Introducing the Sport Concussion Assessment Tool 6 (SCAT6)

The Sport Concussion Assessment Tool: A multidimensional symptom model for detecting elevated post-concussion symptoms

Objective: Investigate whether a four-factor model of post-concussion symptoms (i.e. cognitive, physical, affective, and sleep-arousal) aids in identifying student-athletes with persistent concerns not reflected by a total symptom score. Method: Collegiate student-athletes (N = 32,066) from the Concussion Assessment Research and Education consortium completed the Sport Concussion Assessment Tool, 3rd edition Symptom Evaluation at baseline and two post-injury follow-ups (i.e. beginning RTP and 6-month). Confirmatory factor analysis was used to compare a one- and four-factor model of post-concussion symptoms. Normative reference data were compared across stratifications (e.g. sex, prior concussions, and number of pre-existing conditions) using Mann-Whitney U tests, and elevation rates (i.e. ≥ 84th percentile) for subscales and the total score were recorded. Results: The four-factor model fit well before and after injury (CFIs > .95). Greater symptom severity on the subscale and total scores was associated with female sex (ps<.001, r range: .07 to .14) and more pre-existing conditions (ps<.001, η 2 range: .01 to .04), while having more prior concussions was only related to total symptom scores (ps<.001, η 2<.01). After a concussion, a sizeable portion of student-athletes (i.e., RTP = 11.8%; 6-month = 8.3%) had subscale elevations despite no total score elevation. Physical subscale elevations at RTP were the most common (i.e., 11.9%), driven by head and neck pain. Conclusion: After a sport-related concussion, a four-factor symptom model can be used to assess persistent symptoms in collegiate student-athletes. Identifying athletes with domain-specific elevations may help clinicians identify areas for further assessment and, in some cases, personalized rehabilitation plans.

Comparing return to play protocols after sports-related concussion among international sporting organisations

BACKGROUND

Return to play (RTP) protocols are an important part of recovery management following a sport-related concussion (SRC) and can prevent athletes from returning to competition too early and thereby avoid prolonged recovery times. To assist sporting organizations in the development of RTP guidelines, the Concussion in Sports Group (CISG) provides scientific-based recommendations for the management of SRC in its consensus statement on concussion in sport.

OBJECTIVES

This study investigates commonalities and differences among current RTP protocols of international sporting organizations and examines the implementation of the most recent CISG recommendations.

METHODS

Concussion guidelines and medical rules of 12 international sporting organizations from contact, collision and combat sports were accessed via the organizations websites and compared regarding the management of SRC and the RTP decision.

RESULTS

Only six of the included organizations developed and published their own concussion guidelines, which included an RTP protocol on their website. The number of steps until RTP was similar across the different protocols. Each protocol required at least one medical examination before clearing an athlete to RTP. A high variation among organizations was found for initial resting period after injury, the implementation of sport-specific training drills and the time needed to complete the protocol before returning to competition. At the date of this study (9 September 2023), none of the accessible RTP protocols were updated to include the latest version of the CISG consensus statement.

CONCLUSION

To improve the safety of athletes after a head injury, sporting organizations should develop sport-specific guidelines according to the latest CISG consensus statement, and this should be updated regularly. Implementation is especially important in combat sports, where there is a high incidence of head injury. Thus, there is a requirement for the most up-to-date concussion management protocols in these sports.

Unintended consequences - A qualitative exploration of baseline testing in community rugby concussion management

OBJECTIVES

Understanding key stakeholders' perceptions around the value of baseline testing, as well as barriers or facilitators experienced as part of the process, may assist with the decision-making process of whether to implement baseline testing in community sport. This study explored coaches', players' and physiotherapists' perceptions of the perceived value, barriers and facilitators of baseline testing as part of New Zealand Rugby's (NZR) community concussion initiative.

DESIGN

The study employed a pragmatic, qualitative descriptive design.

METHODS

Semi-structured interviews were used to explore participants' perceptions. In total, 73 individual interviews were conducted. The sample consisted of 36 players, 13 coaches and 24 physiotherapists involved in NZR's concussion management pathway. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis.

RESULTS

In terms of perceived value, baseline testing was reported to play a role in i) facilitating a positive concussion culture; ii) positive perceptions of rugby and player safety and iii) enhancing concussion management as part of the pathway. Barriers and facilitators of the baseline testing process included i) stakeholder buy-in as critical driver of the process and ii) contextual and operational factors. Although contextual and operational challenges exist, these participants, as key stakeholders in the process, perceived the value of baseline testing to be more important than the barriers experienced.

CONCLUSIONS

The value of baseline testing extends beyond concussion assessment and management, by enhancing community concussion awareness, attitudes and player safety. The findings of this study may assist in the decision-making process around inclusion of pre-season baseline testing in community rugby.

Cervical spine proprioception and vestibular/oculomotor function: An observational study comparing young adults with and without a concussion history

OBJECTIVE

To investigate dizziness, vestibular/oculomotor symptoms, and cervical spine proprioception among adults with/without a concussion history.

METHODS

Adults ages 18-40 years with/without a concussion history completed: dizziness handicap inventory (DHI), visio-vestibular exam (VVE), and head repositioning accuracy (HRA, assesses cervical spine proprioception). Linear regression models were used to assess relationships between (1) concussion/no concussion history group and VVE, HRA, and DHI, and (2) DHI with HRA and VVE for the concussion history group.

RESULTS

We enrolled 42 participants with concussion history (age = 26.5 ± 4.5 years, 79% female, mean = 1.4± 0.8 years post-concussion) and 46 without (age = 27.0± 3.8 years, 74% female). Concussion history was associated with worse HRA (β = 1.23, 95% confidence interval [CI]: 0.77, 1.68; p < 0.001), more positive VVE subtests (β = 3.01, 95%CI: 2.32, 3.70; p < 0.001), and higher DHI scores (β = 9.79, 95%CI: 6.27, 13.32; p < 0.001) after covariate adjustment. For the concussion history group, number of positive VVE subtests was significantly associated with DHI score (β = 3.78, 95%CI: 2.30, 5.26; p < 0.001) after covariate adjustment, while HRA error was not (β = 1.10, 95%CI: -2.32, 4.51; p = 0.52).

