Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes Use of the King–Devick test for sideline concussion screening in junior rugby league Evaluation of the King–Devick test as a concussion screening tool in high school football players Concussions in amateur rugby union identified with the use of a rapid visual screening tool A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates. Effect of soccer heading ball speed on S100B, sideline concussion assessments and head impact kinematics Effect of acute exercise on clinically measured reaction time in collegiate athletes. Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: A pilot study Serial Sevens: Not the Most Effective Test of Mental Status in High School Athletes Is neuropsychological testing useful in the management of sport-related concussion? Sideline Performance of the Balance Error Scoring System during a Live Sporting Event Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. The “Value Added” of Neurocognitive Testing after Sports-Related Concussion Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports Blood biomarkers for brain injury in concussed professional ice hockey players. Athletic Trainers' Concussion-Assessment and -Management Practices: An Update. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. Recovery of postural control after cerebral concussion: new insights using approximate entropy. Cognition in the days following concussion: comparison of symptomatic versus asymptomatic athletes. Relation between subjective fogginess and neuropsychological testing following concussion. Grade 1 or “Ding” Concussions in High School Athletes
Background : Sports-related concussion commonly affects the visual pathways . Current sideline protocol s test cognition and balance but do not include assessment s of visual performance . We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels . Methods : Participants in this prospect i ve study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Isl and University . Athletes underwent preseason baseline assessment s using : 1 ) the King – Devick ( K-D ) test , a < 2-minute visual performance measure of rapid number naming , 2 ) the St and ardized Assessment of Concussion ( SAC ) , a test of cognition , and 3 ) a timed t and em gait test of balance .  The SAC and timed t and em gait are components of the currently used Sport Concussion Assessment Tool , 3rd Edition ( SCAT3 and Child-SCAT3 ) . In the event of a concussion during the athletic season , injured athletes were retested on the sideline/rink-side . Nonconcussed athletes were also assessed as control participants under the same testing conditions . Results : Among 243 youth ( mean age 11 ± 3 years , range 5–17 ) and 89 collegiate athletes ( age 20 ± 1 years , range 18–23 )  , baseline time scores for the K-D test were lower ( better ) with increasing participant age ( P < 0.001 , linear regression models ) . Among 12 athletes who sustained concussions during their athletic season , K-D scores worsened from baseline by an average of 5.2 seconds ; improvement by 6.4 seconds was noted for the nonconcussed controls ( n = 14 ) . The  vision-based K-D test  showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury ( receiver operating characteristic [ ROC ] curve areas from logistic regression models , accounting for age = 0.92 for K-D , 0.87 for timed t and em gait , and 0.68 for SAC ; P = 0.0004 for comparison of ROC curve areas ) . Conclusions : Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment . This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision AIM To determine whether the King-Devick ( K-D ) test used as a sideline test in junior rugby league players over 12 matches in a domestic competition season could identify witnessed and incidentally identified episodes of concussion . METHODS A prospect i ve observational cohort study of a club level junior rugby league team ( n=19 ) during the 2014 New Zeal and competition season involved every player completing two pre-competition season baseline trials of the K-D test .  Players removed from match participation , or who reported any signs or symptoms of concussion were assessed on the sideline with the K-D test and referred for further medical assessment . Players with a pre- to post-match K-D test difference > 3s were referred for physician evaluation . RESULTS The baseline test-retest reliability of the K-D test was high ( rs=0.86 ; p<0.0001 ) . Seven concussions were medically identified in six players who recorded pre- to post-match K-D test times greater than 3s ( mean change of 7.4s ) . Post-season testing of players demonstrated improvement of K-D time scores consistent with learning effects of using the K-D test ( 67.7s vs. 62.2s ) . DISCUSSION Although no witnessed concussions occurred during rugby play , six players recorded pre- to post-match changes with a mean delay of 4s result ing in seven concussions being subsequently confirmed post-match by health practitioners . All players were medically managed for a return to sports participation . CONCLUSION The K-D test was quickly and easily administered making it a practical sideline tool as part of the continuum of concussion assessment tools for junior rugby league players OBJECTIVE Concussion is the most common type of traumatic brain injury , and results from impact or impulsive forces to the head , neck or face . Due to the variability and subtlety of symptoms , concussions may go unrecognized or be ignored , especially with the pressure placed on athletes to return to competition . The King-Devick ( KD ) test , an oculomotor test originally design ed for reading evaluation , was recently vali date d as a concussion screening tool in collegiate athletes . A prospect i ve study was performed using high school football players in an attempt to study the KD as a concussion screening tool in this younger population . METHODS 343 athletes from four local high school