Sport-related concussion in adolescents

Do Sport-Related Concussions Later in the Season Take Longer to Recover From?

OBJECTIVE

In a cohort of high-school football athletes with sport-related concussion (SRC), we sought to investigate the role of seasonality, defined as time of injury during a season, on recovery.

DESIGN

Retrospective cohort study.

SETTING

Regional sport concussion center.

PARTICIPANTS

High-school football athletes ages 14 to 19 -years old who sustained an SRC from 11, 2017 to 04, 2022.

INTERVENTION

Athletes were divided into 3 groups based on seasonality: early, middle, and late season.

MAIN OUTCOME MEASURES

The primary outcomes were initial Post-Concussion Symptom Scale score and recovery, as defined by time to return-to-learn (RTL), symptom resolution, and return-to-play (RTP). Descriptive statistics, analysis-of-variance, t tests, and multivariable regressions were performed.

RESULTS

Of our cohort of 273 high-school football players who sustained an SRC, 97 (35.5%) sustained an SRC during early season, 107 (39.2%) during middle season, and 69 (25.3%) during late season. Compared with late-season concussions, early-season concussions took less days to symptom resolution (early = 11.5 ± 12.9 vs late = 25.5 ± 27.0, P = 0.03), but no differences were found in days to RTL (early = 5.3 ± 4.8 vs late = 7.2 ± 15.8, P = 0.51) and RTP (early = 13.5 ± 11.8 vs late = 23.0 ± 22.8, P = 0.08). Seasonality was not a significant predictor for any recovery metric in multivariable regressions.

CONCLUSION

Sport-related concussions occurring in the early third of the season took significantly less time to symptom resolution than those occurring in the later third of the season; however, this was not statistically significant in multivariable analyses. No association was observed between seasonality and time to RTL and RTP. A trend of worse recovery with concussions later in the season may be present.

Putative Concussion Biomarkers Identified in Adolescent Male Athletes Using Targeted Plasma Proteomics

Sport concussions can be difficult to diagnose and if missed, they can expose athletes to greater injury risk and long-lasting neurological disabilities. Discovery of objective biomarkers to aid concussion diagnosis is critical to protecting athlete brain health. To this end, we performed targeted proteomics on plasma obtained from adolescent athletes suffering a sports concussion. A total of 11 concussed male athletes were enrolled at our academic Sport Medicine Concussion Clinic, as well as 24 sex-, age- and activity-matched healthy control subjects. Clinical evaluation was performed and blood was drawn within 72 h of injury. Proximity extension assays were performed for 1,472 plasma proteins; a total of six proteins were considered significantly different between cohorts (P < 0.01; five proteins decreased and one protein increased). Receiver operating characteristic curves on the six individual protein biomarkers identified had areas-under-the-curves (AUCs) for concussion diagnosis ≥0.78; antioxidant 1 copper chaperone (ATOX1; AUC 0.81, P = 0.003), secreted protein acidic and rich in cysteine (SPARC; AUC 0.81, P = 0.004), cluster of differentiation 34 (CD34; AUC 0.79, P = 0.006), polyglutamine binding protein 1 (PQBP1; AUC 0.78, P = 0.008), insulin-like growth factor-binding protein-like 1 (IGFBPL1; AUC 0.78, P = 0.008) and cytosolic 5'-nucleotidase 3A (NT5C3A; AUC 0.78, P = 0.009). Combining three of the protein biomarkers (ATOX1, SPARC and NT5C3A), produced an AUC of 0.98 for concussion diagnoses (P < 0.001; 95% CI: 0.95, 1.00). Despite a paucity of studies on these three identified proteins, the available evidence points to their roles in modulating tissue inflammation and regulating integrity of the cerebral microvasculature. Taken together, our exploratory data suggest that three or less novel proteins, which are amenable to a point-of-care immunoassay, may be future candidate biomarkers for screening adolescent sport concussion. Validation with protein assays is required in larger cohorts.

