Symptoms of Concussion and Comorbid Disorders

Subclinical, long-term psychological symptoms following sport-related concussion: are athletes more depressed than we think?

INTRODUCTION

In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms.

METHODS

A cohort study was conducted of athletes 12-24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used.

RESULTS

Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247-420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04).

CONCLUSIONS

Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

Traumatic brain injury and occupational risk of low-level blast exposure on adverse career outcomes: an examination of administrative and medical separations from Service (2005-2015)

Introduction

Although traumatic brain injury (TBI) has been linked with adverse long-term health, less research has examined whether TBI is linked with non-clinical outcomes including involuntary job loss. Symptoms associated with TBI may influence one's ability to maintain gainful employment including employment in the U.S. military. That influence may impact military service members with exposure to repetitive low-level blast (LLB). Understanding the association between TBI and involuntary job loss outcomes among military populations is particularly important as it may be associated with differences in eligibility for post-service benefits. The purpose of the present research was to determine whether (1) TBI and related conditions are associated with involuntary job loss (i.e., medical and administrative separations from service) among military personnel, and (2) occupational risk of LLB is associated with involuntary job loss in both the presence and absence of clinical diagnoses of TBI and related conditions.

Method

This research leveraged population-level data from the Career History Archival Medical and Personnel System for enlisted personnel who served on active duty between 2005-2015. Risk of LLB exposure was categorized using military occupational specialty as a proxy. Medical diagnoses were identified using ICD-9 codes. Separations for medical and administrative reasons were identified.

Results

Risk for administrative separation differed across medical diagnoses of interest, but those who worked in high-risk occupations were more likely to be administratively separated than those working in low-risk occupations. Risk for medical separation was associated with occupational risk of LLB and each of the diagnoses of interest, though significant interactions suggested that the effects of certain diagnoses of interest (e.g., concussion, cognitive problems, postconcussive syndrome, migraines) on medical separations was greater among those working in high-risk occupations.

Discussion

Taken together, the present research suggests that TBI and associated medical conditions, as well as occupational risk of LLB, are associated with long-term involuntary job loss for medical reasons. This study is the first to demonstrate involuntary military job loss outcomes associated with TBI, mental health conditions, and conditions associated with blast exposure using both inpatient and outpatient population-level data and may have important implications for civilian employment and post-service benefits.

Association of Blast Exposure in Military Breaching with Intestinal Permeability Blood Biomarkers Associated with Leaky Gut

Injuries and subclinical effects from exposure to blasts are of significant concern in military operational settings, including tactical training, and are associated with self-reported concussion-like symptomology and physiological changes such as increased intestinal permeability (IP), which was investigated in this study. Time-series gene expression and IP biomarker data were generated from "breachers" exposed to controlled, low-level explosive blast during training. Samples from 30 male participants at pre-, post-, and follow-up blast exposure the next day were assayed via RNA-seq and ELISA. A battery of symptom data was also collected at each of these time points that acutely showed elevated symptom reporting related to headache, concentration, dizziness, and taking longer to think, dissipating ~16 h following blast exposure. Evidence for bacterial translocation into circulation following blast exposure was detected by significant stepwise increase in microbial diversity (measured via alpha-diversity p = 0.049). Alterations in levels of IP protein biomarkers (i.e., Zonulin, LBP, Claudin-3, I-FABP) assessed in a subset of these participants (n = 23) further evidenced blast exposure associates with IP. The observed symptom profile was consistent with mild traumatic brain injury and was further associated with changes in bacterial translocation and intestinal permeability, suggesting that IP may be linked to a decrease in cognitive functioning. These preliminary findings show for the first time within real-world military operational settings that exposures to blast can contribute to IP.

Self-Reported Symptoms in U.S. Marines Following Blast- and Impact-Related Concussion

INTRODUCTION

Recent research on traumatic brain injury (TBI) has suggested that the mechanism of injury (i.e., whether the TBI was caused by high-level blast [HLB] vs. direct physical impact to the head) may be an important factor in injury severity, symptomology, and recovery because of differences in physiological effects of each type of injury on the brain. However, differences in self-reported symptomology resulting from HLB- vs. impact-related TBIs have not been thoroughly examined. This study tested the hypothesis that HLB- and impact-related concussions result in different self-reported symptoms in an enlisted Marine Corps population.

