Sport Concussion Assessment Tool-2: baseline values for high school athletes

Mixed Martial Arts: Comparing the King-Devick and Sport Concussion Assessment Tool 5 in knockouts, technical knockouts and choke holds

Objective

To compare validity indices of the King-Devick (KD) test and Sport Concussion Assessment Tool 5 (SCAT5) for traumatic events in MMA, and to determine if perfusion events (alterations in consciousness as the result of choke holds) cause similar changes in KD/SCAT5 scores.

Design

A prospective cohort study in MMA fighters who completed KD and SCAT5 assessments before and after a match. Outcomes were categorized as non-event, traumatic event, or perfusion event. KD/SCAT5 changes were compared between all athletes.

Participants

One hundred forty MMA athletes (7 women, 133 men), mean age=27.1 ± 4.9 years.

Intervention

N/A.

Main outcome measures

King-Devick (KD) test and Sport Concussion Assessment Tool 5 (SCAT5).

Results

Among the 140 athletes, 19 sustained traumatic and 15 perfusion events. Testing provided sensitivities/specificities of 21.05%/93.39% (KD) and 77.78%/52.99% (SCAT5) in detecting a traumatic event. KD and SCAT5 Symptom Severity scores differed between athletes with and without traumatic events (P=.041 and .014). KD and SCAT5 Symptoms Score changes were observed between athletes with and without traumatic events (P=.023 and .042). Neither KD nor SCAT5 differed significantly between athletes with and without perfusion events.

Conclusions

The KD test provides high specificity and the SCAT5 demonstrates reasonable sensitivity when detecting a traumatic event. Of the SCAT5, symptoms-related scores may most effectively identify a traumatic event. A traumatic event may cause KD/SCAT5 changes similar to a concussion, while perfusion events did not.

Child Sport Concussion Assessment Tool 5th Edition: Normative Reference Values in Demographically Diverse Youth

OBJECTIVES

Examine sociodemographic differences (gender, age, and language spoken at home) on baseline Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) scores and establish normative reference data for the Child SCAT5 among middle school student athletes.

DESIGN

Cross-sectional study.

SETTING

Nine middle schools in Virginia.

PARTICIPANTS

A sample of 1355 athletes playing competitive school-sponsored sports (ages 11-13, M = 12.3 ± 0.8; 40.1% girls, 59.9% boys) during the 2017 and 2018 school year. Certified athletic trainers administered the Child SCAT5 within the first 2 weeks of the sport season.

INDEPENDENT VARIABLES

Self-reported gender, age, and language spoken at home.

MAIN OUTCOME MEASURES

All Child SCAT5 outcome measures.

RESULTS

Gender, age, and language spoken at home were associated with Child SCAT5 scores, but the magnitude of differences was generally small. Specifically, girls endorsed more symptoms (girls: M = 8.4 ± 5.7, boys: M = 7.5 ± 5.7; P = 0.003) and greater symptom severity (girls: M = 11.6 ± 9.4, boys: M = 10.4 ± 9.3; P = 0.006) than boys and performed slightly better than boys on cognitive and balance tasks. Older students performed slightly better than younger students on tests of cognition (eg, SAC-C: 11-year-olds: M = 21.3 ± 2.1, 13-year-olds: M = 21.7 ± 2.1; P = 0.02). Total symptoms (P = 0.01), symptom severity (P = 0.01), immediate memory (P < 0.001), delayed recall (P = 0.001), and SAC-C total scores (P = 0.002) differed across language groups.

CONCLUSIONS

Gender, age, and language spoken in the home are associated with baseline scores on multiple components of the Child SCAT5 among middle school students, although the magnitudes of observed differences are small. Normative reference values are provided for clinicians when interpreting Child SCAT5 scores.

Concussion Baseline Retesting Is Necessary When Initial Scores Are Low

OBJECTIVE

To determine whether (1) initial baseline scores are significantly better for those who have valid (initial valid) versus invalid scores (initial invalid) on their concussion baseline testing, (2) retesting results in significantly improved baseline scores, and (3) there is a significant difference in scores between those who have valid scores on their initial attempt and those who retook baseline tests (retest valid).

DESIGN

Prospective, repeated-measures.

SETTING

Two years of collegiate preparticipation concussion baseline testing.

PARTICIPANTS

Five hundred forty-seven male and female Division I collegiate athletes (19.02 ± 1.31 years, female = 217).

INDEPENDENT VARIABLES

Participants were divided into initial valid and initial invalid. The retest group was further divided into their initial (initial invalid) and final valid attempt (retest valid).

MAIN OUTCOME MEASURES

Data were analyzed to determine the relationship between the 3 groups and overall initial and final scores on 28 individual items: total symptoms score, coordination, near-point convergence, CNS Vital Signs (CNSVS), Senaptec Sensory Station, and Neurocom Sensory Organization Test (SOT).

RESULTS

The initial valid group scored significantly better than the initial invalid group on 8 CNSVS items and 5 Senaptec items (P < 0.002). The retest valid scores were significantly better compared with the initial invalid scores on 17 items (P < 0.002).

CONCLUSIONS

Retesting is recommended for individuals who score below acceptable ranges. This is important because athletes may experience a learning effect and are highly motivated during postinjury testing, so accurate baseline scores are imperative for athlete safety. Completion time for the coordination test may be a more informative option.

Baseline SCAT Performance in Men and Women: Comparison of Baseline Concussion Screens Between 6288 Elite Men's and 764 Women's Rugby Players

OBJECTIVE

This study compared Sports Concussion Assessment Tool (SCAT) performance in elite male (6288 players) and female (764 players) rugby players, to determine whether reference limits used for the management and diagnosis of concussion should differ between sexes.

DESIGN

Cross-sectional census sample.

SETTING

Data from World Rugby's Head Injury Assessment management system were analyzed. This data set covers global professional rugby.

PARTICIPANTS

All professional players who underwent baseline SCAT testing as part of World Rugby's concussion management requirement formed the study cohort. Ten thousand seven hundred fifty-four SCAT assessments from 6288 elite male rugby players and 1071 assessments from 764 elite female players were analyzed.

INTERVENTION

Elite men and women rugby players are independent variables.

MAIN OUTCOME MEASURES

Sports Concussion Assessment Tool performance, including symptoms endorsed, cognitive submode performance, and balance performance.

RESULTS

Women endorsed significantly more symptoms, with greater symptom severity, than men (relative ratio 1.34, 95% confidence interval, 1.25-1.45 women vs men). Women outperformed men in cognitive submodes with the exception of immediate memory and delayed recall and made fewer balance errors than men during the modified Balance Error Scoring System. Clinical reference limits, defined as submode score achieved by the worst-performing 50% of the cohort, did not differ between men and women.

