Considerations for Implementing the Post-Concussion Collegiate Return-to-Learn Protocol in the National Collegiate Athletic Association Power 5 Conferences

OBJECTIVE

Although concussions affect millions of young adults annually, researchers have yet to assess factors that may affect future implementation of post-concussion academic supports within higher education. Therefore, we sought to evaluate preimplementation outcomes of the acceptability, feasibility, appropriateness, and readiness for change of the Post-Concussion Collegiate Return-to-Learn (RTL) Protocol among university stakeholders.

SETTING

An online survey.

PARTICIPANTS

A convenience sample ( N = 49; 63.3% female) of athletic trainers (ATs; n = 25, age = 30.1 ± 7.6 years) and university faculty/staff ( n = 24, age = 38.3 ± 9.9 years) across the National Collegiate Athletic Association (NCAA) Power 5 Conferences from January to February 2022.

DESIGN

A cross-sectional study.

MAIN MEASURES

To compare preimplementation outcome measures using the Acceptability of Intervention Measure (AIM), Feasibility of Intervention Measure (FIM), Intervention Appropriateness Measure (IAM), and Organizational Readiness for Implementing Change (ORIC) regarding the RTL protocol between ATs and university faculty/staff. Additional outcomes included internal and external barriers to implementing at their respective institutions. Statistical analyses were conducted using Mann-Whitney U tests, with effect sizes estimated using eta-squared coefficient (η 2 ).

RESULTS

Quantitative analyses yielded no statistically significant group differences ( P s > .05) across the AIM, FIM, and IAM outcomes, indicating both groups perceived the protocol to be acceptable, feasible, and appropriate. Moreover, ATs reported higher agreement regarding motivation, desire, willingness to do "whatever it takes," commitment, and determination to implement the novel protocol than faculty/staff. Further, ATs reported higher agreement regarding their institution's confidence to keep track of its progress, support adjustment, maintain momentum, manage institutional politics, coordinate tasks, encourage investment, and handle the challenges of future implementation of the RTL protocol.

CONCLUSIONS

Preliminary findings suggest ATs and university faculty/staff across the NCAA Power 5 Conferences may perceive the RTL protocol to be acceptable, feasible, and appropriate for future use; however, noteworthy internal and external barriers may influence its uptake. Future research should utilize implementation frameworks to support the protocol's adoption and reach.

Recommendations for Medical Discharge Documentation and Academic Supports for University Students Recovering From Concussion

OBJECTIVE

This study sought to (1) collate the experiences of university students with concussion history and academic stakeholders through interviews and (2) develop concussion management recommendations for institutions of higher learning using a multidisciplinary Delphi procedure.

SETTING

Remote semistructured interviews and online surveys.

PARTICIPANTS

The first aim of this study included undergraduate university students with concussion history who did not participate in varsity athletics ( n = 21; 57.1% female), as well as academic faculty/staff with experience assisting university students with their postconcussion academic needs ( n = 7; 71.4% female). The second aim enrolled 22 participants (54.5% female) to serve on the Delphi panel including 9 clinicians, 8 researchers, and 5 academic faculty/staff.

DESIGN

An exploratory-sequential mixed-methods approach.

MAIN MEASURES

Semistructured interviews were conducted to unveil barriers regarding the return-to-learn (RTL) process after concussion, with emergent themes serving as a general framework for the Delphi procedure. Panelists participated in 3 stages of a modified Delphi process beginning with a series of open-ended questions regarding postconcussion management in higher education. The second stage included anonymous ratings of the recommendations, followed by an opportunity to review and/or modify responses based on the group's consensus.

RESULTS

The results from the semistructured interviews indicated students felt supported by their instructors; however, academic faculty/staff lacked information on appropriate academic supports and/or pathways to facilitate the RTL process. Of the original 67 statements, 39 achieved consensus (58.2%) upon cessation of the Delphi procedure across 3 main categories: recommendations for discharge documentation (21 statements), guidelines to facilitate a multidisciplinary RTL approach (10 statements), and processes to obtain academic supports for students who require them after concussion (8 statements).

CONCLUSIONS

These findings serve as a basis for future policy in higher education to standardize RTL processes for students who may need academic supports following concussion.

