Sports Concussion Research Articles

A - 15 Incorporating the Child Opportunity Index and Area Deprivation Index in Sport Concussion Research

Abstract Purpose Social determinants of health, including socioeconomic status (SES) and neighborhood characteristics, are underrepresented in concussion research. We examined two measures of neighborhood advantage and opportunity among patients accessing a multidisciplinary sports concussion clinic in Greater Boston. Method We collected the Child Opportunity Index (COI) and Area Deprivation Index (ADI) state decile scores and national percentile ranks for all new patients who presented to our clinic in 2023. The COI is an index of neighborhood conditions that may impact childhood development (e.g., education quality, SES, access to healthy food) with ratings from Very Low to Very High. The ADI characterizes an area’s socioeconomic conditions (e.g., income, housing quality, employment, education), with higher scores representing more disadvantage. Results There were 247 new patients who visited the clinic (Mage = 17.5, SDage = 5.2, 47.8% Girls/Women, 81.4% White, 4.0% Black, 6.5% Asian, 4.9% Hispanic). The majority lived in an area with a High or Very High state COI (74%) and High or Very High national COI (88%). The median ADI state decile was 2.00 (IQR = 1.00–4.00) and the median national percentile was 10.00 (IQR = 5.00–18.00) (representing the highest 10% of advantage). The state deciles for the two measures were correlated (Spearman rho = 0.64), but not redundant. Conclusions The COI and ADI are important, accessible measures of SES that can be included in future studies. Patients from low SES were greatly underrepresented in the clinic compared to the population of our metropolitan area. Patients were predominantly from higher SES, consistent with prior studies suggesting socioeconomic disparities accessing specialty concussion care.

A - 26 A Survey of Sports Concussion Specialists’Clinical Criteria to Determine Concussion Recovery

Abstract Purpose To identify criteria used by sports concussion specialists in determining recovery from sport-related concussion. We hypothesized differences in use of decision-making criteria among neuropsychologists, physicians, and certified athletic trainers (ATCs). Method 143 sports concussion specialists (neuropsychologists = 45, physicians = 41, and certified athletic trainers (ATCs) = 57) completed a survey rating the importance of specific criteria for determining concussion recovery in youth and adult athletes. Differences between specialist groups were examined with Kruskal-Wallis tests. Results There were significant differences in criteria ratings across specialist groups regarding youth and adults for “use of neurocognitive test scores,”“balance testing,”“physical examination,”“no symptom provocation with neurocognitive testing,”“athlete report of anxiety about return to sport,“and “family member’s report of recovery,“all p’s < 0.001. For youth and adults, physicians ranked “use of neurocognitive test scores”and “no symptom provocation with neurocognitive testing”as less important than other providers, while “physician examination”was ranked as more important. Neuropsychologists ranked “balance testing”and “athlete report of anxiety about return to sport”as less important than other providers; and ATCs ranked “family member’s report of recovery”as less important than other providers. Conclusions Our results advance understanding of multidisciplinary standards of care in determining recovery from sports concussion and suggest the importance of collaboration in establishing clinical criteria common to all sports concussion health care providers.

A - 27 A Preliminary Investigation of the Relationship between Sleep Symptoms and Post-Concussion Cognitive Performance in Adolescents

Abstract Purpose To explore the relationship between self-reported sleep symptoms and post-concussion cognitive test performance in adolescents on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Method 54 adolescents (ages 12–16) referred to a specialized sports concussion private practice completed post-concussion ImPACT. Five symptom clusters were derived from the post-concussion symptom scale: sleep, physical, cognitive, affective, and headache. Two-factor cognitive composites from the ImPACT (memory and speed) were the outcome variables. Multivariate linear regression was conducted to examine the relationship between cognitive variables and sleep symptoms. Post-hoc forward stepwise linear regressions were used to explore the following potential additional predictors of cognitive outcomes: age, number of previous concussions, sex, hours slept the night before, and five symptom clusters. Results Sleep symptoms were significantly associated with cognitive performance, F(1,52) = 9.95, p < 0.001, ƞ2 = 0.28. Higher sleep symptom cluster scores were associated with worse memory, F(1,53) = 13.68, p < 0.001, ƞ2 = 0.21, and speed performance, F(1,53) = 17.84, p < 0.001, ƞ2 = 0.26. Results of post-hoc forward stepwise linear regressions revealed that a final model for speed performance included only the sleep symptom cluster, explaining 16.6% of the variance. The final model for memory performance included only the headache rating, explaining 20.1% of the variance. Conclusions Our results indicate that severity of self-reported sleep symptoms post-concussion are associated with cognitive performance in domains of memory and speed. After considering additional predictors, more severe sleep symptoms were significantly associated with worse speed performance and worse headache severity was significantly associated with memory performance.

