Management of sport-related concussion in young athletes

The Influence of Athletic Identity, Passion, and Perceptions of Severity of Concussions on Athletes' Willingness to Report Concussion Symptoms

CONTEXT

The influence of several psychological characteristics on the willingness of athletes to report concussion behaviors has not been well explored. Therefore, the purpose of this study was to understand how athletic identity and sport passion predicted participants' willingness to report symptoms above what was explained by athlete demographics, concussion knowledge, and perceived seriousness of concussions.

DESIGN

The study was cross-sectional.

METHODS

Three-hundred and twenty-two male and female high school and club sport athletes completed survey measures of concussion knowledge, athletic identity, harmonious and obsessive passion, and degree to which athletes indicated they would report concussions and concussion symptoms.

RESULTS

Athletes scored moderately high on their knowledge of symptoms and other concussion information (mean = 16.21; ± = 2.88) and above the midpoint on their attitudes and behaviors toward reporting concussion symptoms (mean = 3.64; ± = 0.70). There were no differences between gender, t(299) = -.78, P = .44, and previous concussion education, t(296) = 1.93, P = .06, related to concussion knowledge. Results of a hierarchical regression indicated that after entering athlete demographics, concussion knowledge, and perceived seriousness of concussions, of the 3 psychological variables in the final stage of the model, only obsessive passion was a significant predictor of athlete's attitudes to report a concussion.

CONCLUSIONS

Perceived seriousness of concussion, perceived threat to long-term health, and obsessive passion were the strongest predictors of athlete's willingness to report concussions. Athletes who did not believe concussions posed a threat to their current or future health, and those that held an obsessive passion for sport were most at risk for not reporting concussions. Future research should continue to investigate the relationship between reporting behaviors and psychological factors.

Attention-Deficit Hyperactivity Disorder and Learning Disabilities Modify Recovery and Sport Behavior Following Sport-Related Concussion

Limited evidence exists concerning how a diagnosis of attention-deficit hyperactivity disorder and/or learning disabilities (ADHD/LD) modifies recovery and behavior following sport-related concussion (SRC). To understand how ADHD/LD modifies the post-SRC experience, we conducted a retrospective cohort study of concussed young athletes through phone interviews with patients and guardians. Outcomes included time until symptom resolution (SR) and return-to-learn (RTL), plus subjective changes in post-SRC activity and sports behavior. Multivariate Cox and logistic regression was performed, adjusting for biopsychosocial characteristics. The ADHD/LD diagnosis was independently associated with worse outcomes, including lower likelihood to achieve SR (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = [0.41-0.94]; P = .02) and RTL (HR = 0.55, 95% CI = [0.36-0.83]; P < .01) at any time following injury, and increased odds of changing sport behavior after concussion (odds ratio [OR] = 3.26, 95% CI = [1.26-8.42], P = .02), often to a safer style of play (62.5% vs 39.6%; P = .02) or retiring from the sport (37.5% vs 18.5%; P = .02). These results provide further evidence of the unique needs for athletes with ADHD/LD following SRC.

Stroke and Athletes: A Scoping Review

Stroke (i.e., cerebrovascular accident) affects one in 10,000 people between the ages of 14 and 45; however, very little is known about the frequency and type of stroke that occurs in athletes. The risk of injury to the neurovascular structures may depend on the type of sport involvement, although, sport-specific incidence rates are not known. Therefore, the goal of our scoping review was to provide some guidance to better inform the development of a context-fit stroke model by summarizing studies on a broad research topic related to stroke or cerebrovascular accident in sport based on a strict athlete definition. We used the guidance of Arksey and O’Malley’s five-stage-process for a scoping review. Databases included MEDLINE(R) Epub Ahead of Print, In-Process & Other Non- Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), and Embase (OVID databases); CINAHL Plus with Full Text, SportDiscus with Full Text (Ebsco databases); and Scopus. Publication dates were from 1979–2020 across nine different countries resulting in 39 individual cases of stroke with an athlete age range of 14–56 years (95% male). The major inciting event(s) prior to stroke onset were headaches (38.4%), head trauma (30.7%), and neck injury and/or vertebral artery dissection (20.5%). Several sporting activities were represented with American football as the most prevalent (30.7%). In summary, we found that sports with an aspect of impact, collision, or microtrauma can lead to subsequent stroke. These sport-related traumatic events were often difficult to diagnose because of the longer interval before ischemia occurred. Therefore, health care providers should be particularly attuned to the possibility of stroke when evaluating athletes presenting with or without neurological deficit.

Concussions in Soccer: An Epidemiological Analysis in the Pediatric Population

Background

As the popularity of youth soccer has increased in the United States, more attention has been focused on the effect of concussion injuries, with recent debate on whether heading should be disallowed. There is little evidence examining the epidemiology of these injuries.

Purpose/Hypothesis

The purpose of this study was to examine the prevalence and incidence of youth soccer-related concussions. We hypothesized that concussion rates will correlate with increased participation in youth soccer.

