Sport-related concussions have recently been at the forefront of mainstream media, where the attention is now turning to the safety of our young athletes. With the recent rise of concussion lawsuits, coaches need to know concussion basics to protect their athletes and themselves. What we know about concussions has evolved, and it is critical that coaches understand these changes and how they impact the management of their teams’ injuries. In the absence of medical personnel, coaches are responsible for removing athletes from play if they have potentially sustained a concussion. Coaches must therefore understand the different mechanisms of injury, signs and symptoms, and the protocol to follow if they believe their athlete has sustained a concussion.
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Concussion 101: Knowing the Basics to Protect Your Athletes
Theresa Miyashita
Season and Sport-Specific Adolescent Concussions via Online Surveillance in New Jersey Public High Schools 2015–2017
Derek G. Shendell, Tracy A. Listwan, Lauren Gonzalez, and Joseph Panchella
Despite increased awareness of concussions among student-athletes, local epidemiologic surveillance efforts are limited, especially among adolescents. We analyzed data reported through a state public-school-based online surveillance tool during the fall (summer preseason and regular season), winter, and spring seasons of the 2015–2017 school years at seven participating public high schools across New Jersey. Concussions were sustained during interscholastic and intramural sports and in physical education classes. There were 208 concussions: 142 in fall (123 regular season), 22 in winter (21 regular season), and 44 in spring. Reports stated 75% were first concussions, but 17% were second and 2% were third concussions.
The Dynamic Exertion Test for Sport-Related Concussion: A Comparison of Athletes at Return-to-Play and Healthy Controls
Victoria Kochick, Aaron M. Sinnott, Shawn R. Eagle, Indira R. Bricker, Michael W. Collins, Anne Mucha, Christopher Connaboy, and Anthony P. Kontos
Purpose: To describe the Dynamic Exertion Test (EXiT) by comparing physiological, performance, and clinical outcomes between athletes medically cleared following sport-related concussion (SRC) and healthy controls. Methods: One hundred four (female = 41, 39.4%) participants (14–21 y of age) including 52 medically cleared for return to play at 21.48 (15.40) days following SRC and 52 healthy athletes completed the EXiT involving (1) 12-minute aerobic component and (2) 18-minute dynamic component including 2 functional movement and 5 change-of-direction (COD) tasks. Physiological (heart rate and blood pressure), clinical (endorsed symptoms and rating of perceived exertion), and performance (COD-task completion time and errors) outcomes were collected throughout EXiT. Participants also completed the Postconcussion Symptom Scale and vestibular/ocular motor screening before EXiT. Independent-samples t tests were used to compare groups on resting heart rate and blood pressure, COD-task completion time, and Mann–Whitney U tests on Postconcussion Symptom Scale, vestibular/ocular motor screening, and EXiT symptoms, rating of perceived exertion, and errors. Results: COD-task completion time and resting systolic blood pressure and heart rate were similar between groups (P > .05). SRC reported greater rating of perceived exertion during the aerobic component (P < .05) and lower total dizziness (P = .003) and total symptoms (P = .021) during EXiT and had lower near point of convergence distance (P < .001) and total symptoms (P = .007) for vestibular/ocular motor screening than healthy athletes. Conclusion: Physiological, performance, and clinical EXiT outcomes were equivocal between athletes at medical clearance following SRC and healthy controls. The multidomain EXiT may help to inform safe return-to-play decision making post-SRC.
Does Early Low-Intensity Aerobic Exercise Hasten Recovery in Adolescents With Sport-Related Concussion?
Ryan D. Henke, Savana M. Kettner, Stephanie M. Jensen, Augustus C.K. Greife, and Christopher J. Durall
Clinical Scenario: Low-intensity aerobic exercise (LIAEX) below the threshold of symptom exacerbation has been shown to be superior to rest for resolving prolonged (>4 wk) symptoms following sport-related concussion (SRC), but the effects of LIAEX earlier than 4 weeks after SRC need to be elucidated. Focused Clinical Question: Does LIAEX within the first 4 weeks following SRC hasten symptom resolution? Summary of Key Findings: Two randomized controlled trials (RCT) and 1 nonrandomized trial involving adolescent athletes (10–19 y) were included. One RCT reported faster recovery time with LIAEX versus placebo stretching. Likewise, recovery time was faster with LIAEX versus rest in the nonrandomized trial, but not in the underpowered RCT, although effect sizes were similar between these studies (0.5 and 0.4, respectively). All 3 studies reported a reduction in concussion symptom severity with LIAEX; however, the magnitude of symptom reduction across the recovery timeline was greater in the LIAEX group than the rest group in the nonrandomized trial, but not the 2 RCTs. Importantly, no adverse effects or incidence of delayed recovery from LIAEX were reported in any of the studies. Clinical Bottom Line: LIAEX initiated within 10 days after SRC may facilitate a faster recovery time versus placebo stretching or rest, although additional clinical trials are strongly advised to verify this. Strength of Recommendation: Level 1b and 2b evidence suggests subsymptom exacerbation LIAEX may decrease Postconcussion Symptom Scale scores and hasten symptom resolution in adolescent athletes following SRC.
