Evaluating the methodological quality of sports neuropsychology concussion research: A systematic review

The Use of Biofluid Markers to Evaluate the Consequences of Sport-Related Subconcussive Head Impact Exposure: A Scoping Review

BACKGROUND

Amidst growing concern about the safety of sport-related repetitive subconcussive head impacts (RSHI), biofluid markers may provide sensitive, informative, and practical assessment of the effects of RSHI exposure.

OBJECTIVE

This scoping review aimed to systematically examine the extent, nature, and quality of available evidence from studies investigating the effects of RSHI on biofluid markers, to identify gaps and to formulate guidelines to inform future research.

METHODS

PRISMA extension for Scoping Reviews guidelines were adhered to. The protocol was pre-registered through publication. MEDLINE, Scopus, SPORTDiscus, CINAHL, PsycINFO, Cochrane Library, OpenGrey, and two clinical trial registries were searched (until March 30, 2022) using descriptors for subconcussive head impacts, biomarkers, and contact sports. Included studies were assessed for risk of bias and quality.

RESULTS

Seventy-nine research publications were included in the review. Forty-nine studies assessed the acute effects, 23 semi-acute and 26 long-term effects of RSHI exposure. The most studied sports were American football, boxing, and soccer, and the most investigated markers were (in descending order): S100 calcium-binding protein beta (S100B), tau, neurofilament light (NfL), glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE), brain-derived neurotrophic factor (BDNF), phosphorylated tau (p-tau), ubiquitin C-terminal hydrolase L1 (UCH-L1), and hormones. High or moderate bias was found in most studies, and marker-specific conclusions were subject to heterogeneous and limited evidence. Although the evidence is weak, some biofluid markers-such as NfL-appeared to show promise. More markedly, S100B was found to be problematic when evaluating the effects of RSHI in sport.

CONCLUSION

Considering the limitations of the evidence base revealed by this first review dedicated to systematically scoping the evidence of biofluid marker levels following RSHI exposure, the field is evidently still in its infancy. As a result, any recommendation and application is premature. Although some markers show promise for the assessment of brain health following RSHI exposure, future large standardized and better-controlled studies are needed to determine biofluid markers' utility.

The Toronto Concussion Study: a prospective investigation of characteristics in a cohort of adults from the general population seeking care following acute concussion, 2016-2020

Purpose

There is limited research regarding the characteristics of those from the general population who seek care following acute concussion.

Methods

To address this gap, a large cohort of 473 adults diagnosed with an acute concussion (female participants = 287; male participants = 186) was followed using objective measures prospectively over 16 weeks beginning at a mean of 5.1 days post-injury.

Results

Falls were the most common mechanism of injury (MOI) (n = 137, 29.0%), followed by sports-related recreation (n = 119, 25.2%). Male participants were more likely to be injured playing recreational sports or in a violence-related incident; female participants were more likely to be injured by falling. Post-traumatic amnesia (PTA) was reported by 80 participants (16.9 %), and loss of consciousness (LOC) was reported by 110 (23.3%). In total, 54 participants (11.4%) reported both PTA and LOC. Male participants had significantly higher rates of PTA and LOC after their injury compared to their female counterparts. Higher initial symptom burden was associated with a longer duration of recovery for both male and female participants. Female participants had more symptoms and higher severity of symptoms at presentation compared to male participants. Female participants were identified to have a longer recovery duration, with a mean survival time of 6.50 weeks compared to 5.45 weeks in male participants (p < 0.0001). A relatively high proportion of female and male participants in this study reported premorbid diagnoses of depression and anxiety compared to general population characteristics.

Conclusion

Although premorbid diagnoses of depression and/or anxiety were associated with higher symptom burden at the initial visit, the duration of symptoms was not directly associated with a pre-injury history of psychological/psychiatric disturbance. This cohort of adults, from the general population, seeking care for their acute concussion attained clinical and functional recovery over a period of 4-12 weeks.

