bluuebunny/crossref_metadata_2025 huggingface dataset:
Concussion is associated with altered preparatory postural adjustments during gait initiation
Authors: Doherty C , Ryan John , Komaba Yusuke , Inomata Akihiro , Zhao Liang , Caulfield Brian
Published: November 2017

Objective

To quantify the preparatory postural adjustments (PPAs) during gait initiation (GI) in a group with concussion compared with a ‘healthy’ control group.

Design

Case-control study

Setting

University Biomechanics Laboratory.

Outcome measures

Centre of pressure (COP) trajectory computed from a force plate and centre of mass (COM) trajectory as computed from an inertial measurement unit placed on the sacrum.

Results

Concussed patients exhibited decreased COP excursion in the posterior direction on their dominant foot, both when it was the stepping limb (9.71mm [95% CI: 8 to 11mm] vs 15mm [95%CI: 12 to 17mm]) and when it was the support limb (10mm [95% CI: 8 to 12mm] vs 18mm [95%CI: 14 to 21mm]). This was reflected in the trajectory of the COM, wherein concussion patients exhibited lower posterior displacement (19mm [95%CI: 19.4mm to 19.7mm]) compared with controls (23mm [95%CI: 23 to 24]).

Conclusions

: Individuals with concussion display deficits during a GI task comparable to those which have previously been established in populations with supraspinal impairments in motor control.

Competing interests

None.
Driving after concussion: is it safe to drive after symptoms resolve?
Authors: Schmidt Julianne D , Devos Hannes , Hoffman Nicole L , Ranchet Maud , Akinwuntan Abiodun E , Miller L Stephen
Published: November 2017

Objective

To compare simulated driving performance between concussed and control participants.

Design

Cross-sectional.

Setting

Laboratory.

Subjects

Fourteen concussed participants and 14 non-concussed age and driving experience matched controls with no neurological disorders, medications causing drowsiness, or heavy drugs/alcohol use (Age: 20.3years, 95%CI:19.9,20.7).

Intervention

Participants completed a 7.6 minute, 20.5km driving simulation task containing curves, crosswalks, accidents, rural/urban areas, pedestrians, overtaking, and evasion. Concussed participants completed driving simulation within 48 hours of becoming asymptomatic (15.9 days post-concussion, 95%CI: 10.7,21.0) and were deemed clinically recovered by a medical professional using a multifaceted concussion evaluation.

Outcome measures

We compared total number of accidents, tickets, and lane excursions between groups.We also comparedaverage velocity (km/hr), standard deviation of velocity, lateral lane position (m), and lateral lane position standard deviation throughout simulation subsections. One-way ANOVAs were used (α=0.05).

Results

Concussed participants committed more frequent lane excursions compared to controls (concussed: 10.9, 95%CI:8.3,13.5; controls: 7.4, 95%CI:6.0,8.8; p=0.02). Concussed participants exhibited greater lateral lane position standard deviation compared to controls during the first (concussed: 1.1m, 95%CI: 0.8,1.5; controls: 0.7m, 95%CI:0.6, 0.9; p=0.02) and final curve (concussed: 1.2m, 95%CI:1.1,1.3; controls: 1.0m, 95%CI:0.9,1.1; p=0.04).

Conclusions

Despite being considered clinically recovered, concussed participants were less able to centre the vehicle in the lane and entered the shoulder more frequently, especially when navigating curves. A concussion may impair visual, motor, and/or cognitive skills necessary to safely drive. Further research is needed to determine when it is safe to return to driving following concussion.

Competing interests

None.
Near point convergence and other measures of vestibulo-ocular dysfunction are associated with protracted neurological recovery after sports concussion
Authors: Russman Andrew , Linder Susan , Grey Bob , Figler Rick , Cruickshank Jason , Lally Maureen , Alberts Jay , Day Tanujit
Published: November 2017

Objective

To characterise specific measures of neurologic dysfunction and recovery associated with concussion in student-athletes using the clinical examination and Cleveland Clinic Concussion application (C3 app).

Design

Retrospective observational study

Setting

Tertiary sports concussion clinic

Participants

181 student-athletes aged 14-20 diagnosed with concussion by a Cleveland Clinic physician were included.

Interventions

C3 data were collected pre-season, and at least once post-injury, along with a physician clinical examination. Individuals were stratified into two groups based on recovery time: typical <21 days (n=97) or protracted 21+ days (n=84).

Outcome measures

Near point convergence (NPC) and the following modules of the C3 app were administered: 1) Graded symptom checklist (GSC); 2) Standardised Assessment of Concussion (SAC); 3) Trail Making Test (TMT); 4) Simple and Choice Reaction Time; 5) Processing Speed Test (PST); 6) Biomechanical quantification of balance during the BESS.

Main results

At baseline, both groups performed similarly on all C3 modules. Significant differences in NPC were seen among the typical versus protracted group (mean 7.62 cm versus 13.57 cm, p=0.0002). Also, significantly worse performance among the protracted group was seen in GSC (p=0.0001), and measures affected by vestibulo-ocular dysfunction including biomechanical quantification of BESS (p<0.05), simple and choice reaction time (p<0.001), and TMT-B (p=0.01). No difference between groups was noted in BESS errors, SAC, or PST.