CONCLUSIONS

Vestibular/oculomotor symptom provocation and cervical spine proprioception impairments may persist chronically (i.e., 3 years) after concussion. Assessing dizziness, vestibular/oculomotor and cervical spine function after concussion may inform patient-specific treatments to address ongoing dysfunction.

Posttraumatic stress symptoms in recovery from concussion

BACKGROUND

Previous literature suggests that lingering concussion symptoms may be influenced by psychological factors. The relationship of posttraumatic stress symptoms (PTSS) during recovery with pre-existing/injury related factors and concussion symptomology is not fully understood. Identification of factors contributing to symptoms of posttraumatic stress may provide guidance to improve treatment following concussion.

METHOD

This study included 287 participants (Male 40.42%, n = 116; Female 59.58%, n = 171) aged 13-75 years diagnosed with a recent concussion at one of the North Texas Concussion Registry (ConTex) specialty concussion clinic sites. Preinjury emotional history, injury related factors, and emotional state at time of initial evaluation were analyzed as predictors of post-traumatic stress symptoms (PCL-5) during recovery.

RESULTS

Sixty-one percent of participants endorsed at least one PTSS. Correlations were found between initial Sport Concussion Assessment Tool 5Ⓡ (SCAT5) total emotional symptom severity and screening measures for anxiety (GAD-7; r = .453, p < .001) and depression (PHQ-8; r = .550, p < .001) symptom scores. Of the measures from the initial visit included in the multiple regression model predicting severity of PTSS at follow-up (R2 = 0.554, β < .001), three measures predicted PTSS severity: initial SCAT5 total emotional symptom severity (β = 0.565, p < .001), PHQ-8 score (β =.166, p = .009), and GAD-7 score (β = 0.119, p = .044).

CONCLUSIONS

Symptoms of anxiety and depression along with specific SCAT5 emotional symptoms present at the time of initial evaluation may serve to predict overall level of PTSS and increased risk for PTSS during recovery. PTSS may be another dimension of response to injury and concussion recovery, with a large percentage of individuals endorsing at least one PTSS. Clinicians can utilize brief assessments such as the SCAT5 at the time of initial clinical evaluation to identify those at risk for PTSS following concussion.

Associations Between Brain Metabolites Measured With MR Spectroscopy and Head Impacts in High School American Football Athletes

BACKGROUND

While changes in brain metabolites after injury have been reported, relationships between metabolite changes and head impacts are less characterized.

PURPOSE

To investigate alterations in neurochemistry in high school athletes as a function of head impacts, concussion, and the use of a jugular vein compression (JVC) collar.

STUDY TYPE

Prospective controlled trial.

SUBJECTS

A total of 284 male American football players, divided into JVC collar and noncollar groups; 215 included in final analysis (age = 15.9 ± 1.0 years; 114 in collar group).

FIELD STRENGTH/SEQUENCE

3 Tesla/T1-weighted gradient echo, 1H point resolved spectroscopy, acquired between August and November 2018.

ASSESSMENT

Head impacts were quantified using accelerometers. Concussion was diagnosed by medical professionals for each team. Pre- to postseason differences in total N-acetylaspartate (tNAA), total choline (tCho), myo-inositol (myoI), and glutamate + glutamine (Glx), in primary motor cortex (M1) and anterior cingulate cortex (ACC), relative to total creatine (tCr), were determined.

STATISTICAL TESTS

Group-wise comparisons were performed using Wilcoxon signed-rank, Friedman's, and Mann-Whitney U tests. Relationships between ∆metabolite/tCr and mean g-force were analyzed using linear regressions accounting for concussion and JVC collar. Significance was set at P ≤ 0.05.

RESULTS

In participants without concussion, a significant decrease in tCho/tCr (0.233 ± 1.40 × 10-3 to 0.227 ± 1.47 × 10-7) and increase in Glx/tCr (1.60 ± 8.75 × 10-3 to 1.63 ± 1.08 × 10-2) in ACC were observed pre- to postseason. The relationship between ∆tCho/tCr in M1 and ACC and mean g-force from >80 g to >140 g differed significantly between participants with and without concussion (M1 β ranged from 3.9 × 10-3 to 2.1 × 10-3; ACC β ranged from 2.7 × 10-3 to 2.1 × 10-3). Posthoc analyses revealed increased tCho/tCr in M1 was positively associated with mean g-force >100 g (β = 3.6 × 10-3) and >110 g (β = 2.9 × 10-3) in participants with concussion. Significant associations between∆ myoI / tCr $$ \Delta \mathrm{myoI}/\mathrm{tCr} $$ in ACC and mean g-force >110 g (β = -1.1 × 10-3) and >120 g (β = -1.1 × 10-3) were observed in the collar group only.

DATA CONCLUSION

Diagnosed concussion and the use of a JVC collar result in distinct neurochemical trends after repeated head impacts.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 3.

Knowledge, attitude and behaviour around concussion at the FIFA Women's World Cup 2023: part 2 - coaches, performance staff and players

The objective of this observational cross-sectional study was to assess the knowledge, attitude and behaviour of coaches and performance staff (i.e. 'coaching staff'), and players from the 32 teams qualified for the FIFA Women's World Cup 2023 regarding assessment and management of concussion in football. Two online surveys were developed: 1) coaching staff, and 2) players. The results were analysed descriptively. Eighty-four coaching staff and 229 players completed the survey. Concussion knowledge: 39% of coaching staff and 33% of players were aware of concussion protocol(s). Knowledge: concussion symptom onset time was correctly reported by 18% of coaching staff and 11% of players. Knowledge about risks related to sustaining a concussion or returning to play too soon varied in both groups. Attitude: 26% of coaching staff and 31% of players reported being very confident or confident in recognizing a suspected concussion. Half of the players (52%) reported to always report symptoms of concussion if feeling any. One (1%) member of the coaching staff and 24 (10%) players reported feeling that a player can return to play with mild symptoms after a concussion. Behaviour: Most coaching staff reported they would have supportive behaviour if faced with a suspected concussion on the pitch. Among players, 64% stated that they would leave the assessment to their team's medical staff, and 4% would encourage their teammates to keep playing. In conclusion, coaching staff and players showed limited knowledge about concussion. Most coaching staff reported attitudes and intended behaviour towards protecting players' health; whilst players' responses varied.