Study Design

Descriptive epidemiology study.

Methods

The National Electronic Injury Surveillance System was used to collect data on concussion injuries that occurred during soccer in pediatric patients from 2008 through 2016. Soccer-related concussion injuries were identified using specific codes and were analyzed for variation in disposition. The types of contact were categorized into player-to-player, head-to-ball, player-to-post, and player-to-ground contacts. Contact types related to hospitalization were subanalyzed.

Results

A weighted total of 3285 concussion injuries were identified during the study period, with an average of 386 concussions each year. The average age was 13.5 years, and there were no differences seen in incidence between the sexes. The overall incidence of concussion injuries increased (r = 0.789), while hospitalizations decreased (r = -0.574). The most common cause of concussion was found to be player-to-player contact, followed by head-to-ground contact and then head-to-ball contact. Subanalysis showed that 13% of hospitalizations were due to head-to-ball contact, compared with 39% and 44% due to player-to-player contact and head-to-ground contact, respectively. The relative risk of hospitalization from a concussion due to head-to-ball contact was 7.06 compared with 22.60 due to head-to-ground contact.

Conclusion

The incidence of concussion in youth soccer has been increasing over the past decade as predicted, given the growing participation rates in both male and female soccer players. The most common cause of concussion was player-to-player contact, and the majority of concussions resulting in hospitalization occurred because of head-to-ground contact.

Sports and non-sports-related concussions among Medicaid-insured children: health care utilization before and after Ohio's concussion law

Objective

To evaluate patterns of health care utilization for sports-related concussions (SRCs) and non-sports-related concussions (NSRCs) among Medicaid-insured children before and after the enactment of Ohio’s concussion law in April 2013.

Methods

We analyzed claim data from the Partners For Kids (PFK) Ohio Medicaid database. Concussion diagnoses were identified between April 1, 2008 and June 30, 2017. We compared frequency of concussions by age and sex across the law period. We evaluated type of health care utilization before and after law enactment using multinomial logistic regression.

Results

Over the 9 year study period, 6157 concussions were included, most of which (70.4%) were NSRCs. The proportion of SRCs increased with age. Among children younger than 5 years old, the majority (96.1%) of concussions were NSRCs. During the post-law period, greater odds of primary care visits than emergency department (ED) visits were observed for both SRCs (OR = 1.53; 95% CI 1.34, 1.75) and NSRCs (OR = 1.73; 95% CI 1.58, 1.90) compared to the pre-law period.

Conclusions

We observed higher proportions of health care utilization for NSRCs than SRCs in Medicaid insured children and a shift in health care utilization from the ED to primary care in the post-law period. SRCs and NSRCs are likely to have different patterns of health care utilization before and after the enactment of Ohio’s concussion law. Our results demonstrate that Ohio’s youth concussion law had a quantifiable impact on health care utilization.

Prioritizing Pediatricians' Neurosurgical Education: Results From a National Survey of Primary Care Pediatricians

Introduction. We surveyed nonretired American Academy of Pediatrics-member US pediatricians regarding common neurosurgical conditions, identifying specific areas of focus in education. Methods. Data were acquired via self-administered electronic questionnaire. Results. Of 505 total respondents, 56% reported neurology was not a required residency rotation, and 86% had diagnosed craniosynostosis, plagiocephaly, or macrocephaly. Craniosynostosis can mostly be diagnosed by physical examination alone, but almost 50% reported relying on skull X-rays. Fifty-four percent reported diagnosing ocular surface disease (OSD; with 15% to 40% not screening an infant despite well-established cutaneous markers). Seventy-four screened OSD in a patient with sacral dimple. Ninety-seven percent reported treating concussion, but nearly 25% did not manage these patients alone. Two out of 3 patients indicated head injury as most important for continuing education. Conclusion. Improved education for craniosynostosis, OSD, head injury, and concussion management are important for earlier diagnosis, management, and referral of some disorders, while decreasing resource utilization in others. These results should be used when considering pediatrician educational programs.

The influence of education in decision making concerning athlete’s return to sport following a concussion injury: A systematic review

Objectives

Concussions have emerged as one of the most prevalent and controversial injuries sustained within the sporting context. The objective of this review was to determine the influence that education has on decision making concerning athlete’s return to sport following a concussion injury and if the risk is worth it in the eyes of the athletes.

Study design

Systematic review.

Methods

A rapid literature review was performed in PubMed, CINAHL, SPORTDiscus, Embase and Web of Science looking for articles that discussed concussions and any three of the four following search terms: (a) decision making, (b) education/knowledge, (c) sport/return to sport and (d) risk.

Results

Sixteen of 1243 articles were included in this review based on eligibility criteria. Ten were cohort studies, four were cross-sectional studies and two were qualitative research. There was a good agreement between the authors for all studies when determining risk of bias, presenting a Cohen’s κ of 0.901 (95% CI, 0.834, 0.968), p <  0.001.

