Current sport-related concussion teaching and clinical practices of sports medicine professionals

Certified Athletic Trainers' Use of Cervical Clinical Testing in the Diagnosis and Management of Sports-Related Concussion

CONTEXT

Despite evidence implicating cervicogenic symptoms in the development of persistent postconcussion symptoms, factors that influence utilization of cervical clinical tests to identify cervicogenic symptoms following concussion are poorly understood.

OBJECTIVE

Explore barriers to the utilization of cervical clinical testing in multifaceted concussion evaluation.

DESIGN

Cross-sectional.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 122 athletic trainers (AT) (age = 42.6 [6.4] y; female = 51.6%; 52% >10 y of clinical practice; 68% master's degree or greater; 35% treated a minimum of 15 concussions/y).

MAIN OUTCOME MEASURE(S)

Perceived importance, clinical experience, number of concussions treated, utilization of cervical clinical tests following nonspecific cervical pathology and following concussion, comfort with cervical treatment modalities following a concussion, and recommendation for cervical-specific therapy to treat persistent postconcussion symptoms.

RESULTS

Ordinal logistic regression revealed perceived importance had the strongest positive impact on AT's likelihood of high utilization of cervical clinical testing following concussion (95% CI, .17 to .99; P = .005), while clinical experience (95% CI, -.43 to .29; P = .71) and number of concussions treated/y (95% CI, -.21 to .31; P = .71) had no bearing. Moreover, low comfort with cervical treatments following a concussion (95% CI, -2.86 to -.26; P = .018) and low utilization of cervical clinical testing following nonspecific cervical pathology (95% CI, -7.01 to -3.39; P ≤ .001) had a strong positive impact on high utilization of cervical clinical testing following concussion. Two logistic regression models demonstrated how recommendations for cervical-specific therapy in persistent post-concussion symptom patients could be predicted based on (1) cervical test utilization and (2) perceptions and clinical experience with 79% and 78%, respectively.

CONCLUSIONS

Perceived importance played a major role in utilization of cervical clinical test following concussion. ATs who utilized common cervical treatments when dealing with non-concussive injuries were more likely to utilize those same treatments to treat comorbid cervical pathology following a concussion.

Prevention of Sport-Related Concussion

Concussion remains a common injury among sports participants. Implementing risk-reduction strategies for sport-related concussion (SRC) should be a priority of medical professionals involved in the care of athletes. Over the past few decades, a multifaceted approach to reducing SRC risk has been developed. Protective equipment, rule and policy change/enforcement, educational programs, behavioral modifications, legislation, physiologic modifications, and sport culture change are a few of the programs implemented to mitigate SRC risk. In this article, the authors critically review current SRC risk-reduction strategies and offer insight into future directions of injury prevention for SRC.

High School Athletic Directors Report Poor Compliance With Concussion Reporting and Medical Clearance in Massachusetts

Purpose

To assess statewide prevalence of medical access, concussion reporting, and concussion clearance rates of high school athletic departments in Massachusetts after the implementation of state-wide concussion legislation.

Methods

A random sample of 50 athletic directors (ADs) from Massachusetts high schools with an enrollment of >150 students was selected. A 10-minute electronic survey about access to athletic trainers and physicians, and concussion reporting and clearance practices was administered. Responses were anonymous.

Results

The response rate was 80% (n = 40). In total, 90% of respondents were male. Median age and experience of respondents was 52 years old and 10 years, respectively. The median school size was 637 students, represented from all Massachusetts geographic athletic districts. ADs disclosed that on average, 12% (95% confidence interval 7%-20%) of concussions go unreported at their schools. In total, 16% of respondents reported that at least 1 in 4 of concussed athletes at their school returned to play without appropriate medical clearance, and 5% of ADs reported that not all of their coaches had undergone any form of concussion training. Overall, 55% of high schools do not have access to a full-time athletic trainer and 50% do not have a team physician; 20% have affiliations with an orthopaedic surgeon and 8% with a neurologist.

Conclusions

Despite new regulations in Massachusetts, high school ADs report concussion reporting and clearance that are less than 100%. Less than one half of all Massachusetts high schools report access to a full-time athletic trainer or formal relationship with a school physician.

Clinical Relevance

Investigating compliance with Massachusetts school athletics safety regulations could help identify a need for reform of policies designed to help schools keep student athletes safer in situations where a concussion may have occurred.

Assessment of Long-Term Effects of Sports-Related Concussions: Biological Mechanisms and Exosomal Biomarkers

Concussion or mild traumatic brain injury (mTBI) in athletes can cause persistent symptoms, known as post-concussion syndrome (PCS), and repeated injuries may increase the long-term risk for an athlete to develop neurodegenerative diseases such as chronic traumatic encephalopathy (CTE), and Alzheimer's disease (AD). The Center for Disease Control estimates that up to 3.8 million sport-related mTBI are reported each year in the United States. Despite the magnitude of the phenomenon, there is a current lack of comprehensive prognostic indicators and research has shown that available monitoring tools are moderately sensitive to short-term concussion effects but less sensitive to long-term consequences. The overall aim of this review is to discuss novel, quantitative, and objective measurements that can predict long-term outcomes following repeated sports-related mTBIs. The specific objectives were (1) to provide an overview of the current clinical and biomechanical tools available to health practitioners to ensure recovery after mTBIs, (2) to synthesize potential biological mechanisms in animal models underlying the long-term adverse consequences of mTBIs, (3) to discuss the possible link between repeated mTBI and neurodegenerative diseases, and (4) to discuss the current knowledge about fluid biomarkers for mTBIs with a focus on novel exosomal biomarkers. The conclusions from this review are that current post-concussion clinical tests are not sufficiently sensitive to injury and do not accurately quantify post-concussion alterations associated with repeated mTBIs. In the current review, it is proposed that current practices should be amended to include a repeated symptom inventory, a cognitive assessment of executive function and impulse control, an instrumented assessment of balance, vestibulo-ocular assessments, and an improved panel of blood or exosome biomarkers.

A virtual reality head stability test for patients with vestibular dysfunction

BACKGROUND

The contribution of visual information to standing balance in patients with vestibular dysfunction varies between patients. Sensitive tools to detect kinematic response to visual perturbation are needed to individualize treatment.

OBJECTIVE

Using the Oculus Rift headset and sensors, we developed a novel virtual reality (VR) test of head stability (HST) in response to visual perturbation. During the test, head movements were tracked in six degrees-of-freedom. The purpose of this pilot study was to test the sensitivity of the VR_HST to differences between patients with vestibular dysfunction and controls.

METHODS

Seventeen patients and 16 controls performed static balance tasks with eyes closed (feet together or tandem on floor and foam) and observing 'moving stars' (amplitude 32 mm, frequency 0.2 Hz) via the Oculus (tandem). Directional Path and Root Mean Square Velocity were calculated for postural and head oscillations.

RESULTS

Postural sway differed significantly between groups when standing on foam with feet together and on floor while observing the 'moving stars' task. Head oscillations were larger among patients, primarily in pitch, yaw, and roll rotation.

CONCLUSIONS

The VR_HST was found to be sensitive to differences between small and diverse groups. Its clinical utility should be studied in larger samples of patients with vestibular dysfunction.

POST-CONCUSSIVE CHANGES IN BALANCE AND POSTURAL STABILITY MEASURED WITH CANESENSE™ AND THE BALANCE ERROR SCORING SYSTEM (BESS) IN DIVISION I COLLEGIATE FOOTBALL PLAYERS: A CASE SERIES

INTRODUCTION

Impairments in postural stability have been identified following sports-related concussion. CaneSense™ is a recently developed mobile lower limb motion capture system and mobile application for movement assessment which provides an objective measure of postural stability. One of the components within CaneSense™ is the Post-Concussive Excursion Index (PCEI), a measure of postural stability expressed as a percentage of symmetry between lower limbs.

PURPOSE

The purpose of this case series is to examine pre- and post-concussion differences using two separate measures, CaneSense™, and a known test, the Balance Error Scoring System (BESS), in Division I collegiate football players.