The Effectiveness of Hyperbaric Oxygen Therapy as a Treatment for Postconcussion Symptoms
Jeremy R. Hawkins, Kayla E. Gonzalez, and Kristin J. Heumann
Clinical Scenario:
Concussions are a prevalent topic in medicine. Concussion symptoms include headaches, dizziness, nausea, neuropsychiatric symptoms, and cognitive impairments, the persistence of which is referred to as postconcussion syndrome. Hyperbaric oxygen therapy (HBOT) has been proposed and evaluated as an additional treatment of these symptoms. HBOT is an innovative approach that has been considered by many but has received both criticism and acceptance.
Clinical Question:
Is HBOT an effective means of reducing symptoms for individuals suffering from postconcussion syndrome (persistence of symptoms for >3 mo)?
Summary of Search:
The literature was searched for studies that were relevant to the clinical question. Literature provided 5 level 1 studies that were relevant enough to be considered.
Clinical Bottom Line:
Based on the research that is available, the authors conclude that there is more evidence to refute the use of HBOT for postconcussion syndrome than to support it.
Strength of Recommendation:
Four studies disprove the use of HBOT; 1 study supported the use of HBOT. These 5 studies are the same level of evidence (level 1) and provide significant findings in their studies. The strength of this recommendation is a B according to the Centre for Evidence-Based Medicine.
The Effect of Cognitive Rest as Part of Postconcussion Management for Adolescent Athletes: A Critically Appraised Topic
Rachel S. Johnson, Mia K. Provenzano, Larynn M. Shumaker, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon
Clinical Scenario:
It is hypothesized that cognitive activity following a concussion may potentially hinder patient recovery. While the recommendation of cognitive rest is often maintained and rationalized, a causal relationship between cognitive activity and symptom duration has yet to be established.
Clinical Question:
Does the implementation of cognitive rest as part of the postconcussion management plan reduce the number of days until the concussed adolescent patient is symptom free compared to a postconcussion management plan that does not incorporate cognitive rest?
Summary of Key Findings:
A thorough literature search returned 7 possible studies; 5 studies met the inclusion criteria and were included. Three studies indicated that increased cognitive activity is associated with longer recovery from a concussion, and, therefore, supported the use of cognitive rest. One study indicated that the recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution. One study indicated that strict rest, defined as 5 days of no school, work, or physical activity; might prolong symptom duration.
Clinical Bottom Line:
There is moderate evidence to support the prescription of moderate cognitive rest for concussed patients. Clinicians who intend on implementing cognitive rest in their concussion protocols should be aware of inconsistencies and be open-minded to alternative treatment progressions while taking into consideration each individual patient and maintaining adequate patient-centered care principles.
Strength of Recommendation:
Grade B evidence exists that prescription of moderate cognitive rest for concussed patients may be beneficial as a supplement to physical rest as treatment for symptom reduction in adolescents.
The Value of Balance-Assessment Measurements in Identifying and Monitoring Acute Postural Instability Among Concussed Athletes
Andrea Cripps and Scott C. Livingston
Clinical Scenario:
Sport-related concussions are a significant health issue due to the high incidence of concussions sustained each sports season. Current approaches to the evaluation of acutely concussed athletes include the use of balance assessments to identify and monitor underlying postural instability arising from concussion. Balance assessment has been recommended as a primary measurement tool for monitoring recovery and for making return-to-play decisions. Balance impairments have been shown to occur in the initial postconcussion period (ie, 1–10 d). Numerous clinical and laboratory measures have been used in the assessment of balance immediately after concussion, and clinicians are faced with deciding which measures to use.
Focused Clinical Question:
How do clinical or field-based balance-assessment tools compare to laboratory-based balance measures in identifying deficits in postural stability among acutely concussed athletes?
