Youth Preseason Performance on the Sport Concussion Assessment Tool 5 Across Multiple Sports

OBJECTIVE

To examine preseason Sport Concussion Assessment Tool 5 (SCAT5) performance of adolescent sport participants by environment (in-person/virtual), sex, age, concussion history, collision/noncollision sport participation, and self-reported medical diagnoses.

DESIGN

Cross-sectional.

SETTING

Canadian community and high-school sport settings.

PARTICIPANTS

Three thousand eight hundred five adolescent (2493 male, 1275 female, and 37 did not disclose; 11- to 19-year-old) sport participants.

ASSESSMENT OF RISK FACTORS

Sport Concussion Assessment Tool 5 administration method (in-person/virtual), sex (male/female/unreported), age (years), concussion history (0/1/2/3+), collision/noncollision sport participant, and self-reported medical diagnoses [attention deficit disorder or attention-deficit/hyperactivity disorder, headache/migraine, learning disability, and psychiatric disorder (ie, anxiety/depression/other)].

OUTCOME MEASURES

Preseason SCAT5 outcomes including total number of symptoms (TNS; /22), symptom severity score (SSS; /132), Standardized Assessment of Concussion (SAC; /50), and modified Balance Error Scoring System (mBESS; /30).

RESULTS

Multiple multilevel linear or Poisson regression complete case analyses adjusting for clustering and robust standard errors, with β-coefficients (95% CI) back-transformed to indicate an increase/decrease in SCAT5 subdomains when relevant for clinical interpretation. Virtual (V) performance was associated with fewer symptoms reported [TNS Difference V-IP = -1.53 (95% CI, -2.22 to -0.85)], lower SSS [-2.49 (95% CI, -4.41 to -0.58)], and fewer mBESS errors (IP) [-0.52 (95% CI, -0.77 to -0.27)] compared with in-person. For every one-year increase in age, more symptoms [TNS = 0.22 (95% CI, 0.01-0.44)], higher SSS [0.52 (95% CI, 0.01-1.06)], higher SAC [0.27 (95% CI, 0.15-0.38), and poorer balance [mBESS = -0.19 (-0.28 to -0.09)] were observed. Differences between males and females were also seen across all SCAT5 outcomes. Individuals reporting any medical diagnosis or 3+ concussion history also reported more symptoms (TNS) and higher SSS than those who did not.

CONCLUSIONS

Administration environment, sex, age, concussion history, and medical diagnoses were associated with SCAT5 subdomains and are important considerations when interpreting the SCAT5 results.

Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players

OBJECTIVE

To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion.

DESIGN

Prospective cohort study, Safe to Play (2013-2018).

SETTING

Youth hockey leagues in Alberta and British Columbia, Canada.

PARTICIPANTS

Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions.

INDEPENDENT VARIABLES

Psychosocial variables.

MAIN OUTCOME MEASURES

Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit.

RESULTS

Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery.

CONCLUSIONS

Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

Best practices for the dissemination and implementation of neuromuscular training injury prevention warm-ups in youth team sport: a systematic review

OBJECTIVE

To evaluate best practices for neuromuscular training (NMT) injury prevention warm-up programme dissemination and implementation (D&I) in youth team sports, including characteristics, contextual predictors and D&I strategy effectiveness.

DESIGN

Systematic review.

DATA SOURCES

Seven databases were searched.

ELIGIBILITY

The literature search followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

INCLUSION CRITERIA

participation in a team sport, ≥70% youth participants (<19 years), D&I outcomes with/without NMT-related D&I strategies. The risk of bias was assessed using the Downs & Black checklist.

RESULTS

Of 8334 identified papers, 68 were included. Sport participants included boys, girls and coaches. Top sports were soccer, basketball and rugby. Study designs included randomised controlled trials (RCTs) (29.4%), cross-sectional (23.5%) and quasi-experimental studies (13.2%). The median Downs & Black score was 14/33. Injury prevention effectiveness (vs efficacy) was rarely (8.3%) prioritised across the RCTs evaluating NMT programmes. Two RCTs (2.9%) used Type 2/3 hybrid approaches to investigate D&I strategies. 19 studies (31.6%) used D&I frameworks/models. Top barriers were time restrictions, lack of buy-in/support and limited benefit awareness. Top facilitators were comprehensive workshops and resource accessibility. Common D&I strategies included Workshops with supplementary Resources (WR; n=24) and Workshops with Resources plus in-season Personnel support (WRP; n=14). WR (70%) and WRP (64%) were similar in potential D&I effect. WR and WRP had similar injury reduction (36-72%) with higher adherence showing greater effectiveness.

CONCLUSIONS

Workshops including supplementary resources supported the success of NMT programme implementation, however, few studies examined effectiveness. High-quality D&I studies are needed to optimise the translation of NMT programmes into routine practice in youth sport.

Preseason Measures of Cervical Spine Function, Vestibulo-Ocular Reflex, Dynamic Balance, and Divided Attention in Youth Ice Hockey Players