METHODS

A convenience sample of eight football players diagnosed with a concussion, were the subjects in this case series. All subjects underwent baseline testing prior to the start of pre-season camp consisting of the single limb stance (SLS) test with CaneSense™ and the BESS test. Twenty-four to 72 hours following their concussion, SLS with CaneSense™ test and the BESS test, were administered. Segmental excursions for the thigh and shank segments for each lower limb were combined into the Post-Concussion Excursion Profile (PCEP), which represents each segment's maximum excursion in the medial-lateral and anterior-posterior direction. The PCEI is a single metric generated to quantify differences within subjects by comparing the PCEP value between lower limbs during SLS where 100% suggests absolute symmetry.

RESULTS

The PCEI value decreased significantly post-concussion (41.43 ± 15.53% vs. 87.41 ± 6.05%, p < 0.001) demonstrating a 52.6% decrease in inter-limb symmetry when compared to baseline values. There was an unanticipated 36.36% improvement in composite BESS performance post-concussion (10.5 ± 4.87 errors vs. 16.5 ± 8.49 errors, p = 0.10).

CONCLUSIONS

Differences in inter-limb postural stability were found in subjects post-concussion. By assessing postural stability in both lower limbs individually, using the PCEI, impairments were detected that otherwise would have likely gone undiagnosed using the BESS test alone.

LEVELS OF EVIDENCE

Therapy, Level 4.

Considerations for Athletic Trainers: A Review of Guidance on Mild Traumatic Brain Injury Among Children From the Centers for Disease Control and Prevention and the National Athletic Trainers' Association

The Centers for Disease Control and Prevention recently published an evidence-based guideline, "Diagnosis and Management of Mild Traumatic Brain Injury (mTBI) Among Children." The guideline has many applications for athletic trainers. The following commentary provides considerations for athletic trainers regarding the guideline in conjunction with the current National Athletic Trainers' Association position statement "Management of Sport Concussion" and the "Consensus Statement on Concussion in Sport-The 5th International Conference on Concussion in Sport Held in Berlin, October 2016."

Return to Learn After Sport-Related Concussion: A Survey of Secondary School and Collegiate Athletic Trainers

CONTEXT

Recent recommendations have emphasized return-to-learn (RTL) protocols to aid athletes in recovery from sport-related concussion (SRC) but have been based primarily on anecdotal evidence.

OBJECTIVE

To investigate the RTL practices of certified athletic trainers (ATs) after an SRC.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 1083 individuals (27%) from a random sample of 4000 ATs in the National Athletic Trainers' Association membership database completed an electronic survey. Participants consisted of 729 self-identified secondary school ATs (SSATs; 67.3%; experience = 14.0 ± 9.7 years) and 354 self-identified collegiate ATs (CATs; 32.7%; experience = 13.4 ± 9.7 years).

MAIN OUTCOME MEASURE(S)

We used χ² analyses to assess respondent differences related to current knowledge, current practices, and available resources. Independent t tests were used to compare SSATs and CATs on years of certification and annual number of SRCs evaluated.

RESULTS

Of our total respondents, 41.2% (n = 446) correctly indicated the absence of evidence-based RTL guidelines. Whereas most (73.9%, n = 800) respondents had an established RTL policy, only 38.1% (n = 413) used such guidelines in their clinical practice. Most (97.1%, n = 708) SSATs and 82.2% (n = 291) of CATs had access to (a) mental health professional(s); however, minorities of SSATs (21.4%, n = 156) and CATs (37.0%, n = 131) never accessed these resources to care for concussed student-athletes.

CONCLUSIONS

Our results suggested that, despite the absence of empirical evidence, most surveyed ATs incorporated some form of RTL protocol in their SRC management policy. The varying AT knowledge, clinical practices, and resources highlighted by our results should be considered when creating or refining an RTL protocol.

Salivary MicroRNAs: Diagnostic Markers of Mild Traumatic Brain Injury in Contact-Sport

Concussion is difficult to diagnose, particularly when symptoms are atypical or late in presenting. An accurate and timely initial assessment is crucial for clinical management. Cerebral spinal fluid (CSF) and blood markers of traumatic brain injury show promising results but their clinical applicability in concussion has significant limitations. In the study, we explored saliva as a new source of biomarkers of concussion. Saliva samples of concussed players were collected after 48-72 h from concussion and analyzed by high-throughput technologies. A discovery group of 10 concussed rugby professional and semiprofessional athletes and 10 non-concussed matched controls was used for the analysis of 92 inflammatory proteins by the Proseek-Multiplex-Inflammation technology. In addition, saliva samples of 6 concussed and 6 non-concussed athletes were used to screen 800 human microRNAs (miRNAs) by the Nanostring Technology. The results were then validated by RT-qPCR in an enlarged cohort (validation group) comprising 22 concussed athletes. Results showed, no significant variations of the 65 inflammatory proteins detected in saliva between groups but 5 microRNAs, miR-27b-3p (p = 0.016), let-7i-5p (p = 0.001), miR-142-3p (p = 0.008), miR-107 (p = 0.028), miR-135b-5p (p = 0.017) significantly upregulated in concussed athletes. Univariate ROC curve analysis showed that the differentially expressed miRNAs could be considered good classifiers of concussion. Further analyses showed significant correlation between these microRNAs and Reaction Time component of the ImPACT concussion assessment tool. In addition, biocomputation analysis predicted the involvement of these microRNAs in important biological processes that might be related to trauma, such as response to hypoxia, cell death, neurogenesis, axon repair and myelination. Ease of access and non-invasiveness of saliva samples make these biomarkers particularly suitable for concussion assessment.

Healthcare providers' attitudes and behaviours related to paediatric mild traumatic brain injury: results from the 2014 DocStyles survey

OBJECTIVE

Explore healthcare providers' experiences managing mTBI and better understand their use of mTBI assessment tools and guidelines. Cross-sectional Methods: A random sample of 1,760 healthcare providers responded to the web-based DocStyles survey between June 18 and 30, 2014. The sample included family/general practitioners, internists, pediatricians, and nurse practitioners who reported seeing pediatric patients. We examined their experiences with mTBI to identify opportunities to increase preparedness and improve management of mTBI.

RESULTS

Fifty-nine percent of healthcare providers reported that they diagnosed or managed pediatric patients with mTBI within the last 12 months. Of those, 44.4% felt 'very prepared' to make decisions about when pediatric patients can safety return to activities, such as school and sports after a mTBI. When asked how often they use screening or assessment tools to assess pediatric patients with mTBI, almost half reported that they 'seldom' or 'never' use those resources (24.6% and 22.0%, respectively).

CONCLUSION

Most healthcare providers reported seeing pediatric patients with mTBI, yet most feel only somewhat prepared to manage this injury in their practise. Broader use of screening tools and guidelines, that include clinical decision support tools, may be useful for healthcare providers who care for pediatric patients with mTBI.

Use of the stepwise progression return-to-play protocol following concussion among practicing athletic trainers

PURPOSE

The purpose of this study was to determine whether practicing athletic trainers (ATs) were using the stepwise progression to make return-to-play (RTP) decisions after concussion and to determine what factors influenced their decision to use the stepwise progression.

METHODS

A total of 166 ATs (response rate = 16.6%) completed a 21-item questionnaire that evaluated participant demographics, methods of concussion management, and RTP decision-making using the stepwise progression. Descriptive statistics and a logistic regression were completed to analyze data.

RESULTS

Factors such as education level (p = 0.05) and number of concussions treated (p = 0.05) predicted use of the stepwise progression, whereas sex (p = 0.17), employment setting (p = 0.17), state law (p = 0.86), and years practicing (p = 0.17) did not predict whether ATs were following the stepwise progression.

CONCLUSION

The majority of the ATs from this study are employing the stepwise progression to safely return athletes to play after sustaining a concussion. This demonstrates that ATs are providing a standard of care for concussed athletes across various athletic training settings; however, having a graduate degree and treating more concussions per year are predictors of whether an AT follows all steps of the stepwise progression.

A Comparative Meta-Analysis of the Effects of Concussion on a Computerized Neurocognitive Test and Self-Reported Symptoms

CONTEXT

  Meta-analyses examining construct-specific cognitive impairment concurrently with self-reported symptoms postconcussion are sparse.