Achieving Consensus Through a Modified Delphi Technique to Create the Post-concussion Collegiate Return-to-Learn Protocol

BACKGROUND

Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education.

OBJECTIVE

To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery.

METHODS

Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group's overall ratings.

RESULTS

Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol.

CONCLUSION

There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders.

Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes With Recent SARS-CoV-2 Infection: Results From the Big Ten COVID-19 Cardiac Registry

Question

What is the prevalence of myocarditis in competitive athletes after COVID-19 infection, and how would different approaches to screening affect detection?

Findings

In this cohort study of 1597 US competitive collegiate athletes undergoing comprehensive cardiovascular testing, the prevalence of clinical myocarditis based on a symptom-based screening strategy was only 0.31%. Screening with cardiovascular magnetic resonance imaging increased the prevalence of clinical and subclinical myocarditis by a factor of 7.4 to 2.3%.

Meaning

These cardiac magnetic resonance imaging findings provide important data on the prevalence of clinical and subclinical myocarditis in college athletes recovering from symptomatic and asymptomatic COVID-19 infections.

Importance

Myocarditis is a leading cause of sudden death in competitive athletes. Myocardial inflammation is known to occur with SARS-CoV-2. Different screening approaches for detection of myocarditis have been reported. The Big Ten Conference requires comprehensive cardiac testing including cardiac magnetic resonance (CMR) imaging for all athletes with COVID-19, allowing comparison of screening approaches.

Objective

To determine the prevalence of myocarditis in athletes with COVID-19 and compare screening strategies for safe return to play.

Design, Setting, and Participants

Big Ten COVID-19 Cardiac Registry principal investigators were surveyed for aggregate observational data from March 1, 2020, through December 15, 2020, on athletes with COVID-19. For athletes with myocarditis, presence of cardiac symptoms and details of cardiac testing were recorded. Myocarditis was categorized as clinical or subclinical based on the presence of cardiac symptoms and CMR findings. Subclinical myocarditis classified as probable or possible myocarditis based on other testing abnormalities. Myocarditis prevalence across universities was determined. The utility of different screening strategies was evaluated.

Exposures

SARS-CoV-2 by polymerase chain reaction testing.

Main Outcome and Measure

Myocarditis via cardiovascular diagnostic testing.

Results

Representing 13 universities, cardiovascular testing was performed in 1597 athletes (964 men [60.4%]). Thirty-seven (including 27 men) were diagnosed with COVID-19 myocarditis (overall 2.3%; range per program, 0%-7.6%); 9 had clinical myocarditis and 28 had subclinical myocarditis. If cardiac testing was based on cardiac symptoms alone, only 5 athletes would have been detected (detected prevalence, 0.31%). Cardiac magnetic resonance imaging for all athletes yielded a 7.4-fold increase in detection of myocarditis (clinical and subclinical). Follow-up CMR imaging performed in 27 (73.0%) demonstrated resolution of T2 elevation in all (100%) and late gadolinium enhancement in 11 (40.7%).

Conclusions and Relevance

In this cohort study of 1597 US competitive athletes with CMR screening after COVID-19 infection, 37 athletes (2.3%) were diagnosed with clinical and subclinical myocarditis. Variability was observed in prevalence across universities, and testing protocols were closely tied to the detection of myocarditis. Variable ascertainment and unknown implications of CMR findings underscore the need for standardized timing and interpretation of cardiac testing. These unique CMR imaging data provide a more complete understanding of the prevalence of clinical and subclinical myocarditis in college athletes after COVID-19 infection. The role of CMR in routine screening for athletes safe return to play should be explored further.

Diagnosis and management of headache in the weight-lifting athlete

Weight lifters suffer from the same headache syndromes that affect all human beings. They are also susceptible to headache types brought on by their activity. Three headache syndromes, cervicogenic headache, benign exertional headache, and effort-induced migraine headache, appear to be more common in the weight-lifting athlete. This article discusses the diagnosis and treatment of these headache syndromes.

Identifying and treating corneal abrasions

Athletic activities cause up to 10% of all eye injuries in children(1) and account for 25% of severe eye injuries.(2) The sports most commonly associated with eye injury are baseball, basketball, tennis, and ice hockey,(1) but eye injury can occur in any sport.