Concussion Acutely Decreases Plasma Glycerophospholipids in Adolescent Male Athletes

Concussions are frequent in sports and can contribute to significant and long-lasting neurological disability. Adolescents are particularly susceptible to concussions, with accurate determination of the injury challenging. Our previous study demonstrated that concussion diagnoses could be aided by metabolomics profiling and machine learning, with particular weighting on changes in plasma glycerophospholipids (PCs). Here, our aim was to report directional change of PCs after concussion and develop a diagnostic concussion panel utilizing a minimum number of plasma PCs. To this end, we enrolled 12 concussed male athletes at our academic Sport Medicine Concussion Clinic, as well as 17 sex-, age-, and activity-matched healthy controls. Blood was drawn and 71 plasma PCs were measured for statistically significant changes within 72 h of injury, and individual PCs were further analyzed with receiver operating characteristic (ROC) curves. Our data demonstrated that 26 of 71 PCs measured were significantly decreased after sports-related concussion (p < 0.01). None of the PCs increased in plasma after concussion. ROC curve analyses identified the top four PCs with areas under the curve (AUCs) ≥0.86 for concussion diagnosis: PCaeC36:0 (0.92; p < 0.001); PCaaC42:6 (0.90; p < 0.001); PCaeC36:2 (0.86; p = 0.001), and PCaaC32:0 (0.86; p = 0.001). Cut-off values in μM were ≤0.31, 0.22, 5.07, and 4.63, respectively. Importantly, combining these four PCs produced an AUC of 0.96 for concussion diagnoses (p < 0.001; 95% confidence interval, 0.89, 1.00). Our data suggest that as few as four circulating PCs may provide excellent diagnostic potential for adolescent concussion. External validation is required in larger cohorts.

Incidence reporting via online high school concussion surveillance by certified athletic trainers and school nurses, 2015-2018

BACKGROUND

There is an increasing concern over adolescent concussions in sports due to risks of long-term negative effects. This study analyzed data over three school years on reported concussion incidence rates by season, high school grade levels and gender, and reported symptoms by school nurses versus athletic trainers, from New Jersey student-athlete concussion data available from an online school-based surveillance system.

METHODS

School nurses and athletic trainers reported 300 concussions within five days from when each occurred over three school years, 2015-2018, in team sports and physical education in New Jersey high schools. Analysis was further conducted on symptoms and number of symptoms reported by school nurses versus school athletic trainers for each documented student-athlete concussion. Estimated concussion incidence rates were calculated using state agency verified school enrollment data.

FINDINGS

Concussions most commonly occurred during fall, followed by spring, then winter. Concussion incidence rates ranged from 6.3/1000 (4.99, 7.55) - 9.1/1000 (7.27, 10.98) students over the three school years of the study. Athletic trainers completed 86% of the reports while nurses completed 11% (position or title of 3%, or n = 7, were not disclosed); the values were similar when considering only fall pre-season and regular season sports (88, 10, 2%, respectively). On average, across the three school years, athletic trainers reported about 3.5 symptoms per report while nurses reported 2.7 (values in fall seasons only were 3.7 and 3.1, respectively.) CONCLUSIONS: Certified athletic trainers, compared to school nurses, more often completed concussion report forms and reported more symptoms per injured student, perhaps due partly to closer contact and immediate care provided after injury. Additionally, this study had a higher concussion incidence rate during fall sports seasons compared to winter and spring. Future research can further improve our understanding of concussions among adolescent student-athletes to better inform concussion identification, management and recovery protocols.

The Effect of Exertion on Heart Rate and Rating of Perceived Exertion in Acutely Concussed Individuals

Objective

Research suggests that one physiological effect of concussion is a disruption in regulation of autonomic nervous system control that affects the balance between parasympathetic and sympathetic output. While changes in heart rate after concussion have been observed, the nature of the heart rate change during progressive exercise has not been well evaluated in acutely symptomatic patients. Additionally, little is known about the relationship between HR and RPE in this population.

Methods

We compared changes in heart rate and perceived effort during graded treadmill exertion in recently concussed patients to elucidate the effect of brain injury on cardiovascular response to exercise. Resting HR, HR on exercise initiation, and changes in HR and RPE during the Buffalo Concussion Treadmill Test (BCTT) were compared on two test visits: When patients were symptomatic (acute) and after recovery. Results were compared with the test-retest results obtained from a control group consisting of healthy, non-concussed individuals.

