Immediate Removal From Activity After Sport-Related Concussion Is Associated With Shorter Clinical Recovery and Less Severe Symptoms in Collegiate Student-Athletes

Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence

Return to activity (RTA) and return to school (RTS) are important issues in pediatric concussion management. This study aims to update CanChild's 2015 RTA and RTS protocols, on the basis of empirical data and feedback collected from our recently completed prospective cohort study, focusing on concussed children and their caregivers; systematic review of evidence published since 2015; and consultation with concussion management experts. The new protocols highlight differences from the earlier versions, mainly, (1) symptom strata to allow quicker progression for those who recover most quickly; (2) a shortened rest period (24-48 hours) accompanied by symptom-guided activity; (3) the recommendation that children progress through the stages before they are symptom free, if symptoms have decreased and do not worsen with activity; (4) specific activity suggestions at each stage of the RTA protocol; (5) recommendations for the amount of time to spend per stage; and (6) integration of RTS and RTA.

Student-athlete concussion disclosure and coach communication within collegiate athletics

Background

Between 1.6 and 3.8 million sports- and recreation-related concussions occur in the United States annually. Reports indicate that a significant number of athletes who have experienced symptoms of a potential sport-related concussion did not disclose their symptoms.

Aims

The purpose of this study was to investigate the impact of coach communication about concussion disclosure on student-athlete intentions to disclose symptoms of a concussion and encourage another student-athlete to disclose their concussion symptoms.

Methods

A total of 2881 student-athletes completed a web-based survey during Fall of 2016. Multiple linear regression was conducted to primarily investigate the relationship between coach communication and intentions to disclose concussion symptoms. Secondarily, biological sex, year in school, athletic division, and sport category was also assessed.

Results

Coach communication predicted greater intentions to disclose symptoms to their coach, athletic trainer/sports medicine sports medicine staff member and encourage another athlete to disclose their symptoms of a concussion. Biological sex and sport category also predicted intentions to disclose concussion symptoms.

Discussion

Findings from this study provide support for the important role coaches play in an athlete’s regarding concussion safety and introduces preliminary evidence suggesting the impact of coach communication on athlete intentions to disclose concussion symptoms to a coach or athletic trainer/sports medicine staff member.

Conclusion

Future studies and behavioral interventions ought to consider the inclusion of coach communication or other coach-related variables when exploring concussion disclosure among athletes.

Enhancing Concussion Management in the National Football League: Evolution and Initial Results of the Unaffiliated Neurotrauma Consultants Program, 2012-2017

Background

The real-time detection of concussive injury in professional sports can be challenging for the healthcare provider on the sideline. It can be difficult to monitor all on-field players during active game play and diagnose complex injuries such as concussion during a fast-paced athletic event.

Objective

To enhance the in-game identification of potentially concussed professional athletes, the National Football League (NFL) initiated an Unaffiliated Neurotrauma Consultants (UNC) program in 2013, which, in tandem with other in-arena spotters and live video review systems, is designed to improve the safety of the players through enhanced concussion detection efforts.

Methods

This paper reports on the evolution of the UNC program, describes its participants and training requirements, details the role of UNC involvement, and delineates the systematic revisions and enhancements completed each year in the program.

Results

UNC reporting compliance has increased from 56% in 2014 to 100% in 2017. During the 2016 and 2017 seasons, (1) UNCs submitted an average of 1.9 evaluations per game, and (2) the UNC concussion assessments yielded sensitivity (93.4%-97.4%) and specificity (81.0%-88.3%) values.

Conclusion

The UNC program has enhanced the detection of concussion in NFL players. Directions for research and future program improvements are addressed.

Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment

The risk factors of concussion may be categorized as intrinsic (internal factors specific to the individual) or extrinsic (external factors related to the environment or sport). Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. In most cases, the symptoms of concussion resolve in the initial few days following the injury, and a strategy involving a gradual return to sport and school is recommended. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. J Orthop Sports Phys Ther 2019;49(11):799-810. doi:10.2519/jospt.2019.8926.