OBJECTIVES: Report typical scores and examine preseason cervical spine, vestibulo-ocular reflex, dynamic balance, and divided attention measures in competitive youth ice hockey players aged 10 to 18 years with and without a previous concussion history. DESIGN: Cross-sectional secondary analysis. METHODS: The exposure of interest was self-reported history of concussion. The main outcomes were cervical spine measures (Cervical Flexor Endurance [CFE; seconds], Cervical Flexion-Rotation Test [normal/abnormal], Anterolateral Cervical Spine Strength [kilograms], Head Perturbation Test (/8), and Joint Position Error [JPE; centimeters]), vestibulo-ocular reflex (Dynamic Visual Acuity [logMAR], Head Thrust Test [Positive/Negative]), dynamic balance (Functional Gait Assessment [/30]) and divided attention (Walking While Talking Test [seconds]). Multivariable linear or logistic regression, adjusted for age-group, sex, level of play, and clustered by team, were used to assess potential differences by concussion history. RESULTS: We included data from 2311 participants in this study (87.2% male, 12.8% female, 39.0% reported a previous concussion). No differences by concussion history were found across any of the measures (P values range: 0.17-0.99). Measures of cervical spine function and divided attention differed by age group (eg, Median Left Anterolateral Cervical Spine Strength [kilograms] for males: U13 = 7.46, U15 = 9.10, U18 = 9.67). CONCLUSION: Clinical outcomes scores in youth ice hockey players did not differ by concussion history. Performance on cervical spine strength, CFE, and JPE test outcomes may improve with age, highlighting the importance of developmental considerations when interpreting test scores. J Orthop Sports Phys Ther 2024;54(3):1-11. Epub 30 November 2023. doi:10.2519/jospt.2023.11958.

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

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

Academic Accommodations for Middle and High School Students Following a Concussion: Perspectives of Teachers and School Administrators

BACKGROUND

An estimated 1 in 5 adolescents have sustained a concussion in North America. Teachers and school administrators are responsible for implementing academic accommodations and other supports for optimal return to learn following a concussion. The primary objective of this study was to describe the prevalence and feasibility of providing academic accommodations to students following concussion from the perspectives of middle and high school teachers and school administrators.

METHODS

A cross-sectional survey was administered to teachers and school administrators (grades 7-12) across Canada online via REDCap. Participants were recruited via word-of-mouth and social media sampling. Survey responses were analyzed descriptively using proportions.

RESULTS

The survey was completed by 180 educators (138 teachers and 41 school administrators), of whom 86% had previously provided academic accommodations to students following concussion, and 96% agreed that students should have access to accommodations following concussion. Some accommodations (eg, breaks, extra time) were provided more often and were more feasible to provide than others (eg, no new learning, reduced bright light). Educators reported limited preparation time and limited school personnel support to assist students following concussion.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

The most feasible accommodations should be prioritized, ensuring students are supported within the school environment.

CONCLUSIONS

Teachers and school administrators confirmed the importance of providing accommodations to students following concussion.

Differences in injury and concussion rates in a cohort of Canadian female and male youth Rugby Union: a step towards targeted prevention strategies

OBJECTIVE

To examine differences in match and training musculoskeletal injury and concussion rates and describe mechanisms of concussion while considering previous playing experience in female and male Canadian high school Rugby Union ('rugby') players.

METHODS

A 2-year prospective cohort study was completed in a high school league (n=361 females, 421 player-seasons; n=429 males, 481 player-seasons) in Calgary, Canada over the 2018 and 2019 rugby playing seasons. Baseline testing was completed at the start of each season and injury surveillance and individual player participation through session attendance was documented to quantify individual-level player exposure hours. Injury incidence rates (IRs) and incidence rate ratios (IRRs) were calculated using Poisson regression, offset by player exposure hours and clustered by team.

RESULTS

Overall match IR for females was 62% higher than males (overall IRR=1.62, 95% CI: 1.20 to 2.18) and the overall training IR was twice as high for females (overall IRR=2.15, 95% CI: 1.40 to 3.32). The female match concussion IR was 70% higher than the males (concussion IRR=1.70, 95% CI: 1.08 to 2.69). Females had a 75% greater tackle-related IR compared with males (IRR=1.75, 95% CI: 1.20 to 2.56). Additionally, female tacklers had a twofold greater rate of injury compared with male tacklers (IRR=2.17, 95% CI: 1.14 to 4.14). Previous playing experience was not associated with tackle-related injury or concussion IRs.

CONCLUSION

The rate of injury and concussion was significantly higher in females within this Canadian high school cohort. These results emphasise the need for development, implementation and evaluation of female-specific injury and concussion prevention strategies to reduce injury and concussion in female youth rugby.

Unravelling the web: Experiences of adolescents returning to school following a concussion

One in five adolescents will sustain a concussion in their lifetime. A concussion may result in symptoms that affect an adolescent's ability to attend school and engage in learning tasks. This study was guided by interpretivism. We conducted one-on-one semi-structured interviews to explore the perspectives of 20 adolescents (ages 14-18) returning to school after a concussion. Interviews were coded inductively and analyzed using reflexive thematic analysis. Five interconnected themes emerged with returning to school and accessing school supports: (1) concussion symptoms affected adolescents' schoolwork; (2) access to academic accommodations eased adolescents' return to school; (3) having supportive and understanding friends, family, and teachers facilitated adolescents' return to school; (4) communication amongst school stakeholders was desired, but often lacking; and (5) feeling anxious, frustrated, and sad with the return to school process. Adolescents' experiences were multifaceted and many factors contributed to their return to school experiences. Our findings can inform our understanding of the experiences of adolescents returning to school following concussion and can inform the development of concussion management supports at schools.

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

OBJECTIVES

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

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

CRD42020154787.

What tests and measures accurately diagnose persisting post-concussive symptoms in children, adolescents and adults following sport-related concussion? A systematic review

OBJECTIVE

To determine what tests and measures accurately diagnose persisting post-concussive symptoms (PPCS) in children, adolescents and adults following sport-related concussion (SRC).

DESIGN

A systematic literature review.

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and SPORTDiscus through March 2022.

ELIGIBILITY CRITERIA

Original, empirical, peer-reviewed findings (cohort studies, case-control studies, cross-sectional studies and case series) published in English and focused on SRC. Studies needed to compare individuals with PPCS to a comparison group or their own baseline prior to concussion, on tests or measures potentially affected by concussion or associated with PPCS.

