High School Athletes With ADHD and Learning Difficulties Have a Greater Lifetime Concussion History

Baseline ImPACT Composite Scores in Student-Athletes With Attention-Deficit/Hyperactivity Disorder

BACKGROUND

Athletes who are diagnosed with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of concussion compared to other athletes. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is a widely used concussion tool, but it relies on pre-injury baseline testing that can be affected by psychiatric conditions. This research aims to determine if there are differences in pre-injury testing composite scores in student-athletes with ADHD compared to those without ADHD diagnosis.

METHODS

We obtained 11,563 pre-season ImPACT assessments of 7,454 student-athletes (ages: 12-22) from 2009 to 2019. After exclusions, there were 6,920 control and 276 ADHD subjects. Multivariable linear regression analyses compared the independent effect of ADHD on the six ImPACT composite score metrics with Bonferroni correction for multiple comparisons with a = 0.008.

RESULTS

Univariate analyses indicated ADHD is associated with more symptoms as measured by the Post-Concussion Symptom Scale (PCSS) (β = 2.67, 95% CI: 1.47-3.87, p < .0001) and worse Impulse Control scores (β = 0.93, 95% CI: 0.33-1.53, p = .002). In multivariate analysis, this association was the same for symptom score (β = 2.48, 95% CI: 1.22-3.74, p < .0001), but Impulse Control was not significantly different after multiple comparison adjustment (β = 0.87, 95% CI: 0.22-1.15, p = .009).

CONCLUSIONS

The ADHD subjects reported worse symptoms at baseline and had worse Impulse Control in univariate analysis, but not multivariate analysis. These results can further guide clinicians in concussion diagnosis and test interpretations for student-athletes with ADHD, considering the symptom burden at baseline.

The influence of ADHD on recovery from sport concussion among collegiate athletes in the United States: LIMBIC MATARS consortium investigation

OBJECTIVE

The present study aimed to assess the potential influence of a diagnosis of ADHD on concussion recovery among collegiate athletes.

DESIGN

Retrospective and cross-sectional.

METHODS

Data were extracted retrospectively from medical records across LIMBIC MATARS member institutions (n = 11), representing 1,044 concussion cases among collegiate athletes. After exclusions, 406 concussions were included in our analysis (ADHD: n = 38, age = 20.2 ± 1.67 years, 18.4% female; No ADHD: n = 368, age = 19.8 ± 1.39 years, 40.1% female). Mann-Whitney U tests were used to compare days from injury to diagnosis, symptom resolution, and return to sport among athletes with and without ADHD.

RESULTS

No differences were observed for days from concussion until diagnosis (z = -0.33, p = 0.74), until days to symptom resolution (z = -1.30, p = 0.19), or days until return to sport (z = -0.68, p = 0.49); among concussion cases with or without a previously reported diagnosis of ADHD.

CONCLUSION

Our findings further expand the literature that suggests ADHD is not strongly associated with recovery trajectory following sport concussion in collegiate athletes. Future research should extend these findings to be inclusive of additional preexisting health conditions and moderating effects related to medication usage among diverse athlete levels.

Attention-Deficit / Hyperactivity Disorder in Athletes

ADHD is common among the general population and may be slightly more common among athletes. Diagnosis requires six or more DSM-5-TR symptoms to have been present prior to age 12 and to have an effect on functioning in multiple settings. Different sporting organizations have varying requirements for documentation when making a diagnosis. Stimulant medications are the mainstay of treatment; psychosocial interventions, exercise, and non-stimulant medications can serve as adjuncts. Future directions in research on ADHD in sports include determining whether ADHD is overrepresented among the population of elite athletes and parsing out the relationship between ADHD and concussion risk and recovery.

Driving characteristics of young adults prior to and following concussion

OBJECTIVES

This study sought to examine whether young adults who sustain concussions have different driving histories and pre-injury driving styles than uninjured peers. In addition, we assessed whether modifications were made to driving behavior in the acute period following concussion.

METHODS

Self-reported driving and demographic information was collected from 102 16- to 25-year-old drivers. Half of the sample had recently sustained concussions and the other half comprised a matched comparison group.

RESULTS

The groups reported similar pre-injury driving behaviors and styles. However, the recently injured group had more driving citations, higher rates of psychiatric disorders, and greater likelihood of having sustained a prior concussion. Self-reported driving habits postconcussion suggested that most drivers did not modify their driving behavior following concussion, though they were less likely to drive at night or with others in the car.

CONCLUSION

Results highlight the need for postconcussion driving guidelines and support for returning to driving safely.

Longitudinal, prospective study of head impacts in male high school football players

INTRODUCTION

Repetitive, subconcussive events may adversely affect the brain and cognition during sensitive periods of development. Prevention of neurocognitive consequences of concussion in high school football is therefore an important public health priority. We aimed to identify the player positions and demographic, behavioral, cognitive, and impact characteristics that predict the frequency and acceleration of head impacts in high school football players.

METHODS

In this prospective study, three cohorts of adolescent male athletes (N = 53, 28.3% Hispanic) were recruited over three successive seasons in a high school American football program. Demographic and cognitive functioning were assessed at baseline prior to participating in football. Helmet sensors recorded impact frequency and acceleration. Each head impact was captured on film from five different angles. Research staff verified and characterized on-field impacts. Player-level Poisson regressions and year-level and impact-level linear mixed-effect models were used to determine demographic, behavioral, cognitive, and impact characteristics as predictors of impact frequency and acceleration.

RESULTS

4,678 valid impacts were recorded. Impact frequency positively associated with baseline symptoms of hyperactivity-impulsivity [β(SE) = 1.05 impacts per year per unit of symptom severity (1.00), p = 0.01] and inattentiveness [β(SE) = 1.003 impacts per year per T-score unit (1.001), p = 0.01]. Compared to quarterbacks, the highest acceleration impacts were sustained by kickers/punters [β(SE) = 21.5 g's higher (7.1), p = 0.002], kick/punt returners [β(SE) = 9.3 g's higher (4.4), p = 0.03], and defensive backs [β(SE) = 4.9 g's higher (2.5), p = 0.05]. Impacts were more frequent in the second [β(SE) = 33.4 impacts (14.2), p = 0.02)] and third [β(SE) = 50.9 impacts (20.1), p = 0.01] year of play. Acceleration was highest in top-of-the-head impacts [β(SE) = 4.4 g's higher (0.8), p<0.001].

CONCLUSION

Including screening questions for Attention-Deficit/Hyperactivity Disorder in pre-participation evaluations can help identify a subset of prospective football players who may be at risk for increased head impacts. Position-specific strategies to modify kickoffs and correct tackling and blocking may also reduce impact burden.