Results

Patients had a significantly lower HR at onset of exercise when acutely concussed as compared to when recovered and reported greater perceived exertion at every exercise intensity level when symptomatic, despite exercising at lower workloads, than when recovered. Sympathetic response to increased exertion was not affected by concussion - HR increased in response to exercise at a comparable rate in both tests. These differences observed in response to exercise between the first BCTT and follow-up evaluation in initially concussed patients were not present in non-concussed individuals.

Conclusion

Our results suggest that during the acute phase after concussion, acutely concussed patients demonstrated an impaired ability to shift from parasympathetic to sympathetic control over heart rate at the onset of exercise. Changes in the autonomic nervous system after concussion may be more complex than previously reported. Continued evaluation of autonomic regulatory effects in the acute phase after concussion is warranted.

Repetitive concussions in adolescent athletes - translating clinical and experimental research into perspectives on rehabilitation strategies

Sports-related concussions are particularly common during adolescence, a time when even mild brain injuries may disrupt ongoing brain maturation and result in long-term complications. A recent focus on the consequences of repetitive concussions among professional athletes has prompted the development of several new experimental models in rodents, as well as the revision of guidelines for best management of sports concussions. Here, we consider the utility of rodent models to understand the functional consequences and pathobiology of concussions in the developing brain, identifying the unique behavioral and pathological signatures of concussive brain injuries. The impact of repetitive concussions on behavioral consequences and injury progression is also addressed. In particular, we focus on the epidemiological, clinical, and experimental evidence underlying current recommendations for physical and cognitive rest after concussion, and highlight key areas in which further research is needed. Lastly, we consider how best to promote recovery after injury, recognizing that optimally timed, activity-based rehabilitative strategies may hold promise for the adolescent athlete who has sustained single or repetitive concussions. The purpose of this review is to inform the clinical research community as it strives to develop and optimize evidence-based guidelines for the concussed adolescent, in terms of both acute and long-term management.

Concussion symptoms in youth motocross riders: a prospective, observational study

OBJECT

Action motorsports, including motocross, have been gaining popularity among children and adolescents, raising concerns for increased risk of concussions in participating youth. The authors undertook this study to test the following hypotheses: 1) that there is a high rate of concussion symptoms associated with a number of preventable or adjustable risk factors, and 2) that a high percentage of these symptoms are not be reported to adults and medical personnel.

METHODS

The authors identified all motocross riders under the age of 18 at a regional racetrack during the riding season between May and October 2010. The participants completed questionnaires pertaining to demographic characteristics and variables associated with motocross. The questionnaire results were compared with the incidence of self-reported concussion symptoms.

RESULTS

Two hundred two riders were identified who met the criteria for participation in the study, and 139 of them completed the study questionnaire. Of these 139 riders, 67 (48%) reported at least 1 concussion symptom during the season. The majority of riders (98%) reported "always" wearing a helmet, and 72% received professional help with fitting of their helmets. Proper helmet fitting was associated with a 41% decreased risk of concussion symptoms (RR 0.59, 95% CI 0.44-0.81, p < 0.01). Sixty-six riders (47%) reported having received sponsor support for motocross participation. Sponsor support conferred a relative risk for concussion symptoms of 1.48 (95% CI 1.05-2.08, p = 0.02).

CONCLUSIONS

Nearly half of all motocross competitors under the age of 18 reported concussion symptoms. Preventive measures are necessary to limit the negative impact from concussions. The risk of concussive injury can be decreased for pediatric motocross riders if they receive professional help with proper helmet fitting and through implementation of stricter guidelines regarding sponsorship.

Video Educational Intervention Improves Reporting of Concussion and Symptom Recognition

Context

Concussion management is potentially complicated by the lack of reporting due to poor educational intervention in youth athletics.

Objective

Determine if a concussion-education video developed for high school athletes will increase the reporting of concussive injuries and symptom recognition in this group.

Design

Cross-sectional, between groups.

Setting

Athletes participating in South Carolina interscholastic athletics.

Patients or Other Participants

High school athletes (N = 68; males n = 42; females n = 26; mean age = 14.78 ± 1.38 years) participated in this study. The athletes were randomly assigned into 2 groups: concussion education (n = 34) and control (n = 34).

Main Outcome Measures

Participants were administered a survey before and after watching a video about concussion incidence, symptoms, and reporting conditions (intervention group) or a nutrition video (control group). Total symptom score and survey items served as dependent variables. Examination of group differences was performed through χ2 analyses and repeated-measures analysis of variance (ANOVA) calculations in SPSS 19.0 (SPSS Inc, Chicago, IL). Significance levels were set a priori at .05.