MATERIALS AND METHODS

All records of 2008 and 2012 Post-Deployment Health Assessment (PDHA) forms completed by enlisted active duty Marines between January 2008 and January 2017 were examined for self-reported concussion, mechanism of injury, and self-reported symptoms experienced during deployment. Concussion events were categorized as either blast- or impact-related; individual symptoms were categorized as neurological, musculoskeletal, or immunological. A series of logistic regressions were performed to examine associations between self-reported symptoms experienced by healthy controls and Marines who endorsed (1) any concussion (mTBI), (2) a probable blast-related concussion (mbTBI), and (3) a probable impact-related concussion (miTBI); analyses were also stratified by PTSD. To determine if there were significant differences between odds ratios (ORs) for mbTBIs vs. miTBIs, 95% CIs were examined for overlap.

RESULTS

Marines with a probable concussion, regardless of the mechanism of injury, were significantly more likely to report all symptoms (OR range: 1.7-19.3). Overall, mbTBIs, compared with miTBIs, resulted in higher odds of symptom reporting for eight symptoms on the 2008 PDHA (tinnitus, trouble hearing, headache, memory problems, dizziness, dim vision, trouble concentrating, and vomiting) and six symptoms on the 2012 PDHA (tinnitus, trouble hearing, headaches, memory problems, balance problems, and increased irritability), all of which were in the neurological symptom category. Conversely, odds of symptom reporting were higher for Marines experiencing miTBIs (vs. mbTBIs) for seven symptoms on the 2008 PDHA (skin diseases or rashes, chest pain, trouble breathing, persistent cough, red eyes, fever, and other) and one symptom on the 2012 PDHA (skin rash and/or lesion), all of which were in the immunological symptoms category. mbTBI (vs. miTBI) was consistently associated with greater odds of reporting tinnitus, trouble hearing, and memory problems, regardless of PTSD status.

CONCLUSIONS

These findings support recent research suggesting that the mechanism of injury may play an important role in symptom reporting and/or physiological changes to the brain after concussion. The results of this epidemiological investigation should be used to guide further research on the physiological effects of concussion, diagnostic criteria for neurological injuries, and treatment modalities for various concussion-related symptoms.

Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion

OBJECTIVE

To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain.

DESIGN

Cross sectional.

SETTING

Sports medicine clinic.

PATIENTS

Pediatric patients ≤14 days post concussion.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain.

RESULTS

We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90).

CONCLUSIONS

In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Interdisciplinary Rehabilitation for Concussion Recovery (i-RECOveR): protocol of an investigator-blinded, randomised, case series with multiple baseline design to evaluate the feasibility and preliminary efficacy of a 12-week treatment for persistent post-concussion symptoms

BACKGROUND

Up to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored.

METHODS

Fifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews.

DISCUSSION

Results from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes.

TRIAL REGISTRATION

ANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118.

Machine learning to predict sports-related concussion recovery using clinical data

OBJECTIVES

Sport-related concussions (SRCs) are a concern for high school athletes. Understanding factors contributing to SRC recovery time may improve clinical management. However, the complexity of the many clinical measures of concussion data precludes many traditional methods. This study aimed to answer the question, what is the utility of modeling clinical concussion data using machine-learning algorithms for predicting SRC recovery time and protracted recovery?

METHODS

This was a retrospective case series of participants aged 8 to 18 years with a diagnosis of SRC. A 6-part measure was administered to assess pre-injury risk factors, initial injury severity, and post-concussion symptoms, including the Vestibular Ocular Motor Screening (VOMS) measure, King-Devick Test and C3 Logix Trails Test data. These measures were used to predict recovery time (days from injury to full medical clearance) and binary protracted recovery (recovery time > 21 days) according to several sex-stratified machine-learning models. The ability of the models to discriminate protracted recovery was compared to a human-driven model according to the area under the receiver operating characteristic curve (AUC).