RESULTS

Of 3298 records screened, 26 articles were included in the qualitative synthesis, including 1016 participants with concussion and 531 in comparison groups; 7 studies involved adults, 8 involved children and adolescents and 11 spanned both age groups. No studies focused on diagnostic accuracy. Studies were heterogeneous in participant characteristics, definitions of concussion and PPCS, timing of assessment and the tests and measures examined. Some studies found differences between individuals with PPCS and comparison groups or their own pre-injury assessments, but definitive conclusions were not possible because most studies had small convenience samples, cross-sectional designs and were rated high risk of bias.

CONCLUSION

The diagnosis of PPCS continues to rely on symptom report, preferably using standardised symptom rating scales. The existing research does not indicate that any other specific tool or measure has satisfactory accuracy for clinical diagnosis. Future research drawing on prospective, longitudinal cohort studies could help inform clinical practice.

Amsterdam 2022 process: A summary of the methodology for the Amsterdam International Consensus on Concussion in Sport

The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27-30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.

Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis

OBJECTIVE

To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

8 databases searched through 22 March 2022.

ELIGIBILITY CRITERIA

Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool.

RESULTS

278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I²=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I²=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I²=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns.

CONCLUSION

Most athletes have full RTL by 10 days but take twice as long for an RTS.

PROSPERO REGISTRATION NUMBER

CRD42020159928.

Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis

OBJECTIVES

To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and/or head impact risk.

DESIGN

This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review.

ELIGIBILITY CRITERIA

Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English.

RESULTS

In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies.

CONCLUSIONS

Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC.

PROSPERO REGISTRATION NUMBER

CRD42019152982.

Role of biomarkers and emerging technologies in defining and assessing neurobiological recovery after sport-related concussion: a systematic review

OBJECTIVE

Determine the role of fluid-based biomarkers, advanced neuroimaging, genetic testing and emerging technologies in defining and assessing neurobiological recovery after sport-related concussion (SRC).

DESIGN

Systematic review.

DATA SOURCES

Searches of seven databases from 1 January 2001 through 24 March 2022 using keywords and index terms relevant to concussion, sports and neurobiological recovery. Separate reviews were conducted for studies involving neuroimaging, fluid biomarkers, genetic testing and emerging technologies. A standardised method and data extraction tool was used to document the study design, population, methodology and results. Reviewers also rated the risk of bias and quality of each study.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they: (1) were published in English; (2) represented original research; (3) involved human research; (4) pertained only to SRC; (5) included data involving neuroimaging (including electrophysiological testing), fluid biomarkers or genetic testing or other advanced technologies used to assess neurobiological recovery after SRC; (6) had a minimum of one data collection point within 6 months post-SRC; and (7) contained a minimum sample size of 10 participants.

RESULTS

A total of 205 studies met inclusion criteria, including 81 neuroimaging, 50 fluid biomarkers, 5 genetic testing, 73 advanced technologies studies (4 studies overlapped two separate domains). Numerous studies have demonstrated the ability of neuroimaging and fluid-based biomarkers to detect the acute effects of concussion and to track neurobiological recovery after injury. Recent studies have also reported on the diagnostic and prognostic performance of emerging technologies in the assessment of SRC. In sum, the available evidence reinforces the theory that physiological recovery may persist beyond clinical recovery after SRC. The potential role of genetic testing remains unclear based on limited research.

CONCLUSIONS

Advanced neuroimaging, fluid-based biomarkers, genetic testing and emerging technologies are valuable research tools for the study of SRC, but there is not sufficient evidence to recommend their use in clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42020164558.

Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children

OBJECTIVES

To systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3-30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6).

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results.

ELIGIBILITY CRITERIA

(1) Original research, cohort studies, case-control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification.

RESULTS

Of 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening.

CONCLUSION

Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review

OBJECTIVE

To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC.

DATA SOURCES

Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically.

STUDY ELIGIBILITY CRITERIA

Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery.

RESULTS

Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC.

CONCLUSION

No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC.

PROSPERO REGISTRATION NUMBER

CRD42022155121.

Examining later-in-life health risks associated with sport-related concussion and repetitive head impacts: a systematic review of case-control and cohort studies

OBJECTIVE

Concern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes.

DESIGN

Systematic review.

DATA SOURCES

Search of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022.

ELIGIBILITY CRITERIA

Studies measuring future risk (cohort studies) or approximating that risk (case-control studies).

RESULTS

Ten studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias.

CONCLUSION

Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors.

PROSPERO REGISTRATION NUMBER

CRD42022159486.

Rest and exercise early after sport-related concussion: a systematic review and meta-analysis

OBJECTIVE

To synthesise the evidence regarding the risks and benefits of physical activity (PA), prescribed aerobic exercise treatment, rest, cognitive activity and sleep during the first 14 days after sport-related concussion (SRC).

DESIGN

Meta-analysis was performed for PA/prescribed exercise interventions and a narrative synthesis for rest, cognitive activity and sleep. Risk of bias (ROB) was determined using the Scottish Intercollegiate Guidelines Network and quality assessed using Grading of Recommendations, Assessment, Development and Evaluations.

DATA SOURCES

MEDLINE, Embase, APA PsycInfo, Cochrane Central Register of Controlled Trials, CINAHL Plus and SPORTDiscus. Searches were conducted in October 2019 and updated in March 2022.

ELIGIBILITY CRITERIA

Original research articles with sport-related mechanism of injury in >50% of study sample and that evaluated how PA, prescribed exercise, rest, cognitive activity and/or sleep impact recovery following SRC. Reviews, conference proceedings, commentaries, editorials, case series, animal studies and articles published before 1 January 2001 were excluded.