Effects of sport-related repetitive subconcussive head impacts on biofluid markers: a scoping review protocol

INTRODUCTION

Sport-related repetitive subconcussive head impacts (RSHIs) are increasingly thought to be associated with adverse long-term outcomes. However, owing to potentially subtle effects, accurate assessment of harm to the brain as a consequence of RSHI is a major challenge and an unmet need. Several studies suggest that biofluid markers can be valuable objective tools to aid the diagnosis and injury characterisation and help in medical decision-making. Still, by and large, the results have been limited, heterogeneous and inconsistent. The main aims of this scoping review are therefore (1) to systematically examine the extent, nature and quality of available evidence from studies investigating effects of RSHI on fluid biomarkers and (2) to formulate guidelines and identify gaps with the aim to inform future clinical studies and the development of research priorities.

METHODS AND ANALYSES

We will use a comprehensive search strategy to retrieve all available and relevant articles in the literature. The following electronic databases will be systematically searched: MEDLINE (EBSCO host; from 1809 to 2020); Scopus (from 1788 to 2020); SPORTDiscus (from 1892 to 2020); CINAHL Complete (from 1937 to 2020); PsycINFO (from 1887 to 2020); Cochrane Library (to 2020); OpenGrey (to 2020); ClinicalTrials.gov (to 2020) and WHO International Clinical Trials Registry Platform (to 2020). We will consider primarily biomedical studies evaluating the biofluid markers following RSHI. Two independent reviewers will screen articles for inclusion using predefined eligibility criteria and extract data of retained articles. Disagreements will be resolved through consensus or arbitrated by a third reviewer if necessary. Data will be reported qualitatively given the heterogeneity of the included studies. In synthesising the evidence, we will structure results by markers, sample types, outcomes, sport and timepoints.

ETHICS AND DISSEMINATION

Ethics approval is not required. We will submit results for peer-review publication, and present at relevant conferences.

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.

A unified framework for bias assessment in clinical research

Methodological flaws, limitations, and inadequate practices in research are well known and pose threats to the internal validity of any research study. However, there are ways of safeguarding research conduct to reduce the chance of research producing distorted results. Numerous tools now exist to assess the incorporation of such safeguards into primary research studies (also known as quality and/or risk-of-bias assessment). These tools typically include a variety of items that are then checked against those implemented in the study. Despite a lot of research in this area, no comprehensive generic classification of safeguards across study designs exist, although attempts have been made to clarify aspects of this. We review the developments in this area as well as use preliminary data from 100 methodological studies to illustrate our proposed approach. We conclude by proposing a new framework for identifying research studies at risk of being biased and the information in this article will promote a unification of the diverse approaches to facilitating bias assessment in clinical research.

The relationship between fluid biomarkers and clinical outcomes in sports-related concussions: a systematic review

OBJECTIVES

The literature on fluid biomarkers for concussion has primarily focused on comparing athletes with and without a diagnosis of concussion and on examining the relationship between fluid biomarkers and exposure to head trauma. This systematic literature review aims to examine the strength of evidence for fluid biomarkers to be associated with clinically relevant outcomes in sports-related concussion.

METHODS

A systematic literature review was conducted using EmBASE, PubMed, and CINAHL. English-language articles that included athletes participating in organized sports and reported the relationship between at least one fluid biomarker and at least one clinical outcome measure, or provided data that could be used to analyze this relationship, were included.

RESULTS

Studies of the relationship between fluid biomarkers and clinical outcomes of concussion have yielded small or variable effects. There were significant inconsistencies in methodology including duration of time post-injury of biomarker collection, use of control groups, the number of time points post-injury that biomarkers were collected, and what clinical outcomes were utilized.

CONCLUSION

There is currently insufficient evidence to support a relationship between any of the included fluid biomarkers and clinical outcome measures of concussion. Future research including clinical outcome measures and using standardized study design and methodology is necessary.

The effects of repetitive head impacts on postural control: A systematic review

OBJECTIVES

The purpose of our study was to investigate the association between repetitive head impact (RHI) exposure and postural control.

DESIGN

Systematic review.

METHODS

PubMed, Embase and PsycInfo were searched using a self-developed search term including the keywords balance OR postural control AND repetitive OR sub-concussive head impacts. Twenty-one studies excluding non-peer reviewed studies, secondary studies, cross-sectional studies, animal studies, and studies investigating concussion were included for further analyses. We rated Level of Evidence and quality using the Centre for Evidence-Based Medicine tool, the Quality Assessment for the Systematic Review of Effectiveness, and the Sub-concussion Specific Tool.