RESULTS

For 293 males (mean age 14.0 years) and 362 females (mean age 13.7 years), the median (interquartile range) time to recover from an SRC was 26 (18-39) and 21 (14-31) days, respectively. Among 9 machine-learning models trained, the gradient boosting on decision-tree algorithms achieved the best performance to predict recovery time and protracted recovery in males and females. The models' performance improved when VOMS data were used in conjunction with the King-Devick Test and C3 Logix Trails Test data. For males and females, the AUC was 0.84 and 0.78 versus 0.74 and 0.73, respectively, for statistical models for predicting protracted recovery.

CONCLUSIONS

Machine-learning models were able to manage the complexity of the vestibular-ocular motor system data. These results demonstrate the clinical utility of machine-learning models to inform prognostic evaluation for SRC recovery time and protracted recovery.

Characterization of persistent post-traumatic headache and management strategies in adolescents and young adults following mild traumatic brain injury

Characteristics of persistent post-traumatic headache (PTH) in young individuals are poorly known leading to diagnostic problems and diverse management. We aimed to describe headache phenotypes and self-reported management strategies in young individuals with PTH following mild traumatic brain injury (mTBI). A comprehensive structured questionnaire was used to evaluate headache phenotypes/characteristics and management strategies to relieve headache in 107, 15–30-year-old individuals with PTH. Around 4 months post-injury, migraine-like headache in combination with tension-type like headache (40%) was the most commonly encountered headache phenotype followed by migraine-like headache (36%). Around 50% reported aura-like symptoms before/during the headache attack. Medication-overuse headache was diagnosed in 10%. Stress, sleep disturbances, and bright lights were the most common trigger factors. More than 80% reported that their headache was worsened by work-related activity and alleviated by rest/lying down. Simple analgesics were commonly used (88%) whereas prophylactic drugs were rarely used (5%). Bedrest and physiotherapy were also commonly used as management strategies by 56% and 34% of the participants, respectively. In conclusion, most young individuals with PTH after mTBI presented with combined migraine-like and tension-type-like headache followed by migraine-like headache, only. Preventive headache medication was rarely used, while simple analgesics and bedrest were commonly used for short-term headache relief.

The Persistence of Blast- Versus Impact-Induced Concussion Symptomology Following Deployment

OBJECTIVE

To examine the persistence of concussion-related symptoms following injury as a function of mechanism of injury (high-level blast [HLB] vs impact) and low-level blast (LLB) exposure among Marines.

SETTING

Upon return from deployment and approximately 6 months later, respectively, Marines completed the Post-Deployment Health Assessment and Post-Deployment Health Re-Assessment in an operational or clinic setting.

PARTICIPANTS

Data from active duty enlisted Marines who completed both assessments (n = 102 075) and who reported a potentially mild traumatic brain injury (mTBI)-inducing event and completed an mTBI screen (n = 8106) were analyzed.

DESIGN

This was a retrospective cohort study of Marines deployed between 2008 and 2012. Marines were categorized into groups with relatively high versus low risk for occupational risk of LLB exposure. A mixed model analysis of variance was used to examine the number of symptoms Marines reported experiencing during deployment as a function of probable concussion, HLB exposure, occupational risk, type of symptom, and time of measurement.

MAIN MEASURES

Self-reported deployment exposures including HLB, probable mTBIs, and occupational risk of LLB exposure were identified. Outcomes included the proportion of neurological, musculoskeletal, and immunological symptoms for which Marines reported seeking care during and following deployment were analyzed.

RESULTS

Probable HLB-induced mTBIs (vs impact-induced) were associated with significantly more neurological symptoms at return from deployment and approximately 6 months later. Although symptom reporting decreased at statistically equivalent rates regardless of mechanism of injury, those with a probable HLB-induced concussion continued to report elevated symptomology post-deployment. Additionally, Marines with probable concussion working in occupations with LLB exposure reported elevated levels of persistent neurological symptoms. Both HLB and LLB exposure were associated with neurological symptoms that persisted following deployment.

CONCLUSION

These findings suggest that blast-induced brain injuries may be fundamentally different from impact-induced injuries, and that additional screening and symptomatic treatment for blast-exposed patients may be warranted.

