Sensitivity of the concussion assessment battery

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ability of Head Impact Measurements to Predict Sports Concussions: A Review

BACKGROUND AND OBJECTIVES

Provide a review of the current landscape of motion sensor-based analyses of mild traumatic brain injury (concussion) and shed light on avenues for further investigation.

METHODS

A review of the literature on motion sensor-based concussion studies was conducted using search terms "concussion prediction sensor," "concussion prediction motion," "concussion diagnosis sensor," and "concussion diagnosis motion" in PubMed (between January 2000 and March 2024). In total, 207 publications were initially identified. However, only 14 studies were ultimately included, due to lack of requisite measurement variables, focus on different outcomes, or participant overlap with included studies. Consolidation of mean and standard deviation of measurement variables was performed using the application of Cochrane formula.

RESULTS

Across 14 studies, most used head impact data from football (85.7%) and the Head Impact Telemetry system for data acquisition (92.9%). Most of the studies used data sets from collegiate athletes (71.4%). A minority of studies included female athletes (14.3%). On average, male athletes experienced higher linear and rotational accelerations during concussive vs nonconcussive impacts (97.6 ± 33.8 g and 4614.9 ± 2568.7 rad/s2 vs 24.4 ± 16.2 g and 1641.9 ± 1216.6 rad/s2). Moreover, male athletes experienced higher linear accelerations, but similar rotational accelerations, compared with female athletes specifically during concussive impacts (97.6 ± 33.8 g and 4614.9 ± 2568.7 rad/s2 vs 43.0 ± 11.5 g and 4030 ± 1435 rad/s2). Notably, studies that predicted concussion probability using multivariate regression methods (26.7%) demonstrated challenges with accuracy due to low positive predictive values (ranging from 0.3%-0.9%) and high false-positive rates (up to 39.4%).

CONCLUSION

Despite the statistical differences in head impact measurements between concussive and nonconcussive impacts, they have limited clinical utility as a stand-alone concussion identification tool. Head impact measurements may be most useful when used as an adjunct to other clinical and physiological markers.

Psychometric Properties of Vestibular and Ocular Measures Used for Concussion Assessments: A Scoping Review

BACKGROUND

Concussions most commonly affect the vestibular and ocular systems. Clinical measures used in the assessment of vestibular and ocular deficits should contain strong psychometric properties so that clinicians can accurately detect abnormality to guide treatment interventions.

OBJECTIVES

The aim of this scoping review was: (1) to identify the measures used to evaluate the vestibular and ocular domains postconcussion and (2) to document the psychometric properties of the measures.

METHODS

Two databases (Medline (Ovid) and Embase) were searched from inception to May 2023. An updated search was completed in January 2024 using the same databases and search terms. Studies were screened and data were extracted independently by 2 reviewers. Measures were categorized into vestibular, ocular, or both (vestibular and ocular) domains, and relevant psychometric properties were documented.

RESULTS

Fifty-two studies were included in this review. 28 studies explored the use of vestibular measures, 12 explored ocular measures, and 12 explored both vestibular and ocular measures or explored the use of vestibulo-ocular reflex measures. Most studies explored the properties associated with balance measures, particularly the balance error scoring system. Diagnostic accuracy (sensitivity and specificity metrics) of the associated measures was the most frequently documented characteristic in the literature.

CONCLUSION

Identification of clinical measures used to evaluate vestibular and ocular deficits postconcussion is needed to understand the evidence supporting their use in practice. Documenting the psychometric properties will allow clinicians and researchers to understand the status of the current literature and support for the use of certain measures in practice in terms of their ability to appropriately detect deficits in people with concussion when deficits are truly present.

The influence of sport-related concussion history on standing balance during upper limb movements under varying attentional demands

Sport-related concussions can influence athletic performance and everyday function. We implemented a dual-task paradigm whereby perturbed reaching while standing was combined with a simple reaction-time task. The purpose was to explore how concussion history influences balance control with and without external arm perturbations under varying attentional demands. Male athletes with no previous concussions (Hx0; n = 16; 19.3 ± 1.6 years) or history of two or more concussions (Hx2+; n = 16; 19.5 ± 1.8 years) participated. Participants reached to visual targets with their dominant hand and received randomly interspersed perturbations, performed either in isolation or simultaneously with a button press task with the non-dominant hand. Assessments included center of pressure (COP) parameters, hand movement reaction time and kinematics, and button-press reaction time. Participants with multiple concussions exhibited larger peak COP displacements and velocities than those with none. Compared to single task, the dual task increased cognitive processing and divided attention for both groups, demonstrated by slower button press and reaching reaction times, reduced anteroposterior hand velocity, and increased mediolateral hand displacement and velocity. Athletes with a concussion history likely have worse balance control, possibly owing to sensorimotor processing deficits or increased neural time delays leading to a subsequent reduction in motor activation. Because COP responses were overall maintained during the dual task, attentional resources were likely allocated towards maintaining balance control at the expense of upper limb performance.

Youth Soccer Heading Exposure and Its Effects on Clinical Outcome Measures

Purposeful heading, in which players may use their heads to advance the ball in play, is a unique part of soccer. Clinical outcome measures used to aid in the diagnosis of a concussion have long been a cornerstone of the contemporary measurements associated with the short- and long-term effects of monitoring repetitive head impacts (RHI) and soccer heading exposure. The effects of RHI in the youth population are still unknown, therefore, the purpose of this study was to examine if heading exposure is predictive of changes in self-reported symptoms, neurocognitive functioning, gait, and balance in female youth soccer players over the course of one soccer season. Small improvements in neurocognitive functioning and gait and slight deficits in balance were observed from pre- to post-season. All changes were not clinically relevant and likely due to a practice effect. The low heading exposure in our cohort of youth soccer players was likely not enough to elicit any changes in clinical measures. In general, our clinical outcomes did not change after a season of soccer play and change scores were not predicted by heading exposure.

Normative Values for the Head Shake Sensory Organization Test in an Active Duty Military Cohort

INTRODUCTION

The Head Shake Sensory Organization Test (HS-SOT) assesses postural stability while the head is moving and may also identify deficits in attention associated with the dual task conditions of moving the head at a specified speed while maintaining balance. Normative values for the HS-SOT have not been established in a healthy military population or other highly trained populations such as athletes. Establishing normative values in a military population will enable clinicians to compare the scores of patients with medical conditions that affect postural stability and sensory integration such as concussion or traumatic brain injury, vestibular dysfunction, or migraine to those of a healthy population to determine a need for intervention and for return to duty considerations. The purposes of this cross-sectional study were to establish normative values for the HS-SOT within the military population, to determine whether HS-SOT scores differed between men and women or among age groups, and to determine whether HS-SOT scores differed from scores on similar conditions of the Sensory Organization Test (SOT).

MATERIALS AND METHODS

Active duty service members (n = 237, 54 female) at Joint Base Lewis-McChord, Washington, Fort Campbell, Kentucky, and the National Capitol Region (Washington, D.C, Maryland, and Virginia) completed the SOT and HS-SOT on the NeuroCom® Balance Master™. Parametric and non-parametric comparisons were analyzed for the equilibrium scores for the SOT and HS-SOT conditions 2 (SOT-2, HS-SOT-2, respectively) and 5 (SOT-5, HS-SOT-5, respectively) and the equilibrium score ratios (ESRs) for HS-SOT-2 and HS-SOT-5 for the total sample, men and women, and age group categories (18-26 years, 27-35 years, and 36-45 years).

RESULTS

There were no differences in HS-SOT-2 or HS-SOT-5 equilibrium ratio scores between men (0.99 ±.029 and 0.83 ±0.25, respectively) and women (1.00 ±0.03 and 0.81 ±0.21, respectively). There were no differences in the SOT-2 equilibrium scores (F = 2.29, P = 0.10) or SOT-5 equilibrium scores (Kruskal-Wallis H = 3.26, P = 0.20) among the different age groups. SOT-2 equilibrium scores were higher than the HS-SOT-2 equilibrium scores (Z = -4.10, P < 0.001). SOT-5 equilibrium scores were also higher than HS-SOT-5 equilibrium scores (Z = -12.22, P < 0.001), and the HS-SOT-2 and HS-SOT-5 equilibrium scores differed from each other (Z = -13.26, P < 0.001).

CONCLUSIONS

This study established normative values for the HS-SOT in a military population. Equilibrium scores did not differ between men and women or among age groups, suggesting that these values can be used as reference points for most service members. Postural stability was found to be significantly challenged during head motion, indicating the HS-SOT is a valuable tool for identifying subtle impairments in postural stability. These findings have important implications for early detection and intervention in individuals with medical conditions affecting balance, particularly concussions or vestibular disorders.

The Convergent Validity of the SWAY Balance Application to Assess Postural Stability in Military Cadets Recovering from Concussion

Background

Concussions are often accompanied by balance disturbances. Clinically accurate evaluation systems are often expensive, large, and inaccessible to most clinicians. The Sway Balance Mobile Application (SWAY) is an accessible method to quantify balance changes.

Purpose

To determine the known groups and convergent validity of the SWAY to assess balance after a concussion.

Study Design

Case-Control Study.

Methods

Twenty participants with acute concussion and twenty controls were recruited. At initial, one-week, and final return to activity (RTA) evaluations, all participants completed the Sports Concussion Assessment Tool (SCAT-5), and balance control measured by SWAY mBESS and NeuroCom Balance Master Sensory Organization Test (SOT). Mixed model ANOVAs were used to detect differences in SWAY mBESS and NeuroCom SOT scores with time (initial, one-week, final RTA) as the within-subjects factor and group (concussed, healthy) as the between-subjects factor. Spearman's Rho correlations explored the associations between NeuroCom SOT scores, SWAY scores, SCAT-5 symptom scores, and time in days to final RTA.

