The evolving landscape of policies, rules, and law in sport-related concussion

Improving Concussion Education: Do Athletic Trainers' Opinions Match Expert Consensus?

CONTEXT

The National Collegiate Athletic Association and Department of Defense (NCAA-DoD) Mind Matters Challenge created "useful and feasible" consensus recommendations to improve concussion care-seeking behavior in collegiate athletes and military cadets. Given athletic trainers' (ATs') role as providers of concussion education and medical care, it is important to understand if they agree with the expert panel that the recommendations are useful and feasible.

OBJECTIVE

To describe and compare the perceptions of ATs in the secondary school (SS) and collegiate settings of the utility and feasibility of the NCAA-DoD Mind Matters Challenge recommendations on improving concussion education.

DESIGN

Cross-sectional study.

SETTING

Electronic survey.

PATIENTS OR OTHER PARTICIPANTS

Five hundred fifteen (515) ATs (age = 40.7 ± 12.4 years, 53.1% female gender) practicing in the SS (60.6%) or collegiate (38.4%) setting.

MAIN OUTCOME MEASURE(S)

An online survey asked participants about their awareness of the statement followed by 17 pairs of Likert-item questions regarding each recommendation's utility and feasibility with responses ranging from no (1) to yes (9). Mimicking the consensus process, we defined consensus as a mean rating of ≥7.00. We compared utility and feasibility rating responses between SS and collegiate setting participants using Mann-Whitney U tests with α = .05.

RESULTS

Two-thirds (66.6%) of participants were unaware of the consensus statement. Participants felt all recommendations were useful (all means ≥ 7.0); however, 4 recommendations related to collaborating with stakeholders did not meet the feasibility cutoff (mean range = 6.66-6.84). Secondary school ATs rated lower feasibility related to educational content (P value range = .001-.014), providing patient education throughout recovery (P = .002), and promoting peer intervention (P = .019) but higher utility (P = .007) and feasibility (P = .002) for providing parent education than collegiate ATs.

CONCLUSIONS

The NCAA-DoD Mind Matters Challenge recommendations require further dissemination. Athletic trainers rated collaboration with stakeholders as a feasibility barrier. Secondary school ATs require more resources for educational content, messaging, and promoting peer intervention but find educating athletes' parents more useful and feasible than collegiate ATs.

Collegiate student-athletes concussion knowledge and attitudes: what a difference a decade Makes

OBJECTIVE

The purpose of this study was to assess changes in concussion knowledge and attitudes amongst incoming intercollegiate student-athletes over the course of a decade (2010-2012 vs 2021-2023).

METHODS

There were 592 student-athletes from 2 cohorts (2010-2012, 2021-2023) who completed the Rosenbaum Concussion Knowledge and Attitudes Survey (ROCKaS) questionnaire which is comprised of a concussion knowledge index (CKI, 0-24) and attitude index (CAI, 15-75) with higher scores reflecting better performance. A three factor ANOVA (Group, Sex, Concussion History) compared performance on the CKI and CAI. Individual questions were compared between groups with a Chi-Square analysis.

RESULTS

For the CKI, there was a significant main effect for Group (2010-2012: 18.5 ± 2.6, 2021-2023: 19.4 ± 2.5, p < 0.001, η 2 = 0.032 ) . For the CAI, there was also a significant main effect for group (2010-2012: 52.9 ± 6.0, 2021-2023: 62.2 ± 6.5, p < 0.001, η 2 = 0.359 ) .

CONCLUSIONS

The results of this study show a modest increase in concussion knowledge; however, large improvements in concussion attitudes were observed between groups. These results suggest a continued improvement in student-athlete concussion awareness and provide specific areas to continue addressing persistent misconceptions.

Neurocognitive Test Performance and Concussion-Like Symptom Reporting Among Adolescent Athletes With Self-Reported Autism on Preseason Assessments

OBJECTIVE

To examine baseline neurocognitive functioning and symptom reporting among adolescents with self-reported autism.

METHOD

Participants in this cross-sectional, observational study were 60,751 adolescents who completed preseason testing. There were 425 students (0.7%) who self-reported an autism spectrum disorder (ASD) diagnosis. Cognitive functioning was measured by Immediate Post-Concussion Assessment and Cognitive Testing and symptom ratings were obtained from the Post-Concussion Symptom Scale.

RESULTS

Groups differed significantly across all neurocognitive composites (p values <.002); effect size magnitudes for most differences were small, though among boys a noteworthy difference on visual memory and among girls differences on verbal memory and visual motor speed composites were noted. Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 symptoms at a greater rate. Some examples of symptoms that were endorsed at a higher rate among adolescents with self-reported autism were sensitivity to noise (girls: odds ratio, OR = 4.38; boys: OR = 4.99), numbness or tingling (girls: OR = 3.67; boys: OR = 3.25), difficulty remembering (girls: OR = 2.01; boys: OR = 2.49), difficulty concentrating (girls: OR = 1.82; boys: OR = 2.40), sensitivity to light (girls: OR = 1.82; boys: OR = 1.76), sadness (girls: OR = 1.72; boys: OR = 2.56), nervousness (girls: OR = 1.80; boys: OR = 2.27), and feeling more emotional (girls: OR = 1.79; boys: OR = 2.84).