RESULTS

46 studies were included and 34 had acceptable/low ROB. Prescribed exercise was assessed in 21 studies, PA in 15 studies (6 PA/exercise studies also assessed cognitive activity), 2 assessed cognitive activity only and 9 assessed sleep. In a meta-analysis of seven studies, PA and prescribed exercise improved recovery by a mean of -4.64 days (95% CI -6.69, -2.59). After SRC, early return to light PA (initial 2 days), prescribed aerobic exercise treatment (days 2-14) and reduced screen use (initial 2 days) safely facilitate recovery. Early prescribed aerobic exercise also reduces delayed recovery, and sleep disturbance is associated with slower recovery.

CONCLUSION

Early PA, prescribed aerobic exercise and reduced screen time are beneficial following SRC. Strict physical rest until symptom resolution is not effective, and sleep disturbance impairs recovery after SRC.

PROSPERO REGISTRATION NUMBER

CRD42020158928.

Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022

For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.

Targeted interventions and their effect on recovery in children, adolescents and adults who have sustained a sport-related concussion: a systematic review

OBJECTIVES

We evaluated interventions to facilitate recovery in children, adolescents and adults with a sport-related concussion (SRC).

DESIGN

Systematic review including risk of bias (modified Scottish Intercollegiate Guidelines Network tool).

DATA SOURCES

MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, APA PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL Plus with Full Text, SPORTDiscus and Scopus searched until March 2022.

STUDY ELIGIBILITY CRITERIA

(1) Original research including randomised controlled trials (RCTs), quasi-experimental designs, cohort, comparative effectiveness studies; (2) focus on SRC; (3) English; (4) peer-reviewed and (5) evaluated treatment.

RESULTS

6533 studies were screened, 154 full texts reviewed and 13 met inclusion (10 RCTs, 1 quasi-experimental and 2 cohort studies; 1 high-quality study, 7 acceptable and 5 at high risk of bias). Interventions, comparisons, timing and outcomes varied, precluding meta-analysis. For adolescents and adults with dizziness, neck pain and/or headaches >10 days following concussion, individualised cervicovestibular rehabilitation may decrease time to return to sport compared with rest followed by gradual exertion (HR 3.91 (95% CI 1.34 to 11.34)) and when compared with a subtherapeutic intervention (HR 2.91 (95% CI 1.01 to 8.43)). For adolescents with vestibular symptoms/impairments, vestibular rehabilitation may decrease time to medical clearance (vestibular rehab group 50.2 days (95% CI 39.9 to 60.4) compared with control 58.4 (95% CI 41.7 to 75.3) days). For adolescents with persisting symptoms >30 days, active rehabilitation and collaborative care may decrease symptoms.

CONCLUSIONS

Cervicovestibular rehabilitation is recommended for adolescents and adults with dizziness, neck pain and/or headaches for >10 days. Vestibular rehabilitation (for adolescents with dizziness/vestibular impairments >5 days) and active rehabilitation and/or collaborative care (for adolescents with persisting symptoms >30 days) may be of benefit.

Are Self-Reported and Parent-Reported Attention Problems and Hyperactivity Associated With Higher Rates of Concussion in Youth Ice Hockey Players?

OBJECTIVE

To examine the association between self-reported and parent-reported attention problems and hyperactivity and rates of injury and concussion in Canadian youth ice hockey players.

DESIGN

Secondary analyses of 2 prospective cohort studies.

SETTING

Canadian youth ice hockey teams.

PARTICIPANTS

Ice hockey players (ages 11-17 years) were recruited by team, over 4 seasons (2011-2016). A combined 1709 players contributing 1996 player-seasons were analyzed (257 players participated in more than one season).

ASSESSMENT OF RISK FACTORS

Data were collected from preseason baseline questionnaires, including child and parent proxy forms of the Behavior Assessment System for Children, second edition.

MAIN OUTCOME MEASURES

Injury and concussion rates and incidence rate ratios (IRR) comparing players with and without self-identified or parent-identified attention problems and hyperactivity, adjusted for covariates (ie, body checking policy, previous injury/concussion, and age) and a random effect for team, were estimated using multiple multilevel negative binomial regression.

RESULTS

When analyzed continuously, rates of concussion increased with higher self-reported and parent-reported measures of attention problems [IRR SELF = 1.025; 95% confidence interval (CI): 1.011-1.040; IRR PARENT = 1.032; 95% CI: 1.008-1.057]. Self-reported hyperactivity was significantly associated with concussion (IRR = 1.021; 95% CI: 1.007-1.035), but parent-reported hyperactivity was not (IRR = 1.005; 95% CI: 0.983-1.028). A T score ≥ 60 cutoff combining attention problems and hyperactivity scores (an estimate of probable attention-deficit hyperactivity disorder) was not significantly associated with rates of injury or concussion.

CONCLUSIONS

Attention problems and hyperactivity may place youth ice hockey players at increased risk of concussion and injury. Preseason assessments could identify players for targeted concussion education and risk reduction strategies.

Evolving the SCAT5 for Ruling Out Higher-Severity Traumatic Brain Injuries-Can Decision Rules Developed for Emergency Settings Help?

