Assessment, Management and Knowledge of Sport-Related Concussion: Systematic Review

Elevated Autoantibodies to the GluA1 Subunit of the AMPA Receptor in Blood Indicate Risk of Cognitive Impairment in Contact Sports Athletes, Irrespective of Concussion

To address the need for objective tests of concussion in athletes, we conducted a prospective clinical study in National Collegiate Athletic Association athletes of the relationship between neurocognitive performance and blood levels of the GluA1 subunit of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor peptides and autoantibodies to GluA1. Specifically, we compared 44 contact sport athletes to 16 noncontact sport athletes, with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), as well as blood sample collection, before the start of the season and at the end of the season. Contact sport athletes exhibited significantly elevated serum GluA1 autoantibodies at the end of season, compared with preseason levels, irrespective of whether they sustained a concussion. Noncontact sport athletes showed no change in serum GluA1 autoantibodies, and neither group showed differences in GluA1 peptides. Amongst contact-sport athletes, the 'high GluA1 autoantibody group' (≥4 ng/mL) displayed impaired reaction time, a measure of cognitive impairment, while the 'low GluA1 autoantibody group' (<4 ng/mL) displayed normal reaction time. Our results reveal that contact sport athletes are at risk for developing cognitive impairment even without sustaining a diagnosed concussion and that serum GluA1 autoantibodies provide a blood-based biomarker of this risk. This could guide future studies on the differing susceptibility to cognitive impairment in contact sport athletes and facilitate efficient allocation of resources to contact sport athletes identified as having increased risk of developing cognitive impairment.

Use of the concussion check protocol for concussion assessment in a female soccer team over two consecutive seasons in New Zealand

AIM

Address deficiencies in access to sports sideline medical care by using a Concussion Check Protocol (CCP) for non-medically-trained people.

METHOD

A prospective observational cohort study was undertaken on a single amateur female club-based soccer team over two consecutive years in New Zealand utilising a non-medically trained support person termed a Safety officer. CCP is an extension of the King-Devick test with features such as warning signs and symptoms of concussion built into the application. All players suspected of having a potential concussive injury were tested on the match sideline.

RESULTS

The study overall incidence of match-related concussions was 20.8 (95% CI: 11.8 to 36.6) per 1000 match-hrs, with mean missed-match duration of 31 (95% CI: 27.9 to 34.1) days. Twelve players over the study had a significantly slower post-injury KD (49.9 [44.3 to 64.1]s; χ2(1) = 11.0; p = 0.0009; z = -2.9; p = 0.0033; d = 0.30) and/or reported symptoms, compared with their own baseline (47.2 [44.3 to 64.1]s). CCP had an overall sensitivity of 100% (95% CI: 73.5% to 100.0%), specificity of 100% (95% CI: 69.2% to 100.0%) and positive predictive value (PPV) of 100% (84.6% to 100.0%).

CONCLUSION

Sideline use of CCP was undertaken successfully by non-medically trained people and provided a reliable platform for concussion identification.

S100B, Actor and Biomarker of Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) accounts for approximately 80% of all TBI cases and is a growing source of morbidity and mortality worldwide. To improve the management of children and adults with mTBI, a series of candidate biomarkers have been investigated in recent years. In this context, the measurement of blood biomarkers in the acute phase after a traumatic event helps reduce unnecessary CT scans and hospitalizations. In athletes, improved management of sports-related concussions is also sought to ensure athletes’ safety. S100B protein has emerged as the most widely studied and used biomarker for clinical decision making in patients with mTBI. In addition to its use as a diagnostic biomarker, S100B plays an active role in the molecular pathogenic processes accompanying acute brain injury. This review describes S100B protein as a diagnostic tool as well as a potential therapeutic target in patients with mTBI.

Cross-Cultural Adaptation of the Urdu Version of Rosenbaum Concussion Knowledge and Attitude Survey—Student Version in Pakistan

Evaluating athletes’ knowledge of and attitudes toward sports-related concussions is important. However, there is limited research involving South Asian athletes, partly due to the lack of a valid and reliable tool. This study, therefore, aimed to translate and validate the Rosenbaum Concussion Knowledge and Attitude Survey—Student Version, an established tool used to measure knowledge and attitude toward concussion, into Urdu. Rosenbaum Concussion Knowledge and Attitude Survey—Student Version was translated into Urdu using the standard guidelines and then completed by 369 athletes participating in contact sports at different universities in Pakistan. Confirmatory factor analysis was performed on the Concussion Attitude Index items to examine the underlying factorial structure. Construct validity of Concussion Attitude Index factors was also investigated using convergent and discriminant validity. The results showed that the Urdu version of the Rosenbaum Concussion Knowledge and Attitude Survey—Student Version has good psychometric properties and is a valid and reliable tool for evaluating Urdu-speaking athletes’ knowledge of and attitudes toward concussions.

The Effect of Whole-Body Fatigue on King-Devick Test and Balance

Purpose: Fatigue may mimic suboptimal brain functioning seen after a concussion and lead to false-positive King-Devick (K-D) scores and decreased balance. The purpose of this study was to investigate if whole-body fatigue has an effect on K-D scores or postural sway. Method: A total of 38 healthy participants (20 females; age = 23.5 ± 2.63 y; height = 170 ± 0.1 cm; mass = 75.2 ± 10.3 kg) volunteered for the study. Participants completed the King-Devick (K-D) test and the modified Clinical Test of Sensory Interaction of Balance (mCTSIB) on the Biodex BioSway^TM Portable Balance System prior to and immediately following the completion of a fatigue protocol on a Concept2 Rower. Results: Half of the participants demonstrated a positive K-D test post-fatigue. Balance scores were poorer post-fatigue. No difference was found between participants based on history of concussion. Among the participants that had a positive post-fatigue K-D test, 71% had also a worse composite sway index score (χ² = 6.3, p = .02). Conclusions: Whole-body fatigue may negatively impact a person's ability to perform the K-D test and balance assessments. It is recommended that the athlete is allowed a period of time to accommodate for the acute effects of fatigue before administering these assessments following a suspected concussion.

