Adolescent sports concussion

Epidemiology of pediatric sports-related concussions presenting to the emergency room over the last decade in the United States

BACKGROUND

There continues to be clinical significance of pediatric sports-related concussion (pSRC) for pediatric specialists. The overall trends of pSRC are not well understood. The aim of this study was to summarize the epidemiology of pSRC presenting to the emergency room (ER) in the United States (US) over the last decade.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was retrospectively interrogated to identify pediatric (≤ 18 years) presenting to ERs in the US between 2013 and 2022. Weighted estimates and 95 % confidence intervals (CI) were generated using survey data analyses, and trends evaluated using linear regression analyses.

RESULTS

In 2022, an estimated total of 96,135 [95 % CI 71,486-120,783] cases of pSRC presented to the ER, equivalent to 132 [97-165] cases per 100,000 pediatric population. There has been a significant downtrend in pSRC presentations over the last decade (P = 0.02), with 2020 having the lowest number of cases in the 2013-2022 time period. In terms of gender, the latest proportion of presentations were 65 % [63-67 %] male and 35 % [33-37 %] female, with there being a significantly higher proportion of females and lower proportion of males over the last decade (P < 0.01). Of all causes for pSRC, the most frequent by proportion were football in 23 % [20-26 %], soccer in 9.6 % [7.7-12 %], basketball in 8.6 % [7.0-10 %], bicycle in 5.0 % [4.0-6.3 %], and baseball 4.1 % [3.3-5.0 %], with both football and basketball rates decreasing over the last decade. In 2020, there was a noticeable, non-sustained, decrease in proportion of football and basketball presentations, and an increase in proportion of bicycle presentations. Finally, there were multiples differences between sports and gender with only four in common sports causes amongst the ten most common sports (football, basketball, soccer, bicycle), although they were differently ranked by gender.

CONCLUSIONS

In the last decade, the incidence of pSRC presenting to the ER in the US has decreased. This is likely driven by decrease in proportion of football and basketball related injuries, which in turn has led to an increase in proportion of female pSRC which more commonly result from other sports. The Covid-19 pandemic in 2020 resulted in a number of trend anomalies which have since largely resolved. This data implicates that future prevention and treatment protocols should be more individualized.

Heterogeneity of persisting symptoms after sport-related concussion (SRC): exploring symptom subtypes and patient subgroups

This study aimed to explore the heterogeneity of persisting symptoms after sport-related concussion (SRC). We examined the structure of symptom subtypes within 163 patients with SRC (M = 16.7 weeks post-injury). Subsequently, we investigated the existence of subgroups of patients based on comparable configuration of co-occurring symptom subtypes. To explore factors that may contribute to the emergence of SRC patient subgroups, subgroups were compared on pre-injury (i.e., demographics and medical history), personality (Severity Indices of Personality Problems Short Form) and SRC characteristics (i.e., history of prior concussions, loss of consciousness and post-traumatic amnesia). To investigate the relevance of SRC subgrouping for clinical outcome, subgroups were compared on symptom severity (Sport Concussion Assessment Tool 5). The results provide empirical evidence for the existence of symptom subtypes, characterized as a: neurocognitive, fatigue, emotional, migraine and vestibular-ocular symptom subtype in patients with persisting SRC. Study results also showed evidence for the existence of SRC subgroups of patients with a comparable configuration of co-occurring prevailing symptom subtypes, including a neurocognitive-migraine, fatigue, migraine-emotional and neurocognitive-emotional subgroup. The subgroups differed on pre-injury, personality and SRC characteristics, suggesting that these factors may contribute to the emergence of specific SRC patient subgroups. The subgroups also differed in the severity of persisting symptoms, highlighting the clinical relevance of SRC subgrouping. These results support the idea that patient subgroups with persisting SRC with a comparable pattern of co-occurring symptom subtypes exists, which may require targeted prognosis, clinical management and treatment to optimize recovery.

Electrographic seizures and brain hyperoxia may be key etiological factors for post-concussive deficits

Repetitive mild traumatic brain injuries (RmTBIs) are increasingly recognized to have long-term neurological sequelae in a significant proportion of patients. Individuals that have had RmTBIs exhibit a variety of sensory, cognitive, or behavioral consequences that can negatively impact quality of life. Brain tissue oxygen levels (PO2) are normally maintained through exquisite regulation of blood supply to stay within the normoxic zone (18–30 mmHg in the rat hippocampus). However, during neurological events in which brain tissue oxygen levels leave the normoxic zone, neuronal dysfunction and behavioral deficits have been observed, and are frequently related to poorer prognoses. The oxygenation response in the brain after RmTBIs/repeated concussions has been poorly characterized, with most preliminary research limited to the neocortex. Furthermore, the mechanisms by which RmTBIs impact changes to brain oxygenation and vice versa remain to be determined. In the current study, we demonstrate that upon receiving RmTBIs, rats exhibit posttraumatic, electrographic seizures in the hippocampus, without behavioral (clinical) seizures, that are accompanied by a long-lasting period of hyperoxygenation. These electrographic seizures and the ensuing hyperoxic episodes are associated with deficits in working memory and motor coordination that were reversible through attenuation of the posttraumatic and postictal (postseizure) hyperoxia, via administration of a vasoconstricting agent, the calcium channel agonist Bay K8644. We propose that the posttraumatic period characterized by brain oxygenation levels well above the normoxic zone, may be the basis for some of the common symptoms associated with RmTBIs.