OBJECTIVE

  To review the literature on the effects of concussion on construct-specific neurocognitive declines and to compare them with self-reported symptoms before 1 week and between 1 and 3 weeks postconcussion.

DATA SOURCES

  Relevant studies in PubMed, CINAHL, and PsycINFO published from January 1, 1999 through November 30, 2015.

STUDY SELECTION

  Studies were included if participants completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) before and after concussion and if test performance and Postconcussion Symptom Scale (PCSS) scores were reported at both times.

DATA EXTRACTION

  After reviewing the full texts, we extracted data from 17 studies consisting of 29 independent samples; therefore, this meta-analysis consisted of 1777 unique participants.

DATA SYNTHESIS

  The Hedges g effect size (ES) was estimated. A random-effects or fixed-effects model was used based on heterogeneity findings. When heterogeneity was present, we used meta-regression to assess unexplained between-studies variance. Within the first week of injury, the ESs were small to moderate for cognitive declines, ranging from -0.43 (95% confidence interval [CI] = -0.52, -0.35) to -0.67 (95% CI = -0.77, -0.58), and large for the PCSS score (Hedges g = -0.81; 95% CI = -0.91, -0.71). After 1 week, the ESs for cognitive declines (Hedges g range = -0.25 [95% CI = -0.35, -0.15] to -0.37 [95% CI = -0.55, -0.19]) and PCSS score (Hedges g = -0.38; 95% CI = -0.53, -0.22) were also small. Within 2 weeks of injury, PCSS score and time since injury weakly moderated the cognitive ES.

CONCLUSIONS

  When a neurocognitive test was administered within 1 week of injury, the ES was larger for self-reported symptoms than for ImPACT scores generated at the same session. After 1 week of injury, the ESs for ImPACT and PCSS scores were comparable. If the athlete reports symptoms within 1 week of injury, administering a cognitive test does not appear to offer additional information to the clinician. However, if the athlete does not report symptoms postconcussion, cognitive testing may inform the clinical management of the injury.

Reliability of Computerized Neurocognitive Tests for Concussion Assessment: A Meta-Analysis

OBJECTIVE

  Although widely used, computerized neurocognitive tests (CNTs) have been criticized because of low reliability and poor sensitivity. A systematic review was published summarizing the reliability of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores; however, this was limited to a single CNT. Expansion of the previous review to include additional CNTs and a meta-analysis is needed. Therefore, our purpose was to analyze reliability data for CNTs using meta-analysis and examine moderating factors that may influence reliability.

DATA SOURCES

  A systematic literature search (key terms: reliability, computerized neurocognitive test, concussion) of electronic databases (MEDLINE, PubMed, Google Scholar, and SPORTDiscus) was conducted to identify relevant studies.

STUDY SELECTION

  Studies were included if they met all of the following criteria: used a test-retest design, involved at least 1 CNT, provided sufficient statistical data to allow for effect-size calculation, and were published in English.

DATA EXTRACTION

  Two independent reviewers investigated each article to assess inclusion criteria. Eighteen studies involving 2674 participants were retained. Intraclass correlation coefficients were extracted to calculate effect sizes and determine overall reliability. The Fisher Z transformation adjusted for sampling error associated with averaging correlations. Moderator analyses were conducted to evaluate the effects of the length of the test-retest interval, intraclass correlation coefficient model selection, participant demographics, and study design on reliability. Heterogeneity was evaluated using the Cochran Q statistic.

DATA SYNTHESIS

  The proportion of acceptable outcomes was greatest for the Axon Sports CogState Test (75%) and lowest for the ImPACT (25%). Moderator analyses indicated that the type of intraclass correlation coefficient model used significantly influenced effect-size estimates, accounting for 17% of the variation in reliability.

CONCLUSIONS

  The Axon Sports CogState Test, which has a higher proportion of acceptable outcomes and shorter test duration relative to other CNTs, may be a reliable option; however, future studies are needed to compare the diagnostic accuracy of these instruments.

Cumulative Effects of Concussion History on Baseline Computerized Neurocognitive Test Scores: Systematic Review and Meta-analysis

Context:

It is unclear whether individuals with a history of single or multiple clinically recovered concussions exhibit worse cognitive performance on baseline testing compared with individuals with no concussion history.

Objective:

To analyze the effects of concussion history on baseline neurocognitive performance using a computerized neurocognitive test.

Data sources:

PubMed, CINAHL, and psycINFO were searched in November 2015. The search was supplemented by a hand search of references.

Study Selection:

Studies were included if participants completed the Immediate Post-concussion Assessment and Cognitive Test (ImPACT) at baseline (ie, preseason) and if performance was stratified by previous history of single or multiple concussions.

Study Design:

Systematic review and meta-analysis.

Level of Evidence:

Level 2.

Data Extraction:

Sample size, demographic characteristics of participants, as well as performance of participants on verbal memory, visual memory, visual-motor processing speed, and reaction time were extracted from each study.

Results:

A random-effects pooled meta-analysis revealed that, with the exception of worsened visual memory for those with 1 previous concussion (Hedges g = 0.10), no differences were observed between participants with 1 or multiple concussions compared with participants without previous concussions.

Conclusion:

With the exception of decreased visual memory based on history of 1 concussion, history of 1 or multiple concussions was not associated with worse baseline cognitive performance.

Validity of the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT)

BACKGROUND

The immediate post concussion assessment and cognitive testing (ImPACT) is the most widely used concussion assessment tool. Despite its popularity, it is unclear if validation studies for the ImPACT test covered all aspects of validity to support its widespread use in research and clinical practice.

OBJECTIVE

The purpose of this report is to review literature surrounding the validity and the utility of the ImPACT test.

DATA SOURCES AND APPRAISAL

A systematic review of relevant studies in PubMed, CINAHL, and PsycINFO was carried out. Studies were evaluated using the STROBE (strengthening the reporting of observational studies in epidemiology) or the STARD (standards for reporting of diagnostic accuracy) criteria.

RESULTS

The literature search yielded 5968 studies. Sixty-nine studies met the inclusion criteria and were included in the qualitative review. Although the convergent validity of ImPACT was supported, evidence of discriminant and predictive validity, diagnostic accuracy and responsiveness was inconclusive. The utility of the ImPACT test after acute symptom resolution was sparse. The review found many factors influenced the validity and utility of ImPACT scores.

CONCLUSION

Clinicians must consider the benefit of ImPACT testing for their patients on a case-by-case scenario and must take the psychometric properties of the test into account when interpreting results.

Rest and Return to Activity After Sport-Related Concussion: A Systematic Review of the Literature

OBJECTIVE

To systematically review the literature regarding rest and return to activity after sport-related concussion.

DATA SOURCES

The search was conducted in the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, physical and cognitive rest, and return to activity.

STUDY SELECTION

Studies were included if they were published in English; were original research; and evaluated the use of, compliance with, or effectiveness of physical or cognitive rest or provided empirical evidence supporting the graded return-to-activity progression.

DATA EXTRACTION

The study design, patient or participant sample, interventions used, outcome measures, main results, and conclusions were extracted, as appropriate, from each article.

DATA SYNTHESIS

Articles were categorized into groups based on their ability to address one of the primary clinical questions of interest: use of rest, rest effectiveness, compliance with recommendations, or outcome after graded return-to-activity progression. A qualitative synthesis of the results was provided, along with summary tables.

CONCLUSIONS

Our main findings suggest that rest is underused by health care providers, recommendations for rest are broad and not specific to individual patients, an initial period of moderate physical and cognitive rest (eg, limited physical activity and light mental activity) may improve outcomes during the acute postinjury phase, significant variability in the use of assessment tools and compliance with recommended return-to-activity guidelines exists, and additional research is needed to empirically evaluate the effectiveness of graded return-to-activity progressions. Furthermore, there is a significant need to translate knowledge of best practices in concussion management to primary care providers.