CONCLUSIONS

Women and men perform differently during SCAT baseline testing, although differences are small and do not affect either the baseline or clinical reference limits that identify abnormal test results for most submodes. The greater endorsement of symptoms by women suggests increased risk of adverse concussion outcomes and highlights the importance of accurate evaluation of any symptom endorsement at baseline.

Sport Concussion Assessment Tool-5th Edition (SCAT5): Normative Reference Values for the National Rugby League Women's Premiership

Objective: To establish normative reference values for the Sport Concussion Assessment Tool-5th Edition (SCAT5) for the new National Rugby League Women's Premiership. Methods: Preseason SCAT5 baseline testing was administered individually to all National Rugby League Women's Premiership players (N = 117). Testing was completed by the medical staff. Normative reference values were calculated for the components of the SCAT5, including the Standardized Assessment of Concussion, modified Balance Error Scoring System, and the Symptom Scale. A small case series of players who sustained concussions were included to illustrate the use of the new normative data. Results: The median Standardized Assessment of Concussion total score was 27.0 (M = 26.9, SD = 2.1). The median modified Balance Error Scoring System score was 2.0 (M = 2.4, SD = 2.2). The median number of symptoms score was 1.0 (M = 3.2, SD = 4.7) and the median symptom severity score was 2.0 (M = 5.4, SD = 8.2). The most common baseline symptom was fatigue or low energy (33%), followed by trouble sleeping (24%), headache (23%), neck pain (22%), and difficulty remembering (21%). In the total sample, 41% reported no symptoms. The clinical interpretation of these new normative data to a case series of women with concussions is provided. Conclusions: Normative reference values are provided for the SCAT5 for women who are professional rugby league players. Using these normative data will improve clinical interpretation of SCAT5 scores following a concussion.

Assessment and Treatment of Concussion in the Pediatric Population

Traumatic brain injury (TBI) is common in children. The evaluation and management of children with TBI is based on the research performed in adults. There is a relative paucity of research in the literature involving children and many of the practice recommendations for this age are based on expert opinion in the absence of good research studies in both sports and non-sports-related injuries. The pediatric population is heterogeneous and the approach might be specific for infants, preschoolers, school age children, and adolescents. Children may also suffer from neurodevelopmental disabilities, making their evaluation even more challenging. Adult neurologists are often asked to see children due to increasing demands. This review will focus on specific issues related to TBI in children that might be useful to adult neurologists. Science, however, is evolving rapidly and physicians should make sure to remain up to date to offer evidence-based services to their patients.

Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion

OBJECTIVES

To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion.

STUDY DESIGN

Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury.

RESULTS

Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009).

CONCLUSIONS

Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.

Normative Data for the Sway Balance System

OBJECTIVE

Static balance, postural stability, and reaction time are commonly impaired after a sport-related concussion. The Sway Balance System assesses postural sway (ie, stability) and simple reaction time using the triaxial accelerometer built into iOS mobile devices. The purpose of this study was to provide normative data for children and adolescents and to examine for age and sex differences on the Sway Balance System.

DESIGN

Cross-sectional study.

SETTING

Middle and high schools across the United States.

PARTICIPANTS

Participants were 3763 youth aged 9 to 21 years who completed the Sway Balance System Sports protocol in accordance with the company's recommended methods (ie, 1 acclimation trial and 2-3 baseline tests).

INDEPENDENT VARIABLES

Age and sex.

MAIN OUTCOME MEASURES

Sway Balance score (0-100) and Sway Reaction Time score (0-100).

STATISTICAL ANALYSIS

A multivariate analysis of variance examined the effects of age and sex on balance and reaction time scores.

RESULTS

Sway Balance and Reaction Time scores significantly differed by age [F(10, 7494) = 39.68, P < 0.001, V = 0.10, = 0.05] and sex [F(4, 7494) = 55.29, P < 0.001, V = 0.06, = 0.03]. Post hoc analyses revealed that older groups generally had better scores than younger groups on all balance comparisons (ps < 0.001) and many reaction time comparisons. Girls performed better than boys on balance [F(2, 3747) = 53.79, P < 0.001, = 0.03] and boys had faster reaction times [F(2, 3747) = 37.11, P < 0.001, = 0.02].

CONCLUSIONS

Age and sex are important factors to consider when assessing Balance and Reaction Time scores using the Sway Balance System's Sports protocol in youth. We provide age- and sex-based normative values for the Sway Balance System, which will likely be helpful when using this technology to assess and manage concussions.

Effect of a concussion on subsequent baseline SCAT performance in professional rugby players: a retrospective cohort study in global elite Rugby Union

OBJECTIVES

This study assessed whether concussion affects subsequent baseline performance in professional rugby players. Annual baseline screening tests are used to guide return-to-play decisions and concussion diagnosis during subsequent screens. It is important that baseline performances are appropriate and valid for the duration of a season and unaffected by factors unrelated to the current head impact event. One such factor may be a concussion following baseline assessment.

SETTING

The World Rugby concussion management database for global professional Rugby Union.

PARTICIPANTS

501 professional rugby players with two baseline Sports Concussion Assessment Tools (SCATs) and an intervening concussion (CONC) were compared with 1190 control players with successive annual SCAT5s and no diagnosed concussion (CONT).

PRIMARY AND SECONDARY OUTCOME MEASURES

Symptom endorsement, cognitive and balance performance during annual SCAT baseline assessments.

RESULTS

Players with a diagnosed concussion (CONC) endorsed fewer symptoms (change -0.42, 95% CI -0.75 to -0.09), and reported lower symptom severity scores during their second assessment (T2, p<0.001) than non-concussed players (CONT). Concussed players also improved Digits Backward and Final Concentration scores in T2 (p<0.001). Tandem gait time was improved during T2 in CONT. No other sub-mode differences were observed in either group.

CONCLUSIONS

Reduced symptom endorsement and improved cognitive performance after concussion may be the result of differences in the motivation of previously concussed players to avoid exclusion from play, leading to under-reporting of symptoms and greater effort in cognitive tests. Improved cognitive performance may be the result of familiarity with the tests as a result of greater exposure to concussion screening. The changes are small and unlikely to have clinical significance in most cases, though clinicians should be mindful of possible reasons, possibly repeating sub-modes and investigating players whose baseline scores change significantly after concussion. The findings do not necessitate a change in the sport's concussion management policy.

Sport Concussion Assessment Tool: baseline and clinical reference limits for concussion diagnosis and management in elite Rugby Union

OBJECTIVES

Rugby Union has adapted the Sports Concussion Assessment Tool (SCAT) into an abridged off-field concussion screen and the complete SCAT is used during diagnostic screens performed after head impact events. No firm guidelines exist as to what should be considered "abnormal" and warrant further evaluation. This study evaluates SCAT performances in 13,479 baseline SCAT assessments, and proposes clear reference limits for each sub-component of the SCAT5. Baseline reference limits are proposed to guide management of baseline testing by identifying abnormal sub-tests, enhancing the clinical validity of baseline screens, while clinical reference limits are identified to support concussion diagnosis when no baseline is available.