Neurophysiological Biomarkers of Persistent Post-concussive Symptoms: A Scoping Review

Background and Objectives: Persistent post-concussive symptoms (PCS) consist of neurologic and psychological complaints persisting after a mild traumatic brain injury (mTBI). It affects up to 50% of mTBI patients, may cause long-term disability, and reduce patients' quality of life. The aim of this review was to examine the possible use of different neuroimaging modalities in PCS.

Methods: Articles from Pubmed database were screened to extract studies that investigated the relationship between any neuroimaging features and symptoms of PCS. Descriptive statistics were applied to report the results.

Results: A total of 80 out of 939 papers were included in the final review. Ten examined conventional MRI (30% positive finding), 24 examined diffusion weighted imaging (54.17% positive finding), 23 examined functional MRI (82.61% positive finding), nine examined electro(magneto)encephalography (77.78% positive finding), and 14 examined other techniques (71% positive finding).

Conclusion: MRI was the most widely used technique, while functional techniques seem to be the most sensitive tools to evaluate PCS. The common functional patterns associated with symptoms of PCS were a decreased anti-correlation between the default mode network and the task positive network and reduced brain activity in specific areas (most often in the prefrontal cortex).

Significance: Our findings highlight the importance to use functional approaches which demonstrated a functional alteration in brain connectivity and activity in most studies assessing PCS.

Cardiovascular Sequalae of Sports-Related Concussions

We are becoming more aware of sports-related concussions (SRCs). Current return-to-play (RTP) guidelines are often based on subjective clinical symptoms rather than objective physiologic measures. Although evidence is limited, the purpose of this manuscript is to summarize the data pertaining to acute and chronic cardiovascular effects of SRCs, and to determine whether there are objective metrics that could improve currently used RTP protocols. Research shows that SRCs cause cardiovascular autonomic nervous system (CV-ANS) dysfunction induced by decreased baroreceptor sensitivity (BRS). This disturbance persists past the point of clinical symptom resolution and can worsen through subsequent exertion, which may impact long-term recovery. Further studies are needed to establish the most appropriate physiologic metrics for analyzing recovery post-SRC and whether the addition of physiologic measures to RTP guidelines improves recovery from these injuries. This is an understudied area that carries important clinical implications. Larger and more robust trials are warranted to inform the development of guidelines that should focus on lessening the compounding effects of multiple concussions and improve the management of SRCs. This article is protected by copyright. All rights reserved.

A cross-sectional study reporting concussion exposure, assessment and management in Western Australian general practice

Background

General Practitioners (GPs) may be called upon to assess patients who have sustained a concussion despite limited information being available at this assessment. Information relating to how concussion is actually being assessed and managed in General Practice is scarce. This study aimed to identify characteristics of current Western Australian (WA) GP exposure to patients with concussion, factors associated with GPs’ knowledge of concussion, confidence of GPs in diagnosing and managing patients with concussion, typical referral practices and familiarity of GPs with guidelines.

Methods

In this cross-sectional study, GPs in WA were recruited via the RACGP WA newsletter and shareGP and the consented GPs completed an electronic survey. Associations were performed using Chi-squared tests or Fisher’s Exact test.

Results

Sixty-six GPs in WA responded to the survey (response rate = 1.7%). Demographics, usual practice, knowledge, confidence, identification of prolonged recovery as well as guideline and resource awareness of GPs who practised in regional and metropolitan areas were comparable (p > 0.05). Characteristics of GPs were similar between those who identified all symptoms of concussion and distractors correctly and those who did not (p > 0.05). However, 84% of the respondents who had never heard of concussion guidelines were less likely to answer all symptoms and distractors correctly (p = 0.039). Whilst 78% of the GPs who were confident in their diagnoses had heard of guidelines (p = 0.029), confidence in managing concussion was not significantly associated with GPs exposure to guidelines. It should be noted that none of the respondents correctly identified signs of concussion and excluded the distractors.

Conclusions

Knowledge surrounding concussion guidelines, diagnosis and management varied across GPs in WA. Promotion of available concussion guidelines may assist GPs who lack confidence in making a diagnosis. The lack of association between GPs exposure to guidelines and confidence managing concussion highlights that concussion management may be an area where GPs could benefit from additional education and support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01384-1.