If You're Not Measuring, You're Guessing: The Advent of Objective Concussion Assessments

Sport-related concussion remains one of the most complex injuries presented to sports medicine professionals. Although the injury has been recognized since ancient times, the concussion-assessment process has seen significant advances over the last 30 years. This review outlines the addition of objective measures to the clinical evaluation of the concussed athlete, beginning in the 1980s and continuing through the modern age. International and domestic organizations now describe standardized symptom reports, neurostatus and neurocognitive-function evaluations, and postural-control measures as standards of medical care, a significant shift from a short time ago. Despite this progression, much about the injury remains unknown, including new clinical and research-based assessment techniques and how the injury may influence the athlete's cognitive health over the long term.

Knowledge of Concussion and Reporting Behaviors in High School Athletes With or Without Access to an Athletic Trainer

CONTEXT

Increased sport participation and sport-related concussion incidence has led to an emphasis on having an appropriate medical professional available to high school athletes. The medical professional best suited to provide medical care to high school athletes is a certified athletic trainer (AT). Access to an AT may influence the reporting of sport-related concussion in the high school athletic population; however, little is known about how the presence of an AT affects concussion knowledge, prevention, and recognition.

OBJECTIVE

To evaluate knowledge of concussion and reporting behaviors in high school athletes who did or did not have access to an AT.

DESIGN

Cross-sectional study.

SETTING

Survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 438 athletes with access to an AT and 277 without access to an AT.

INTERVENTION(S)

A validated knowledge-of-concussion survey consisting of 83 items addressing concussion history, concussion knowledge, scenario questions, signs and symptoms of a concussion, and reasons why an athlete would not report a concussion. The independent variable was access to an AT.

MAIN OUTCOME MEASURE(S)

We examined the proportion of athletes who correctly identified knowledge of concussion, signs and symptoms of concussion, and reasons why high school student-athletes would not disclose a potential concussive injury by access to an AT. Frequency statistics, χ² tests, independent t tests, and linear regression were conducted to analyze the data.

RESULTS

The underreporting of concussion among high school athletes was 55%. Athletes with access to an AT had more knowledge of concussion than did athletes without such access (P ≤ .001). Chi-square tests did not demonstrate a significant relationship between AT access and a higher percentage reporting concussions.

CONCLUSIONS

High school athletes with access to an AT had more concussion knowledge, but they did not report suspected concussions to an authority figure more frequently than athletes without access to an AT.

Neuropsychological Screening of Sport-Related Concussion

Neuropsychological assessment is a key component of the multidimensional approach recommended by international consensus guidelines for evaluation of athletes affected by sport-related concussion (SRC). Over the past 2 decades, a number of conventional and computerized neuropsychological test batteries have been developed for the assessment of SRC. Standardized neurocognitive assessment tools are now commonly used across the continuum of concussion care, ranging from the sports sideline to critical care setting and the outpatient concussion clinic. We provide a brief, high-level overview of current approaches to best practice in neuropsychological assessment of SRC.

A preliminary study of youth sport concussions: Parents' health literacy and knowledge of return-to-play protocol criteria

PRIMARY OBJECTIVE

To preliminarily explore parents' health literacy and knowledge of youth sport league rules involving concussion education and training, and return-to-play protocols.

RESEARCH DESIGN AND METHODS

This study was guided by the Knowledge, Attitude and Practice (KAP) model of health knowledge to examine parents' concussion literacy, and understanding of concussion education and training, and return-to-play protocols in youth sports. The mixed-method design involved 119 participants; that included in-person (n=8) and telephone (n=4) interviews, and web-based surveys administered through Mechanical Turk via Qualtrics (n=98).

MAIN OUTCOMES AND RESULTS

Most respondents were not familiar with concussion protocols, but trusted coaches' knowledge in return-to-play rules. More than half of the respondents report that the return-to-play concussion criteria have not been clearly explained to them. The majority of respondents were not familiar with the CDC's 'Heads Up' online concussion training programme, nor were they familiar with any other educational/training tool. About one-fifth of the parents had conversations with a coach or medical staff about youth sport concussions.

CONCLUSION

Parents have a general understanding of how to identify concussion symptoms, but lack knowledge of immediate steps to take following an incident other than seeking medical help.

Prospective, Head-to-Head Study of Three Computerized Neurocognitive Assessment Tools Part 2: Utility for Assessment of Mild Traumatic Brain Injury in Emergency Department Patients

OBJECTIVES

The aim of this study was to evaluate the reliability and validity of three computerized neurocognitive assessment tools (CNTs; i.e., ANAM, DANA, and ImPACT) for assessing mild traumatic brain injury (mTBI) in patients recruited through a level I trauma center emergency department (ED).

METHODS

mTBI (n=94) and matched trauma control (n=80) subjects recruited from a level I trauma center emergency department completed symptom and neurocognitive assessments within 72 hr of injury and at 15 and 45 days post-injury. Concussion symptoms were also assessed via phone at 8 days post-injury.

RESULTS

CNTs did not differentiate between groups at any time point (e.g., M 72-hr Cohen's d=-.16, .02, and .00 for ANAM, DANA, and ImPACT, respectively; negative values reflect greater impairment in the mTBI group). Roughly a quarter of stability coefficients were over .70 across measures and test-retest intervals in controls. In contrast, concussion symptom score differentiated mTBI vs. control groups acutely), with this effect size diminished over time (72-hr and day 8, 15, and 45 Cohen's d=-.78, -.60, -.49, and -.35, respectively).

CONCLUSIONS

The CNTs evaluated, developed and widely used to assess sport-related concussion, did not yield significant differences between patients with mTBI versus other injuries. Symptom scores better differentiated groups than CNTs, with effect sizes weaker than those reported in sport-related concussion studies. Nonspecific injury factors, and other characteristics common in ED settings, likely affect CNT performance across trauma patients as a whole and thereby diminish the validity of CNTs for assessing mTBI in this patient population. (JINS, 2017, 23, 293-303).

Survey of Primary Contact Medical and Chiropractic Clinicians on Self-Reported Knowledge and Recognition of Mild Traumatic Brain Injuries: A Pilot Study

OBJECTIVE

The purpose of this study was to assess the self-reported knowledge of concussion recognition and treatment with first-contact family medical and chiropractic practitioners by means of a pilot study of the need, construct validity, and feasibility for further investigation of mild traumatic brain injury (MTBI) knowledge base.

METHODS

Two hundred forty-eight practicing chiropractic and 120 medical physicians in the south and northeastern sections of the United States were contacted by e-mail, telephone, and postal mail to answer an 18-item survey on knowledge, diagnosis, and common practice with respect to traumatic brain injury patients. Descriptive analysis was used to assess common trends.

RESULTS

Twenty-three chiropractic and 11 medical primary care practitioners returned completed surveys, making this a low-power pilot study. The majority claimed confidence in diagnosis of MTBI, but a lack of knowledge of many of the assessment tools and the international guidelines. Chiropractic and medical clinicians revealed similar competencies and differing deficiencies. Both groups admitted infrequent diagnosis of MTBI in practice. There was recognition of major TBI signs, but lack of recognition or inquiry for subtle MTBI signs.

CONCLUSIONS

There is a need and feasibility for further study of the knowledge transfer to the chiropractic physician with a larger population. These findings correlate with similar medical practitioner studies, and may also support previous findings of underreporting of the prevalence of MTBI. The survey instrument appears to provide valid data on knowledge of MTBIs, with some modifications.

Concussion Management in the Classroom

There is a new emphasis on the team approach to pediatric concussion management, particularly in the classroom. However, it is expected that educators are unfamiliar with the "Returning to Learning" recommendations. The authors' primary objective was to assess and improve high school educators' knowledge regarding concussions and management interventions using an online education tool. A total of 247 high school educators completed a 12 question pretest to assess core knowledge of concussions and classroom management followed by a 20-minute online literature-based education module. Participants then completed an identical posttest. The improvement in core knowledge was statistically significant (P < .001). Initial areas of weakness were the description and identification of concussions. Questions regarding concussion classroom management also showed a statistically significant increase in scores (P < .001). This study identifies the deficits in the knowledge of educators regarding concussions and classroom management as well as the significant improvement after an online educational module.