football teams were recruited to participate . These athletes were given baseline KD tests prior to competition . Individual demographic information was collected on the subjects . St and ard team protocol was employed to determine if a concussion had occurred during competition . Immediately after diagnosis , the KD test was re-administered to the concussed athlete for comparison to baseline . Post-season testing was also performed in non-concussed individuals . RESULTS Of the 343 athletes , nine were diagnosed with concussions . In all concussed players , cumulative read times for the KD test were significantly increased ( p<0.001 ) . Post-season testing of non-concussed athletes revealed minimal change in read times relative to baseline . Univariate analysis revealed that history of concussion was the only demographic factor predictive of concussion in this cohort . CONCLUSION The KD test is an accurate and easily administered sideline screening tool for concussion in adolescent football players AIM To use the King-Devick ( KD ) test and Sports Concussion Assessment Tool 2 ( SCAT2 ) in amateur rugby union players to identify witnessed and unrecognised episodes of concussion that occurred from match participation . METHODS A prospect i ve observational cohort study was conducted on a premier club level amateur rugby union team during the 2012 competition in New Zeal and . Every player completed a pre-competition question naire on concussion history , a baseline PCSS and two trials of the KD before they participated in any match activities . RESULTS For players reporting a concussion in the previous three years there was an average of 4.0±2.8 concussions per player . There were 22 concussive incidents recorded over the duration of the competition ( 46 per 1000 match hours ) . Five concussive incidents were witnessed ( 11 per 1000 match hours ) and 17 unrecognised concussive incidents were identified with the KD ( 37 per 1000 match hours ) . Witnessed concussions recorded , on average , a longer KD on the day of injury ( 5.5±2.4s ) than unrecognised concussions ( 4.4±0.9s ) when compared with their baseline KD . DISCUSSION The KD was able to identify players that had not shown , or reported , any signs or symptoms of a concussion but who had meaningful head injury . The current rate of concussion reported was a ten-fold increase in previously reported concussion injury rates . This makes the KD suitable for rapid assessment in a limited time frame on the sideline such as a five-minute window to assess and review suspected concussed players in rugby union OBJECT The objective of this study was to measure the incidence of concussion ( scaled relative to number of athlete exposures ) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players ( 16 - 21 years old ) during 1 regular season . METHODS A prospect i ve cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season ( 2009 - 2010 ) involving 67 male fourth-tier ice hockey players ( mean age 18.2 ± 1.2 years , range 16 - 21 years ) from 2 teams . Prior to the start of the season , every player underwent baseline assessment s using the Sideline Concussion Assessment Tool 2 ( SCAT2 ) and the Immediate Post-Concussion Assessment and Cognitive Test ( ImPACT ) . The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing . If the protocol was not followed , the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels . Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer . Players who suffered a suspected concussion were evaluated at the game . If a concussion diagnosis was made , the player was subsequently examined in the physician 's office for a full clinical evaluation and the SCAT2 and ImPACT were repeated . Based on these evaluations , players were counseled on the decision of when to return to play . Athlete exposure was defined as 1 game played by 1 athlete . RESULTS Twenty-one concussions occurred during the 52 physician-observed games ( incidence 21.5 concussions per 1000 athlete exposures ) . Five players experienced repeat concussions . No concussions were reported during practice sessions . A concussion was diagnosed by the physician in 19 ( 36.5 % ) of the 52 observed games . One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician , and as a result this single case was not included in the total of 21 total concussions . This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated . CONCLUSIONS The incidence of game-related concussions ( per 100 [ corrected ] athlete exposures ) in these fourth-tier junior [ corrected ] ice hockey players was 7 [ corrected ] times higher than [ corrected ] previously reported in the literature . This difference may be the result of the use of st and ardized direct physician observation , diagnosis , and subsequent treatment . The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings . These follow-up studies should involve other contact sports ( for example football and rugby ) and also include the full spectrum of gender , age , and skill levels Abstract Objective : To examine the effect of soccer heading ball speed on S-100B serum concentration , concussion sideline assessment s and linear head impact acceleration . Methods : Sixteen division I soccer players participated in this pre-test post-test design study . Athletes performed five st and ing headers over a 10 minute period at 30 ( n = 5 ) , 40 ( n = 5 ) or 50 ( n = 6 ) miles per hour ( mph ) ( r and omized ) . S-100B serum concentration ( ng mL−1 ) and sideline concussion assessment s were measured prior to and post-heading . Peak result ant linear head acceleration ( gravitational units ; g ) was measured during soccer heading . Results : No statistically significant interaction effects were identified between ball velocity groups over time on S100B ( effect sizes ranged from 0.03–0.23 ) or concussion assessment s tests . There was a non-significant increase ( p = 0.06 ) in head impact acceleration from the 