RESULTS

All included studies were grouped into Category I and II studies. Category I included trials investigating the effects of controlled soccer heading on postural control (n=8) and Category II studies were cohort studies investigating on-the-field changes between preseason and postseason assessments on postural control measures (n=13). Findings were heterogeneous, with a tendency towards no effects of RHI on clinical postural control measures. Most laboratory studies in Category I used instrumented assessments whereas on-the-field studies in Category II used both instrumented and non-instrumented assessments.

CONCLUSIONS

Due to heterogeneous findings, future studies aiming to investigate the effects of RHI on different athlete populations are needed on other participant cohorts. Furthermore, the combination of objective clinical balance measures may be a promising approach to accurately measure how, and to what degree, postural control may be affected by RHI.

Neuroimaging and Neuropsychological Studies in Sports-Related Concussions in Adolescents: Current State and Future Directions

Sports-related concussion, is a serious neurological concern that many adolescent athletes will face during their athletic careers. In some instances, the effects of sports-related head injury are long-lasting. Due to their still-developing brains, adolescents appear to be more vulnerable to long-term repercussions of these injuries. As all sports-related concussions are mild traumatic brain injuries (mTBI), this review we will examine the pathophysiology of mTBI, its acute effects and long-term risks from sustaining injury, and current and needed advancements in the areas of neuropsychological testing, accelerometer telemetry, and neuroimaging. Current methods do not adequately measure the extent of an injury that an athlete may sustain, potentially putting these athletes at a much greater risk for long-term effects. To better understand mTBI, neuropsychological testing best practices need to be developed, standardized, and implemented based on sound scientific evidence in order to be propagated as clinical guidelines. Wearable accelerometers can be used to assess thresholds for mTBI and cumulative effects of concussive and subconcussive injuries. Novel neuroimaging methods that can detect anatomical abnormalities and functional deficits with more specificity and sensitivity should be developed. Young athletes are particularly a vulnerable population warranting immediate and significant research aimed at protecting them against sports related injury and mitigating their long-term deficits.

Altered Blood Biomarker Profiles in Athletes with a History of Repetitive Head Impacts

The long-term health effects of concussion and sub-concussive impacts in sport are unknown. Growing evidence suggests both inflammation and neurodegeneration are pivotal to secondary injury processes and the etiology of neurodegenerative diseases. In the present study we characterized circulating brain injury and inflammatory mediators in healthy male and female athletes according to concussion history and collision sport participation. Eighty-seven university level athletes (male, n = 60; female, n = 27) were recruited before the start of the competitive season. Athletes were healthy at the time of the study (no medications, illness, concussion or musculoskeletal injuries). Dependent variables included 29 inflammatory and 10 neurological injury analytes assessed in the peripheral blood by immunoassay. Biomarkers were statistically evaluated using partial least squares multivariate analysis to identify possible relationships to self-reported previous concussion history, number of previous concussions and collision sport participation in male and female athletes. Multiple concussions were associated with increases in peripheral MCP-1 in females, and MCP-4 in males. Collision sport participation was associated with increases in tau levels in males. These results are consistent with previous experimental and clinical findings that suggest ongoing inflammatory and cerebral injury processes after repetitive mild head trauma. However, further validation is needed to correlate systemic biomarkers to repetitive brain impacts, as opposed to the extracranial effects common to an athletic population such as exercise and muscle damage.

Behavioral, blood, and magnetic resonance imaging biomarkers of experimental mild traumatic brain injury

Repeated mild traumatic brain injuries (mTBI) may lead to serious neurological consequences, especially if re-injury occurs within the period of increased cerebral vulnerability (ICV) triggered by the initial insult. MRI and blood proteomics might provide objective measures of pathophysiological changes in mTBI, and indicate when the brain is no longer in a state of ICV. This study assessed behavioral, MRI, and blood-based markers in a rat model of mTBI. Rats were given a sham or mild fluid percussion injury (mFPI), and behavioral testing, MRI, and blood collections were conducted up to 30 days post-injury. There were cognitive impairments for three days post-mFPI, before normalizing by day 5 post-injury. In contrast, advanced MRI (i.e., tractography) and blood proteomics (i.e., vascular endothelial growth factor) detected a number of abnormalities, some of which were still present 30 days post-mFPI. These findings suggest that MRI and blood proteomics are sensitive measures of the molecular and subtle structural changes following mTBI. Of particular significance, this study identified novel tractography measures that are able to detect mTBI and may be more sensitive than traditional diffusion-tensor measures. Furthermore, the blood and MRI findings may have important implications in understanding ICV and are translatable to the clinical setting.