A - 19 Reliability of Mobile Ecologic Momentary Assessment Platform ReCoUPS to Monitor Concussion Symptoms and Psychological HRQoL

Abstract Purpose The purpose of this study was to determine the psychometric properties of a concussion symptom checklist and psychological health-related quality of life (PHRQoL) inventories administered by novel, mobile ecological momentary assessment (EMA) platform, Recovering Concussion Update on Progression of Symptoms (ReCoUPS) in healthy individuals. Method We enrolled 53 healthy individuals (female = 34; Μ age = 20.79 years, SD = 2.68) into our test–retest reliability study using the ReCoUPS platform on participants’smartphones. Thirty survey questions from the Sport Concussion Assessment Tool6 (SCAT-6) and the PROMIS Emotional Distress Shorts Forms Anxiety and Depression (PROMISAnx and PROMISDepress), were administered at random times, daily, for 7 days via ReCoUPS text messages. Eight days after enrollment, participants completed recalled PHRQoL (rPHRQoL) inventories (i.e., “within the past 7 days”). Cronbach’s alpha (Α) determined the internal consistency of momentary PHRQoL (mPHRQoL). Intraclass correlation coefficients (ICC), 2-way mixed effects model (95% confidence intervals,[CI]) measured agreement between rHRQoL and mPHRQoL. Spearman’s rho (rs) correlation coefficients determined linear relationships between mPHRQoL and SCAT-6 symptom clusters. Results There was strong internal consistency among all mPHRQoL items (PROMISAnx Α = 0.83; PROMISDepress Α = 0.95). rPHRQoL demonstrated excellent agreement with mPHRQoL (PROMISAnx ICC = 0.92, 95% CI: 0.57–0.99; PROMISDepress ICC = 0.79, 95% CI: −0.09-0.99). mPROMISAnx was significantly correlated with all clusters (affective rs = 0.81, p < 0.001; cognitive-fatigue rs = 0.66, p < 0.001; migraine rs = 0.34; p < 0.001). mPROMISDepress was significantly correlated with affective (rs = 0.69, p < 0.001) and cognitive-fatigue (rs = 0.58, p < 0.001) clusters. Conclusions These findings ensure the robustness and generalizability of administering the SCAT-6 symptom checklist, PROMISAnx, and PROMISDepress via ReCoUPS for monitoring concussion symptoms and PHRQoL in healthy participants.

A - 50 The Role of Family Functioning on Concussion Recovery in Adolescents and Young Adults

Abstract Purpose This study examined the role of overall family functioning (FF) in concussion recovery among adolescents and young adults. The authors hypothesized that participants with unhealthy FF would demonstrate prolonged recovery times compared to participants with healthy FF. Method A prospective cohort study assessed FF and concussion recovery in a university laboratory setting. Participants completed demographics, medical history, injury characteristics, Sport Concussion Assessment Tool-5 (SCAT5), and the General Functioning Scale of the Family Assessment Device (GF-FAD) at two visits. Participants were categorized into healthy (<2) and unhealthy (>2) FF groups based on their GF-FAD composite score.2 Chi-square tests compared categorical data, and Mann–Whitney U tests compared continuous data between groups. Results One hundred one participants (52 female; age = 20.5 ¬ ± 2.5 years) were included in the unhealthy FF group. When controlling for demographic and medical history, both days to symptom resolution (F(1, 87) = 4.7, p = 0.03) and days to medical clearance (F(1, 87) = 5.4, p = 0.02) were significantly different between groups. The unhealthy group experienced significantly longer time to symptom resolution (12.5 days vs. 8.0 days, p = 0.004) and time to medical clearance than the healthy group (15.0 days vs. 12.0 days, p = 0.006). Conclusions Participants in the unhealthy FF group demonstrated significantly longer times to symptom resolution and medical clearance compared to those in the healthy FF group. Results highlight the importance of a comprehensive clinical interview during the initial visit, as these factors may contribute to prolonged recovery. Future studies should examine how access to healthcare and adherence to treatment moderate the relationship between FF and concussion recovery.