Concussion in Parasport: A Narrative Review of Research Published since the Concussion in Para Sport (CIPS) Group Statement (2021)

Sports-related concussion (SRC) is an injury whereby impact to the face/head/neck impairs cognitive functioning. Parasport athletes have an increased risk for SRC. The Previous Concussion in Sport Group iterations lack guidance for parasport SRC assessment, management, and return-to-play. This article aims to investigate the research relating to parasport SRCs published since the 2021 Concussion in Para Sport (CIPS) position statement and highlights possible new recommendations. A literature review of parasport concussions was conducted. Articles citing the 2021 publication and/or published since then were reviewed. Relevant data were extracted and discussed in this article. Since 2021, twelve (n = 12) articles emerged investigating parasport SRC. Parasport athletes experience greater concussion symptoms and severity scores compared to able-bodied athletes. Visually impaired athletes account for >50% of parasport SRCs. Wheelchair basketball and rugby have the highest SRC incidence rates across parasports. Current SRC assessment methodologies are not designed with consideration of parasport athletes' unique experiences. Guidelines lack a return-to-learning protocol, making returning to education/work challenging for such athletes. Understanding these athletes' SRC experiences is paramount in supporting their recovery. Specific guidelines for SRC assessment, management, return-to-play, and return-to-learn for parasport athletes are necessary to enhance their rehabilitation and avoid the occurrence of long-term symptoms.

Feasibility of superimposed supine cycling and lower body negative pressure as an effective means of prolonging exercise tolerance in individuals experiencing persisting post-concussive symptoms: Preliminary results

To examine the feasibility, utility and safety of superimposed lower body negative pressure (LBNP) and tilt during supine cycling in individuals suffering from persisting post-concussive symptoms (PPCS). Eleven individuals aged 17-31 (6 females/5 males) participated in two randomized separate visits, 1 week apart. A ramp-incremental test was performed during both visits until volitional failure. Visits included no pressure (control) or LBNP at -40 Torr (experimental) with head-up tilt at 15 degrees (females) or 30 degrees (males). Transcranial Doppler ultrasound was utilized to quantify middle cerebral artery velocity (MCAv), while symptom reports were filled out before and 0, 10, and 60 min post-exertion. Ratings of exertion and overall condition followed similar trends for participants across both tests. The relative increase in MCAv was blunted during the experimental condition (8%) compared to control (24%), while a greater heart rate (17 beats/min) was achieved during the LBNP condition (P = 0.047). Symptom severity at the 0 and 10 min post-exertion time points displayed negligible-to-small effect sizes between conditions (Wilcoxon's r < 0.11). Symptom reporting was lower at the 60 min post-exertion time point with these displaying a moderate effect size (Wilcoxon's r = 0.31). The combination of LBNP and tilt during supine cycling did not change the participants' subjective interpretation of the exertional test but attenuated the hyperpnia-induced vasodilatory MCAv response, while also enabling participants to achieve a higher heart rate during exercise and reduced symptoms 1 h later. As this protocol is safe and feasible, further research is warranted in this area for developing PPCS treatment options. HIGHLIGHTS: What is the central question of this study? What are the feasibility, safety and utility of combining head-up tilt with lower body negative pressure during supine cycling for blunting the increase in cerebral blood velocity seen during moderate-intensity exercise in individuals experiencing persisting post-concussion symptoms? What is the main finding and its importance? Although no differences were found in symptoms between conditions within the first 10 min following exertion, symptom severity scores showed a clinically meaningful reduction 60 min following the experimental condition compared to the non-experimental control condition.

Baseline Normative and Test-Retest Reliability Data for Sideline Concussion Assessment Measures in Youth

Tools used for the identification, evaluation, and monitoring of concussion have not been sufficiently studied in youth or real-world settings. Normative and reliability data on sideline concussion assessment measures in the youth athlete population is needed. Pre-season normative data for 515 athletes (93.5% male) aged 5 to 16 on the Standardized Assessment of Concussion (SAC/SAC-Child), modified Balance Errors Scoring System (mBESS), Timed Tandem Gait (TTG), and the King-Devick Test (KDT) are provided. A total of 212 non-injured athletes repeated the measures post-season to assess test-retest reliability. Mean performance on the SAC-C, mBESS, TTG, and KDT tended to improve with age. KDT was the only measure that demonstrated good to excellent stability across age ranges (ICC = 0.758 to 0.941). Concentration was the only SAC/SAC-C subtest to demonstrate moderate test-retest stability (ICC = 0.503 to 0.706). TTG demonstrated moderate to good (ICC = 0.666 to 0.811) reliability. mBESS demonstrated poor to moderate reliability (ICC = -0.309 to 0.651). Commonly used measures of concussion vary regarding test-retest reliability in youth. The data support the use of at least annual sport concussion baseline assessments in the pediatric population to account for the evolution in performance as the child ages. Understanding the variation in the stability and the evolution of baseline performance will enable improved identification of possible injury.

Judgement and Decision Making in Clinical and Return-to-Sports Decision Making: A Narrative Review

Making return-to-sport decisions can be complex and multi-faceted, as it requires an evaluation of an individual's physical, psychological, and social well-being. Specifically, the timing of progression, regression, or return to sport can be difficult to determine due to the multitude of information that needs to be considered by clinicians. With the advent of new sports technology, the increasing volume of data poses a challenge to clinicians in effectively processing and utilising it to enhance the quality of their decisions. To gain a deeper understanding of the mechanisms underlying human decision making and associated biases, this narrative review provides a brief overview of different decision-making models that are relevant to sports rehabilitation settings. Accordingly, decisions can be made intuitively, analytically, and/or with heuristics. This narrative review demonstrates how the decision-making models can be applied in the context of return-to-sport decisions and shed light on strategies that may help clinicians improve decision quality.