DESIGN

Cross sectional census sample.

METHODS

13,479 baseline SCATs from 7565 elite male rugby players were evaluated. Baseline reference limits were identified for each sub-test as the sub-test result achieved by approximately 5% of the population, while clinical references limits corresponded to the sub-test score achieved by as close as possible to 50% of the cohort.

RESULTS

Players reported symptoms 35% (95% CI 1.29-1.42) more frequently during SCAT5 than SCAT3 baseline assessments (mean 1.4±2.7 vs 1.0±2.4). Ceiling effects were identified for many cognitive sub-tests within the SCAT. Baseline and Clinical reference limits corresponding to the worst performing 5th percentile and 50th percentile were described.

CONCLUSIONS

Targeted baseline re-testing should be repeated when abnormal sub-tests are identified according to proposed baseline reference limits, while a more conservative clinical reference limit supports concussion diagnosis during screens in diagnostic settings.

Baseline Performance of High School Rugby Players on the Sport Concussion Assessment Tool 5

CONTEXT

Version 5 of the Sport Concussion Assessment Tool (SCAT5) was released in 2017 with an additional 10-word list option in the memory section and additional instructions for completing the symptom scale.

OBJECTIVE

To provide reference scores for high school rugby union players on the SCAT5, including immediate memory using the 10-word list, and examine how age, sex, and concussion history affected performance.

DESIGN

Cross-sectional study.

SETTING

Calgary, Alberta high schools.

PATIENTS OR OTHER PARTICIPANTS

High school rugby union players (ages 15-18 years) participating in a 2018 season cohort study (n = 380, males = 210, females = 170).

MAIN OUTCOME MEASURE(S)

Sport Concussion Assessment Tool 5 scores, including total number of symptoms (of 20), symptom severity (of 132), 10-word immediate memory (of 30), delayed memory (of 10), modified Standardized Assessment of Concussion (of 50), and balance examination (of 30).

RESULTS

The median number of symptoms reported at baseline ranged from 5 to 8 across sex and age stratifications. Median symptom severity was lowest in males with no concussion history (7; range, 0-28) and highest in females with a concussion history (13, range = 0-45). Median total scores on immediate memory were 2-3 (range = 0-4) for males and 21 (range = 9-29) for females. Median total scores were 3 (range = 0-4) on digits backward and 7 (range = 0-20) on delayed memory (all groups). Based on simultaneous quantile (q) regression at 0.50 and 0.75, adjusted for age and concussion history, being female was associated with a higher total symptoms score (q0.75 β_female = 2.85; 99% confidence interval [CI] = 0.33, 5.37), higher total symptom severity score (q0.75 β_female = 8.00; 99% CI = 2.83, 13.17), and lower number of errors on the balance examination (q0.75 β_female = -3.00; 99% CI = -4.85, -1.15). Age and concussion history were not associated with any summary measures.

CONCLUSIONS

The 10-word list option in the memory section reduced the likelihood of a ceiling effect. A player's sex may be an important consideration when interpreting the SCAT5 after concussion.

Differential Effect of Recurrent Concussions on Symptom Clusters in Sport Concussion Assessment Tool

CONTEXT

Symptom checklist in Sport Concussion Assessment Tool has been widely used in preseason assessment and in concussion diagnosis, but the impact of prior concussions on the graded symptoms after a new concussion has not been evaluated.

OBJECTIVE

This study was undertaken to examine reported symptoms associated with recurrent concussions using data of a comprehensive survey among athletes.

DESIGN

Retrospective survey and cross-sectional study.

SETTING

College athletes.

PARTICIPANTS

Student athletes who sustained one or more concussions.

MAIN OUTCOME MEASURES

Concussion history and graded symptoms of the most recent concussion at time of the survey were surveyed. The impact of prior concussions was examined over symptoms and aggregated symptoms.

RESULTS

Multiple concussions were associated with greater reporting of individual symptoms related to emotion and physical symptoms of sensitivity to light and noise: more emotional (z = 2.3, P = .02); sadness (z = 2.4, P = .02); nervousness (z = 2.4, P = .02); irritability (z = 3.6, P = .01); sensitivity to light (z = 2.6, P = .01); and sensitivity to noise (z = 2.4, P = .04). The composite scores of emotional symptom and sensitivity symptom clusters were significantly higher: t = 2.68 (P < .01) and t = 3.35 (P < .01), respectively.

CONCLUSIONS

The significant rises in emotional and sensitivity symptoms may be an important additive effect of concussive injury. Closer attention should be given to these symptom clusters when evaluating concussion injury and recovery.

Diagnosis of Concussion on the Sidelines

The forthcoming discussion will review the current state of the literature surrounding best practice guidelines for diagnosis of sports-related concussions on the sidelines. A sports-related concussive event is a complex process to define, which further increases its diagnostic process. At present there is no singular, gold-standard assessment tool available for the diagnosis of sports-related concussions on the sideline. Current best-practice recommendations suggest the utilization of a multifactorial examination process in a controlled environment. Sideline evaluations must include assessments of symptoms, physical and neurologic status, cognitive function, balance capabilities, and clinical assessments for the presence of cervical spine injuries, skull fractures, and intracranial bleeds. Clinical utility is emerging for involvement of assessments of oculomotor and reaction time function, medical spotters/replay technology, and equipment-based motion/impact sensors. The diagnostic process of sports-related concussions can be enhanced when performed by a sports medicine professional with specific experience with the patient at hand due to increased familiarity with premorbid patient disposition and function. Larger scale research studies with sound methodological processes is needed to further bolster best practice recommendations, with specific attention to the youth demographic.

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

The Age Variable in Childhood Concussion Management: A Systematic Review

Background

Sports-related concussion in young children has become a significant international public health issue. This paper reviews the research literature in an effort to shed light on the question, "At what age should young children be managed differently than adults or older adolescents?"

Method

A systematic review, registered with PROSPERO and using PRISMA guidelines, was conducted rendering 37 sports concussion original research studies that examined age as a variable (5-18 years), and which met specific inclusion/exclusion criteria.

Findings

There are no defined, evidence-based age groups for childhood concussion to substantiate differential management across the childhood and adolescent age span. There is evidence to support: (1) concussion may present differently across developmental stages; (2) with increasing age, adolescents may exhibit more symptoms from concussion; (3) the age range of 12-13 is the most frequently used cutoff point between younger and older children; (4) sports concussion research has classified the age variable in children in a number of manners: educational, developmental, sport level, or as a continuous variable, or matter of sample convenience; and (5) four general groupings of young versus pre-puberty child and early versus late adolescent are often utilized.

