Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015

BACKGROUND

Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment.

OBJECTIVE

To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion.

METHODS

On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device.

RESULTS

A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%.

CONCLUSION

Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments.

ABBREVIATIONS

ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

Removal From Play After Concussion and Recovery Time

OBJECTIVE

Despite increases in education and awareness, many athletes continue to play with signs and symptoms of a sport-related concussion (SRC). The impact that continuing to play has on recovery is unknown. This study compared recovery time and related outcomes between athletes who were immediately removed from play and athletes who continued to play with an SRC.

METHODS

A prospective, repeated measures design was used to compare neurocognitive performance, symptoms, and recovery time between 35 athletes (mean ± SD age, 15.61 ± 1.65 years) immediately removed after an SRC (REMOVED group) compared with 34 athletes (mean ± SD age, 15.35 ± 1.73 years) who continued to play (PLAYED group) with SRC. Neurocognitive and symptom data were obtained at baseline and at 1 to 7 days and 8 to 30 days after an SRC.

RESULTS

The PLAYED group took longer to recover than the REMOVED group (44.4 ± 36.0 vs 22.0 ± 18.7 days; P = .003) and were 8.80 times more likely to demonstrate protracted recovery (≥21 days) (P < .001). Removal from play status was associated with the greatest risk of protracted recovery (adjusted odds ratio, 14.27; P = .001) compared with other predictors (eg, sex). The PLAYED group exhibited significantly worse neurocognitive and greater symptoms than the REMOVED group.

CONCLUSIONS

SRC recovery time may be reduced if athletes are removed from participation. Immediate removal from play is the first step in mitigating prolonged SRC recovery, and these data support current consensus statements and management guidelines.

Incidence of Concussion in Youth Ice Hockey Players

BACKGROUND

Ice hockey is a fast-paced collision sport that entails both intentional (ie, body checking) and incidental contact that may involve the head. The objective of this study was to determine the incidence of concussions in relation to games/practices and age among competition-level youth ice hockey players (ages 12-18 years).

METHODS

Participants included 397 youth ice hockey players from Western Pennsylvania; Boston, Massachusetts; and Birmingham, Alabama, during the 2012-2013 and 2013-2014 youth ice hockey seasons. Incidence rates (IRs) and incidence rate ratios (IRRs) of concussion were calculated for games/practices and age groups.

RESULTS

A total of 23 369 (12 784 practice/10 585 game) athletic exposures (AEs) involving 37 medically diagnosed concussions occurred. More than 40% of concussions involved illegal contact. The combined IR for games and practices was 1.58 concussions per 1000 AEs. The IRR was 2.86 times (95% confidence interval 0.68-4.42) higher during games (2.49 per 1000 AEs) than practices (1.04 per 1000 AEs).

CONCLUSIONS

The overall IR for concussion in youth ice hockey was comparable to those reported in other youth collision sports. The game-to-practice IRR was lower than previously reported in ice hockey and other youth sports, although more concussions per exposure occurred in games compared with practices. Younger players had a higher rate of concussions than older players.

A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings

BACKGROUND

Vestibular and ocular motor impairments and symptoms have been documented in patients with sport-related concussions. However, there is no current brief clinical screen to assess and monitor these issues.

PURPOSE

To describe and provide initial data for the internal consistency and validity of a brief clinical screening tool for vestibular and ocular motor impairments and symptoms after sport-related concussions.

STUDY DESIGN

Cross-sectional study; Level of evidence, 2.

METHODS

Sixty-four patients, aged 13.9 ± 2.5 years and seen approximately 5.5 ± 4.0 days after a sport-related concussion, and 78 controls were administered the Vestibular/Ocular Motor Screening (VOMS) assessment, which included 5 domains: (1) smooth pursuit, (2) horizontal and vertical saccades, (3) near point of convergence (NPC) distance, (4) horizontal vestibular ocular reflex (VOR), and (5) visual motion sensitivity (VMS). Participants were also administered the Post-Concussion Symptom Scale (PCSS).

RESULTS

Sixty-one percent of patients reported symptom provocation after at least 1 VOMS item. All VOMS items were positively correlated to the PCSS total symptom score. The VOR (odds ratio [OR], 3.89; P < .001) and VMS (OR, 3.37; P < .01) components of the VOMS were most predictive of being in the concussed group. An NPC distance ≥5 cm and any VOMS item symptom score ≥2 resulted in an increase in the probability of correctly identifying concussed patients of 38% and 50%, respectively. Receiver operating characteristic curves supported a model including the VOR, VMS, NPC distance, and ln(age) that resulted in a high predicted probability (area under the curve = 0.89) for identifying concussed patients.

CONCLUSION

The VOMS demonstrated internal consistency as well as sensitivity in identifying patients with concussions. The current findings provide preliminary support for the utility of the VOMS as a brief vestibular/ocular motor screen after sport-related concussions. The VOMS may augment current assessment tools and may serve as a single component of a comprehensive approach to the assessment of concussions.

Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not

OBJECTIVE

To identify predictors of prolonged symptoms in athletes who sustain concussions.

STUDY DESIGN

This was a multicenter prospective cohort study of patients in 2 sport concussion clinics. Possible predictors of prolonged symptoms from concussion were compared in 2 groups, those whose symptoms resolved within 28 days and those whose symptoms persisted beyond 28 days. Candidate predictor variables were entered into a logistic regression model that was used to generate aORs.

RESULTS

A total of 182 patients met the inclusion criteria during the study period. The mean patient age was 15.2 ± 3.04 years. More than one-third of the patients (n = 65) underwent computerized neurocognitive testing on their initial visit. On univariate analyses, Post-Concussion Symptom Scale (PCSS) score and all composite scores on computerized neurocognitive testing were apparently associated with prolonged symptom duration. Sex, age, loss of consciousness at time of injury, and amnesia at time of injury were not associated with prolonged symptom duration. After adjusting for potential confounding, only total PCSS score was associated with the odds of suffering prolonged symptoms.

CONCLUSION

Further efforts to develop clinical tools for predicting which athletes will suffer prolonged recoveries after concussion should focus on initial symptom score.