Sports-related concussions

Sports-Related Concussions in Children: Differences in Care and Expectations When Seen in an Emergency Department Versus a Sports Medicine Clinic

OBJECTIVES

Patient and parent expectations can potentially influence management of care. We compared expectations in the diagnosis of concussion between patients who presented to a pediatric emergency department (ED) and those who presented to a sports medicine clinic, and if there was a difference in computed tomography (CT) scans performed.

METHODS

Head-injured athletes aged 8 to 18 years presenting to a pediatric ED and a sports medicine clinic were enrolled. Both groups completed questionnaires on their understanding of concussion and expectations of care. Charts were then reviewed.

RESULTS

Forty patients were enrolled in the study: 23 from a pediatric ED and 17 from a sports medicine clinic. Forty-one percent of athletes received a head CT in the pediatric ED versus 12% of those in the clinic population with no abnormal findings (P = 0.04). Forty-one percent of athletes and 48% of parents in the pediatric ED setting reported that a CT was "necessary" to diagnose concussion versus 18% in both groups from the clinic (P = 0.12, P = 0.07). Athletes presenting to the clinic were more likely to have been evaluated by an athletic trainer after the injury than those presenting to the pediatric ED (80% vs 23%, P = 0.004).

CONCLUSIONS

Patients and parents who presented to a pediatric ED for sports-related head injury had a trend toward higher expectations of a CT scan being necessary to diagnose concussion and did have a higher rate of CT scans performed. Education of athletes and parents engaging in organized sports may be worthwhile to assist in setting expectations in diagnosis of concussion.

What Definition Is Used to Describe Second Impact Syndrome in Sports? A Systematic and Critical Review

Concern about what has been termed, "second impact syndrome" (SIS) is a major factor determining return-to-play decisions after concussion. However, definitions of SIS vary. We used Scopus to conduct a systematic review and categorize the definitions used to describe SIS. Of the 91 sources identified, 79 (87%) clearly specified that SIS involved either cerebral edema or death after a concussion when a prior concussion had not resolved. Twelve articles (13%) could be interpreted as merely the events of two consecutive concussions. Among the articles that listed mortality rates, nearly all (33/35, 94%) said the rate of death was "high" (e.g., 50% to 100%). Our review found that most articles define SIS as a syndrome requiring catastrophic brain injury after consecutive concussive episodes. Given that it is unclear how common it is to have a second concussion while not fully recovered from a first concussion, the actual mortality rate of SIS is unknown.

Genetic variation in SLC17A7 promoter associated with response to sport-related concussions

OBJECTIVE

To determine the association of the single nucleotide polymorphism (SNP) rs74174284 within SLC17A7 promoter with concussion severity or duration.

DESIGN

A between-subjects design was utilized.

METHODS

Saliva samples and concussion severity and duration data were collected from 40 athletes diagnosed with a sport-related concussion by a physician, utilizing a standardized concussion assessment protocol. DNA was extracted, estimated and genotyped.

RESULTS

An association was found between the dominant genetic model (CC vs GG + GC; p = 0.0179) and recovery, where those carrying the minor allele were 6.33-times more likely to experience prolonged recovery rates. Within the ImPACT assessment, those carrying the CC genotype (33.38 ± 10.15, p = 0.01) had worse motor speed scores upon initial assessment compared to both heterozygous (CG) and homozygous (GG) genotypes (41.59 ± 7.39).

CONCLUSIONS

This study was the first to demonstrate an association between genetic polymorphism at rs7417284 SNP in the promoter region of the SLC17A7 gene and concussion severity and duration. Based upon these findings, rs74174284 is a potential predictive genetic marker for identifying athletes who are more susceptible for altered recovery times and worse motor speed ImPACT scores after sport-related concussion.

Use of the King-Devick test for sideline concussion screening in junior rugby league

AIM

To determine whether the King-Devick (K-D) test used as a sideline test in junior rugby league players over 12 matches in a domestic competition season could identify witnessed and incidentally identified episodes of concussion.

METHODS

A prospective observational cohort study of a club level junior rugby league team (n=19) during the 2014 New Zealand competition season involved every player completing two pre-competition season baseline trials of the K-D test. Players removed from match participation, or who reported any signs or symptoms of concussion were assessed on the sideline with the K-D test and referred for further medical assessment. Players with a pre- to post-match K-D test difference >3s were referred for physician evaluation.

RESULTS

The baseline test-retest reliability of the K-D test was high (rs=0.86; p<0.0001). Seven concussions were medically identified in six players who recorded pre- to post-match K-D test times greater than 3s (mean change of 7.4s). Post-season testing of players demonstrated improvement of K-D time scores consistent with learning effects of using the K-D test (67.7s vs. 62.2s).

DISCUSSION

Although no witnessed concussions occurred during rugby play, six players recorded pre- to post-match changes with a mean delay of 4s resulting in seven concussions being subsequently confirmed post-match by health practitioners. All players were medically managed for a return to sports participation.

CONCLUSION

The K-D test was quickly and easily administered making it a practical sideline tool as part of the continuum of concussion assessment tools for junior rugby league players.

Assessment of parental knowledge and attitudes toward pediatric sports-related concussions

Background:

Parents of young athletes play a major role in the identification and management of sports-related concussions. However, they are often unaware of the consequences of concussions and recommended management techniques.

Hypothesis:

This study quantitatively assessed parental understanding of concussions to identify specific populations in need of additional education. We predicted that parents with increased education and prior sports- and concussion-related experience would have more knowledge and safer attitudes toward concussions.

Study Design:

Cross-sectional survey.

Level of Evidence:

Level 5.

Methods:

Participants were parents of children brought to a pediatric hospital and 4 satellite clinics for evaluation of orthopaedic injuries. Participants completed a validated questionnaire that assessed knowledge of concussion symptoms, attitudes regarding diagnosis and return-to-play guidelines, and previous sports- and concussion-related experience.

Results:

Over 8 months, 214 parents completed surveys. Participants scored an average of 18.4 (possible, 0-25) on the Concussion Knowledge Index and 63.1 (possible, 15-75) on the Concussion Attitude Index. Attitudes were safest among white women, and knowledge increased with income and education levels. Previous sports experience did not affect knowledge or attitudes, but parents who reported experiencing an undiagnosed concussion had significantly better concussion knowledge than those who did not.

Conclusion:

Parents with low income and education levels may benefit from additional concussion-related education.

Clinical Relevance:

There exist many opportunities for improvement in parental knowledge and attitudes about pediatric sports-related concussions. Ongoing efforts to understand parental knowledge of concussions will inform the development of a strategic and tailored approach to the prevention and management of pediatric concussions.

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.