Conclusions

Abnormal NPC or convergence insufficiency is associated with protracted recovery and should be included in the assessment of student-athletes at baseline and post-injury. Identification of vestibulo-ocular dysfunction helps guide post-concussion assessment, treatment, and return-to-play decision-making.

Competing interests

Bob Gray, Rick Figler, Jason Cruickshank, Maureen Lally, Tanujit Day: None. Susan Linder and Jay Alberts have authored intellectual property associated with the mobile application presented in this study.
Postural control deficits in collegiate athletes following mild concussions within the first 48 hours
Authors: Soria Selena Mae , Rauh Mitchell J , Goble Daniel J , Baweja Harsimran S
Published: November 2017

Objective

The purpose of this study was to determine the extent of postural control deficits accompanying concussions in Division I collegiate athletes within 48 hours of injury.

Design

Cross-sectional study.

Setting

University Athletic Training Department & Biomechanics Laboratory.

Participants

Preseason baseline balance testing of 519 healthy Division I college athletes was performed with the BTrackS Balance Test (San Diego, CA). Of the baselined athletes, 26 (18–23 years; 14 females) experienced a concussion during the ensuing sport season. Post-injury balance testing was performed on these concussed athletes within 48 hours of injury. Additionally, 20 healthy young adults (19–25 years; 10 females) were baselined on 2 sessions 7 days apart.

Outcome measures

All testing consisted of three 20s trials of quiet unperturbed standing with eyes closed; feet shoulder width apart and hands on the hips. We calculated total centre of pressure (COP), COP antero-posterior (AP), and COP medio-lateral (ML) sway displacements. A principle component analysis was used to calculate the 99% confidence intervals (CI) of the COP area.

Main results

There were no preseason baseline differences in any of the balance measures between athletes and controls. However, postural displacement in all directions (AP, ML, and Total) increased significantly in athletes post-injury. Furthermore, ~80% of the increase in COP excursions was accounted for by a ~7 fold increase in the COP area post-injury.

Conclusions

Our findings are indicative of a decrease in postural control and multisensory integration post-concussion. Future studies should investigate the long-term effects and recovery from concussions in athletes.

Competing interests

One author (Goble) holds an equity stake in the parent company for the BTrackS Balance Plate. This conflict of interest was strictly managed by San Diego State University through a mitigation plan that limits his involvement in all primary aspects of data collection and analysis. All other authors have no conflict of interest to declare.
Mild traumatic brain injury is associated with increased levels of axonal injury biomarkers in blood
Authors: Shahim Pashtun , Blennow Kaj , Zetterberg Henrik , Tegner Yelverton
Published: November 2017

Objective

To investigate whether sports-related concussion is associated with elevated blood biomarkers reflecting axonal injury (total-tau [T-tau], [tau-A] and [tau-C]) and astroglial injury (S100B), as well as neurons-specific enolase (NSE).

Design and setting

A multicenter prospective cohort study involving all 12 teams of the top professional ice hockey league in Sweden.

Participants

A total of 288 players consented to participate in the study. Thirty-five players sustained concussions, of whom 28 underwent repeated blood samplings at 1, 12, 36, and 144 hours after the trauma, or when the player returned to play (7->90 days).

Outcome measures

Concentrations of T-tau was, tau-A, tau-C, S100B and NSE in blood.

Results

Players with sports-related concussion had increased levels of the axonal injury biomarker T-tau compared to preseason values. The highest biomarker concentrations of T-tau were measured immediately after a concussion and decreased during rehabilitation. There was no significant increase in the levels of tau-A in post-concussion samples compared with preseason values. However, serum levels of tau-C were significantly higher in post-concussion samples compared with preseason. The levels of the astroglial injury biomarker S100B were also increased in players with sports-related concussion compared to preseason values. No significant changes were measured in the levels of NSE.

Conclusions

Sports-related concussion in professional ice hockey players is associated with acute axonal and injury. Plasma T-tau may be used both in the diagnosis and clinical decision-making when an athlete is declared fit to return to play.

Competing interests

None.
Concussion education: a randomised trial with undergraduate students
Authors: Kobitowich Tara , Mrazik Martin
Published: November 2017

Objective

To evaluate optimal methods for educating individuals about concussions.

Design

Prospective randomised controlled trial.

Setting

University setting.

Participants

162 undergraduate students.

Intervention

Students from a university participant pool were randomly assigned to one of three conditions: 1) control group (CN); 2) internet group (IG); 3) presentation group (PG). All subjects completed the knowledge concussion questionnaire (18 questions) in the concussion knowledge section of the questionnaire published by Rosenbaum & Arnett (2014). Subjects completed a pretest and a posttest. The IG was provided with 3 websites and given 30 minutes to review this material. The PG group was involved in a 45 minute interactive lecture from a neuropsychologist.

Main outcome measure

Concussion knowledge.

Main results

A repeated measures ANOVA suggested a significant interaction between group and time F (2, 159)=30.2, p<0.001. The PG demonstrated significantly higher scores at posttest compared with both the IG and CN groups [(F (2, 159)=12.6, p<0.001 although all groups presented with improved scores at the posttest interval compared with the pretest. Post-hoc pairwise comparison at posttest interval between CN and IG groups did not reach statistical significance (p=0.50). Specific items suggested inaccurate information about concussions may be common in the undergraduate population.

Conclusions

There are many methods used to educate athletes about concussions. As expected, an interactive presentation about concussions was more effective at improving concussion knowledge than reviewing information from the internet. Results also suggested the importance of clarifying existing myths about concussions

Conflicts

There were no conflicts to declare.