Results

The sampled population was predominantly male and age (20 ± 1), and BMI differences were insignificant between groups. The SWAY did not detect differences between healthy and concussed participants and did not detect change over time [F(2,40) = .114, p = 0.89; F(2,40)= .276, p =0.60]. When assessing the relationship between the SWAY and the SOT, no correlation was found at any time point (r = -0.317 to -0.062, p > 0.05). Time to RTA demonstrated a moderate correlation with both SCAT-5 symptom severity score (r = .693, p < 0.01) and SCAT-5 total symptom score (r = .611, p < 0.01) at the one-week follow-up.

Conclusion

The SWAY mBESS does not appear to be a valid balance assessment for the concussed patient. The SWAY mBESS in patients with concussion failed to demonstrate convergent validity and did not demonstrate an ability to validate known groups. When assessing the time to final RTA, the one-week post-initial assessment SCAT-5 symptom severity and total scores may help determine the length of recovery in this population.

Level of Evidence

Level 3.

Use of Reactive Balance Assessments With Clinical Baseline Concussion Assessments in Collegiate Athletes

CONTEXT

Current clinical concussion evaluations assess balance deficits using static or dynamic balance tasks while largely ignoring reactive balance. Including a reactive balance assessment might provide a more comprehensive concussion evaluation.

OBJECTIVES

To identify redundancy in current clinical baseline assessments of concussion and determine whether reactive balance adds unique information to these evaluations.

DESIGN

Cross-sectional study.

SETTING

Clinical assessment.

PATIENTS OR OTHER PARTICIPANTS

A total of 279 healthy National Collegiate Athletic Association Division I athletes.

INTERVENTION(S)

Two cohorts of data were collected at the beginning of the athletic season. For cohort 1 (n = 191), the Immediate Post-Concussion Assessment and Cognitive Tool, instrumented modified push and release (I-mP&R), and Balance Error Scoring System (BESS) were administered. For cohort 2 (n = 88), the I-mP&R, BESS, timed tandem gait, walking with eyes closed, and clinical reaction time were administered.

MAIN OUTCOME MEASURE(S)

The strengths of the relationships between the Immediate Post-Concussion Assessment and Cognitive Tool cognitive indices, mP&R clinical score, instrumented measures (BESS sway; I-mP&R time to stability, latency, and step length), BESS score, timed tandem gait, walking time to completion, and clinical reaction time were characterized.

RESULTS

The strongest interinstrument correlation value was between single-task time to stability from the I-mP&R and clinical reaction time but was considered weak (r = 0.35, P = .001). The mP&R and I-mP&R clinical scores were weakly associated with the other assessments.

CONCLUSIONS

Weak correlations between interassessment variables indicated that little redundancy was present in the current clinical evaluations. Furthermore, reactive balance represents a unique domain of function that may improve the comprehensiveness of clinical assessments.

Psychometric Properties of Computerized Cognitive Tools and Standard Neuropsychological Tests Used to Assess Sport Concussion: A Systematic Review

Athletic programs are more frequently turning to computerized cognitive tools in order to increase efficiencies in concussion assessment. However, assessment using a traditional neuropsychological test battery may provide a more comprehensive and individualized evaluation. Our goal was to inform sport clinicians of the best practices for concussion assessment through a systematic literature review describing the psychometric properties of standard neuropsychological tests and computerized tools. We conducted our search in relevant databases including Ovid Medline, Web of Science, PsycINFO, and Scopus. Journal articles were included if they evaluated psychometric properties (e.g., reliability, sensitivity) of a cognitive assessment within pure athlete samples (up to 30 days post-injury). Searches yielded 4,758 unique results. Ultimately, 103 articles met inclusion criteria, all of which focused on adolescent or young adult participants. Test-retest reliability estimates ranged from .14 to .93 for computerized tools and .02 to .95 for standard neuropsychological tests, with strongest correlations on processing speed tasks for both modalities, although processing speed tasks were most susceptible to practice effects. Reliability was improved with a 2-factor model (processing speed and memory) and by aggregating multiple baseline exams, yet remained below acceptable limits for some studies. Sensitivity to decreased cognitive performance within 72 h of injury ranged from 45%-93% for computerized tools and 18%-80% for standard neuropsychological test batteries. The method for classifying cognitive decline (normative comparison, reliable change indices, regression-based methods) affected sensitivity estimates. Combining computerized tools and standard neuropsychological tests with the strongest psychometric performance provides the greatest value in clinical assessment. To this end, future studies should evaluate the efficacy of hybrid test batteries comprised of top-performing measures from both modalities.

The Effect of Ball Heading and Subclinical Concussion On the Neuromuscular Control Of The Lower Limb: A Systematic Review

Background

Soccer is unique among sports because it is the only sport that involves purposeful use of the head to control, pass, or shoot the ball. Over the previous five years, a relationship between lower extremity (LE) injury and sports related concussion (SRC) has been established in various sporting populations. Athletes at the high school, collegiate, and professional levels have demonstrated a greater risk for sustaining a LE injury post SRC. The purpose of this systematic review was to examine the relationship of the SRC with the incidence of LE injuries.

Methods

Ten databases were searched with the following keywords: Lower limb, ball heading, neuromuscular control, concussion, MEDLINE, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R), EMBASE, and Scopus. The search was limited to English-language and peer-reviewed publications, until 15/12/2022. The PEDro scale was used for the assessment of the risk of bias among the included studies. All included papers were qualitatively analyzed.

Results

A total of 834 studies were identified and 10 articles (four concussion-MSK biomechanics, six concussion-MSK injury) were included in the qualitative analyses. Included papers ranged from low to high quality. Due to the heterogeneous nature of the included study designs, quantitative meta-analysis was unable to be performed. All four of the included concussion-MSK biomechanics studies demonstrated, to some degree, that worse cognitive performance was associated with lower extremity MSK biomechanical patterns suggestive of greater risk for MSK injury. Among the six injury related studies, two investigations failed to determine group differences in cognitive performance between subsequently injured and non-injured athletes.

Conclusion

More research is needed to better understand the relationship of SRC and lower extremity injuries and the extent to which they are related to concussions and/or repetitive neurotrauma after ball heading sustained in soccer.

Level of Evidence

2.

Multisystem recovery after sport-related concussion in adolescent rugby players: a prospective study protocol

INTRODUCTION

Sport-related concussion is one of the most common injuries in adolescent rugby players with evidence of prolonged recovery in some concussed athletes. Concussion is a complex pathophysiological process that can affect a variety of subsystems with multifactorial presentation. Most research on adolescents recovery after concussion focuses on neurocognitive functioning and symptom outcomes over the short term. There is a need to explore concussion recovery over time across multiple subsystems in adolescent rugby players.

METHODS AND ANALYSIS

This prospective study will use sensorimotor and oculomotor outcomes in adolescent male and female rugby players aged 16-18 years. Players will be recruited from school or club rugby teams across the province of Ulster. Baseline assessment will be undertaken at the start of the playing season and will include questionnaires, Quantified Y Balance Test and Pupillary Light Reflex. Players who sustain a concussive event will be reassessed on all outcomes at 3 days, 7 days, 14 days, 23 days, 90 days, 180 days and 365 days postconcussion. For serial outcome data, we will examine response curves for each participant and make comparisons between known groups. We will use logistic regression to explore any association between demographic variables and recovery. The strength of the predictive model will be determined using R2, p values and ORs, with 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been granted for this study from Ulster University Research Ethics Committee (REC/14/0060). This study will be published in an open-access research journal on completion.

TRIAL REGISTRATION NUMBER

ACTRN12622000931774p.

Osteopathic manipulative treatment for concussions and postconcussive syndrome in athletes: a literature review

CONTEXT

Concussions are the most common type of traumatic brain injury (TBI) and can often occur in athletes. These injuries have many deleterious acute symptoms and can lead to the development of postconcussive syndrome (PCS). Osteopathic manipulative treatment (OMT) is a treatment option that may benefit patients with concussions and PCS.

OBJECTIVES

The objective of this review is to determine whether OMT can improve symptoms associated with concussions and PCS in athletes.

METHODS

A comprehensive literature review was conducted between August 2021 and March 2022 by two authors (Z.K.L. and K.D.T.) who searched the literature utilizing PubMed, Google Scholar, and Cochrane Library. Articles reviewed included case reports, case studies, randomized control trials, meta-analyses, and peer-reviewed journal articles. Search terms included concussion, postconcussive symptoms, osteopathic manipulative medicine, and manipulation. To be included into this study, articles must have included OMT from an osteopathic physician or manipulative techniques by nonosteopathic providers for patients with a concussion or PCS, and the insulting injury must have occurred in an athletic setting. No disagreements occurred between authors about what studies to include. However, we were prepared to come to a unanimous decision through discussion among the authors. A narrative synthesis was performed. No other data analyses were conducted in this study.

RESULTS

Included in this review were nine articles including randomized control trials, retrospective review, case series, longitudinal, retrospective studies, and case reports. The literature shows the positive effects of OMT and manipulative techniques on symptom resolution after a concussion. However, most of the literature is qualitative rather than quantitative in nature, lacking in randomized control trials.