30 ( 30.6 ; SD = 6.2 g ) to 50 mph ( 50.7 ; SD = 7.7 g ) ball speed . Conclusions : In this controlled setting , an acute bout of soccer heading across various ball velocities did not affect S100B or concussion assessment test scores . These findings are preliminary , as the small sample size in each group may have played a role in the lack of significant findings PURPOSE We have developed a reliable and valid clinical test of reaction time ( RTclin ) that is sensitive to the acute effects of concussion . If RTclin is to be used as a sideline concussion assessment tool then the acute effects of exercise on RTclin may need to be controlled for . The purpose of this study was therefore to determine the effect of exercise on RTclin . METHODS A gender-balanced group of 42 collegiate athletes were assigned to an  exercise ( n = 28 ) and a  control ( n = 14 ) group using 2:1 block r and omization . The exercise group completed a grade d four-stage exercise protocol on a stationary bicycle ( 100 W × 5 min ; 150 W × 5 min ; 200 W × 5 min ; sprint × 2 min ) , whereas the control group was tested at identical periods without exercising .  Mean RTclin was calculated for eight trials as the fall time of a vertically suspended rigid shaft after its release by the examiner before being caught by the athlete . RTclin was measured at baseline and after each of the four stages . RESULTS As both HR and RPE significantly increased for the four stages in the exercise group ( P < 0.001 ) , mean RTclin showed a significant overall decline during repeated test administration ( P < 0.008 ) . However , there were no significant group ( exercise vs control , P = 0.822 ) or group-by-stage interaction ( P = 0.169 ) effects on RTclin as assessed by repeated- measures analysis of variance . CONCLUSIONS Exercise did not appear to affect RTclin performance in this study . This suggests that RTclin measured during a sideline concussion assessment does not need to be adjusted to account for the acute effects of exercise AIM This study undertook to use the K-D sideline test with the SCAT2 to see if concussions could be identified in amateur rugby league players over a representative competition period . METHOD A prospect i ve cohort study was conducted on two teams participating in an amateur rugby league . All players were tested for signs of concussion utilising the K-D test and players with longer times than their baseline scores undertook a further concussion assessment with the SCAT2 . RESULTS Five athletes with suspected concussion were evaluated by K-D testing .  Three concussions were associated with witnessed events during the matches and two athletes were identified by the team medic as having longer K-D time scores incidentally post-match compared to baseline . Post-match K-D scores for all concussed athletes were worse than baseline for those with reported or witnessed concussion events ( 7s ; 5.0 - 7.1 ; p=0.025 ) and for those identified incidentally ( > 5s ; 8.9 - 9.1s ) . Both groups also reported more symptoms on the PCSS ( a part of the SCAT2 ) post-match . DISCUSSION In this rugby cohort , the K-D test was not only useful in identifying changes in players with witnessed head trauma , but in identifying changes in players with an un-witnessed suspected concussion Objective To evaluate the ability of uninjured high school athletes to pass three mental status tests that are commonly used on the sidelines for the evaluation of concussions : the serial sevens test , the serial threes test , and recitation of months of year in reverse order ( MOYR ) . Participants High school student athletes in grade s 9 , 10 , 11 , and 12 having sports preparticipation physical examinations . The initial study tested 522 consecutive athletes . The follow-up study tested 109 consecutive athletes . InterventionThe athletes of the initial group were asked to perform a serial sevens test , followed by a serial threes test , and finally to recite the MOYR . The second group was asked to perform the same tests in a r and om order . Main Outcome Measures Participants were given 1-min time limits for each test , with passing defined as either 7 consecutive correct iterations or 11 correct with one mistake . Results For the initial group , 51.3 % successfully performed serial sevens , 78.7 % successfully performed serial threes , and 89.5 % successfully recited the MOYR . For the second group , 52.7 % successfully performed serial sevens , 78.1 % success-fully performed serial threes , and 88.9 % successfully recited the MOYR . The pass rates were significantly different for both groups . The pass rates were similar for both sexes , all grade levels , and all sports in both test groups . Participants , both overall and in all subgroups , failed serial sevens more often than serial threes and MOYR ( p < 0.001 for the initial group ; p < 0.0001 for the second group ) . They failed serial threes more often than MOYR ( p < 0.001 for the initial group ; p < 0.01 for the second group ) . Conclusions The percentage of uninjured high school athletes successfully completing serial sevens is too low to make the test useful for evaluation of concussion ; the test lacks specificity . The percentage of athletes passing the MOYR was greatest , perhaps making this a better sideline test than the traditional serial sevens test . However , testing needs to be done in injured athletes before clinical application can be recommended OBJECTIVE Neuropsychological ( NP ) testing has been used for several years as a way of detecting the effects of sport-related concussion in order to aid in return-to-play determinations . In addition to st and ard pencil- and -paper tests , computerized NP tests are being commercially marketed for this purpose to professional , collegiate , high school , and elementary school programs . However , a number of important questions regarding the clinical validity and utility of these tests remain unanswered , and these questions present serious challenges to the applicability of NP testing for the management of sport-related concussion . Our purpose is to outline the criteria that should be met in order to establish the utility of NP instruments as a tool in the management of sport-related concussion and to review the degree to which existing tests have met these criteria . DATA SOURCES A comprehensive literature review of MEDLINE and PsychLit from 1990 to 2004 , including all prospect i ve , controlled studies of NP testing in sport-related concussion . DATA SYNTHESIS The effects of concussion on NP test performance are so subtle even during the acute phase of injury ( 1 - 3 days postinjury ) that they often fail to reach statistical significance in group studies . Thus , this method may lack utility in individual decision making because of a lack of sensitivity . In addition , most of these tests fail to meet other psychometric criteria ( eg , adequate reliability ) necessary for this purpose . Finally , it is unclear that NP testing can detect impairment in players once concussion-related symptoms ( eg , headache ) have resolved . Because no current guideline for the management of sport-related concussion allows a symptomatic player to return to sport , the incremental utility of NP testing remains question able . CONCLUSIONS / RECOMMENDATIONS Despite the theoretic rationale for the use of NP testing in the management of sport-related concussion , no NP tests have met the necessary criteria to support a clinical application at this time . Additional research is necessary to establish the utility of these tests before they can be considered part of a routine st and ard of care , and concussion recovery should be monitored via the st and ard clinical examination and subjective symptom checklists until NP testing or other methods are proven effective for this purpose Objective : The purpose was to examine the influence of a live sporting sideline environment on balance error scoring system ( BESS ) performance . Design : Prospect i ve longitudinal cohort study . Setting : The BESS was performed by all participants at 3 locations : ( 1 ) quiet laboratory , ( 2 ) football stadium sidelines , and ( 3 ) basketball arena sidelines . Participants : The experimental group had 38 participants ( age : 20.1 ± 1.1 years ; height : 170.0 ± 7.7 cm ; mass : 66.7 ± 9.5 kg ) who were female intercollegiate student-athletes ( SA ) . The control group consisted of 38 recreationally active female college students ( age : 20.8 ± 1.1 years ; height : 162.6 ± 6.0 cm ; mass : 63.7 ± 10.6 kg ) . Interventions : The 2 groups performed the tests at the same locations , the SA group during live sporting events and the control group when no event was occurring . Main Outcome Measures : The dependent variable was the total BESS score . Separate 2 × 3 mixed methods analyses of variance investigated the influence of the environment and practice effect . Results : There was a significant interaction for group by environment ( P = 0.004 ) , and the SA group committed more errors at both the football and the basketball setting s than the control group . The SA group also committed more errors at football ( P = 0.028 ) than baseline . The control group demonstrated a likely practice effect with fewer errors during each administration . Conclusions : The BESS score deteriorated when performed on the sidelines of a live sporting event potentially challenging the clinical utility of the BESS . Clinicians need to consider the role of the local environment when performing the BESS test and should perform postinjury tests in the same environment as the baseline test . Clinical Relevance : When performing balance testing of patients with suspected concussions , clinicians need to consider the environment in which the test is performed and attempt to match the preseason testing environment This study explored the diagnostic utility of the composite scores of Immediate Post-Concussion Assessment and Cognitive Testing ( ImPACT ) and Post Concussion Symptom Scale scores ( PCSS ) . Recently concussed high school athletes ( N=72 ) were tested within 72 h of sustaining a concussion , and data were compared to non-concussed high school athletes with no history of concussion ( N=66 ) . Between-groups MANOVA revealed a significant multivariate effect of concussion on test performance ( p<.001 ) ; univariate ANOVAS revealed all six measures contributed to the between-groups differences . A discriminant function analyses was conducted to measure the ability of the five ImPACT composite scores , as well as the PCSS to classify concussion status . One discriminant function was identified that consisted of the Visual Memory , Processing Speed , and Impulse Control composite scores PCSS , which correctly classified 85.5 % of the cases . Approximately 82 % of participants in the concussion group and 89 % of participants in the control group were correctly classified . Using these data , the sensitivity of ImPACT was 81.9 % , and the specificity was 89.4 % . As part of a formal concussion management program , ImPACT is a useful tool for the assessment of the neurocognitive and neurobehavioral sequelae of concussion , and can also provide post-injury cognitive and symptom data that can assist a practitioner in making safer return to play decisions Background Concussion is one of the most commonly occurring injuries in sport today . The Sport Concussion Assessment Tool ( SCAT ) is a commonly used paper neurocognitive tool . To date , little is known about SCAT baseline normative values in youth athletes . Objective The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players . Methods This is a secondary data analysis of pooled data from three prospect i ve cohort studies examining the risk of injury in paediatric ice hockey players aged 9–17 years . A preseason baseline demographic and injury history question naire was completed by each player . Results A total of 4193 players completed SCATs at baseline and were included in the analysis . 