Competing interests

None.
Knowledge, attitudes and intended behaviours in relation to concussion in professional rugby union players
Authors: Stokes Keith , Kemp Simon , Michell Miss Rachel , Standage Martyn , McKay Carly
Published: November 2017

Objective

To investigate knowledge, attitudes and intended behaviours in relation to concussion in professional Rugby Union players.

Design

Cross-sectional study.

Setting

English Premiership and Championship (the highest levels of domestic competition in England).

Participants

1236 professional male players enrolled on a compulsory online concussion education module were invited to respond to an online survey in October 2014. 383 players completed the survey (age 17–40 years; 0.5–19 years of professional rugby).

Outcome measures

Number of career self-reported concussions; pre-module concussion identification and management knowledge score (5 multiple-choice questions); attitudes towards concussion (14 7-point Likert-scale questions; higher scores represent more favourable attitudes); intended behaviours regarding concussion reporting (3 7-point Likert-scale questions; lower scores represent more favourable intended behaviours).

Main results

271 players (71%) recalled at least one concussion during their playing career; 249 (65%) recalled 1–5, 17 (4%) recalled 6-10 and 3 (1%) recalled >10 concussions. Knowledge scores (n=292) ranged from 0 to 5 correct answers out of 5; mean(SD) 3.4 (1.8). Attitudes scores (n=383) ranged from 42 to 98 out of a possible 98; mean(SD), 75.7 (11.9). Intended behaviour scores (n=383) ranged from 6 to 21 out of a possible 21; mean(SD), 10.2 (3.3). Spearmans Rank indicated that knowledge scores and concussion history were not associated with attitudes or intended behaviours; however, more favourable attitude scores were associated with more favourable intended behaviour scores (rs=−0.34, p<0.001).

Conclusions

Concussion education interventions should focus on positively influencing player attitudes towards concussion as this has the greatest potential to improve player behaviour.

Competing interests

Dr. Keith Stokes – Receives research funding from the Rugby Football Union

Dr. Simon Kemp – Employed by the Rugby Football Union

Miss Rachel Michell – Employed by Rugby Players Associationis

Dr. Martyn Standage, Dr. Carly McKay - None.
Pre-injury variables and risk of sport concussion
Authors: Mylabathula Sandhya , Mainwaring Lynda , Hutchison Michael , Richards Doug , Comper Paul
Published: November 2017

Objective

The study examined whether cognitive functioning, history of concussion (HOC), and sex predicted risk of sport concussion.

Design

Retrospective study design. Predictive models were used to determine the predictive ability of each variable.

Setting

Canadian University.

Participants

708 data observations from 701 varsity athletes (41.2% female), representing 14 sports.

Assessment of risk factors

Two measures of cognitive functioning (mean reaction time and throughput [speed and accuracy]) were assessed using the Automated Neuropsychological Assessment Metrics testing battery. Categorical and continuous measures of HOC, and sex, were examined.

Outcome measures

Occurrence of concussion after baseline testing.

Main results

HOC was a significant predictor for both sexes. For every previous concussion, the odds of sustaining another concussion increased by 1.5 (95% Confidence Interval [CI]: 1.1, 2.1 [females]; 1.2, 1.9 [males]). Females with a HOC had twice the odds of sustaining another concussion than those without a HOC (CI: 1.1, 4.0). For males, the odds were three times (CI: 1.7, 5.6). Cognitive functioning and sex were not meaningful predictors.

Conclusions

This study supports previous findings that HOC is a risk factor and suggests that pre-injury cognitive functioning is not a risk factor for sport concussion. Assessing HOC in all athletes prior to their competitive season provides information regarding their risk of future sport concussion. Thus, it is important for clinicians to record HOC, and to encourage athletes to report concussions to ensure an accurate HOC record. Pre-injury cognitive screening of athletes is not recommended for assessing risk of future concussion.

Competing interests

Sandhya Mylabathula, Lynda Mainwaring, and Michael Hutchison None.

Doug Richards is the Medical Director at the MacIntosh Sports Medicine Clinic at the University of Toronto

Paul Comper is a clinical neuropsychologist consultant with the NHLPA and a member of the Concussion Working Group, but neither were related to the current research
The effect of a national body checking policy change on concussion risk in youth ice hockey players
Authors: Black Amanda , Palacios-Derflingher Luz , Schneider Kathryn J , Hagel Brent E , Emery Carolyn A
Published: November 2017

Objective

To determine if the risk of game-related concussion differs for Pee Wee (11–12 years) ice hockey players in the season following a national policy change disallowing body checking (2013/2014) when compared to a season (2011/2012) when body checking was allowed.

Design

Historical cohort study.

Setting

Community ice hockey rinks.

Participants

Pee Wee players were recruited from 59 teams in all divisions of play in Alberta (n=883) in 2011/12 prior to the rule change and from 73 teams in 2013/14 following the rule change (n=617).

Assessment of risk factors

Pee Wee ice hockey players before and after a national body checking policy change.

Outcome measures

Suspected concussions were identified by a team therapist/safety designate and referred to a sport medicine physician. Concussions were included if they met the Zurich 2013 Consensus definition of concussion.