The Significance of Off-Season Tailor-Made Baseline Measurements in the Assessment of Post-Concussion in University Athletes

This study aimed to investigate the significance of baseline measurements for amateur team athletes playing contact and collision team sports with a specific focus on the Sports Concussion Assessment Tool (SCAT) to improve concussion management. Symptoms of sports-related concussions (SRCs) can be diverse and long-lasting and include cognitive impairment, sleep disturbances, and vestibular dysfunction. Therefore, comprehensive baseline data are essential to preventing recurrent concussions and secondary injuries. This study was conducted during the 2023 off-season and evaluated the baseline condition of 65 male university rugby players using the SCAT5, which includes self-reported symptoms, and the modified Balance Error Scoring System (mBESS). The athletes were assessed for the presence or absence of SRC, and the mean values were compared using the Mann-Whitney U test. Among the participants, 35.38% (23/65) reported symptoms, with an average of 1.5 ± 2.8 symptoms per player and an average symptom score of 2.66 ± 5.93. In the mBESS, no errors were observed in the tandem stance test; however, 72.31% (47/65) made errors in the single-leg stance test on the non-dominant foot, with an average of 1.7 ± 1.5 errors. Many athletes self-reported symptoms and balance errors, even during asymptomatic periods before experiencing concussion, indicating unresolved issues. In the injury history survey, the baseline evaluations and injury histories of the participants classified into the SRC and non-SRC groups were compared. In the mBESS single-leg stance test (non-dominant foot), 84.21% (32/38) of the SRC group participants made errors, with an average score of 2.13 ± 1.52, whereas 55.55% (15/27) of the non-SRC group participants made errors, with an average score of 1.15 ± 1.35, showing a significant difference (p = 0.007). Additionally, significant differences were observed in the average number of ankle sprains (p = 0.027) and fractures (p = 0.048) between patients with and without a history of SRC. These findings indicate that athletes may have underlying issues even during normal periods before concussion. Moreover, the results highlighted the impact of previous concussions on motor control and injury risk. This underscores the importance of preseason baseline measurements using the SCAT to identify at-risk athletes and implement preventive measures. These findings align with the recommendations of the 6th International Conference on Concussion in Sport and suggest further refinement of concussion assessment tools.

The Diagnostic Utility of Cervical Spine Proprioception for Adolescent Concussion

OBJECTIVE

Cervical spine proprioception may be impaired after concussion. Our objective was to determine the diagnostic utility of cervical spine proprioception for adolescent concussion.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

Adolescents ≤18 days of concussion and uninjured controls.

INTERVENTIONS

N/A.

MAIN OUTCOMES

Head repositioning accuracy (HRA) testing, a measure of cervical spine proprioception. The HRA test involved patients relocating their head back to a neutral starting position with eyes closed after maximal cervical spine flexion, extension, and right and left rotations. The overall HRA error score was the mean error (distance from the starting point to self-reported return to neutral) across 12 trials: 3 trials in each direction. We used t-tests to compare group means and logistic regression (outcome = group, predictor = HRA, covariates) to calculate odds ratios. We used a receiver operator characteristic curve to evaluate area under the curve (AUC) and calculate the optimal HRA cutpoint to distinguish concussion from controls.

RESULTS

We enrolled and tested 46 participants with concussion (age = 15.8 ± 1.3 years, 59% female, mean = 11.3 ± 3.3 days postconcussion) and 83 uninjured controls (age = 16.1 ± 1.4 years, 88% female). The concussion group had significantly worse HRA than controls (4.3 ± 1.6 vs 2.9 ± 0.7 degrees, P < 0.001, Cohen d = 1.19). The univariable HRA model AUC was 0.81 (95% CI = 0.73, 0.90). After adjusting for age, sex, and concussion history, the multivariable model AUC improved to 0.85 (95% CI = 0.77, 0.92). The model correctly classified 80% of participants as concussion/control at a 3.5-degree cutpoint.

CONCLUSIONS

Adolescents with concussion demonstrated worse cervical spine proprioception than uninjured controls. Head repositioning accuracy may offer diagnostic utility for subacute concussion.

Latent Profiles of Acute Symptoms, Cognitive Performance, and Balance in Sport-Related Concussions

BACKGROUND

A sport-related concussion (SRC) is a common injury that affects multiple clinical domains such as cognition, balance, and nonspecific neurobehavioral symptoms. Although multidimensional clinical assessments of concussion are widely accepted, there remain limited empirical data on the nature and clinical utility of distinct clinical profiles identified by multimodal assessments.

PURPOSE

Our objectives were to (1) identify distinct clinical profiles discernible from acute postinjury scores on the Sport Concussion Assessment Tool (SCAT), composed of a symptom checklist, a cognitive assessment (Standardized Assessment of Concussion), and a balance assessment (Balance Error Scoring System), and (2) evaluate the clinical utility of the identified profiles by examining their association with injury characteristics, neuropsychological outcomes, and clinical management-related outcomes.

STUDY DESIGN

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

METHODS

Up to 7 latent profiles were modeled for 1885 collegiate athletes and/or military cadets who completed the SCAT at 0 to 12 hours after an injury. Chi-square tests and general linear models were used to compare identified profiles on outcomes at 12 to 72 hours after the injury. Kaplan-Meier analysis was used to investigate associations between clinical profiles and time to return to being asymptomatic and to return to play.

RESULTS

There were 5 latent profiles retained: low impairment (65.8%), high cognitive impairment (5.4%), high balance impairment (5.8%), high symptom severity (16.4%), and global impairment (6.5%). The latent profile predicted outcomes at 12 to 72 hours in expectable ways (eg, the high balance impairment profile demonstrated worse balance at 12 to 72 hours after the injury). Time to return to being asymptomatic and to return to play were different across profiles, with the high symptom severity and global impairment profiles experiencing the longest recovery and the high balance impairment profile experiencing an intermediate-length recovery (vs low impairment profile).

CONCLUSION

An SRC is a heterogeneous injury that presents in varying ways clinically in the acute injury period and results in different recovery patterns. These data support the clinical prognostic value of diverse profiles of impairment across symptom, cognitive, and balance domains. By identifying distinct profiles of an SRC and connecting them to differing outcomes, the findings support more evidence-based use of accepted multimodal clinical assessment strategies for SRCs.

Analyzing Dual-Task Paradigms to Improve Postconcussion Assessment and Management

CONTEXT

Dual-task (simultaneous cognitive-motor activities) assessments have been adapted into reliable and valid clinical concussion measures. However, abundant motor and cognitive variations leave researchers and clinicians uncertain about which combinations elicit the intended dual-task effect. Our objective was to examine differences between commonly employed dual-task motor and cognitive combinations among healthy, college-aged individuals.

DESIGN

Cross-sectional laboratory study.