A social dilemma model of information self-disclosure, applied to the concussion domain

Under-reporting of concussions is a well-known public health problem. Unfortunately, concussion researchers and practitioners do not have an explicit theoretical foundation for understanding the psychology of concussion non-disclosure. We used interdependence theory, a theory based on the structure of social relationships, to develop a social dilemma model of personal information non-disclosure and apply it to the concussion domain. Self-disclosure becomes problematic when individuals perceive a need to report their concussions but also perceive that disclosure could be detrimental in some way. Individuals who experience these disclosure dilemmas can evaluate the value of concussion self-disclosure using direct outcomes (e.g. losing scholarships, improved recovery), self-concept outcomes (e.g. viewing disclosure as “weak” or “sensible”), and social status outcomes (e.g. being perceived poorly or favorably by teammates). These immediate, personal outcomes are integrated with relationship-specific motives and ethical considerations ultimately leading to disclosure or non-disclosure. Providing an explicit theoretical basis for self-disclosure dilemmas is critical for understanding concussion non-disclosure and mitigating its corresponding harm. Our social dilemma model highlights (a) the foundational psychological basis for concussion non-disclosure, (b) possible reasons that initiatives designed to increase concussion disclosure have been ineffective, and (c) the need to consider the decision-making autonomy of concussed individuals. Although we explain our social dilemma model using concussion self-reporting, we believe that this model is applicable to any domain where individuals are reluctant to disclose personal information to others who need it.

The Future of Concussion

Over the past 2 decades, concussion care is increasingly in demand as research and media attention shed light on the importance of proper diagnosis and medical management to prevent complex, potentially disabling sequelae. The purpose of this review is to discuss the future of clinical concussion care across selected topics under the broad themes of diagnosis/assessment, intervention/treatment, and patient characteristics/presentations with the intent to direct clinicians' attention to important anticipated developments in the field. The current status of biomarkers, clinical settings, models of clinical concussion, return-to-activity, clinical subpopulations, treatment approaches, patient perceptions of injury, and social media are reviewed along with predictions for future developments.

Treatment of Acute Sports-Related Concussion

PURPOSE OF REVIEW

Here, we summarize the current scientific literature on the management of sports-related concussion (SRC) in the acute period (< 6 weeks post-injury) with a focus on rest, return to learn, return to play, and emerging treatments.

RECENT FINDINGS

While relative rest is recommended for the first 24-48 h following acute SRC, the most recent guidelines highlight the lack of evidence for complete rest and in fact show that prolonged cognitive and physical rest can be detrimental. Gradual return to learn and play is recommended. Return to sport should only occur once the patient is symptom free. While there are no FDA-approved medications for acute treatment of concussion, there is preclinical data for the benefit of omega 3 fatty acids. Evidence is limited around the benefits of treating sleep disorders, vestibular-ocular dysfunction, and neck pain in the acute period. After 24-48 h of rest, SRC patients may gradually resume cognitive and physical activity. More research is needed to determine if any supplements, medications, and/or physical therapy are indicated in the management in acute SRC.

Pilots and athletes: Different concerns, similar concussion non-disclosure

Objectives

Concussion non-disclosure research has focused almost exclusively on athletes. The focus on athletic populations has been sensible considering athletes’ demonstrated susceptibility to sustaining and concealing concussions. Nevertheless, the habitual use of athletic populations has allowed researchers and practitioners to omit the development of generalized perceived costs and perceived rewards as critical determinants of concussion self-disclosure. We hypothesized that perceiving concussion disclosure as generally more costly than rewarding would predict negative attitudes towards disclosure and decreased intent to disclose. We also hypothesized that generalized perceived costs and rewards could explain concussion non-disclosure in different populations, athletes and future pilots specifically, even when those populations perceive concussion self-disclosure as costly for different specific reasons.

Methods

We examined concussion disclosure using 2,504 cadets at the United States Air Force Academy. Cadets completed anonymous surveys assessing their intention to self-disclose undiagnosed concussions (Anticipated Concussion Disclosure) as well as several variables potentially related to concussion self-disclosure: perceived cost, perceived reward, personal identity, attitudes, normative behavior, social support, and self-efficacy.