NEW & NOTEWORTHY We monitor oxygenation and electrographic activity in the hippocampus, immediately before and after mild traumatic brain injury. We demonstrate that as the number of injuries increases from 1 to 3, the proportion of rats that exhibit electrographic seizures and hyperoxia increases. Moreover, the presence of electrographic seizures and hyperoxia are associated with postinjury behavioral impairments, and if the hyperoxia is blocked with Bay K8644, the behavioral deficits are eliminated.

Participation in Collision Sports and Cognitive Aging Among Swedish Twins

We examined the association between early-life participation in collision sports and later-life cognitive health over a 28-year period in a population-based sample drawn from the longitudinal Swedish Adoption/Twin Study of Aging (1987-2014). Cognitive measures included the Mini-Mental State Examination and performance across multiple cognitive domains (e.g., global cognition, verbal ability, spatial ability, memory, processing speed). Among a sample of 660 adults (mean age at baseline, 62.8 years (range: 50-88); 58.2% female), who contributed 10,944 person-years of follow-up, there were 450 cases of cognitive impairment (crude rate = 41.1/1,000 person-years). Early-life participation in collision sports was not significantly associated with cognitive impairment at baseline or with its onset over a 28-year period in a time-to-event analysis, which accounted for the semi-competing risk of death. Furthermore, growth curve models revealed no association between early-life participation in collision sports and the level of or change in trajectories of cognition across multiple domains overall or in sex-stratified models. We discuss the long-term implications of adolescent participation in collision sports on cognitive health.

Subtypes of Sport-Related Concussion: a Systematic Review and Meta-cluster Analysis

Objective

Current clinical guidelines provide a unitary approach to manage sport-related concussion (SRC), while heterogeneity in the presentation of symptoms suggests that subtypes of SRC may exist. We systematically reviewed the available evidence on SRC subtypes and associated clinical outcomes.

Data Sources

Ovid Medline, Embase, PsycINFO, and SPORTDiscus

Eligibility Criteria for Selecting Studies

Electronic databases were searched for studies: (i) identifying SRC symptom clusters using classification methodology; or (ii) associating symptom clusters to clinical outcome variables. A total of 6,146 unique studies were identified, of which 75 full texts were independently assessed by two authors for eligibility. A total of 22 articles were included for systematic review.

Data Extraction

Two independent authors performed data extraction and risk of bias analysis using the Cochrane Collaboration tool.

Data Synthesis

Six studies found evidence for existence of SRC symptom clusters. Combining the available literature through Multiple Correspondence Analysis (MCA) provided evidence for the existence of a migraine cluster, a cognitive–emotional cluster, a sleep–emotional cluster, a neurological cluster, and an undefined feelings cluster. Nineteen studies found meaningful associations between SRC symptom clusters and clinical outcomes. Clusters mapping to the migraine cluster were most frequently reported in the literature and were most strongly related to aspects of clinical outcome.

Conclusions

The available literature provides evidence for the existence of at least five subtypes in SRC symptomatology, with clear relevance to clinical outcome. Systematically embedding the differentiation of SRC subtypes into prognosis, clinical management, and intervention strategies may optimize the recovery from SRC.

Electronic supplementary material

The online version of this article (10.1007/s40279-020-01321-9) contains supplementary material, which is available to authorized users.

Neurophysiological markers of cognitive deficits and recovery in concussed adolescents

OBJECTIVE

The present study sought to determine: 1) whether concussed adolescents exhibited deficits in neurocognitive functioning as reflected by neurophysiological alterations; 2) if neurophysiological alterations could be linked to supplementary data such as the number of previous concussions and days since injury; and 3) if deficits in psychological health and behavioural tests increased during diagnosis duration.

METHODS

Twenty-six concussed adolescents were compared to twenty-eight healthy controls with no prior concussions. Self-report inventories evaluated depressive and concussive symptomatology, while behavioral tests evaluated cognitive ability qualitatively. To assess neurophysiological markers of cognitive function, two separate auditory oddball tasks were employed: 1) an active oddball task measuring executive control and attention as reflected by the N2b and P300, respectively; and 2) a passive oddball task assessing the early, automatic pre-conscious awareness processes as reflected by the MMN.

RESULTS

Concussed adolescents displayed delayed N2b and attenuated P300 responses relative to controls; showed elevated levels of depressive and concussive symptomatology; scored average-to- low-average in behavioral tests; and exhibited N2b response latencies that correlated with number of days since injury.

CONCLUSION

These findings demonstrate that concussed adolescents exhibit clear deficiencies in neurocognitive function, and that N2b response latency may be a marker of concussion recovery.