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.

Sensitivity and Specificity of the ImPACT Neurocognitive Test in Collegiate Athletes and US Military Service Academy Cadets with ADHD and/or LD: Findings from the NCAA-DoD CARE Consortium

BACKGROUND AND OBJECTIVE

Computer-based neurocognitive tests are widely used in sport-related concussion management, but the performance of these tests is not well understood in the participant population with attention-deficit/hyperactivity disorder (ADHD) and/or learning disorder (LD). This research estimates the sensitivity and specificity performance of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computer-based neurocognitive test in identifying concussion in this population.

METHODS

Study participants consisted of collegiate university athletes and military service academy cadets from the National Collegiate Athletic Association-Department of Defense CARE Consortium who completed the ImPACT test between 2014 and 2021. Participants who self-identified as belonging to one of the subgroups of interest (ADHD with or without LD [ADHD:LD+/-], LD with or without ADHD [LD:ADHD+/-], ADHD and/or LD [ADHD a/o LD]) and completed a baseline (1874 ADHD:LD+/-, 779 LD:ADHD+/-, 2338 ADHD a/o LD) or 24-48 h post-concussion (175 ADHD:LD+/-, 77 LD:ADHD+/-, 216 ADHD a/o LD) ImPACT assessment were included. Sensitivity and specificity were calculated using a normative data method and three machine learning classification methods: logistic regression, classification and regression tree, and random forest.

RESULTS

Using the four methods, participants with ADHD:LD+/- had sensitivities that ranged from 0.474 to 0.697, and specificities that ranged from 0.538 to 0.686. Participants with LD:ADHD+/- had sensitivities that ranged from 0.455 to 0.688, and specificities that ranged from 0.456 to 0.588. For participants with ADHD a/o LD, sensitivities ranged from 0.542 to 0.755, and specificities ranged from 0.451 to 0.724.

CONCLUSIONS

For all subgroups and analytical methods, the results illustrate sensitivity and specificity values below typically accepted levels indicative of clinical utility. These findings support that using ImPACT alone may be insufficient to inform concussion diagnoses and encourages the use of a multi-dimensional concussion assessment.

Are Self-Reported and Parent-Reported Attention Problems and Hyperactivity Associated With Higher Rates of Concussion in Youth Ice Hockey Players?

OBJECTIVE

To examine the association between self-reported and parent-reported attention problems and hyperactivity and rates of injury and concussion in Canadian youth ice hockey players.

DESIGN

Secondary analyses of 2 prospective cohort studies.

SETTING

Canadian youth ice hockey teams.

PARTICIPANTS

Ice hockey players (ages 11-17 years) were recruited by team, over 4 seasons (2011-2016). A combined 1709 players contributing 1996 player-seasons were analyzed (257 players participated in more than one season).

ASSESSMENT OF RISK FACTORS

Data were collected from preseason baseline questionnaires, including child and parent proxy forms of the Behavior Assessment System for Children, second edition.

MAIN OUTCOME MEASURES

Injury and concussion rates and incidence rate ratios (IRR) comparing players with and without self-identified or parent-identified attention problems and hyperactivity, adjusted for covariates (ie, body checking policy, previous injury/concussion, and age) and a random effect for team, were estimated using multiple multilevel negative binomial regression.

RESULTS

When analyzed continuously, rates of concussion increased with higher self-reported and parent-reported measures of attention problems [IRR SELF = 1.025; 95% confidence interval (CI): 1.011-1.040; IRR PARENT = 1.032; 95% CI: 1.008-1.057]. Self-reported hyperactivity was significantly associated with concussion (IRR = 1.021; 95% CI: 1.007-1.035), but parent-reported hyperactivity was not (IRR = 1.005; 95% CI: 0.983-1.028). A T score ≥ 60 cutoff combining attention problems and hyperactivity scores (an estimate of probable attention-deficit hyperactivity disorder) was not significantly associated with rates of injury or concussion.

CONCLUSIONS

Attention problems and hyperactivity may place youth ice hockey players at increased risk of concussion and injury. Preseason assessments could identify players for targeted concussion education and risk reduction strategies.

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.

Acute effects of concussion among adolescents with attention-deficit/hyperactivity disorder

Adolescents with ADHD have a greater lifetime history of concussion and experience concussion-like symptoms in the absence of a concussion, complicating concussion assessment and management. It is well established that individuals who experience greater acute symptoms following concussion are at risk for slower recovery and persistent symptoms. We examined whether youth with ADHD experience worse acute effects, within the first 72 h following concussion, compared to youth without ADHD. We hypothesized that youth with ADHD would perform worse on neurocognitive testing and endorse more severe symptoms acutely following injury, but the magnitude of change from pre injury to post injury would be similar for both groups, and thus comparable to baseline group differences. The sample included 852 adolescents with pre-injury and post-injury ImPACT results (within 72 h); we also conducted supplementary case-control analyses on a subset of youth with and without ADHD matched on demographics and pre-injury health history. For both samples, there were significant interaction effects for the Verbal Memory and Visual Motor Speed composites (p < 0.01, η²=.01-.07, small-medium effect), such that youth with ADHD showed a greater magnitude of diminished cognitive functioning from pre-injury to post-injury testing. There were no significant differences in the magnitudes of changes from pre injury to post injury with regard to overall symptom reporting (i.e., total symptom severity scores, total number of symptoms endorsed); however, there were group differences in endorsement rates for several individual symptoms. Further research is needed to determine whether such differential acute effects are associated with recovery time in youth with ADHD.

Neurocognitive functioning and symptoms across levels of collision and contact in male high school athletes

OBJECTIVE

We sought to determine whether male collision sport athletes perform worse on computerised neurocognitive assessments and report higher symptom burdens than athletes in contact (but not collision) sports and athletes in non-contact sports.

METHODS

This cross-sectional study used data collected by the Massachusetts Concussion Management Coalition on high school boys who underwent computerised neurocognitive testing between 2009 and 2018. We divided sports participation in three different sport types: (1) collision, (2) contact, non-collision and (3) non-contact. Our outcomes included the four computerised neurocognitive composite scores (verbal memory, visual memory, visual motor speed and reaction time) and the total symptom score. The independent variable was sport type (collision, contact, non-contact), adjusted for age, concussion history and comorbidities.