781 players ( 18.6 % ) reported a previous history of concussion . Fatigue and low energy followed by headache were the most commonly reported symptoms in all players . The majority of youth players could recite all five words immediately but only three words when delayed . A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age . The median number of digits recited in reverse order was 4 . Conclusions Youth ratings varied between age groups , gender and from previously reported ratings of varsity athletes , possibly reflecting developmental and gender differences . An underst and ing of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion OBJECT The authors investigated return-to-play duration for initial and recurrent concussion in the same season in 2 teams of junior ( 16 - 21-year-old ) ice hockey players during a regular season . METHODS The authors conducted a prospect i ve cohort study during 1 junior regular season ( 2009 - 2010 ) of 67 male fourth-tier ice hockey players ( mean age 18.2 ± 1.2 years [ SD ] , range 16 - 21 years ) from 2 teams . Prior to the start of the season , every player underwent baseline assessment s that were determined using the  Sideline Concussion Assessment Tool 2 ( SCAT2 ) and the Immediate Post-Concussion Assessment and Cognitive Test ( ImPACT ) . The study protocol also required players who entered the study during the season to complete a baseline SCAT2 and ImPACT . If the protocol was not followed , the postinjury test results of a player without true baseline test results were compared with previously established age- and sex-matched group normative levels . Each game was directly observed by a physician and at least 1 neutral nonphysician observer . Players suspected of suffering a concussion were evaluated by the physician during the game . If a concussion was diagnosed , the player underwent clinical evaluation at the physician 's office within 24 hours . The return-to-play decision was based on clinical evaluation guided by the Zurich return-to-play protocol ( contained in the consensus statement of international expert opinion at the 3rd International Conference on Concussion in Sport held in Zurich , November 2008 ) . This clinical evaluation and return-to-play protocol was augmented by the 2 tests ( SCAT2 and ImPACT ) also recommended by the Zurich consensus statement , for which baseline values had been obtained . RESULTS Seventeen players sustained a physician-observed or self-reported , physician-diagnosed concussion during a physician-observed ice hockey game . The mean clinical return-to-play duration ( in 15 cases ) was 12.8 ± 7.02 days ( median 10 days , range 7 - 29 days ) ; the mean number of physician office visits by players who suffered a concussion ( 15 cases ) was 2.1 ± 1.29 ( median 1.5 visits ) . Five of the 17 players who sustained a concussion also suffered a recurrent or second concussion . One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician , and as a result this single case was not included in the total of 21 concussions . This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated . The mean interval between the first and second concussions in these 5 players was 78.6 ± 39.8 days ( median 82 days ) , and the mean time between the return-to-play date of the first and second concussions was 61.8 ± 39.7 days ( median 60 days ) . CONCLUSIONS The mean rates of return to play for single and recurrent concussions were higher than rates cited in recent studies involving sport concussions . The time interval between the first and second concussions was also greater than previously cited . This difference may be the result of the methodology of direct independent physician observation , diagnosis , and adherence to the Zurich return-to-play protocol Background Neurocognitive testing has been endorsed as a “ cornerstone ’ of concussion management by recent Vienna and Prague meetings of the Concussion in Sport Group . Neurocognitive testing is important given the potential unreliability of athlete self-report after injury . Relying only on athletes'ormalities after injury . Study Design Case control study ; Level of evidence , 3 . Methods High school and college athletes with a diagnosed concussion were tested 2 days after injury . Postinjury neurocognitive performance ( Immediate Postconcussion Assessment and Cognitive Testing ) and symptom ( postconcussion symptom ) scores were compared with preinjury ( baseline ) scores and with those of an agex and education-matched noninjured athlete control group . “ Abnormal ” test performance was determined statistically with Reliable Change Index scores . Results Sixty-four percent of concussed athletes reported a significant increase in symptoms , as judged by postconcussion symptom scores , compared with preinjury baseline at 2 days after injury . Eighty-three percent of the concussed sample demonstrated significantly poorer neurocognitive test results relative to their own baseline performance . The addition of neurocognitive testing result ed in a net increase in sensitivity of 19 % . Ninety-three percent of the sample had either abnormal neurocognitive test results or a significant increase in symptoms , relative to their own baseline ; 30 % of a control group demonstrated either abnormalities in neurocognitive testing or elevated symptoms , as judged by postconcussion symptom scores . For the concussed group , use of symptom and neurocognitive test results result ed in an increased yield of 29 % overreliance on symptoms alone . In contrast , 0 % of the control group had both symptoms and abnormal neurocognitive testing . Conclusion Reliance on patients ’ self-reported symptoms after concussion is likely to result in underdiagnosis of concussion and may result in premature return to play . Neurocognitive testing increases diagnostic accuracy when used in conjunction with self-reported symptoms Context With increasing knowledge and research about concussion , there have been few objective studies that have used neuropsychological domain scores and postural stability to assess concussion . Objective To evaluate the recovery curve of athletes who incur sport-related concussion from repeated serial testing of neuropsychological and posturography testing . Design A prospect i ve epidemiological model was used for the course of the study . Setting Division I intercollegiate athletics . Participants Athletes participating in football , soccer , basketball , softball , and cheerleading . Main Outcome Measures  Neuropsychological scores and posturography measures  were obtained preseason and serially at day 1 , day 2 , day 3 , and day 10 postconcussion .  