CONCLUSION

Students with self-reported autism participating in organized sports likely experience a low degree of functional impairment, on average. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery.

Concussion education perceptions among secondary school athletic trainers

PURPOSE

Describe concussion education perceptions among secondary school athletic trainers and determine the relationship between education program characteristics and perceived effectiveness.

METHODS

Two hundred and three participants completed at least one survey item (age = 35.2 ± 9.4 years; male = 27.6%). We used descriptive statistics to describe concussion education characteristics and point out biserial correlations to determine if relationships existed between concussion education characteristics and perceived effectiveness.

RESULTS

The most frequently used mandated concussion education programs were informational handouts created by the state interscholastic association, the Centers for Disease Control and Prevention's (CDC) Heads Up materials, and the National Federation of State High School Athletic Association's materials. The CDC's Heads Up materials, handouts created by the state interscholastic association, and in-person presentations created by respondents were the most frequent concussion educational programs utilized by respondents who indicated no specific program mandated. Educational programs that were engaging increased perceived effectiveness (n = 131, r_pb = 0.31,p < 0.001).

CONCLUSIONS

Our results highlight that materials created by state interscholastic association and the CDC's Heads Up program among others are utilized to satisfy mandates and are perceived to be moderately effective, especially when perceived to be engaging. These results can help guide future studies to examine specific educational tools and administration strategies to determine effectiveness on concussion disclosure.

Utility of VOMS, SCAT3, and ImPACT Baseline Evaluations for Acute Concussion Identification in Collegiate Athletes: Findings From the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium

BACKGROUND

The Vestibular/Ocular-Motor Screening (VOMS) is a valuable component of acute (<72 hours) sports-related concussion (SRC) assessments and is increasingly used with the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) instrument and the third edition of the Sport Concussion Assessment Tool (SCAT3). Research has suggested that VOMS acute postinjury scores are useful in identifying acute concussion. However, the utility of preseason baseline measurements to improve diagnostic accuracy remains ambiguous. To this end, there is a need to determine how reliable VOMS baseline assessments are across years and whether incorporating individuals' baseline performance improves diagnostic yield for acute concussions.

PURPOSE

To analyze VOMS, SCAT3, and ImPACT to evaluate the test-retest reliability of consecutive-year preseason baseline assessments to directly compare the diagnostic utility of these tools when incorporating baseline assessments versus using postinjury data alone to identify acute SRC.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Preseason and postinjury VOMS, SCAT3, ImPACT Post-Concussion Symptom Scale (PCSS), and ImPACT composite scores were analyzed for 3958 preseason (47.7% female) and 496 acute (≤48 hours) SRC (37.5% female) collegiate athlete evaluations in the National Collegiate Athletic Association-Department of Defense Concussion Assessment Research and Education Consortium. Descriptive statistics, Kolmogorov-Smirnov significance, and Cohen d effect size were calculated. Consecutive-year baseline reliability was evaluated for a subset of 447 athlete encounters using Pearson r, Cohen κ, Cohen d, and 2-way mixed intraclass correlation coefficients (ICCs). Wilcoxon signed rank tests were used to determine the statistical significance between population performances, and the 90% reliable change index (RCI) was calculated from the test-retest results. Preseason to postinjury change scores were then calculated from each tool's RCI. Finally, receiver operating characteristic (ROC) curve analyses were conducted, and DeLong method was used to compare the area under the curve (AUC) of raw postinjury scores versus change scores from preseason baseline assessments. Potential effects of sex, medical history (learning disorders or attention-deficit/hyperactivity disorder), and outlier data were also explored.

RESULTS

Effect sizes were large, and overall predictive utilities were clinically useful for postinjury VOMS Total (d = 2.44; AUC = 0.85), the SCAT3 Symptom Evaluation total severity score (d = 1.74; AUC = 0.82), and the ImPACT PCSS total severity score (d = 1.67; AUC = 0.80). Comparatively, effect sizes were small and predictive utilities were poor for Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (mBESS), and all ImPACT composites (d = 0.11-0.46; AUC = 0.48-0.59). Preseason baseline test-retest reliability was poor to moderate (r = 0.23-0.52; κ = 0.32-0.36; ICC = 0.36-0.68) for all assessments except ImPACT Visual Motion Sensitivity (r = 0.73; ICC = 0.85). Incorporating baseline scores for VOMS Total, SCAT3 (Symptom Evaluation, SAC, mBESS), ImPACT PCSS, or ImPACT composites did not significantly improve AUCs.

CONCLUSION

VOMS Total and symptom severity (SCAT3, PCSS) total scores had large effect sizes and clinically useful AUCs for identifying acute concussion. However, all tools demonstrated high within-patient test-retest variability, resulting in poor reliability. The findings in this sample of collegiate athletes suggest that incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion.