Biomechanical Comparison of Real World Concussive Impacts in Children, Adolescents, and Adults

Accidental falls occur to people of all ages, with some resulting in concussive injury. At present, it is unknown whether children and adolescents are at a comparable risk of sustaining a concussion compared to adults. This study reconstructed the impact kinematics of concussive falls for children, adolescents, and adults and simulated the associated brain tissue deformations. Patients included in this study were diagnosed with a concussion as defined by the Zurich Consensus guidelines. Eleven child, 10 adolescent, and 11 adult falls were simulated using mathematical dynamic models(MADYMO), with three ellipsoid pedestrian models sized to each age group. Laboratory impact reconstruction was conducted using Hybrid III head forms, with finite element model simulations of the brain tissue response using recorded impact kinematics from the reconstructions. The results of the child group showed lower responses than the adolescent group for impact variables of impact velocity, peak linear acceleration, and peak rotational acceleration but no statistical differences existed for any other groups. Finite element model simulations showed the child group to have lower strain values than both the adolescent and adult groups. There were no statistical differences between the adolescent and adult groups for any variables examined in this study. With the cases included in this study, young children sustained concussive injuries at lower modeled brain strains than adolescents and adults, supporting the theory that children may be more susceptible to concussive impacts than adolescents or adults.

Lived Experiences of Adolescent Athletes Following Sport-Related Concussion

Background:

Previous studies have identified the effect of sport-related concussion on health-related quality of life through the use of patient-reported outcome measures. However, there has been little research exploring the underlying mechanisms that influence these perceptions of health-related quality of life among adolescent athletes who have sustained a sport-related concussion.

Purpose:

To explore the psychosocial aspects of concussion among adolescent athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 12 interscholastic athletes (4 girls, 8 boys; mean ± SD age, 15.7 ± 1.7 years; grade level, 10.2 ± 1.4) were interviewed via a semistructured interview protocol between 15 and 30 days postinjury. Data analysis was guided by the consensual qualitative research tradition. Themes and categories emerged through consensus by a 3-person research team, and bias was minimized through the use of multiple-analyst triangulation.

Results:

Participants identified numerous postconcussion symptoms that resulted in increasing difficulty with emotions (eg, irritable, easily frustrated), roles at school (eg, concentration difficulties, fatigue), and roles in their social environment (eg, letting the team down, not being able to contribute to sport). As a result, participants expressed how they tried to minimize or mask symptoms to decrease the potential of being viewed differently by their peers.

Conclusion:

Adolescent athletes perceived a significant effect of sport-related concussion on numerous areas of psychosocial and emotional health and well-being. Anticipatory guidance—with education regarding the possible signs and symptoms, risk factors, and recovery expectations following a concussion—is important to include in postinjury management. A better understanding of sport-related concussion and expected recovery could help to improve perceptions of this injury among interscholastic athletes. Additionally, best practices should be identified to assist health care professionals and school personnel in the development of temporary adjustments or formal academic adjustment policies in the secondary school setting, therefore ensuring that the patients receive the support that they need to maintain their roles as students.

Exploring Accelerometer Versus Self-Report Sleep Assessment in Youth With Concussion

This study examines accelerometer-based and self-report assessment of sleep disturbance from a larger prospective cohort of youth 5 to 18 years of age with postconcussive injury. Twenty-one participants with self-reported sleep disturbance were evaluated using accelerometers. Participants completed the Pittsburgh Sleep Quality Index (PSQI) every 48 hours and also measured sleep via accelerometry. Correlations were conducted matching PSQI scores to accelerometry assessment. PSQI scores were significantly correlated only with “average number of awakenings” (r = −0.21; P = .049). Accelerometer-measured mean (standard deviation) sleep efficiency was 79.9% (5.20%), with normal sleep defined as >85%. The mean (standard deviation) PSQI global score was 10.5 (3.78) out of 21, where scores of >5 indicate subjective insomnia. Results suggest the PSQI and accelerometers may be measuring different attributes of sleep. Both may be needed as actual sleep is important but so is perception of good sleep. These findings call for further validity testing of objective sleep assessment measures and commonly used self-report tools.

Behavioral and pathophysiological outcomes associated with caffeine consumption and repetitive mild traumatic brain injury (RmTBI) in adolescent rats

Given that caffeine consumption is exponentially rising in adolescents and they are at increased risk for repetitive mild traumatic brain injury (RmTBI), we sought to examine the pathophysiological outcomes associated with early life caffeine consumption and RmTBI. Adolescent male and female Sprague Dawley rats received either caffeine in the drinking water or normal water and were then randomly assigned to 3 mild injuries using our lateral impact device or 3 sham procedures. Following injury induction, behavioral outcomes were measured with a test battery designed to examine symptoms consistent with clinical manifestation of PCS (balance and motor coordination, anxiety, short-term working memory, and depressive-like behaviours). In addition, pathophysiological outcomes were examined with histological measures of volume and cellular proliferation in the dentate gyrus, as well as microglia activation in the ventromedial hypothalamus. Finally, modifications to expression of 12 genes (Adora2a, App, Aqp4, Bdnf, Bmal1, Clock, Cry, Gfap, Orx1, Orx2, Per, Tau), in the prefrontal cortex, hippocampus, and/or the hypothalamus were assessed. We found that chronic caffeine consumption in adolescence altered normal developmental trajectories, as well as recovery from RmTBI. Of particular importance, many of the outcomes exhibited sex-dependent responses whereby the sex of the animal modified response to caffeine, RmTBI, and the combination of the two. These results suggest that caffeine consumption in adolescents at high risk for RmTBI should be monitored.