A - 18 Sport Concussion Assessment Tool-5th Edition (SCAT5) Normative Reference Values for Professional Men’s Rugby League Players

Abstract Purpose The Sport Concussion Assessment Tool-5th Edition (SCAT5) is a standardized assessment that is administered to athletes at preseason and after suspected concussion. We provide normative reference values for men’s professional National Rugby League (NRL) players. Method Baseline SCAT5 scores were obtained from 1005 NRL players during the 2018 and 2019 seasons (Mage = 25.9). Players self-identified whether they considered their cultural heritage or ethnicity to be “Pasifika (Pacific Islander) or Māori” (n = 243; 24.2%) or “Indigenous Australian” (n = 82; 8.2%). Those who identified as being from any other race, ethnicity, or cultural heritage were combined into a single group (n = 680; 67.7%). We provide normative values for the Standardized Assessment of Concussion (SAC), Symptom Evaluation (i.e., symptom severity and symptom number), and the Modified Balance Error Scoring System (mBESS). Results There were no significant differences between the cultural heritage or ethnicity groups for SAC total scores, symptom severity or number, or mBESS errors (p’s > 0.05). The median SAC score was 27 (IQR = 25–28), median symptom severity was 0 (IQR = 0–2), median symptom number was 0 (IQR = 0–1), and median mBESS error score was 3 (IQR = 1–5). SAC scores of <23 and mBESS errors >7 were uncommon in the sample while SAC scores of 26–30 and mBESS scores of 0–4 were considered within normal expectations (WNE). Reporting >4/22 symptoms and > 6/132 severity was uncommon while 0–1 symptoms and 0–1 symptom severity was WNE. Conclusions Normative reference values for the SCAT5 are provided for a sample of elite professional men’s rugby league players from Australia.

Concussion and brain injuries in sport: conceptual, ethical and legal perspectives

ABSTRACT This special issue examines critical ethical, legal, and policy debates surrounding brain trauma in sport, focusing on challenges in concussion management practices and protocols. Brain injury concerns extend beyond traditional contact sports like boxing, encompassing sporting activities involving rapid acceleration, deceleration, and surface impacts, such as cycling and equestrian sports. Among such problems are the identification and management of brain injuries, the roles of officials and healthcare professionals, and the broader implications for sport integrity and athlete careers. The special issue is organized into four sections: ethics of concussion medicine, socio-legal aspects, sport ethical dimensions, and public health policies. Contributions discuss concussion management in youth sport, sport federations’ and athletes’ duties involvement in concussion-related research, strategies to support and enhance athlete autonomy, public health-informed brain injury frameworks, conflict of interest in concussion management protocols, litigation and liability in concussion research and collaboration, race and genomics in brain-injury scientific discourses, rule changes in sport to reduce head impact, the contextual nature of brain injury and athlete decision-making, the ethical use of genetic testing in brain-injury related research, marketing strategies to advertise tackle football to children and adolescents, and policy purposes and evidence underpinning concussion management practices. This comprehensive exploration offers diverse disciplinary insights, making it a crucial resource for sport humanities scholars, policymakers, and medical professionals. Keywords: brain injury, sport ethics, concussion, sport law, sport policy.

Concussions in ice hockey: mixed methods study including assessment of concussions on games missed and cap hit among National Hockey League players, systematic review, and concussion protocol analysis.