CONCLUSIONS

There is a scarcity of high-quality studies evaluating the effectiveness of OMT on concussions and PCS. More research is needed to understand the degree of benefit for this treatment option.

Relationship Between Sensory Organization Testing Scores With Lower Extremity Injuries and Prior Concussion in Professional Soccer Players

OBJECTIVE

To evaluate for associations between concussion history or lower extremity (LE) injury and computerized sensory organization testing (SOT) performance in professional soccer players.

DESIGN

Cross-sectional study.

SETTING

Tertiary care center.

PARTICIPANTS

Thirty-three, professional, male soccer players on an American club, between the years 2019 and 2021.

ASSESSMENT OF RISK FACTORS

Player age, history of reported LE injury (gluteal, hamstring, ankle, knee, hip, groin, and sports hernia), history of diagnosed concussion, and the number of prior concussions were documented for each player.

MAIN OUTCOME MEASURES

Baseline SOT of postural sway was conducted in 6 sensory conditions for all players.

RESULTS

Eleven athletes (33%) reported a previous concussion, and 15 (45%) reported a previous LE injury. There were no significant differences in SOT scores between those with and without a previous diagnosis of concussion ( P > 0.05). Those reporting a previous LE injury performed better on condition 3 (eyes open, unstable visual surround) than those who did not ( P = 0.03). Athletes aged 25 years or younger performed worse on condition 3 ( P = 0.01) and had worse, although not statistically significant, median performance on all other balance measures than those older than 25 years. Intraclass correlation coefficient for repeat SOT assessment was 0.58, indicating moderate reliability, without an evident practice effect.

CONCLUSIONS

Professional soccer players with a previous concussion or history of LE injury did not demonstrate long-term deficits in postural control, as assessed by multiyear computerized SOT baseline testing. The SOT was reliable over time with younger athletes exhibiting greater postural sway than older athletes.

Association of Sleep Disturbance With Neurocognition, Symptom Severity, and Recovery in Pediatric Concussion: A 10-Year Retrospective Analysis of a Tertiary Referral Concussion Clinic

OBJECTIVES

To investigate the relationship between sleep disturbance, neurocognition, symptom severity, and recovery in children and adolescents with concussion. Sex-related comparisons were also examined.

SETTING

Pediatric tertiary referral concussion clinic.

PARTICIPANTS

Children and adolescents (aged 6-18 years; n = 554) diagnosed with concussion.

DESIGN

Cross-sectional retrospective study.

MAIN MEASURES

Assessment data were obtained from Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Applications. Sleep disturbance was quantified using the sleep-related domains of the Post-Concussion Symptom Scale (PCSS) and self-report sleep duration. Sleep duration was categorized as short (<7 hours), intermediate (7-9 hours), and long (≥9 hours). Outcome measures included neurocognition, measured via composite scores of ImPACT cognitive domains (verbal memory, visual memory, visual motor speed, reaction time); symptom severity, using the PCSS; and concussion recovery time (days).

RESULTS

Short sleep resulted in significantly poorer verbal memory ( P = .03), visual memory ( P = .02), and reaction time ( P = .01). Sleep disturbance was strongly associated with total symptom burden (ρ = 0.90, P < .001). Recovery time, median (interquartile range), was significantly prolonged with short sleep, 61 (30-136) days, compared with intermediate, 38 (21-72) days, and long, 34 (19-71) days, sleep ( P < .001). Overall, female participants demonstrated significantly longer recovery times than male participants (mean 91 ± 95 vs 58 ± 85 days, P < .001). Females exhibited similar concussion recovery times irrespective of reported sleep duration ( P = .95), whereas mean recovery time in males was significantly longer with short sleep (84 ± 82 days) than with intermediate (61 ± 106 days) and long (49 ± 62 days) sleep ( P < .001).

CONCLUSION

Sleep disturbance following concussion poses as a promising modifiable risk factor to alleviate postinjury impairments, including cognitive deficits and symptom burden. Female children were found to experience more severe concussion symptoms and protracted recovery times than their male counterparts. Investigations into the factors that may contribute to sex-related differences following concussion are warranted.

Concussion Assessment and Management Practices Among Irish and Canadian Athletic Therapists: An International Perspective

CONTEXT

Certified athletic therapists in Ireland and Canada serve essential concussion assessment and management roles, but their health care practices and concussion knowledge have not been established.

OBJECTIVE

To examine Irish and Canadian athletic therapist cohorts' (1) concussion knowledge, (2) current concussion assessment and management techniques across all job settings, and (3) the association of concussion assessment and management practices with years of clinical experience and highest degree attained.

DESIGN

Cross-sectional cohort study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Licensed Irish (49.7%, n = 91/183) and Canadian (10.1%, n = 211/2090) athletic therapists.

MAIN OUTCOME MEASURE(S)

Athletic therapists completed an online survey assessing their demographics, concussion knowledge (symptom recognition, patient-clinician scenarios), frequency of concussions assessed annually, and assessment and return-to-play (RTP) measures using a modified, previously validated survey. Symptom recognition consisted of 20 (8 true, 12 false) items on recognition of signs and symptoms that were scored as total correct. Descriptive statistics and odds ratios were used to examine survey responses where appropriate.

RESULTS

Irish (86.8%, n = 46/53) and Canadian (93.4%, n = 155/166) athletic therapists indicated RTP guidelines were the most common method for determining RTP. Symptom recognition scores were 72.8% ± 17.0% among Irish and 76.6% ± 17.0% among Canadian athletic therapists. Irish (91.2%, n = 52/57) and Canadian (90.4%, n = 161/178) athletic therapists reported standardized sideline assessments as the most used concussion assessment method. Irish and Canadian athletic therapists' use of 2-domain (Irish: 38.6% [n = 22/57]; Canadian: 73.6% [n = 131/178]) and 3-domain (Irish: 3.5% [n = 2/57]; Canadian: 19.7% [n = 35/178]) minimum assessments (ie, symptoms, balance, or neurocognitive) was not associated with education or clinical experience (P ≥ .07), except for Canadian athletic therapists with master's degrees having greater odds of completing 2-domain assessments at initial evaluation than those with bachelor's degrees (odds ratio = 1.80; 95% CI = 1.41, 1.95).

CONCLUSIONS

Irish and Canadian athletic therapists demonstrated similar concussion knowledge; however, most did not fully adhere to international consensus guidelines for concussion assessment as evidenced by low 2- and 3-domain assessment use. Athletic therapists should aim to implement multidimensional concussion assessments to ensure optimal health care practices and patient safety.

Test-Retest Reliability and Efficacy of Individual Symptoms in Concussion Management

OBJECTIVE

(1) To determine test-retest reliability of individual Sport Concussion Assessment Tool-Third Edition (SCAT-3) symptom scores and symptom severity scores, (2) to examine the specificity/sensitivity of individual SCAT-3 symptom severity scores acutely (24-48 hours) postconcussion, and (3) to develop a model of symptoms best able to differentiate concussed from nonconcussed student athletes and cadets.

DESIGN

Prospective, longitudinal, and cross-sectional.

SETTING

Twenty-six civilian schools and 3 US service academies.

PARTICIPANTS

Collegiate student athletes (n = 5519) and cadets (n = 5359) from the National Collegiate Athletic Association-Department of Defense Grand Alliance: Concussion Assessment, Research and Education Consortium, including 290 student athletes and 205 cadets, assessed 24 to 48 hours postconcussion.

INDEPENDENT VARIABLES

Concussed and nonconcussed student athlete and cadet groups.

MAIN OUTCOME MEASURES

Sport Concussion Assessment Tool-Third Edition individual symptom severity scores, total symptom scores, and symptom severity scores.

RESULTS

Results indicated poor test-retest reliability across all symptom scores (intraclass correlation coefficient = 0.029-0.331), but several individual symptoms had excellent predictive capability in discriminating concussed from nonconcussed participants (eg, headache, pressure in the head, and don't feel right had area under the curve >0.8, sensitivity >70%, and specificity >85%) regardless of baseline testing. These symptoms were consistent with Chi-square Automatic Interaction Detector classification trees with the highest mean probability.

CONCLUSIONS

Findings support the excellent diagnostic accuracy of honest symptom reporting, notwithstanding the known limitations in symptom underreporting, and suggest that there may be added value in examining individual symptoms rather than total symptom scores and symptom severity scores alone. Finally, findings suggest that baseline testing is not necessary for interpreting postconcussion symptom scores.

Concussion-related visual memory and reaction time impairment in college athletes improved after osteopathic manipulative medicine: a randomized clinical trial

CONTEXT

Concussion is an acute, transient disruption in brain function due to head injury. Previous studies suggest osteopathic manipulative medicine (OMM) improved recovery from concussion.

OBJECTIVES

The hypothesis was that new-onset impairments (NOI) of neurological functions identified by Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) will improve more so after OMM than after concussion-education.

METHODS

College athletes presenting to the outpatient academic healthcare center (AHCC) with concussion due to head injury within the preceding 2 weeks were recruited for this IRB-approved, randomized, single-blinded trial. Consented men and women were randomized into groups receiving two OMM treatments or two concussion-education sessions to control for social effects. Preseason, Baseline, ImPACT was compared to Post-Injury scores to determine NOI. Baseline, Post-Injury, and Post-Interventions ImPACTs were compared by analysis of variance (ANOVA, α≤0.05). Post-Injury correlations and mean changes in King-Devick (KD) scores were analyzed.