A Collaborative Model for Return to Academics After Concussion: Athletic Training and Speech-Language Pathology

PURPOSE

In this article, we describe an academic concussion management protocol designed for grades Pre-K to 12, called Cognitive Return to Exertion (CoRTEx). Collaboration between the speech-language pathologist (SLP) and athletic trainer (AT) is highlighted.

METHOD

A description of CoRTEx is provided, and the need for collaboration is emphasized. A case study illustrates an example of how CoRTEx can be implemented at the individual student level.

RESULTS

A total of 165 students went through CoRTEx from the pilot in April 2014 through December 2016. Referrals to CoRTEx were highest for football, blows to the head, and soccer. Anecdotal evidence suggests that CoRTEx provided necessary support for students and their families, although research is needed to provide objective data.

CONCLUSIONS

CoRTEx and other similar protocols can be used as models for SLPs to create their own academic concussion management protocols. For cases in which the injured student is an athlete, the SLP-AT collaboration is critical to carefully coordinate return to academics and return to play so that students are successful in school, as well as ready to safely return to sport. Suggestions are made for designing research studies that can provide empirical evidence for the efficacy of such academic concussion management protocols.

Gender Differences in Concussion Reporting Among High School Athletes

Background:

An athlete’s lack of concussion knowledge could lead to significant underreporting and injury mismanagement. To provide more effective management strategies of concussions in adolescent athletes, further examination of reporting behaviors is of critical importance.

Hypothesis:

The hypotheses for this study were as follows: (1) Girls are more likely to report concussion, (2) girls are more likely to report future concussions after an educational intervention, and (3) a difference in rationale for not reporting concussion will be found between sexes.

Study Design:

Cross-sectional, cohort design.

Level of Evidence:

Level 3.

Methods:

Survey answers were collected on 454 high school athletes (212 girls, 242 boys; mean age, 15.7 ± 1.15 years). Individual team meetings lasting approximately 30 minutes were held to collect data and provide an educational lecture. Participants were randomly provided an iClicker to submit a response to questions asked.

Results:

Girls were more likely to report a concussion (χ² = 8.32, df = 3, N = 454, P = 0.040) and more likely to report future concussions after educational intervention (χ² = 8.54, df = 2, N = 454, P = 0.014). There were no differences between sexes regarding rationale for not reporting a concussion (χ² = 6.42, df = 4, N = 454, P = 0.170).

Conclusion:

There is concern these athletes still fail to understand the severity and potential sequelae of concussion injury. Both sexes cited that concussion is not a serious enough injury to warrant reporting to a medical professional.

Clinical Relevance:

High school athletes recover more slowly from concussions compared with college athletes; therefore, educating this population and promoting the importance of being knowledgeable regarding concussion recognition may increase reporting prevalence.

Relationship Between Cognitive Assessment and Balance Measures in Adolescents Referred for Vestibular Physical Therapy After Concussion

OBJECTIVE

To examine the relationship between cognitive and balance performance in adolescents with concussion.

DESIGN

Retrospective case series.

SETTING

Tertiary.

PATIENTS

Sixty patients.

INTERVENTIONS

Correlation analyses were performed to describe the relationship between symptoms, cognitive measure, and balance measure at the time of initiation of vestibular physical therapy.

MAIN OUTCOME MEASURES

Cognitive performance was assessed using the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT). The dizziness and balance function measures included dizziness severity rating, Activities-specific Balance Confidence scale (ABC), Dizziness Handicap Inventory (DHI), Functional Gait Assessment, gait speed, Timed "UP and GO," Five Times Sit to Stand, and Sensory Organization Test (SOT). To account for multiple comparisons, the False Discovery Rate method was used.

RESULTS

Performance measures of balance were significantly correlated with cognitive measures. Greater total symptom scores were related to greater impairment in the ABC and DHI (r = 0.35-0.39, P ≤ 0.008) and worse performance in condition 2 of the SOT (r = -0.48, P = 0.004). Among the ImPACT composite scores, lower memory scores were correlated with impaired balance performance measures (r = 0.37-0.59, P ≤ 0.012). Lower visual memory was also correlated with worse ABC scores.

CONCLUSIONS

The significant relationships reported between the cognitive performance scores and balance measures may reflect that similar levels of functioning exist across domains in individuals with protracted recovery who receive vestibular physical therapy.

CLINICAL RELEVANCE

The weak-to-moderate relationships warrant the continuous use of multiple domains of assessment. A better understanding to the relationships between the domains of functioning after concussion may improve the overall management approach for adolescents with concussion.

Qualitative Examination of Adolescent Health-Related Quality of Life at 1 Year Postconcussion

CONTEXT

Moderate to severe traumatic brain injuries can negatively influence health-related quality of life (HRQOL) in adolescent patients. The effect of sport-related concussion on adolescent HRQOL remains unclear.

OBJECTIVE

To investigate the perceptions of adolescent student-athletes and their parents regarding the adolescents' HRQOL 1 year after sport-related concussion.

DESIGN

Qualitative study.

SETTING

Secondary school.

PATIENTS OR OTHER PARTICIPANTS

Seven adolescent student-athletes (age range, 12-16 years) who sustained a sport-related concussion at least 1 year (15.3 ± 2.8 months) before the study participated along with their primary care-giving parents (n = 7).