Reliability and Validity of the Sport Concussion Assessment Tool-3 (SCAT3) in High School and Collegiate Athletes

BACKGROUND

The Sport Concussion Assessment Tool-3 (SCAT3) facilitates sideline clinical assessments of concussed athletes. Yet, there is little published research on clinically relevant metrics for the SCAT3 as a whole.

PURPOSE

We documented the psychometric properties of the major SCAT3 components (symptoms, cognition, balance) and derived clinical decision criteria (ie, reliable change score cutoffs and normative conversation tables) for clinicians to apply to cases with and without available preinjury baseline data.

STUDY DESIGN

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

METHODS

High school and collegiate athletes (N = 2018) completed preseason baseline evaluations including the SCAT3. Re-evaluations of 166 injured athletes and 164 noninjured controls were performed within 24 hours of injury and at 8, 15, and 45 days after injury. Analyses focused on predictors of baseline performance, test-retest reliability, and sensitivity and specificity of the SCAT3 using either single postinjury cutoffs or reliable change index (RCI) criteria derived from this sample.

RESULTS

Athlete sex, level of competition, attention-deficit/hyperactivity disorder (ADHD), learning disability (LD), and estimated verbal intellectual ability (but not concussion history) were associated with baseline scores on ≥1 SCAT3 components (small to moderate effect sizes). Female sex, high school level of competition (vs college), and ADHD were associated with higher baseline symptom ratings (d = 0.25-0.32). Male sex, ADHD, and LD were associated with lower baseline Standardized Assessment of Concussion (SAC) scores (d = 0.28-0.68). Male sex, high school level of competition, ADHD, and LD were associated with poorer baseline Balance Error Scoring System (BESS) performance (d = 0.14-0.26). After injury, the symptom checklist manifested the largest effect size at the 24-hour assessment (d = 1.52), with group differences diminished but statistically significant at day 8 (d = 0.39) and nonsignificant at day 15. Effect sizes for the SAC and BESS were small to moderate at 24 hours (SAC: d = -0.36; modified BESS: d = 0.46; full BESS: d = 0.51) and became nonsignificant at day 8 (SAC) and day 15 (BESS). Receiver operating characteristic curve analyses demonstrated a stronger discrimination for symptoms (area under the curve [AUC] = 0.86) than cognitive and balance measures (AUCs = 0.58 and 0.62, respectively), with comparable discrimination of each SCAT3 component using postinjury scores alone versus baseline-adjusted scores (P = .71-.90). Normative conversion tables and RCI criteria were created to facilitate the use of the SCAT3 both with and without baseline test results.

CONCLUSION

Individual predictors should be taken into account when interpreting the SCAT3. The normative conversion tables and RCIs presented can be used to help interpret concussed athletes' performance both with and without baseline data, given the comparability of the 2 interpretative approaches.

Concussion Incidence and Return-to-Play Time in National Basketball Association Players: Results From 2006 to 2014

BACKGROUND

Various research efforts have studied concussions in the National Football League, Major League Baseball, and the National Hockey League. However, no study has investigated the incidence and return-to-play trends in the National Basketball Association (NBA), which this study aims to do.

HYPOTHESIS

Increased media scrutiny and public awareness, in addition to the institution of a league-wide concussion protocol, may have resulted in more conservative return-to-play practices.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

All concussions to NBA players that were publicly reported in the media from the beginning of the 2006 NBA season to the end of the 2014 season were included. The incidence and return-to-play statistics were generated by synthesizing information from publicly available records.

RESULTS

There were 134 publicly reported concussions to NBA players from the beginning of the 2006 season to the conclusion of the 2014 season, resulting in an average of 14.9 concussions per season. The incidence has not changed significantly during this time span. The average games missed after a concussion from 2006 to 2010 was 1.6, significantly less than the 5.0 games missed from 2011 to 2014, following the institution of the NBA concussion protocol (P = .023).

CONCLUSION

Although the incidence of publicly reported concussions in the NBA has not changed appreciably over the past 9 seasons, the time missed after a concussion has. While players often returned in the same game in the 2006 season, the combination of implemented policy, national coverage, medical staff awareness, and player education may have contributed to players now missing an average of 4 to 6 games after a concussion. A multitude of factors has resulted in more conservative return-to-play practices for NBA players after concussions.

Clinical Practices in Collegiate Concussion Management

BACKGROUND

In recent years, sports leagues and sports medicine experts have developed guidelines for concussion management. The extent to which current clinical practice is consistent with guideline recommendations is unclear. At the collegiate level, there have been few examinations of concussion management practices and the extent to which meaningful differences across divisions of competition exist.

PURPOSE

The purposes of this study were to (1) examine current practices in concussion diagnosis and management at National Collegiate Athletic Association (NCAA) member colleges, (2) explore the extent to which current practices reflect current recommendations for concussion diagnosis and management, and (3) determine whether there are differences in management patterns across divisions of competition.

DESIGN

Descriptive epidemiology study.

METHODS

An electronic questionnaire was sent to sports medicine clinicians at all NCAA member colleges during September and October 2013. Clinicians were asked about baseline assessments, diagnosis and management practices, return-to-play protocols, the perceived prevalence of underdiagnosis, and basic demographic information.

RESULTS

Approximately 30% (n = 866) of contacted clinicians, representing nearly 50% (n = 527) of NCAA member colleges, responded to the questionnaire. Preparticipation baseline examinations were administered at the majority of schools (95%), but most (87.5%) administered baseline assessments only to selected high-risk athletes. Computerized neurocognitive testing and balance assessments were most commonly used as preseason baseline and postinjury assessments. Multimodal examination in line with NCAA and other guidance was used only at a minority of institutions. Athletic trainers most commonly administered and interpreted the preseason baseline examination. Most clinicians reported that their institutions' practices were in line with NCAA guidelines during the first 24 hours of an athlete's concussion diagnosis, with exact percentages varying across measures. Differences across divisions of competition included shorter return-to-play time at Division I schools than Division III schools (9.13 vs 10.31 days, respectively) and more frequently referring concussed athletes to a physician within 24 hours of diagnosis at Division I schools.

CONCLUSION

Concussion management at many colleges in the United States incorporates elements recommended by current guidelines; however, there is room to improve. Increasing the use of a multimodal baseline and postinjury examination will elevate the concussion care provided to college athletes and better align with best practice guidance.

Examining Academic Support After Concussion for the Adolescent Student-Athlete: Perspectives of the Athletic Trainer

CONTEXT

Student-athletes may require cognitive rest and academic support after concussion. Athletic trainers (ATs) in secondary schools are uniquely positioned to provide medical care and to collaborate with school professionals while managing concussions. However, little is known regarding return-to-learn policies and their implementation in secondary schools.

OBJECTIVE

To examine ATs' perspectives on return to learn, cognitive rest, and communication with school professionals after concussion.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 1124 secondary school ATs completed the survey (28.5% response rate). The majority of participants were employed full time (752/1114 [67.5%]) in public schools (911/1117 [81.6%]).

MAIN OUTCOME MEASURE(S)

School and AT employment characteristics, demographics, number of concussions evaluated annually, and perceptions of school professionals' familiarity with ATs' responsibilities were independent variables.

RESULTS

Of the ATs, 44% reported having an existing return-to-learn policy. The strongest predictor of a return-to-learn policy was frequent communication with teachers after concussion (odds ratio = 1.5; 95% confidence interval = 1.2, 1.7). Most ATs recommended complete cognitive rest (eg, no reading, television; 492/1087 [45.3%]) or limited cognitive activity based upon symptoms (391/1087 [36.0%]). Common academic accommodations were postponed due dates (789/954 [82.7%]), rest breaks (765/954 [80.2%]), and partial attendance (740/954 [77.6%]). Athletic trainers self-reported as primary monitors of health (764/1037 [73.7%]) and academic progression (359/1011 [35.5%]). The strongest predictor of ATs' communication with school professionals was their perception of school professionals' understanding of ATs' roles.