RESULTS

Post-Injury NOI were found in 77.8% (14/18) men and 85.7% (6/7) women, including ImPACT subscore indices for verbal and visual memory, processing speed (PS), and reaction time (RT). Of those with NOI, mean visual memory recovered by 50.0% following one and by 104.9% (p=0.032) following two OMM treatments in men and by 82.8% (p=0.046) following one treatment in women. Following two interventions, the mean RT in men receiving OMM improved by 0.10 more than education (p=0.0496). The effect sizes of OMM were large (Cohen's d=1.33) on visual memory and small (Cohen's d=0.31) on RT.

CONCLUSIONS

The NOI in visual memory and RT following concussion significantly improved in the OMM group compared to the education group. Integrating OMM utilizing physical exam and this treatment was a safe individualized approach in athletes with acute uncomplicated concussions. Further research is warranted to improve the utilization of OMM for individuals with concussion.

Identification of Clinical Measures to Use in a Virtual Concussion Assessment: Protocol for a Mixed Methods Study

BACKGROUND

Workplace concussions can have a significant impact on workers. The impact of concussion symptoms, combined with challenges associated with clinical environments that are loud, bright, and busy, create barriers to conducting effective in-person assessments. Although the opportunity for remote care in rural communities has long been recognized, the COVID-19 pandemic has catalyzed the transition to virtual assessments and care into the mainstream. With this rapid shift, many clinicians have been completing remote assessments. However, the approaches and measures used in these assessments have not yet been standardized. Furthermore, the psychometric properties of the assessments when completed remotely using videoconference have not yet been documented.

OBJECTIVE

Through this mixed methods study, we aim to (1) identify the concussion assessment measures clinicians are currently using in person and are most relevant to the following 5 physical domains: neurological examination (ie, cranial nerve, coordination, motor, and sensory skills), cervical spine, vestibular, oculomotor, and effort assessment; (2) document the psychometric properties of the measures identified; (3) identify measures that appear feasible in a virtual context; and (4) identify practical and technical barriers or challenges, facilitators, and benefits to conducting or engaging in virtual concussion assessments.

METHODS

This study will follow a sequential mixed methods design using a survey and Delphi approach, working groups with expert clinicians, and focus groups with experienced clinicians and people living with concussions. Our target sample sizes are 50 clinicians for the Delphi surveys, 4 clinician-participants for the working group, and 5-7 participants for each focus group (roughly 6-10 total groups being planned with at least two groups consisting of people living with concussions). The results from this study will inform the decision regarding the measures that should be included in a virtual assessment tool kit to be tested in a future planned prospective evaluation study.

RESULTS

The study is expected to be completed by January 2023.

CONCLUSIONS

This mixed methods study will document the clinical measures that are currently used in person and will identify those that are most relevant to assessing the physical domains impacted by concussions. Potential feasibility of using these measures in a virtual context will be explored.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40446.

The Clinical Utility of the Child SCAT5 for Acute Concussion Assessment

Background

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5 and 12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion.

Methods

Our participants included 34 concussed (21 boys, 13 girls; age = 12.8 ± 0.86 years) and 44 non-concussed (31 boys, 13 girls; age = 12.4 ± 0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r=\frac{Z}{\sqrt{n}}$$\end{document}r=Zn) were calculated to assess the magnitude of difference for each comparison. The diagnostic properties (sensitivity, specificity, diagnostic accuracy, predictive values, likelihood ratios, and diagnostic odds ratio) of each Child SCAT5 score were also calculated.

Results

Concussed children endorsed more symptoms (p < 0.001, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.45), higher symptom severity (p < 0.001, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.44), and had higher double leg (p = 0.046, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.23), single leg (p = 0.035, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.24), and total scores (p = 0.022, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.26) for the mBESS than the non-concussed children. No significant differences were observed for the SAC-C scores (p’s ≥ 0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC = 0.76–0.77), negative predictive values (NPV = 0.84–0.88), and negative likelihood ratios (-LR = 0.22–0.31) of the Child SCAT5 scores.

Conclusions

Clinicians should prioritize interpretation of the symptom evaluation form of the Child SCAT5 as it was the most effective component for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion.

Monitoring the acute and subacute recovery of cognitive ocular motor changes after a sports-related concussion

Identifying when recovery from a sports-related concussion (SRC) has occurred remains a challenge in clinical practice. This study investigated the utility of ocular motor (OM) assessment to monitor recovery post-SRC between sexes and compared to common clinical measures. From 139 preseason baseline assessments (i.e. before they sustained an SRC), 18 (12 males, 6 females) consequent SRCs were sustained and the longitudinal follow-ups were collected at 2, 6, and 13 days post-SRC. Participants completed visually guided, antisaccade (AS), and memory-guided saccade tasks requiring a saccade toward, away from, and to a remembered target, respectively. Changes in latency (processing speed), visual–spatial accuracy, and errors were measured. Clinical measures included The Sports Concussion Assessment Tool, King-Devick test, Stroop task, and Digit span. AS latency was significantly longer at 2 days and returned to baseline by 13-days post-SRC in females only (P &lt; 0.001). Symptom numbers recovered from 2 to 6 days and 13 days (P &lt; 0.05). Persistently poorer AS visual–spatial accuracy was identified at 2, 6 and 13 days post-SRC (P &lt; 0.05) in both males and females but with differing trajectories. Clinical measures demonstrated consistent improvement reminiscent of practice effects. OM saccade assessment may have improved utility in tracking recovery compared to conventional measures and between sexes.

Immediate Post-Concussion and Cognitive Testing (ImPACT): Effects of Data Integration Strategies on Classification Accuracy

OBJECTIVE

The current study aimed to evaluate varying data integration procedures and their effects on the classification accuracy of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).

SETTING

Data were collected from an independent secondary school that included students in grades 9 to 12.

PARTICIPANTS

The study examined 300 consecutive ImPACT score reports generated by secondary school students between 2010 and 2015.

DESIGN

To appraise ImPACT's utility as a serialized measure, standardized regression-based equations were formulated to compute reliable change index scores. Discriminant function analyses (DFAs) consisting of varying combinations of ImPACT composite scores were conducted and their accuracy was compared to that produced by the standard interpretive procedure.

MAIN MEASURES

Varying combinations of scores produced on Verbal Memory, Visual Memory, Visual Motor Speed, Reaction Speed, and the Postconcussion Symptom Scale were included in analyses.

RESULTS

DFAs yielded sensitivities ranging from 31% to 49%, specificities from 88% to 95%, positive predictive values (PPVs) from 61% to 83%, and negative predictive values (NPVs) from 67% to 75%. Conversely, the standard interpretive procedure yielded a sensitivity of 73%, specificity of 43%, PPV of 45%, and NPV of 72%.

CONCLUSION

The standard interpretive procedure produced a higher sensitivity than the DFAs; however, its PPV did not exceed chance levels. Conversely, DFA equations produced superior PPVs; however, their sensitivity hovered around 50%, leaving a substantial proportion of individuals with concussion undetected. Cognitive composite scores did not appear to offer significant incremental utility in relation to symptom self-report. Base rate conditions and psychometric factors appeared to contribute to ImPACT's limited classification accuracy.

Test-retest reliability of the neurotracker compared to the impact test for the management of mild traumatic brain injuries during two consecutive university sport seasons

INTRODUCTION

Neurocognitive assessment tools such as the Neurotracker and ImPACT have been proposed to optimize sports-related mild traumatic brain injury (mTBI) management. Baseline testing is recommended with such assessments to individualize monitoring of athletes' remission. While the ideal timeframe between baseline updates has been studied for the ImPACT, these data are missing for the Neurotracker.

OBJECTIVE

The current study aimed to compare the test-retest reliability of the ImPACT and Neurotracker for two consecutive seasons in university athletes participating in sports at risk for mTBI.

METHODS

At the start of two consecutive seasons, 30 athletes with no recent history of mTBI completed a baseline assessment including the Neurotracker and the ImPACT. The test-retest reliability of the results was analyzed by considering intra-class correlation (ICC), Becker's standardized mean difference (d_B) and Bland-Altman' plot of each outcome.

RESULTS

The Neurotracker and the Visual Motor Speed composite score of the ImPAC were the only outcomes with significative ICCs and acceptable d_B between the two seasons. Neurotracker was the only outcome with a significative bias (+0.179).

CONCLUSION

Our research suggests that the Neurotracker has an acceptable level of test-retest reliability after one year in comparison to the ImPACT.

The 100 Most-Cited and Influential Articles in Collegiate Athletics

Background

Bibliometric citation analyses have been widely used in medicine to help researchers gain foundational knowledge about a topic and identify subtopics of popular interest for further investigations. There is a lack of similar research in collegiate athletics.

Purpose

To identify the 100 most-cited research publications related to collegiate athletics.

Study Design

Cross-sectional study.

Methods

The Clarivate Analytics Web of Knowledge database was used to generate a list of articles relating to collegiate athletics on January 24, 2022. Articles were filtered by the total number of citations, and the 100 most-cited articles were selected. For each article, we identified and analyzed the following: author name, publication year, country of origin, journal name, article type, main research topic area, competitive level, sex of study population, and level of evidence.

Results

Of the top 100 most-cited articles, 63 were related to medicine. In total, 96% of articles were published in the United States, and 80% were published in the year 2000 or later. Of the top 100 articles, 85 were observational; only 5 were experimental. The sport most represented was soccer, followed by football, baseball, and basketball. Of the top 100 articles, 21 were published in a single journal, the American Journal of Sports Medicine. Ten authors published ≥5 of the top 100 most-cited studies.

