleep module. Univariate risk ratios for future sports-related concussions were computed with ISI and NHANES sleepiness scores as independent predictors. An additional multiple logistic regression model including sport, sports-related concussion history, and significant univariate predictors jointly assessed the odds of sustaining a concussion.

RESULTS

Clinically moderate-to-severe insomnia severity (RR = 3.13, 95% CI: 1.320-7.424, p = 0.015) and excessive daytime sleepiness two or more times per month (RR = 2.856, 95% CI: 0.681-11.977, p = 0.037) increased concussion risk. These variables remained significant and comparable in magnitude in a multivariate model adjusted for sport participation.

CONCLUSION

Insomnia and daytime sleepiness are independently associated with increased sports-related concussion risk. More completely identifying bidirectional relationships between concussions and sleep requires further research. Clinicians and athletes should be cognizant of this relationship and take proactive measures - including assessing and treating sleep-disordered breathing, limiting insomnia risk factors, improving sleep hygiene, and developing daytime sleepiness management strategies - to reduce sports-related concussion risk and support overall athletic performance.