Match and training injury incidence in rugby league: A systematic review, pooled analysis, and update on published studies

In studies reporting rugby league injuries, match injuries varied depending upon participation level. To review and update pooled data estimates for rugby league injury epidemiology and add information for participation levels in match and training environments. A systematic review and pooled analysis for published studies reporting rugby league match and training injuries. Searches were performed in the PubMed, CINHAL, ScienceDirect, Scopus, SPORTDiscus, SpringerLink, and Wiley Online databases. Studies were considered if they reported on rugby league match or training injuries between Jan 1990 to June 2021. Two authors (DK, TC) extracted the study characteristics, numerical data and assessed the article quality, by adhering to the protocol for systematic review of observational studies (MOOSE) and the STrengthening and Reporting of OBservational studies in Epidemiology (STROBE) statement. The 46 studies included a combined exposure of 419,037 h and 18,783 injuries incorporating 158,003 match-hr and 15,706 match injuries (99.4 [95%CI: 97.9–101.0] per 1000 match-hr) and 264,033 training-hr and 3077 training injuries (11.8 [95%CI: 11.4–12.2] per 1000 training-hr). Of included studies, 47.9% utilised a medical attention/treatment injury definition. There was a five-fold difference in injuries for the semi-professional participation level (431.6 per 1000 match-hr) compared with professional (RR: 4.92; p < 0.001) and elite (RR: 3.77; p < 0.001) participation levels. The hooker recorded the highest pooled injury incidence (93.1 per 1000 match-hr). Compared to the 2014 analysis there was a 10-fold increase for head-neck region (RR: 10.7; p < 0.001) injury incidence, and more injuries for the ball carrier (RR: 1.1; p = 0.008) and tackler (RR: 1.2; p = 0.001). There was a three-fold decrease in injury incidence in the first half (RR: 2.9; p < 0.001) and a two-fold decrease in the second half (RR: 2.3; p < 0.001) of matches. While rugby league match and training injury incidence had decreased since 2014, the increase in head injuries, and greater injury rate at the semi-professional level, mean further injury prevention interventions are needed.

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Based on 46 studies, updated estimates of injury incidence for rugby league-related activities ranged from 14.6 per 1000 match-hr (Junior) to 431.6 per 1000 match-hr (Semi-Professional) participation levels for match activities and 5.3 per 1000 training-hr (Professional) to 97.1 per 1000 training-hr (Elite) participation levels for training activities.

Compared with the pooled analysis in 2014, the current analysis showed:•

The hooker playing position continues to have the highest match injury risk (93.1 per 1000 match-hr).

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The lower limb (64.5 per 1000 match-hr) continues to be the body region with the highest injury risk.

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The quadriceps was the most reported injury site (28.5 per 1000 match-hr).

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The incidence of concussion in studies reporting on rugby league match injuries increased (7.7 vs. 11.6 per 1000 match-hr); and

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Most concussions took 28 days to recover, which conflicts with the Concussion in Sport Consensus Statement that reported 80%–90% of all concussions recover in seven to ten days.

Wearables in rugby union: A protocol for multimodal digital sports-related concussion assessment

Background

Pragmatic challenges remain in the monitoring and return to play (RTP) decisions following suspected Sports Related Concussion (SRC). Reliance on traditional approaches (pen and paper) means players readiness for RTP is often based on self-reported symptom recognition as a marker for full physiological recovery. Non-digital approaches also limit opportunity for robust data analysis which may hinder understanding of the interconnected nature and relationships in deficit recovery. Digital approaches may provide more objectivity to measure and monitor impairments in SRC. Crucially, there is dearth of protocols for SRC assessment and digital devices have yet to be tested concurrently (multimodal) in SRC rugby union assessment. Here we propose a multimodal protocol for digital assessment in SRC, which could be used to enhance traditional sports concussion assessment approaches.

Methods

We aim to use a repeated measures observational study utilising a battery of multimodal assessment tools (symptom, cognitive, visual, motor). We aim to recruit 200 rugby players (male n≈100 and female n≈100) from University Rugby Union teams and local amateur rugby clubs in the North East of England. The multimodal battery assessment used in this study will compare metrics between digital methods and against traditional assessment.

Conclusion

This paper outlines a protocol for a multimodal approach for the use of digital technologies to augment traditional approaches to SRC, which may better inform RTP in rugby union. Findings may shed light on new ways of working with digital tools in SRC. Multimodal approaches may enhance understanding of the interconnected nature of impairments and provide insightful, more objective assessment and RTP in SRC.

Clinical trial registration

NCT04938570. https://clinicaltrials.gov/ct2/results?cond=NCT04938570&term=&cntry=&state=&city=&dist=

Annual Baseline King-Devick Oculomotor Function Testing Is Needed Due to Scores Varying by Age

Objective: To document baseline King-Devick (K-D) oculomotor function scores for male and female participants aged between 4 and 20 years old. Methods: Utilising a cross section of schools, rugby clubs and gymnastic clubs, 1936 participants (1300 male, 636 female) completed the spiral-bound K-D test for the identification of disturbed oculomotor function. Results: This study identified that overall, the baseline scores of the K-D test became faster by 1.4 (0.3 to 4.5) s per year, when compared with the previous age group in the same number of reading card groups. When comparing normative values of the original K-D validation study with the same age groups of the current cohort, participants aged 6 to 11 years recorded a faster baseline time (range 3.5 to 8.6 s), while those in the 12 to 14 years. age group recorded slower baseline times (range −3.9 to −7.9 s). Discussion: In general, there were age group differences, but not sex differences, for K-D test times in the current cohort. Analysis of single card times, across all age groups, showed changes likely due to improved reading time. Conclusion: The results support the need for individualised annual pre-injury baseline testing of the K-D test.

Sports related concussion: an emerging era in digital sports technology

Sports-related concussion (SRC) is defined as a mild traumatic brain injury (mTBI) leading to complex impairment(s) in neurological function with many seemingly hidden or difficult to measure impairments that can deteriorate rapidly without any prior indication. Growing numbers of SRCs in professional and amateur contact sports have prompted closer dialog regarding player safety and welfare. Greater emphasis on awareness and education has improved SRC management, but also highlighted the difficulties of diagnosing SRC in a timely manner, particularly during matches or immediately after competition. Therefore, challenges exist in off-field assessment and return to play (RTP) protocols, with current traditional (subjective) approaches largely based on infrequent snapshot assessments. Low-cost digital technologies may provide more objective, integrated and personalized SRC assessment to better inform RTP protocols whilst also enhancing the efficiency and precision of healthcare assessment. To fully realize the potential of digital technologies in the diagnosis and management of SRC will require a significant paradigm shift in clinical practice and mindset. Here, we provide insights into SRC clinical assessment methods and the translational utility of digital approaches, with a focus on off-field digital techniques to detect key SRC metrics/biomarkers. We also provide insights and recommendations to the common benefits and challenges facing digital approaches as they aim to transition from novel technologies to an efficient, valid, reliable, and integrated clinical assessment tool for SRC. Finally, we highlight future opportunities that digital approaches have in SRC assessment and management including digital twinning and the "digital athlete".

Level of knowledge and misconceptions about brain concussion in Brazilian adults

BACKGROUND

Brain concussion (BC) is seen as a public health priority due to its high incidence and morbidity rate, among thousands of people around the world. There are needs for fast identification, accurate diagnosis and correct management in order to reduce the short and long-term problems relating to BC. Proper knowledge of BC in the population and among clinicians is a critical factor in achieving this.

OBJECTIVES

To evaluate the level of self-reported BC knowledge and gaps/misconceptions, and to identify variables correlated with this level.