Conclusions

Due to limited measures and challenges of assessing younger children, current research presents a limited understanding of childhood concussion. Studies in children often lack explained rationales or theories behind age groupings or cutoffs. There is a need for studies dedicated to the question of how concussion varies developmentally from preschool through late adolescence to guide diagnosis and management.

Comparison of baseline and postconcussion SCAT3 scores and symptoms in varsity athletes: an investigation into differences by sex and history of concussion

OBJECTIVE

To investigate the use of the Sport Concussion Assessment Tool 3 (SCAT3) as an assessment tool in the varsity population, as well as the effects of sex and concussion history on both baseline and postconcussion scores.

METHODS

A comparison between baseline and postconcussion SCAT3 scores of varsity level athletes was conducted through retrospective chart review. Differences in both baseline and postconcussion scores were further analysed by sex and history of concussion.

RESULTS

The only clinically significant change on the SCAT3 elicited by a concussion was that of self-reported symptoms. There were no clinically significant differences based on sex or history of concussion.

CONCLUSION

The SCAT3 in its entirety may not be useful in this population. Additional research on sociocultural and sport aspects that may be affecting symptom reporting in this population is needed.

Time Trends in Concussion Symptom Presentation and Assessment Methods in High School Athletes

BACKGROUND

Concussion rates have increased significantly over the past decade. This may reflect an increase in the knowledge and diagnosis of the symptoms of a concussion rather than a true increase in the incidence. Assessing trends in the way that concussions are presenting to and being identified by clinicians over the same period may provide additional insight into the apparent rise in concussions.

PURPOSE

To evaluate patterns of change in concussion symptom presentation, diagnostic/evaluation methods, and symptom resolution time reported for United States high school athletes from the 2007-2008 through 2014-2015 academic years.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This study is a retrospective analysis of a web-based longitudinal high school sports injury surveillance database (High School RIO [Reporting Information Online]) collected from 2007-2008 through 2014-2015. For each concussion, athletic trainers entered data regarding symptom presentation, resolution time, and diagnostic/evaluation tools utilized. Academic year was the primary exposure in assessing each aim. Time trends were then assessed using linear regression or the Cochran-Armitage test for trends, depending on the outcome distribution.

RESULTS

The proportion of concussed athletes presenting with amnesia, loss of consciousness (LOC), and tinnitus significantly decreased from 2007-2008 through 2014-2015, while the proportion presenting with drowsiness, irritability, light sensitivity, and noise sensitivity increased significantly. The use of diagnostic radiography, magnetic resonance imaging, and computed tomography all significantly decreased during the study period, while the use of computerized neurocognitive tests increased. Concussion symptoms took significantly longer to resolve in more recent years.

CONCLUSION

The decrease in what have traditionally been considered severe symptoms (LOC, amnesia) and the increase in what were traditionally considered minor symptoms (drowsiness, irritability, light sensitivity) suggest that clinicians may have a lower threshold in diagnosing sports-related concussions in more recent years. The significant reduction in the use of all forms of diagnostic head imaging demonstrates an increased recognition of concussions as functional disturbances rather than structural abnormalities. Improved concussion education and the nationwide passage of state-level concussion legislation have likely led to the increased recognition of lingering symptoms in athletes with a diagnosed concussion, thereby leading to a longer symptom resolution time.

Descriptive Values for Dancers on Baseline Concussion Tools

CONTEXT

  Capturing baseline data before a concussion can be a valuable tool in individualized care. However, not all athletes, including dancers, have access to baseline testing. When baseline examinations were not performed, clinicians consult normative values. Dancers are unique athletes; therefore, describing values specific to dancers may assist those working with these athletes in making more informed decisions.

OBJECTIVE

  To describe values for key concussion measures of dancers. Our secondary aim was to examine whether differences existed between sexes and professional status. Finally, we explored factors that may affect dancers' scores.

DESIGN

  Cross-sectional study.

SETTING

  Professional dance companies and a collegiate dance conservatory.

PATIENTS OR OTHER PARTICIPANTS

  A total of 238 dancers (university = 153, professional = 85; women = 171; men = 67; age = 21.1 ± 4.8 years).

MAIN OUTCOME MEASURE(S)

  We calculated the total symptom severity from the Sport Concussion Assessment Tool-3rd edition; the Standardized Assessment of Concussion score; the modified Balance Error Scoring System score; and the King-Devick score for each participant. Group differences were analyzed with Mann-Whitney or t tests, depending on the data distribution. We used bivariate correlations to explore the effects of other potential influencing factors.

RESULTS

  Participants demonstrated the following baseline outcomes: symptom severity = 16.6 ± 12.8; Standardized Assessment of Concussion = 27.5 ± 1.8; modified Balance Error Scoring System = 3.2 ± 3.1 errors; and King-Devick = 41.5 ± 8.2 seconds. A Mann-Whitney test revealed differences in King-Devick scores between female (40.8 ± 8.0 seconds) and male (43.4 ± 8.4 seconds) dancers ( P = .04). An independent-samples t test also demonstrated a difference in modified Balance Error Scoring System scores between female (2.95 ± 3.1 errors) and male (3.8 ± 3.1 errors) dancers ( P = .02). Age, hours of sleep, height, and history of concussion, depression, or injury did not display moderate or strong associations with any of the outcome measures.

CONCLUSIONS

  Dancers' symptom severity scores appeared to be higher than the values reported for other athletes. Additional studies are needed to establish normative values and develop a model for predicting baseline scores.

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

OBJECTIVE

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

DESIGN

Prospective cohort.

SETTING

Seven Wisconsin high schools.

PARTICIPANTS

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

INDEPENDENT VARIABLES

Sex, age, and concussion history.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Sport concussion assessment tool-Third edition normative reference values for professional Rugby Union players

OBJECTIVES

To establish normative reference data for the SCAT3 in professional Rugby Union players.

DESIGN

A cross sectional study in professional Rugby Union players competing in national and international professional competitions between 2015 and 2016.

METHODS

The SCAT3 was administered pre-season or prior to tournaments. Data was collected electronically using a custom tablet application. SCAT3 subcomponents distributions were described and normative ranges determined using percentile cut-offs for average, unusually low/high, and extremely low/high scores. The association between player characteristics and performance in SCAT3 subcomponents was also investigated in exploratory analyses.

RESULTS

A total of 3611 professional Rugby Union players were included. The most common baseline symptom was fatigue (14%). The symptom score median (md) was 0 (interquartile range (IQR)=0-1). Symptom severity md was 0 (IQR=0-1). The md of the SAC score was 28 (IQR=26-29). The md of the MBESS was 2 (IQR=0-4). The Tandem gait md was 11.1s (IQR=10.0-12.7s). Upper limb coordination was normal in 98.4%. Younger age and lower educational level were associated with worse performance on delayed recall and reverse month sub-components of the SCAT3 (p<0.0001). No statistically significant differences in SCAT3 subcomponents were evident across gender.