Conclusion

Education can make a difference in athlete’s decision making process to return to sport; however, their awareness of the health risks that they put themselves in by returning to sport too soon is clouded by other external and internal factors. What is not fully understood is why do they put themselves at this risk? Further studies should explore athletes’ risk aversion behaviour and how it impacts their decision to return to sport following a concussion.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective

Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes' specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes' attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes' injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes' injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes' injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.

Public Attitudes and Knowledge About Youth Sports Participation and Concussion Risk in an Urban Area

BACKGROUND

Every year, millions of children in the United States participate in youth full-contact sports, which carry concussion risks-the long-term sequelae of which are not well understood. We examined the attitudes and knowledge of adults in Chicago about youth sports participation, concussion risk, and whether physicians should counsel against youth participation in full-contact sports.

METHODS

An anonymous paper survey featuring 13 attitudinal, 13 demographic, and 9 knowledge questions was distributed to a convenience sample of adults ≥18 years in hospital waiting areas and four Chicago parks. Participants were asked to hypothetically consider themselves the parent of a 10-year-old child regarding attitudes towards full-contact sports participation.

RESULTS

Between June 13 and July 27, 2016, 1091 partial or complete valid surveys were collected. Almost half (46%) of respondents would not allow a hypothetical 10-year-old son to play tackle football. The majority (74%) of respondents agreed that it was appropriate for physicians to counsel against youth participation in full-contact sports. Respondents obtained information about concussions from, on average, 2-3 sources, although only 34% received information from physicians. Respondents demonstrated a high concussion knowledge level (average: 6.75 of 9 questions). However, only 39% of respondents correctly answered that the following statement was false: "After a mild concussion, there are usually visible changes on medical imaging".

CONCLUSIONS

Overall, respondents are well-informed about concussions. They are divided about the participation of youth in full-contact sports and are amenable to physician counseling against youth participation in full-contact sports.

Comparison of video-based and sensor-based head impact exposure

Previous research has sought to quantify head impact exposure using wearable kinematic sensors. However, many sensors suffer from poor accuracy in estimating impact kinematics and count, motivating the need for additional independent impact exposure quantification for comparison. Here, we equipped seven collegiate American football players with instrumented mouthguards, and video recorded practices and games to compare video-based and sensor-based exposure rates and impact location distributions. Over 50 player-hours, we identified 271 helmet contact periods in video, while the instrumented mouthguard sensor recorded 2,032 discrete head impacts. Matching video and mouthguard real-time stamps yielded 193 video-identified helmet contact periods and 217 sensor-recorded impacts. To compare impact locations, we binned matched impacts into frontal, rear, side, oblique, and top locations based on video observations and sensor kinematics. While both video-based and sensor-based methods found similar location distributions, our best method utilizing integrated linear and angular position only correctly predicted 81 of 217 impacts. Finally, based on the activity timeline from video assessment, we also developed a new exposure metric unique to American football quantifying number of cross-verified sensor impacts per player-play. We found significantly higher exposure during games (0.35, 95% CI: 0.29-0.42) than practices (0.20, 95% CI: 0.17-0.23) (p<0.05). In the traditional impacts per player-hour metric, we observed higher exposure during practices (4.7) than games (3.7) due to increased player activity in practices. Thus, our exposure metric accounts for variability in on-field participation. While both video-based and sensor-based exposure datasets have limitations, they can complement one another to provide more confidence in exposure statistics.

Epidemiology of sports concussion in the United States

Sports and recreation-related (SRR) activities are common in the United States. Beyond the benefits to health, SRR activities can create new friendships, give people a sense of belonging, foster teamwork and other leadership skills, and develop sportsmanship and a respect for rules that govern play. Public awareness about the risk of concussion has grown as the long-term consequences of traumatic brain injury (TBI) have become better known, and likely explains the increasing concussion incidence rates. Currently, surveillance systems capture SRR concussions among high school and college athletes participating in sanctioned sports. National estimates of SRR TBI presenting to an emergency department also exist. Persons under the age of 19 sustain a majority of SRR concussions. Concussion risk is greatest for boys in contact/collision sports like football, ice hockey, and lacrosse, and is more likely to occur in competition versus practice settings. Girls have elevated concussion rates in gender-comparable sports. Despite better data, concussions are still underreported, undermanaged, and often not properly identified. This is especially true for concussions occurring outside organized sports, in nonsport recreational activities, and for concussions either not seen or evaluated in nonemergency department settings. A new surveillance system proposed by the Centers for Disease Control and Prevention aims to fill the gap.