Effect of Hearing Status on Concussion Knowledge and Attitudes of Collegiate Athletes
Matthew P. Brancaleone, René R. Shingles, and Zachary A. Weber
Context: Collegiate athletes who are deaf or hard-of-hearing (D/HoH) are diagnosed with concussions at a similar rate as athletes who are hearing; however, little evidence exists on knowledge and attitudes of athletes who are D/HoH toward concussions. This study aimed to examine differences in knowledge of and attitudes toward concussions between athletes who are D/HoH and athletes who are hearing. Design: Cross-sectional research design. Methods: Of the 310 athletes who are D/HoH and 430 athletes who are hearing that were invited to participate, 90 athletes who are D/HoH, and 72 athletes who are hearing completed the survey. The Rosenbaum Concussion Knowledge and Attitudes Survey was used to quantify knowledge of and attitude toward concussions. The Rosenbaum Concussion Knowledge and Attitudes Survey consists of the concussion knowledge index (CKI) and the concussion attitudes index (CAI) subscales. Linear regressions were run to test the association of hearing status with CKI and CAI scores. Pearson correlations were performed to determine relationships between CKI and CAI for athletes who are D/HoH and athletes who are hearing. Alpha level was set a priori at P ≤ .05. Results: Athletes who are hearing demonstrated a higher CKI component score (19.58 [2.19]) compared to athletes who are D/HoH (16.14 [3.31]; P < .001). There were no statistical differences in CAI between hearing groups (hearing: 57.18 [8.73], D/HoH: 55.97 [9.92]; P = .41). There was a moderate positive correlation between CKI and CAI (r = .58) for athletes who are D/HoH, while a weak positive correlation (r = .30) for athletes who are hearing was observed. Conclusions: Athletes who are D/HoH have poorer knowledge of concussions but similar attitudes toward concussion as that of athletes who are hearing. Current concussion educational interventions are in written or spoken form which may not be inclusive to athletes who are D/HoH. Health care professionals should consider an athlete’s preferred communication mode to improve the efficiency and effectiveness of education.
Does Neuromuscular Training Reduce the Risk of Lower-Extremity Musculoskeletal Injury in High School Female Athletes With a History of Sport-Related Concussion?
April L. McPherson, Taylor M. Zuleger, Kim D. Barber Foss, Shayla M. Warren, Jennifer A. Hogg, Jed A. Diekfuss, and Gregory D. Myer
Context: There is a well-established increased risk of lower-extremity (LE) musculoskeletal (MSK) injury following a sport-related concussion (SRC). Neuromuscular training programs improve biomechanics associated with LE MSK injury and reduce LE MSK injury incidence, but their relative effectiveness in athletes with history of SRC is unknown. The purpose of this study was to evaluate LE MSK injury incidence in female adolescent athletes with history of SRC following a neuromuscular training intervention. Design: Prospective case-control. Methods: Seventy-seven adolescent female athletes aged 12–18 years who participated in soccer, volleyball, or basketball were recruited from a single institutional sports medicine research and performance center to complete a 6-week neuromuscular training program prior to competitive athletic season. Group (Control, History of SRC) comparisons of athlete exposure and relative LE MSK injury risk and rates during the competitive athletic season were assessed. Results: Ten injuries were recorded by 9 athletes. Female athletes who reported history of SRC had increased injury risk (Risk Ratio 3.9, 95% CI, 1.1–13.8, P = .01) and increased injury rate (rate ratio 4.1, 95% CI, 1.1–15.8, P = .03) compared with female athletes without history of SRC. Conclusions: Female adolescent athletes with history of SRC showed a greater risk of LE MSK injury compared with athletes with no history of SRC. Future work is still needed to understand the underlying mechanisms associated with future LE MSK injury following SRC and interventions that ameliorate elevated injury risk.
Do the Physical Characteristics of a Virtual Reality Device Contraindicate Its Use for Balance Assessment?
Jason P. Mihalik, Luv Kohli, and Mary C. Whitton
Context:
Virtual reality environments may allow researchers to investigate functional balance performance without risks associated with testing in the real world.
Objective:
To investigate the effects of the mass of a head-mounted display (HMD) on balance performance.
Design:
Counterbalanced pretest-posttest.
Setting:
Virtual reality laboratory.
Participants:
20 healthy college students.
Intervention(s):
Balance Error Scoring System (BESS) with a tracker-only headband and again with tracker plus HMD was performed.
Main Outcome Measures:
BESS error scores, elliptical sway area, and center of pressure travel distance were recorded.
Results:
No effect of the HMD mass on balance performance was observed. A significant stance by surface interaction was present but was negated when the HMD conditions were included in the model.
Conclusions:
The mass of a HMD has not been proven to adversely affect balance performance. These data suggest the HMD mass is not a contraindication to the use of immersive virtual environments in future concussion research involving balance.