Computerized Cognitive Testing in the Management of Youth Sports-Related Concussion

Computerized neurocognitive testing has become a growing practice across medical populations, but particularly within sports medicine and the management of sports-related concussion. Although traditional neuropsychological measures are solely administered and interpreted by neuropsychologists, computerized cognitive tests are marketed to and utilized by a wide range of professionals involved in the management of sports-related concussions, many of whom lack specialized psychometric training. Although the benefits of computerized testing allow for many youth athletes to be evaluated quickly, professionals implementing their use should be aware of the potential pitfalls and the high potential for misuse. After briefly reviewing the recommended guidelines set forth by the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology, we review the benefits/limitations of computerized testing in the management of sports-related concussion and the basic psychometric properties of some of the more widely used computerized measures. Lastly, we discuss the practical application of these devices.

Screening for traumatic brain injury: findings and public health implications

OBJECTIVE

To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI).

SETTING

Diverse community settings.

PARTICIPANTS

Homeless persons (n = 111), individuals with HIV seeking vocational rehabilitation (n = 173), youth in the juvenile justice system (n = 271), public schoolchildren (n = 174), substance users (n = 845), intercollegiate athletes (n = 90), and other community-based samples (n = 396).

DESIGN

Cross-sectional.

MAIN MEASURE

Brain Injury Screening Questionnaire.

RESULTS

Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9% to 12% of individuals report TBI with chronic symptoms.

CONCLUSION

Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

Advanced topics in neuropsychological assessment following sport-related concussion

OBJECTIVE

This study examined seven topics relating to neuropsychological assessment following sport-related concussion: (i) traditional vs. computerized tests; (ii) the value of baseline, pre-season testing; (iii) invalid baseline scores and poor effort; (iv) when to assess following injury; (v) the reliability of neuropsychological tests; (vi) reliable change methodology; and (vii) new methods for identifying cognitive impairment.

MAIN RESULTS

Baseline testing can be helpful for quantifying cognitive deficits following injury and for assessing recovery. At present, however, there is insufficient evidence to conclude that having baseline test results is clearly superior to not having baseline test results. Although invalid baseline test performance can be detected in some athletes, validity indicators cannot determine the extent to which the results were due to deliberately poor performance, confusion or misunderstanding regarding some aspect of the test, distractions in group testing environments or some combination of factors. When interpreting baseline and post-injury data, sophisticated psychometric methods (e.g. reliable change, multivariate base rates) are available to assist with more accurate identification of cognitive impairment and the serial monitoring of recovery.

CONCLUSIONS

The value of neuropsychological assessment in the management of sport-related concussion has a strong empirical foundation. Additional research is needed, however, to refine its use.

Neurological assessment and its relationship to CSF biomarkers in amateur boxers

Background

Mild traumatic brain injury (TBI) or concussion is common in many sports. Today, neuropsychological evaluation is recommended in the monitoring of a concussion and in return-to-play considerations. To investigate the sensitivity of neuropsychological assessment, we tested amateur boxers post bout and compared with controls. Further the relationship between neuropsychological test results and brain injury biomarkers in the cerebrospinal fluid (CSF) were investigated.

Method

Thirty amateur boxers on high elite level with a minimum of 45 bouts and 25 non-boxing matched controls were included. Memory tests (Rey Osterrieth Complex Figure, Listening Span, Digit Span, Controlled Word Association Test, and computerized testing of episodic memory), tests of processing speed and executive functions (Trail Making, Reaction Time, and Finger Tapping) were performed and related to previously published CSF biomarker results for the axonal injury marker neurofilament light (NFL).