Main results

There were 104 game-related concussions (IR=2.79/1000 game-hours) in Alberta prior to the rule change and 24 concussions (IR=1.08/1000 game-hours) after. Based on a multivariable Poisson regression model adjusting for player size, age, body checking attitudes, previous injury, level of play, and position, accounting for clustering by team, the rate of concussion declined following the policy change [IRR=0.34 (95% CI; 0.21 – 0.56)]. Overall, a physician diagnosed 67.3% and 79.1% of suspected game concussions in 2011/2012 and 2013/2014, respectively.

Conclusions

Introduction of the national policy change disallowing body checking in Pee Wee resulted in a 66% reduction in the Alberta Pee Wee ice hockey concussion rate. These findings have important implications for youth ice hockey policy.

Competing interests

None.
Ability of scat3 and childscat3 to discriminate children with concussion from children with upper limb injuries and uninjured children in the emergency department
Authors: Babl Franz E , Dionisio Diana V , Davenport Lucy , Baylis Amy , Hearps Stephen , Bressan Silvia , Anderson Vicki , Oakley Ed , Davis Gavin A
Published: November 2017

Objective

To evaluate the ability of SCAT3 and ChildSCAT3 to discriminate children with concussion from children with upper limb injuries and uninjured children in the emergency department

Design

Prospective observational study.

Setting

Tertiary children’s hospital emergency department.

Participants

264 children presenting to ED with concussion (CONC, n=90) and two control groups (i) upper limb injury (ULI, n=90) and (ii) well children (WELL, n=84) with equal sized subgroups in three age bands of 5–8, 9–12, and 13–16 years.

Assessment and outcome

Child-SCAT3 was used in 5-12 years, SCAT3 in 13–16 years, administered by trained research assistants. Differences between study groups were analysed using ANOVA. Effect sizes were also assessed.

Results

The number and severity of child and parent reported symptom scores for SCAT3 and the child-SCAT3 were significantly higher in CONC than either control group (p<0.001). Mean double and tandem stance errors were also significantly higher (p<0.001), and immediate memory and concentration were significantly lower for the CONC group (p<0.01). No group differences were found for orientation and digit backwards.Among SCAT3 symptoms, headache and pressure in head had the highest effect size (0.51 and 0.44 respectively, p<0.001). Among Child SCAT3 symptoms, I have headaches and I feel dizzy had the highest effect size (0.31 and 0.23 respectively, p<0.001). There were no significant differences between ULI and WELL control groups.

Conclusions

Overall, SCAT3 and child-SCAT3 can differentiate concussed from non-concussed patients, in particular for number and symptom severity. However, some neuropsychological subtests do not differentiate concussed patients and controls.

Competing interests

GAD is an honorary member of the Australian Football League Concussion Working Group, and has attended meetings organised by sporting organisations including the National Football League (USA), National Rugby League (Australia) and FIFA (Switzerland); however has not received any payment, research funding, or other monies from these groups other than for travel costs. GAD is a member of the International Concussion in Sport group that developed the SCAT3 and ChildSCAT3
Defining the elite: normative values for scat major components in healthy elite athletes
Authors: Moreau William J , Walden Taylor , Nabhan Dustin
Published: November 2017

Objective

Describe normative baseline SCAT 2 and 3 (SCAT) performance in elite athletes.

Design

Retrospective cohort.

Setting

United States Olympic Committee Sports Medicine Clinics.

Participants

Six hundred and forty-one SCAT baseline evaluations were performed on a population of 565 elite athletes (291 women and 350 men, mean age 24.9±5.2 years) representing 23 Summer and Winter Olympic sports as part of a multimodal concussion management program.

Intervention

No intervention was applied. The SCAT evaluations were administered as a component of baseline testing on healthy athletes.

Main Outcome Measurements

Baseline SCAT performance on major components is described. T-tests were used to compare differences in baseline performance by sex.

Results

During baseline evaluation elite athletes reported a mean of 2.1 (1.8–2.4) symptoms with average symptom severity scores of 3.4 (3.0–3.9). Mean scores on SCAT 3 components in this population were; orientation 4.9 (4.8–4.9), immediate memory 14.5 (14.4–14.5), concentration 3.9 (3.8–4.0), tandem gait 11.7 (11.4–12.0), delayed recall 3.7 (3.6–3.8), balance 2.83 (2.2–3.4), SAC total 26.9 (26.8–27.1). This population reported historys of 1.19 (1.0–1.4) previous concussions. Females reported significantly more symptoms (3.9 vs 3.0, P=0.04), and scored significantly higher on the orientation (4.9 vs. 4.8, P=0.004), immediate memory (14.6 vs. 14.4, P=0.003), concentration (4.1 vs 3.8, P=0.0013) SAC total score (27.3 vs. 26.6, P<0.01)

Conclusions

Population specific normative values for baseline SCAT performance in a population of elite athletes are presented in this case series.

Clinical relevance

Clinicians are encouraged to reference population specific normative values when interpreting SCAT performance.

Acknowledgements

None.

Competing interests

None.
Reliability of the scat2/3 in college athletes
Authors: Mrazik Martin , Lenchyshyn Jessica , Borza Carley , Naidu Dhiren , Lebrun Constance M
Published: November 2017

Objective

To evaluate psychometric properties of the Sport Concussion Assessment Tool (SCAT).

Design

Retrospective clinical study in which athletes completed the SCAT over 2 consecutive seasons. Athletic therapists administered the SCAT and a pre-season medical questionnaire.