METHODS

A cross-sectional descriptive survey was performed. A Brain Concussion Knowledge Questionnaire (BCKQ) that had been created to capture data was widely distributed. Total scores, domain partial scores and percentages of correct and incorrect answers were calculated to ascertain the level of knowledge relating to BC.

RESULTS

The sample was formed by 1,247 Brazilian adults (age: 41.7±11.8 years). Partial scores of the BCKQ revealed the existence of poor knowledge and misconceptions in all domains of the questionnaire, especially regarding questions about recovery from and management of BC. Moderate correlations between BCKQ scores and professions (p=0.312; P=0.00) or previous brain concussion knowledge (p=0.489; P=0.00) were observed. In a multiple linear regression model, age, profession and sports practice were predictors of BC knowledge.

CONCLUSION

This first study to analyze the level of BC knowledge in a sample of Brazilian adults suggests that poor knowledge and misconceptions are present. Thus, meaningful and useful information was provided by this study for developing health education programs about BC for the population in order to improve fast diagnosis and correct BC management.

Topical Review: Perceptual-cognitive Skills, Methods, and Skill-based Comparisons in Interceptive Sports

SIGNIFICANCE

We give a comprehensive picture of perceptual-cognitive (PC) skills that could contribute to performance in interceptive sports. Both visual skills that are low level and unlikely influenced by experience and higher-level cognitive-attentional skills are considered, informing practitioners for identification and training and alerting researchers to gaps in the literature.Perceptual-cognitive skills and abilities are keys to success in interceptive sports. The interest in identifying which skills and abilities underpin success and hence should be selected and developed is likely going to grow as technologies for skill testing and training continue to advance. Many different methods and measures have been applied to the study of PC skills in the research laboratory and in the field, and research findings across studies have often been inconsistent. In this article, we provide definitional clarity regarding whether a skill is primarily visual attentional (ranging from fundamental/low-level skills to high-level skills) or cognitive. We review those skills that have been studied using sport-specific stimuli or tests, such as postural cue anticipation in baseball, as well as those that are mostly devoid of sport context, considered general skills, such as dynamic visual acuity. In addition to detailing the PC skills and associated methods, we provide an accompanying table of published research since 1995, highlighting studies (for various skills and sports) that have and have not differentiated across skill groups.

Athletes' and Coaches' Attitudes Toward Protective Headgear as Concussion and Head Injury Prevention: A Scoping Review

The purpose of this article is to map existing research literature on athletes and coaches' attitudes toward protective headgear in sport in relation to concussion and head injury prevention, and to identify and analyse knowledge gaps in the field. A scoping review was conducted in three databases; PubMed, Scopus, SportDiscus, and reference lists were searched to identify relevant grey literature. This process lead to an in-depth analysis of 18 peer-reviewed journal articles. Of the 18 studies identified, the majority focused on athletes (n = 14), only two studies focused on coaches, and two studies included a sample of both athletes and coaches. The findings in this scoping review suggests that there is a discrepancy between attitudes and beliefs about the protective effects of headgear, athletes' behaviour as far as wearing protective headgear, and coaches' behaviour in terms of recommending use of protective headgear to their athletes. The majority of athletes in most of the reviewed literature believed that headgear had protective effects against concussion and other head injuries, however relatively few athletes report wearing this protective headgear unless it was mandatory by competition rules.

The Current Status of Concussion Assessment Scales: A Critical Analysis Review

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Concussion is a complex pathophysiologic process that affects the brain; it is induced by biomechanical forces, with alteration in mental status with or without loss of consciousness.

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Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers.

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The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete.

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Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.

Soccer, concussions, and safety: Perceptions of parents of youth soccer participants

INTRODUCTION

The rate of concussions in youth soccer is among the highest of all youth sports. Parents play an important role in caring for their children and making decisions regarding whether they should participate in a sport, such as soccer, where concussions are well known. This study examined parental perceptions regarding: (a) coaches' role in concussion management, (b) heading restriction policies, and (c) overall concussion risk and participation issues.

METHOD

Online surveys were completed by 419 parents of youth soccer players who participated in the largest U.S. youth soccer programs nationwide.

RESULTS

Findings indicated 44.5% of the respondents had considered keeping their children from playing organized soccer and 47.2% were concerned about a potential decline in youth soccer participation due to concussions. Nearly 69% of responding parents agreed that heading should be banned for participants 10 years old or younger, while 56.5% thought heading should not be limited for participants 13 or older. Only 35% of parents were very confident about their child's coach's ability to properly identify concussions and remove those suspected of a concussion from play. Parents' socioeconomic status (SES), soccer coaching and playing experience, and previous history of concussion(s) were key predictors of greater perceived risk about concussions.

CONCLUSIONS

Findings from this study shed light on parents' perceptions about concussions and related safety issues in youth soccer. Understanding what parents believe about concussions is vital to preserve youth soccer participation and can be used to strengthen education and policies that promote a safer environment for youth sport participants. Practical Applications: Youth soccer coaches can benefit from stronger, comprehensive educational efforts at the league/club level. Additionally, parents of youth athletes who are in the lower SES communities should be targeted to receive concussion safety information and/or interventions that would improve their knowledge, attitude, and practices regarding concussion safety.

Factors Associated with Symptom Reporting in U.S. Service Academy Cadets and NCAA Student Athletes without Concussion: Findings from the CARE Consortium

BACKGROUND

Symptom resolution is a key marker in determining fitness for return to activity following concussion, but in some cases, distinguishing persistent symptoms due to concussion versus symptoms related to other factors can be challenging.

OBJECTIVE

To determine base rates of postconcussional syndrome (PCS) diagnostic categorization in healthy cadets and student athletes with no recent concussion.

METHODS

13,009 cadets and 21,006 student athletes completed baseline preseason testing. After inclusion/exclusion criteria were applied, the final sample included 12,039 cadets [9123 men (75.8%); 2916 women (24.2%)] and 18,548 student athletes [10,192 men (54.9%); 8356 women (45.1%)]. Participants completed the Sport Concussion Assessment Tool-3rd Edition (SCAT3) symptom evaluation as part of baseline preseason testing. The PCS diagnostic categorization was classified by the International Classification of Diseases, 10th Revision (ICD-10) symptom criteria for PCS.

RESULTS

In the absence of recent concussion, subgroups of cadets (17.8% of men; 27.6% of women) and student athletes (11.4% of men; 20.0% of women) reported a cluster of symptoms that would meet the ICD-10 symptom criteria for PCS. Participants with insufficient sleep and/or preexisting conditions (e.g., mental health problems), freshmen cadets, and cadets at the U.S. Coast Guard Academy and at the U.S. Air Force Academy (freshmen were tested during basic cadet training) were more likely to report a cluster of symptoms that would meet the ICD-10 symptom criteria for PCS.