Concussions can occur at any level of ice hockey. Incidence estimates of concussions in ice hockey vary, and optimal prevention strategies and return-to-play (RTP) considerations have remained in evolution. The authors performed a mixed-methods study with the aim of elucidating the landscape of concussion in ice hockey and catalyzing initiatives to standardize preventative mechanisms and RTP considerations. The authors performed a five-part mixed-methods study that includes: 1) an analysis of the impact of concussions on games missed and income for National Hockey League (NHL) players using a publicly available database, 2) a systematic review of the incidence of concussion in ice hockey, 3) a systematic review of preventative strategies, 4) a systematic review of RTP, and 5) a policy review of documents from major governing bodies related to concussions in sports with a focus on ice hockey. The PubMed, Embase, and Scopus databases were used for the systematic reviews and focused on any level of hockey. In the NHL, 689 players had 1054 concussions from the 2000-2001 to 2022-2023 seasons. A concussion led to a mean of 13.77 ± 19.23 (range 1-82) games missed during the same season. After cap hit per game data became available in 2008-2009, players missed 10,024 games due to 668 concussions (mean 15.13 ± 3.81 per concussion, range 8.81-22.60 per concussion), with a cap hit per game missed of $35,880.85 ± $25,010.48 (range $5792.68-$134,146.30). The total cap hit of all missed games was $385,960,790.00, equating to $577,635.91 per concussion and $25,724,052.70 per NHL season. On systematic review, the incidence of concussions was 0.54-1.18 per 1000 athlete-exposures. Prevention mechanisms involved education, behavioral and cognitive interventions, protective equipment, biomechanical studies, and policy/rule changes. Rules prohibiting body checking in youth players were most effective. Determination of RTP was variable. Concussion protocols from both North American governing bodies and two leagues mandated that a player suspected of having a concussion be removed from play and undergo a six-step RTP strategy. The 6th International Conference on Concussion in Sport recommended the use of mouthguards for children and adolescents and disallowing body checking for all children and most levels of adolescents. Concussions in ice hockey lead to substantial missed time from play. The authors strongly encourage all hockey leagues to adopt and adhere to age-appropriate rules to limit hits to the head, increase compliance in wearing protective equipment, and utilize high-quality concussion protocols.

“I Quit”

Abstract This article examines concussion in 1990s wrestling, specifically during the World Wrestling Federation's (WWF) “Attitude Era,” an epoch marked by intense physicality and boundary-pushing narratives. Conventional discourse about concussion in sports typically centers on the inherent risks and regulations associated with athletic competition. However, to truly comprehend the nature and frequency of concussions in the Attitude Era, it is imperative to consider wrestling, especially in the WWF context, as primarily an entertainment medium rather than a conventional sporting endeavor. This perspective shift necessitates an exploration into the production pressures, viewer expectations, and dramatic storytelling that often overshadowed wrestler safety during live broadcasts. Importantly, this reconsideration of wrestling can offer broader insights into the intersection of entertainment, commercial broadcasting, and injury in televised sports at large. As the lines between spectacle and competition blur across various broadcast sports, the wrestling case study underscores the urgent need for a nuanced approach that incorporates the imperatives of entertainment in understanding and mitigating risks such as concussion.

The Double Folds of Racism and History

Abstract Aboriginal and Torres Strait Islander men have been overrepresented proportionately in specific sports—boxing, rugby league, and Australian rules football—that have been associated with concussion, but there is little written material, research, scholarship, commentary, or understanding about how they have been affected by traumatic brain injuries related to their participation. This article addresses this silence by examining two overlapping folds of history. The first fold explores the general silences about sport concussion that existed until recently. The second fold is centered on the traumatic consequences of colonization on the health and well-being of Australia's First Nations peoples. While the first silence is being addressed in a multitude of complex ways, the second silence remains a disturbing feature of contemporary sport. We argue that for the recognition, diagnoses, and treatment of concussion and brain injuries in Aboriginal and Torres Strait Islander peoples, there needs to be an appreciation of the continuing consequences of colonization and significant changes in the Western health system.

SCAT5 baseline values, test-retest reliability, and reliable change metrics in high school athletes.