DATA COLLECTION AND ANALYSIS

Fourteen semistructured face-to-face interviews (7 adolescents, 7 parents) were completed. Interviews were transcribed and inductively analyzed by a team of 3 athletic trainers with 32 combined years of professional experience. Themes were negotiated through a consensual review process. Participant checks were completed to ensure trustworthiness of the results.

RESULTS

Four major themes emerged from the interviews: (1) significant effect of symptoms, (2) feelings of frustration, (3) influence on school attendance and activities, and (4) nature of interpersonal and team relationships. Participants indicated that the physical symptoms of the concussion substantially affected their emotional and academic function. The influence of the concussion on social interactions seemed to depend on the nature of interpersonal relationships.

CONCLUSIONS

Sport-related concussion can negatively influence physical and emotional function, academics, and interpersonal interactions as perceived by adolescent student-athletes and their parents. Education of parents and their children, school professionals, coaches, and teammates remains critical to effectively recognize and manage sport-related concussion. Secondary school districts also play a critical role in the concussion-management process by establishing and implementing accommodation policies that alleviate student concerns about falling behind while ensuring a healthy return to normal school routines. Furthermore, adolescent support systems must be considered throughout the recovery process.

Variability of the modified Balance Error Scoring System at baseline using objective and subjective balance measures

Aim:

To investigate preseason modified Balance Error Scoring System (mBESS) performance in a collegiate football cohort; to compare scores to an objective mobile balance measurement tool.

Materials & methods:

Eighty-two athletes completed simultaneous balance testing using mBESS and the King–Devick Balance Test, an objective balance measurement tool. Errors on mBESS and objective measurements in the double-leg, single-leg (SS) and tandem stances were compared.

Results:

Mean mBESS error score was 7.23 ± 4.65. The SS accounted for 74% of errors and 21% of athletes demonstrated the maximum error score. There was no significant correlation between mBESS score and objective balance score.

Conclusion:

The high variability and large number of errors in the SS raises concerns over the utility of the SS in identifying suspected concussion.

Repetitive head trauma, chronic traumatic encephalopathy and tau: Challenges in translating from mice to men

Chronic traumatic encephalopathy (CTE) is a neurological and psychiatric condition marked by preferential perivascular foci of neurofibrillary and glial tangles (composed of hyperphosphorylated-tau proteins) in the depths of the sulci. Recent retrospective case series published over the last decade on athletes and military personnel have added considerably to our clinical and histopathological knowledge of CTE. This has marked a vital turning point in the traumatic brain injury (TBI) field, raising public awareness of the potential long-term effects of mild and moderate repetitive TBI, which has been recognized as one of the major risk factors associated with CTE. Although these human studies have been informative, their retrospective design carries certain inherent limitations that should be cautiously interpreted. In particular, the current overriding issue in the CTE literature remains confusing in regard to appropriate definitions of terminology, variability in individual pathologies and the potential case selection bias in autopsy based studies. There are currently no epidemiological or prospective studies on CTE. Controlled preclinical studies in animals therefore provide an alternative means for specifically interrogating aspects of CTE pathogenesis. In this article, we review the current literature and discuss difficulties and challenges of developing in-vivo TBI experimental paradigms to explore the link between repetitive head trauma and tau-dependent changes. We provide our current opinion list of recommended features to consider for successfully modeling CTE in animals to better understand the pathobiology and develop therapeutics and diagnostics, and critical factors, which might influence outcome. We finally discuss the possible directions of future experimental research in the repetitive TBI/CTE field.

Vestibular Deficits following Youth Concussion

OBJECTIVE

To characterize the prevalence and recovery of pediatric patients with concussion who manifest clinical vestibular deficits and to describe the correlation of these deficits with neurocognitive function, based on computerized neurocognitive testing, in a sample of pediatric patients with concussion.

METHODS

This was a retrospective cohort study of patients ages 5-18 years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010 to December 31, 2011. A random sample of all eligible patient visits was obtained, and all related visits for those patients were reviewed.

RESULTS

A total of 247 patients were chosen from 3740 eligible visits for detailed review and abstraction; 81% showed a vestibular abnormality on initial clinical examination. Those patients with vestibular signs on the initial examination took a significantly longer time to return to school (median 59 days vs 6 days, P=.001) or to be fully cleared (median 106 days vs 29 days, P=.001). They additionally scored more poorly on initial computerized neurocognitive testing, and it took longer for them to recover from neurocognitive deficits. Those patients with 3 or more previous concussions had a greater prevalence of vestibular deficits, and it took longer for those deficits to resolve.

CONCLUSION

Vestibular deficits in children and adolescents with a history of concussion are highly prevalent. These deficits appear to be associated with extended recovery times and poorer performance on neurocognitive testing. Further studies evaluating the effectiveness of vestibular therapy on improving such deficits are warranted.

Should an increase in cerebral neurochemicals following head kicks in full contact karate influence return to play?

Background:

Cerebral neurochemicals are markers of traumatic brain injury (TBI).

Objectives:

The aim of the study was to determine whether kicks to the head (KTH) in full contact karate significantly increased serum concentrations of protein S-100B, and neurone specific enolase (NSE). Kicks to the body (KTB) were also quantified to asses muscle tissue injury. Muscle damage was assessed by analysis of serum total creatine kinase (CK).