CONCLUSION

The ICD-10 symptom criteria for PCS can be mimicked by preexisting conditions, insufficient sleep, and/or stress. Findings support person-specific assessment and management of symptoms following concussion.

Physician Medical Assessment in a Multidisciplinary Concussion Clinic

Concussive brain injury (CBI) is encountered by clinicians in sports medicine, pediatrics, neurosurgery, neurology, physiatry, and primary care. There is no gold standard diagnostic test for CBI, nor is there consensus on what neuromusculoskeletal physical examination tests should be performed on patients who have sustained CBI. This article presents an approach to the history and physical examination of the patient who has sustained a CBI that is based on a review of the literature evidence and the authors' extensive experience with this patient population. Suggested components include an elemental neurological examination that emphasizes the oculomotor/ophthalmologic and vestibular systems, as well as appropriate musculoskeletal assessment of the craniocervical and upper shoulder girdle complex. The use of supplementary tests for CBI, including assessment of exercise tolerance using the Buffalo Concussion Treadmill Test and tests of neurocognitive function, can aid in the differential diagnosis of CBI. The proposed protocol is envisioned for initial and follow-up assessments in the clinic after CBI, as well as for those with more protracted signs or symptoms. If symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents, then referral to a multidisciplinary center that focuses on CBI is recommended.

Therapeutic Effect of Aerobic Exercise for Adolescents After Mild Traumatic Brain Injury and Sport-Related Concussion: A Meta-Analysis from Randomized Controlled Trials

BACKGROUND

We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials from January 1980 to April 2018 for adolescents with mild traumatic brain injury (mTBI) to explore the value of aerobic exercise in sport-related concussion (SRC) and mTBI treatment.

METHODS

A meta-analysis for the postconcussion symptom scale (PCSS) score and time to recovery was performed with STATA software.

RESULTS

We found that aerobic exercise versus usual treatment significantly decreased the PCSS score (weighted mean difference = 6.51, 95% confidence interval: 0.29, 12.72; P = 0.040), as well as the time to recovery (weighted mean difference = -3.87; 95% confidence interval: -6.50, -1.23; P = 0.004). However, aerobic exercise showed no significant improvement in immediate postconcussion assessment and cognitive testing (P = 0.471/0.129/0.648/0.800, respectively, in verbal memory, visual memory, visual motor speed, and reaction time).

CONCLUSIONS

Compared with usual treatment, aerobic exercise promoted mTBI adolescents' recovery, assessed by PCSS and time to recovery. However, aerobic exercise may not help with neurocognitive function recovery.

Sports Medicine Fellowship Training Improves Sport-related Concussion Evaluation

Evaluating acute sport-related concussion (SRC) differs among providers, who apply international consensus and national guidelines variably. Retrospective medical record review was completed for 889 outpatients aged 7 to 18 years, diagnosed with SRC from 2014 to 2017. Associations between board-certified sports medicine fellowship (SMF) training status and assessment of concussion-specific history and physical examination items were tested using nonparametric χ tests. Differential odds (by fellowship training status) of using history and physical examination items were assessed using multivariable logistic regression modeling. Each SRC history and physical examination items were assessed in higher proportions by SMFs, as compared with non-SMFs, statistically significant for all tested items with the exception of headache history. SMFs demonstrated higher odds of detailed neurologic examinations and clinical cognitive testing compared with non-SMFs, after adjusting for patient and physician characteristics. Physicians caring for concussed patients should seek continuing education opportunities aligning them with training provided to sports medicine fellows.

The effect of diagnostic terminology on cognitive, emotional, and post-concussive sequelae following mild brain injury

Objective: We sought to determine whether the diagnostic terms 'mild traumatic brain injury (mTBI)' and 'concussion' result in differences in perceived cognitive, emotional, and post-concussive sequelae.Method: A total of 81 healthy university students (79% female; 69% of Asian descent) were randomly assigned to one of two conditions: mTBI (n = 41), or concussion (n = 40), and were instructed to simulate on a battery of cognitive (Neuropsychological Assessment Battery - Screening Module), emotional (Beck Anxiety Inventory, Beck Depression Inventory-II), and post-concussive (Rivermead Postconcussive Symptoms Questionnaire) measures.Results: There were no significant group differences between expected cognitive, emotional, or post-concussive consequences. However, both groups received poorer scores than the normative data.Conclusions: These results suggest that diagnostic terminology does not appear to influence anticipated recovery following mild brain injury. However, the presentation of information about the injury itself may impact recovery outcomes. This study provides preliminary support for the potential negative effects that may arise as a result of providing participants with non-evidence based information about mild brain injuries.

Content analysis of concussion education for coaches of youth and high school sport

OBJECTIVE

Describe the extent to which concussion education provided to coaches of US high school and youth sport is inclusive of information necessary for them to engage in target behaviors related to the prevention, identification and management of concussion.

METHODS

Sport organizations included in the sample were US state high school governing bodies and national governing bodies (NGBs) for youth sports with the highest concussion incidence rates. The concussion education resources made available online for coaches by these organizations were coded for content relevant to concussion prevention, identification and management.

RESULTS

All but one state high school governing body required coach concussion education, two NGBs required coach education, seven recommended it and only one did not require or recommend it. All educational materials covered at least 84% (n = 16/19) of the relevant knowledge domains.

DISCUSSION

Existing concussion education for coaches is addressing most, but not all, topics that may help coaches engage in concussion prevention, identification and management. Additional program development work is warranted to augment educational content related to coach communication about concussion safety with athletes and parents. Content appropriateness notwithstanding, further research is needed to understand the acceptability, efficacy, and implementation of concussion education for coaches.

Concussion knowledge, attitudes and behaviour in equestrian athletes

OBJECTIVE

To determine knowledge, attitudes and behaviour towards concussion in adult equestrian athletes.

DESIGN

Nationwide, cross-sectional, questionnaire.

METHODS

Participants were recruited via advertisements circulated through social media, community presentations and equestrian organisations. Participants were sent a web link to an online questionnaire previously designed for high school athletes and modified to ensure relevance to equestrian activities. The percentage of correct responses per item and a total knowledge score were calculated. Differences in concussion knowledge by age, sex, level of experience and previous history of concussion were explored using t-tests, 95% confidence intervals (CI) and effect sizes.

RESULTS

The questionnaire was completed by 1486 participants (Mean age=39.1±15.4). Knowledge of what concussion was, how to recognise it and key symptoms (except poor sleep) was high (>80%). In contrast, awareness of guidelines was moderate (56%) and inability of helmets to prevent concussion was low (12%). Significantly higher levels of knowledge of concussion were identified in females compared with males (t=-6.55 p<0.001, 95%CI=-3.26 to -1.75). The majority (87%) of participants reported that a helmet should be replaced after a fall, yet 46% reported re-using a helmet following a hit to the head.