GAIT DEFICITS UNDER DUAL - TASK CONDITIONS IN THE CONCUSSED ADOLESCENT AND YOUNG ATHLETE POPULATION: A SYSTEMATIC REVIEW

BACKGROUND

There are no current sport concussion assessments that capture the effects of dual-task conditions on gait. Multiple studies have evaluated changes, but none have comprehensively examined literature related to the adolescent and young adult population.Purpose: The purpose of this systematic review is to synthesize documented changes in gait under dual-task conditions in adolescents and young adults after sustaining a concussion.Study Design: Systematic Review.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was consulted to guide this systematic review. Six databases were searched: Cinahl, ProQuest, PubMed, Scopus, SPORTdiscus, and Web of Science. Concussion, gait, and dual-task, along with their synonymous terms were the search terms used. Inclusion criteria consisted of adolescent and young adult age groups, acute concussion, dual-tasking, and matched controls. Quality assessment was performed using The Joanna Briggs Institute Critical Appraisal Checklist for Case Control Studies.

RESULTS

Ten full-text articles were selected for inclusion. Concussed individuals demonstrated longer stride times with shorter stride lengths, increased mediolateral displacement with corresponding increases in sagittal and frontal plane peak velocity, and decreased sagittal plane Center of Mass (COM) and Center of Pressure (COP) displacement. The majority of included studies demonstrated moderate to large effect sizes in these gait characteristics.

CONCLUSION

Concussed individuals demonstrated decreased gait stability while ambulating with a dual-task condition. Though statistically significant differences between concussed individuals and matched controls lasted only 72 hours, concussed individuals demonstrated continued improvements in gait for up to two months post-injury, which has the potential to affect an athlete's ability to perform. Further research is needed to determine if a gait examination with a dual-task condition is a realistic, reliable, and valid measure to be included in return to sport testing.

LEVEL OF EVIDENCE

2a.

Underreporting of Concussions and Concussion-Like Symptoms in Female High School Athletes

Underreporting of concussions and concussion-like symptoms in athletes continues to be a serious medical concern and research focus. Despite mounting worry, little evidence exists examining incidence of underreporting and documenting characteristics of head injury in female athletes participating in high school sports. This study examined the self-reporting behaviors of female high school athletes. Seventy-seven athletes participated, representing 14 high school sports. Nearly half of the athletes (31 participants) reported a suspected concussion, with 10 of the 31 athletes refraining from reporting symptoms to training staff after injury. Only 66% reported receiving concussion education. Concussion education appeared to have no relationship with diagnosed concussion rates in athletes, removing athletes from play, or follow-up medical care after injury. In conclusion, female high school athletes underreport signs and symptoms of concussions. Concussion education should occur at higher rates among female athletes to influence reporting behaviors.

Evaluation and management of sport-related concussions in adolescent athletes

Sport-related concussions in young athletes are common, generally under reported and often go unrecognized. Concussion in sport may result either from a direct impact to the head or from indirect forces transmitted to the brain from impact elsewhere on the body. Concussions may also result from sudden acceleration, deceleration or rotational forces to the brain. The key features of concussion include confusion, impaired memory and reduced speed of information processing. Recovery may occur from a few days to several weeks or months. Both physical and cognitive rests are recommended for recovery. Long-term cognitive and behavioral complications are a concern. Preventive strategies include education, modification of sport rules, use of equipment such as headgears, face masks and mouth guards, and neck muscle training. Evidence is limited to support effectiveness of these preventive measures with the exception of rule modification in some sports. Laws have been enacted that require medical evaluation and clearance prior to return to play; however, evidence thus far does not show that laws have been effective in reducing the incidence of concussions in sport. More research is needed in all areas of preventive measures. Sports participation is a complex personal decision on the part of adolescent and his or her family. They should be provided with all information on inherent risks so that they can make an informed decision.

Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial

Background

Injury risk in youth rugby has received much attention, highlighting the importance of establishing evidence-based injury reduction strategies.

Aim

To determine the efficacy of a movement control exercise programme in reducing injuries in youth rugby players and to investigate the effect of programme dose on injury measures.

Methods

In a cluster-randomised controlled trial, 40 independent schools (118 teams, 3188 players aged 14–18 years) were allocated to receive either the intervention or a reference programme, both of which were to be delivered by school coaches. The intervention comprised balance training, whole-body resistance training, plyometric training, and controlled rehearsal of landing and cutting manoeuvres. Time-loss (>24 hours) injuries arising from school rugby matches were recorded by coaches and medical staff.

Results

441 time-loss match injuries (intervention, 233; control, 208) were reported across 15 938 match exposure-hours (intervention, 9083; control, 6855). Intention-to-treat results indicated unclear effects of trial arm on overall match injury incidence (rate ratio (RR)=0.85, 90% confidence limits 0.61 to 1.17), although clear reductions were evident in the intervention arm for concussion incidence (RR=0.71, 0.48 to 1.05). When trial arm comparisons were limited to teams who had completed three or more weekly programme sessions on average, clear reductions in overall match injury incidence (RR=0.28, 0.14 to 0.51) and concussion incidence (RR=0.41, 0.17 to 0.99) were noted in the intervention group.