Results

The results demonstrate that concussion non-disclosure develops when a population perceives disclosure as more costly (i.e. directly or emotionally) and less rewarding. Perceived Cost and Perceived Reward variables alone accounted for 50% of the variance in Anticipated Conclusion Disclosure (Adjusted R²= 0.50, F(2,2312) = 1,145.31, p < 0.001). As expected, Anticipated Conclusion Disclosure developed for different reasons within different sub-populations. Consistent with existing research, cadet intercollegiate athletes reported being primarily concerned that concussion self-disclosure would cause them to miss practice or game time (t (736.7) = 14.20, p < .001, Cohen’s d = 0.96). In contrast, cadet future pilots reported being primarily concerned that concussion self-disclosure would have negative United States Air Force career repercussions (t (1828) = 10.25, p < .001, Cohen’s d = 0.50).

Conclusions

These results suggest that cultures of concussion non-disclosure can develop in any population where disclosure is perceived as having undesirable consequences, not just athletic populations. Concussion researchers and practitioners should devote more attention to the perceived cost-benefit structures that create concussion non-disclosure to address this crucial public health issue more effectively.

Concussion Incidence, Duration, and Return to School and Sport in 5- to 14-Year-Old American Football Athletes

OBJECTIVE

To collect prospective data on concussion incidence, risk factors, duration of symptoms, and return to school and sport in 5- to 14-year-old American football participants.

STUDY DESIGN

We conducted a prospective cohort study over 2 years collecting data during two 10-week fall seasons. Youth with concussion were followed to determine time to return to school, sport, and baseline level of symptoms. Logistic regression was used to estimate the risk of sustaining a concussion associated with baseline demographic factors. Time to return to school, sport, and baseline symptoms were analyzed using Kaplan-Meier survival curves.

RESULTS

Of 863 youth followed (996 player-seasons), 51 sustained a football-related concussion, for an athlete-level incidence of 5.1% per season. Youth with history of concussion had a 2-fold increased risk for sustaining an incident concussion (OR, 2.2; 95% CI, 1.1-4.8). Youth with depression had a 5-fold increased risk of concussion (OR, 5.6; 95% CI, 1.7-18.8). After a concussion, 50% of athletes returned to school by 3 days, 50% returned to sport by 13 days, and 50% returned to a baseline level of symptoms by 3 weeks.

CONCLUSIONS

Concussion rates in this study were slightly higher than previously reported, with 5 of every 100 youth sustaining a football-related concussion each season. One-half of youth were still symptomatic 3 weeks after injury. Further research is needed to address the risk of concussion in youth football.

Concussion and National Hockey League Player Performance: An Advanced Hockey Metrics Analysis

CONTEXT

Postconcussion deficits in neurocognitive performance and postural control may persist at the time of return to sport participation. How these deficits, if present, affect athletic performance is largely unknown, with prior studies showing mixed results.

OBJECTIVE

To evaluate postconcussion National Hockey League player performance using advanced hockey metrics over short- (5 games), medium- (10 games), and long-term (remainder of the season) seasonal performance.

DESIGN

Retrospective cohort study.

PATIENTS OR OTHER PARTICIPANTS

National Hockey League players who sustained a sport-related concussion (SRC; n = 93) and returned during the same season and players (n = 51) who missed time for non-injury-related reasons.

MAIN OUTCOME MEASURE(S)

Six performance metrics were used: (1) points per 60 minutes, (2) Corsi percentage, (3) personal Fenwick shooting percentage, (4) scoring chances per 60 minutes, (5) penalty difference, and (6) PDO (not an acronym but sometimes referred to as SVSP% [save percentage shooting percentage]). Performance was compared using 2 (group) × 2 (time) repeated-measures analyses of variance for 3 time windows: (1) ±5 games, (2) ±10 games, and (3) the remainder of the season postconcussion. Alpha values were set at a conservative .01 to account for the lack of independence among dependent variables.

RESULTS

No significant interactions were present for any of the 6 dependent variables at any of the 3 time windows. Overall, none of the secondary variables differed.

CONCLUSIONS

Using advanced, sport-specific metrics, we found that National Hockey League players did not display worse seasonal performance during 3 postinjury time frames after they sustained an SRC. Whereas laboratory studies have identified lingering neurologic deficits after concussion, our results suggest that these deficits, if present, either do not translate to worse athletic performance or were not captured by these 44 metrics. Further, prospective efforts are needed to accurately quantify performance after SRC among professional hockey players.