In the United States, more than 1 million sport-related concussions afflict children annually, with many cases undetected or unreported. The Sport Concussion Assessment Tool (SCAT) is widely used to detect concussions in high school, collegiate, and professional sports. The objective of this study was to establish baseline values for the SCAT version 5 (SCAT5) in high school athletes. Baseline SCAT5 evaluations were conducted in students (ages 14-19 years) from 19 high schools in central Illinois who were participating in various school-sponsored sports. The SCAT5 evaluations were retrospectively extracted from the electronic medical record system for analysis. Statistical analyses included the Wilcoxon rank-sum test for continuous variables and the chi-square test for categorical variables, considering significance at p < 0.05. Test-retest reliability at < 6 months, 10-14 months, and 16-20 months was computed using intraclass correlation and Spearman's rho (ρ). Reliable change indices are provided using the Iverson formula. A total of 2833 unique athletes were included, and the average age was 15.5 ± 1.14 (SD) years. There were 721 female (25.5%) and 2112 male (74.5%) athletes. Students ≥ 15 years old had more prior concussions (p < 0.001), and male athletes were more frequently hospitalized for head injury (p = 0.013). Female athletes exhibited a significantly higher prevalence of mood disorders (14.7% vs 4.6%, p < 0.001), whereas attention-deficit/hyperactivity disorder was more common in male athletes (5.2% vs 13.2%, p < 0.001). Symptom number and severity were significantly greater in female athletes (3.17 ± 4.39 vs 2.08 ± 3.49, p < 0.001; 5.47 ± 9.21 vs 3.52 ± 7.26, p < 0.001, respectively), with mood-related symptoms representing the largest differences. Female athletes and students ≥ 15 years old performed better on most cognitive assessments. Female athletes and students < 15 years old performed better on the modified Balance Error Scoring System (p < 0.001). Test-retest reliability was poor to moderate for most assessment components. Reliable change index cutoff values differed slightly by sex, with female athletes often having a greater cutoff value. This study underscores the variability of SCAT5 baseline values influenced by age, sex, and medical history among adolescent athletes. It provides a robust dataset, delineating baseline values stratified by sex and age within this demographic. Additionally, the results provide enhanced guidance to clinicians for interpretation of change and reliability of baselines.

Pediatric sport and nonsport concussions presenting to emergency departments: injury circumstances, characteristics, and clinical management.

The aim of this study was to compare injury circumstances, characteristics, and clinical management of emergency department (ED) presentations for sports-related concussion (SRC) and non-SRC. This multicenter prospective observational study identified patients 5-17 years old who presented to EDs within 24 hours of head injury, with one or more signs or symptoms of concussion. Participants had a Glasgow Coma Scale score of 13-15 and no abnormalities on CT (if performed). Data were stratified by age: young children (5-8 years), older children (9-12 years), and adolescents (13-17 years). Of 4709 patients meeting the concussion criteria, non-SRC accounted for 56.3% of overall concussions, including 80.9% of younger child, 51.1% of older child, and 37.0% of adolescent concussions. The most common mechanism of non-SRC was falls for all ages. The most common activity accounting for SRC was bike riding for younger children, and rugby for older children and adolescents. Concussions occurring in sports areas, home, and educational settings accounted for 26.2%, 21.8%, and 19.0% of overall concussions. Concussions occurring in a sports area increased with age, while occurrences in home and educational settings decreased with age. The presence of amnesia significantly differed for SRC and non-SRC for all age groups, while vomiting and disorientation differed for older children and adolescents. Adolescents with non-SRC were admitted to a ward and underwent CT at higher proportions than those with SRC. Non-SRC more commonly presented to EDs overall, with SRC more common with increasing age. These data provide important information to inform public health policies, guidelines, and prevention efforts.

Quantitative pupillometry as a biomarker for prediction of return to play in mild traumatic brain injury: a Military Traumatic Brain Injury Initiative study.