Control participants  were tested at the same intervals .  Neuropsychological scores were converted to st and ards score and then into domains of attention , learning , speed of information processing , concentration , memory , and verbal fluency . Analysis of covariance with the baseline test as the covariate was used to analyze the data with univariate post hoc tests performed . Results Significant group differences were found for self reported symptoms ( P = 0.001 ) , speed of information processing ( P = 0.005 ) , mean stability ( P = 0.002 ) , and vestibular function ( P = 0.003 ) between injured and control participants . A group , by day , planned comparison found that speed of information processing and composite balance measures demonstrated significant differences through day 10 postinjury , while symptoms and the vestibular ratio remained significant only through day 3 . Conclusions The concussion recovery curve demonstrated short-term neuropsychological and posturography deficits following injury . A comprehensive approach to concussion management should be used to assess the injury and make return-to-play decisions IMPORTANCE Lack of objective biomarkers for brain damage hampers acute diagnosis and clinical decision making about return to play after sports-related concussion . OBJECTIVES To determine whether sports-related concussion is associated with elevated levels of blood biochemical markers of injury to the central nervous system and to assess whether plasma levels of these biomarkers predict return to play in professional ice hockey players with sports-related concussion . DESIGN , SETTING , AND PARTICIPANTS Multicenter prospect i ve cohort study involving all 12 teams of the top professional ice hockey league in Sweden , the Swedish Hockey League . Two hundred eighty-eight professional ice hockey players from 12 teams contesting during the 2012 - 2013 season consented to participate . All players underwent clinical preseason baseline testing regarding concussion assessment measures . Forty-seven players from 2 of the 12 ice hockey teams underwent blood sampling prior to the start of the season . Thirty-five players had a concussion from September 13 , 2012 , to January 31 , 2013 ; of these players , 28 underwent repeated blood sampling at 1 , 12 , 36 , and 144 hours and when the players returned to play . MAIN OUTCOMES AND MEASURES Total tau , S-100 calcium-binding protein B , and neuron-specific enolase concentrations in plasma and serum were measured . RESULTS Concussed players had increased levels of the axonal injury biomarker total tau(median , 10.0 pg/mL ; range , 2.0 - 102 pg/mL ) compared with preseason values ( median , 4.5pg/mL ; range , 0.06 - 22.7 pg/mL ) ( P < .001 ) . The levels of the astroglial injury biomarker S-100 calcium-binding protein B were also increased in players with sports-related concussion(median , 0.075 μg/L ; range , 0.037 - 0.24 μg/L ) compared with preseason values ( median,0.045 μg/L ; range , 0.005 - 0.45 μg/L ) ( P < .001 ) . The highest biomarker concentrations of total tau and S-100 calcium-binding protein B were measured immediately after a concussion , and they decreased during rehabilitation . No significant changes were detected in the levels of neuron-specific enolase from preseason values ( median , 6.5 μg/L ; range,3.45 - 18.0 μg/L ) to postconcussion values ( median , 6.1 μg/L ; range , 3.6 - 12.8 μg/L ) ( P = .10 ) . CONCLUSIONS AND RELEVANCE Sports-related concussion in professional ice hockey players is associated with acute axonal and astroglial injury . This can be monitored using blood biomarkers , which may be developed into clinical tools to guide sport physicians in the medical counseling of athletes in return-to-play decisions CONTEXT Athletic trainers ( ATs ) are often the first health care providers to conduct concussion assessment s and carry out postinjury management . Best practice s for concussion evaluation and management have changed rapidly in recent years , outdating previous reports of ATs ' concussion practice s. OBJECTIVE To examine ATs ' current concussion- assessment and -management techniques . DESIGN Cross-sectional study . SETTING Web-based survey . PATIENTS OR OTHER PARTICIPANTS A r and om convenience sample of 8777 ATs ( response rate = 15.0 % [ n = 1307 ] ; years certified = 15.0 ± 10.6 ) from the National Athletic Trainers ' Association membership . MAIN OUTCOME MEASURE(S ) Survey Web links were e-mailed to prospect i ve participants , with 2 follow-up e-mails sent by the National Athletic Trainers ' Association . The survey collected demographic information , the number of concussions assessed , the concussion-recovery patterns , and the assessment and return-to-participation ( RTP ) decision-making methods used . RESULTS The ATs reported assessing a median of 12.0 ( range = 0 - 218 ) concussions per year . A total of 95.3 % ( 953/1000 ) ATs cited clinical examination as the most frequently used concussion- assessment tool , followed by symptom assessment ( 86.7 % ; 867/1000 ) . A total of 52.7 % ( 527/1000 ) ATs described a 3-domain minimum multidimensional