METHODS

Twenty participants (age: 21.3 [2.4] y; height: 176.0 [9.1] cm; mass: 76.0 [16.4] kg; 20% with concussion history) completed 4 motor tasks (gait, tandem gait, single-leg balance, and tandem balance) under 5 cognitive conditions (single task, subtraction, month reversal, spelling backward, and visual Stroop) in a research laboratory. The motor performance outcomes were spatiotemporal variables for gait and tandem gait and center of pressure path length (in centimeters) for single-leg and tandem balance. Cognitive outcomes were response rate (responses/second) and cognitive accuracy. We used separate repeated-measures analyses of variance for each motor and cognitive outcome with post hoc Tukey t tests.

RESULTS

Gait velocity, gait stride length, and tandem gait velocity demonstrated significant cognitive-motor interactions (P's < .001) such that all dual-task conditions resulted in varyingly slower or shorter movement than single task. Conversely, single-leg balance (P = .627) and tandem balance (P = .434) center of pressure path length did not significantly differ among the dual-task cognitive conditions or relative to single task. Statistically significant cognitive-motor interactions were observed only for spelling backward accuracy (P = .004) and response rates for spelling backward, month reversal, and visual Stroop (P's < .001) such that worse accuracy, but faster response rates, occurred during motor tasks.

CONCLUSIONS

Gait and tandem gait motor tasks accompanied with spelling backward or subtraction cognitive tasks demonstrated consistently strong dual-task effects and, therefore, may be the best suited for clinical and research use following concussion.

High school rugby coaches' knowledge and opinions of concussion in Kwa-Zulu Natal province in South Africa: an ecological cross-sectional study

BACKGROUND

Concussions in Rugby Union are common with an increased risk to adolescent players. Coaches are key to injury prevention and a greater understanding of their knowledge and sentiments may guide future initiatives. There is a lack of data on rugby coaches, especially in South Africa. This study aimed to investigate the knowledge and opinions of high school rugby coaches regarding concussion management.

METHODS

This cross-sectional study of 37 high school rugby coaches in South Africa, was conducted via a self-reported questionnaire. Concussion knowledge was scored for correct answers only with closed-question scaling methods to measure the importance of items of concussion management using a graphical rating scale. An attitude scale (Likert) was used to assess self-reported opinions and behaviours. Associations were calculated for participant characteristics and overall concussion injury knowledge.

RESULTS

More participants showed good overall knowledge of ≥ 75% (n = 22, 59% vs. n = 15, 40%), especially those with greater coaching experience (p = 0.021). Player welfare was perceived more important than player performance (185 vs. 164), with concussion prevention most important (184 of 185). Appealing characteristics of an injury prevention programme were the improvement of player skill (173, SD ± 0.75, mean 4.68), being adaptable (171, ± 0.86, 4.62), and being completed in the warm-up (167, ± 0.93, 4.51). The biggest perceived barriers were duration (138, ± 1.59, mean 3.73), effort (130, ± 1.56, 3.51), compliance and lack of knowledge (both 127, ± 1.68, 3.43).

CONCLUSION

These results support the implementation of ongoing concussion education for rugby coaches and identify areas for promoting awareness and knowledge of concussion injury prevention, identification, and specific management of younger athletes. Appealing characteristics and barriers are highlighted and may allow for improved implementation and adherence to concussion prevention programmes.

Evaluating Post-concussion Clinical Management of University-Aged Performing Artists: A Systematic Review

INTRODUCTION

Contemporary concussion literature has yet to establish appropriate clinical management guidelines to address the unique needs of performing arts populations, especially at the collegiate level. Therefore, the purpose of this investigation was to collate current evidence regarding post-concussion return to performance management among university-aged performing artists to generate broad clinical implications.

METHODS

The research team was comprised of two faculty members in the performing arts, one concussion researcher, and athletic trainer, two university librarians, and one physical therapy graduate student with expertise in post-concussion management among performing arts patients. Two librarians searched the literature using PubMed, Cochrane, SPORTdiscus, and Education Research Complete. Studies were eligible for preliminary inclusion if they were written in English, conducted in the United States, as well as published in a peer-reviewed journal. There were no restrictions on publication date due to the limited literature on this topic. The most recent search was conducted in July 2023.

RESULTS

Of the 18 studies identified during the search process, only 2 met the inclusion criteria. Broadly, this investigation identified common mechanisms of injury among stage crew/technicians and dancers who are of university-age. Furthermore, both studies identified several patients who opted to return to performing arts on their own volition. However, there were no studies that solely focused on the collegiate performing arts population and their return to performance procedures.

CONCLUSIONS

Overall, these findings highlight a momentous gap in concussion literature regarding how to guide clinicians and academic teams when returning collegiate performing artists back to their performance environment(s). Thus, additional research is strongly warranted to understand the lived experiences of performing artists with concussion, as well as how to address specific coursework-related demands to support their recovery.

Diagnosis of Sports-Related Concussion Using Symptom Report or Standardized Assessment of Concussion

Importance

The Sports Concussion Assessment Tool-5 (SCAT5) has been recommended for concussion evaluation and utilizes both a subjective reported symptom grading scale and objective measures of concussion including a cognitive evaluation: the Standardized Assessment of Concussion (SAC). The SAC includes testing for orientation, immediate memory, concentration, and delayed recall; a 10-word list is used to assess immediate memory and delayed recall.

Objective

To determine the diagnostic accuracy of components of the SCAT5 and to provide a framework for clinical interpretation.

Design, Setting, and Participants

This prospective case-control study of National Collegiate Athletic Association Division I athletes from any sport was conducted from July 2020 to December 2022 at 4 universities. Athletes completed baseline SCAT5 testing using the 10-word list. When an athlete presented acutely with suspected concussion (sideline or within 2 days), the tests were repeated. If a concussion was diagnosed, a control athlete underwent the same tests. Controls were identified and matched on comorbid conditions, sex and gender, sport, season, and baseline scores. Data analysis was conducted from August to October 2023.

Main Outcomes and Measures

The primary outcomes were area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive and negative predictive value, and test-retest reliability of the symptom score; symptom severity score; the total SAC score; and the orientation, immediate memory, concentration, and delayed memory subcomponent scores on the SCAT5 compared with clinical diagnosis of concussion.