Conclusion

The majority of top 100 articles were published in the United States after 1999 and primarily focused on medicine-related topics. Soccer was studied by more articles than football, baseball, and basketball. An author's prestige may have influenced the likelihood of citation. The top 100 most-cited studies provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to the literature on collegiate athletics.

The Non-Concordance of Self-Reported and Performance-Based Measures of Vestibular Dysfunction in Military and Civilian Populations Following TBI

As a predominately young, physically active, and generally healthy population, service members (SMs) with vestibular dysfunction (VD) following a TBI may not be accurately represented by the current civilian reference ranges on assessments of VD. This study enrolled SMs who were referred for vestibular rehabilitation following a mild/moderate TBI. The participants self-reported VD using the Activities-specific Balance Confidence (ABC) scale and the Dizziness Handicap Inventory (DHI) followed by evaluation of vestibular performance using computerized dynamic posturography sensory organizational test (CDP−SOT). Retrospective analysis of these outcomes comparing the study sample of SMs to the reported civilian samples revealed SMs self-reported lower VD with significantly higher balance confidence (ABC: 77.11 ± 14.61, p < 0.05) and lower dizziness (DHI: 37.75 ± 11.74, p < 0.05) than civilians. However, the SMs underperformed in performance-based evaluations compared to civilians with significantly lower CDP−SOT composite and ratio scores (COMP: 68.46 ± 13.46, p < 0.05; VIS: 81.36 ± 14.03, p < 0.01; VEST: 55.63 ± 22.28, p < 0.05; SOM: 90.46 ± 10.17, p < 0.05). Correlational analyses identified significant relationships between the ABC and CDP−SOT composite (r = 0.380, p < 0.01) and ratio scores (VIS: r = 0.266, p < 0.05; VEST: r = 0.352, p < 0.01). These results highlight the importance of recognizing and understanding nuances in assessing VD in SMs to ensure they have access to adequate care and rehabilitation prior to returning to duty.

Recovery of symptoms, neurocognitive and vestibular-ocular-motor function and academic ability after sports-related concussion (SRC) in university-aged student-athletes: a systematic review

BACKGROUND

Physiological differences between a maturing and matured brain alters how Sports-Related Concussion (SRC) affects different age groups; therefore, a review specific to university-aged student-athletes is needed.

OBJECTIVES

Determine time to recovery for symptom burden, neurocognitive and Vestibular-Ocular-Motor (VOM) function and academic impact in university-aged student-athletes.

METHODS

Searches were conducted in PubMed, SpringerLink, PsycINFO, Science Direct, Scopus, Cochrane, Web of Science and EMBASE. Articles were included if they contained original data collected within 30 days in university-aged student-athletes, analysed SRC associated symptoms, neurocognitive or VOM function or academic ability and published in English. Two reviewers independently reviewed sources, using the Oxford Classification of Evidence-Based Medicine (CEBM) and the Downs and Black checklist, and independently extracting data before achieving consensus.

RESULTS

58 articles met the inclusion criteria. Recovery of symptoms occurred by 7 and 3-5.3 days for neurocognition. The evidence base did not allow for a conclusion on recovery time for VOM function or academic ability. Few papers investigated recovery times at specified re-assessment time-points and have used vastly differing methodologies.

CONCLUSIONS

To fully understand the implication of SRC on the university-aged student-athlete' studies using a multi-faceted approach at specific re-assessments time points are required.Systematic review registration number: CRD42019130685.

Two Symptoms to Triage Acute Concussions: Using Decision Tree Modeling to Predict Prolonged Recovery After a Concussion

OBJECTIVE

The objective was to examine the 22 variables from the Sport Concussion Assessment Tool's 5th Edition Symptom Evaluation using a decision tree analysis to identify those most likely to predict prolonged recovery after a sport-related concussion.

DESIGN

A cross-sectional design was used in this study. A total of 273 patients (52% men; mean age, 21 ± 7.6 yrs) initially assessed by either an emergency medicine or sport medicine physician within 14 days of concussion (mean, 6 ± 4 days) were included. The 22 symptoms from the Sport Concussion Assessment Tool's 5th Edition were included in a decision tree analysis performed using RStudio and the R package rpart. The decision tree was generated using a complexity parameter of 0.045, post hoc pruning was conducted with rpart, and the package carat was used to assess the final decision tree's accuracy, sensitivity and specificity.

RESULTS

Of the 22 variables, only 2 contributed toward the predictive splits: Feeling like "in a fog" and Sadness. The confusion matrix yielded a statistically significant accuracy of 0.7636 (P [accuracy > no information rate] = 0.00009678), sensitivity of 0.6429, specificity of 0.8889, positive predictive value of 0.8571, and negative predictive value of 0.7059.

CONCLUSIONS

Decision tree analysis yielded a statistically significant decision tree model that can be used clinically to identify patients at initial presentation who are at a higher risk of having prolonged symptoms lasting 28 days or more postconcussion.

Top-100 Most-Cited Sports-Related Concussion Articles Focus on Symptomatology, Epidemiology, and Demographics

Purpose

To analyze the top-100 cited articles on sports-related concussions together with a bibliometric analysis to determine citations by year, level of evidence, study design, and several other factors related to the top referenced articles in sports concussions.

Methods

The Clarivate Analytics Web of Knowledge database was used to gather data using Boolean queries to capture all possible iterations of sports-related concussion research. Articles were organized in descending order based on the number of citations and included or excluded based on relevance to concussion. Collected information included author name, publication year, country of origin, journal name, article type, study focus, and the level of evidence.

Results

The top-100 articles were cited 31,197 times with an average of 312.0 citations per publication. More than one half were published in 2006 or later (52). Cohort studies and descriptive articles were the most prevalent study types (22 each). Studies with Level V evidence were the most common (33). The most common areas of study were symptomatology (short term, long term) with 17 articles, followed by epidemiology/demographics with 16 articles. The least common area of study was concussion prevention (2 articles), followed by management/treatment, diagnostics (labs, imaging) with 4 articles each.

Conclusions

We identified the most influential studies in sports-related concussion based on number of citations and citation density. A majority of these articles were published in the United States after 2006 and are most commonly cohort studies (Level IV evidence) and descriptive articles (Level V evidence). Current research focuses most heavily on the symptomatology and epidemiology/demographics of sports concussion.

Clinical Relevance

This study serves to identify the most influential articles in sports-related concussion and identify research topics with general deficiencies within the field of sports-related concussion research.

Prospective study with specific Re-Assessment time points to determine time to recovery following a Sports-Related Concussion in university-aged student-athletes

BACKGROUND

Time to recovery for symptom burden and neurocognition following a Sports-Related Concussion (SRC) has previously been determined by consolidating varying re-assessment time points into a singular point, and has not been established for Vestibular-Ocular-Motor (VOM) function or academic ability.

OBJECTIVES

Establish when recovery of symptom burden, neurocognition, VOM function, and academic ability occurs in university-aged student-athletes.

METHODS

Student-athletes completed an assessment battery (Post-Concussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), Vestibular Ocular-Motor Screening (VOMS), Perceived Academic Impairment Tool (PAIT)) during pre-season (n = 140), within 48 hours, 4, 8 and 14 days post-SRC and prior to Return To Play (RTP) and were managed according to the Rugby Football Union' community pathway (n = 42). Student-athletes were deemed recovered or impaired according to Reliable Change Index' (RCI) or compared to their individual baseline.

RESULTS

Symptom burden recovers by four days post-SRC on RCI and to baseline by eight days. VOM function and academic ability recovers by 8 days. Some student-athletes demonstrated worse performance at RTP on all tests by RCI and to baseline, except for on VOMS score and near point convergence by RCI change.

CONCLUSIONS

Variation in individual university-aged student-athletes requires a multi-faceted approach to establish what dysfunctions post-SRC exist and when recovery occurs.

Head Impact Research Using Inertial Sensors in Sport: A Systematic Review of Methods, Demographics, and Factors Contributing to Exposure

BACKGROUND

The number and magnitude of head impacts have been assessed in-vivo using inertial sensors to characterise the exposure in various sports and to help understand their potential relationship to concussion.

OBJECTIVES

We aimed to provide a comprehensive review of the field of in-vivo sensor acceleration event research in sports via the summary of data collection and processing methods, population demographics and factors contributing to an athlete's exposure to sensor acceleration events.

METHODS

The systematic search resulted in 185 cohort or cross-sectional studies that recorded sensor acceleration events in-vivo during sport participation.

RESULTS

Approximately 5800 participants were studied in 20 sports using 18 devices that included instrumented helmets, headbands, skin patches, mouthguards and earplugs. Female and youth participants were under-represented and ambiguous results were reported for these populations. The number and magnitude of sensor acceleration events were affected by a variety of contributing factors, suggesting sport-specific analyses are needed. For collision sports, being male, being older, and playing in a game (as opposed to a practice), all contributed to being exposed to more sensor acceleration events.

DISCUSSION

Several issues were identified across the various sensor technologies, and efforts should focus on harmonising research methods and improving the accuracy of kinematic measurements and impact classification. While the research is more mature for high-school and collegiate male American football players, it is still in its early stages in many other sports and for female and youth populations. The information reported in the summarised work has improved our understanding of the exposure to sport-related head impacts and has enabled the development of prevention strategies, such as rule changes.

CONCLUSIONS

Head impact research can help improve our understanding of the acute and chronic effects of head impacts on neurological impairments and brain injury. The field is still growing in many sports, but technological improvements and standardisation of processes are needed.