Head Position and Posturography: A Novel Biomarker to Identify Concussion Sufferers

Balance control systems involve complex systems directing muscle activity to prevent internal and external influences that destabilize posture, especially when body positions change. The computerized dynamic posturography stability score has been established to be the most repeatable posturographic measure using variations of the modified Clinical Test of Sensory Integration in Balance (mCTSIB). However, the mCTSIB is a standard group of tests relying largely on eyes-open and -closed standing positions with the head in a neutral position, associated with probability of missing postural instabilities associated with head positions off the neutral plane. Postural stability scores are compromised with changes in head positions after concussion. The position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores than the standardized head neutral position of the mCTSIB in Post-Concussion Syndrome (PCS) subjects but not in normal healthy controls. This phenomenon may serve as a diagnostic biomarker to differentiate PCS subjects from normal ones as well as serving as a measurement with which to quantify function or the success or failure of a treatment. Head positions off the neutral plane provide novel biomarkers that identify and differentiate subjects suffering from PCS from healthy normal subjects.

Self-Reported Concussion Symptomology during Deployment: Differences as a Function of Injury Mechanism and Low-Level Blast Exposure

Traumatic brain injury (TBI), which can result from either direct impact to the head or blast exposure, has been the leading cause of morbidity and mortality in recent military conflicts. However, little research has compared mTBIs by mechanism of injury. The present research addressed two research questions: (1) Are blast-related mTBIs (mbTBIs) associated with significantly more symptoms than impact-related mTBIs (miTBIs), and (2) are mTBIs associated with more self-reported symptoms among service members with higher (vs. lower) risk of low-level blast (LLB) exposure. We obtained data from 181,423 active duty enlisted United States Marines deployed between 2003 and 2012, who completed the Post-Deployment Health Assessment. We examined the self-reported symptoms of Marines who completed an mTBI screen and could be classified as at high or low risk for LLB exposure, using their military occupation as a proxy (n = 12,013). Symptoms were compared as a function of blast exposure (blast vs. impact), probable mTBI (yes vs. no), occupational risk of LLB (high vs. low), and symptom type (neurological vs. musculoskeletal vs. immunological). Overall, musculoskeletal symptoms were reported more frequently than neurological and immunological symptoms. However, Marines with probable mTBIs (regardless of mechanism of injury) and those with probable mbTBIs specifically reported more neurological symptoms, which rose to the level of musculoskeletal symptom reporting. Among Marines with probable mTBI, those with high risk of LLB exposure also reported significantly more neurological symptoms. Our results indicate that mbTBIs and miTBIs may be fundamentally different, and that LLB may increase susceptibility to injury.

Concussion Symptom Underreporting Among Incoming National Collegiate Athletic Association Division I College Athletes

OBJECTIVE

Accurate diagnosis of sport-related concussions relies heavily on truthful self-reporting of symptom severity. Previous studies have emphasized lack of knowledge as a factor in symptom nondisclosure. This study sought to examine concussion knowledge and the relationship of knowledge to reasons for symptom nondisclosure.

DESIGN

Cross-sectional study.

SETTING

Data were collected during preparticipation athletic evaluations via electronic survey.

PARTICIPANTS

One hundred fifty-six incoming National Collegiate Athletic Association Division I student-athletes.

MAIN OUTCOME MEASURES

Survey items included previous concussion diagnosis, concussion fact and symptom knowledge, reasons and situational contexts for nondisclosure, and stakeholder attitudes.

RESULTS

Participants, on average, had substantial concussion symptom and fact knowledge. Unexpectedly, participants with higher concussion fact knowledge endorsed more reasons that athletes may hide symptoms. Concussion symptom knowledge was unrelated to reasons for nondisclosure. Athletes believed that symptom reporting was less likely in high-stakes versus low-stakes situations and consistently identified their teammates as holding attitudes that support underreporting and athletic trainers as engaging in behaviors that support player safety.

