Variations in Time to Recovery from Pediatric Concussion Based on Differing Outcomes of Interest

ObjectiveTo quantify variability in pediatric concussion recovery across multiple outcomes of interest.BackgroundPediatric concussion studies are hindered by a common significant limitation: lack of agreement on a standard definition of “recovery.” A variety of clinical outcomes of interest utilized across studies, including symptom self-report, neurocognitive testing results, self-reported return to activity, and physician clearance for activity, leads to challenges for both research, as well as clinical concussion management.Design/MethodsWe enrolled concussed youth, ages 11–18 years, from a specialty sports medicine clinic = 28 days of injury. Patients were followed as part of clinical care for concussion for up to 13 weeks. At each visit, participants completed questionnaires and a battery of clinical measures. From these data, we constructed 10 potential definitions of recovery: 3 based on self-reported symptoms (change from pre-injury, no symptoms, below pre-determined thresholds), 2 based on visio-vestibular examination (VVE) deficits (none, = 1), 2 based on physician clearance (for return to school/sport), and 3 based on self-assessment (“back to normal”, return to school/exercise).ResultsOne hundred seventy-four concussed youth were enrolled (median age: 15 years, 54.6% female) with a median time from injury to initial visit of 12 days (IQR: 7, 20). Median number of visits was 2 (range: 1, 5). We observed a wide variation in the proportion of participants recovered across the 10 definitions. Depending on definition, between 4% and 45% were considered recovered within 4 weeks, and between 10% and 80% were considered recovered at the end of follow-up. The VVE-based definition (=1 deficit) consistently had the highest proportion recovered at all time points, while self-reported return to exercise had the lowest proportion.ConclusionsRecovery from concussion is not a single unitary point in time. These results will provide valuable guidance to clinicians in managing concussion and researchers in designing future observational and interventional trials of pediatric concussion.

The Effect of Test Setting Upon Test-Retest Reliability of ImPACT Baseline Tests in High School Athletes

ObjectiveTo determine the test-retest reliability of ImPACT baseline tests across different schools within the same larger concussion management program.BackgroundImPACT is the most widely used concussion management cognitive testing tool. Baseline testing is often required for high school sports participation. Typically, testing occurs every 2 years based on test-retest reliability statistics in previous studies. Demographic and environmental factors, such as age, sex, number of participants, and supervision, all impact baseline performance. Studies to date have not examined test-retest differences across testing sites, such as between school differences.Design/MethodsCross-sectional retrospective design. Valid baseline tests from high school athletes over a 2-year interval were included. Participants who experienced concussions prior to or between tests were excluded. A total of 979 student athletes from 5 schools were included. The Intra-class correlations were determined over a 2-year period for each ImPACT composite score and school.ResultsICC estimates averaged between schools reflected good reliability for visual-motor speed (0.833), visual memory (0.673) and reaction time (0.615) over the two-year period. Verbal memory (0.586) and impulse control (0.556) were less reliable. Between schools a greater range of composite reliability was observed for reaction time (0.484–0.730) and impulse control (0.461–0.655) compared to verbal memory (0.534–0.637), visual memory (0.61–0.719), and visual-motor speed (0.769–914).ConclusionsAs previously established, reliability of ImPACT baselines vary by composite. This study revealed that reliability also varies by setting, as different schools yielded different ICCs. Consistent with the literature, the most reliable measure was visual-motor speed. The greatest difference in reliability between schools was for reaction time. These results suggest that test setting and environment affect reliability of ImPACT baseline scores, with varying effects per composite. Attention must be paid to environmental setting to improve reliability of baseline cognitive test performance to maximize athlete safety.

The rugby tug-of-war: Exploring concussion-related behavioural intentions and behaviours in youth community rugby union in New Zealand

Rugby union is a popular team sport, with a high rate of concussions. In adolescents, concussions are further complicated by issues of under-reporting. To encourage more responsible concussion behaviours, it is imperative to understand the factors that influence youth players’ behaviours, including the attitudes and behaviours of their coaches and parents. The aim of this study was to explore concussion-related behavioural intentions and behaviours that may influence effective concussion management across a youth rugby system. The study adopted a pragmatic, descriptive qualitative design and included high schools from four youth rugby catchment areas in New Zealand. Nineteen focus groups and 2 individual interviews were conducted with n = 75 players, n = 22 parents, and n = 8 coaches (N = 105) during the 2018 rugby season. A thematic analysis was conducted, guided by a system’s approach and the Theory of Planned Behaviour. The themes generated reflected a ‘tug-of war’ between various behavioural intentions and reported behaviours present in a youth rugby system. Additionally, the behavioural intentions and reported behaviours of coaches, parents, players and their teammates are intricately linked and collectively influence effective concussion management. Being aware of concussions and caring about their management and consequences was a strong theme present across the system. However, these favourable attitudes and behaviours were countered by players, parents and coaches disregarding the system, downplaying the seriousness of concussion, being competitive and driven to win, regardless of the risks. In players the warrior mentality theme, which included bravado, being tough, and playing through the pain further complicated effective concussion management. The findings suggest that there is not always a strong, favourable network in place that would facilitate similarly favourable concussion-related behaviours. To effect change, a system-wide approach, that takes the unique needs of each stakeholder into account and ultimately aims to reconcile performance and brotherhood with positive concussion related behaviours, is needed.