RESULTS

Of the 92 979 athletes (age: 15.59±2.08 years) included in our study, collision sport athletes performed minimally but significantly worse than other athletes on neurocognitive composite scores (verbal memory: β=-1.64, 95% CI -1.85 to -1.44; visual memory: β=-1.87, 95% CI -2.14 to -1.60; visual motor speed: β=-2.12, 95% CI -2.26 to -1.97; reaction time: β=0.02, 95% CI 0.02 to 0.02). Collision and contact sport athletes also had slightly but significantly lower total symptom scores (collision: 3.99±7.17; contact: 3.78±6.81; non-contact: 4.32±7.51, p<0.001, η2=0.001) than non-contact sport athletes.

CONCLUSION

There are minimal observed differences in performance on neurocognitive assessments between collision sport, contact sport and non-contact sport athletes. The repetitive subconcussive head impacts associated with collision sport participation do not appear to negatively affect self-reported symptoms or neurocognitive functioning in current youth athletes.

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.

Risk of Mental Health Problems in Children and Youths Following Concussion

IMPORTANCE

Concussion may exacerbate existing mental health issues. Little evidence exists on whether concussion is associated with the onset of new psychopathologies or long-term mental health problems.

OBJECTIVE

To investigate associations between concussion and risk of subsequent mental health issues, psychiatric hospitalizations, self-harm, or suicides.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study including children and youths aged 5 to 18 years with a concussion or orthopedic injury incurred between April 1, 2010, and March 31, 2020, in Ontario, Canada. Participants had no previous mental health visit in the year before the index event for cohort entry and no prior concussion or traumatic brain injury 5 years before the index visit. Data were collected from provincewide health administrative databases. Participants with concussion were included in the exposed cohort, and those with an orthopedic injury were included in the comparison cohort; these groups were matched 1:2, respectively, on age and sex.

EXPOSURES

Concussion or orthopedic injury.

MAIN OUTCOMES AND MEASURES

The primary outcome was mental health problems, such as psychopathologies and psychiatric disorders, identified from health care visits in emergency departments, hospitalizations, or primary care settings. Secondary outcomes were psychiatric hospitalizations, self-harm health care visits, and death by suicide (identified in health care or vital statistics databases).

RESULTS

A total of 152 321 children and youths with concussion (median [IQR] age, 13 [10-16] years; 86 423 [56.7%] male) and 296 482 children and youths with orthopedic injury (median [IQR] age, 13 [10-16] years; 171 563 [57.9%] male) were matched by age and sex. The incidence rates of any mental health problem were 11 141 per 100 000 person-years (exposed group) and 7960 per 100 000 person-years (unexposed group); with a difference of 3181 (95% CI, 3073-3291) per 100 000 person-years. The exposed group had an increased risk of developing a mental health issue (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.37-1.40), self-harm (aHR, 1.49; 95% CI, 1.42-1.56), and psychiatric hospitalization (aHR, 1.47; 95% CI, 1.41-1.53) after a concussion. There was no statistically significant difference in death by suicide between exposed and unexposed groups (HR, 1.54; 95% CI, 0.90-2.61).

CONCLUSIONS AND RELEVANCE

Among children and youths aged 5 to 18 years, concussion was associated with an increased risk of mental health issues, psychiatric hospitalization, and self-harm compared with children and youths with an orthopedic injury.

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

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

Diagnosed and Nondisclosed Sport-Related Concussion: An Exploratory Comparison Study by ADHD Status in Collegiate Athletes

OBJECTIVE

To determine if ADHD status in collegiate athletes was associated with differences in the number of diagnosed and nondisclosed sport-related concussions, and reasons why suspected concussive injuries were not reported.

METHOD

A cross-sectional survey was completed by 858 collegiate athletes (65 with ADHD; 793 without ADHD). The survey included self-report items regarding ADHD status and histories of diagnosed and nondisclosed sport-related concussions. Groups were matched for gender, age, and sport with a ratio of one participant with ADHD to four without ADHD.

RESULTS

Collegiate athletes with ADHD reported significantly more diagnosed sport-related concussions and were more likely to have a history of diagnosis compared to those without ADHD. There were no significant differences between groups regarding sport-related concussion nondisclosure history.

CONCLUSION

Collegiate athletes with ADHD have an increased prevalence rate of diagnosed sport-related concussions compared to those without ADHD; however, this developmental disorder may not influence injury nondisclosure decisions.

Lifetime History of Concussion Among Youth With ADHD Presenting to a Specialty Concussion Clinic

Child and adolescent student athletes with attention-deficit/hyperactivity disorder (ADHD) report a greater lifetime history of concussion than those without ADHD. This case-control study compared youth with and without ADHD presenting for care at a specialty concussion clinic on their lifetime history of concussion. We hypothesized that a greater proportion of youth with ADHD would report a history of prior concussion. Archival clinical data from patients presenting to a specialty concussion clinic in Montreal, Québec, Canada between September 2015 and August 2019 were analyzed. The sample included 2,418 children and adolescents (age: M = 13.6, SD = 2.7, range 5–18 years; 50.9% girls), including 294 (12.2%) with ADHD and 2,124 (87.8%) without ADHD. The proportion with prior concussion among youth with ADHD (43.9%) was significantly greater than youth without ADHD [37.5%, χ² = 4.41, p = 0.04, OR = 1.30, 95% confidence interval (CI): 1.02–1.67]. A significantly higher proportion of boys with ADHD had a prior concussion history (48.1%) than boys without ADHD [38.4%, χ² = 5.33, p = 0.02, OR = 1.48 (95% CI: 1.06–2.09)], but this difference was not observed for girls (χ² = 0.31, p = 0.58). Youth with ADHD did not differ with regard to their estimated longest duration of symptoms from a prior concussion (Z = 1.52, p = 0.13) and the proportion who reported taking longer than 28 days to recover from a prior concussion did not differ between those with ADHD (15.3%) and without ADHD (12.2%), χ² = 2.20, p = 0.14. Among youth presenting to a specialty clinic, ADHD was associated with greater lifetime history of concussion but not a greater duration of symptoms from a prior injury.

Influence of Autism and Other Neurodevelopmental Disorders on Cognitive and Symptom Profiles: Considerations for Baseline Sport Concussion Assessment

OBJECTIVE

The presence of neurodevelopmental disorders (ND) such as attention-deficit/hyperactivity disorder (ADHD) and learning disorders (LD) have demonstrated effects on Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) performance. No current research has directly examined whether autism spectrum disorder (ASD) has similar effects. The current study compared ImPACT cognitive and symptom profiles in athletes with self-reported ASD to other NDs and healthy controls using case-control matching.