Methods:

Twenty-four full contact karate practitioners were observed and filmed during actual competition and divided into two main groups post event: (1) Kicks to the head and body group (KTH): n = 12; mean ± SD; age, 30.4 ± 6.7 years; height, 1.74 ± 0.1 m; weight, 79.1 ± 2.1 kg; and (2): Kicks to the body group (KTB): n = 12; mean ± SD; age, 28.2 ± 6.5 years; height, 1.75 ± 0.1 m; weight, 79.2 ± 1.7 kg. The KTH group received direct kicks to the head, while group KTB received kicks and punches to the body. Blood samples were taken before and immediately post-combat for analysis of serum S-100B, NSE, CK and cardiac troponin.

Results:

Significant increases in serum concentrations of S-100B (0.12 ± 0.17 vs. 0.37 ± 0.26, µg.L−1) and NSE (11.8 ± 4.1 vs. 20.2 ± 9.1 ng.mL−1) were encountered after combat in the KTH group and CK (123 ± 53 vs. 184 ± 103 U.L−1) in the KTB group (all P <0.05).

Conclusions:

Head kicks in full contact karate cause elevation of neurochemical markers associated with damaged brain tissue. The severity of injury is related to the early post-traumatic release of protein S-100B and NSE. The early kinetics and appearance post injury can reflect intracranial pathology, and suggest S-100B and NSE are extremely sensitive prognostic markers of TBI.

Multimodal evaluation and management of children with concussion: using our heads and available evidence

BACKGROUND

Significant attention has been focused on concussions in children, but a dearth of research evidence exists supporting clinical evaluation and management.

AIM

The primary objective of this review paper is to describe a multimodal, developmentally adapted, standardized concussion assessment and active rehabilitation approach for children as young as 5 years old.

METHODS

This study reviews the CDC-funded research programme, including the development of tools for post-concussion symptom assessment involving the child and parent, measurement of specific neurocognitive functions and assessment of dynamic cognitive exertional effects.

RESULTS

A clinical approach to active, individualized, moderated concussion rehabilitation management is presented, including a 10-step guide to symptom management, with a specific focus on the school challenges faced by the recovering student.

CONCLUSION

To better inform concussion practice across the developmental age spectrum, a significant need exists for further research evidence to refine clinical assessment methods and develop effective treatment approaches.

Concussion knowledge in high school football players

CONTEXT

Participating in sports while experiencing symptoms of a concussion can be dangerous. An athlete's lack of knowledge may be one factor influencing his or her decision to report symptoms. In an effort to enhance concussion education among high school athletes, legislation in Florida has attempted to address the issue through parental consent forms.

OBJECTIVE

To survey high school varsity football players to determine their level of knowledge about concussions after the initiation of new concussion-education legislation.

DESIGN

Cross-sectional study.

SETTING

Descriptive survey administered in person during a team meeting.

PATIENTS OR OTHER PARTICIPANTS

A total of 334 varsity football players from 11 high schools in Florida.

MAIN OUTCOME MEASURE(S)

Participants completed a survey and identified the symptoms and consequences of a concussion among distractors. They also indicated whether they had received education about concussions from a parent, formal education, neither, or both.

RESULTS

The most correctly identified symptoms were headache (97%), dizziness (93%), and confusion (90%), and the most correctly identified consequence was persistent headache (93%). Participants reported receiving education from their parents (54%) or from a formal source (60%). Twenty-five percent reported never receiving any education regarding concussions. No correlations were found between the method of education and the knowledge of symptoms or consequences of concussion.

CONCLUSIONS

The high school football players we surveyed did not have appropriate knowledge of the symptoms and consequences of concussions. Nausea or vomiting, neck pain, grogginess, difficulty concentrating, and personality or behavioral changes were often missed by participants, and only a small proportion correctly identified brain hemorrhage, coma, and death as possible consequences of inappropriate care after a concussion. Even with parents or guardians signing a consent form indicating they discussed concussion awareness with their child, 46% of athletes suggested they had not.

Athletes' age, sex, and years of education moderate the acute neuropsychological impact of sports-related concussion: a meta-analysis

The objective of this study is to determine which pre-existing athlete characteristics, if any, are associated with greater deficits in functioning following sports-related concussion, after controlling for factors previously shown to moderate this effect (e.g., time since injury). Ninety-one independent samples of concussion were included in a fixed+systematic effects meta-analysis (n = 3,801 concussed athletes; 5,631 controls). Moderating variables were assessed using analogue-to-ANOVA and meta-regression analyses. Post-injury assessments first conducted 1-10 days following sports-related concussion revealed significant neuropsychological dysfunction, postural instability and post-concussion symptom reporting (d = -0.54, -1.10, and -1.14, respectively). During this interval, females (d = -0.87), adolescent athletes competing in high school competitions (d = -0.60), and those with 10 years of education (d = -1.32) demonstrated larger post-concussion neuropsychological deficits than males (d = -0.42), adults (d = -0.25), athletes competing at other levels of competition (d = -0.43 to -0.41), or those with 16 years of education (d = -0.15), respectively. However, these sub-groups' differential impairment/recovery beyond 10 days could not be reliably quantified from available literature. Pre-existing athlete characteristics, particularly age, sex and education, were demonstrated to be significant modifiers of neuropsychological outcomes within 10 days of a sports-related concussion. Implications for return-to-play decision-making and future research directions are discussed.