CONCLUSIONS

Greater concussion knowledge did not reduce the number of reasons that participants viewed as drivers for concussion nondisclosure. In other words, participants understood why athletes choose to hide symptoms even when they also understood the symptoms, risks, sequelae, and consequences of concussion (and potential harm of nondisclosure). Situational contexts and important stakeholder attitudes also appeared to importantly influence symptom disclosure decisions. A multifaceted approach that goes beyond current educational strategies to addresses situational, social, and athletic pressures may be needed to initiate a widespread cultural shift away from concussion nondisclosure.

Can the Neck Contribute to Persistent Symptoms Post Concussion? A Prospective Descriptive Case Series

BACKGROUND

Persistent symptoms post concussion can arise from a range of sources, including the neck. There is little description of neck assessment findings in people with persistent symptoms post concussion.

OBJECTIVES

To assess people with persistent symptoms following a concussion and determine whether the neck has also been injured, and to evaluate the potential of the neck to contribute to their symptoms.

METHODS

A consecutive series of participants (n = 20) referred for neck assessment were prospectively recruited by 2 providers of a multidisciplinary concussion service for people with persistent symptoms. Data were collected at initial assessment and on completion of neck treatment, which included standard questionnaires (Rivermead Post Concussion Symptoms Questionnaire, Neck Disability Index, Dizziness Handicap Inventory); patient-reported measures of headache, dizziness, and neck pain; physical examination findings; and details of comorbidities.

RESULTS

Participants were evaluated at a mean of 7.5 weeks post concussion (median, 5 weeks). On neck assessment, 90% were considered by the clinician to have a neck problem contributing to their current symptoms. Multiple findings were consistent with this view, including moderate-to-severe Neck Disability Index scores (mean ± SD, 33.4 ± 9.5 points), frequent neck pain (85%), frequent moderate-to-severe pain on occiput-C4 segmental assessment (85%), a positive flexion-rotation test (45%), and muscle tenderness (50%-55%).

CONCLUSION

Multiple findings were indicative of concurrent neck injury, particularly involving the upper cervical spine. These neck-related findings are important to recognize, as they have the potential to contribute to persistent symptoms post concussion and may respond to neck treatment. This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001183471). J Orthop Sports Phys Ther 2019;49(11):845-854. Epub 1 Jun 2019. doi:10.2519/jospt.2019.8547.

Design of an early intervention for persistent post-concussion symptoms in adolescents and young adults: A feasibility study

BACKGROUND

About 5-15 % of patients with concussion experience persistent post-concussion symptoms (PCS) longer than 3 months post-injury.

OBJECTIVE

To explore the feasibility of a new intervention for young patients with persistent PCS and long-term changes after intervention.

METHODS

Thirty-two consecutive patients (15-30 years) with persistent PCS 2-4 months post-injury were recruited from a cohort study or referred to a non-randomized feasibility study of an individually tailored, 8-week, multidisciplinary intervention. Assessment was performed at baseline, end of intervention (EOI), and at 3- and 12-month follow-up (FU). Main measures were The Experience of Service Questionnaire (ESQ), Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and The Quality of Life after Brain Injury - Overall Scale (QOLIBRI-OS).

RESULTS

Twenty-three (72%) patients completed the intervention. The ESQ demonstrated high patient satisfaction. There was a decrease of PCS and an increase in quality of life from baseline to EOI: RPQ score -8.9 points, 95% CI 4.5 to 13.3, p < 0.001; QOLIBRI-OS score +10.5 points, 95% CI 2.5 to 18.5, p = 0.010. Improvement was maintained at 3- and 12-month FU.

CONCLUSION

The new early intervention is feasible and may prevent chronification of PCS. An RCT is currently performed to evaluate the effect of the intervention.

No change in plasma tau and serum neurofilament light concentrations in adolescent athletes following sport-related concussion