BACKGROUND: Decision rules (eg, Canadian computed tomography head rule [CCHR] for adults and Pediatric Emergency Care Applied Research Network [PECARN] rule for children/adolescents) are used in emergency settings (emergency room [ER] rules) to assess traumatic brain injuries (TBIs). The rules have a high-sensitivity and near-perfect negative predictive value that help to rule out more severe TBI. CLINICAL QUESTION: Which criteria should be added to the Sport Concussion Assessment Tool 5 (SCAT5) to reach the sensitivity of the ER rules and improve the utility of the SCAT5 for screening for higher-severity head and brain injuries? KEY RESULTS: We performed a comparative analysis of the SCAT5 with the CCHR and PECARN rules. We compared the presence (yes or no) and comparative "face value" sensitivity (lower, identical, or higher) of the SCAT5 criteria to the ER rules criteria. Loss of consciousness, vomiting, severe/increasing headache, and seizure are SCAT "red flags" with similar or higher sensitivity compared to ER rules criteria. Five criteria had lower sensitivity or were absent from the SCAT. Emergency room rules include any abnormality on the Glasgow Coma Scale (GCS<15), but only a "deterioration of the state of consciousness" is considered a "red flag" in the SCAT5. Persistent retrograde amnesia for more than 30 minutes, age>65, severity of the mechanism of injury, and signs of skull fractures are not mentioned in the SCAT5. CLINICAL APPLICATION: We identified 5 criteria that could inform the evolution the SCAT5 to improve its ability to rule out more severe TBI in a sideline assessment context. J Orthop Sports Phys Ther 2023;53(3):113-119. Epub: 9 December 2022. doi:10.2519/jospt.2022.11301.

It Takes Two to Tango: High Rates of Injury and Concussion in Ball Carriers and Tacklers in High School Boys' Rugby

OBJECTIVE

To examine injury and concussion rates, mechanisms, locations, and types of injury in Canadian high school male rugby.

DESIGN

Prospective cohort study.

SETTING

High school male rugby.

PARTICIPANTS

A total of 429 high school players (2018: n = 225, 2019: n = 256) were recruited from 12 teams in 7 schools in Calgary, Canada.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Injury surveillance included baseline questionnaires, weekly exposure, and injury reports. Injuries included those requiring medical attention, resulted in time loss and/or inability to complete a session. Concussion was defined as per the fifth Consensus on Concussion in Sport, and all players with a suspected concussion were referred to a study sport medicine physician.

RESULTS

A total of 134 injuries were captured, leading to an injury incidence rate (IR) of 57.9/1000 hours [95% confidence intervals (CIs): 45.4-73.8]. Median time loss was 6 days (range: 0-90). Injuries to the head were the most common (40%), followed by shoulder (12%) and ankle (10%). The concussion IR was 22.0/1000 hours (95% CIs: 15.9-30.4), which was the most common injury type (38%), followed by sprain (20%) and strain (15%). Sixty-five percent of injuries occurred in the tackle (ball carrier 35%, tackler 30%) and 76% of concussions (ball carrier 41%, tackler 35%).

CONCLUSIONS

The rate of injury and concussion in Canadian youth high school male rugby is high, with tackle-related injuries and concussions the most common. Given this, there is a critical need for implementation of prevention strategies, in particular targeting concussion and the tackle event (eg, neuromuscular, tackle training, and law changes).

One-year stability of preseason Sport Concussion Assessment Tool 5 (SCAT5) values in university level collision and combative sport athletes

OBJECTIVES

To determine the stability of the Sport Concussion Assessment Tool (SCAT) 5 between consecutive seasons in uninjured collision and combative varsity athletes.

METHODS

Thirty-six athletes (19 females) were recruited to participate (wrestling [n = 12], rugby [n = 14], and hockey [n = 10]). The SCAT5 was administration at the start of the 2017 and 2018 seasons. Median baseline demographics for 2017 were as follows: age (19 years [range: 17-24 years]), height (174 cm [range: 149-195 cm]), and weight (76 kg [range: 57-118 kg]). Outcome metrics included subcomponents of the SCAT5: symptom reporting, standardized assessment of concussion (SAC), neurological screening, and balance performance measured with the modified balance error scoring system (mBESS). Wilcoxon signed-rank tests and Cronbach's alpha (α) values were calculated to determine the stability between consecutive years for the SCAT5 variables in the same cohort of athletes. Bonferroni corrections were applied for Wilcoxon signed-rank tests, where alpha = 0.006 (0.05/9).

RESULTS

Between the 2017 and 2018 seasons, no differences were noted in symptom reporting (p = 0.14), SAC (p = 0.32), neurological screening (p = 0.98), and balance performance on the mBESS (p = 0.01). The Cronbach's alpha displayed unacceptable to questionable levels of within-subject stability (range: α = 0.34-0.70) for all subcomponents, except months in reverse order (α = 0.92).

CONCLUSIONS

While no statistical differences were present for all SCAT5 subcomponent metrics between 2017 and 2018 baselines, all but one displayed unacceptable to questionable stability (α ≤ 0.70) when retested one year later. Further research is needed to understand the appropriate time duration baseline SCAT5 values can reliably be utilized within longitudinal studies; as well as the normal variation of SCAT5 reporting/scoring.

Injuries in Youth Volleyball Players at a National Championship: Incidence, Risk Factors, and Mechanisms of Injury

OBJECTIVE

To evaluate injury incidence rates, types, mechanisms, and potential risk factors in youth volleyball.

DESIGN

Prospective cohort.

SETTING

2018 Canadian Youth National Volleyball Tournament.

PARTICIPANTS

Thousand eight hundred seventy-six players [466 males, 1391 females, mean age 16.2 years (±1.26)] consented to participate (19.5%).

ASSESSMENT OF RISK FACTORS

Sex (male/female), age group, position, and underage players.