Conclusion

A preventive movement control exercise programme can reduce match injury outcomes, including concussion, in schoolboy rugby players when compared with a standardised control exercise programme, although to realise the greatest effects players should complete the programme at least three times per week.

An evaluation of Gaelic Athletic Association (GAA) athletes' self-reported practice of playing while concussed, knowledge about and attitudes towards sports-related concussion

BACKGROUND/AIM

Sports-related concussions are now recognized as a major public health concern. However, despite the association of concussion with short- and long-term health consequences, many young athletes still lack basic knowledge about concussion and seem to believe that concussions may be "toughed out" and do not require medical attention. This study assessed self-reported practice of playing in training or a match while concussed among Gaelic Athletic Association (GAA) athletes in Ireland aged 13-25 years old (M=19.19, SD=3.54). This study also assessed knowledge about and attitudes towards sports-related concussion in GAA players in Ireland.

METHODS

Using a self-report questionnaire, data were captured electronically on GAA athletes aged 13-25 years old (n=80) regarding knowledge about the detection, assessment and management of sports-related concussion, as well as participant's attitudes towards concussion and self-reported practice of playing in training or a match while concussed. Data were collected from June to August 2013.

RESULTS

This study revealed that approximately one in four athletes reported having played while concussed in practice or during a match. Males were significantly more likely to play while concussed than females (40.9% and 17.2%, respectively). Results from this study indicated participants lack a complete understanding of concussion, as common misconceptions about concussion prevailed. Analyses revealed that participants generally have safe attitudes towards concussion and concussion management.

CONCLUSION

Generating awareness of the potential short- and long-term health consequences of concussion, coupled with the promotion of safer attitudes towards this injury, could minimize the number of players who return-to-play pre-maturely and promote a more safety-conscious sports culture in Ireland.

Developmental and gender influences on executive function following concussion in youth hockey players

BACKGROUND

Concussion is the most common athletic injury in youth who are simultaneously undergoing rapid developmental changes in the brain, specifically the development of executive functions (EF). The developing brain is more vulnerable to concussive injury with a protracted and different trajectory of recovery than that of adults. Thus, there is a critical need to enhance understanding of how concussion affects EF in youth.

OBJECTIVE

To investigate the effects of age, gender and concussion history (i.e. concussion incidence, recency, severity) on EF in youth hockey players.

METHODS

This 3-year cross-sectional and longitudinal multiple cohort study examined data from 211 hockey players of 8-15 years of age. Mixed-effects modelling was used to examine the influence of age, gender and concussion on EF in youth athletes.

FINDINGS

Baseline analyses revealed significant age and gender effects on measures of EF. Multiple effects of concussion history on measures of cognitive flexibility (F = 2.48, p = 0.03) and psychomotor speed (F = 2.59, p = 0.04) were found.

IMPLICATIONS

This study highlights the impact of age, gender and concussion on EF in youth. These findings provide foundational knowledge to better manage cognitive sequelae following sports-related concussion.

Minor and repetitive head injury

Traumatic brain injury (TBI) is the leading cause of death and disability in the young, active population and expected to be the third leading cause of death in the whole world until 2020. The disease is frequently referred to as the silent epidemic, and many authors highlight the "unmet medical need" associated with TBI.The term traumatically evoked brain injury covers a heterogeneous group ranging from mild/minor/minimal to severe/non-salvageable damages. Severe TBI has long been recognized to be a major socioeconomical health-care issue as saving young lives and sometimes entirely restituting health with a timely intervention can indeed be extremely cost efficient.Recently it has been recognized that mild or minor TBI should be considered similarly important because of the magnitude of the patient population affected. Other reasons behind this recognition are the association of mild head injury with transient cognitive disturbances as well as long-term sequelae primarily linked to repeat (sport-related) injuries.The incidence of TBI in developed countries can be as high as 2-300/100,000 inhabitants; however, if we consider the injury pyramid, it turns out that severe and moderate TBI represents only 25-30 % of all cases, while the overwhelming majority of TBI cases consists of mild head injury. On top of that, or at the base of the pyramid, are the cases that never show up at the ER - the unreported injuries.Special attention is turned to mild TBI as in recent military conflicts it is recognized as "signature injury."This chapter aims to summarize the most important features of mild and repetitive traumatic brain injury providing definitions, stratifications, and triage options while also focusing on contemporary knowledge gathered by imaging and biomarker research.Mild traumatic brain injury is an enigmatic lesion; the classification, significance, and its consequences are all far less defined and explored than in more severe forms of brain injury.Understanding the pathobiology and pathomechanisms may aid a more targeted approach in triage as well as selection of cases with possible late complications while also identifying the target patient population where preventive measures and therapeutic tools should be applied in an attempt to avoid secondary brain injury and late complications.

High School Athletes' Perceptions of Concussion

BACKGROUND

The perception high school athletes have regarding concussions may influence their injury-reporting behavior, and if their perceptions are based on incorrect or incomplete information, they may be at risk for subsequent head injuries.

