The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients After Concussion: A Systematic Review of the Literature

OBJECTIVE

The objective of this systematic review was to investigate if a positive vestibular or oculomotor screening is predictive of recovery in patients after concussion.

DATA SOURCES

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search through PubMed, Ovid MEDLINE, SPORTDiscus, and the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searches of included articles.

STUDY SELECTION

Two authors evaluated all articles for inclusion and assessed their quality using the Mixed Methods Assessment Tool.

DATA EXTRACTION

After quality assessment was completed, the authors extracted recovery time, vestibular or ocular assessment results, study population demographics, number of participants, inclusion and exclusion criteria, symptom scores, and any other outcomes of assessments reported in the included studies.

DATA SYNTHESIS

Data were critically analyzed by 2 of the authors and categorized into tables regarding the ability of researchers of each article to answer the research question. Many patients who have vision, vestibular, or oculomotor dysfunction appear to have longer recovery times than patients who do not.

CONCLUSIONS

Researchers routinely reported that vestibular and oculomotor screenings are prognostic of time to recovery. Specifically, a positive Vestibular Ocular Motor Screening test appears to consistently predict longer recovery.

Recommendations for Medical Discharge Documentation and Academic Supports for University Students Recovering From Concussion

OBJECTIVE

This study sought to (1) collate the experiences of university students with concussion history and academic stakeholders through interviews and (2) develop concussion management recommendations for institutions of higher learning using a multidisciplinary Delphi procedure.

SETTING

Remote semistructured interviews and online surveys.

PARTICIPANTS

The first aim of this study included undergraduate university students with concussion history who did not participate in varsity athletics ( n = 21; 57.1% female), as well as academic faculty/staff with experience assisting university students with their postconcussion academic needs ( n = 7; 71.4% female). The second aim enrolled 22 participants (54.5% female) to serve on the Delphi panel including 9 clinicians, 8 researchers, and 5 academic faculty/staff.

DESIGN

An exploratory-sequential mixed-methods approach.

MAIN MEASURES

Semistructured interviews were conducted to unveil barriers regarding the return-to-learn (RTL) process after concussion, with emergent themes serving as a general framework for the Delphi procedure. Panelists participated in 3 stages of a modified Delphi process beginning with a series of open-ended questions regarding postconcussion management in higher education. The second stage included anonymous ratings of the recommendations, followed by an opportunity to review and/or modify responses based on the group's consensus.

RESULTS

The results from the semistructured interviews indicated students felt supported by their instructors; however, academic faculty/staff lacked information on appropriate academic supports and/or pathways to facilitate the RTL process. Of the original 67 statements, 39 achieved consensus (58.2%) upon cessation of the Delphi procedure across 3 main categories: recommendations for discharge documentation (21 statements), guidelines to facilitate a multidisciplinary RTL approach (10 statements), and processes to obtain academic supports for students who require them after concussion (8 statements).

CONCLUSIONS

These findings serve as a basis for future policy in higher education to standardize RTL processes for students who may need academic supports following concussion.

Achieving Consensus Through a Modified Delphi Technique to Create the Post-concussion Collegiate Return-to-Learn Protocol

BACKGROUND

Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education.

OBJECTIVE

To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery.

METHODS

Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group's overall ratings.

RESULTS

Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol.

CONCLUSION

There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders.

Going Beyond the State Law: Investigating High School Sport-Related Concussion Protocols

CONTEXT

State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination.

OBJECTIVE

To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality.

DESIGN

Qualitative document analysis.

SETTING

High school athletics.

PARTICIPANTS

In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018-2019 academic year.

MAIN OUTCOME MEASURES

Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test.

RESULTS

There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5-22.5] versus 6 [3-10.5] median components; U = 377.5, p < .001) Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

Consensus Statement on Sports-Related Concussions in Youth Sports Using a Modified Delphi Approach

IMPORTANCE

Given the importance of sports-related concussions among youth athletes, the rapid progress of research on this topic over the last decade, and the need to provide further guidance to youth athletes, their families, medical professionals, and athletic personnel and organizations, a panel of experts undertook a modified Delphi consensus process to summarize the current literature and provide recommendations regarding the prevention, assessment, and management of sports-related concussions for young athletes.

METHODS

A consensus panel of 11 experts was created to represent a broad spectrum of expertise in youth sports and concussions. The specific questions to be addressed were developed through an iterative process consisting of 3 rounds, and a review of the literature was conducted to identify research studies related to each question. The consensus panel used a modified Delphi process to reach consensus on the conclusions and recommendations for each question.

RESULTS AND CONCLUSIONS

In 3 Delphi consensus rounds, 7 questions were addressed by the consensus panel of 11 experts, and 26 recommendations for the prevention, assessment, and management of sports-related concussions among young athletes were developed. For many of the questions addressed in this consensus statement, limitations existed in the quantity and quality of the evidence available to develop specific recommendations for youth sports stakeholders.