Results

Baseline and postinjury data were collected on 92 athletes with concussion and 92 matched control athletes (96 men [52%] and 88 women [48%]; 110 who played a sport other than football [59%]). Diagnostic utility was considered excellent for symptom score (AUC, 0.93; 95% CI, 0.89-0.96) and symptom severity score (AUC, 0.94; 95% CI, 0.90-0.97). An increase of 2 points on the symptom score was associated with a sensitivity of 86% (95% CI, 78%-92%), specificity of 80% (95% CI, 70%-87I%), and positive predictive value of 81% (95% CI, 72%-88%). The total SAC score had poor to fair diagnostic utility (AUC, 0.70; 95% CI, 0.63-0.77); however, 41 athletes with concussion (45%) had a total SAC score at or above their baseline score (ie, within normal limits). The diagnostic utility was poor to fair for immediate memory (AUC, 0.68, 95%CI, 0.61-0.75) and delayed recall (AUC, 0.69; 95% CI, 0.62-0.77) and not useful for orientation (AUC, 0.49; 95% CI, 0.43-0.56) and concentration (AUC, 0.52 95% CI, 0.44-0.61). Test-retest reliability was fair for total SAC and poor for immediate memory and delayed recall, orientation, and concentration.

Conclusions and Relevance

In this case-control study of the diagnostic accuracy of reported symptoms and the SAC, reported symptoms were the most accurate indicator of concussion while the 10-word SAC had limited sensitivity. These findings suggest that understanding the properties of the SAC is important when making the diagnosis of concussion.

A Perspective on the 6th International Conference on Sports Concussion

The International Conference on Sports Concussion, held every four years since 2001, has been instrumental in forming the international consensus on sports-related concussions. However, due to the unprecedented global pandemic of COVID-19, not only the Tokyo Olympics 2020, but also the initially scheduled sixth conference was postponed multiple times. Finally, the 6th International Conference on Sports Concussion took place in Amsterdam at the end of October 2022. In July 2023, the Amsterdam Declaration, reflecting the outcomes of this sixth conference, was released. This paper provides an overview of the conference, in which significant updates were revealed and introduced, including revisions to the definition of sports-related concussions, as well as the latest version of the Sports Concussion Assessment Tool (SCAT), known as SCAT6, the Office Assessment Tool (SCOAT), and the updated staged return-to-play protocol.

Differences in pre-season balance among student athletes based on level of contact, age, and sex

BACKGROUND

Assessing postural control is important for the assessment of motor function after concussion. Data used for postural control assessment typically do not take the sport played, age, or sex of the athlete into consideration. It is plausible these variables may be significant when making return-to-play decisions.

RESEARCH QUESTION

This study used the BTrackS database to examine differences in postural control in athletes playing different types of sports and across sex and age.

METHODS

BTrackS data from 9093 high school to college-aged athletes (aged 14-22 years) were examined employing a One-way ANOVA with a post-hoc test to compare CoP path length between sport types. A moderation analysis was used to test interaction effects of sex and age on a CoP/BMI ratio.

RESULTS

Significant differences were observed between sport types, F(3,9089) = 42.4, p <.001, η2 = 0.014. Post hoc tests indicated that collision (M = 25.0, SD = 7.6) sport athletes exhibited significantly higher CoP measures compared to the contact (M = 23.4, SD = 7.4), limited contact (M = 22.9, SD = 6.9), and non-contact (M = 23.0, SD = 7.4) athletes. There was no difference between other sport types (p >.20). A significant mean sex difference (Mmale = 0.924, Mfemale = 0.898, p <.001) and a quadratic association with age, (β = -0.042, p <.001) was observed. Further, magnitude of those age differences decreased with age (β = 0.011, p <.001). An interaction of age and sex was significant for linear (β = 0.020, p <.001) and quadratic terms (β = -0.006, p <.001).

SIGNIFICANCE

Athletes exhibited different postural control when the type of sport, age, and sex was taken into consideration. This data possess clinical significance as this suggests that normative postural control data for collision sport athletes should be derived from data based upon type of sport played, age, and sex of the athlete.

The effect of repeated concussions on clinical and neurocognitive symptom severity in different contact sports

INTRODUCTION

The potential consequences of repeated concussions in sport are well documented. However, it remains unclear whether the cumulative impact of sports-related concussions differs between different contact sports. Therefore, the aim of the current study was to investigate the cumulative effects of sports-related concussions on clinical and neurocognitive health in different contact sports.

MATERIALS AND METHODS

In a prospective multicenter study, we examined 507 (74 females) active professional athletes between 18 and 40 years of age from five different contact sports (soccer, handball, American football, basketball, and ice hockey). Data collection involved concussion history, clinical symptom evaluation, neurocognitive assessment, and the collection of other sports-related information. Composite scores were built for clinical symptoms (such as neck pain and balance disturbances) and for neurocognitive symptoms (such as memory and attention impairments).

RESULTS

Athletes having suffered 3+ concussions in the past showed disproportionally higher clinical symptom severity than athletes with less than three concussions across all sports. The level of clinical symptom burden in athletes with 3+ concussions indicated mild impairment. The number of past concussions did not affect neurocognitive performance.

DISCUSSION

Repeated sports-related concussions appear to have a cumulative impact on clinical-but not cognitive-symptom severity. Although clinical symptom burden in athletes with 3+ concussions in the past was not alarmingly high yet in our sample, increased caution should be advised at this point. Despite few exceptions, results are similar for different contact sports, suggesting a similar multidisciplinary concussion management across all types of sport.

A international cross-sectional study examining knowledge and attitudes towards sport-related concussion in Touch

OBJECTIVE

To determine the current level of knowledge and attitudes towards sport-related concussion (SRC) amongst key stakeholders in touch rugby.

DESIGN

An international cross-sectional study. Participants n = 141 (male, n = 88; female, n = 53) from 15 Touch Associations.

MAIN OUTCOME MEASURE

Online questionnaire including non-validated sections captured participant characteristics, first aid training, previous concussion, awareness of SRC guidelines, combined with Rosenbaum Concussion Knowledge and Attitudes Survey. Distributed online to Touch athletes internationally. Concussion knowledge index (CKI) and attitude index (CAI) scores were calculated. A linear regression was performed to determine whether awareness of concussion, previous concussion and role affected CKI and CAI scores.