PURPOSE

To determine whether the recent influx of concussion information has had a positive impact on high school athletes' knowledge of concussions, to determine their perceptions regarding the severity of a concussion injury, and to determine whether receiving correct information will potentially alter their future reporting behavior.

STUDY DESIGN

Cross-sectional study; Level of evidence, 4.

METHODS

A total of 454 high school athletes (212 females, 242 males; mean age, 15.7 ± 1.15 years) from 6 different schools participated in an anonymous survey. The researchers met with teams individually at their high schools to collect data and provide an educational intervention regarding sports-related concussions. The survey questions assessed the athletes' personal injury histories and perceptions and knowledge of the severity of concussion injuries.

RESULTS

There was a difference in the number of athletes who reported having their "bell rung" (n = 297) versus the number of athletes reporting at least 1 concussion (n = 172) (t (453) = -11.60, P = .000, d = -0.54). There was also a difference in the number of athletes who reported a history of at least 1 concussion at the beginning of the study session (n = 172) versus the number of athletes who reported at least 1 concussion at the end of the session (n = 292) (t (453) = -12.018, P = .000, d = 0.732). Fifty percent of athletes also stated that the importance of a game/event should dictate when they return to play.

CONCLUSION

High school athletes continue to fail to realize when they have sustained a concussion. Additionally, athletes lack understanding regarding the severity and seriousness of a concussion. A better effort at formalized education must be made if the culture of sports is to change.

CLINICAL RELEVANCE

Allied health care professionals need to continue to put forth a great effort in educating all student athletes on what a concussion is and the dangers of a concussion injury. Preseason meetings should be used as an opportunity to provide formalized education to all student athletes.

Impact locations and concussion outcomes in high school football player-to-player collisions

BACKGROUND

Little research has examined concussion outcomes in terms of impact location (ie, the area on the head in which the impact occurred). This study describes the epidemiology of concussions resulting from player-to-player collision in high school football by impact location.

METHODS

National High School Sports-Related Injury Surveillance Study data (2008/2009-2012/2013) were analyzed to calculate rates and describe circumstances of football concussion (eg, symptomology, symptom resolution time, return to play) resulting from player-to-player collisions by impact location (ie, front-, back-, side-, and top-of-the-head).

RESULTS

Most concussions resulting from player-to-player collisions occurred from front-of-the-head (44.7%) and side-of-the-head (22.3%) impacts. Number of symptoms reported, prevalence of reported symptoms, symptom resolution time, and length of time to return to play were not associated with impact location. However, a larger proportion of football players sustaining concussions from top-of-the-head impacts experienced loss of consciousness (8.0%) than those sustaining concussions from impacts to other areas of the head (3.5%) (injury proportion ratio 2.3; 95% confidence interval 1.2-4.2; P = .008). Players had their head down at the time of impact in a higher proportion of concussions caused by top-of-the-head impacts (86.4%) than concussions from impacts to other areas of the head (24.0%) (injury proportion ratio 3.6; 95% confidence interval 3.2-4.0; P < .001).

CONCLUSIONS

Among high school football players who sustained concussions due to player-to-player collisions, concussion outcomes were generally independent of impact location. Recommended strategies for reducing the proportion of top-of-the-head impacts include improved education regarding tackling with proper "head-up" technique.

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.

Preseason reports of neck pain, dizziness, and headache as risk factors for concussion in male youth ice hockey players

OBJECTIVE

The objective of this study was to determine the risk of concussion in youth male hockey players with preseason reports of neck pain, headaches, and/or dizziness.

DESIGN

Secondary data analysis of pooled data from 2 prospective cohort studies.

SETTING

Ice hockey rinks in Alberta and Quebec, Canada.

PARTICIPANTS

A total of 3832 male ice hockey players aged 11 to 14 years (280 teams) participated.

ASSESSMENT OF RISK FACTORS

Participants recorded baseline preseason symptoms of dizziness, neck pain, and headaches on the Sport Concussion Assessment Tool. Incidence rate ratios (IRR) were estimated using Poisson regression, adjusted for cluster by team, hours of exposure, and other covariates.

MAIN OUTCOME MEASURES

Concussions that occurred during the season were recorded using a validated prospective injury surveillance system.

RESULTS

Preseason reports of neck pain and headache were risk factors for concussion (IRR = 1.67; 95% confidence interval [CI], 1.15-2.41 and IRR = 1.47; 95% CI, 1.01-2.13). Dizziness was a risk factor for concussion in the Pee Wee nonbody checking cohort (IRR = 3.11; 95% CI, 1.33-7.26). A combination of any 2 symptoms was a risk factor in the Pee Wee nonbody checking cohort (IRR = 3.65; 95% CI, 1.20-11.05) and the Bantam cohort (IRR = 2.40; 95% CI, 1.15-4.97).

CONCLUSIONS

Male youth athletes reporting headache and neck pain at baseline were at an increased risk of concussion during the season. The risk associated with dizziness and any 2 of dizziness, neck pain, or headaches depended on age group and body checking.