Video analysis of potential concussions in elite male Hurling: are players being assessed according to league guidelines?

Background Hurling is a fast-paced contact sport that places players at risk of concussion. Given the consequences of repeated concussive impacts, it is imperative that concussion management guidelines are followed. Hypothesis/Purpose. The aim of this study is to determine if potential concussive events (PCEs) in elite Hurling are assessed in accordance with league management guidelines. The secondary objective is to investigate the effectiveness of current concussion training programs. Methods Investigators used a video analysis approach to identify PCEs throughout the 2018 and 2019 inter-county Hurling seasons and championships. Subsequent assessment, return to play (RTP) decision, and signs of concussion were evaluated based on previously validated methods. The results were then compared year-over-year with previous research in Gaelic Football (GF). Results A total of 183 PCEs were identified over 82 matches. PCEs were frequently assessed (86.3%, n = 158) by medical personnel. The majority of assessments were less than 1 min in duration (81.0%, n = 128). Thirteen (7.1%) players were removed following a PCE. There were 43 (23.5%) PCEs that resulted in one or more signs of concussion, of which 10 (23.3%) were removed from play. There was no difference in rate of assessment, duration of assessment, or rate of RTP between 2018 and 2019 in both Hurling and GF, suggesting that current concussion training programs have had limited success. Conclusion In Hurling, players suspected of having sustained a concussion are frequently subject to a brief assessment, and are rarely removed from play. Affirmative action is needed to ensure the consistent application of standardized concussion assessment across the Gaelic Games.

Sex-Related Differences in Visuomotor Skill Recovery Following Concussion in Working-Aged Adults

Background: The ability to perform visually-guided motor tasks requires the transformation of visual information into programmed motor outputs. When the guiding visual information does not align spatially with the motor output, the brain processes rules to integrate somatosensory information into an appropriate motor response. Performance on such rule-based, “cognitive-motor integration” tasks is affected in concussion. Here, we investigate the relationship between visuomotor skill performance, concussion history, and sex during the course of a post-concussion management program. Methods: A total of 43 participants, divided into 3 groups based on their concussion history, completed a recovery program over the course of 4 weeks. Prior to, mid-way, and following the program, all participants were tested on their visuomotor skills. Results: We observed an overall change in visuomotor behaviour in all groups, as participants completed the tasks faster and more accurately. Specifically, we observed significant visuomotor skill improvement between the first and final sessions in participants with a concussion history compared to no-concussion-history controls. Notably, we observed a stronger recovery of these skills in females. Conclusions: Our findings indicate that (1) concussion impairs visuomotor skill performance, (2) the performance of complex, rule-based tasks can be improved over the course of a recovery program, and (3) stronger recovery in females suggests sex-related differences in the brain networks controlling skilled performance, and the effect of injury on these networks.

Management of Traumatic Brain Injuries with Brain Concussion – A Review

A typical occurrence in emergency rooms is traumatic brain injury (TBI) resulting from head trauma which is normally responsible for far more than 1 million visits per year. The magnitude of TBIs varies from mild, intermittent symptoms to longer periods of altered states of consciousness. The precise mechanism of concussion is indefinite. In serious brain trauma, Axon tearing is expected, but there is no evidence for this concussion process. Most concussion patients improve rapidly and entirely. Concussion management is usually supportive and some cases may need hospital admissions and ICU care according to severity of injury and related symptoms.

A-14 Mechanisms and Neuropsychological Correlates of Sleep Disruption in Concussed College Athletes

Objective First, to explore demographic/injury characteristics associated with increased sleep disruption post-concussion. Second, to examine the association between sleep disruption post-concussion and symptom reporting and cognitive variability. Method 124 athletes (M = 103, F = 21) completed neuropsychological testing within 14 days of concussion. Athletes were categorized as sleep-disrupted (n = 52) or not sleep-disrupted (n = 72). Athletes in the sleep-disrupted group endorsed one or more of the following from the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) Post-Concussion Symptom Scale (PCSS): trouble falling asleep, sleeping more than usual, and sleeping less than usual. Loss of consciousness (LOC) and concussion history were explored. Two neurocognitive variability measures were derived from the neuropsychological battery: intraindividual standard deviation (ISD) and maximum discrepancy score (MDS). Variability in memory and attention/processing speed (APS) composites were explored. Total PCSS symptom score, without sleep items, was calculated. Results A significantly greater proportion of sleep-disrupted athletes experienced LOC (30%) compared to not sleep-disrupted athletes (13%), χ2(1,N = 118) = 4.99, p < 0.03, φ = 0.21. Sleep-disrupted athletes reported more symptoms, t(122) = −5.42, p < 0.001, d = 0.98, and demonstrated more memory variability (memory ISD, t(122) = −2.22, p = 0.03, d = 0.40, and memory MDS, t(122) = −2.29, p = 0.02, d = 0.41) than not sleep-disrupted athletes. Groups did not differ in APS variability or concussion history. Conclusions Given the higher rate of LOC in sleep-disrupted athletes, it is possible that LOC is a mechanism leading to post-concussion sleep difficulties. Furthermore, sleep disruption following concussion results in more variable memory performance and higher symptom reporting. Symptom reporting and/or return to baseline cognitive functioning are often decision-making tools in concussion management. The difficulties experienced by sleep-disrupted athletes may complicate recovery.