CONCLUSIONS

Knowledge of and attitudes towards concussion were positive. However, there were knowledge gaps and discrepancies between some attitudes and behaviour on some aspects of concussion. Targeted campaigns to promote awareness of concussion and improve recognition and onward management are needed. Education related to equestrian activities such as helmet use and injury mechanisms is needed to change behaviour and minimise the risk of injury.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population

OBJECTIVES

To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education.

DESIGN

Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit.

SETTING

Three military treatment facilities.

PARTICIPANTS

Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury.

RESULTS

Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time.

CONCLUSIONS

Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider's use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Sports-Injury Encephalopathy

Sports-related encephalopathies are a growing concern among athletes who have experienced head trauma. Anxiety is heightened for the public and especially among parents of children playing contact sports. The most common neuropsychological conditions are concussions and traumatic encephalopathies. Concussions result from brain traumas that can be asymptomatic, but more serious concussions can include loss of consciousness, neurological abnormalities, and/or posttraumatic amnesias. Repetitive concussions lead to persistent brain pathology, known as chronic traumatic encephalopathies. This gradually progressive neurodegenerative disease frequently presents with cognitive and neurological deficits, which can result in significant parkinsonian features and dementia. Imaging studies may be noncontributory; however, diffusion tensor imaging, magnetic resonance spectroscopy, and functional magnetic resonance imaging can detect changes indicative of these encephalopathies. Progressive neuronal degeneration with tau proteins are documented on pathological examination. Prevention, early diagnosis, and proper treatment are the recommended approach to these conditions.

A review of concussion diagnosis and management in Australian professional sporting codes

Objectives: The recognition and management of concussion has become a major health concern across all sports. Despite recent attention, concussion assessment and return-to-play protocols appear to be highly variable between leading professional sporting bodies across Australia. Without readily available guidelines, players at all levels may be at risk of suboptimal management following in-game trauma. The purpose of this study was to explore the publicly available concussion guidelines of the major Australian sporting codes with an aim to identify potential opportunities to develop a national sporting consensus.Methods: Internet sites of the major sporting organizations within Australia were accessed between June 2018 to July 2018. Sites were reviewed for information pertaining to an available concussion protocol or guidelines including; concussion definition, player education documentation, requirement of baseline testing, standard concussion diagnostic measures, use of sideline testing and removal from play guidelines, return-to-play, minimum return-to-play intervals and the implementation of external evaluation of potential concussion cases.Results: Twelve sites were visited. There was consensus between many of the sporting organizations in terms of concussion definition, removal of play and sideline testing protocols. A step-wise return-to-play protocol was prevalent across most sports. A number of sporting sites however did not have readily available information.Conclusions: There is notable room for the development of concussion guidelines in Australian sport. Researchers and sporting organizations need to continuously amend current protocols to ensure this reflects best evidence-based practice.

Improved Concussion Discharge Instructions in a Pediatric Emergency Department

Pediatric concussions are common and many children seek care in emergency departments. Providing concussion discharge instructions to patients and families is part of routine standard of care. The objective of this study was to determine whether the use of the Acute Concussion Evaluation-Emergency Department Discharge Instructions (ACE-ED DI) improves the caregiver's knowledge of injury management, specifics about returning to school and sports activities, and outpatient follow-up. This was a quasi-experimental study conducted in an urban Level 1 trauma center pediatric emergency department (PED). A convenience sample of caregivers of children aged 5-18 years who presented to the PED with a concussion was recruited and consented to participate. Caregivers completed a 16-item survey to assess overall understanding of concussion management after instructions were given. Caregivers received the standard discharge instructions (SDIs) in Phase 1 and SDIs plus the ACE-ED DI in Phase 2. Descriptive statistics were used for demographic variables and t-test to compare groups. Sixty-three of 68 (93%) caregivers participated; 30 in the SDI group and 33 in the SDI plus ACE-ED DI group. Demographic characteristics were similar between groups. Caregivers who received the ACE-ED DI reported a 24% increase in helpfulness of written materials (p < 0.001), a 25% increase in perceived understanding about concussion injury and management (p < 0.001), a 23% increase in understanding about returning to school activities (p < 0.001), and were 17% more likely to follow up with their primary care provider (p < 0.001). The ACE-ED DI used in a PED was found to be more effective at increasing caregivers' perceived knowledge of concussion management, specifics about returning to school and sports activities, and outpatient follow-up.

Sports Medicine Update: Concussion

A systematic approach is required for patients with a suspected concussion. Although standardized tools can aid in assessment, the diagnosis of concussion remains a clinical one. At the time of diagnosis, patients should be given both verbal and written review of the common symptoms of concussion, expected course of recovery, as well as strategies to manage symptoms. Most patients benefit from a brief period of rest, followed by a gradual reintroduction of activities, and a graduated return-to-sport protocol. Patients with prolonged recovery from a concussion may benefit from exercise, vestibular, and cognitive rehabilitation programs.

Sports-related concussion management as a control problem: using STAMP to examine concussion management in community rugby

The effective management of sports-related concussion is an on-going problem in amateur sport due to a number of systemic issues. These factors have often been studied in isolation with minimal consideration for the interactions between them, or the overall system in which they occur. The aim of this research was to model the actors, controls, and feedback mechanisms influencing the management of concussion in community rugby union using the Systems-Theoretic Accident Model and Processes (STAMP) method. Findings show that there are currently many inadequate controls, that are directly and indirectly impacting effective concussion management. The practical implications of these findings are discussed (e.g. improved guideline education, mandatory medical presence, rule amendments). Additionally, the model provides a sound framework similar team sports can use to inform research into injury management and prevention (e.g. rugby league, hockey, AFL). Practitioner Summary: Research shows that concussion management in regional sport is inconsistent due to contextual limitations. Systems-Theoretic Accident Model and Processes was applied to identify the systemic factors currently influencing concussion management practices in community sport. Findings show inadequate controls precipitate concussion management gaps. Practical implications of the findings are discussed.

A systems approach to understanding the identification and treatment of sport-related concussion in community rugby union

AIM

The aim of the present study was to utilise a systems thinking approach to explore the perceived responsibilities for identifying and treating concussion held by different actors across the community rugby system (e.g., players, coaches, parents, medics, referees, and management), as well as their role-specific concussion management strategies.

METHODS

A systems approach was taken to assess what different stakeholders within rugby systems perceive their roles to be regarding concussion identification and treatment. Through an online survey, 118 members of the amateur (community) rugby union system were asked about their role-specific concussion management responsibilities and strategies. Respondents included players, parents, medics, coaches, club managers, administrators, and volunteers.

RESULTS

The majority of respondents indicated that they were able to identify the symptoms of rugby-related concussion, however, only medics stated their responsibility to use formal concussion assessments (e.g., SCAT2). A smaller number of the respondents indicated that they were involved in treating concussion within their current role/s (majority of which were medics).