Machine Learning for Subtyping Concussion Using a Clustering Approach

Background: Concussion subtypes are typically organized into commonly affected symptom areas or a combination of affected systems, an approach that may be flawed by bias in conceptualization or the inherent limitations of interdisciplinary expertise.

Objective: The purpose of this study was to determine whether a bottom-up, unsupervised, machine learning approach, could more accurately support concussion subtyping.

Methods: Initial patient intake data as well as objective outcome measures including, the Patient-Reported Outcomes Measurement Information System (PROMIS), Dizziness Handicap Inventory (DHI), Pain Catastrophizing Scale (PCS), and Immediate Post-Concussion Assessment and Cognitive Testing Tool (ImPACT) were retrospectively extracted from the Advance Concussion Clinic's database. A correlation matrix and principal component analysis (PCA) were used to reduce the dimensionality of the dataset. Sklearn's agglomerative clustering algorithm was then applied, and the optimal number of clusters within the patient database were generated. Between-group comparisons among the formed clusters were performed using a Mann-Whitney U test.

Results: Two hundred seventy-five patients within the clinics database were analyzed. Five distinct clusters emerged from the data when maximizing the Silhouette score (0.36) and minimizing the Davies-Bouldin score (0.83). Concussion subtypes derived demonstrated clinically distinct profiles, with statistically significant differences (p < 0.05) between all five clusters.

Conclusion: This machine learning approach enabled the identification and characterization of five distinct concussion subtypes, which were best understood according to levels of complexity, ranging from Extremely Complex to Minimally Complex. Understanding concussion in terms of Complexity with the utilization of artificial intelligence, could provide a more accurate concussion classification or subtype approach; one that better reflects the true heterogeneity and complex system disruptions associated with mild traumatic brain injury.

Review of wearable technologies and machine learning methodologies for systematic detection of mild traumatic brain injuries

Mild traumatic brain injuries (mTBIs) are the most common type of brain injury. Timely diagnosis of mTBI is crucial in making 'go/no-go' decision in order to prevent repeated injury, avoid strenuous activities which may prolong recovery, and assure capabilities of high-level performance of the subject. If undiagnosed, mTBI may lead to various short- and long-term abnormalities, which include, but are not limited to impaired cognitive function, fatigue, depression, irritability, and headaches. Existing screening and diagnostic tools to detect acute andearly-stagemTBIs have insufficient sensitivity and specificity. This results in uncertainty in clinical decision-making regarding diagnosis and returning to activity or requiring further medical treatment. Therefore, it is important to identify relevant physiological biomarkers that can be integrated into a mutually complementary set and provide a combination of data modalities for improved on-site diagnostic sensitivity of mTBI. In recent years, the processing power, signal fidelity, and the number of recording channels and modalities of wearable healthcare devices have improved tremendously and generated an enormous amount of data. During the same period, there have been incredible advances in machine learning tools and data processing methodologies. These achievements are enabling clinicians and engineers to develop and implement multiparametric high-precision diagnostic tools for mTBI. In this review, we first assess clinical challenges in the diagnosis of acute mTBI, and then consider recording modalities and hardware implementation of various sensing technologies used to assess physiological biomarkers that may be related to mTBI. Finally, we discuss the state of the art in machine learning-based detection of mTBI and consider how a more diverse list of quantitative physiological biomarker features may improve current data-driven approaches in providing mTBI patients timely diagnosis and treatment.

Vestibular-Evoked Myogenic Potential Outcomes Associated with Pediatric Sports-Related Concussion

OBJECTIVES/HYPOTHESIS

To 1) characterize vestibular-evoked myogenic potential responses in children and young adults with sports-related concussion (SRC) histories as compared with a normal healthy control group, and 2) correlate VEMP characteristics to SRC/sport history outcomes.

STUDY DESIGN

Prospective cohort study.

METHODS

Seventy-six children and young adults with and without a history of SRC received cervical and ocular VEMP testing using a 500 Hz tone burst air conduction stimuli. VEMP response parameters (response rates, peak latencies, and peak-to-peak amplitudes) were assessed. Other clinical vestibular measures were performed. In the SRC group, sport history outcomes including number of SRC sustained over a lifetime, years of playing contact sports, and length of time playing contact sports were collected via in-person questionnaire.

RESULTS

Children and young adults with SRC had significantly reduced oVEMP responses and peak-to-peak amplitudes and greater amplitude response asymmetries between left and right ear. There was no effect of group on cVEMP findings. A greater frequency of SRCs sustained throughout a lifetime, a greater number of contact sports played, and a longer duration of playing a contact sport correlated with significantly poorer VEMP response characteristics.

CONCLUSIONS

Our results suggest that SRC and repeated subclinical head impact events have an effect on oVEMP outcomes. SRC may affect the utricle, superior vestibular nerve, and/or brainstem-mediated vestibular-ocular-reflex pathway. The prevalence of post-concussion-related dizziness is becoming increasingly common in a pediatric-otology clinic, thus performing VEMP testing in youth post-SRC provides an objective, noninvasive, and cost-effective method for monitoring the effects of sports-related impact on the vestibular system and related neural pathways.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Optimizing Order of Administration for Concussion Baseline Assessment Among NCAA Student-Athletes and Military Cadets

BACKGROUND

Concussion pre-injury (i.e., baseline) assessments serve as a benchmark comparison point in the event an individual sustains a concussion and allows clinicians to compare to post-injury measures. However, baseline assessments must reflect the individual's true and most optimized performance to serve as a useful comparison. Mental fatigue and motivation throughout baseline testing may alter individual assessment performance, indicating an order of administration (OoA) may play an influential role in assessment outcomes.

OBJECTIVE

To examine the influence concussion baseline battery OoA has on symptom, postural stability, cognitive screening, and computerized neurocognitive test outcomes.

METHODS

We employed a retrospective observational cohort study to examine healthy collegiate student-athletes and military cadets (n = 2898, 19.0 ± 1.4 years, 66.1% male, 75.6% white, 54.4% Division-I) baseline assessment performance on the Sport Concussion Assessment Tool (SCAT; total symptom number and severity), Balance Error Scoring System (BESS; total error scores), Standardized Assessment of Concussion (SAC; total score), and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) domain scores (verbal and visual memory, visual-motor speed, reaction time). Assessments were binned to beginning, middle, or end tertiles based upon OoA. We used one-way ANOVAs with Tukey post-hoc t tests, 95% confidence intervals (CI), and Cohen's d effect sizes for significant models (α = 0.05).

RESULTS

SCAT total symptom number (mean difference = 2.23; 95% CI 1.76-2.70; d = 0.49, p < 0.001) and severity (mean difference = 5.58; 95% CI 4.42-6.74; d = 0.50; p < 0.001) were lower when completed at the end of baseline testing compared to the middle. Total BESS errors were 1.06 lower when completed at the middle relative to the end (95% CI 0.43-1.69; d = 0.17; p = 0.001). Total SAC scores were better at the beginning relative to middle (mean difference = 0.58; 95% CI 0.25-0.90; d = 0.33; p < 0.001) and end (mean difference = 0.44; 95% CI 0.16-0.73; d = 0.24; p = 0.001). Verbal memory, visual memory, and reaction time performance were highest at the beginning (p ≤ 0.002), while visual-motor speed performance was highest at the middle (p = 0.001).

CONCLUSION

Completing baseline assessments in the order of (1) ImPACT, (2) SAC, (3) BESS, and (4) SCAT symptom checklist may improve performance across assessments collectively. Clinicians and researchers should consider completing baseline assessments in this order when possible to potentially aid in optimizing concussion baseline assessment performance and maximize post-concussion comparisons.

The Current Status of Concussion Assessment Scales: A Critical Analysis Review

»

Concussion is a complex pathophysiologic process that affects the brain; it is induced by biomechanical forces, with alteration in mental status with or without loss of consciousness.

»

Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers.

»

The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete.

»

Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.

Developing Insights for Possible and Probable Acute Concussions Using Cluster Analysis

Few studies have analyzed the Sport Concussion Assessment Tool's (SCAT) utility among athletes whose concussion assessment is challenging. Using a previously published algorithm, we identified possible and probable concussions at <6 h (n = 393 males, n = 265 females) and 24-48 h (n = 323 males, n = 236 females) post-injury within collegiate student-athletes and cadets from the Concussion Assessment, Research, and Education (CARE) Consortium. We applied cluster analysis to characterize performance on the Standard Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and the SCAT symptom checklist for these athletes. Among the cluster sets that best separated acute concussions and normal performances, total symptom number raw score and change and post-traumatic migraine raw score and change score were the most frequent clustering variables across males and females at <6 h and 24-48 h. Similarly, total symptom number raw score and change score and post-traumatic migraine raw score and change score were most significantly different between clusters for males and females at <6 h and 24-48 h. Our results suggest that clinicians should focus on total symptom number, post-traumatic migraine symptoms, and cognitive-fatigue symptoms when assessing possible and probable concussions, followed by the SAC and BESS scores.

Examination of Reaction Time Deficits Following Concussion: A Systematic Review and Meta-analysis

BACKGROUND

Reaction time (RT) deficits are reported following concussion, but it is unknown when these deficits normalize to pre-injury status. It is also unclear how factors such as RT measurement technique and participant characteristics influence post-concussion RT.

OBJECTIVE

The purpose of this systematic review and meta-analysis was to (1) characterize acute post-concussion (0-3 days) RT impairments, (2) examine RT recovery over time, and (3) explore moderating factors related to acute RT impairment following concussion.