MAIN OUTCOME MEASURES

Players completed a questionnaire (demographic information, injury, and concussion history). Medical attention injuries were recorded by tournament medical personnel through an injury report form (eg, mechanism and type). Injury was defined as any physical complaint seeking onsite medical attention. Concussion was defined using the fifth International Consensus. Injury rates adjusted for cluster by team were calculated by sex. Exploratory multivariable Poisson regression was used to analyze potential risk factors (eg, sex, age group, position, and underage players) for injury, adjusted for cluster by team and offset by athlete exposures (AEs).

RESULTS

There were 101 injuries in the 7-day tournament {IRFemale = 6.78 injuries/1000 AEs [95% confidence interval (CI), 5.27-8.72]; IRMale = 4.30 injuries/1000 AEs (95% CI, 2.55-7.24)}. Joint sprain (n = 29, 28.71%) and concussion (n = 26, 25.74%) were the most common. Most concussions were associated with ball-to-head contact (61.5%). There was no statistically significant difference in injury rate by sex (IRRF/M: 1.47; 95% CI, 0.80-2.69). The rates of injury in U14 were higher than U18 (IRRU14: 2.57; 95% CI, 1.11-5.98).

CONCLUSIONS

Injury rates are high in youth volleyball tournament play, with the highest rates in U14. More research is needed to inform the development of volleyball-specific injury prevention strategies.

Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada

BACKGROUND

We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada.

METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped.

RESULTS

Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically.

CONCLUSIONS

The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion.

IMPACT

This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Determining the Agreement Between Common Measures Related to Vestibulo-ocular Reflex Function After a Mild Traumatic Brain Injury in Children and Adolescents

•

A battery of complementary tests is needed to assess vestibulo-ocular reflex (VOR) in pediatric mild traumatic brain injury (mTBI).

•

This battery should include both symptom- and performance-based measures.

•

Best practice recommendation is needed for such a battery in clinical settings.

•

Cervical injury presence may influence symptoms induced during VOR testing.

•

There is value of assessing for cervical injury post pediatric mTBI.

Objective

To (1) determine the level of agreement between symptom provocation and performance-based tests of vestibulo-ocular reflex (VOR) function after pediatric mild traumatic brain injury (mTBI) and (2) describe the level of symptom provocation induced by a VOR task in individuals with and without cervical findings.

Design

Cross-sectional.

Setting

This study was conducted at a tertiary care pediatric hospital.

Participants

A total of 101 participants (N=101) aged 6-18 years within 3 weeks of mTBI diagnosis were included (54.5% female; mean age, 13.92±2.63 years; mean time since injury at assessment, 18.26±6.16 days).

Interventions

None.

Main Outcome Measures

Symptom provocation (Vestibular/Ocular Motor Screening tool), performance (clinician-observed VOR performance, head thrust test [HTT], computerized dynamic visual acuity test, video head impulse test), and cervical impairment (cervical flexion-rotation test, range of motion test, self-reported neck pain). Agreement was evaluated using Cohen's κ statistic.

Results

No outcomes demonstrated agreement with symptom provocation (κ=−0.15 to 0.14). Fair agreement demonstrated between clinician-observed VOR performance and HTT (κ=0.32), with little to no agreement demonstrated between other measures. Proportions reporting test-induced dizziness and headache were greater among individuals with cervical findings (29.1%-41.8%) than without (2.3%-6.8%).

Conclusions

Findings support that symptom provocation and performance-based tests measure different constructs and thus have distinct roles when assessing VOR function. Findings suggest results from measures of symptom provocation may be influenced by coexisting cervical impairments, underlining the value of assessing for cervical injury after pediatric mTBI.

Balance impairment in patients with moderate-to-severe traumatic brain injury: Which measures are appropriate for assessment?

Left untreated, balance impairment following moderate-to-severe traumatic brain injury (TBI) can be highly debilitating and hinder activities of daily life. To detect impairments, clinicians need appropriate assessment tools. The objective of this study was to evaluate the feasibility and utility of a battery of clinical balance assessments in adults with moderate-to-severe TBI within 6-months of injury. Thirty-seven adults with TBI [Glasgow Coma Scale score ≤ 12 (33 M/4 F) age 18–50 years] participated in balance testing. Assessments included the Balance Error Scoring System (BESS), National Institutes of Health Standing Balance Test (NIH-SBT), Functional Gait Assessment (FGA), Advanced Functional Gait Assessment (FGA-A), Tandem Gait Test (TGT), Berg Balance Scale (BBS), and Walking While Talking Test (WWTT). We identified pronounced ceiling effects on the BBS and FGA, two widely used clinical balance assessments. The NIH-SBT, WWTT, and FGA used in conjunction with the FGA-A, offered versatility in their capacity to assess patients across the balance severity spectrum. This study provides evidence to support a stepwise approach to balance assessment that can be adapted to the broad range of balance ability found in moderate-to-severe TBI.

Characterizing the evolution of oculomotor and vestibulo-ocular function over time in children and adolescents after a mild traumatic brain injury

Background

Impairments to oculomotor (OM) and vestibulo-ocular reflex (VOR) function following pediatric mTBI have been demonstrated but are poorly understood. Such impairments can be associated with more negative prognosis, affecting physical and mental wellbeing, emphasizing the need to more fully understand how these evolve.

Objectives

to determine i) the extent to which performance on clinical and computerized tests of OM and VOR function varies over time in children and adolescents at 21 days, 3-, and 6-months post-mTBI; ii) the proportion of children and adolescents with mTBI presenting with abnormal scores on these tests at each timepoint.

Design

Prospective longitudinal design.

Setting

Tertiary care pediatric hospital.

Participants

36 participants with mTBI aged 6 to18.

Procedures

Participants were assessed on a battery of OM and VOR tests within 21 days, at 3- and 6-months post injury.