Injection and aspiration techniques for the primary care physician

Aspiration and injection techniques are useful, relatively safe office procedures. The physician must have a good understanding of the basic technique and pertinent anatomy. The indications, contraindications and specific injection and aspiration techniques are discussed.

Blunt abdominal trauma in sports

Abdominal injuries are rare in sports, but when they do occur it is important that the physician recognize the warning signs of potentially life-threatening injury to the liver, spleen, or hollow abdominal viscera. Though the sports medicine physician may not always provide definitive treatment of many of these conditions, he or she should be familiar with the preferred diagnostic modalities and latest treatment options. This information is not only essential to appropriately participate in treatment decisions, but is also important in order to make return-to-play determinations.

Spondylolysis in active adolescents: expediting return to play

Spondylolysis is the most common identifiable cause of back pain in active adolescents, who often cope with the condition by hoping it will just go away. If the pain is prolonged or severe enough to bring them to a physician, an aggressive work-up for a specific diagnosis should be initiated. History and physical exam findings are suggestive but not diagnostic. Radiographs provide a first look, but other tests (eg, bone scans, CT, and MRI) are necessary to determine the metabolic activity and full extent of any lesions. Conservative therapy, including activity modification, physical therapy, and sometimes bracing, provides pain relief and focuses on return to full activity and prevention of recurrence.

Site-specific techniques of joint injection. Useful additions to your treatment repertoire

Joint and soft-tissue aspiration and injection procedures are relatively easy to master once the physician has acquired an understanding of the techniques and subtleties of performing these procedures at certain sites. These techniques can be used to diagnose and treat many painful joint and soft-tissue conditions and are useful additions to the primary care physician's treatment repertoire.

Basics of joint injection. General techniques and tips for safe, effective use

Successful joint and soft-tissue aspiration and injection rely on the physician's understanding of the indications, contraindications, and general techniques involved in these procedures. The procedures are generally well tolerated and can be used to treat many painful musculoskeletal and soft-tissue conditions.

Practical methods of preventing ankle injuries

Each year ankle sprains account for a significant degree of disability and expense. Thus, it is important that family physicians become familiar with methods of preventing ankle sprains. Both internal and external methods prevent ankle injuries. Internal methods include improving flexibility, strength and proprioception; effective external methods of ankle protection include using athletic tape, lace-up stabilizers and semirigid orthoses.

Occipital neuralgia in a football player: a case report

Occipital neuralgia, a painful condition thought to be caused by nerve entrapment, has been described in the general population. Athletes, particularly those who participate in collision sports, such as football, may be predisposed to this condition. An illustrative case is presented along with discussion of the differential diagnosis and treatment of this type of headache.

Disqualifying criteria in a preparticipation sports evaluation

BACKGROUND

This study was undertaken to demonstrate the relative frequency of disqualifying criteria in a complete history and physical sports examination.

METHODS

A review was conducted of 2574 preparticipation physical evaluations (PPEs) performed on 11- to 18-year-old student athletes to determine which factors are associated with denial of unrestricted sports participation.

RESULTS

Eighty-five percent of the student athletes passed the screening. Of those who did not, the denial decision was based on the medical history alone in 58% of cases (P < .05). A logistic regression analysis identified seven items associated with denial: dizziness with exercise, history of asthma, body mass index, systolic blood pressure, visual acuity, heart murmur, and musculoskeletal examination.

CONCLUSIONS

Although physicians often take a complete history and perform physical examinations, relatively few variables appear related to denial of eligibility for participation in organized sports. The history is one of the most important aspects of the PPE. A directed PPE may be more efficient, thereby allowing more time to address other important issues.

Management of thyroid nodules

Clinically apparent thyroid nodules occur in about 5 percent of the population. Because most patients with thyroid nodules present initially to their primary care physician, family physicians should have a thorough understanding of the diagnosis and treatment of thyroid nodules. The history and physical examination may be helpful in detecting thyroid nodules but are not useful in predicting malignancy. Furthermore, laboratory studies, ultrasonography and nuclear medicine scans do not reliably differentiate between benign and malignant thyroid nodules. In most cases, fine-needle aspiration biopsy can accurately identify malignant thyroid nodules. Fine-needle aspiration biopsy is safe and can be performed in an office setting.