METHODS

Database searches (PubMed, CINAHL, EBSCOhost) were conducted according to PRISMA guidelines for articles published in English from January 2002 to March 2019. Studies compared baseline-to-post-injury RT within individuals (within-subject) and/or RT in concussed individuals to non-concussed controls (between-subject). Sixty studies met inclusion criteria, reporting on a total of 9688 participants with 214 discrete RT effects (Hedges' d; between-subject: N = 29, k = 129; within-subject: N = 42, k = 85). Of the 214 effects, 93 occurred in the acute (0-3 days) post-injury timeframe (k = 47 between-subject). Numerous demographic [sex, age, concussion history, population type (athlete, military, and general population), athlete level (high school, college), and sport], and method-based (RT test and measure type, computerized neurocognitive testing platform, concussion definition, and time post-injury) moderators were examined for mean effect influence. Mixed-effects multi-level modeling with restricted-maximum-likelihood estimation was used to account for nested effects and high heterogeneity for the pooled effect size (D+).

RESULTS

Significant medium-magnitude RT deficits were observed acutely for between- (D+ = - 0.7279, 95% CI - 0.9919, - 0.4639, I² = 88.66, p < 0.0001) and within-subject (D+ = - 0.7472, 95% CI - 0.9089, - 0.5855, I² = 89.21, p < 0.0001) effect models. RT deficits were present at the sub-acute and intermediate-term timeframes for between-subject effects (sub-acute: D+ = - 0.5655, 95% CI - 0.6958, - 0.4352, p < 0.0001; intermediate-term: D+ = - 0.3219, 95% CI - 0.5988, - 0.0450, p = 0.0245). No significant RT mean effect was observed for the between-subject model at the long-term timeframe, indicating RT recovery among concussed participants relative to controls (D+ = 0.3505, 95% CI - 0.4787, 1.1797, p = 0.3639). Sex was a significant moderator for between-subject effects, with every 1% male sample size increase demonstrating - 0.0171 (95% CI - 0.0312, - 0.0029, p = 0.0193) larger RT deficits. Within-subject effect models resulted in RT measure type (simple: [D+ = - 0.9826] vs. mixed: [D+ = - 0.6557], p = 0.0438) and computerized neurocognitive testing platforms (ANAM: [D+ = - 0.3735] vs. HeadMinder CRI: [D+ = - 1.4799] vs. ImPACT: [D+ = - 0.6749], p = 0.0004) having significantly different RT-deficit magnitudes. No other moderators produced significantly different RT-deficit magnitudes (between-subject: [p ≥ 0.0763], within-subject: [p ≥ 0.1723]).

CONCLUSIONS

Robust RT deficits were observed acutely following concussion. Minimal magnitude differences were noted when comparing between- and within-subject effects, suggesting that pre-injury baselines may not add clinical value in determining post-injury RT impairment. RT deficits persisted up till the intermediate-term (21-59 days post-injury) timeframe and indicate lingering deficits exist. Mean effect size differences were observed between RT measure types and computerized neurocognitive testing platforms; however, all categories displayed negative effects consistent with impaired RT following concussion. Clinical interpretation suggests that measuring RT post-concussion is more important than considering the RT method employed so long as reliable and valid tools are used. PROSPERO Registration #CRD42019119323.

Prevalence of concussion and adherence to return-to-play guidelines amongst male secondary school rugby and hockey players

Background

Concussion injuries are common in contact sports. Young players can suffer life-threatening complications if concussion is not recognised and managed.

Objectives

To determine the prevalence of concussion amongst secondary school rugby and hockey players and describe players’ knowledge and adherence to return-to-play guidelines.

Method

A mixed-method approach included Phase A, which utilised a questionnaire completed by 221 players (n = 139 rugby; n = 82 hockey) between 13 and 18 years of age, and Phase B, which utilised three focus group discussions of 15 participants who had suffered a concussion.

Results

The prevalence of concussion (n = 221) was 31.2% (n = 69). Of those, 71% (n = 49) were rugby players. Those who had suffered a concussion were more confident in identifying symptoms of concussion in themselves and others compared with those who did not suffer a concussion (p = 0.001), were more aware of return-to-play guidelines and more confident in their knowledge of concussion (p = 0.001). There were no differences between groups when identifying concussion symptoms. Of those who had a concussion, 30.4% (n = 21) adhered to return-to-play guidelines and followed graded return-to-play after their concussion. Explanations for non-adherence to return-to-play protocols included peer pressure, intrinsic motivation and ignorance.

Conclusion

Nearly a third had suffered a concussion injury; having suffered a concussion, and awareness of return-to-play guidelines, did not guarantee adherence to return-to-play protocols. Peer pressure and intrinsic factors explained this lack of adherence.

Clinical implications

Physiotherapists are often involved with the diagnosis and management of concussion injuries among rugby and hockey players. Understanding the prevalence and the reasons why young players do not adhere to the ‘return to play’ guidelines may inform preventative strategies.

Sideline Concussion Assessment: The Current State of the Art

More than 200 million American adults and children participate in organized physical activity. Growing awareness has highlighted that concussion, especially when repeated, may be associated with prolonged neurological, cognitive, and/or neuropsychiatric sequelae. Objective diagnosis of concussion remains challenging. Although some concussion symptoms may be apparent even to nonmedical observers, diagnosis and removal from play for evaluation depend on validated assessment tools and trained, vigilant healthcare personnel. Over the past 2 decades, sideline concussion measures have undergone significant revision and augmentation to become more comprehensive batteries in order to detect a wide spectrum of symptomatology, eg, neurocognitive function, postconcussive symptoms, gait/balance, and saccadic eye movements. This review summarizes the current state-of-the-art concussion evaluation instruments, ranging from the Sports Concussion Assessment Tool (SCAT) and tools that may enhance concussion detection, to near-term blood-based biomarkers and emerging technology (eg, head impact sensors, vestibulo-ocular/eye-tracking, and mobile applications). Special focus is directed at feasibility, utility, generalizability, and challenges to implementation of each measure on-field and on the sidelines. This review finds that few instruments beyond the SCAT provide guidance for removal from play, and establishing thresholds for concussion detection and removal from play in qualification/validation of future instruments is of high importance. Integration of emerging sideline concussion evaluation tools should be supported by resources and education to athletes, caregivers, athletic staff, and medical professionals for standardized administration as well as triage, referral, and prevention strategies. It should be noted that concussion evaluation instruments are used to assist the clinician in sideline diagnosis, and no single test can diagnose concussion as a standalone investigation.

The use of inertial measurement units to assess gait and postural control following concussion

BACKGROUND

Impairments in gait and balance function are typical after concussion. There is evidence that these neuromuscular deficits persist past the typical time of symptom resolution. The ability to quantify these changes in gait and balance may provide useful information when making return to play decisions in clinical settings.

RESEARCH QUESTION

Are changes in gait function and postural control evident across the course of a concussion management program?

METHODS

A retrospective analysis of a convenience sample of 38 patients who were seen for concussion between October 2017 and May 2019 was performed. Gait and balance measures were assessed at their initial clinic visit post-injury and at their clearance visit using inertial measurement units. During dual-task walking trials, the medial-lateral motion of the center of mass and gait velocity were measured. Postural sway complexity and jerk index were measured during both eyes-open and eyes-closed balance trials.

RESULTS

Paired samples t-tests and Wilcoxon signed rank tests were used to determine whether statistically significant changes occurred for the gait and balance variables, respectively. Medial-lateral sway decreased (4.4 ± 1.3 cm to 4.0 ± 1.2 cm, p = 0.018) and gait velocity increased (0.78 ± 0.23 m/s to 0.91 ± 0.18 m/s, p <  0.001) from initial to clearance testing. Jerk index decreased (6.41 ± 11.06 m²/s⁵ to 5.73 ± 4.28 m²/s⁵, p = 0.031) and (11.87 ± 26.42 m²/s⁵ to 7.87 ± 8.38 m²/s⁵, p = 0.003) from initial to clearance testing for the eyes-open and eyes-closed conditions, respectively. Complexity index increased (2.38 ± 1.08-2.86 ± 0.72, p = 0.010) from initial to clearance testing for the eyes-closed condition. There was no change in complexity index for the eyes-open condition.

SIGNIFICANCE

These preliminary results support the potential use of measures of gait and postural control to assess recovery following a concussion in a clinical setting.

Sensitivity and Specificity of Computer-Based Neurocognitive Tests in Sport-Related Concussion: Findings from the NCAA-DoD CARE Consortium

BACKGROUND

To optimally care for concussed individuals, a multi-dimensional approach is critical and a key component of this assessment in the athletic environment is computer-based neurocognitive testing. However, there continues to be concerns about the reliability and validity of these testing tools. The purpose of this study was to determine the sensitivity and specificity of three common computer-based neurocognitive tests (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT], CNS Vital Signs, and CogState Computerized Assessment Tool [CCAT]), to provide guidance on their clinical utility.

METHODS

This study analyzed assessments from a cohort of collegiate athletes and non-varsity cadets from the NCAA-DoD CARE Consortium. The data were collected from 2014-2018. Study participants were divided into two testing groups [concussed, n = 1414 (baseline/24-48 h) and healthy, n = 8305 (baseline/baseline)]. For each test type, change scores were calculated for the components of interest. Then, the Normative Change method, which used normative data published in a similar cohort, and the Reliable Change Index (RCI) method were used to determine if the change scores were significant.