Concussions in the National Hockey League: Analysis of Incidence, Return to Play, and Performance

Background:

Concussion injuries are common in professional hockey; however, their effect on player performance remains unclear.

Purpose:

To quantify the effect of concussions on the performance of position players in the National Hockey League (NHL).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Concussion data from the NHL were collected using publicly available databases for the seasons between 2009-2010 and 2015-2016, coinciding with new NHL concussion rules. Age, body mass index, position, number of concussions during a player’s NHL career, games played, and time on ice were recorded. Basic and advanced performance metrics were collected for 1 season pre- and postconcussion (short-term period) and 3 seasons before and after concussion (long-term period) to assess short- and long-term changes in performance. A control group of players without an identified concussion who competed during the study period was assembled for comparison. Wilcoxon signed rank tests were used to evaluate pre- to postconcussion data in the short- and long-term settings as well as to compare the cohorts at each time point.

Results:

Overall, 48 players were identified as having a concussion during the study period. Players missed 17.2 ± 15.1 days (mean ± standard deviation) and 7.5 ± 6.9 games postconcussion. There were no significant differences in any metric when pre- and postconcussion intraseason performance was assessed. Athletes who were concussed demonstrated significantly deceased performance metrics (assists per 60 minutes, points per 60 minutes, Corsi percentage, and Fenwick percentage) in the 3 years after the concussion as compared with the year before injury ( P < .05). However, no difference was found between the concussed group and matched control group in the short- or long-term period. Players with concussion played fewer career games (856.4 ± 287.4 vs 725.7 ± 215.0; P < .05) than did controls.

Conclusion:

A high rate of NHL players were able to return to play after a concussion injury. Players with concussion did not experience a reduction in performance metrics in the short- or long-term setting when compared with matched controls. The concussed cohort maintained a similar workload up to 3 seasons postconcussion but played in fewer career games when compared with matched controls.

Awareness of Concussion-Education Requirements, and -Management Plans and Concussion Knowledge in High School and Club Sport Coaches

Context

A growing number of high-school–aged athletes participate on club sport teams. Some, but not all, state concussion laws apply to both interscholastic and private sport organizations. However, concussion education, management plans, and knowledge have not been examined in club coaches who coach high school-aged athletes.

Objective

To determine if differences in concussion education, management plans, and knowledge exist between high school coaches and coaches of club sport teams.

Design

Cross-sectional study.

Setting

Online survey.

Patients or Other Participants

A total of 769 coaches (497 high school coaches, 272 club coaches coaching high school-aged athletes; 266 women [34.6%], 503 men [65.4%]) completed an anonymous online questionnaire.

Main Outcome Measure(s)

The questionnaire consisted of demographic and team information, requirements for concussion-education and -management plans, and concussion knowledge.

Results

High school coaches were more likely than club coaches to report that their organizing bodies or leagues required them to receive concussion-education information (97.4% versus 80.4%; P &lt; .001) and that their organizing bodies or leagues had a concussion-management plan (94.0% versus 70.2%; P &lt; .001). High school coaches were more likely than club coaches to correctly agree that most concussions resolve in 7 to 10 days (48.6% versus 40.1%; P = .02) and disagree that loss of consciousness is required to diagnose a concussion (87.1% versus 80.9%; P = .02).

Conclusions

Club coaches were less likely to be aware of requirements for concussion-education and -management plans from their parent organizations and scored lower on specific concussion-knowledge questions than high school coaches despite the same education requirements across groups under their state concussion laws. These results raise concerns regarding the proper management of concussions in club sports and suggest a need for greater oversight and enforcement of state laws in the club sport setting.

Going Beyond the State Law: Investigating High School Sport-Related Concussion Protocols

CONTEXT

State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination.

OBJECTIVE

To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality.

DESIGN

Qualitative document analysis.

SETTING

High school athletics.

PARTICIPANTS

In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018-2019 academic year.

MAIN OUTCOME MEASURES

Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test.

RESULTS

There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5-22.5] versus 6 [3-10.5] median components; U = 377.5, p < .001) Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

Postconcussion Exertion Evolution: Clinical and Behavioral Considerations

The philosophy and practices concerning concussion management have evolved from passive to active strategies that incorporate immediate, guided rest followed by early integration of physical and cognitive activity as tolerated by symptoms. Recent research and clinical evidence support guidance that symptom tolerable and clinically guided activity is beneficial postconcussion both acutely and in the longer term. Furthermore, recent studies illustrate benefits of targeted deficit-based therapies (vestibular, cervicogenic, visual, psychological, etc.) postconcussion subacutely and in those with persistent symptoms. The dissemination of this new information occurs at a fast pace and is often difficult to rapidly integrate into clinical practice due to necessary policy and behavior changes. This review will outline recent evidence concerning both rest and exertion postconcussion through the lens of the socioecological model to more rapidly promote policy and practice changes.