METHOD

The current study compared ImPACT baselines of high school athletes with ASD to athletes with other NDs (ADHD, LD, and co-occurring ADHD/LD) and healthy controls on cognitive composites and symptom reporting. Participants included 435 athletes (87 controls, 87 with ASD, 87 with ADHD, 87 with LD, and 87 with ADHD/LD) selected from a larger naturalistic sample. Athletes were matched to the ASD group based on age, sex, and sport using randomized case-matched selection from the larger database.

RESULTS

Results revealed that athletes with ASD performed more poorly than healthy controls on the Visual Motor Speed composite. No differences were found for Post-concussion Symptom Scale (PCSS) domain scores. Differences in cognitive and symptom profiles among the athletes with other NDs were also found.

CONCLUSIONS

Results elucidate patterns of baseline performance for athletes with ASD, demonstrating that there may not be significant differences between ASD and healthy controls on four of the five ImPACT composites, and no symptom reporting differences. Cognitive and symptom differences found for other NDs should be considered when interpreting baseline performance and for making return-to-play decisions in the absence of baseline assessment.

Concussion Among Children in the United States General Population: Incidence and Risk Factors

The objective of this study was to examine the incidence of concussion and risk factors for sustaining concussion among children from the United States general population. This prospective cohort study used data from the Adolescent Brain Cognitive Development (ABCD) Study^®. Children were recruited from schools across the US, sampled to reflect the sociodemographic variation of the US population. The current sample includes 11,013 children aged 9 to 10 years old (47.6% girls; 65.5% White) who were prospectively followed for an average of 1 year (mean = 367.9 days, SD = 40.8, range 249–601). The primary outcome was caregiver-reported concussion during a 1 year follow-up period. Logistic regression was used to determine which potential clinical, health history, and behavioral characteristics (assessed at baseline) were prospectively associated with concussion. In the 1 year follow-up period between ages 10 and 11, 1 in 100 children (n = 123, 1.1%) sustained a concussion. In univariate models, three baseline predictors (ADHD, prior concussion, and accident proneness) were significantly associated with sustaining a concussion. In a multivariate model, controlling for all other predictors, only prior concussion remained significantly associated with the occurrence of a concussion during the observation period (Odds Ratio = 5.49, 95% CI: 3.40–8.87). The most robust and only independent prospective predictor of sustaining a concussion was history of a prior concussion. History of concussion is associated with 5.5 times greater odds of sustaining concussion between ages 10 and 11 among children from the general US population.

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.

Concussion Incidence and Recovery Among Youth Athletes With ADHD Taking Stimulant-Based Therapy

Background:

Attention deficit hyperactivity disorder (ADHD) may affect concussion risk and recovery in youth athletes.

Purpose:

To evaluate the association between incidence of concussion and postinjury recovery of symptoms and neurocognitive dysfunction among youth athletes with ADHD and differential stimulant use.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

From 2009 to 2019, the authors administered the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) to youth athletes at the beginning of each season. Throughout the season, athletes with concussions were examined and readministered the ImPACT both postinjury and again 7 days after the postinjury administration. These athletes (N = 7453) were divided into those with ADHD on stimulant-based therapy (ADHD+meds; n = 167), those with ADHD not on stimulant-based therapy (ADHD-only; n = 354), and those with no ADHD (non-ADHD; n = 6932). Recovery of neurocognitive dysfunction at postinjury and follow-up was calculated using the ImPACT symptom score, verbal memory, visual memory, visual motor skills, and reaction time (calculated as standardized deviations from baseline). Univariate results were confirmed with multivariate analysis.

Results:

The ADHD+meds cohort had a lower incidence of concussion (37.3 concussions per 100 patient-years) compared with the ADHD-only group (57.0 concussions per 100 patient-years) (odds ratio [OR], 0.51 [95% CI, 0.37-0.71]; P < .0001) and non-ADHD group (52.8 concussions per 100 patient-years) (OR, 0.50 [95% CI, 0.37-0.67]; P < .0001). At postinjury, ImPACT scores were elevated from baseline to a similar extent in the ADHD+meds cohort compared with the other 2 groups. By follow-up, however, deviations from baseline were lower among the ADHD+meds group compared with the non-ADHD group in verbal memory (OR, 0.46 [95% CI, 0.28-0.76]; P = .002), visual memory (OR, 0.27 [95% CI, 0.10-0.66]; P = .005), and visual motor skills (OR, 0.58 [95% CI, 0.33-0.99]; P = .048). The deviation at follow-up was also lower among the ADHD+meds group compared with the ADHD-only group in visual memory (OR, 0.56 [95% CI, 0.33-0.96]; P = .04) and visual motor skills (OR, 0.42 [95% CI, 0.22-0.81]; P = .01).

Conclusion:

Stimulant use among youth athletes with ADHD was independently associated with reduced incidence for concussion and lower deviation from baseline in verbal memory, visual memory, and visual motor skills at 7 days postconcussion, suggesting lower neurocognitive impairment at follow-up in this group versus their peers.

Association of Attention-Deficit/Hyperactivity Disorder Diagnoses With Pediatric Traumatic Brain Injury: A Meta-analysis

IMPORTANCE

There are conflicting accounts about the risk for attention-deficit/hyperactivity disorder (ADHD) following traumatic brain injury (TBI), possibly owing to variations between studies in acute TBI severity or when ADHD was assessed postinjury. Analysis of these variations may aid in identifying the risk.

OBJECTIVE

To conduct a meta-analysis of studies assessing ADHD diagnoses in children between ages 4 and 18 years following concussions and mild, moderate, or severe TBI.

DATA SOURCES

PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials (1981-December 19, 2019) were searched including the terms traumatic brain injury, brain injuries, closed head injury, blunt head trauma, concussion, attention deficit disorders, ADHD, and ADD in combination with childhood, adolescence, pediatric, infant, child, young adult, or teen.

STUDY SELECTION

Limited to English-language publications in peer-reviewed journals and patient age (4-18 years). Differences about inclusion were resolved through consensus of 3 authors.

DATA EXTRACTION AND SYNTHESIS

MOOSE guidelines for abstracting and assessing data quality and validity were used. Odds ratios with 95% credible intervals (CrIs) are reported.

MAIN OUTCOMES AND MEASURES

The planned study outcome was rate of ADHD diagnoses.