American Medical Society for Sports Medicine Position Statement on Concussion in Sport

Sport-related concussion (SRC) is a common injury in recreational and organized sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment, and management of SRC. In addition to a growing need for knowledgeable health care professionals to provide evidence-based care for athletes with SRC, media attention and legislation have created awareness and, in some cases, fear about many issues and unknowns surrounding SRC. The American Medical Society for Sports Medicine formed a writing group to review the existing literature on SRC, update its previous position statement, and address current evidence and knowledge gaps regarding SRC. The absence of definitive outcomes-based data is challenging and requires relying on the best available evidence integrated with clinical experience and patient values. This statement reviews the definition, pathophysiology, and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short- and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The American Medical Society for Sports Medicine is committed to best clinical practices, evidence-based research, and educational initiatives that positively impact the health and safety of athletes.

American Medical Society for Sports Medicine position statement on concussion in sport

Sport-related concussion (SRC) is a common injury in recreational and organised sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment and management of SRC. In addition to a growing need for knowledgeable healthcare professionals to provide evidence-based care for athletes with SRC, media attention and legislation have created awareness and, in some cases, fear about many issues and unknowns surrounding SRC. The American Medical Society for Sports Medicine (AMSSM) formed a writing group to review the existing literature on SRC, update its previous position statement, and to address current evidence and knowledge gaps regarding SRC. The absence of definitive outcomes-based data is challenging and requires relying on the best available evidence integrated with clinical experience and patient values. This statement reviews the definition, pathophysiology and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short-term and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The AMSSM is committed to best clinical practices, evidence-based research and educational initiatives that positively impact the health and safety of athletes.

Concussions in Sports

Although concussions are common, they are complex, variable, and not entirely understood in terms of pathophysiology and treatment. The incidence of concussion is expected to continue to rise with the increased participation of youth in sports and improved awareness. The role of orthopedic surgeons in concussion management is murky. However, the existing literature does provide a foundation from which orthopedic surgeons who are exposed to concussed patients can function. [Orthopedics. 2019; 42(1):12-21.].

Posttraumatic headache in pediatrics: an update and review

PURPOSE OF REVIEW

Headache following concussion and mild traumatic brain injury is very common in pediatrics. There is significant concern about appropriate management of acute and persistent headache following mild head injuries in children among affected youth, their families and care providers.

RECENT FINDINGS

The current article will review definitions and diagnoses of posttraumatic headache (PTHA), recent research regarding risk factors for persistence of postconcussion symptoms and headaches, current recommendations for the evaluation of youth with PTHA, recent data regarding efficacy of treatment options for PTHA, and current recommendations for the treatment of acute and persistent PTHA.

SUMMARY

PTHA is common following concussion in pediatrics. Some of the most consistent risk factors for persistent symptoms following concussion include female sex, adolescent age, prior concussion with prolonged recovery, prior headache history and high number of acute symptoms, particularly migrainous symptoms, following concussion. There are few prospective studies of the treatment of PTHA in pediatrics; however, a recent study found that short-term use of ibuprofen for those with acute PTHA following concussion may be associated with lower risk of symptoms and better function 1 week after injury. Currently complete rest or cocooning following concussion is not recommended as it may actually be associated with longer recovery time; a gradual return to cognitive and physical activity appears to be most effective strategy but more study is needed.

The modern landscape of sport-related concussion research: key achievements and future directions

The study of contact and collision sport athletes at risk for concussion began approximately three decades ago. Since then, sport-related concussion (SRC) research across several medical specialties has helped to develop consensus guidelines for clinical management through interdisciplinary efforts. The modern landscape of SRC research includes large-scale investigations to define the natural history of concussion and identify factors that should guide prevention, diagnosis, and treatment specific to the individual patient. We now know that the clinical and physiologic effects of concussion are related but independent constructs deserving further scientific exploration. This has sparked research that incorporates advanced neuroimaging, fluid biomarkers, biomechanics, and genomics, in addition to standard clinical outcomes. Additionally, translational research has informed our understanding of optimal rehabilitation strategies and led to a shift from the "complete rest" approach to earlier, active management interventions after concussion. Collectively, these advancements are likely to substantially improve patient outcomes after SRC and, ultimately, may prove beneficial for identifying and appropriately managing those at risk for longer-term difficulties associated with repetitive head impact exposure. The broader public health implications of improving sports safety and encouraging developmentally appropriate participation among youth and adolescents are a particularly important byproduct of continued research into SRC.