CONCLUSIONS

This study illustrated that the current challenges in the identification and treatment of rugby-related concussion in community sport may be due to role/responsibility confusion and possible overreliance on field-side medics. These findings offer insight into the possible limitations of the current concussion management guidelines and may offer empirically based direction for future revisions.

Assessing concussion knowledge and awareness in faculty and staff in a collegiate setting

Purpose

To examine faculty and academic support staff members’ awareness and knowledge regarding concussions.

Design

Cross-sectional, web-based questionnaire.

Setting

Division II collegiate setting.

Subjects

A total of 123 collegiate faculty, administrative and academic support staff participated in the study. Measure(s): Participants completed the Faculty and Staff Concussion Awareness and Knowledge Survey. Analysis: Descriptive statistics were compiled for demographic information within the survey. Analysis of variance was performed on concussion awareness and concussion knowledge survey questions.

Results

The majority of the sample had teaching responsibilities in the University (75%). There was a significant effect of college departments within the university on individuals’ level of awareness (F (5, 117) = 9.74, p < .001). The Athletics department scored the highest in awareness of concussion symptomology, while the Business department scored the lowest. Females demonstrated significantly more awareness of concussion symptoms than males (F (1, 121) = 10.488, p = .002). University department significantly impacted knowledge of concussion treatments (F (5, 117) = 3.67, p < .004). The Health Sciences department scored the highest in knowledge of concussion treatments, while the Business department scored the lowest. Past experience with academic accommodations was associated with respondents’ knowledge of concussion treatment (F (1, 121) = 4.046, p = .047).

Conclusions

Concussion management in a collegiate setting should include the faculty and academic support staff. Colleges and Universities should consider educational programming regarding etiology and recovery from concussions for effective management when student experience a concussion.

Parental knowledge of concussion: Evaluation of the CDC's "Heads up to parents" educational initiative

BACKGROUND

Potential negative outcomes associated with sport-related concussion drive the need for resources to educate parents about prevention, recognition, and management of concussion in the youth athlete. Parents play a critical role in the recognition and management of concussion for their child.

PURPOSE

This study aims to (a) investigate current knowledge of concussion among parents whose children age 5-18 years play a club sport and (b) identify effects of an online video versus online print educational intervention on concussion knowledge change and learning.

METHODS

140 parents whose children played a club sport answered questions regarding their knowledge of sport-related concussion pre- and post-random assignment to an educational intervention: CDC Concussion Awareness video or CDC Concussion Fact Sheet for Parents.

RESULTS

Participating parents demonstrated a moderate level of pre-intervention knowledge, but critical gaps in knowledge were identified. Knowledge of concussion improved slightly following intervention regardless of intervention type.

CONCLUSIONS

This study confirms the presence of gaps in knowledge of concussion in parents whose children play club sports. Without the protection of concussion legislation, those athletes who participate in club sports are at particular risk due to lack of concussion knowledge and education. This study confirms that education can have a positive impact on parental knowledge of concussion. Practical applications: Pre-knowledge of concussion is the greatest predictor of post-knowledge of concussion, therefore pre-assessment of target audience knowledge followed by a custom educational intervention taking into account principles of adult learning, would be the most beneficial to increasing concussion knowledge.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Traumatic brain injuries in New Zealand: National Insurance (Accident Compensation Corporation) claims from 2012 to 2016

AIM

To provide epidemiological data and related costs to the national health insurance scheme for traumatic brain injury (TBI) in New Zealand.

METHOD

A retrospective analytical review utilising detailed descriptive minor and moderate-to-severe epidemiological TBI data obtained from the Accident Compensation Corporation (ACC) for 2012-2016. Injuries were analysed by three levels of increasing severity: moderate, moderate-to-serious (MSC) and severe claims categories.

RESULTS

Over the January 2012 to December 2016 period there were 97,955 claims for TBI costing ACC $1,450,643,667 [equivalent to £$743,417,120]. Falls accounted for nearly half (41.7%, 8262), and over a quarter (39.9%; $67,626,000 [£34,662,176]) of the moderate claims for TBI. Motor vehicle accidents recorded the highest percentage (36.5%), total costs ($610,978,229 [£313,170,000]) and highest mean cost per-moderate claim per-year ($47,372 ± $2401 [£24,282 ± £1231]) for MSC TBI claims. This was similar for severe claims where motor vehicles accidents accounted for 56% of the total serious claims, 65.1% of the costs with a mean cost per-serious claim of $64,913 ± 4331 [£32,759 ± £2186] per-year.

CONCLUSION

There were 97,955 TBI injury claims lodged over the duration of the study with 36% (n = 35,304) classified as MSC. The incidence of total TBI in New Zealand was 432 per 100,000 population, and 155 per 100,000 for MSC TBI claims. Despite the growing number of studies reporting on the effects of sports-related TBI, there is a paucity of studies reporting on the longitudinal effects of TBI in falls, assaults and motor vehicle accidents. Further research is warranted into the assessment and management of intimate partner violence and child abuse victims for TBI's.

Epidemiology of Head Injuries Focusing on Concussions in Team Contact Sports: A Systematic Review

BACKGROUND

Although injuries to the head represent a small proportion of all sport injuries, they are of great concern due to their potential long-term consequences, which are even suspected in mild traumatic brain injuries.

OBJECTIVE

The aim of this review was to compare the incidence of concussions and other head injuries in elite level football, rugby, ice hockey and American Football.

METHODS

Four electronic databases (CINAHL, PsycINFO, Web of Science, PubMed) were searched. Prospective cohort studies on the incidence of concussion in elite athletes aged 17 years or older that were published in an English-language peer-reviewed journal since 2000 were included. Two authors independently evaluated study eligibility and quality. The extracted data on concussions were pooled in a meta-analysis using an inverse-variance fixed-effects model. The extracted data on head injuries were reported in a narrative and tabular summary.

RESULTS

The search yielded 7673 results of which 70 articles were included in the qualitative and 47 in the quantitative analysis. In our meta-analysis, we found the highest concussion incidences in rugby match play (3.89 and 3.00 concussions per 1000 h and athletic exposures (AEs), respectively), and the lowest in men's football training (0.01 and 0.08 per 1000 h and AEs, respectively). Overall, concussions and all head injuries were rare in training when compared to match play. Female players had an increased concussion risk in football and ice hockey when compared to male players.

CONCLUSION

Future research should focus on concussion in women's contact sports, as there is little evidence available in this area. Methodological deficits are frequent in the current literature, especially regarding sample size and study power, and should be avoided.

Incidence of Concussion and Head Impacts in Australian Elite-Level Male and Female Cricketers After Head Impact Protocol Modifications

Background:

Concussion in sport is a topic of growing interest in Australia and worldwide. To date, relatively few studies have examined the true incidence of concussion in cricket.

Hypothesis:

Concussion in cricket is more common than current literature suggests.

Study Design:

Descriptive epidemiology study.

Level of Evidence:

Level 4.