RESULTS

A total of 12 374 unique patients with TBI of all severity levels and 43 491 unique controls were included in the 24 studies in this review (predominantly male: TBI, 61.8%; noninjury control, 60.9%; other injury control, 66.1%). The rate of pre-TBI ADHD diagnoses was 16.0% (95% CrI, 11.3%-21.7%), which was significantly greater than the 10.8% (95% CrI, 10.2%-11.4%) incidence of ADHD in the general pediatric population. Compared with children without injuries, the odds for ADHD were not significantly increased following concussion (≤1 year: OR, 0.32; 95% CrI, 0.05-1.13), mild TBI (≤1 year: OR, 0.56; 0.16-1.43; >1 year: OR, 1.07; 95% CrI, 0.35-2.48), and moderate TBI (≤1 year: OR, 1.28; 95% CrI, 0.35-3.34; >1 year: OR, 3.67; 95% CrI, 0.83-10.56). The odds for ADHD also were not significantly increased compared with children with other injuries following mild TBI (≤1 year: OR, 1.07; 95% CrI, 0.33-2.47; >1 year: OR, 1.18; 95% CrI, 0.32-3.12) and moderate TBI (≤1 year: OR, 2.34; 95% CrI, 0.78-5.47; >1 year: OR, 3.78; 95% CrI, 0.93-10.33). In contrast, the odds for ADHD following severe TBI were increased at both time points following TBI compared with children with other injuries (≤1 year: OR, 4.81; 95% CrI, 1.66-11.03; >1 year: OR, 6.70; 95% CrI, 2.02-16.82) and noninjured controls (≤1 year: OR, 2.62; 95% CrI, 0.76-6.64; >1 year: OR, 6.25; 95% CrI, 2.06-15.06), as well as those with mild TBI (≤1 year OR, 5.69; 1.46-15.67: >1 year OR, 6.65; 2.14-16.44). Of 5920 children with severe TBI, 35.5% (95% CrI, 20.6%-53.2%) had ADHD more than 1 year postinjury.

CONCLUSIONS AND RELEVANCE

This study noted a significant association between TBI severity and ADHD diagnosis. In children with severe but not mild and moderate TBI, there was an association with an increase in risk for ADHD. The high rate of preinjury ADHD in children with TBI suggests that clinicians should carefully review functioning before a TBI before initiating treatment.

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.

Severity of Ongoing Post-Concussive Symptoms as a Predictor of Cognitive Performance Following a Pediatric Mild Traumatic Brain Injury

OBJECTIVE

This study aimed to examine the predictors of cognitive performance in patients with pediatric mild traumatic brain injury (pmTBI) and to determine whether group differences in cognitive performance on a computerized test battery could be observed between pmTBI patients and healthy controls (HC) in the sub-acute (SA) and the early chronic (EC) phases of injury.

METHOD

203 pmTBI patients recruited from emergency settings and 159 age- and sex-matched HC aged 8-18 rated their ongoing post-concussive symptoms (PCS) on the Post-Concussion Symptom Inventory and completed the Cogstate brief battery in the SA (1-11 days) phase of injury. A subset (156 pmTBI patients; 144 HC) completed testing in the EC (~4 months) phase.

RESULTS

Within the SA phase, a group difference was only observed for the visual learning task (One-Card Learning), with pmTBI patients being less accurate relative to HC. Follow-up analyses indicated higher ongoing PCS and higher 5P clinical risk scores were significant predictors of lower One-Card Learning accuracy within SA phase, while premorbid variables (estimates of intellectual functioning, parental education, and presence of learning disabilities or attention-deficit/hyperactivity disorder) were not.

CONCLUSIONS

The absence of group differences at EC phase is supportive of cognitive recovery by 4 months post-injury. While the severity of ongoing PCS and the 5P score were better overall predictors of cognitive performance on the Cogstate at SA relative to premorbid variables, the full regression model explained only 4.1% of the variance, highlighting the need for future work on predictors of cognitive outcomes.

Nonsteroidal anti-inflammatory drug use and concussions in adolescent athletes: incidence, severity, and recovery

OBJECTIVE

Given concerns about the potential long-term effects of concussion in young athletes, concussion prevention has become a major focus for amateur sports leagues. Athletes have been known to frequently use anti-inflammatory medications to manage injuries, expedite return to play, and treat concussion symptoms. However, the effects of baseline nonsteroidal anti-inflammatory drug (NSAID) use on the susceptibility to head injury and concussion remain unclear. This study aims to assess the effects of preinjury NSAID use on concussion incidence, severity, and recovery in young athletes.

METHODS

Data from 25,815 ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) tests were obtained through a research agreement with ImPACT Applications Inc. Subjects ranged in age from 12 to 22 years old. Those who reported NSAID use at baseline were assigned to one (anti-inflammatory [AI]) cohort, whereas all others were assigned to the control (CT) cohort. Differences in head trauma and concussion incidence, severity, and recovery were assessed using chi-square tests, unpaired t-tests, and Kaplan-Meier plots.

RESULTS

The CT cohort comprised a higher percentage (p < 0.0001) of males (66.30%) than the AI cohort (44.16%) and had a significantly greater portion of athletes who played football (p = 0.004). However, no statistically significant differences were found between the two cohorts in terms of the incidence of head trauma (CT = 0.489, AI = 0.500, p = 0.9219), concussion incidence (CT = 0.175, AI = 0.169, p = 0.7201), injury severity, or median concussion recovery time (CT = 8, AI = 8, p = 0.6416). In a multivariable analysis controlling for baseline differences between the cohorts, no association was found between NSAID use and concussion incidence or severity.

CONCLUSIONS

In this analysis, the authors found no evidence that preinjury use of NSAIDs affects concussion risk in adolescent athletes. They also found no indication that preinjury NSAID use affects the severity of initial injury presentation or concussion recovery.

Stimulant Therapy Utilization for Neurocognitive Deficits in Mild Traumatic Brain Injury

CONTEXT

There are 3.8 million mild traumatic brain injuries (mTBIs) that occur each year in the United States. Many are left with prolonged life-altering neurocognitive deficits, including difficulties in attention, concentration, mental fatigue, and distractibility. With extensive data on the safety and efficacy of stimulant medications in treating attention deficit, concentration difficulties and distractibility seen with attention deficit disorder, it is not surprising that interest continues regarding the application of stimulant medications for the persistent neurocognitive deficits in some mTBIs.

EVIDENCE ACQUISITION

Studies were extracted from PubMed based on the topics of neurocognitive impairment, mTBI, stimulant use in mTBI, stimulants, and the association between attention deficit/hyperactivity disorder and mTBI. The search criteria included a date range of 1999 to 2020 in the English language.