Sport-related concussion (SRC), a mild form of traumatic brain injury (TBI), is a common injury in contact sports. Health care professionals rely on subjective criteria (e.g., symptoms), as there is no objective marker for identification of athletes with SRC. Blood-based biomarkers have shown promise as diagnostic and prognostic tools following TBI and SRC. In the present study, we examined plasma tau and serum NF-L, two biomarkers for neuronal/axonal injury, concentrations at preseason and following SRC in contact sport athletes (n = 11) using ultrasensitive single molecule array (Simoa) assays. Preseason baseline samples were collected, and post-concussion samples were obtained at 6- and 14-days following injury. We found no difference between baseline, 6-day and 14-day post-concussion concentrations of tau (p = 0.14) or NF-L (p = 0.53). Further, no difference was found between preseason baseline and all post-SRC samples for tau (p = 0.22) or NF-L (p = 0.98). The total number of symptoms reported on the Standardized Assessment of Concussion– 3^rd Edition (SCAT3) and associated symptom severity scores increased from preseason to 6-days post-SRC but returned to baseline values at 14-days (p = 0.02 and p = 0.003, respectively). These results suggest that the severity of neuronal injury in this cohort of contact sport athletes with clinical uncomplicated SRC was too low to be detected by tau and NF-L measurements in blood samples obtained at 6- and 14-days post-injury.

Epidemiology of mental health conditions in incoming division I collegiate athletes

OBJECTIVES

The purpose of this study is to examine the epidemiology of mental health conditions in incoming American Division I collegiate athletes.

METHODS

Pre-participation physical questionnaires from 1118 incoming student athletes at a Division I Institution were collected retrospectively from 2011-2017. Data collected included lifetime history of any mental health condition, musculoskeletal injuries, concussions, and post-concussion depression. History of any mental health condition was evaluated by gender and sport played. It was also evaluated in comparison to musculoskeletal injuries and concussions.

RESULTS

The lifetime prevalence of any mental health condition was 14.0% for all athletes, 14.2% for male athletes, and 13.6% for female athletes. Individual sports reported a greater prevalence (17.2%) than did team sports (11.8%) (p = 0.010). The prevalence was also higher in contact sports (16.4%) than in non-contact sports (12.5%), although this difference was not statistically significant (p = 0.072). There was a significant association between mental health condition and all four major groups of injuries examined: upper extremity (p = 0.043), lower extremity (p = 0.007), axial skeletal (p < 0.001), and concussions (p = 0.039). Post-concussion depression occurred in 2.0% of all athletes reporting a concussion.

CONCLUSION

The lifetime prevalence of mental health conditions in this population (14.0%) is far less than estimates in the general population. This observation may be due to a combination of factors including exercise/athletic participation mitigating depressive symptoms, competitive selection, and underreporting. History of a mental health condition may be associated with injury, although causation cannot be determined.

Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis

BACKGROUND

Concussion is typically defined as a mild brain injury, and yet the brain is unlikely to be the only source of persistent post-concussion symptoms. Concurrent injury to the cervical spine in particular is acknowledged as a potential source of common persistent symptoms such as headache, dizziness and neck pain.

OBJECTIVES

To describe the cervical spine findings and outcomes of treatment in a series of patients with persistent post-concussion symptoms, and describe the clinical characteristics of a cervicogenic component when it is present.

DESIGN

Retrospective chart review of a consecutive series of patients with concussion referred to a physiotherapist for cervical spine assessment.

METHOD

Patient charts for all patients over a calendar year referred by a concussion service provider to a physiotherapist for cervical spine assessment were de-identified and transferred to the research team. Clinical data were independently extracted by two research assistants and analysed using descriptive statistics.

RESULTS/FINDINGS

Data were analysed from 46 patient charts. Those with a cervicogenic component (n = 32) were distinguished from those without a cervicogenic component (n = 14) by physical examination findings, particularly pain on manual segmental examination. Physiotherapy treatment of the cervicogenic component (n = 21) achieved improvements in function (mean increase of 3.8 in the patient-specific functional scale), and pain (mean decrease of 4.6 in the numeric pain-rating scale).

CONCLUSIONS

The clinical characteristics described give preliminary support to the idea that the cervical spine may contribute to persistent post-concussion symptoms, and highlight the value of physiotherapy assessment and treatment of the cervical spine following a concussive injury.

Neuropsychiatric aspects of concussion: acute and chronic sequelae

Concussion – also known as mild traumatic brain injury – is a transient disturbance of neurological function resulting from traumatic forces imparted to the brain that often produce cognitive, behavioral and systemic symptoms. In this review of the literature, we discuss the pathophysiology of both acute and chronic neuropsychiatric sequelae of concussions, followed by a brief overview of evaluation and management of these sequelae.