RESULTS

Using the Normative Change method, ImPACT performed best with an 87.5%-confidence interval and 1 number of components failed (NCF; sensitivity = 0.583, specificity = 0.625, F1 = 0.308). CNS Vital Signs performed best with a 90%-confidence interval and 1 NCF (sensitivity = 0.587, specificity = 0.532, F1 = 0.314). CCAT performed best when using a 75%-confidence interval and 2 NCF (sensitivity = 0.513, specificity = 0.715, F1 = 0.290). When using the RCI method, ImPACT performed best with an 87.5%-confidence interval and 1 NCF (sensitivity = 0.626, specificity = 0.559, F1 = 0.297).

CONCLUSION

When considering all three computer-based neurocognitive tests, the overall low sensitivity and specificity results provide additional evidence for the use of a multi-dimensional assessment for concussion diagnosis, including symptom evaluation, postural control assessment, neuropsychological status, and other functional assessments.

Using functional movement tests to investigate the presence of sensorimotor impairment in amateur athletes following sport-related concussion: A prospective, longitudinal study

OBJECTIVE

To longitudinally investigate the presence of sensorimotor impairments in amateur athletes following sport-related concussion using two functional movement tests.

DESIGN

Prospective, longitudinal study.

SETTING

Human movement analysis laboratory.

PARTICIPANTS

Athletes who presented to a hospital emergency department and were diagnosed with sport-related concussion, and sex-, age-, and activity-matched non-concussed, control athletes. Concussed participants were assessed within one-week following sport-related concussion, upon clearance to return-to-sporting activity (RTA), and two weeks after RTA. Control participants were assessed at an initial time-point and approximately two and four weeks following their initial study assessment.

MAIN OUTCOMES MEASURES

At each laboratory assessment, participants completed two functional movement tests: the Star Excursion Balance Test to evaluate anterior reach distance (normalised for leg length) and fractal dimension (centre of pressure path complexity), and the Multiple Hop Test to evaluate corrective postural strategies and time-to-stabilisation.

RESULTS

Fifty concussed athletes and 50 control athletes completed the study. There were no significant differences at any study assessment between the concussion and control group on the Star Excursion Balance Test anterior reach distance or fractal dimension (centre of pressure path complexity). During the Multiple Hop Test, the concussion group used a significantly greater number of corrective postural strategies than the control group one-week following sport-related concussion and upon clearance to RTA, but not two weeks following RTA.

CONCLUSION

Recently concussed athletes made a greater number of corrective postural strategies than control participants during the Multiple Hop Test upon clearance to RTA but not two weeks after RTA. The Multiple Hop Test may offer a clinically useful tool for practitioners to examine the recovery of subtle sensorimotor impairments and related RTA readiness.

Neuropsychological Assessment of Sport-Related Concussion

Neuropsychological assessment is a key component in a comprehensive, multidisciplinary approach to assessment of sport-related concussion (SRC). Currently computerized tests are the most commonly used modality of neurocognitive testing and involve both baseline and postinjury assessments. A comprehensive neuropsychological assessment should not only include neurocognitive testing but also incorporate symptom inventories, vestibular-ocular screening, and a psychological evaluation. Neuropsychological assessments are most effective when completed by a Clinical Neuropsychologist, given their specialized training in test interpretation and conceptualization of the psychological, cognitive, behavioral, physiologic, as well as neurologic principals when treating and managing SRC.

No Clinical Predictors of Postconcussion Musculoskeletal Injury in College Athletes

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Neuroimaging in Pediatric Patients with Mild Traumatic Brain Injury: Relating the Current 2018 Centers for Disease Control Guideline and the Potential of Advanced Neuroimaging Modalities for Research and Clinical Biomarker Development

The Center for Disease Control and Prevention (CDC)'s 2018 Guideline for current practices in pediatric mild traumatic brain injury (mTBI; also referred to as concussion herein) systematically identified the best up-to-date practices based on current evidence and, specifically, identified recommended practices regarding computed tomography (CT), magnetic resonance imaging (MRI), and skull radiograph imaging. In this article, we discuss types of neuroimaging not discussed in the guideline in terms of their safety for pediatric populations, their potential application, and the research investigating the future use of certain modalities to aid in the diagnosis and treatment of mTBI in children. The role of neuroimaging in pediatric mTBI cases should be considered for the potential contribution to children's neural and social development, in addition to the immediate clinical value (as in the case of acute structural findings). Selective use of specific neuroimaging modalities in research has already been shown to detect aspects of diffuse brain injury, disrupted cerebral blood flow, and correlate physiological factors with persistent symptoms, such as fatigue, cognitive decline, headache, and mood changes, following mTBI. However, these advanced neuroimaging modalities are currently limited to the research arena, and any future clinical application of advanced imaging modalities in pediatric mTBI will require robust evidence for each modality's ability to provide measurement of the subtle conditions of brain development, disease, damage, or degeneration, while accounting for variables at both non-injury and time-post-injury epochs. Continued collaboration and communication between researchers and healthcare providers is essential to investigate, develop, and validate the potential of advanced imaging modalities in pediatric mTBI diagnostics and management.

The Effects of Mild Traumatic Brain Injury on Cognitive-Motor Integration for Skilled Performance

Adults exposed to blast and blunt impact often experience mild traumatic brain injury, affecting neural functions related to sensory, cognitive, and motor function. In this perspective article, we will review the effects of impact and blast exposure on functional performance that requires the integration of these sensory, cognitive, and motor control systems. We describe cognitive-motor integration and how it relates to successfully navigating skilled activities crucial for work, duty, sport, and even daily life. We review our research on the behavioral effects of traumatic impact and blast exposure on cognitive-motor integration in both younger and older adults, and the neural networks that are involved in these types of skills. Overall, we have observed impairments in rule-based skilled performance as a function of both physical impact and blast exposure. The extent of these impairments depended on the age at injury and the sex of the individual. It appears, however, that cognitive-motor integration deficits can be mitigated by the level of skill expertise of the affected individual, suggesting that such experience imparts resiliency in the brain networks that underly the control of complex visuomotor performance. Finally, we discuss the next steps needed to comprehensively understand the impact of trauma and blast exposure on functional movement control.

Institutionally Based ImPACT Test® Normative Values May Differ from Manufacturer-Provided Normative Values

OBJECTIVE

The necessity for pre-injury baseline computerized neurocognitive assessments versus comparing post-concussion outcomes to manufacturer-provided normative data is unclear. Manufacturer-provided norms may not be equivalent to institution-specific norms, which poses risks for misclassifying the presence of impairment when comparing individual post-concussion performance to manufacturer-provided norms. The objective of this cohort study was to compare institutionally derived normative data to manufacturer-provided normative values provided by ImPACT® Applications, Incorporated.

METHOD

National Collegiate Athletic Association Division 1 university student athletes (n = 952; aged 19.2 ± 1.4 years, 42.5% female) from one university participated in this study by completing pre-injury baseline Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) assessments. Participants were separated into 4 groups based on ImPACT's age and gender norms: males <18 years old (n = 186), females <18 years old (n = 165), males >19 years old (n = 361) or females >19 years old (n = 240). Comparisons were made between manufacturer-provided norms and institutionally derived normative data for each of ImPACT's clinical composite scores: Verbal (VEM) and Visual (VIM) Memory, Visual Motor Speed (VMS), and Reaction Time (RT). Outcome scores were compared for all groups using a Chi-squared goodness of fit analysis.

RESULTS

Institutionally derived normative data indicated above average performance for VEM, VIM, and VMS, and slightly below average performance for RT compared to the manufacturer-provided data (χ2 ≥ 20.867; p < 0.001).

CONCLUSIONS

Differences between manufacturer- and institution-based normative value distributions were observed. This has implications for an increased risk of misclassifying impairment following a concussion in lieu of comparison to baseline assessment and therefore supports the need to utilize baseline testing when feasible, or otherwise compare to institutionally derived norms rather than manufacturer-provided norms.

Clinical Detection and Recovery of Vestibular and Oculomotor Impairments Among Amateur Athletes Following Sport-Related Concussion: A Prospective, Matched-Cohort Study

OBJECTIVE

To (1) quantify the diagnostic accuracy of the vestibular/oculomotor screening (VOMS), and (2) determine the recovery of vestibular and oculomotor impairments exhibited by concussed athletes compared with nonconcussed athletes using the VOMS.

SETTING

Clinical assessment laboratory.

PARTICIPANTS

Amateur athletes who were diagnosed with sport-related concussion by emergency department physicians, and non-concussed, control athletes.

DESIGN

Prospective, longitudinal study.

MAIN MEASURES

Participants were assessed 1 week following sport-related concussion, upon clearance to return-to-sporting activity, and 2 weeks following return-to-sporting activity by a study investigator who administered the VOMS. We calculated test sensitivity, specificity, and positive and negative predictive values to estimate the diagnostic accuracy of the VOMS. We performed a mixed-design analysis of variance to assess differences in VOMS symptom scores reported by concussed athletes compared with control athletes.

RESULTS

Fifty concussion participants and 50 control participants completed the study. The VOMS demonstrated sensitivity and specificity of 96% and 46%, respectively, and produced positive and negative predictive values of 64% and 92%, respectively. The concussion group exhibited a significantly greater symptom provocation change score from baseline than the control group for all test domains of the VOMS only in the first week following concussion.

CONCLUSION

The VOMS may be most useful as a clinical screening tool to rule out, rather than confirm, the presence of sport-related concussion. The VOMS may be appropriate to inform the recovery of vestibular and oculomotor impairments exhibited by concussed individuals over time.