Outcome measures

Clinical measures: Vestibular/ocular motor screening tool (VOMS) (symptom provocation and performance); Computerized measures: reflexive saccade test (response latency), video head impulse test (VOR gain), and dynamic visual acuity test (LogMAR change).

Analysis

Generalized estimating equations (parameter estimates and odd ratios) estimated the effect of time. Proportions above and below normal cut-off values were determined.

Results

Our sample consisted of 52.8% females [mean age 13.98 (2.4) years, assessed on average 19.07 (8–33) days post-injury]. Older children performed better on visual motion sensitivity (OR 1.43, p = 0.03) and female participants worse on near point of convergence (OR 0.19, p = 0.03). Change over time (toward recovery) was demonstrated by VOMS overall symptom provocation (OR 9.90, p = 0.012), vertical smooth pursuit (OR 4.04, p = 0.03), voluntary saccade performance (OR 6.06, p = 0.005) and right VOR gain (0.068, p = 0.013). Version performance and VOR symptom provocation showed high abnormal proportions at initial assessment.

Discussion

Results indicate impairments to the VOR pathway may be present and driving symptom provocation. Vertical smooth pursuit and saccade findings underline the need to include these tasks in test batteries to comprehensively assess the integrity of OM and vestibular systems post-mTBI.

Implications

Findings demonstrate 1) added value in including symptom and performance-based measures in when OM and VOR assessments; 2) the relative stability of constructs measured beyond 3 months post mTBI.

Using a Prism Paradigm to Identify Sensorimotor Impairment in Youth Following Concussion

OBJECTIVE

The study assesses the intrarater reliability and utility of a prism paradigm to identify sensorimotor impairment following sports-related concussion in youth, (recent and history of concussion) compared with youth with no concussion.

SETTING

University of Calgary.

PARTICIPANTS

Three groups of 40 ice hockey players ranging in age from 11 to 17 years were included: (1) no concussion; (2) recent concussion, mean number of days since last concussion 5 (95% CI, 4-6); and (3) history of concussion, mean number of days since last concussion 631 (95% CI, 505-730).

DESIGN

Cross-sectional study.

MAIN MEASURES

The vestibulo-ocular reflex is a fundamental reflex of the central nervous system that stabilizes the position of the eyes during head movement and adapts when sensory input is altered (the bend of the light on the retina by prism glasses). The prism adaptation measure was the number of throws taken to adapt to wearing prism glasses while throwing balls at a central target.

RESULTS

The intraclass correlation coefficient (0.73; 95% CI, 0.55-0.84) and the Bland-Altman 95% levels of agreement (lower limit -18.5; 95% CI, -22.4 to -14.6); and upper limit 16.6; 95% CI, 12.7-20.5) reflected good intrarater reliability. Prism adaptation measures were significantly different across groups ( F2,119 = 51.9, P < .001, r = 0.52, power of 90%), with the mean number of throws for youth (aged 11-17 years) in each group as follows: 10 (95% CI, 8-12) no concussion history; 25 (95% CI, 23-27) recent concussion (1-11 days); and 17 (95% CI, 15-20) history of concussion (90-1560 days).

CONCLUSION

Use of a prism paradigm as a clinical measurement tool has the potential to alter concussion management in youth. The prism paradigm is objective, is readily translatable to the clinical arena, has minimal associated costs, and is easily administered, reliable, and portable.

Feasibility and Reliability of a Novel Game-Based Test of Neurological Function in Youth: The Equilibrium Test Battery

Background

An estimated 11% of Canadian adolescents will sustain a sport-related concussion each year. However, diagnostic tools to detect and monitor concussive outcomes are limited.

Purpose

To evaluate the feasibility and test-retest reliability of the Highmark Interactive Equilibrium (HIEQ) test battery in uninjured adolescents.

Study Design

Observational study with repeated measurements.

Methods

Participants completed the HIEQ test battery, a game-based platform on an iPad application, that assesses balance, cognitive function, and visual function, for up to 15 consecutive school days in a group classroom setting. Feasibility for use of the HIEQ was evaluated by (1) recruitment rates; (2) retention rates; (3) test completion without assistance; and (4) adverse events. Test-retest reliability was examined using Bland Altman 95% limits of agreement and intraclass correlation coefficients comparing the first and second and second and third obtained scores. Reliability across multiple baseline assessments was also analyzed using intraclass correlations for the second to sixth and seventh to eleventh obtained scores.

Results

Fifty-five uninjured high school students (31 females and 24 males, mean age = 16.24 [1.09]) from three high schools participated in the study. Three participants (5%) completed all 15 days of testing, and 73% completed at least 10 of 15 test days. No adverse events were reported. Although the test was feasible, all subtests showed wide limits of agreement from first to second and from second to third testing occasions. Results indicate poor-to-moderate reliability (<0.50 to 0.75) across those intervals, as well as across the second to sixth and seventh to eleventh testing occasions.

Conclusion

The HIEQ is feasible in high school students; however, performance was characterized by wide limits of agreement and poor-to-moderate reliability across test occasions. Future evaluation of the HIEQ in visual and auditory distraction free individual testing settings is warranted.

Level of Evidence

Level 3.

Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada

BACKGROUND

Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.

MATERIALS AND METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC.

RESULTS

194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care.

CONCLUSION

Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.

Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents

OBJECTIVES

The objective of this study is to evaluate the effect of policy change disallowing body checking in adolescent ice hockey leagues (ages 15-17) on reducing rates of injury and concussion.