concussion- assessment battery . Published RTP guidelines were the most common RTP decision-making tool ( 91.0 % ; 864/949 ) , followed by clinical examination ( 88.2 % ; 837/949 ) . The ATs with master 's degrees were 1.36 times ( 95 % confidence interval [ CI ] = 1.02 , 1.81 ) more likely to use a 3-domain concussion- assessment battery than ATs with only bachelor 's degrees ( χ2 = 4.44 , P = .05 ) . Collegiate ATs were 2.12 ( 95 % CI = 1.59 , 2.84 ) and 1.63 ( 95 % CI = 1.03 , 2.59 ) times more likely to use a 3-domain concussion- assessment battery than high school and clinic-based ATs , respectively ( χ2 = 26.29 , P < .001 ) . CONCLUSIONS Athletic trainers were using the clinical examination , st and ardized assessment tools , and a 3-domain concussion- assessment -battery approach more frequently in clinical practice than previously reported . However , despite practice improvements , nearly half of ATs were not using a 3-domain minimum concussion- assessment battery . Clinicians should strive to implement multidimensional concussion assessment s in their practice s to ensure optimal diagnosis and management CONTEXT Lack of empirical data on recovery time following sport-related concussion hampers clinical decision making about return to play after injury . OBJECTIVE To prospect ively measure immediate effects and natural recovery course relating to symptoms , cognitive functioning , and postural stability following sport-related concussion . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study of 1631 football players from 15 US colleges . All players underwent preseason baseline testing on concussion assessment measures in 1999 , 2000 , and 2001 . Ninety-four players with concussion ( based on American Academy of Neurology criteria ) and 56 noninjured controls underwent assessment of symptoms  , cognitive functioning  , and postural stability immediately , 3 hours , and 1 , 2 , 3 , 5 , 7 , and 90 days after injury . MAIN OUTCOME MEASURES Scores on the Grade d Symptom Checklist ( GSC ) , St and ardized Assessment of Concussion ( SAC ) , Balance Error Scoring System ( BESS ) , and a neuropsychological test battery . RESULTS No player with concussion was excluded from participation ; 79 players with concussion ( 84 % ) completed the protocol through day 90 . Players with concussion exhibited more severe symptoms ( mean GSC score 20.93 [ 95 % confidence interval [ CI ] , 15.65 - 26.21 ] points higher than that of controls ) , cognitive impairment ( mean SAC score 2.94 [ 95 % CI , 1.50 - 4.38 ] points lower than that of controls ) , and balance problems ( mean BESS score 5.81 [ 95 % CI , -0.67 to 12.30 ] points higher than that of controls ) immediately after concussion . On average , symptoms gradually resolved by day 7 ( GSC mean difference , 0.33 ; 95 % CI , -1.41 to 2.06 ) , cognitive functioning improved to baseline levels within 5 to 7 days ( day 7 SAC mean difference , -0.03 ; 95 % CI , -1.33 to 1.26 ) , and balance deficits dissipated within 3 to 5 days after injury ( day 5 BESS mean difference , -0.31 ; 95 % CI , -3.02 to 2.40 ) . Mild impairments in cognitive processing and verbal memory evident on neuropsychological testing 2 days after concussion resolved by day 7 . There were no significant differences in symptoms or functional impairments in the concussion and control groups 90 days after concussion . CONCLUSIONS Collegiate football players may require several days for recovery of symptoms , cognitive dysfunction , and postural instability after concussion . Further research is required to determine factors that predict variability in recovery time after concussion . St and ardized measurement of postconcussive symptoms , cognitive functioning , and postural stability may enhance clinical management of athletes recovering from concussion CONTEXT The return-to-play decision after sport-related cerebral concussion depends in part on knowing when an athlete has fully recovered postural control after injury . OBJECTIVE To describe the postconcussion recovery of postural control using approximate entropy ( ApEn ) , a regularity statistic from nonlinear dynamics . DESIGN Retrospective case series analysis . SETTING Sports medicine research laboratory . PATIENTS OR OTHER PARTICIPANTS Collegiate athletes from whom center-of-pressure and symptom data were collected at preseason , less than 48 hours after injury , and 48 to 96 hours after injury . MAIN OUTCOME MEASURE(S ) Approximate entropy values reflecting the amount of r and omness contained in center-of-pressure oscillations were calculated for anterior-posterior ( AP ) and medial-lateral ( ML ) time series . Equilibrium scores reflecting the amplitude of center-of-pressure AP oscillations were used to indicate postural stability . The number and severity of symptoms were described . RESULTS Compared with the healthy preseason state , ApEn values for the AP and ML time series generally declined immediately after injury in both steady and unsteady injured athletes . At 48 to 96 hours after injury , ApEn values for the ML time series remained significantly depressed ( mean difference compared with preseason = -0.268 , st and ard error = 0.072 ) , even among athletes whose initial postural instability had resolved . We found few significant relationships between changes in ApEn values and changes in symptoms before and after injury . CONCLUSIONS The effects of cerebral concussion on postural control appear to persist for longer than 3 to 4 days , even among athletes with no signs of unsteadiness . Our results may reflect changes in neurophysiologic or mechanical constraints on postural control . Approximate entropy provides a theoretically distinct , valuable measurement alternative that may prove useful for reducing uncertainty in the return-to-play decision BACKGROUND Concussion is a common neurological injury occurring during contact sport . Current guidelines recommend that no athlete should return to play while symptomatic or displaying cognitive dysfunction . This study compared post-concussion cognitive function in recently concussed athletes who were symptomatic/asymptomatic at the time of assessment with that of non-injured ( control ) athletes . METHODS Prospect i ve study of 615 male Australian Rules footballers . Before the season , all participants ( while healthy ) completed a battery of baseline computerised ( CogSport ) and paper and pencil cognitive tasks .  