Setting

University setting.

Participants

165 college athletes who were enrolled at a university in Western Canada who played collision sports.

Intervention

the SCAT2 and subsequently the SCAT3 was administered to all participants at baseline.

Main outcome measures

Intraclass coefficients (ICC’s) and paired sample t-tests.

Main results

The intraclass reliability coefficients for demographic variables ranged from moderate to good (0.66 to 0.94). The reliability of the cognitive test results and balance error scoring system (BESS) was rated as good (0.83 and 0.88 respectively). Total symptom report and symptom severity report was moderate, with significant differences noted between males and females. History of concussion did not significantly impact reliability coefficients. Among the 22 athletes who suffered concussions during a competitive season, the reliability of the core components of the SCAT remained high.

Conclusions

The reliability of the SCAT2/3 is classified as good although symptom report is more variable

Competing interests

None.

Keywords: concussion, sport concussion assessment tool, psychometric properties
To document false-positive scores on the sport concussion assessment tool (scat3) in high school athletes
Authors: Covassin Tracey , Elbin RJ , Schatz Philip , Beidler Erica , Wallace Jessica
Published: November 2017

Objective

To document false-positive scores on the Sport Concussion Assessment Tool(SCAT3) in high school athletes.

Design

Pre-Test Only.

Setting

Six high schools in the Mid-West and Central Region of the USA.

Participants

The sample was composed of a total of 489 high school athletes who completedall components of the SCAT3: 157 female (Mean age=15.6, SD=1.8 years) and 322 male(Mean age=15.9, SD=1.5 years) adolescent athletes.

Intervention

The SCAT3 was administered to all athletes.

Outcome measures

Cases were identified as “false-positive” by surpassing cutoff scores using 95% confidence intervals from the sample on SCAT3 components: Standardised Assessment ofConcussion (SAC: Mean 26.06±2.34, Cutoff<21), total severity of symptoms (Males: Mean:3.24±5.93, Cutoff>15; Females: Mean: 4.16±6.96, cutoff>18), tandem gait (Mean:15.55±4.52, Cutoff>25 sec), and total errors on the modified Balance Error Scoring System(mBESS: Mean: 3.42±2.67, Cutoff>9 errors).

Main results

Overall, 16% of athletes (n=78) obtained scores falling beyond false-positivecutoffs on at least one sub-component of the SCAT, and only 2% (N=10) obtained two or morescores beyond cutoffs. False-positive rates on individual components were as follows: SAC:5.7% (n=28), mBESS: 5.5% (n=27), tandem gait: 3.9% (n=19), total symptom severity: 4.9% (n=24).

Conclusions

While rates of false positives fell generally within 95% CIs for individual components of the SCAT, the overall SCAT3 false-positive rate was 16%. Comparisons between post-concussion and baseline SCAT3 data should be based on 2 or more components falling outside 95% CIs.

Competing interests

Dr. Schatz serves on the ImPACT Scientific Advisory Board
The effects of age and learning disabilities in the king-devick test in adolescent ice-hockey players
Authors: Hokkanen Laura , Peltonen Kati , Vartiainen Matti , Laitala-Leinonen Tiina
Published: November 2017

Objective

King-Devick (K-D) is becoming a popular screening test for sport concussion. Rapid number naming may be impaired in developmental dyslexia and other learning disabilities (LD). The aim was to study the interaction of age and LD in K-D in adolescence. The hypothesis was that those with LD perform more poorly on the test regardless of age.

Design

A case-control, cross-sectional nation-wide study.

Setting

Pre-season 2015–16 baseline tests in all junior teams in the Finnish ice hockey League.

Participants

A total of 805 male adolescents aged 12–21 (divided in 7 age groups), 75 of them reported LD.

Outcome measures

The K-D performance was measured twice. Time in the three subtests was combined to produce a sum score. Sum scores, and their difference, were used as outcome measures.

Main Results

In the youngest age group the mean of the K-D second trial was 49.7 (48.3–51.0, 95% confidence intervals) and in the oldest age group 44.7 (42.9–46.5). In a two-way ANOVA those with LD performed poorer (p=0.014, ηp²=0.008) but there was no interaction between age and LD. Similarly, a repeated analysis of covariance yielded a significant main effect for the trial (p<0.001, ηp²=0.042) and for LD (p<0.001, ηp²=0.026) but not for their interaction when the effect of age was controlled.

Conclusions

Adolescent players improve their performance in K-D with age, but those with learning disabilities remain slower despite maturation. If K-D is used as a single test for screening, and no baseline data is available, this needs to be recognised.

Competing interests

None.
A systematic review and meta-analysis on the role of exercise or rest in patients with concussion and mild traumatic brain injury
Authors: Lal Avtar , Kolakowsky-Hayner Stephanie , Ghajar Jamshid , Vazquez Oscar , Balamane Maya
Published: November 2017

Objective

To conduct a systematic review and meta-analysis evaluating the role of exercise or rest in patients with concussion or mild traumatic brain injury.

Design

Systematic review and meta-analysis.

Data sources

Medline, PsychInfo, Scopus, Cochrane Controlled Trials Registers and Sport Discus, till March 2016 and hand search of some articles.

Study selection

Randomised controlled trials (RCTS) and observational studies (OBS) comparing the effect of exercise or rest in patients with concussion, on different outcomes.