CONCLUSIONS

Representative normative reference values for the SCAT3 among professional Rugby Union players are provided. Baseline performance on concentration and delayed recall tests may be lower in younger athletes or in those with lower educational level.

Establishing Baseline Normative Values for the Child Sport Concussion Assessment Tool

IMPORTANCE

The Child Sport Concussion Assessment Tool (SCAT3) is a postconcussion sideline assessment tool measuring symptoms, cognition, and balance in preadolescent children. Minimal normative baseline data exist to aid decision making in clinical and athletic settings.

OBJECTIVE

To collect normative baseline data for the Child SCAT3 in a large cohort of young athletes.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was conducted from May 31 to August 12, 2014, at various sporting events (basketball, soccer, baseball, and swimming) in Central Wisconsin among children 5 to 13 years of age who were English-speaking and did not report a lower leg injury within the past 2 months or a concussion within the past month. Data were analyzed between October 8, 2014, and September 12, 2016.

MAIN OUTCOMES AND MEASURES

All Child SCAT3 components were assessed: child and parent report of symptom number and severity, cognition (Standardized Assessment of Concussion-child version [SAC-C]), and balance (modified Balance Error Scoring System [mBESS] and tandem gait). Summary statistics, mean differences, and effect sizes were calculated for each test component.

RESULTS

Participants included 478 children (234 girls and 241 boys; mean [SD] age, 9.9 [1.9] years]) and their parents. Age had the largest effect on all Child SCAT3 components, with children 5 to 7 years of age reporting higher mean (SD) symptom severity scores compared with those 11 to 13 years of age (18.2 [10.0] vs 11.3 [9.0]; mean difference, 6.86 [95% CI, 4.22-9.50]; effect size, 0.74) and performing more poorly on the total SAC-C (mean [SD] score, 19.5 [5.1] vs 26.1 [2.1]; mean difference, -6.59 [95% CI, -7.49 to -5.68]; effect size, -2.1), mBESS (mean [SD] score, 1.67 [1.8] vs 0.76 [1.2]; mean difference, 0.91 [95% CI, 0.53-1.29]; effect size, 0.68), and tandem gait (mean [SD] time, 22.2 [8.3] vs 14.0 [3.7] seconds; mean difference, 8.23 seconds [95% CI, 6.63-9.82]; effect size, 1.55). Sex had a small effect on the mean (SD) number and severity of symptoms reported by the child (severity: boys, 15.1 [9.8] vs girls, 11.8 [9.2]; mean difference, 3.31 [95% CI, 1.60-5.02]; effect size, 0.35), mean (SD) number and severity of symptoms reported by the parent (severity: boys, 11.1 [7.7] vs girls, 9.4 [8.1]; mean difference, 1.63 [95% CI, 0.21-3.05]; effect size, 0.21), mean (SD) total SAC-C score (boys, 23.9 [3.9] vs girls, 24.9 [3.5]; mean difference, -0.92 [95% CI, -1.61 to -0.23]; effect size, -0.25), and mean (SD) mBESS score (boys, 1.21 [1.5] vs girls, 0.71 [1.0]; mean difference, 0.50 [95% CI, 0.27-0.74]; effect size, 0.38).

CONCLUSIONS AND RELEVANCE

Child SCAT3 baseline normative symptom, cognitive, and balance scores were different, with a large main effect for age and a small effect for sex. These findings may assist health care professionals with interpretation of Child SCAT3 scores for young athletes with a concussion in athletic and clinical settings.

What is the difference in concussion management in children as compared with adults? A systematic review

AIM

To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC.

RESULTS

A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5-12 years.

SUMMARY/CONCLUSIONS

This systematic review recommends that in children: child and adolescent age-specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016:CRD42016039184.

Clinical Evaluation of the Concussed Athlete: A View From the Sideline

CONTEXT

The sideline assessment of concussion is challenging, given its variable presentations, the limited sensitivity and specificity of sideline assessment tools, and how the presentation of the injury evolves over time. In addition, the diagnostic process, as well as the tools used to assess and manage concussion, continue to progress as research and what we know about concussion advance. This paper focuses on the initial assessment on the sideline by reviewing the concussion-evaluation literature, drawing from clinical experience to emphasize a standardized approach, and underscoring the importance of both familiarity with the athlete and clinical judgment.

OBJECTIVE

To review the evidence regarding the clinical assessment of sport-related concussion on the sideline. Additional considerations included making same-day return-to-play decisions, the sensitivity and specificity of sideline testing, and the importance of ongoing assessment and follow-up of injured athletes.

DATA SOURCES

I conducted a systematic literature review of the assessment of concussion on the sideline. The PubMed and MEDLINE databases were searched using the key term athletic injuries with concussion and mild traumatic brain injury. The search was refined by adding the key terms sideline assessment and on-field assessment. In addition, select additional position statements and guidelines on concussion were included in the review.

RESULTS

The PubMed search using athletic injuries and concussion as key terms produced 1492 results. Refining the search by sideline assessment and on-field assessment produced 29 and 35 results, respectively. When athletic injuries and traumatic brain injury were combined, 1912 results were identified. Refining the search by sideline assessment and on-field assessment led to 28 and 35 results, respectively. Only papers that were English-language titles, original work, and limited to human participants and included sideline assessments of sport-related concussion in athletes older than 13 years were considered for this discussion. A total of 96 papers were reviewed, including systematic reviews, consensus guidelines, and position statements.

CONCLUSIONS

The sideline assessment of sport-related concussion is challenging given the elusiveness and variability of presentation, reliance on athlete-reported symptoms, and the varying specificity and sensitivity values of sideline assessment tools. In addition, the recognition of injury and assessment often occur in a time-pressured environment, requiring rapid disposition and decision making. Clinicians should begin the evaluation by assessing for cervical spine injury, intracranial bleeding, and other injuries that can present in a similar fashion or in addition to concussion. The sideline concussion evaluation should consist of a symptom assessment and a neurologic examination that addresses cognition (briefly), cranial nerve function, and balance. Emerging tools that assess visual tracking may provide additional information. The sensitivity and specificity of commonly implemented sideline assessment tools are generally good to very good, especially for symptom scores and cognitive evaluations performed within 48 hours of injury, and they are improved when a baseline evaluation is available for comparison. Serial assessments are often necessary as objective signs and symptoms may be delayed. A standardized assessment is paramount in evaluating the athlete with a suspected concussion, but there is no replacement for being familiar with the athlete and using clinical judgment when the athlete seems "not right" despite a "normal" sideline assessment. Ultimately, the clinician should err on the side of caution when making a return-to-play decision.