Results

Of all participants, 70.5% (48/68) reported not knowing the signs and symptoms of concussion before the study, and 26.5% (n = 18) reported having had at least 1 prior concussion. A statistically significant difference existed between those reporting having vs. not having knowledge of the signs and symptoms of concussion on total symptom score at baseline (t1,66 = 2.17, P = .038). Repeated-measures ANOVA calculated a statistically significant difference for concussion symptom recognition before and after the intervention (F1,66 = 7.47, P = .008)

Conclusions

A large percentage of high school athletes do not know the signs and symptoms of concussion. After an educational video, participants' symptom knowledge and previous concussions reported increased. Education of those involved in athletics using a standardized tool may increase reporting and aid in the assessment and management of concussion in this population.

Patterns and predictors of follow-up in patients with mild traumatic brain injury

BACKGROUND

This study was undertaken to identify factors that influence follow-up for patients with mild traumatic brain injury (MTBI).

METHODS

One hundred and ninety-nine consecutive inpatients diagnosed with MTBI at a Trauma Centre (or TC) were monitored for establishment of care with a brain injury specialist after discharge. Bivariate statistics were calculated to determine subject characteristics impacting the decision to pursue TBI-related specialty care.

RESULTS

One hundred and nineteen patients (59.8%) followed up with the TC for routine post-injury care. Patients who followed up were older (age >40: OR = 2.48, p = 0.01, 95% CI = 1.03-8.96) and had longer hospital lengths of stay (LOS > 3 days: OR = 2.99, p < 0.001, 95% CI = 1.33-7.67). Upon follow-up, providers identified 20 patients (16.8%) with persistent neurologic symptoms, seven (3.5%) of whom saw a brain injury specialist. Lack of insurance significantly decreased the likelihood of follow-up with the TC and/or establishment of care with a TBI specialist. (OR = 0.76, p = 0.01, 95% CI = 0.62-0.95).

CONCLUSIONS

Being insured was strongly predictive for follow-up at the TC and for establishing with a brain injury specialist post-MTBI. The TC post-injury visit identified MTBI patients with persistent symptoms, suggesting post-acute TC follow-up is an important venue for MTBI sequelae screening and referral.

An epidemiologic profile of pediatric concussions: identifying urban and rural differences

BACKGROUND

The objective of this study was to describe the epidemiology of concussions presenting to the emergency department (ED).

METHODS

A retrospective cohort of concussions for pediatric (age < 18 years) patients treated in the ED of a regional pediatric Level 1 trauma center from 2006 to 2011 was examined. Descriptive and geographic analyses were completed, with comparisons by age groups and residence (urban/rural).

RESULTS

There were a total of 2,112 treated pediatric concussions. Two thirds of the concussions occurred in males (67%), with a median age of 13 years (interquartile range [IQR], 6). Nearly half of the pediatric concussions were sports related (48%); 36% of these concussions were from hockey. Significant differences were found in the distribution of the mechanism of injury across age groups (p < 0.001). Falls were most prevalent among young children, and sports concussions, for children 10 years and older. Two fifths of concussions occurred during winter months. Discharge disposition significantly differed by age (p < 0.001), with home discharge increasing with age up to 14 years. There were a total of 387 rural (19%) and 1,687 urban (81%) concussed patients, for a mean ED concussion visit rate of 2.2 per 1,000 and 3.5 per 1,000, respectively. Rural patients were older (14 [IQR, 6] vs. 13 [IQR, 6], p = 0.019] and sustained 2.5 times more concussions from a motor vehicle crash compared with urban youth patients (p < 0.001).

CONCLUSION

Males in early adolescence are at highest risk for concussion, particularly from sport-related activities. Urban and rural children have differences in their etiology and severity of concussions. Concussions are predictable, and their prevention should be targeted based on epidemiologic and environmental data.

LEVEL OF EVIDENCE

Epidemiologic, study, level III.

Adolescent concussions: when to return to play

Increased awareness of adolescent sport concussions has led to legislation requiring a medical professional's permission to return to play. These patient-specific and evidence-based recommendations for nurse practitioners will ensure safe return to play decisions.