CLINICAL RELEVANCE

Baseline testing may be of benefit to identify individuals with symptoms of dizziness, neck pain, and headaches who may be at a higher risk of concussion during the season.

Epidemiology of concussions among United States high school athletes in 20 sports

BACKGROUND

In the United States (US), an estimated 300,000 sports-related concussions occur annually. Among individuals 15 to 24 years of age, sports are second only to motor vehicle crashes as the leading cause of concussions.

PURPOSE

To investigate the epidemiology of concussions in high school athletes by comparing rates and patterns of concussion among 20 sports.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Using an Internet-based data collection tool, RIO, certified athletic trainers from a large, nationally disperse sample of US high schools reported athlete exposure and injury data for 20 sports during the 2008-2010 academic years.

RESULTS

During the study period, 1936 concussions were reported during 7,780,064 athlete-exposures (AEs) for an overall injury rate of 2.5 per 10,000 AEs. The injury rate was higher in competition (6.4) than practice (1.1) (rate ratio [RR], 5.7; 95% confidence interval [CI], 5.2-6.3). The majority of concussions resulted from participation in football (47.1%, n = 912), followed by girls' soccer (8.2%, n = 159), boys' wrestling (5.8%, n = 112), and girls' basketball (5.5%, n = 107). Football had the highest concussion rate (6.4), followed by boys' ice hockey (5.4) and boys' lacrosse (4.0). Concussions represented a greater proportion of total injuries among boys' ice hockey (22.2%) than all other sports studied (13.0%) (injury proportion ratio [IPR], 1.7; 95% CI, 1.4-2.1; P < .01). In gender-comparable sports, girls had a higher concussion rate (1.7) than boys (1.0) (RR, 1.7; 95% CI, 1.4-2.0). The most common mechanisms of injury were player-player contact (70.3%) and player-playing surface contact (17.2%). In more than 40% of athletes in sports other than girls' swimming and girls' track, concussion symptoms resolved in 3 days or less. Athletes most commonly returned to play in 1 to 3 weeks (55.3%), with 22.8% returning in less than 1 week and 2.0% returning in less than 1 day.

CONCLUSION

Although interest in sports-related concussions is usually focused on full-contact sports like football and ice hockey, concussions occur across a wide variety of high school sports. Concussion rates vary by sport, gender, and type of exposure. An understanding of concussion rates, patterns of injury, and risk factors can drive targeted preventive measures and help reduce the risk for concussion among high school athletes in all sports.

Return to play guidelines cannot solve the football-related concussion problem

BACKGROUND

High school football players are the single largest cohort of athletes playing tackle football, and account for the majority of sport-related concussions. Return to play guidelines (RTPs) have emerged as the preferred approach for addressing the problem of sport-related concussion in youth athletes.

METHODS

This article reviews evidence of the risks and effects of football-related concussion and subconcussive brain trauma, as well as the effectiveness of RTPs as a preventative measure. Literature review utilized PubMed and Google Scholar, using combinations of the search terms "football,""sports,""concussion,""Chronic Traumatic Encephalopathy,""athlete,""youth," and "pediatric." Literature review emphasized medical journals and primary neuroscientific research on sport-related concussion and concussion recovery, particularly in youth athletes.

RESULTS

Sport-related concussion is a significant problem among student athletes. Student athletes are more vulnerable to concussion, and at risk of neurocognitive deficits lasting a year or more, with serious effects on academic and athletic performance. RTPs do little to address the problem of sport-related concussion or the chronic damage caused by subconcussive brain trauma.

CONCLUSIONS

Emphasizing RTPs as the solution to the concussion problem in tackle football risks neglecting genuine reforms that would prevent concussions. More effective concussion prevention is needed. Eliminating tackling from school football for youth under 16 is recommended to reduce concussions. Additional modifications to football are recommended to enhance safety and reduce brain trauma at all levels of play.

Pediatric concussions in United States emergency departments in the years 2002 to 2006

OBJECTIVES

To estimate the incidence and demographics of concussions in children coming to emergency departments (EDs) in the United States and describe the rates of neuroimaging and follow-up instructions in these patients.

STUDY DESIGN

This is a cross-sectional study of children 0 to 19 years old diagnosed with concussion from the National Hospital Ambulatory Medical Care Survey. National Hospital Ambulatory Medical Care Survey collects data on approximately 25,000 visits annually to 600 randomly selected hospital emergency and outpatient departments. We examined visits to United States emergency departments between 2002 and 2006. Simple descriptive statistics were used.

RESULTS

Of the 50,835 pediatric visits in the 5-year sample, 230 observations, representing 144,000 visits annually, were for concussions. Sixty-nine percent of concussion visits were by males. Thirty percent were sports-related. Sixty-nine percent of patients diagnosed with a concussion had head imaging. Twenty-eight percent of patients were discharged without specific instructions to follow-up with an outpatient provider for further treatment.