Participants

Children and adults with concussion or mild traumatic brain injury.

Intervention

Exercise or Rest.

Outcomes

Post concussive symptoms (PCCS), balance error scoring system (BESS), immediate post concussion assessment and cognitive testing (ImPACT).

Main results

Our search generated 921 studies. Of these, 5 RCTs and 12 OBS met our inclusion criteria. Methodological quality of most of the studies was poor. Meta-analysis of 6 studies involving more than 556 patients showed statistical significant decrease in PCCS with exercise compared to control, Mean Difference (MD) [95% Confidence Interval (CI)], −14.6 [−17.8, −11.3], p<0.001. There was some clinical, but no statistical heterogeneity among the studies (I2=32%). Exercise did not affect BESS, neuropsychological scale and ImPACT score.

There was not effect of rest on total symptoms in patients with concussion and number of patients with symptoms.

Conclusion

Our systematic review and meta-analysis showed clear benefits of exercise in PCCS. However, the evidence was based on poor quality studies that vary in duration, frequency and intensity of exercise. A good quality RCT needs to be conducted to evaluate a clear effect of exercise and rest in patients with concussion.

Competing interests

None.
Pilot survey regarding “the green folder” – an educator-designed secondary school return to learn protocol after a sport-related concussion
Authors: Carson James D , Safwan Aliya , Kraft Sari A , Kuwahara Nariko , Moser Stefanie E , Rabinovitch Sarah T , Mansoora Qurat-ul-Ain , Jegatheesan Vijitha , Moineddin Rahim , Fremont Pierre
Published: November 2017

Objective

To demonstrate whether a user-centred (teacher accepted and student focused) return to learn (RTL) protocol after a sport-related concussion (SRC)has an efficacious role.

Design

Prospective pilot survey.

Setting

Four sport medicine clinics in Ontario, Canada.

Participants

Twenty-eight collegiate athletes (21 males and 7 females: age=20.2 ± 1.7 years, height=182.2 ± 11.9 cm, mass=90.3 ± 24.2 kg) without history of: headaches or migraines, substances/alcohol abuse, and/or psychiatric conditions.

Intervention

NineSRC students from one (index) school who used the new protocol and a control group (11 SRC students) from other schools, who did not use the new protocol,completed a web-based survey.

Outcome measures

Primary outcome measures include student perception of school support during their SRC RTL.

Main results

Twenty surveys were completed from an eligible 52 students (38.5%).Among students who received the Green Folder at the index school, 71.4% either strongly or mostly agreed thatsuch an RTL protocol could shorten the duration of SRC symptoms. At that school, 100% strongly or mostly agreed (versus 14.3% from the other schools) that the school was very helpful advising about the RTL steps and when they should return to school. 85.7% of students at the index school versus 28.6% from other schools, strongly or mostly agree that the school staff fully understands RTL strategies after SRC.

Conclusions

The “Green Folder” incorporating RTL steps and a daily class-by-class accommodation sign off by a guidance counsellor, appears to have perceived efficacy for SRC students. Further research will determine whether such a user-centred RTL protocol results in a more efficacious implementation of expert recommendations about concussion management, worthy of widespread dissemination.

Competing interests

None.
Survey of educators regarding the return to learn after a sport-related concussion
Authors: Carson James D , Garel Alisha , Rendely Alexandra , Meaney Christopher , Moser Stefanie E , Rabinovitch Sarah T , Kraft Sari A , Fremont Pierre
Published: November 2017

Objective

To evaluate the impact of an educational intervention upon educators’ knowledge of sport-related concussion (SRC) management strategies and their understanding of academic accommodations as part of the return to learn (RTL) strategy after an SRC.

Design

A pre- and post-intervention study.

Setting

A sport-focused Ontario (Canada) secondary school.

Participants

94 educational staff, including teachers, administrators and school psychologists.

Interventions

Three ten-minute didactic lectures were followed by ninety minute facilitated focus groups during an educators’ professional development workshop. Participants learned about the nature and management of SRC with an emphasis upon RTL. Participants also had to reflect on their own experiences with some of the 63 students who had RTL at that school, after an SRC during the prior 3.5 years.

Outcome measures

Participants answered pre and post intervention surveys directed toward knowledge of SRC management principles and acknowledgement of accommodations.

Main results

81 of the 94 participants submitted two matched pre and post surveys. Educators indicated significantly increased understanding of SRC management and showed a significantly increased support of accommodations after the intervention (p<0.05).

Conclusions

Educators’ understanding of SRC management strategies is essential to facilitate a successful RTL. This study suggests that a brief educational intervention can improve the support of educators for academic accommodations as part of the RTL phase of SRC management.

Competing interests

None.
Utilisation of an electronic incident report to document injury-related demographics and medical triage in youth, high school and college athletes
Authors: Alberts Jay L , Linder Susan M , Russman Andrew , Figler Rick , Cruickshank Jason , Grey Bob , Lally Maureen , Day Tanujit
Published: November 2017

Objective

To develop and utilise a custom mobile application to provide a portable yet systematic method to characterise injury demographics, post-injury disposition, and immediate medical care of sport-related concussion in youth, high school and college settings.

Design

Retrospective observational study.

Setting

Academic medical centre.

Participants

Athletes under the care of Cleveland Clinic Concussion Centre clinicians from August 5, 2014-March 1, 2016. The sample included youth (n=110), high school (n=1175) and college (n=309) athletes; approximately 35% of the sample were female.