STUDY DESIGN

Literature review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Currently, there is very limited literature, and no guidelines for evaluating the use of stimulant medication for the treatment of prolonged neurocognitive impairments due to mTBI. However, a limited number of studies have demonstrated efficacy and safety of stimulants in the treatment of neurocognitive sequelae of mTBI in the adult, pediatric, military, and athletic populations.

CONCLUSION

There is limited evidence to suggest stimulant medication may be beneficial in patients with mTBI with persistent neurocognitive symtpoms. The decision to utilize stimulant medication for mTBI patients remains physician and patient preference dependent. Given the limited encouraging data currently available, physicians may consider stimulant medication in appropriate patients to facilitate the recovery of prolonged neurocognitive deficits, while remaining cognizant of potential adverse effects.

Children with ADHD Have a Greater Lifetime History of Concussion: Results from the ABCD Study

This case-control study using baseline data from the population cohort Adolescent Brain Cognitive Development (ABCD) Study^® compared lifetime history of concussion between children with and without attention-deficit/hyperactivity disorder (ADHD). We hypothesized that children with ADHD would have a greater lifetime history of concussion than children without ADHD. Children were recruited from schools across the United States, sampled to provide strong generalizability to the US population. The current sample included 10,585 children (age: mean = 9.9; standard deviation = 0.6; range 9-10 years; 48.9% girls; 64.6% White), including 1085 with ADHD and 9500 without ADHD. The prevalence of prior concussion among children with ADHD was 7.2% (95% CI: 6.6-7.8%) compared with 3.2% (3.1-3.3%) among children without ADHD, meaning current ADHD status was associated with twice the odds of experiencing a prior concussion [χ² = 44.54; p < 0.001; odds ratio = 2.34 (1.81-3.03)]. No significant differences were observed in proportion of boys and girls with ADHD who had a prior concussion history. The number of current ADHD symptoms were not meaningfully associated with prior concussion history. Lower socioeconomic status was associated with lower rates of reported concussion, but not differentially in association with ADHD. ADHD is associated with twice the lifetime prevalence of prior concussion before age 11 among children from the general U.S. population. Boys and girls with ADHD did not differ in proportions with prior concussion and concussion history was not related to the number of ADHD symptoms reported by parents.

The Relationship between Sport-Related Concussion and Sensation-Seeking

Sensation-seeking, or the need for novel and exciting experiences, is thought to play a role in sport-related concussion (SRC), yet much remains unknown regarding these relationships and, more importantly, how sensation-seeking influences SRC risk. The current study assessed sensation-seeking, sport contact level, and SRC history and incidence in a large sample of NCAA collegiate athletes. Data included a full study sample of 22,374 baseline evaluations and a sub-sample of 2037 incident SRC. Independent samples t-test, analysis of covariance, and hierarchical logistic regression were constructed to address study hypotheses. Results showed that (1) among participants without SRC, sensation-seeking scores were higher in athletes playing contact sports compared to those playing limited- or non-contact sports (p < 0.001, R² = 0.007, η²_p = 0.003); (2) in the full study sample, a one-point increase in sensation-seeking scores resulted in a 21% greater risk of prior SRC (OR = 1.212; 95% CI: 1.154-1.272), and in the incident SRC sub-sample, a 28% greater risk of prior SRC (OR = 1.278; 95% CI: 1.104-1.480); (3) a one-point increase in sensation-seeking scores resulted in a 12% greater risk of incident SRC among the full study sample; and (4) sensation-seeking did not vary as a function of incident SRC (p = 0.281, η²_p = 0.000). Our findings demonstrate the potential usefulness of considering sensation-seeking in SRC management.

Premorbid anxiety and depression and baseline neurocognitive, ocular-motor and vestibular performance: A retrospective cohort study

Concussion has become a growing concern among sport and healthcare practitioners. Experts continue to investigate ways to advance the quality of concussion evaluation, diagnosis and management. Psychological conditions have been reported to influence concussion assessment outcomes at baseline and post-concussion; however, little evidence has examined psychological conditions and their effect on multifaceted measures of concussion. A retrospective cohort design was employed to examine differences between those with and without a premorbid psychological condition for high school and collegiate athletes who completed a preseason baseline battery, consisting of symptom reporting, computerized neurocognitive assessment, Vestibular-Ocular Motor Screening (VOMS), and the King-Devick (KD) test. Forty athletes within the sample self-reported a diagnosed psychological risk factor, consisting of depression and/or anxiety, and each were matched with a discordant control. Controls were matched on sex, age, sport, concussion history and ocular history. Athletes with psychological conditions reported higher symptom severity and had worse visual motor speed than controls. There were no differences between groups on other neurocognitive domains, VOMS, or KD. These results suggest that vestibular-ocular tools may be more consistent or less likely to vary between those with and without a premorbid psychological diagnosis, adding value to tools such as the KD and VOMS.

Concussion Management for the Orthopaedic Surgeon

Orthopaedic surgeons functioning as team physicians are in a unique position to recognize subtle changes in an athlete's behavior and may be the first responders to concussions at sporting events. The rate of sports-related concussions has increased over the past few decades, necessitating that orthopaedic team physicians gain a greater understanding of the diagnosis and management of this condition. During the sideline evaluation, life-threatening injuries must be ruled out before concussion evaluation may take place. In most cases, patients experience a resolution of symptoms within a week; however, a smaller subset of patients experience persistent symptoms. Physicians covering sporting events must remain current regarding recommendations for treating sports-related concussions and must document their management plan to minimize potential harm to an athlete.

Attention-Deficit/Hyperactivity Disorder and Outcome After Concussion: A Systematic Review

OBJECTIVE

To synthesize the literature and conduct a gap analysis on the association between attention-deficit/hyperactivity disorder (ADHD) and clinical outcome from sport-related concussion.

METHOD

The electronic search for this systematic review (PROSPERO ID: CRD42019128281) was conducted in February 2019 using terms related to concussion, sports/athletics, and predictors/modifiers of outcome to search the PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science databases. Eligible studies evaluated the association between ADHD and outcome from sport-related concussion. Of 4014 studies screened, 359 full-text articles were reviewed, with 14 studies ultimately included, involving 3623 participants (n = 359 [9.9%] with ADHD).

RESULTS

Study samples were primarily from specialty medical clinics (57.1%) and high school or college athletic groups (28.6%). Only 2 studies reported a statistically significant association between ADHD and worse clinical outcome. Of these, 1 included 13 participants with ADHD and the other included only 8 participants with ADHD. Only 1 previous study in this review was designed specifically to examine ADHD and prolonged concussion recovery, and that study did not report a statistically significant association.