CONCLUSIONS

Approximately 144,000 pediatric patients present to emergency departments each year with a concussion. Most of these patients undergo computed tomography of the head, and nearly one-third are discharged without specific instructions to follow-up with an outpatient provider for further treatment.

Sport-related concussion in adolescents

Sport-related concussion is a common problem encountered by pediatricians and other primary care physicians. Assessment of concussion is based on clinical evaluation. The Zurich consensus statement provides a basic framework to guide concussion management decisions and recommends an individualized approach and the exercising of clinical judgment in return-to-play decisions. This article reviews practice aspects of concussion for the adolescent athletes who present in the primary care office or clinic setting.

"My child doesn't have a brain injury, he only has a concussion"

OBJECTIVE

The term "concussion" is frequently used in clinical records to describe a traumatic head injury; however, there are no standard definitions of this term, particularly in how it is used with children. The goals of this study were to examine the clinical correlates of the concussion diagnosis and to identify the factors that lead to the use of this term in a regional pediatric center.

METHODS

Medical data were prospectively collected from 434 children with traumatic brain injury who were admitted to a Canadian children's hospital. A proportional hazards regression was used to examine the association of the concussion diagnosis and the times until discharge and school return. A classification-tree analysis modeled the clinical correlates of patients who received a concussion diagnosis.

RESULTS

The concussion label was significantly more likely to be applied to children with mild Glasgow Coma Scale scores of 13 to 15 (P = .03). The concussion label was strongly predictive of earlier hospital discharge (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.2-1.9; P = .003) and earlier return to school (OR: 2.4 [95% CI: 1.6-3.7]; P < .001). A diagnosis of a concussion was significantly more likely when the computed-tomography results were normal and the child had lost consciousness.

CONCLUSIONS

Children with mild traumatic brain injuries have an increased frequency of receiving the concussion label, although the label may also be applied to children with more-severe injuries. The concussion diagnosis is associated with important clinical outcomes. Its typical use in hospital settings likely refers to an impact-related mild brain injury, in the absence of indicators other than a loss of consciousness. Clinicians may use the concussion label because it is less alarming to parents than the term mild brain injury, with the intent of implying that the injury is transient with no significant long-term health consequences.

Caring for Student-Athletes Following a Concussion

The school nurse plays a dynamic role in the care and treatment of a concussed athlete. Concussions in the adolescent populations are of special concern due to their potential impact on mental development and cognitive function, as well as an increased risk of serious complications including second impact syndrome. The complexity of a concussion requires collaboration between of a variety of health care and school personnel to create an optimal situation for the student-athlete and their family. As the primary health care provider for students during the school day, school nurses can help ensure all necessary steps are taken to aid the recovery of an injured student-athlete. It is important that school nurses are up-to-date on current concussion information to allow for optimal care following injury and during the recovery process.

Sport-related concussion

Sport-related concussion is a common injury in children and adolescents. Athletes seldom report concussive symptoms, which makes the diagnosis a challenge. The management of sport-related concussion has changed significantly over the last several years. The previously used grading systems and return-to-play guidelines have been abandoned in favor of more individualized assessment and management. Neuropsychological testing is being used more frequently to assist in management. After recovery, it is recommended that an athlete's return-to-play progress in a gradual, stepwise fashion while being monitored by a health care provider. Proper assessment and management of a sport-related concussion is crucial, because repeat concussions can result in decreased neurocognitive functioning, increased symptomatology, and, at times, catastrophic outcomes.

Expert opinion and controversies in sports and musculoskeletal medicine: concussion in the young athlete

Concussion is a common injury in young athletes and can be very challenging for clinicians to diagnose and manage. Debate exists over not only the incidence of long-term risks of multiple concussions but also the potential for catastrophic outcomes after sports-related head injury. Decisions on returning athletes to competition can be difficult, and there are limited prospective data on which to make these decisions. This has resulted in the existence of a number of published guidelines and consensus statements on the management of concussion in athletes. Athletes sustaining a concussion need appropriate on-field care and structured follow-up. Baseline cognitive assessments can be helpful, but clinicians must be aware that head trauma may result in a wide array of clinical signs and symptoms. Delivery of care and decisions on return to play need to be based on an individual assessment of the affected athlete.

Sport-related concussion in the young athlete

PURPOSE OF REVIEW

The purpose of this review is to present an overview of sport-related concussion in the young athlete and review recent publications of clinical and scientific importance.

RECENT FINDINGS

Recent findings show that young athletes are more susceptible to concussions than older athletes and more likely to develop second impact syndrome, as well as long-term negative cumulative consequences. Further, ongoing research suggests a more prolonged disturbance of brain function following a concussion than previously believed.

SUMMARY

Given the increased vulnerability of the young athlete, current research suggests conservative management of concussion and return-to-play decisions. A decision tree diagram to assist the practitioner in making return-to-play recommendations for the young athlete is included in this review.