RESULTS

Median CKI and CAI scores were 21 ± 2.0 and 67 ± 6.3, respectively, across all key stakeholders. 39% of participants reported a previous SRC and 32% of respondents were aware of concussion guidelines form their Association. Regression analysis showed minimal influence of key contextual information on CKI and CAI.

CONCLUSIONS

Findings suggest that key stakeholders in Touch have high to very high knowledge and safe attitudes towards SRC. However, there were some areas where further improvement could be targeted by those involved in Touch such as individual associations at the direction of the sport's governing body.

Instrumented Balance Error Scoring System in Children and Adolescents-A Cross Sectional Study

Background: The Balance Error Scoring System (BESS) is a commonly used method for clinically evaluating balance after traumatic brain injury. The utilization of force plates, characterized by their cost-effectiveness and portability, facilitates the integration of instrumentation into the BESS protocol. Despite the enhanced precision associated with instrumented measures, there remains a need to determine the clinical significance and feasibility of such measures within pediatric cohorts. Objective: To report a comprehensive set of posturographic measures obtained during instrumented BESS and to examine the concurrent validity, reliability, and feasibility of instrumented BESS in the pediatric point of care setting. Methods: Thirty-seven participants (18 female; aged 13.32 ± 3.31 years) performed BESS while standing on a force plate to simultaneously compute stabilometric measures (instrumented BESS). Ellipse area (EA), path length (PL), and sway velocity (VM) were obtained for each of the six BESS positions and compared with the respective BESS scores. Additionally, the effects of sex and age were explored. A second BESS repetition was performed to evaluate the test-retest reliability. Feedback questionnaires were handed out after testing to evaluate the feasibility of the proposed protocol. Results: The BESS total score was 20.81 ± 6.28. While there was no statistically significant age or sex dependency in the BESS results, instrumented posturography demonstrated an age dependency in EA, VM, and PL. The one-leg stance on a soft surface resulted in the highest BESS score (8.38 ± 1.76), EA (218.78 cm2 ± 168.65), PL (4386.91 mm ± 1859.00), and VM (21.93 mm/s ± 9.29). The Spearman's coefficient displayed moderate to high correlations between the EA (rs = 0.429-0.770, p = 0.001-0.009), PL (rs = 0.451-0.809, p = 0.001-0.006), and VM (rs = 0.451-0.809, p = 0.001-0.006) when compared with the BESS scores for all testing positions, except for the one-leg stance on a soft surface. The BESS total score significantly correlated during the first and second repetition (rs = 0.734, p ≤ 0.001), as did errors during the different testing positions (rs = 0.489-0.799, p ≤ 0.001-0.002), except during the two-legged stance on a soft surface. VM and PL correlated significantly in all testing positions (rs = 0.465-0.675, p ≤ 0.001-0.004; (rs = 0.465-0.675, p ≤ 0.001-0.004), as did EA for all positions except for the two-legged stance on a soft surface (rs = 0.392-0.581, p ≤ 0.001-0.016). A total of 92% of participants stated that the instructions for the testing procedure were very well-explained, while 78% of participants enjoyed the balance testing, and 61% of participants could not decide whether the testing was easy or hard to perform. Conclusions: Instrumented posturography may complement clinical assessment in investigating postural control in children and adolescents. While the BESS score only allows for the consideration of a total score approximating postural control, instrumented posturography offers several parameters representing the responsiveness and magnitude of body sway as well as a more differentiated analysis of movement trajectory. Concise instrumented posturography protocols should be developed to augment neuropediatric assessments in cases where a deficiency in postural control is suspected, potentially stemming from disruptions in the processing of visual, proprioceptive, and/or vestibular information.

A prospective investigation of the effects of soccer heading on cognitive and sensorimotor performances in semi-professional female players

Introduction

Repetitive head impacts (RHI) from routine soccer (football) heading have been suggested to contribute to the long-term development of neurodegenerative disorders. However, scientific evidence concerning the actual risk of these RHI on brain health remains inconclusive. Moreover, female athletes-despite a presumably increased vulnerability toward the effects of RHI-are largely underrepresented in previous approaches. Therefore, our aim was to prospectively investigate the effects of heading on cognitive and sensorimotor performances, health perception, and concussion symptoms in semi-professional female soccer players.

Methods

An extensive test battery was used to assess cognitive and sensorimotor performances as well as health status (SF-36) and concussion symptoms (SCAT3) of a total of 27 female soccer players (22.2 ± 4.2 years) and 15 control subjects (23.2 ± 3.0 years) before and after one-and-a-half years. Throughout this period, soccer players' heading exposure was determined using video analysis.

Results

Subgroup comparisons (control [n = 12], low exposure [n = 7], high exposure [n = 8]) showed no time-dependent differences in SF-36 or SCAT3 scores. Similarly, across most behavioral tests, soccer players' performances evolved equally or more favorably as compared to the control subjects. However, there were significant effects pointing toward slightly negative consequences of heading on aspects of fine motor control (p = 0.001), which were confirmed by correlation and multiple regression analyses. The latter, further, yielded indications for a relationship between heading exposure and negative alterations in postural control (p = 0.002).

Discussion

Our findings do not provide evidence for negative effects of soccer heading on female players' health perception, concussion symptoms, and cognitive performances over the course of one-and-a-half years. However, we found subtle negative alterations in fine motor and postural control that could be attributed to heading exposure. Other factors, like the number of previous head injuries, were not linked to the observed changes. Given the reduction of our initial sample size due to player fluctuation, the results need to be interpreted with caution and validated in larger-scale studies. These should not only focus on cognitive outcomes but also consider sensorimotor changes as a result of RHI from soccer heading.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Adolescent Sport-Related Concussion and the Associated Neurophysiological Changes: A Systematic Review

BACKGROUND

Sport-related concussion (SRC) has been shown to induce cerebral neurophysiological deficits, quantifiable with electroencephalography (EEG). As the adolescent brain is undergoing rapid neurodevelopment, it is fundamental to understand both the short- and long-term ramifications SRC may have on neuronal functioning. The current systematic review sought to amalgamate the literature regarding both acute/subacute (≤28 days) and chronic (>28 days) effects of SRC in adolescents via EEG and the diagnostic accuracy of this tool.

METHODS

The review was registered within the Prospero database (CRD42021275256). Search strategies were created and input into the PubMed database, where three authors completed all screening. Risk of bias assessments were completed using the Scottish Intercollegiate Guideline Network and Methodological Index for Non-Randomized Studies.