Methods:

This is a prospective registry and subsequent analysis of head impacts and concussions in elite-level male and female cricketers in Australia over 2 seasons (2015-2016 and 2016-2017). A total of 172 male and 106 female domestic and international players in 2015-2016 and 179 males and 98 females in 2016-2017 were included.

Results:

There were 92 head impacts (29 concussions) in men’s matches and 15 head impacts (8 concussions) in women’s matches. Match incidence rates per 1000 player days were 7.2 head impacts (2.3 concussions) in elite male cricket and 3.7 head impacts (2.0 concussions) in elite female cricket. This equates to a head impact every 2000 balls and concussion every 9000 balls in male domestic cricket. Concussion rates per 1000 player-match hours were 0.4 for elite males and 0.5 for elite females; 53% of head impacts in females were diagnosed as concussions compared with 32% in males, and 83% of concussions resulted in missing no more than 1 game.

Conclusion:

The rate of concussion in cricket is higher than previously appreciated; however, the majority of patients recovered quickly, and players generally did not miss much playing time as a result. The institution of concussion policies after head impact, including player substitution, appears to have had an effect on increasing reporting of symptoms, resulting in an increase in diagnosis of concussion.

Clinical Relevance:

Concussion in cricket is not as infrequent as previously assumed. Ongoing review of the rules and regulations is required to ensure that protection of player welfare lies in parallel with other sporting codes.

Sport-Related Concussion and Mental Health Outcomes in Elite Athletes: A Systematic Review

Background

Elite athletes can experience a diverse range of symptoms following post-concussive injury. The impact of sport-related concussion on specific mental health outcomes is unclear in this population.

Objective

The aim was to appraise the evidence base regarding the association between sport-related concussion and mental health outcomes in athletes competing at elite and professional levels.

Methods

A systematic search of PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane, and Cinahl databases was conducted.

Results

A total of 27 studies met inclusion criteria for review. Most of the included studies (67%, n = 18) were published in 2014 or later. Study methodology and reporting varied markedly. The extant research has been conducted predominantly in North America (USA, n = 23 studies; Canada, n = 3), often in male only (44.4%, n = 12) and college (70.4%, n = 19) samples. Depression is the most commonly studied mental health outcome (70.4%, n = 19 studies). Cross-sectional retrospective studies and studies including a control comparison tend to support an association between concussion exposure and depression symptoms, although several studies report that these symptoms resolved in the medium term (i.e. 1 month) post-concussion. Evidence for anxiety is mixed. There are insufficient studies to draw conclusions for other mental health domains.

Conclusion

Consistent with current recommendations to assess mood disturbance in post-concussive examinations, current evidence suggests a link between sports-related concussion and depression symptoms in elite athletes. Causation cannot be determined at this stage of enquiry because of the lack of well-designed, prospective studies. More research is required that considers a range of mental health outcomes in diverse samples of elite athletes/sports.

Electronic supplementary material

The online version of this article (10.1007/s40279-017-0810-3) contains supplementary material, which is available to authorized users.

Public Attitudes and Knowledge About Youth Sports Participation and Concussion Risk in an Urban Area

BACKGROUND

Every year, millions of children in the United States participate in youth full-contact sports, which carry concussion risks-the long-term sequelae of which are not well understood. We examined the attitudes and knowledge of adults in Chicago about youth sports participation, concussion risk, and whether physicians should counsel against youth participation in full-contact sports.

METHODS

An anonymous paper survey featuring 13 attitudinal, 13 demographic, and 9 knowledge questions was distributed to a convenience sample of adults ≥18 years in hospital waiting areas and four Chicago parks. Participants were asked to hypothetically consider themselves the parent of a 10-year-old child regarding attitudes towards full-contact sports participation.

RESULTS

Between June 13 and July 27, 2016, 1091 partial or complete valid surveys were collected. Almost half (46%) of respondents would not allow a hypothetical 10-year-old son to play tackle football. The majority (74%) of respondents agreed that it was appropriate for physicians to counsel against youth participation in full-contact sports. Respondents obtained information about concussions from, on average, 2-3 sources, although only 34% received information from physicians. Respondents demonstrated a high concussion knowledge level (average: 6.75 of 9 questions). However, only 39% of respondents correctly answered that the following statement was false: "After a mild concussion, there are usually visible changes on medical imaging".

CONCLUSIONS

Overall, respondents are well-informed about concussions. They are divided about the participation of youth in full-contact sports and are amenable to physician counseling against youth participation in full-contact sports.

Using sideline concussion tests in the emergency department

Purpose

Traumatic brain injury (TBI) is a significant cause of death and disability in the United States. Many patients with TBI are initially treated in the emergency department (ED), but there is no evidence-based method of detecting or grading TBI in patients who have normal structural neuroimaging. This study aims to evaluate the validity of two common sideline concussion tests. The Concussion Symptom Severity Score (CSSS) and modified Balance Error Scoring System (mBESS) tests are well-validated sideline tests for concussion, but have not been validated in the setting of non-sport-related concussion, in settings other than the sideline or athletic training room or in moderate or severe TBI.

Patients and methods

One hundred forty-eight subjects who had sustained a TBI within the previous 72 hours and 53 healthy control subjects were enrolled. CSSS and mBESS were administered. Clinical outcomes were followed up prospectively.

Results

The CSSS was collected in 147 TBI subjects but only 51 TBI subjects were able to complete the mBESS. The CSSS was collected for all 53 control subjects, and the mBESS was completed for 51 control subjects. The mean CSSS for TBI and control subjects was 32.25 and 2.70, respectively (P < 0.001). The average mBESS for TBI and control subjects was 7.43 and 7.20, respectively (P = 0.82). CSSS greater than 5.17 was 93.43% sensitive and 69.84% specific for TBI.

Conclusion

The mBESS is poorly tolerated and, among those who can complete the test, not sensitive to TBI in the ED. The CSSS is both sensitive to TBI and well tolerated.

Injury incidence in elite youth field hockey players at the 2016 European Championships

Despite being an essential consideration when deciding rule changes, injury prevention strategies, and athlete development models, there is little epidemiological data of U18 field hockey player injuries-something explicitly referred to in the 2015 International Olympic Committee's Consensus Statement on Youth Athlete Development. The aim of this study was to quantify incidence and characteristics of injuries in elite youth field hockey players during a major international tournament. Standardized reporting forms detailing time, location on pitch, mechanism and anatomical location of injury were completed for new musculoskeletal conditions resulting in a time stoppage by the umpire and where a player was noticeably affected by an injury for up to 20 s regardless of time stoppage. Injury incidence was 1.35 and 2.20 injuries/match or 53 and 86 injuries per 1000 player match hours for boys (B) and girls (G) respectively; girls were over three times more likely to have a minor injury. Most injuries were contusions due to being hit by the ball or stick (B: 12, G: 27), with high numbers of injuries to the torso (B: 8) and head/face (G: 7). Injuries during the penalty corner (B: 3, G: 4) were to the lower limb and hand, and boys were less likely to wear facial protection (B: 65.9%, G: 86.4%). Results form an essential initial dataset of injuries in U18 field hockey players. Current reporting protocols under-report injuries and must be addressed by the international governing body. The high number of head/face injuries, particularly in females, requires further investigation.