Performance of high school adolescents on functional gait and balance measures

PURPOSE

To describe the performance of high school adolescents during common functional gait and balance measures used in vestibular physical therapy.

METHODS

A cross-sectional study of 91 participants determined their performance on the Activities-specific Balance Confidence (ABC) scale, Dynamic Gait Index, Functional Gait Assessment, Timed "Up and Go" (TUG), Five Times Sit to Stand (FTSTS) test, tests of gait speed (GS), and the Balance Error Scoring System. In a subset of this sample, GS, TUG, and the FTSTS were repeated twice to examine test-retest reliability.

RESULTS

The measures of GS, TUG, and FTSTS were normally distributed. The Activities-specific Balance Confidence, Dynamic Gait Index, and Functional Gait Assessment exhibited a ceiling effect. The timed measures exhibited moderate to good reliability.

CONCLUSIONS

These performance scores may provide end points for discharge from vestibular physical therapy. However, clinicians should be aware of the ceiling effect exhibited by some measures.

Neuropsychological evaluation and management of sport-related concussion

PURPOSE OF REVIEW

Sport-related concussion (SRC) is common in children and adolescents. Although symptoms are typically self-limiting and short-lived, some individuals suffer persistent negative outcomes. The risk of repeat injury and prolonged recovery can be reduced by accurate diagnosis and management. In the absence of reported symptoms, neuropsychological assessment has been identified as objective means of determining dysfunction following concussion. Most research to date has focused on adult populations. This review summarizes the literature regarding neuropsychological evaluation of SRC in the pediatric athlete.

RECENT FINDINGS

As with adult populations, neuropsychological evaluation of children and adolescents diagnosed with SRC has documented skills and abilities that are particularly sensitive to head injury. Difficulties with attention and concentration, speed of information processing, and memory are commonly reported in the literature. There is also some evidence to suggest that younger children are particularly vulnerable to neurologic insult and are at greater risk for secondary consequences. Although such findings argue for more conservative management, the availability of diagnostic tools, including computerized neurocognitive assessment batteries, is limited.

SUMMARY

The neuropsychological impact of SRC on functioning is well established. Because documented deficits have the potential to interfere with critical aspects of normal development in children and adolescents, accurate diagnosis and management of SRC are especially important. Despite some limitations, there is good evidence to support the use of neuropsychological assessment to inform treatments and return-to-play decision making.

School and the concussed youth: recommendations for concussion education and management

School learning and performance is arguably the critical centerpiece of child and adolescent development, and there can be significant temporary upset in cognitive processing after a mild traumatic brain injury, also called a concussion. This injury results in a cascade of neurochemical abnormalities, and, in the wake of this dysfunction, both physical and cognitive activities become sources of additional neurometabolic demand on the brain and may cause symptoms to reemerge or worsen. This article provides a foundation for postinjury management of cognitive activity, particularly in the school setting, including design and implementation of schoolwide concussion education and management programs.

Return-to-play guidelines in concussion: a closer look at the literature

Traumatic brain injuries that occur during sports have gained significant attention in the literature. Despite improved education and research on proper identification, risk management, and treatment, standardized methods for returning an athlete to play after a concussion are lacking in universal applicability. Current return-to-play guidelines are considered appropriate for the majority of athletes who recover within a few weeks. However, applicability of such guidelines becomes difficult when treating those athletes who experience prolonged symptoms or do not have the resources available to adequately manage complex presentations of concussions. Understanding the guidelines with consideration to special populations will assist the treating physician in providing an appropriate and individualized evaluation and treatment plan to safely return an athlete with a concussion back to play without compromising his or her health.

Sport-related concussions: knowledge translation among minor hockey coaches

OBJECTIVE

The objective of this study was to investigate minor hockey coaches' knowledge base of sport-related concussions.

DESIGN

Cross-sectional survey.

SETTING

Subjects independently completed the written survey at preseason organizational meetings.

PARTICIPANTS

One hundred seventy-eight active coaches spanning 5 age levels (ages 5-15 years). Coaches reported 2.62 ± 3.73 years of coaching experience.

MAIN OUTCOME MEASURES

Resources where coaches obtained information about concussions, perceptions of variables associated with concussions, knowledge level of issues associated with concussions, and decision-making practices.

RESULTS

Newspapers and magazines were the most frequent source of information regarding concussions, yet were rated as not very helpful. Family physicians were less frequently sought but were rated as most helpful. A majority of coaches reported limited knowledge about concussions but rated this knowledge as being important. There was a significant relationship between head coaching experience and concussion knowledge [R = 0.09, F3,156 = 4.41, P = 0.005]. Most coaches demonstrated a good knowledge base of common issues associated with concussions, and a majority of individuals correctly identified return-to-play practices.

CONCLUSIONS

A majority of minor hockey coaches correctly recognized and understood issues related to sport-related concussions. Results suggested that knowledge translation through various formal and informal sources has had a positive effect. However, a majority of coaches reported having limited knowledge about concussions yet consider it an important topic.