CONCLUSION

There is not a clear association between ADHD and worse clinical outcome from concussion. However, eligible studies had limitations in research design, and nearly all studies were underpowered and evaluated the association between ADHD and concussion outcome as a secondary focus rather than the primary research question, precluding definitive conclusions. The association between ADHD and clinical outcomes remains unclear, and future research specifically examining ADHD and concussion recovery is needed.

Adolescents With ADHD Do Not Take Longer to Recover From Concussion

The objective of this study was to determine whether adolescents with attention-deficit/hyperactivity disorder (ADHD) have prolonged return to school and sports following concussion compared to those without ADHD and whether medication status or concussion history is associated with recovery time. We hypothesized that having ADHD would not be associated with longer recovery time. This prospective observational cohort study, conducted between 2014 and 2019, examined concussion recovery among school sponsored athletics throughout Maine, USA. The sample included 623 adolescents, aged 14-19 years (mean = 16.3, standard deviation = 1.3 years), 43.8% girls, and 90 (14.4%) reported having ADHD. Concussions were identified by certified athletic trainers. We computed days to return to school (full time without accommodations) and days to return to sports (completed return to play protocol) following concussion. Adolescents with ADHD [median days = 7, interquartile range (IQR) = 3-13, range = 0-45] did not take longer than those without ADHD (median days = 7, IQR = 3-13, range = 0-231) to return to school (U = 22,642.0, p = 0.81, r = 0.01; log rank: χ 1 2 = 0.059, p = 0.81). Adolescents with ADHD (median days = 14, IQR = 10-20, range = 2-80) did not take longer than those without ADHD (median days = 15, IQR = 10-21, range = 1-210) to return to sports (U = 20,295.0, p = 0.38, r = 0.04; log rank: χ 1 2 = 0.511, p = 0.48). Medication status and concussion history were not associated with longer recovery times. Adolescents with ADHD did not take longer to functionally recover following concussion. Recovery times did not differ based on whether adolescents with ADHD reported taking medication to treat their ADHD or whether they reported a prior history of concussion.

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.

Risk of Repeat Concussion Among Patients Diagnosed at a Pediatric Care Network

OBJECTIVE

To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury.

STUDY DESIGN

For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion.

RESULTS

Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]).

CONCLUSIONS

We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts.

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.

Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review

Background

Elite athletes can experience a diverse range of symptoms following post-concussive injury. The impact of sport-related concussion on specific mental health outcomes is unclear in this population.

Objective

The aim was to appraise the evidence base regarding the association between sport-related concussion and mental health outcomes in athletes competing at elite and professional levels.

Methods

A systematic search of PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane, and Cinahl databases was conducted.

Results

A total of 27 studies met inclusion criteria for review. Most of the included studies (67%, n = 18) were published in 2014 or later. Study methodology and reporting varied markedly. The extant research has been conducted predominantly in North America (USA, n = 23 studies; Canada, n = 3), often in male only (44.4%, n = 12) and college (70.4%, n = 19) samples. Depression is the most commonly studied mental health outcome (70.4%, n = 19 studies). Cross-sectional retrospective studies and studies including a control comparison tend to support an association between concussion exposure and depression symptoms, although several studies report that these symptoms resolved in the medium term (i.e. 1 month) post-concussion. Evidence for anxiety is mixed. There are insufficient studies to draw conclusions for other mental health domains.

Conclusion

Consistent with current recommendations to assess mood disturbance in post-concussive examinations, current evidence suggests a link between sports-related concussion and depression symptoms in elite athletes. Causation cannot be determined at this stage of enquiry because of the lack of well-designed, prospective studies. More research is required that considers a range of mental health outcomes in diverse samples of elite athletes/sports.

Electronic supplementary material

The online version of this article (10.1007/s40279-017-0810-3) contains supplementary material, which is available to authorized users.

Sport concussion and attention deficit hyperactivity disorder in student athletes: A cohort study

Background

Attention deficit hyperactivity disorder (ADHD) is associated with impulsive behavior and inattention, making it a potential risk factor for sport-related concussion (SRC). The objectives of this study were to determine whether ADHD is an antecedent risk factor for SRC and whether ADHD complicates recovery from SRC in youth athletes.

Methods

Student athletes with a history of SRC were evaluated for the presence of ADHD using diagnostic interview and to determine whether ADHD symptoms began before or after SRC. Concussion-specific measures of concussive symptoms and cognitive function were compared in SRC + ADHD and SRC + No ADHD groups to assess SRC recovery between groups.

Results

ADHD was overrepresented in youth with SRC compared with population rates. ADHD was found to be an antecedent risk factor for SRC, with age at ADHD onset earlier than the date of SRC. Student athletes with SRC and ADHD reported more concussive symptoms compared with athletes without ADHD and were more likely to have a history of greater than one concussion.

Conclusions

The results of this study support our hypothesis that ADHD is an antecedent risk factor for SRC and may contribute to a more complicated course of recovery from SRC. Future research should focus on determining whether screening, diagnosis, and treating ADHD in youth athletes may prevent SRC. Providers that care for youth athletes with ADHD should be aware of the vulnerabilities of this population toward SRC and its complications.

Identifying dyslexia risk for sport-related concussion management: Sensitivity and specificity of self-report and rapid naming

BACKGROUND

Dyslexia is the most common type of learning disability and studies have shown that student-athletes with learning disabilities sustain more concussions than their non-affected peers. However, current methods of dyslexia identification in college students are potentially invalid because they rely on students to self-report formal dyslexia diagnoses.

METHODS

To test the accuracy of self-report against two alternative methods of dyslexia screening, 94 college students completed three dyslexia symptom inventories, two rapid naming (RAN) tasks, and a standard word reading measure.

RESULTS

Reliability was acceptable for screening purposes on the inventories (α =.70, -.72), and excellent for RAN (α = .91, -.94). Specificity was acceptable (82.5%), but sensitivity was low (14.3%) when students self-reported suspected diagnoses of reading impairment. Sensitivity and specificity were higher for the digit RAN task (71 and 98%, respectively) compared to the letter RAN task (57 and 90%). Sensitivity (92.7%) and specificity (92.5%) were optimal when a cut-score of ≥27 seconds was used. A binary logistic regression showed digit RAN alone significantly predicted whether students were classified as typical or inefficient readers, p< .001, whereas the most reliable dyslexia inventory alone did not, p=.284. Including inventories along with RAN provided no additional predictive value.

CONCLUSION

Self-report inventories missed many cases of inefficient word reading. The digit RAN task classified 93.6% of the cases correctly compared to 72.3% for self-report inventory. Thus, we recommend that neuropsychologists working with college concussion management programs add to their baseline screening protocols the digit RAN task, which can be completed in less than one minute.