Comparison of video-based and sensor-based head impact exposure

Previous research has sought to quantify head impact exposure using wearable kinematic sensors. However, many sensors suffer from poor accuracy in estimating impact kinematics and count, motivating the need for additional independent impact exposure quantification for comparison. Here, we equipped seven collegiate American football players with instrumented mouthguards, and video recorded practices and games to compare video-based and sensor-based exposure rates and impact location distributions. Over 50 player-hours, we identified 271 helmet contact periods in video, while the instrumented mouthguard sensor recorded 2,032 discrete head impacts. Matching video and mouthguard real-time stamps yielded 193 video-identified helmet contact periods and 217 sensor-recorded impacts. To compare impact locations, we binned matched impacts into frontal, rear, side, oblique, and top locations based on video observations and sensor kinematics. While both video-based and sensor-based methods found similar location distributions, our best method utilizing integrated linear and angular position only correctly predicted 81 of 217 impacts. Finally, based on the activity timeline from video assessment, we also developed a new exposure metric unique to American football quantifying number of cross-verified sensor impacts per player-play. We found significantly higher exposure during games (0.35, 95% CI: 0.29-0.42) than practices (0.20, 95% CI: 0.17-0.23) (p<0.05). In the traditional impacts per player-hour metric, we observed higher exposure during practices (4.7) than games (3.7) due to increased player activity in practices. Thus, our exposure metric accounts for variability in on-field participation. While both video-based and sensor-based exposure datasets have limitations, they can complement one another to provide more confidence in exposure statistics.

Semi-Professional Rugby League Players have Higher Concussion Risk than Professional or Amateur Participants: A Pooled Analysis

A combined estimate of injuries within a specific sport through pooled analysis provides more precise evidence and meaningful information about the sport, whilst controlling for between-study variation due to individual sub-cohort characteristics. The objective of this analysis was to review all published rugby league studies reporting injuries from match and training participation and report the pooled data estimates for rugby league concussion injury epidemiology. A systematic literature analysis of concussion in rugby league was performed on published studies from January 1990 to October 2015. Data were extracted and pooled from 25 studies that reported the number and incidence of concussions in rugby league match and training activities. Amateur rugby league players had the highest incidence of concussive injuries in match activities (19.1 per 1000 match hours) while semi-professional players had the highest incidence of concussive injuries in training activities (3.1 per 1000 training hours). This pooled analysis showed that, during match participation activities, amateur rugby league participants had a higher reported concussion injury rate than professional and semi-professional participants. Semi-professional participants had nearly a threefold greater concussion injury risk than amateur rugby league participants during match participation. They also had nearly a 600-fold greater concussion injury risk than professional rugby league participants during training participation.

Association between ondansetron use and symptom persistence in children with concussions: A 5P substudy

Objective

Ondansetron is increasingly administered to children suffering from concussion-associated nausea/vomiting. We examined the association between ondansetron administration and post-concussion symptoms in children at 1 week and 1 month following the concussion.

Methods

This was a secondary analysis of data collected prospectively in a cohort study conducted in nine pediatric emergency departments (EDs) (5P study). Participants were children ages between 5 and 17.99 years who sustained a concussion in the previous 48 hours. For the current study, only 5P participants who reported nausea and/or vomiting in the ED were eligible. The exposure of interest was ondansetron administration; the comparison group included all other participants. The primary outcome was an increase in at least three symptoms of the Post-Concussion Symptom Inventory score at 1 week and 1 month following trauma.

Results

Among the 3,063 children included in the 5P study, 1805 (59%) reported nausea and provided data at 1 week and/or 1 month. Among them, 132 (7%) received ondansetron. Multivariable logistic regression adjusted for confounders did not show an association between ondansetron use and the risk of persistent post-concussion symptoms at 1 week (OR: 1.13 [95% CI: 0.86-1.49]), but it was associated with a higher risk at 1 month (OR: 1.33 [95% CI: 1.05-1.97]).

Conclusion

In children presenting to the ED with an acute concussion, ondansetron use was associated with a higher risk of persistent post-concussion symptoms at 1 month. Although this may be related to the limitations of the design, it highlights the importance of evaluating this association using a randomized clinical trial.

A Preliminary Examination of Concussion Knowledge by Collegiate Athletes and Non-Athletes

PURPOSE

Concussions affect various populations, including collegiate athletes and non-athletes. The purpose of this study was to compare collegiate varsity athletes, recreational athletes, and non-athletes' knowledge of concussion definition, symptoms, and support services available following injury. Preferred method of concussion education delivery was also examined.

METHOD

We surveyed 306 current college students using an online survey system. The survey included free recall and forced-choice question formats. Quantitative analyses were used to analyze results and compare responses among groups.

RESULTS

Collegiate athletes and non-athletes demonstrate incomplete knowledge of concussion definition, related symptoms, and professionals involved in postinjury management. Varsity athletes rated self-knowledge of concussion parameters significantly higher than the other groups (p < .001), though few significant differences in actual knowledge levels were observed. Overall, respondents reported having the highest preference for concussion education delivered by medical professionals.

CONCLUSION

Knowledge concerning concussion is incomplete in the collegiate population. Varsity athletes' exposure to formal education did not result in higher knowledge levels compared with other groups. Further examination of concussion educational delivery models' effect on change in concussion-related behavior in this population is warranted.

Parent Knowledge and Perceptions of Concussion Related to Youth Football

Introduction

There is increased concern about concussion in youth athletes, yet there is little research on parent knowledge of concussion.

Purpose 

The purpose of the current study was to investigate attitudes to and knowledge of concussion among parents of youth football players.

Methods

We surveyed 180 parents/guardians of youth football players, ages 5-12, regarding their knowledge and beliefs concerning concussion.

Results

We found that the vast majority of respondents (86%) had confidence in their ability to recognize concussions. Yet, a significant number also held misconceptions about concussions, such as ‘too much sleep’ (48%) or ‘eating certain foods’ (26%) make concussion symptoms worse. Most (82%) had not heard of the Zurich guidelines, and less than half (44%) were aware that sustained mental activity could worsen symptoms. Parents were concerned about their child sustaining a concussion, but a substantial minority also reported ‘serious concern’ about their children losing playing time or their position. 

Discussion

Results are somewhat positive in terms of parents’ general knowledge of concussions; yet, response variability and misconceptions point to a continued need for concussion education for parents. Medical professionals can play an important role in informing families about concussion symptoms, management, and recovery.