Psychological and Lifestyle Factors That Influence the Serial Reporting of Postconcussion-like Symptoms in a Non-concussed Population

BACKGROUND

Symptoms related to concussion are generally nonspecific in nature, as they are also reported by non-concussed individuals. What is currently not known is whether the symptoms vary over time, and whether they are also influenced by a multitude of factors.

OBJECTIVE

The aim of this study was to investigate the potential influence of psychological, lifestyle, and situational factors on the change in postconcussion-like symptoms reported over 7 consecutive days in a cohort of normal individuals.

DESIGN

This was a longitudinal observational study.

SETTING

The setting was a real-world context.

PARTICIPANTS

A convenience sample of 180 non-concussed university students were enrolled. Of these, 110 participants provided data for the entire period of the study.

METHODS

An experience-sampling methodology was used to document the symptoms reported over time. Stepwise multivariate linear mixed-effects modeling was performed to identify the predictors contributing to the serially reported symptoms.

INDEPENDENT VARIABLES

Independent variables considered were gender, time of the day, location, primary activity, and type of interactant (person) of the participant, physical activity status, trouble sleeping, alcohol consumption, caffeine consumption, stress, anxiety, depression, mental and physical fatigue, and life stressors.

MAIN OUTCOME MEASURES

The key outcome measures were the change in total symptom score (TSS_change) and symptom severity score (SSS_change) reported over 7 consecutive days.

RESULTS

The predictors of location at the time of reporting, physical fatigue (estimate: -0.98, P < .001) and mental fatigue (estimate: -0.53, P < .001) contributed to the TSS_change. Post hoc analysis of the variable of location at the time of reporting revealed that participants reported increased TSS_change when they were at a café/restaurant compared to a flat/college or university.

CONCLUSIONS

A number of factors within the context of daily life influenced the postconcussion-like symptoms reported over time. These findings indicate that clinicians need to be cautious when interpreting the serially assessed symptom scores to track the recovery profile of a concussed athlete to make decisions on return-to-play. Additional investigation is warranted to examine the change in symptom scores reported over time by concussed individuals, considering that this study was conducted in a nonconcussed cohort.

LEVEL OF EVIDENCE

Not applicable.

Multiple Past Concussions in High School Football Players: Are There Differences in Cognitive Functioning and Symptom Reporting?

BACKGROUND

There is increasing concern about the possible long-term effects of multiple concussions, particularly on the developing adolescent brain. Whether the effect of multiple concussions is detectable in high school football players has not been well studied, although the public health implications are great in this population.

PURPOSE

To determine if there are measureable differences in cognitive functioning or symptom reporting in high school football players with a history of multiple concussions.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Participants included 5232 male adolescent football players (mean [±SD] age, 15.5 ± 1.2 years) who completed baseline testing between 2009 and 2014. On the basis of injury history, athletes were grouped into 0 (n = 4183), 1 (n = 733), 2 (n = 216), 3 (n = 67), or ≥4 (n = 33) prior concussions. Cognitive functioning was measured by the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery, and symptom ratings were obtained from the Post-Concussion Symptom Scale.

RESULTS

There were no statistically significant differences between groups (based on the number of reported concussions) regarding cognitive functioning. Athletes with ≥3 prior concussions reported more symptoms than did athletes with 0 or 1 prior injury. In multivariate analyses, concussion history was independently related to symptom reporting but less so than developmental problems (eg, attention or learning problems) or other health problems (eg, past treatment for psychiatric problems, headaches, or migraines).

CONCLUSION

In the largest study to date, high school football players with multiple past concussions performed the same on cognitive testing as those with no prior concussions. Concussion history was one of several factors that were independently related to symptom reporting.

SCAT2 and SCAT3 scores at baseline and after sports-related mild brain injury/concussion: qualitative synthesis with weighted means

Objective

Identify all Sport Concussion Assessment Tool (SCAT2/3) studies, compare baseline and postconcussion results.

Design

Systematic review (qualitative synthesis, weighted means).

Data sources

18 databases, 9 grey literature resources searched for SCAT2/3 data; 9150 articles identified, titles/abstracts assessed/data-entry independently by two reviewers.

Eligibility criteria for selecting studies

Any studies reporting partial/complete SCAT2/3 data.

Results

21 studies with data (partial/complete data 16 SCAT2 (4087 athletes); 5 SCAT3 (891). Newcastle-Ottawa risk-of-bias scale: studies with maximum possible score of 4, 85% scored 3 or 4; studies with maximum possible score of 6, 75% scored 5 or 6. SCAT2 high schoolers: weighted mean score for symptoms 18.46 (22=no symptoms), Balance Error Scoring System (BESS) 26.14, Standardised Assessment of Concussion (SAC) 26.00 and SCAT2 total 88.63. Collegiate/adults weighted means: symptoms 20.09, BESS 25.54, SAC 27.51 and total SCAT2 91.20. Between-study and within-study variability similar to those of the high schoolers. Limited variability between genders. Only 2 studies report baseline and postconcussion scores and 9 partial scores, but data are too limited to provide weighted average scores.

Conclusions

Group mean baseline SCAT scores for high school and collegiate athletes are similar, with minimal gender differences; baseline symptoms show more variability than other components. There are minimal data for elementary students and professionals, no data for adult non-collegiate athletes. Two studies provide preconcussion and postconcussion scores. No data on minimal significant clinical differences to guide players/coaches in withdrawing from a game in progress and deciding when recovery is complete and play can be resumed. The SCAT needs supplementing with clinical and neuropsychological return-to-play assessments.

Do children and adolescent ice hockey players with and without a history of concussion differ in robotic testing of sensory, motor and cognitive function?

Background

KINARM end point robotic testing on a range of tasks evaluating sensory, motor and cognitive function in children/adolescents with no neurologic impairment has been shown to be reliable. The objective of this study was to determine whether differences in baseline performance on multiple robotic tasks could be identified between pediatric/adolescent ice hockey players (age range 10–14) with and without a history of concussion.

Methods

Three hundred and eighty-five pediatric/adolescent ice hockey players (ages 10–14) completed robotic testing (94 with and 292 without a history of concussion). Five robotic tasks characterized sensorimotor and/or cognitive performance with assessment of reaching, position sense, bimanual motor function, visuospatial skills, attention and decision-making. Seventy-six performance parameters are reported across all tasks.

Results

There were no significant differences in performance demonstrated between children with a history of concussion [median number of days since last concussion: 480 (range 8–3330)] and those without across all five tasks. Performance by the children with no history of concussion was used to identify parameter reference ranges that spanned 95 % of the group. All 76 parameter means from the concussion group fell within the normative reference ranges.

Conclusions

There are no differences in sensorimotor and/or cognitive performance across multiple parameters using KINARM end point robotic testing in children/adolescents with or without a history of concussion.

