First-time sports-related concussion recovery revisited: management changes and impact on recovery

A comparison of public views about sports concussion recovery with current guidelines: where are the gaps and overlaps?

Background Sports concussion (SC) management guidelines have recently been updated. A key focus is the emphasis on rest (immediately postinjury) followed by gradual resumption of activity (active recovery). This study aimed to explore community views on SC management and compared these with the guidelines. Methods A total of 157 volunteers completed an online SC survey, including listing three pieces of advice for a concussed person immediately postinjury, and after 2weeks (subacute). Quantitative data were statistically compared, and qualitative data underwent content analysis. Results Almost all participants offered different immediate versus subacute advice; however, rest featured highly at both timepoints. Commonly expressed themes, consistent with guidelines were immediate rest; safety and reinjury prevention; and symptom monitoring. Two themes were identified in the community advice with limited emphasis in the guidelines: general health advice and psychological and social support. Expert clinical assessment was not always identified in community advice. Conclusion Community members hold some views that align with expert advice for SC, particularly the importance of immediate postinjury rest. However, there is scope to grow public awareness of some recommended practices, including expert clinical assessment following injury and when to engage in active recovery.

Systematic Review of Pre-injury Migraines as a Vulnerability Factor for Worse Outcome Following Sport-Related Concussion

Background

Individuals with migraine disorders may be affected differently by concussions compared to individuals without migraine disorders. Prior studies on this topic have had mixed results. The purpose of this study was to systematically examine clinical outcomes following a sport-related concussion in athletes who have a pre-injury history of migraines.

Methods

All studies published prior to 15 May 2021 that examined pre-injury migraines as a possible predictor of clinical recovery from concussion were included. The search included (i) sport/athlete-related terms, (ii) concussion-related terms, and (iii) diverse predictor/modifier terms. After removing duplicates, 5,118 abstracts were screened, 538 full-text articles were reviewed, and 27 articles were included for narrative synthesis without meta-analysis (n = 25 with unique samples). Risk of bias was assessed using the domain-based Quality In Prognosis Studies (QUIPS) tool.

Results

Most studies did not find pre-injury migraines to be associated with concussion outcome, but several of these studies had small or very small sample sizes, as well as other methodological weaknesses. Risk of bias varied greatly across studies. Some of the larger, better-designed studies suggested pre-injury migraines may be a risk factor for worse concussion outcome. Most articles examined pre-injury migraines as an exploratory/secondary predictor of concussion outcome; very few were designed to examine migraine as the primary focus of the study. Migraine history was predominantly based on self-report and studies included minimal information about migraine (e.g., age of onset, frequency/severity, past treatment). Effect sizes were usually not reported or able to be calculated from reported study data.

Conclusion

There is some evidence to suggest that pre-injury migraines may be a vulnerability factor for a worse outcome following concussion, with studies having the lowest risk of bias reporting a positive association. Future studies should focus on improving methodological quality when assessing the relationship between pre-injury migraines and concussion outcome and better characterizing pre-injury migraine status.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128292, identifier: PROSPERO 2019 CRD42019128292.

Literature Review of Sex Differences in mTBI

INTRODUCTION

Traumatic brain injury (TBI) remains a significant source of morbidity worldwide and is of particular concern for the military. Scientific literature examining sex differences in TBI is highly contradictory with some reporting better outcomes in men, others reporting better outcomes in women, and others reporting mixed results or no difference. While the exact cause is currently debated, the existence of such differences has important implications for surveillance techniques, treatment options, and management of long-term consequences. As the number of women within the U.S. military ranks increases and with the opening of combat roles to women in 2013, increased awareness of probable sex differences regarding TBI responses will enable better standard of care.

MATERIALS AND METHODS

Using the PubMed database, a keyword search using gender, "sex factors", "sex dependent", "gender disparity", TBI, "traumatic brain injury", mTBI (mild TBI), and "cranial trauma" was used to identify articles of interest. Results were filtered for written in the last 5 years, English, and free full text. References of relevant articles were cross-checked for additional publications. Articles familiar to the authors were also included.

RESULTS

We review literature that includes analysis of age as an interaction in TBI, hypothesized mechanisms to explain variations in outcomes between men and women, and the need for inclusion of sex as a criterion in future studies.

CONCLUSIONS

Emerging studies underscore the complexity of interpreting sex differences in TBI. The long-held belief that women have a neuroprotective advantage compared to men based on higher levels of sex hormones is being re-evaluated. Past conclusions have relied extensively on clinical studies that include a disproportionate number of men or do not stratify results based on sex. While sex hormones may be neuroprotective, underlying mechanisms are far from clarified. Future TBI studies must include women and gonadal hormone levels should be measured to address potential variables. Given the significant number of TBIs within the military, an improved understanding of TBI pathophysiology and outcomes is important considerations for mission success and servicemember longevity.