Sixty one injured athletes ( symptomatic = 25 and asymptomatic = 36 ) were reassessed within 11 days of being concussed ; 84 controls were also reassessed . The serial cognitive function of the three groups was compared using analysis of variance . RESULTS The performance of the symptomatic group declined at the post-concussion assessment on computerised tests of simple , choice , and complex reaction times compared with the asymptomatic and control groups . The magnitude of changes was large according to conventional statistical criteria . On paper and pencil tests , the symptomatic group displayed no change at re assessment , whereas large improvements were seen in the other two groups . CONCLUSION Injured athletes experiencing symptoms of concussion displayed impaired motor function and attention , although their learning and memory were preserved . These athletes displayed no change in performance on paper and pencil tests in contrast with the improvement observed in asymptomatic and non-injured athletes . Athletes experiencing symptoms of concussion should be withheld from training and competition until both symptoms and cognitive dysfunction have resolved The purpose of this study was to examine the relation between the subjective report of feeling foggy at one-week post concussion and acute neuropsychological outcome . The outcome variables were derived from a computerized neuropsychological screening battery , Immediate Post-Concussion Assessment and Cognitive Testing ( ImPACT ) . Participants were 110 high school students who sustained a sports-related concussion and were evaluated 5 - 10 days post injury ( M = 6.8 days ) . Athletes were divided into two groups on the basis of self-reported fogginess . The first group reported no fogginess ( n = 91 ) , whereas the second group reported experiencing some degree of fogginess ( n = 19 ) on a 6-point scale . The athletes with persistent fogginess experienced a large number of other post-concussion symptoms , compared to the athletes with no reported fogginess . In addition , the athletes with persistent fogginess had significantly slower reaction times , reduced memory performance , and slower processing speed . Thus , athletes with any degree of self-reported fogginess at one-week post injury are likely to have adverse effects from their concussions in multiple domains Background Recent concussion management guidelines have suggested that athletes with mild ( grade 1 ) concussions may be returned to play if asymptomatic for 15 minutes . The purpose of this study was to assess the utility of a current concussion management guideline in classifying and managing mild concussion . Hypothesis High school athletes diagnosed with a grade 1 concussion will demonstrate measurable decline in neuropsychological functioning that persists during the 1st week of recovery . Study Design Prospect i ve study design ed to evaluate neuropsychological functioning both prior to and following concussion . Methods Forty-three high school athletes completed  neuropsychological test performance  and  symptom ratings  prior to the season and at two times during the 1st week following  mild concussion . Results Thirty-six hours after injury , mildly concussed high school athletes demonstrated a decline in memory ( P < 0.003 ) and a dramatic increase in self-reported symptoms ( P < 0.00001 ) compared to baseline performance . Conclusions Athletes with grade 1 concussion demonstrated memory deficits and symptoms that persisted beyond the context in which they were injured . These data suggest that current grade 1 return-to-play recommendations that allow for immediate return to play may be too liberal . Clinical Relevance A reconsideration of current concussion grading systems appears to be warranted
The sensitivity and specificity of commonly implemented sideline assessment tools are generally good to very good , especially for symptom scores and cognitive evaluations performed within 48 hours of injury , and they are improved when a baseline evaluation is available for comparison .
CONTEXT The sideline assessment of concussion is challenging , given its variable presentations , the limited sensitivity and specificity of sideline assessment tools , and how the presentation of the injury evolves over time .
In addition , the diagnostic process , as well as the tools used to assess and manage concussion , continue to progress as research and what we know about concussion advance .
This paper focuses on the initial assessment on the sideline by review ing the concussion-evaluation literature , drawing from clinical experience to emphasize a st and ardized approach , and underscoring the importance of both familiarity with the athlete and clinical judgment .
OBJECTIVE To review the evidence regarding the clinical assessment of sport-related concussion on the sideline .
Additional considerations included making same-day return-to-play decisions , the sensitivity and specificity of sideline testing , and the importance of ongoing assessment and follow-up of injured athletes .
CONCLUSIONS The sideline assessment of sport-related concussion is challenging given the elusiveness and variability of presentation , reliance on athlete-reported symptoms , and the varying specificity and sensitivity values of sideline assessment tools .
In addition , the recognition of injury and assessment often occur in a time-pressured environment , requiring rapid disposition and decision making .