CONCLUSIONS

Overall, ATs followed best practices for cognitive rest and return to learn after concussion. Although ATs are central to the management of student-athletes' physical health after concussion, school professionals may be better suited to monitor academic progress. Increased communication between the AT and school professionals is recommended to monitor recovery and facilitate academic support for symptomatic student-athletes.

Policies, Procedures, and Practices Regarding Sport-Related Concussion in Community College Athletes

CONTEXT

College sport organizations and associations endorse concussion-management protocols and policies. To date, little information is available on concussion policies and practices at community college institutions.

OBJECTIVE

To assess and describe current practices and policies regarding the assessment, management, and return-to-play criteria for sport-related concussion (SRC) among member institutions of the California Community College Athletic Association (CCCAA).

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 55 head athletic trainers (ATs) at CCCAA institutions.

MAIN OUTCOME MEASURE(S)

Data about policies, procedures, and practices regarding SRC were collected over a 3-week period in March 2012 and analyzed using descriptive statistics, the Fisher exact test, and the Spearman test.

RESULTS

Almost half (47%) of ATs stated they had a policy for SRC assessment, management, and return to play at their institution. They reported being in compliance with baseline testing guidelines (25%), management guidelines (34.5%), and return-to-play guidelines (30%). Nearly 31% of ATs described having an SRC policy in place for academic accommodations. Conference attendance was positively correlated with institutional use of academic accommodations after SRC (r = 0.44, P = .01). The number of meetings ATs attended and their use of baseline testing were also positively correlated (r = 0.38, P = .01).

CONCLUSIONS

At the time of this study, nearly half of CCCAA institutions had concussion policies and 31% had academic-accommodation policies. However, only 18% of ATs at CCCAA institutions were in compliance with all of their concussion policies. Our findings demonstrate improvements in the management of SRCs by ATs at California community colleges compared with previous research but a need for better compliance with SRC policies.

Prospective, Head-to-Head Study of Three Computerized Neurocognitive Assessment Tools (CNTs): Reliability and Validity for the Assessment of Sport-Related Concussion

Limited data exist comparing the performance of computerized neurocognitive tests (CNTs) for assessing sport-related concussion. We evaluated the reliability and validity of three CNTs-ANAM, Axon Sports/Cogstate Sport, and ImPACT-in a common sample. High school and collegiate athletes completed two CNTs each at baseline. Concussed (n=165) and matched non-injured control (n=166) subjects repeated testing within 24 hr and at 8, 15, and 45 days post-injury. Roughly a quarter of each CNT's indices had stability coefficients (M=198 day interval) over .70. Group differences in performance were mostly moderate to large at 24 hr and small by day 8. The sensitivity of reliable change indices (RCIs) was best at 24 hr (67.8%, 60.3%, and 47.6% with one or more significant RCIs for ImPACT, Axon, and ANAM, respectively) but diminished to near the false positive rates thereafter. Across time, the CNTs' sensitivities were highest in those athletes who became asymptomatic within 1 day before neurocognitive testing but was similar to the tests' false positive rates when including athletes who became asymptomatic several days earlier. Test-retest reliability was similar among these three CNTs and below optimal standards for clinical use on many subtests. Analyses of group effect sizes, discrimination, and sensitivity and specificity suggested that the CNTs may add incrementally (beyond symptom scores) to the identification of clinical impairment within 24 hr of injury or within a short time period after symptom resolution but do not add significant value over symptom assessment later. The rapid clinical recovery course from concussion and modest stability probably jointly contribute to limited signal detection capabilities of neurocognitive tests outside a brief post-injury window. (JINS, 2016, 22, 24-37).

False-Positive Rates of Reliable Change Indices for Concussion Test Batteries: A Monte Carlo Simulation

BACKGROUND

Neurocognitive testing is widely performed for the assessment of concussion. Athletic trainers can use preseason baselines with reliable change indices (RCIs) to ascertain whether concussed athletes' cognitive abilities are below preinjury levels. Although the percentage of healthy individuals who show decline on any individual test is determined by its RCI's confidence level (eg, 10% false-positive rate using an RCI with an 80% confidence interval), the expected rate of 1 or more significant RCIs across multiple indices is unclear.

OBJECTIVE

To use a Monte Carlo simulation procedure to estimate the normal rate (ie, base rate) of significant decline on 1 or more RCIs in multitest batteries.

RESULTS & CONCLUSION

For batteries producing 7 or more uncorrelated RCIs (80% confidence intervals), the majority of normal individuals would show significant declines on at least 1 RCI. Expected rates are lower for tests with fewer indices, higher inter-RCI correlations, and more stringent impairment criteria. These reference points can help testers interpret RCI output for multitest batteries.

Recognizing the Symptoms of Mental Illness following Concussions in the Sports Community: A Need for Improvement

OBJECTIVE

To evaluate the awareness of concussion-related symptoms amongst members of the sports community in Canada.

METHODS

A cross-sectional national electronic survey was conducted. Youth athletes, parents, coaches and medical professionals across Canada were recruited through mailing lists from sports-related opt-in marketing databases. Participants were asked to identify, from a list of options, the symptoms of a concussion. The proportion of identified symptoms (categorized as physical, cognitive, mental health-related and overall) as well as participant factors associated with symptom recognition were analyzed.

RESULTS

The survey elicited 6,937 responses. Most of the respondents (92.1%) completed the English language survey, were male (57.7%), 35-54 years of age (61.7%), with post-secondary education (58.2%), or high reported yearly household income (>$80,000; 53.0%). There were respondents from all provinces and territories with the majority of respondents from Ontario (35.2%) or British Columbia (19.1%). While participants identified most of the physical (mean = 84.2% of symptoms) and cognitive (mean = 91.2% of symptoms), they on average only identified 53.5% of the mental health-related symptoms of concussions. Respondents who were older, with higher education and household income, or resided in the Northwest Territories or Alberta identified significantly more of the mental health-related symptoms listed.

INTERPRETATION

While Canadian youth athletes, parents, coaches and medical professionals are able to identify most of the physical and cognitive symptoms associated with concussion, identification of mental health-related symptoms of concussion is still lagging.

Concussion-Management Practice Patterns of National Collegiate Athletic Association Division II and III Athletic Trainers: How the Other Half Lives

CONTEXT

The National Collegiate Athletic Association (NCAA) has published concussion-management practice guidelines consistent with recent position and consensus statements. Whereas NCAA Division I athletic trainers appear highly compliant, little is known about the concussion-management practice patterns of athletic trainers at smaller institutions where staffing and resources may be limited.

OBJECTIVE

To descriptively define the concussion-management practice patterns of NCAA Division II and III athletic trainers.

DESIGN

Cross-sectional study.

SETTING

Web-based questionnaire.

PATIENTS OR OTHER PARTICIPANTS

A total of 755 respondents (response rate = 40.2%) from NCAA Division II and Division III institutions.

MAIN OUTCOME MEASURE(S)

The primary outcome measures were the rate of multifaceted concussion-assessment techniques, defined as 3 or more assessments; the specific practice patterns of each assessment battery; and tests used during a clinical examination.

RESULTS

Most respondents indicated using a multifaceted assessment during acute assessment (Division II = 76.9%, n = 473; Division III = 76.0%, n = 467) and determination of recovery (Division II = 65.0%, n = 194; Division III = 63.1%, n = 288) but not at baseline (Division II = 43.1%, n = 122; Division III = 41.0%, n = 176). Typically, when a postconcussion assessment was initiated, testing occurred daily until baseline values were achieved, and most respondents (80.6% [244/278]) reported using a graded exercise protocol before return to participation.

CONCLUSIONS

We found limited use of the multifaceted assessment battery at baseline but higher rates at both acute assessment and return-to-participation time points. A primary reason cited for not using test-battery components was a lack of staffing or funding for the assessments. We observed limited use of neuropsychologists to interpret neuropsychological testing. Otherwise, most respondents reported concussion-management protocols consistent with recommendations, including a high level of use of objective measures and incorporation of a progressive return-to-participation protocol.