SCAT3 assessment of non-head injured and head injured athletes competing in a large international youth soccer tournament

To our knowledge, no study has evaluated Sideline Concussion Assessment Tool -3rd Edition (SCAT3) scores during competition in athletes who have not had a head injury. The purpose of our pilot study was to compare SCAT3 scores in non-injured (NI), injured (but not head injured) (I), and head injured (HI) youth soccer players during competition and to establish preliminary baseline data for non-head injured athletes in a competitive setting. The HI group demonstrated significantly more symptoms (M = 9.7, SE = 0.8) than the I and NI (3.3, SE = 1.2, and 3.2, SE = 0.7, respectively) groups. The HI group also demonstrated a significantly higher symptom severity score (25.3, SE = 2.8) than the I and NI groups (7.7, SE = 4.1, and 5.9, SE = 2.5, respectively). There were no statistically significant differences in mean total Standardized Assessment of Concussion (SAC) scores and mean subsection SAC scores between the groups. Clinicians should also be aware that non-injured in-competition athletes may report more symptoms on the SCAT3 than those evaluated in a non-competition setting.

Sideline Management of Concussion

Concussion associated with sport is a common occurrence with an estimated 1.6 to 3.8 million sports-related concussions yearly in the United States. The sideline assessment of concussion focuses on four areas: cognitive ability, balance, associated symptoms, and visual tracking. Tools available on the sideline to assist in the diagnosis of concussion are discussed in this article. Some of these tools are validated and reliable and some are developing and have yet to be proven to be sensitive enough for routine use. These tools along with a thorough history and physical examination enable a sideline physician to accurately diagnose concussion.

The Sport Concussion Assessment Tool: a systematic review

OBJECTIVE

Over the last 2 decades, sport-related concussion (SRC) has garnered significant attention. Even with increased awareness and athlete education, sideline recognition and real-time diagnosis remain crucial. The need for an objective and standardized assessment of concussion led to the eventual development of the Sport Concussion Assessment Tool (SCAT) during the Second International Conference on Concussion in Sport in 2004, which is now in its third iteration (SCAT3). In an effort to update our understanding of the most well-known sideline concussion assessment, the authors conducted a systematic review of the SCAT and the evidence supporting its use to date.

METHODS

English-language titles and abstracts published between 1995 and October 2015 were searched systematically across 4 electronic databases and a review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines adapted for the review of a heterogeneous collection of study designs. Peer-reviewed journal articles were included if they reported quantitative data on any iteration of the SCAT, Standardized Assessment of Concussion (SAC), or modified Balance Error Scoring System (mBESS) data at baseline or following concussion in an exclusively athlete population with any portion older than 13 years of age. Studies that included nonathletes, only children less than 13 years old, exclusively BESS data, exclusively symptom scale data, or a non–SCAT-related assessment were excluded.

RESULTS

The database search process yielded 549 abstracts, and 105 full-text articles were reviewed with 36 meeting criteria for inclusion. Nineteen studies were associated with the SAC, 1 was associated with the mBESS exclusively, and 16 studies were associated with a full iteration of the SCAT. The majority of these studies (56%) were prospective cohort studies. Male football players were the most common athletes studied. An analysis of the studies focused on baseline differences associated with age, sex, concussion history, and the ability to detect an SRC.

CONCLUSIONS

Looking toward the upcoming Concussion in Sport Group meeting in fall 2016, one may expect further revision to the SCAT3. However, based on this systematic review, the authors propose further, in-depth study of an already comprehensive concussion test, with acute, diagnostic, as well as long-term use.

Factors Associated With Concussion-like Symptom Reporting in High School Athletes

IMPORTANCE

Every state in the United States has passed legislation for sport-related concussion, making this health issue important for physicians and other health care professionals. Safely returning athletes to sport after concussion relies on accurately determining when their symptoms resolve.

OBJECTIVE

To evaluate baseline concussion-like symptom reporting in uninjured adolescent student athletes.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional, observational study, we studied 31 958 high school athletes from Maine with no concussion in the past 6 months who completed a preseason baseline testing program between 2009 and 2013.

RESULTS

Symptom reporting was more common in girls than boys. Most students with preexisting conditions reported one or more symptoms (60%-82% of boys and 73%-97% of girls). Nineteen percent of boys and 28% of girls reported having a symptom burden resembling an International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS). Students with preexisting conditions were even more likely to endorse a symptom burden that resembled PCS (21%-47% for boys and 33%-72% for girls). Prior treatment of a psychiatric condition was the strongest independent predictor for symptom reporting in boys, followed by a history of migraines. For girls, the strongest independent predictors were prior treatment of a psychiatric condition or substance abuse and attention-deficit/hyperactivity disorder. The weakest independent predictor of symptoms for both sexes was history of prior concussions.

CONCLUSIONS AND RELEVANCE

In the absence of a recent concussion, symptom reporting is related to sex and preexisting conditions. Consideration of sex and preexisting health conditions can help prevent misinterpretation of symptoms in student athletes who sustain a concussion.

Months backward test: A review of its use in clinical studies

AIM: To review the use of the Months Backwards Test (MBT) in clinical and research contexts.

METHODS: We conducted a systematic review of reports relating to the MBT based upon a search of PsychINFO and MEDLINE between January 1980 and December 2014. Only reports that specifically described findings pertaining to the MBT were included. Findings were considered in terms of rating procedures, testing performance, psychometric properties, neuropsychological studies and use in clinical populations.

RESULTS: We identified 22 data reports. The MBT is administered and rated in a variety of ways with very little consistency across studies. It has been used to assess various cognitive functions including focused and sustained attention as well as central processing speed. Performance can be assessed in terms of the ability to accurately complete the test without errors (“MB accuracy”), and time taken to complete the test (“MB duration”). Completion time in cognitively intact subjects is usually < 20 s with upper limits of 60-90 s typically applied in studies. The majority of cognitively intact adults can complete the test without error such that any errors of omission are strongly suggestive of cognitive dysfunction. Coverage of clinical populations, including those with significant cognitive difficulties is high with the majority of subjects able to engage with MBT procedures. Performance correlates highly with other cognitive tests, especially of attention, including the digit span backwards, trailmaking test B, serial threes and sevens, tests of simple and complex choice reaction time, delayed story recall and standardized list learning measures. Test-retest and inter-rater reliability are high (both > 0.90). Functional magnetic resonance imaging studies comparing the months forward test and MBT indicate greater involvement of more complex networks (bilateral middle and inferior frontal gyri, the posterior parietal cortex and the left anterior cingulate gyrus) for backwards cognitive processing. The MBT has been usefully applied to the study of a variety of clinical presentations, for both cognitive and functional assessment. In addition to the assessment of major neuropsychiatric conditions such as delirium, dementia and Mild Cognitive Impairment, the MBT has been used in the assessment of concussion, profiling of neurocognitive impairments in organic brain disorders and Parkinson’s disease, prediction of delirium risk in surgical patients and medication compliance in diabetes. The reported sensitivity for acute neurocognitive disturbance/delirium in hospitalised patients is estimated at 83%-93%. Repeated testing can be used to identify deteriorating cognitive function over time.