Intervention

Electronic incident reports were completed on all student-athletes with suspected concussion to triage injury severity, document injury-related demographics along with immediate medical management. Total time to complete the incident report was less than three minutes.

Outcome measures

Sport, mechanism of injury, red flags, immediate symptoms, and post-injury disposition were recorded for all participants.

Main results

Football and soccer represented the greatest frequency of injury across males and females respectively. Despite significantly fewer red flags in youth, they were

sent to the emergency department four times more frequently (22%) than high school or college athletes (5%).

Conclusions

The systematic characterisation of injury profiles indicates athletes across the continuum of age share general characteristics in terms of incidence as a function of sport and setting (practice vs. competition). The disproportional disposition to emergency departments, despite the absence of red flags, indicates a more conservative approach to youth concussion triage compared to high school and college athletes.

Competing interests

None.
Does concussion education have an impact in behaviours amongst school-age rugby players?
Authors: Bosshardt Chris , England Mike , Medici Akbar de , Kipps Courtney
Published: November 2017

Background

Concussion is a common injury in school-boy rugby, if managed incorrectly it can have serious consequences such as further injury, prolonged symptoms, and second impact syndrome. Adolescent players show poor knowledge levels and symptoms-reporting behaviour.

Objective

Investigate the effects of an educational presentation on the knowledge and behaviour of school age rugby players regarding concussion.

Design

Questionnaire based study.

Setting

120 male rugby players, aged 16–18.

Participants

Three large rugby union playing schools in England.

Interventions

Independent Variable – Educational presentation aimed at school-age rugby players to improve their education and behaviours related to the condition.

Players completed a questionnaire testing for likely behavioural responses from a selection of common concussion scenarios. Additional questions assessed knowledge of concussion symptoms, diagnosis and management. The questionnaires were completed pre-season and repeated 2–3 months after the presentation.

Outcome

Dependent variable: Questionnaire scores.

Results

The students had significantly improved their responses giving 53.9% appropriate responses after the presentation (Md=55, n=34) compared to 46.1% before (Md=33.5,n=34) (U=400,Z=-2.18,p=0.029) with a moderate effect size (r?=?0.37).

The knowledge of students increased from 37.85% correct responses before (Md=28,n=35) and 44.07% on follow up?(Md=28,n=35) but with no significant difference (U?=?575.5,Z?=?-?0.88,p=0.378 with a small effect size (r?=?0.15)).

Completed surveys showed increased awareness of guidelines from 19.4% to 73.2% (p=0.00 McNemars Test).

Conclusions

The students had showed improved concussion behaviour in response to concussion scenarios at 2–3 month follow up in contrast to previous studies on educational interventions. There was no increase in players knowledge of concussion. The literature shows increases in short-term knowledge with other forms of concussion education but this effect is often lost at long term follow up. There was increased awareness of guidelines. Future concussion education should be modeled on the educational presentation to improve behavioural outcomes.
Head impact exposure and time to recovery in youth american football players diagnosed with a concussion
Authors: Valentine Verle D , Dorman Jason C , Munce Thayne A
Published: November 2017

Objective

To compare head impact exposure (HIE) sustained by youth American football players on days of concussion with prior sessions, and to evaluate concussion resolution with objective assessments.

Design

Prospective,observational study.

Setting

Youth American football.

Participants

Youth American football players (11-14 yr, n=57) who had head impact sensors embedded in their helmets; six were diagnosed with a concussion.

Interventions

Over four consecutive seasons, baseline and post-injury concussion assessments were performed and HIE was monitored (Head Impact Telemetry system) for all practice/game sessions.

Outcome measures

Baseline/Post-concussion assessments – symptoms, balance, reaction time, neurocognitive function (ImPACT), and oculomotor performance (King-Devick). HIE – location, frequency, and magnitude (linear acceleration [LA] and rotational acceleration [RA]).

Main results

For concussive impacts, the average peak LA was 85.9g(39.7-156.8g) and average peak RA was 6918rad·sec-2(4508-8433rad·sec-2). On average, players sustained 21.3 impacts/session on days of concussion vs. 10.2 in previous sessions. Median LA and RA did not differ on days of concussion when compared to prior sessions (21.9 vs. 20.7g; 1480 vs. 1485 rad·sec-2). Average duration for a concussed player to have his assessment values return to baseline and be cleared for play was 32 days (17-53).

Conclusions

Considerable variation in magnitude existed between impacts that lead to concussion in this population. Players sustained more head impacts in sessions with a concussion compared to prior sessions. Frequency and magnitude of head impacts on the day of concussion did not correlate with time to recovery. Continued observation of a larger cohort is warranted.

Competing interests

None.
Longitudinal changes in health-related quality of life during concussion recovery among youth athletes
Authors: Russell Kelly , Selci Erin , Fineblit Samuel , Ellis Michael
Published: November 2017

Objective

Determine longitudinal changes in health-related quality of life (HRQoL) in youth during recovery from a sport-related concussion.

Design

Prospective case-series.

Participants

68 youth (13–18 years; 62% male) with an acute sport-related concussion were enrolled with 5 lost to follow-up.

Intervention (or assessment of risk factors)

Subsequently developing Post-Concussion Syndrome (PCS: symptomatic after 30 days), initial symptom severity (Post Concussion Symptom Scale), concussion history, sex, age, and academic accommodations during recovery.

