Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in NCAA Division III Collegiate Athletes

Factors Influencing Time to Return to Learn Among NCAA Student-Athletes Enrolled in the Concussion Assessment, Research, and Education (CARE) Study

PURPOSE

The aim was to describe the demographic and post-injury factors that influence time to return to learn (RTL) among student-athletes enrolled in the Concussion Assessment, Research and Education (CARE) Consortium.

METHODS

A total of 47,860 student-athletes enrolled in the National Collegiate Athletic Association-Department of Defense (NCAA-DoD) CARE Consortium study from 2014 to 2020, with 1485 sport-related concussions (SRCs) analyzed in the present dataset. Demographic and post-injury characteristics were calculated using descriptive statistics, followed by Kaplan-Meier estimates to examine median time to return to normal academic performance (i.e., RTL) by sex (male, female), baseline psychiatric conditions (depression, anxiety) and/or learning disorder, NCAA division (I, II, III), SRC history (0, 1, 2, 3+), NCAA sport category (contact, limited contact, non-contact sport), and median difference in baseline/post-injury symptom severity scores (< 21, ≥ 21). Further, a multivariable zero-inflated negative binomial (ZINB) regression model was used to examine their association with RTL.

RESULTS

Overall, time to RTL (mean = 4.96 ± 8.24 days, median = 3.0 [interquartile range = 0.0, 6.0] days) was found to be influenced by several factors resulting in earlier trajectories. Notably, nearly 25% of the sample demonstrated immediate RTL (i.e., 0 days). Among student-athletes who did not immediately RTL, males demonstrated a decreased rate in RTL (rate = 0.79; 95% CI 0.66-0.96) compared to females. Further, student-athletes with a ≥ 21 change in symptom severity score (post-injury baseline) demonstrated a higher rate of RTL (rate = 1.47; 95% CI 1.21-1.79) compared to student-athletes with a symptom severity change score < 21. Lastly, male student-athletes demonstrated two times higher odds (odds ratio = 1.95; 95% CI 1.02-3.73) of immediate RTL compared to female student-athletes. No other covariates were associated with time to RTL.

CONCLUSION

Collectively, the present findings suggest a rapid return to the classroom following concussion. Specifically, males demonstrated higher odds of time to RTL, whereas those with greater differences in symptom severity resulted in a higher rate of time to RTL among those who did not immediately RTL. Ultimately, these findings support prior work emphasizing an individualized approach to SRC management.

Association of Use of a Mobile Tackling Dummy During College Football Practice With Reduced Sport-Related Concussion: Results of a Pilot Investigation

Background

Considering the multifaceted consequences of improperly managed sport-related concussions (SRCs) in American football, identifying efficacious prevention measures for enhancing player safety is crucial.

Purpose

To investigate the association of primary prevention measures (no-tackle practices and using a mobile tackling dummy in practice) with the frequency of SRCs within college football programs in the United States.

Study Design

Descriptive epidemiology study.

Methods

In this pilot study, we analyzed the frequency of new SRCs recorded during various settings (total, in preseason, in season, in practice, and game) across 14 seasons (2007-2019 and 2021) for Dartmouth College and across 7 seasons (2013-2019) for the 7 other teams in the Ivy League men's athletic football conference. Trends between seasons and the number of SRCs sustained were examined using correlations and basic descriptive statistics. We also examined SRC frequency in relation to primary prevention measures (no-tackle practices, use of mobile tackling dummies during practice) in the Dartmouth College football program, and we compared SRCs with regard to the no-tackle practice policy in the other Ivy League teams.

Results

There was a statistically significant reduction in the number of SRCs over the seasons studied, with the strongest finding observed for Dartmouth College in-game SRCs (r = -0.52; P = .029). Relatedly, the strongest between-season effect was seen for the Dartmouth College practice policy on in-game SRCs (η2 = 0.510; P = .01). The use of mobile tackling dummies was found to be independently associated (adjusting for no-tackle practice) with a lower number total (β = -0.53; P = .049), in-season (β = -0.63; P = .023), and in-game (β = -0.79; P = .003) SRCs. While seasons with the no-tackle practice were not meaningfully associated with SRCs for Dartmouth College, stronger trends were observed in the other Ivy League teams, such that seasons with this policy were associated with lower SRC prevalence.

Conclusion

Our data indicate that the use of the mobile tackling dummy in practice was related to the reduced number of SRCs sustained at multiple settings during the football season. To a lesser extent, the no-tackle practice policy was also associated with a reduced number of SRCs.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review

OBJECTIVES

To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6).

DATA SOURCES

Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation.

ELIGIBILITY CRITERIA

(1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC.

DATA EXTRACTION

Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool.

RESULTS

Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children.

CONCLUSION

Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis

OBJECTIVE

To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

8 databases searched through 22 March 2022.

ELIGIBILITY CRITERIA

Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool.

RESULTS

278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I²=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I²=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I²=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns.

CONCLUSION

Most athletes have full RTL by 10 days but take twice as long for an RTS.

PROSPERO REGISTRATION NUMBER

CRD42020159928.

'If in Doubt, Sit Them Out': How Long to Return to Elite Cycling Competition following a Sports-Related Concussion (SRC)?

INTRODUCTION

A concussion or sports-related concussion (SRC) is a traumatic brain injury induced by biomechanical forces. After a SRC diagnosis is made, a concussed individual must undergo a period away from competition while they return to their baseline level of functioning. The Union Cycliste Internationale (UCI) currently recommend a minimum of 6 days restriction from competitive cycling following a SRC but there is a growing feeling amongst those involved in brain injury research that this period is too short. Therefore, how much time should cyclists be removed from competitive sporting action following a SRC?

AIMS

To review the time out of competition following the diagnosis of a SRC for elite cyclists within British Cycling (BC).

METHODS

All medical records for elite cyclists within BC were audited for diagnoses of "concussion" or "sports-related concussions" from January 2017 until September 2022. The days out of competition following the concussion until ready to compete again (that is, returned to full training) was then calculated. All diagnoses and management of SRC were undertaken by the medical team at BC and in-keeping with current international guidelines.

RESULTS

Between January 2017 and September 2022, there were 88 concussions diagnosed, 54 being males and 8 in para-athletes. The median duration for time out of competition for all concussions was 16 days. There was no statistical difference between males (median 15.5 days) and females (median 17.5 days) for time out of competition (p-value 0.25). The median duration out of competition following a concussion for able-bodied athletes was 16 (80 athletes) compared to 51 days (8 athletes) in para-cyclists, which was not statistically different (p-value 0.39).

CONCLUSIONS

This is the first study to report SRC concussion recovery times in elite cycling, including para-athletes. Between January 2017 and September 2022, there were 88 concussions diagnosed at BC and the median duration for time out of competition for all concussions was 16 days. There was no statistically significant difference in recovery times between male and females and para- and able-bodied athletes. This data should be used to help establish minimum withdrawal times post-SRC for elite cycling participation and we call on the UCI to review this data when establishing SRC protocols for cycling, with further research required in para-cyclists.

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

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