METHODS

This is a prospective cohort study. Players 15-17 years-old were recruited from teams in non-elite divisions of play (lower 40%-70% by division of play depending on year and city of play in leagues where policy permits or prohibit body checking in Alberta and British Columbia, Canada (2015-18). A validated injury surveillance methodology supported baseline, exposure-hours and injury data collection. Any player with a suspected concussion was referred to a study physician. Primary outcomes include game-related injuries, game-related injuries (>7 days time loss), game-related concussions and game-related concussions (>10 days time loss).

RESULTS

44 teams (453 player-seasons) from non-body checking and 52 teams (674 player-seasons) from body checking leagues participated. In body checking leagues there were 213 injuries (69 concussions) and in non-body checking leagues 40 injuries (18 concussions) during games. Based on multiple multilevel mixed-effects Poisson regression analyses, policy prohibiting body checking was associated with a lower rate of injury (incidence rate ratio (IRR): 0.38 (95% CI 0.24 to 0.6)) and concussion (IRR: 0.49; 95% CI 0.26 to 0.89). This translates to an absolute rate reduction of 7.82 injuries/1000 game-hours (95% CI 2.74 to 12.9) and the prevention of 7326 injuries (95% CI 2570 to 12083) in Canada annually.

CONCLUSIONS

The rate of injury was 62% lower (concussion 51% lower) in leagues not permitting body checking in non-elite 15-17 years old leagues highlighting the potential public health impact of policy prohibiting body checking in older adolescent ice hockey players.

Evaluating the Vestibulo-Ocular Reflex Following Traumatic Brain Injury: A Scoping Review

Purpose:To identify the tests and tools used to evaluate vestibulo-ocular reflex (VOR) function after traumatic brain injury (TBI) in all age groups and across TBI severity.Methods: An electronic search was conducted to include relevant peer-reviewed literature published up to November 2019. Studies included those done with humans, of all ages, and had assessments of oculomotor and/or vestibulo-ocular function in TBI.Results: Of the articles selected (N = 48), 50% were published in 2018/2019. A majority targeted mild TBI, with equal focus on non-computerized versus computerized measures of VOR. Computerized assessment tools used were videonystagmography, dynamic visual acuity/gaze stability, rotary chair, and caloric irrigation. Non-computerized tests included the head thrust, dynamic visual acuity, gaze stability, head shaking nystagmus, rotary chair tests and the vestibular/oculomotor screening tool. High variability in administration protocols were identified. Namely: testing environment, distances/positioning/equipment used, active/passive state, procedures, rotation frequencies, and variables observed.Conclusions: There is a rapid growth of literature incorporating VOR tests in mild TBI but moderate and severe TBI continues to be under-represented. Determining how to pair a clinical test with a computerized tool and developing standardized protocols when administering tests will help in developing an optimal battery assessing the VOR in TBI.

Altered Vestibular Balance Function in Combat Sport Athletes

Combat sports pose a risk for accumulative injuries to the nervous system, yet fighters have remained an understudied population. Here, our purpose was to determine whether repetitive blows to the head have an effect on vestibular balance reflexes in combat sports athletes. We compared lower-limb muscle responses evoked with electrical vestibular stimuluation (EVS) between fighters (boxing/muay thai) and non-fighter controls. Each participant received stochastic vestibular stimulation (0-25 Hz, ±3 mA) over their mastoid processes while they stood relaxed with their head to the left or right. Surface electromyography was recorded from the medial gastrocnemius and soleus muscles bilaterally. Short and medium latency response (SLR/MLR) peaks were significantly delayed in the fighter group compared to controls. SLR and MLR peak amplitudes were also significantly lower in fighters. Fighter-estimated cumulative repetitive head impact (RHI) events demonstrated strong positive correlations with the timing of SLR and MLR peaks. Cumulative RHI events also negatively correlated with peak MLR amplitude and response gain at frequencies above 5 Hz. Our results provide evidence of a progressive vestibular impairment in combat sports athletes, potentially resulting from blows to the head accumulated in sparring practice and competitive bouts throughout their careers. Taken together, EVS-based vestibular assessments may provide a valuable clinical diagnostic tool and help better inform "return-to-play" and career-length decisions for not only combat sports athletes, but potentially other populations at risk of RHIs.

The effect of high-intensity physical exertion on measures of cervical spine, vestibular/ocular-motor screening, and vestibulo-ocular reflex function in university level collision and combative sport athletes

OBJECTIVES

To examine how high-intensity physical exertion affects clinical measures of cervical spine (CSp), vestibular/ocular motor screen (VOMS), and vestibulo-ocular reflex (VOR) function.

DESIGN

Case series.

SETTING

Sports Medicine Centre.

PARTICIPANTS

A total of 37 athletes consented to participate (22 rugby, 15 wrestling; 9 men, 28 women; median age = 19 years [range 17-23 years]).

MAIN OUTCOME MEASURES

Outcome measures included tests of CSp (cervical flexor endurance, head perturbation test, cervical flexion rotation test and anterolateral strength), VOR (head thrust test and dynamic visual acuity [DVA]), and a quantified version of the VOMS. These metrics were assessed prior to and after completing the 30-15 Intermittent Fitness Test. Bland-Altman plots and Wilcoxon signed-rank tests were utilized to analyze the data using an alpha of p < 0.004.

RESULTS

Cervical anterolateral strength (kg) was reduced post-exertion on the left (z = 3.87; p < 0.001), but not on the right between conditions (z = -1.49; p = 0.14). Athletes reported increased dizziness (z = -3.55; p = 0.004) and had reduced DVA following exertion (z = -2.78; p < 0.001). All other metrics were not significantly different following exertion (p > 0.011).

CONCLUSION

Reduced performance on DVA, decreased left-anterolateral strength, and increased dizziness occurred following high-intensity exertion in varsity collision and combative athletes, which has implications for sideline screening for sport-related concussion.