Results

The neurological assessment showed no significant differences between boxers and controls, although elevated CSF NFL, as a sign of axonal injury, was detected in about 80% of the boxers 1–6 days post bout. The investigation of the relationship between neuropsychological evaluation and CSF NFL concentrations revealed that boxers with persisting NFL concentration elevation after at least 14 days resting time post bout, had a significantly poorer performance on Trail Making A (p = 0.041) and Simple Reaction Time (p = 0.042) compared to other boxers.

Conclusion

This is the first study showing traumatic axonal brain injury can be present without measureable cognitive impairment. The repetitive, subconcussive head trauma in amateur boxing causes axonal injury that can be detected with analysis of CSF NFL, but is not sufficient to produce impairment in memory tests, tests of processing speed, or executive functions. The association of prolonged CSF NFL increase in boxers with impairment of processing speed is an interesting observation, which needs to be verified in larger studies.

Concussions and heading in soccer: a review of the evidence of incidence, mechanisms, biomarkers and neurocognitive outcomes

BACKGROUND

Soccer is currently the most popular and fastest-growing sport worldwide. Similar to many sports, soccer carries an inherent risk of injury, including concussion. Soccer is also unique in the use of 'heading'. The present paper provides a comprehensive review of the research examining the incidence, mechanisms, biomarkers of injury and neurocognitive outcomes of concussions and heading in soccer.

METHODS

Seven databases were searched for articles from 1806 to 24 May 2013. Articles obtained by the electronic search were reviewed for relevance, with 229 selected for review. Ultimately, 49 articles met criteria for inclusion in the present review.

RESULTS

Female soccer players have a higher incidence of concussions than males. The most frequent injury mechanism is player-to-player contact for both genders. Few studies examined the effects of concussion in soccer players; however, neurocognitive outcomes were similar to those reported in the larger sport concussion literature, while the effect of heading is less clear.

CONCLUSION

Despite variation in research designs and study characteristics, the outcomes of concussions in soccer align with the greater concussion literature. This review makes recommendations for future research to increase standardization of research for improved understanding of concussions in soccer as well as the effects of heading.

Do injury characteristics predict the severity of acute neuropsychological deficits following sports-related concussion? A meta-analysis

The utility of injury characteristics for predicting the severity of post-concussion outcomes remains equivocal. The purpose of this meta-analysis was to quantify the predictive relationship between these variables to inform classification of acute injury severity. Thirty-one empirical samples of concussed athletes, for which rates of loss of consciousness and/or amnesia were reported, were included in a meta-analysis evaluating acute outcomes following sports-related concussion. Outcome measures of interest were neuropsychological tests first administered 1-10 days post-injury. Loss of consciousness and anterograde amnesia significantly predicted more severe neuropsychological deficits within 10 days of concussion in studies using pre-injury baseline, but not control group, comparisons. Retrograde amnesia significantly predicted acute neuropsychological dysfunction (d = -1.03) irrespective of comparison group. Although small sample sizes require conservative interpretation and future replication, the evidence suggests that retrograde amnesia, rather than loss of consciousness, may be used to classify the acute severity of concussion.

Administration and environment considerations in computer-based sports-concussion assessment

Computer-based testing has become a vital tool for the assessment of sport-related concussion (SRC). An increasing number of papers have been published on this topic, focusing on subjects such as the purpose and validity of baseline testing, the performance of special populations on computer-based tests, the psychometric properties of different computerized neurocognitive tools, and considerations for valid and reliable administration of these tools. The current paper describes several considerations regarding computerized test design, input and output devices, and testing environment that should be described explicitly when administering computer-based cognitive testing, regardless of whether the assessment is used for clinical or research purposes. The paper also reviews the conclusions of recent literature (2007-2013) using computer-based testing for the assessment of SRC, with special attention to the methods used in these studies. We also present an appendix checklist for clinicians and researchers that may be helpful in ensuring proper attention to factors that could influence the reliability and validity of computer-based cognitive testing. We believe that explicit attention to these technological factors may lead to the development of standards for the development and implementation of computer-based tests. Such standards have the potential to enhance the accuracy and utility of computer-based tests in SRC.

Executive functions and intraindividual variability following concussion

The long-term outcomes of executive functions and intraindividual variability (IIV; i.e., trial-to-trial or across-task variability in cognitive performance) following concussion are unclear due to inconsistent and limited research findings, respectively.