Outcome measures

PedsQL Cognitive Functioning Scale and PedsQL 4.0 measured physical, social, and emotional domains of HRQoL. They were administered before each appointment until medical clearance. Multivariable mixed modelling accounted for repeated measures within an athlete and expressed as point increase per week.

Main results

Initial mean HRQoL was highest for social (non-PCS: 92.7 out of 100; PCS: 86.3), followed by emotional (non-PCS: 86.45; PCS: 69.7), physical (non-PCS: 80.95; PCS: 49.2), and cognitive domains (non-PCS: 69.1; PCS: 50.3). There was effect modification by developing PCS. Changes in HRQoL subscores were: cognitive functioning non-PCS (+9.8 points [95% CI: 6.9, 12.7]) and PCS (+4.2 points [95% CI: 2.8, 5.6]); social HRQoL non-PCS (+2.3 points [1.0, 4.0]) and PCS (+0.5 points [0.1, 1.0); emotional HRQoL non-PCS (+5.0 points [95% CI: 2.9, 7.0]) and PCS points (+2.2 [1.6, 2.9]); and physical non-PCS (+6.3 points [95% CI: [3.5, 9.2]) and PCS (+3.3 points (95% CI: 2.5, 4.2).

Conclusions

HRQoL significantly improved longitudinally with greater improvement among non-PCS athletes. HRQoL impairment was most apparent in the cognitive and physical domains.

Competing interests

None.
Physical activity and concussion risk in male youth ice hockey players
Authors: A Blake Tracy , H Meeuwisse Willem , K Doyle-Baker Patricia , L Brooks Brian , Palacios-Derflingher Luz , A Emery Carolyn
Published: November 2017

Objective

To evaluate the association between self-reported physical activity (PA) and concussion incidence in male youth ice hockey players.

Design

pooled data from three prospective cohort studies.

Setting

Community ice hockey rinks and sport medicine clinics.

Participants

PeeWee (ages 11–12), Bantam (ages 13–14), and Midget (ages 15–17) male youth ice hockey players (n=1208).

Assesment of risk factors

Participants reported six-week physical education and extra-curricular sport participation history upon study entry. Concussion incidence rate ratios [IRRs (95% CI)] associated with 1). total six-week PA volume, and 2). meeting the Canadian PA recommendations of one hour of daily PA (≥42 hours/six weeks) were calculated using multivariable Poisson regression (covariates: age, competition level, concussion history). Models were adjusted for hockey exposure, and cluster by team, study year and city (α<0.05).

Outcome measure

Medically-diagnosed concussions during the study period.

Main results

Total PA volume did not affect concussion incidence in male youth ice hockey players [IRR: 0.996 (95% CI: 0.990–1.003]. Concussion incidence was higher in male ice hockey players who did not meet the PA recommendations versus those who met the PA recommendations amongst PeeWee [IRR: 2.94 (95% CI: 1.29–6.66)] and Bantam [IRR: 2.18 (95% CI: 1.12–3.94)] participants, but not amongst Midget participants [IRR: 1.37 (95% CI: 0.72–2.59)]. There was no evidence of confounding or modification by competition level or concussion history.

Conclusions

While total PA volume was not associated with concussion risk, PeeWee and Bantam male youth ice hockey players whose six-week PA history was below the PA recommendations were at greater risk of concussion. This research will inform future studies examining the mechanism of this association.

Competing interests

None.
Presenting symptoms and recovery time among youth athletes with and without a history of concussion
Authors: Russell Kelly , Krisko Cameron , Ellis Michael
Published: November 2017

Objective

Determine if youth athletes with a history of concussion had more symptoms, higher symptom score, longer recovery, or were more likely to be diagnosed with Post-Concussion Syndrome (PCS) than those with no history of concussion.

Design

Retrospective chart review.

Setting

Paediatric, multi-disciplinary concussion.

Participants

306 youth (mean 14.0 years, SD 2.3; 65.5% male) with an acute sport-related concussion.

Intervention (or assessment of risk factors)

Self-reported concussion history.

Outcome measures

Recovery days were days between concussion and medical clearance by the neurosurgeon. Medical clearance occurred after tolerating full-time school, completing return-to-play protocol, and absence of vestibulo-ocular dysfunction. Initial symptoms were reported on the Post Concussion Symptom Severity score (PCSS); symptom severity was the total PCSS score. The neurosurgeon diagnosed Post-Concussion Syndrome (PCS) using ICD-10 criteria of symptoms for at least 30 days.

Main results

Median number of initial symptoms was 5.5 (IQR: 1–10) for youth with no concussion history and 7.0 (IQR: 2–14) with a concussion history (p=0.04). Initial median PCSS score was 9 (IQR: 1–22) for youth with no concussion history and 13 (IQR: 3–34) with a concussion history (p=0.03). Median recovery days was 22 (IQR: 15–43) for those with no concussion history compared to 23 (IQR: 16–39) with a concussion history (p=0.41). There was no significant difference in subsequently being diagnosed with PCS (no concussion history: 40.1%, ?concussion history: 41.7%, p=0.73).

Conclusions

Despite a significantly higher initial symptom burden among those with a concussion history, there was no increased risk of protracted recovery or subsequent diagnosis of PCS.

Competing interests

None.