Sport Participation and Specialization Characteristics Among Pediatric Soccer Athletes

Background:

Soccer is an increasingly popular sport for children and adolescents in the United States. Little is known about participation patterns related to sport specialization.

Purpose:

To investigate soccer participation levels and sport specialization characteristics among youth soccer athletes.

Study Design:

Cross-sectional study.

Methods:

Adolescent athletes aged between 12 and 18 years completed an online survey addressing participant demographics, sports and soccer participation history, and level of specialization. Descriptive analyses characterized participation, while chi-square and Kruskal-Wallis tests assessed the influence of specialization, sex, and grade on survey variables.

Results:

Overall, 83.7% of 746 respondents participated in an organized soccer league outside of school, and 37% played in multiple leagues concurrently. Nearly three-quarters of respondents trained in soccer more than 8 months of the year, with those who participated in club soccer being more likely to train more than 8 months of the year. More respondents were classified as high specialization (37.5%), followed by moderate (35.6%) and low (28.6%) specialization. No differences between sexes were noted for level of specialization or quitting other sports to specialize in soccer, but male athletes were more likely to train more than 8 months per year compared with female athletes. Respondents in older grades (9th-10th and 11th-12th grades) were more likely to be highly specialized and quit other sports to focus on soccer. No differences between grade levels were found among respondents training more than 8 months per year.

Conclusion:

The study findings suggest that many youth soccer athletes participated in multiple teams or leagues at the same time and trained more than 8 months of the year. Characteristics including participation on a club team, level of specialization, and male sex were associated with a greater likelihood of exceeding the 8-month training recommendation.

Sport Specialization and Risk of Overuse Injuries: A Systematic Review With Meta-analysis

CONTEXT

Sport specialization is theorized to increase the risk of sustaining overuse musculoskeletal injuries.

OBJECTIVE

To complete a systematic review and meta-analysis of the literature to determine if sport specialization is associated with overuse musculoskeletal injuries.

DATA SOURCES

An electronic search was conducted using the search terms "specialization," "year-round," "overuse," "repetitive stress," "injury," "young," "pediatric," and "sports."

STUDY SELECTION

Studies were included if their population was ≤18 years of age, if they compared athletes with high or single-sport specialization with athletes with low or multisport specialization, and focused on overuse injuries.

DATA EXTRACTION

Of the 12 articles that were identified for full-text review, 5 studies met all the inclusion criteria. Four studies provided adequate data for the meta-analysis. Quality scores on the modified Downs and Black scale ranged from 69% to 81%.

RESULTS

Athletes with high specialization were at an increased risk of sustaining an overuse injury compared with athletes with low (pooled relative risk [RR] ratio: 1.81; 95% confidence interval [CI]: 1.26-2.60) and moderate (pooled RR: 1.18; 95% CI: 1.05-1.33) specialization. Athletes with moderate specialization were at a higher risk of injury compared with athletes with low specialization (RR: 1.39 [95% CI: 1.04-1.87]).

LIMITATIONS

Four of the 5 studies included in this systematic review were included in the meta-analysis because of the lack of access to the original data set for 1 article.

CONCLUSIONS

Sport specialization is associated with an increased risk of overuse musculoskeletal injuries (Strength of Recommendation Taxonomy grade: B).

School Nurses' Management and Collaborative Practices for Student-Athletes Following Sport-Related Concussion

The purpose of this study was to examine school nurses' management and collaboration with health-care providers (HCPs) for student-athletes following a concussion. Secondary school nurses accessed an online survey titled the Beliefs, Attitudes, and Knowledge of Pediatric Athletes with Concussions (access rate = 15.6%; n = 1,246/8,000). Approximately 40% of schools where nurses were employed administered baseline and postinjury concussion assessments. No significant differences were found between employment model (single vs. multiple sites) in regard to conducting baseline (p = .908) administration at their site; however, those employed at a single school more frequently offered postinjury assessments at their site than those at multiple sites (p = .019). School nurses most frequently reported relationships with an athletic trainer (38.8%, n = 483/1,246) compared to other HCPs. A concussion management team, including school nurses, and other recommended members should develop comprehensive concussion management plans. Plans should comprise of multiple concussion assessments to aid in the return-to-learn/play processes.

Reliability and Concurrent Validity of Select C3 Logix Test Components

We sought to investigate the one-week and within-session reliability of the instrumented balance error scoring system test and the concurrent validity/one-week reliability of two neurocognitive assessments available through C3 Logix. (n = 37) Participants completed two balance error scoring system tests separated by the Trails A, Trails B, and Symbol Digit Modality test available through C3 Logix, and with paper and pencil. We found that the instrumented balance error scoring system test demonstrated strong one-week reliability and that neuropsychological tests available through C3 Logix show acceptable concurrent validity with standard (comparable) paper and pencil measures.

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.