OBJECTIVE

Responding to these gaps in scientific understanding, the current study aimed to assess the utility of both executive functions and IIV at predicting concussion history.

METHOD

Altogether 138 self-identified athletes (Mage = 19.9 ± 1.91 years, 60.8% female, 19.6% with one concussion, 18.1% with two or more concussions) completed three executive-related cognitive tasks (i.e., n-back, go/no-go, global-local). Ordinal logistic regression analyses examined the joint effect of person-mean and IIV as predictors of concussion status.

RESULTS

Only mean response time for the global-local task predicted the number of past concussions, while no IIV variables reached unique significance.

CONCLUSIONS

IIV research on concussion remains limited; however, the preliminary results do not indicate any additional value of IIV indices above mean performances at predicting past concussion. For executive functions, shifting appears most sensitive at detecting concussion group differences, with past researchers identifying post concussion impairment in attentional processing.

Sport as Laboratory: Lessons Learned From Baseline and Postconcussion Assessment Research

Knowledge and awareness of sport concussion has been forwarded by research modeled on the neuropsychological testing paradigm associated with Barth’s “sport as laboratory” assessment model. The purpose of this paper is to elucidate lessons learned from that research. Key considerations for planning and implementing large-scale studies of concussion in sport while making adequate provision for the clinical needs of concussed athletes are reviewed. Toward that end, logistical, methodological, and ethical considerations are discussed within the context of research conducted in a university setting. Topics addressed include culture of sport and risk; research planning and design; communication with strategic partners; defining injury; choosing a test battery; data management, outcomes, and analyses; dissemination of results; and finally, clinical and ethical implications that may arise during the research enterprise. The paper concludes with a summary of the main lessons learned and directions for future research.

The utility of post-concussion neuropsychological data in identifying cognitive change following sports-related MTBI in the absence of baseline data

Neuropsychological tests have become commonplace in the assessment of sports-related concussion. Typically, post-injury test data are compared to pre-injury "baselines." Baseline testing can be expensive and logistically challenging, yet the usefulness of neuropsychological baseline testing has not been tested empirically. This paper examines the extent to which baseline testing is useful for detecting neurocognitive deficits following sports concussion in a college-age population. A total of 223 collegiate athletes from multiple sports who sustained concussions and had both baseline and post-injury testing using Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) were included in the study. Reliable change (RC) in scores was determined by two approaches, the Jacobson and Truax (JT) and the Gulliksen-Lord-Novick (GLN) methods. The 90% confidence interval was used for both. Classification using these methods was compared to standard normative methods that compared post-concussion performance to baseline population means. Agreement between reliable change and normative methods was examined using Cohen's Kappa scores to determine whether post-injury scores alone could identify reliable cognitive decline. Mean time from concussion to post-injury testing was 3.40 days. The percentage of athletes who declined when using the JT method was similar to the percentage that would be expected to decline due to chance alone. Although the GLN and JT methods demonstrated moderate to substantial agreement, the GLN method consistently identified more cognitively compromised athletes than the JT method. Post-injury scores alone identified a significant majority of athletes with a reliable decline on ImPACT. Although preliminary and in need of replication across age groups and instruments, these findings suggest that the majority of collegiate athletes who experience clinically meaningful post-concussion cognitive decline can be identified without baseline data.

A Model of Current Best Practice for Managing Concussion in University Athletes: The University of Toronto Approach

Along with the ever growing awareness among the scientific community and the general public that concussion is a serious health care issue at all levels of sport, with potentially devastating long term health effects, the number of concussion surveillance clinical monitoring programs has significantly increased internationally over the past 10–15 years. An effective concussion program (a “best practice” model) is clinically prudent and evidence-based, one that is an interdisciplinary model involving health professionals who manage, educate, and provide psychosocial support to athletes. The integration of neuropsychological assessment is a component of many present day programs, and therefore, the neuropsychologist is an integral member of the concussion management team. The University of Toronto Concussion Program, operational since 1999, integrates best practices and current evidence into a working model of concussion management for university athletes. The model uses an interdisciplinary approach to monitor and assess athletes with concussions, as well as to educate its athletes, coaches, and administrators. A research component is also integral to the program.