CONCLUSION: The MBT is a simple, versatile tool that is sensitive to significant cognitive impairment. Performance can be assessed according to accuracy and speed of performance. However, greater consistency in administration and rating is needed. We suggest two approaches to assessing performance - a simple (pass/fail) method as well as a ten point scale for rating test performance (467).

The Diagnosis and Management of Concussion in Children and Adolescents

BACKGROUND

Concussion is a complex brain injury that results in more than 100,000 emergency department visits for school-aged children each year in the United States. All 50 US states have passed concussion legislation designed to promote safety in youth sports. Most of these laws require medical clearance by a licensed health care provider before returning to sport, which may have contributed to an increase in pediatric subspecialty referrals, particularly referrals to the child neurologist.

METHODS

We reviewed the literature on pediatric concussion.

RESULTS

This review summarizes the current knowledge and recommendations for concussion diagnosis and management in children and adolescents, athletes and nonathletes. It highlights concussion epidemiology, pathophysiology, advances in neuroimaging, and potential health risks including second impact syndrome and chronic traumatic encephalopathy. It also underscores clinical areas where evidence is lacking.

CONCLUSIONS

The diagnosis and management of concussion requires specific considerations in children. Further concussion research must be done to minimize injury risk and to optimize medical care for this common problem.

Balance Error Scoring System Performance in Children and Adolescents With No History of Concussion

BACKGROUND

The Balance Error Scoring System (BESS) is a useful means of measuring postural stability, which frequently exhibits deficits after a concussion. However, it has limited applicability for children since there is insufficient normative data available for the BESS in the pediatric population. The purposes of this study were to report scores for the BESS in children 10 to 17 years old with no history of concussion and to identify whether BESS score is correlated with age, sex, sports participation, height, weight, or body mass index.

HYPOTHESIS

Baseline BESS scores will be related to age and sports participation.

STUDY DESIGN

Descriptive laboratory study.

LEVEL OF EVIDENCE

Level 3.

METHODS

One examiner recruited 100 participants 10 to 17 years old over a period of 4 months; performed all of the BESS tests; surveyed participants regarding age, sex, and sports participation; recorded participants' heights and weights; and calculated body mass indices. Intrarater reliability was measured. The main outcome measures were total, firm, and foam surface BESS scores. We assessed data for normality using the Shapiro-Wilk test and used the Spearman rank test to determine whether BESS scores correlated with sex, age, sports participation, height, weight, or body mass index.

RESULTS

There was no correlation between the BESS firm surface (5.37 ± 4.4), BESS foam surface (12.28 ± 4.43), or total surface scores (17.64 ± 7.52) and age, anthropometrics, or sports participation. Male and female subjects had similar scores except in the 10- to 13-year-old age group on the foam surface, where girls performed better than boys (10.42 ± 4.53 vs 13.07 ± 4.23; P = 0.02).

CONCLUSION

Baseline BESS scores in children aged 10 to 17 years were normally distributed and were not related to age, sex, height, weight, body mass index, or sports participation.

CLINICAL RELEVANCE

These results provide a reference for clinicians using BESS to evaluate and manage children and teens with concussions.

Baseline SCAT2 Assessment of Healthy Youth Student-Athletes: Preliminary Evidence for the Use of the Child-SCAT3 in Children Younger Than 13 Years

OBJECTIVE

To compare baseline scores of middle and high school students on the Sport Concussion Assessment Tool 2 (SCAT2) by sex and age.

DESIGN

Cross-sectional study.

SETTING

Single private school athletic program.

PARTICIPANTS

Three hundred sixty-one middle and high school student-athletes.

INTERVENTION

Preseason SCAT2 was administered to student-athletes before athletic participation.

MAIN OUTCOME MEASURES

Total SCAT2 score, symptoms, symptom severity, Glasgow coma scale, modified Balance Error Scoring System (BESS), coordination, and Standardized Assessment of Concussion (SAC) with subsections: Orientation, Immediate Memory, Concentration, and Delayed Recall.

RESULTS

No differences were found in total SCAT2 scores between sex (P = 0.463) or age (P = 0.21). Differences were found in subcomponents of the SCAT2. Twelve year olds had significantly lower concentration scores (3.3 ± 1.2) than 15 and 18 year olds (3.9 ± 1.0 and 4.2 ± 1.0, respectively). The 12 year olds also had the lowest percentage of correct responses for the SAC's concentration 5-digit (46%), 6-digit (21%), and months' backward (67%) tasks. Females presented with more symptoms (20.0 ± 2.2 vs. 20.6 ± 2.1 P = 0.007) better immediate memory (14.6 ± 0.9 vs. 14.3 ± 1.0, P = 0.022) and better BESS scores (27.2 ± 2.3 vs. 26.6 ± 2.6, P = 0.043) than their male counterparts.

CONCLUSIONS

Normative values for total SCAT2 and subscale scores show differences in concentration between ages, whereas symptoms, BESS, and immediate memory differed between sexes. We also found that 12 year olds have increased difficultly with the advanced concentration tasks, which lends support to the development of a separate instrument, such as the Child-SCAT3. The presence of developmental differences in the younger age groups suggests the need for annual baseline testing.

CLINICAL RELEVANCE

Subtle differences between age and sex have been identified in many components of the SCAT2 assessment. These differences may support the current evolution of concussion assessment tools to provide the most appropriate test. Baseline testing should be used when available, and clinicians should be aware of potential differences when using normalized values.

A normative study of the sport concussion assessment tool (SCAT2) in children and adolescents

Recent clinical practice parameters encourage systematic use of concussion surveillance/management tools that evaluate participating athletes at baseline and after concussion. Office-based tools (Sports Concussion Assessment Tool; SCAT2) require accurate baseline assessment to maximize utility but no normative data exist for children on the SCAT2, limiting identification of "normal" or "impaired" score ranges. The purpose of this study was to develop child and adolescent baseline norms for the SCAT2 to provide reference values for different age groups. A community-based approach was implemented to compile baseline performance data on the SCAT2 in 761 children aged 9 to 18 to create age- and sex-graded norms. Findings indicate a significant age effect on SCAT2 performance such that older adolescents and teenagers produced higher (better) total scores than younger children (ages 9 to 11) driven by age differences on individual components measuring cognition (SAC), postural stability (BESS), and symptom report. Females endorsed greater numbers of symptoms at baseline than males. Normative data tables are presented. Findings support the SCAT2 as a useful clinical tool for assessing baseline functioning in teenagers, but suggest clinical utility may be limited in children under age 11. Follow-up studies after incident concussion are needed to confirm this assumption.