Concussion Knowledge among Medical Students and Neurology/Neurosurgery Residents

Background and Objectives:

Concussion is a prevalent brain injury in the community. While primary prevention strategies need to be enhanced, it is also important to diagnose and treat concussions expertly and expeditiously to prevent serious complications that may be life-threatening or long lasting. Therefore, physicians should be knowledgeable about the diagnosis and management of concussions. The present study assesses Ontario medical students’ and residents’ knowledge of concussion management.

Methods:

A survey to assess the knowledge and awareness of the diagnosis and treatment of concussions was developed and administered to graduating medical students (n= 222) and neurology and neurosurgery residents (n = 80) at the University of Toronto.

Results:

Residents answered correctly significantly more of the questions regarding the diagnosis and management of concussions than the medical students (mean = 5.8 vs 4.1, t= 4.48, p<0.01). Gender, participation in sports, and personal concussion history were not predictive of the number of questions answered correctly. Several knowledge gaps were identified in the sample population as a whole. Approximately half of the medical students and residents did not recognize chronic traumatic encephalopathy (n = 36) or the second impact syndrome (n = 44) as possible consequences of repetitive concussions. Twenty-four percent of the medical students (n = 18) did not think that “every concussed individual should see a physician” as part of management.

Conclusions:

A significant number of medical students and residents have incomplete knowledge about concussion diagnosis and management. This should be addressed by targeting this population during undergraduate medical education.

National Collegiate Athletic Association Division I athletic trainers' concussion-management practice patterns

CONTEXT

A cornerstone of the recent consensus statements on concussion is a multifaceted concussion-assessment program at baseline and postinjury and when tracking recovery. Earlier studies of athletic trainers' (ATs') practice patterns found limited use of multifaceted protocols; however, these authors typically grouped diverse athletic training settings together.

OBJECTIVE

To (1) describe the concussion-management practice patterns of National Collegiate Athletic Association (NCAA) Division I ATs, (2) compare these practice patterns to earlier studies, and (3) objectively characterize the clinical examination.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 610 ATs from NCAA Division I institutions, for a response rate of 34.4%.

MAIN OUTCOME MEASURE(S)

The survey had 3 subsections: demographic questions related to the participant's experiences, concussion-assessment practice patterns, and concussion-recovery and return-to-participation practice patterns. Specific practice-pattern questions addressed balance, cognitive and mental status, neuropsychological testing, and self-reported symptoms. Finally, specific components of the clinical examination were examined.

RESULTS

We identified high rates of multifaceted assessments (i.e., assessments using at least 3 techniques) during testing at baseline (71.2%), acute concussion assessment (79.2%), and return to participation (66.9%). The specific techniques used are provided along with their adherence with evidence-based practice findings. Respondents endorsed a diverse array of clinical examination techniques that often overlapped objective concussion-assessment protocols or were likely used to rule out associated potential conditions. Respondents were cognizant of the Third International Consensus Statement, the National Athletic Trainers' Association position statement, and the revised NCAA Sports Medicine Handbook recommendations.

CONCLUSIONS

Athletic trainers in NCAA Division I demonstrated widespread use of multifaceted concussion-assessment techniques and appeared compliant with recent consensus statements and the NCAA Sports Medicine Handbook.

Translating Guidelines for the Diagnosis and Management of Sports-Related Concussion Into Practice

Sports injuries are a significant clinical and public health concern. There is a growing call to improve the translation of available evidence-based and expert-informed sports injury prevention interventions into sustained use in practice by physicians and others (eg, athletic trainers, coaches, and parents) who care for injured athletes. This article provides a brief overview of the current sport injury prevention implementation literature before focusing specifically on the translation of guidelines (including consensus and position statements) developed to assist physicians and others diagnose and manage athletes with sport-related concussion and the associated return-to-play decisions. The outcomes of more than 20 published studies indicate that physician, athletic trainer, coach, parent, and athlete knowledge, use of, and compliance with sport-related concussion guidelines are limited. More concerted, coordinated, and theory-informed efforts are required to facilitate the widespread dissemination, translation, and implementation of such guidelines. An example is provided of how implementation drivers could be used to inform the development of a comprehensive, multilevel implementation strategy targeting the individual, organizational, and system-level changes necessary to support the translation of available sport-related concussion guidelines in both the clinical and sports settings.

Age and test setting affect the prevalence of invalid baseline scores on neurocognitive tests

BACKGROUND

Prevalence rates of invalid baseline scores on computerized neurocognitive assessments for high school, collegiate, and professional athletes have been published in the literature. At present, there is limited research on the prevalence of invalid baseline scores in pre-high school athletes.

HYPOTHESIS

Pre-high school athletes assessed with baseline neurocognitive tests would show higher prevalence rates of invalidity than older youth athletes, and those athletes, regardless of age, who were tested in a large group setting would show a higher prevalence rate of invalidity than athletes tested in a small group setting.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 502 athletes between the ages of 10 and 18 years completed preseason baseline neurocognitive tests in "large" or "small" groups. All athletes completed the online version of ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). Baseline test results that were "flagged" by the computer software as being of suspect validity and labeled with a "++" symbol were identified for analysis. Participants were retrospectively assigned to 2 independent groups: large group or small group. Test administration of the large group occurred off-site in groups of approximately 10 athletes, and test administration of the small group took place at a private-practice neuropsychology center with only 1 to 3 athletes present.

RESULTS

Chi-square analyses identified a significantly greater proportion of participants obtaining invalid baseline results on the basis of age; younger athletes produced significantly more invalid baseline scores (7.0%, 17/244) than older athletes (2.7%, 7/258) (χ2 (1) = 4.99; P = .021). Log-linear analysis revealed a significant age (10-12 years, 13-18 years) × size (small, large) interaction effect (χ2 (4) = 66.1; P < .001) on the prevalence of invalidity, whereby younger athletes tested in larger groups were significantly more likely to provide invalid results (11.9%) than younger athletes tested in smaller groups (5.4%), older athletes tested in larger groups (2.7%), and older athletes tested in smaller groups (2.7%).

CONCLUSION

Younger athletes tend to exhibit a greater prevalence of invalid baseline results on neurocognitive computerized tests than older youth athletes; the prevalence increases when testing is conducted in a large group and nonclinical setting.

Concussion Management, Education, and Return-to-Play Policies in High Schools: A Survey of Athletic Directors, Athletic Trainers, and Coaches

Background:

Concussions represent 8.9% to 13.2% of all high school athletic injuries. How these injuries are managed is currently unknown.

Hypothesis:

There are differences in concussion management and awareness among boys football, boys ice hockey, and boys and girls soccer.

Study Design:

Descriptive epidemiologic study.

Methods:

High school athletic directors were contacted via e-mail and asked to complete, and request that their staff complete, an online survey with 4 sections aimed at athletic directors, head coaches, team physicians, and certified athletic trainers.

Results:

According to coaches, concussion awareness education was provided for football (97%), hockey (65%), and boys and girls soccer (57% and 47%, respectively) (P < 0.01). Use of sideline screening tools was significantly greater for football (P = 0.03). All participants agreed that a player who has suffered a concussion cannot return to play the same day.

Conclusion:

There is a difference in concussion management and awareness among the 4 sports. Concussion education is well promoted in football but should be expanded in soccer and hockey. Players are not allowed to return to play the same day, and the majority are referred to a physician.

Clinical Relevance:

Study results highlight the differences in concussion education among sports. Health care providers should address these gaps.

Understanding athletic trainers' beliefs toward a multifacted sport-related concussion approach: application of the theory of planned behavior

CONTEXT

Practice guidelines recommend a multifaceted approach for managing concussions, but a relatively small percentage of athletic trainers (ATs) follow these recommendations. Understanding ATs' beliefs toward the recommended concussion practice guidelines is the first step in identifying interventions that could increase compliance. The theory of planned behavior (TPB) allows us to measure ATs' beliefs toward the recommended concussion practice guidelines.

OBJECTIVE

To examine the influence of ATs' beliefs toward the current recommended concussion guidelines on concussion-management practice through an application of the TPB.

DESIGN

Cross-sectional study.

SETTING

A Web link with a survey was e-mailed to 1000 randomly selected members of the National Athletic Trainers' Association (NATA).

PATIENTS OR OTHER PARTICIPANTS

A total of 221 certified ATs working in secondary school/clinic, high school, and college/university settings.