Direct Hits to the Head during Amateur Boxing is Associated with a Rise in Serum Biomarkers for Brain Injury

Boxing exposes participants to the physiological response to high intensity exercise and also to direct body and brain trauma. Amateur boxing is increasing and females have also been included in the Olympics. The aim of this study is to assess the stress response and possible brain injury incurred during a match by measuring serum biomarkers associated with stress and cellular brain injury before and after combat. Sixteen male amateur boxers were studied retrospectively. The study population was divided into two groups: (a) a group that received predominantly punches to the head (PTH) and (b) a group that received predominantly punches to the body (PTB). Blood samples were taken before and five minutes after each contest. They were analysed for S-100B, neuron-specific enolase (NSE), creatine kinase (CK) and cortisol. The PTH group received direct contacts to the head (not blocked, parried or avoided) and to the body ( n=8, age: 17.6 ± 5.3, years; height: 1.68 ± 0.13, meters; mass: 65.4 ± 20.3, kg). The PTB group received punches to the body including blocked and parried punches, but received no direct punches to the head, ( n=8, mean ± SD, age: 19.1 ± 3.2 years; height: 1.70 ± 0.75, meters; mass: 68.5 ± 15 kg). Significant increases ( P<0.05) were observed between pre- and post-combat serum concentrations in serum concentrations in PTH of S-100B (0.35 ± 0.61 vs. 0.54 ± 0.73, μg.L−1) NSE (19.7 ± 14 vs.31.1 ± 26.6, ng.ml−1) and cortisol (373 ± 202 vs. 756± 93, nmol.L−1). Significant increases ( P<0.05) of creatine kinase were recorded in both groups. This study demonstrates significant elevations in neurochemical biomarkers in boxers who received direct blows to the head. However, further work is required to quantify this volumetric brain damage and long term clinical sequelae.

Vestibular rehabilitation for dizziness and balance disorders after concussion

BACKGROUND AND PURPOSE

Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion.

METHODS

A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8-18 years]; 47 adults older than 18 years [mean, 41 years; range, 19-73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures.

RESULTS

The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P < .05). Children improved by a greater amount in dizziness severity (P = .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P < .025).

DISCUSSION

Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults.

CONCLUSIONS

Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest.

Supporting the student-athlete's return to the classroom after a sport-related concussion

OBJECTIVE

This article provides a framework for school athletic trainers to use in advising colleagues about the health and academic needs of student-athletes presenting with concussions.

BACKGROUND

Management of sport-related concussions has been an area of growing concern for school athletic programs. Recent work in this area has highlighted significant risks for student-athletes presenting with these mild traumatic brain injuries.

DESCRIPTION

Topics covered include general teaching points for the athletic trainer to use with school colleagues. An integrated model for school management of sport concussion injuries is presented that includes involvement of the student's athletic trainer, school nurse, guidance counselor, teachers, social worker, psychologist, physicians, and parents.

CLINICAL ADVANTAGES

Academic accommodations for specific postconcussion symptoms are proposed that may help the student-athlete strike an optimum balance between rest and continued academic progress during recovery.

American Academy of Pediatrics. Clinical report--sport-related concussion in children and adolescents

Sport-related concussion is a "hot topic" in the media and in medicine. It is a common injury that is likely underreported by pediatric and adolescent athletes. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports. A clear understanding of the definition, signs, and symptoms of concussion is necessary to recognize it and rule out more severe intracranial injury. Concussion can cause symptoms that interfere with school, social and family relationships, and participation in sports. Recognition and education are paramount, because although proper equipment, sport technique, and adherence to rules of the sport may decrease the incidence or severity of concussions, nothing has been shown to prevent them. Appropriate management is essential for reducing the risk of long-term symptoms and complications. Cognitive and physical rest is the mainstay of management after diagnosis, and neuropsychological testing is a helpful tool in the management of concussion. Return to sport should be accomplished by using a progressive exercise program while evaluating for any return of signs or symptoms. This report serves as a basis for understanding the diagnosis and management of concussion in children and adolescent athletes.

Concussion management and treatment considerations in the adolescent population

Over the past decade, significant advances have been made in understanding concussions. Information regarding proper identification, pathophysiology, risks, outcomes, and management protocols has shifted the treatment paradigm from a generalized grading system to an individualized approach. Early identification and timely management of a concussion is necessary to ensure that patients minimize persistent post-concussive symptoms affecting the physical, behavioral, emotional, and cognitive domains. Adolescents are particularly vulnerable to concussions, having greater susceptibility and more prolonged recovery after sustaining an injury. This article aims to inform clinicians on how to improve symptom relief and functional outcomes for adolescent patients with concussion via immediate intervention, neuropsychological management, and pharmacological treatment.

Online training in sports concussion for youth sports coaches

The purpose of this study was to evaluate ACTive: Athletic Concussion Training using Interactive Video Education, an interactive e-learning program designed to train community coaches of youth ages 10-18 in effective sports concussion prevention and management practices. Seventy-five youth sports coaches from across the country completed the study over the Internet. Results of a randomized control trial demonstrated significant differences between treatment and control participants on measures of (a) knowledge about sports concussion, management, and prevention; (b) attitudes about the importance of preventing sports concussion; and (c) intention and self-efficacy in sports concussion management and prevention. The results suggest that ACTive is an effective method of training youth sports coaches who are in an important position to reduce risks associated with sports concussion.