RESULTS

A total of 128 articles were identified; however, only seven satisfied all inclusion criteria. The studies ranged from 2012 to 2021 and included sample sizes of 21 to 81 participants, albeit only ∼14% of the included athletes were females. The studies displayed low-to-high levels of bias due to the small sample sizes and preliminary nature of most investigations. Although heterogeneous methods, tasks, and analytical techniques were used, 86% of the studies found differences compared with control athletes, in both the symptomatic and asymptomatic phases of SRC. One study used raw EEG data as a diagnostic indicator demonstrating promise; however, more research and standardization are a necessity.

CONCLUSIONS

Collectively, the findings highlight the utility of EEG in assessing adolescent SRC; however, future studies should consider important covariates including biological sex, maturation status, and development.

The spectrum of acute and chronic consequences of neurotrauma in professional and amateur boxing - A call to action is advocated to better understand and prevent this phenomenon

Introduction

Despite changes in regulations, boxing-related injuries and fatalities are still occurring. The numbers available in the literature regarding mortality and long-term consequences may not accurately represent the actual situation. Indeed, the real extent of this phenomenon remains poorly known.

Research question

Delineating the spectrum of acute and chronic consequences of boxing-related traumatic brain injuries (TBI).

Material and methods

Narrative review of the literature concerning acute and chronic boxing-related TBI. Keywords such as mortality, boxing, subdural hematoma were used to search in PubMed and Google scholar. An updated analysis of the Velazquez fatalities collection in boxing was undertaken.

Results

The Velazquez collection includes 2076 fatalities from 1720 to the present with a death rate of 10 athletes per year. More than half of the deaths (N = 1354, 65.2%) occurred after a knock-out, and nearly 75% happened during professional bouts. In Australia, from 1832 to 2020, 163 fatalities were recorded (75% professional). In Japan, from 1952 to 2016, 38 deaths were recorded with a mean age of 23.9 years. Up to 40% of retired professional boxers in the United States were diagnosed with symptoms of chronic brain injury. Clinical dementia is far more prevalent among professional boxers than in amateurs with an incidence of 20%.

Discussion and conclusions

A concerted effort to raise awareness and shed light on boxing-related neuro-trauma is required. Similar considerations can be made for other combat sports or contact sports. A call to action to address this knowledge gap, decrease and prevent this phenomenon is advocated.

Maximizing the Clinical Value of Blood-Based Biomarkers for Mild Traumatic Brain Injury

Mild traumatic brain injury (TBI) and concussion can have serious consequences that develop over time with unpredictable levels of recovery. Millions of concussions occur yearly, and a substantial number result in lingering symptoms, loss of productivity, and lower quality of life. The diagnosis may not be made for multiple reasons, including due to patient hesitancy to undergo neuroimaging and inability of imaging to detect minimal damage. Biomarkers could fill this gap, but the time needed to send blood to a laboratory for analysis made this impractical until point-of-care measurement became available. A handheld blood test is now on the market for diagnosis of concussion based on the specific blood biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl terminal hydrolase L1 (UCH-L1). This paper discusses rapid blood biomarker assessment for mild TBI and its implications in improving prediction of TBI course, avoiding repeated head trauma, and its potential role in assessing new therapeutic options. Although we focus on the Abbott i-STAT TBI plasma test because it is the first to be FDA-cleared, our discussion applies to any comparable test systems that may become available in the future. The difficulties in changing emergency department protocols to include new technology are addressed.

Validity and Reliability of Methods to Assess Movement Deficiencies Following Concussion: A COSMIN Systematic Review

BACKGROUND

There is an increased risk of subsequent concussion and musculoskeletal injury upon return to play following a sports-related concussion. Whilst there are numerous assessments available for clinicians for diagnosis and during return to play following concussion, many may lack the ability to detect these subclinical changes in function. Currently, there is no consensus or collated sources on the reliability, validity and feasibility of these assessments, which makes it difficult for clinicians and practitioners to select the most appropriate assessment for their needs.

OBJECTIVES

This systematic review aims to (1) consolidate the reliability and validity of motor function assessments across the time course of concussion management and (2) summarise their feasibility for clinicians and other end-users.

METHODS

A systematic search of five databases was conducted. Eligible studies were: (1) original research; (2) full-text English language; (3) peer-reviewed with level III evidence or higher; (4) assessed the validity of lower-limb motor assessments used to diagnose or determine readiness for athletes or military personnel who had sustained a concussion or; (5) assessed the test-retest reliability of lower-limb motor assessments used for concussion management amongst healthy athletes. Acceptable lower-limb motor assessments were dichotomised into instrumented and non-instrumented and then classified into static (stable around a fixed point), dynamic (movement around a fixed point), gait, and other categories. Each study was assessed using the COSMIN checklist to establish methodological and measurement quality.

RESULTS

A total of 1270 records were identified, with 637 duplicates removed. Titles and abstracts of 633 records were analysed, with 158 being retained for full-text review. A total of 67 records were included in this review; 37 records assessed reliability, and 35 records assessed the validity of lower-limb motor assessments. There were 42 different assessments included in the review, with 43% being non-instrumented, subjective assessments. Consistent evidence supported the use of instrumented assessments over non-instrumented, with gait-based assessments demonstrating sufficient reliability and validity compared to static or dynamic assessments.

CONCLUSION

These findings suggest that instrumented, gait-based assessments should be prioritised over static or dynamic balance assessments. The use of laboratory equipment (i.e. 3D motion capture, pressure sensitive walkways) on average exhibited sufficient reliability and validity, yet demonstrate poor feasibility. Further high-quality studies evaluating the reliability and validity of more readily available devices (i.e. inertial measurement units) are needed to fill the gap in current concussion management protocols. Practitioners can use this resource to understand the accuracy and precision of the assessments they have at their disposal to make informed decisions regarding the management of concussion.

TRAIL REGISTRATION

This systematic review was registered on PROSPERO (reg no. CRD42021256298).

Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review

OBJECTIVES

To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6).

DATA SOURCES

Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation.

ELIGIBILITY CRITERIA

(1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC.

DATA EXTRACTION

Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool.

RESULTS

Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children.

CONCLUSION

Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes.

PROSPERO REGISTRATION NUMBER

CRD42020154787.