MAIN OUTCOME MEASURE(S)

A 66-item survey reflecting the current recommended concussion guidelines of the NATA and International Conference on Concussion in Sport was created to measure beliefs using the TPB constructs attitude toward the behavior (BA), subjective norms (SN), perceived behavioral control (PBC), and behavioral intention (BI) of ATs. We used a linear multiple regression to determine if the TPB constructs BA, SN, and PBC predicted BI and if PBC and BI predicted behavior according to the TPB model.

RESULTS

We found that BA, SN, and PBC predicted BI (R = 0.683, R(2) = 0.466, F3,202 = 58.78, P < .001). The BA (t202 = 5.53, P < .001) and PBC (t202 = 9.64, P < .001) contributed to the model, whereas SN (t202 = -0.84, P = .402) did not. The PBC and BI predicted behavior (R = 0.661, R(2) = 0.437, F2,203 = 78.902, P < .001).

CONCLUSIONS

In this sample, the TPB constructs predicted BI and behavior of ATs' compliance with recommended concussion-management guidelines. The BA and PBC were the most influential constructs, indicating that those with positive attitudes toward concussion-management recommendations are more likely to implement them, and ATs are less likely to implement them when they do not believe they have the power to do so. We theorize that interventions targeting ATs' attitudes and control perceptions will lead to improved compliance.

Balance error scoring system performance changes after a competitive athletic season

OBJECTIVE

To evaluate the change in Balance Error Scoring System (BESS) performance after an athletic season.

DESIGN

A prospective longitudinal group study.

SETTING

University biomechanics research laboratory.

PARTICIPANTS

A total of 58 college-aged females (23 soccer student-athletes, 16 volleyball student-athletes, and 19 recreationally active healthy college students) participated in the study.

INTERVENTIONS

The BESS test was administered on 2 occasions 90 days apart. For the student-athletes, the first test (PRE) was administered before the start of their athletic season and the second test (POST) was administered immediately after the season. For the recreationally active college students, the PRE test was at the beginning of the academic semester and the POST test exactly 90 days thereafter.

MAIN OUTCOME MEASURES

Total BESS score at PRE and POST was compared with a 3 × 2 repeated measures analysis of variance. The overall change score and absolute value change score were also calculated and compared with a 1-sample t test to an expected change of zero errors.

RESULTS

There was no group by time interaction; however, there was a main effect for time. There was a significant improvement (P = 0.003) between PRE (9.00 ± 2.97 errors) and POST (7.92 ± 2.78 errors) BESS performance. There were significant differences for both the overall change score (1.08 errors) and the absolute value change score (2.00 errors).

CONCLUSIONS

A clinically and statistically significant difference in BESS performance was identified after a 90-day intercollegiate athletic season.

Sports-related concussion testing

Due to the recent focus on concussion in sports, a number of tests have been developed to diagnose and manage concussion. While each test measures different brain functions, no single test has been shown to quickly and reliably assess concussion in all cases. In addition, most of the current concussion tests have not been validated by scientific investigation. This review identifies the pros and cons of the most commonly used noninvasive tests for concussion in order to provide a more complete picture of the resources that are available for concussion testing. The potential utility of research tools such as the head impact telemetry system, advanced magnetic resonance imaging protocols, and biomarkers are discussed in the context of the currently employed tools.

Prevalence of invalid computerized baseline neurocognitive test results in high school and collegiate athletes

CONTEXT

Limited data are available regarding the prevalence and nature of invalid computerized baseline neurocognitive test data.

OBJECTIVE

To identify the prevalence of invalid baselines on the desktop and online versions of ImPACT and to document the utility of correcting for left-right (L-R) confusion on the desktop version of ImPACT.

DESIGN

Cross-sectional study of independent samples of high school (HS) and collegiate athletes who completed the desktop or online versions of ImPACT. Participants or Other Participants: A total of 3769 HS (desktop = 1617, online = 2152) and 2130 collegiate (desktop = 742, online = 1388) athletes completed preseason baseline assessments.

MAIN OUTCOME MEASURE(S)

Prevalence of = ImPACT validity indicators, with correction for L-R confusion (reversing left and right mouse-click responses) on the desktop version, by test version and group. Chi-square analyses were conducted for sex and attentional or learning disorders.

RESULTS

At least 1 invalid indicator was present on 11.9% (desktop) versus 6.3% (online) of the HS baselines and 10.2% (desktop) versus 4.1% (online) of collegiate baselines; correcting for L-R confusion (desktop) decreased this overall prevalence to 8.4% (HS) and 7.5% (collegiate). Online Impulse Control scores alone yielded 0.4% (HS) and 0.9% (collegiate) invalid baselines, compared with 9.0% (HS) and 5.4% (collegiate) on the desktop version; correcting for L-R confusion (desktop) decreased the prevalence of invalid Impulse Control scores to 5.4% (HS) and 2.6% (collegiate). Male athletes and HS athletes with attention deficit or learning disorders who took the online version were more likely to have at least 1 invalid indicator. Utility of additional invalidity indicators is reported.

CONCLUSIONS

The online ImPACT version appeared to yield fewer invalid baseline results than did the desktop version. Identification of L-R confusion reduces the prevalence of invalid baselines (desktop only) and the potency of Impulse Control as a validity indicator. We advise test administrators to be vigilant in identifying invalid baseline results as part of routine concussion management and prevention programs.

Deficiencies in concussion education in Canadian medical schools

BACKGROUND

Recent reports raise concern that physician knowledge of the identification and management of concussion may be deficient. There is little information known about the adequacy of concussion education provided to physicians or medical students. The present study assesses the concussion curriculum offered at medical schools in Canada.

METHODS

We asked all 17 Canadian medical schools to complete a questionnaire on their concussion curriculum, including the following: year of medical school offered; format/setting; and estimated teaching hours. The responses were organized into three categories: (1) concussion-specific education; (2) head injury education incorporating a concussion component; and (3) no concussion education.

RESULTS

Replies were received from 14 (82%) of the 17 medical schools in Canada. Of the 14 responding schools, four (29%) provided concussion-specific education, six (43%) offered head injury education that incorporated a concussion component, and four (29%) reported no concussion teaching in their curriculum.

CONCLUSION

We found deficiencies in the concussion education curriculum provided in the majority of Canadian medical schools. To address this issue, we recommend that all medical schools should, at a minimum, include a one-hour formal concussion-specific teaching session in an early year of their curriculum to be followed by clinical exposure to concussed patients in the later years of medical school. Future studies will be necessary to evaluate if these recommended curricular enhancements are effective in remedying the reported gaps in physicians' concussion knowledge and whether the improved curriculum translates into better care for patients suffering concussion.

Comparative analysis of state-level concussion legislation and review of current practices in concussion

Object

Forty-two states and the District of Columbia have passed legislation based on the Lystedt law of Washington state, enacted in 2009 to protect young athletes who have sustained a concussion. The aim of this study was to note the several similarities and differences among the various laws.

Methods

Concussion legislation was compared for 50 states and the District of Columbia. Evaluation parameters of this study included stipulations of concussion education, criteria for removal from play, requirements for evaluation and return to play after concussion, and individuals required to assess young athletes. Other parameters that were not consistent across states were also noted.

Results

Forty-three states and the District of Columbia have passed concussion legislation, and an additional 4 states have pending legislation. All states with existing legislation support concussion education for coaches; however, only 48% require coaches to undergo formal education. Athletes must be educated on concussion in 86% of states and parents in 88.7%. Suspicion of concussion is a criterion for removal from play in 75% of states; signs and symptoms of concussion are criteria for removal from play in 16% of states. The individuals allowed to evaluate and clear an athlete for return to play differ greatly among states.

Conclusions

Injury prevention legislation holds historical precedent, and given the increasing attention to long-term sequelae of repeated head trauma and concussion, concussion legislation has been rapidly passed in 43 states and the District of Columbia. Although the exact stipulations of these laws vary among states, the overall theme is to increase recognition of concussion in young athletes and ensure that they are appropriately cleared for return to play after concussion.