Neurocognitive Deficits Associated With ADHD in Athletes: A Systematic Review

Context:

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder and is frequently diagnosed in young adults. Emerging studies suggest a relationship between ADHD and concussion.

Objective:

To determine whether athletes with ADHD are at increased risk for neurocognitive deficits related to concussion risk, symptom reporting, and recovery.

Data Sources:

A comprehensive search of PubMed, CINAHL, PsychInfo, and Cochrane Library databases was performed. Studies conducted between 2006 and 2017 were reviewed, although only those between 2013 and 2017 met inclusion criteria.

Study Selection:

Studies that examined neurocognitive deficits in adolescent and young adult athletes aged 15 to 19 years who had ADHD and reported using notable neuropsychological evaluation tools were included.

Study Design:

Systematic review.

Level of Evidence:

Level 2.

Results:

A total of 17 studies met the inclusion criteria. The prevalence of ADHD in athletes varied between 4.2% and 8.1%. Overall, athletes with ADHD demonstrated lower scores on neurocognitive testing such as the ImPACT (Immediate Post-Concussion Assessment and Cognitive Test), increased risk for concussion, and increased symptom reporting. There was no evidence that treatment with stimulant medication changed these risks.

Conclusion:

ADHD is associated with increased neurocognitive deficits in athletes, although pathophysiology remains unclear. Evidence for stimulant treatment in athletes with ADHD continues to be sparse.

Attention-deficit/hyperactivity disorder is associated with baseline child sport concussion assessment tool third edition scores in child hockey players

OBJECTIVES

The objectives of this study were to report baseline, preseason data for the Child-SCAT3, stratified by attention deficit hyperactivity disorder (ADHD) status, and examine group differences in Child-SCAT3 performance between children with and without ADHD.

DESIGN

Cross-sectional study.

METHODS

Young male hockey players (n = 304), aged 8-12 years, were administered the Child-SCAT3 during pre-season. Child-SCAT3 measures included a 20-item symptom scale, a Standardised Assessment of Concussion Child Version (SAC-C), a modified Balance Error Scoring System (m-BESS), a tandem gait task, and a coordination test.

RESULTS

Children with ADHD (n = 20) endorsed significantly more symptoms (d = 0.95) and greater symptom severity (d = 1.13) compared to children without ADHD. No statistically significant differences were found between groups on Child-SCAT3 measures of cognitive or physical functioning (e.g. balance and coordination).

CONCLUSIONS

ADHD should be considered when interpreting Child-SCAT3 scores, especially symptom reporting, in the context of concussion assessment. Better understanding of symptom reporting in uninjured child athletes with ADHD can inform the clinical interpretation of symptoms at baseline and following an actual or suspected concussion. Normative data for the Child-SCAT3 that is not stratified by or otherwise accounts for ADHD status should be used with caution when appraising performance of children with ADHD.

Identifying Dyslexia Risk in Student-Athletes: A Preliminary Protocol for Concussion Management

Learning disability (LD) has been identified as a potential risk factor for a sport-related concussion, yet students with LD are rarely included in concussion research. Here, we draw special attention to dyslexia, a common but often underdiagnosed LD. Reading and learning problems commonly associated with dyslexia are often masked by protective factors, such as high verbal ability or general intelligence. Hence, high-achieving individuals with dyslexia may not be identified as being in a high-risk category. To ensure that students with dyslexia are included in LD concussion research and identified as LD in baseline testing, we provide athletic trainers with an overview of dyslexia and a preliminary screening protocol that is sensitive to dyslexia, even among academically high-achieving students in secondary school and college.

Predictors of clinical recovery from concussion: a systematic review

OBJECTIVE

A systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion. Clinical recovery was defined functionally as a return to normal activities, including school and sports, following injury.

DESIGN

Systematic review.

DATA SOURCES

PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus and Web of Science.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies published by June of 2016 that addressed clinical recovery from concussion.

RESULTS

A total of 7617 articles were identified using the search strategy, and 101 articles were included. There are major methodological differences across the studies. Many different clinical outcomes were measured, such as symptoms, cognition, balance, return to school and return to sports, although symptom outcomes were the most frequently measured. The most consistent predictor of slower recovery from concussion is the severity of a person's acute and subacute symptoms. The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. Those with a preinjury history of mental health problems appear to be at greater risk for having persistent symptoms. Those with attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk. There is some evidence that the teenage years, particularly high school, might be the most vulnerable time period for having persistent symptoms-with greater risk for girls than boys.

CONCLUSION

The literature on clinical recovery from sport-related concussion has grown dramatically, is mostly mixed, but some factors have emerged as being related to outcome.

Head Impact Density: A Model To Explain the Elusive Concussion Threshold

Concussion is a heterogeneous injury occurring throughout a range of impact magnitudes. Consequently, research focusing on a single or set of variables at the time of injury to understand concussive biomechanics has been thwarted by low injury prediction sensitivity. The current study examined the role of Impact Density in estimating concussive injury risk. Head impact data were collected across seven high school football seasons with the Head Impact Telemetry System (HIT System). Over the study period, 29 concussions were included for data analysis. The linear acceleration of the concussive impact was matched to a Control athlete, along with impacts in the 24 h before. Linear and rotational acceleration for the 19 impacts leading into the final event and the cumulative accelerations over time were evaluated. Analyses indicated no difference in impact counts within the final 24 h, or impact magnitudes for linear and rotational acceleration among the final 20 impacts (p > 0.05). A novel metric, Impact Density, was calculated from the final 20 impacts by summing the acceleration magnitude divided by time from the previous impact. Analyses indicated the Concussed athletes incurred a significantly higher linear (concussed: 255.4g/sec (standard error of the mean [SEM] = 40.1), controls:145.4g/sec (SEM = 23.8), p = 0.016), and rotational (Concussed:10311.3 rad/s/s/s (SEM = 1883.7), Controls: 6083.8 rad/s/s/s (SEM = 1115.9), p = 0.029) Impact Density than the Control athletes. Similar to other investigations, there was no difference in individual linear or rotational impact magnitude in the 20 impacts before and including the injury. The measure of Impact Density, however, revealed differences between the Concussed and Control athletes. These data suggest that the biomechanical threshold for concussion fluctuates downwardly with a greater impact magnitude and number with a return to pre-impact levels with time, suggesting physiological vulnerability to repeated head impacts. The current results highlight that time between impacts, not just impact magnitude, influences risk for concussion.