This study aimed to determine the validity of quantitative pupillometry to predict the length of time for return to full activity/duty after a mild traumatic brain injury (mTBI) in a cohort of injured cadets at West Point. Each subject received baseline (T0) quantitative pupillometry, in addition to evaluation with the Balance Error Scoring System (BESS), Standardized Assessment of Concussion (SAC), and Sport Concussion Assessment Tool 5th Edition Symptom Survey (SCAT5). Repeat assessments using the same parameters were conducted within 48 hours of injury (T1), at the beginning of progressive return to activity (T2), and at the completion of progressive return to activity protocols (T3). Pupillary metrics were compared on the basis of length of time to return to full play/duty and the clinical scores. The authors' statistical analyses found correlations between pupillometry measures at T1, including end-initial diameter and maximum constriction velocity, with larger change and faster constriction predicting earlier return to play. There was also an association with maximum constriction velocity at baseline (T0), predicting faster return to play. The authors conclude that that pupillometry may be a valuable tool for assessing time to return to duty from mTBI by providing a measure of baseline resiliency to mTBI and/or autonomic dysfunction in the acute phase after mTBI.

The influence of prior COVID-19 diagnosis on concussion recovery outcomes.

While the clinical presentations of COVID-19 and concussion are not identical, there is a significant overlap in symptomology (e.g., fatigue, headache) and neurological deficits (e.g., cognitive, vestibular). However, limited research has examined the effect of prior COVID-19 diagnosis on concussion outcomes. Therefore, the purpose of this study was to determine if prior diagnosis of COVID-19 influences concussion outcomes, including concussion assessment scores and recovery time, in college-aged individuals. A prospective study of college-aged individuals (COVID-19: n = 43, mean age 21.3 [SD 2.5] years; no COVID-19: n = 51, mean age 21.0 [SD 2.5] years) diagnosed with concussion was conducted. Demographics, injury details, the Sport Concussion Assessment Tool 5th Edition (SCAT5), and the Vestibular/Ocular Motor Screening (VOMS) were completed at the acute (within 5 days after concussion) and full medical clearance (FMC) (within 3 days after FMC) visits. Mann-Whitney U-tests determined differences in concussion outcomes between groups. Cox proportional hazards regression models were fitted to assess the relationship between factors associated with concussion symptom resolution and days to FMC, and covariates were selected based on previous literature indicating potential confounds (e.g., female sex, acute symptom severity, preexisting mental health conditions). Hazard ratios with 95% confidence intervals were reported for each predictor variable. No significant differences were found between groups for SCAT5 and VOMS composite and total scores. Significant differences were found between COVID-19 and no-COVID-19 groups in days to symptom resolution (11.5 days vs 8 days, p = 0.021), but not in days to FMC (14 days vs 12 days, p = 0.099). The association between COVID-19 groups and days to clearance was not significant when adjusting for sex, race, history of depression/anxiety, and total number of concussion symptoms at the acute visit [χ2(5) = 8.349, p = 0.138]. However, male sex (HR 2.036, 95% CI 1.033-4.014; p = 0.040) was associated with a quicker time to FMC. Prior COVID-19 diagnosis did not influence cognitive abilities and vestibular/ocular functioning as measured by the SCAT5 and VOMS postconcussion. While prior COVID-19 diagnosis did result in a significantly longer duration to symptom resolution when compared with individuals who did not have a prior COVID-19 diagnosis, prior COVID-19 did not significantly influence time to FMC by a healthcare provider. Clinicians should consider that individuals with a prior diagnosis of COVID-19 might experience prolonged symptoms postconcussion.

The association between continuing to play, clinical domains, and recovery outcomes in collegiate athletes following concussion.

Continued play following concussion can lead to worse outcomes and longer recoveries compared with athletes who immediately report. This has been well documented in youth athletes, while less attention has been paid to collegiate athletes despite differences in healthcare access, recovery trajectories, and additional pressures to play. Therefore, the purpose of this study was to determine if continuing to play immediately following a concussion influenced clinical outcomes and recovery time in collegiate athletes. A prospective, repeated-measures design was used to compare clinical outcomes and recovery time between collegiate athletes who continued playing (n = 37) and those immediately removed (n = 56) after a concussion. Assessments were conducted within 5 days of the concussion and at full medical clearance (FMC; ± 3 days) using the Sport Concussion Assessment Tool-5th edition (SCAT5), Vestibular/Ocular Motor Screening assessment, and High-Level Mobility Assessment Tool. Mann-Whitney U-tests determined differences in clinical outcomes between groups. Cox proportional hazards regression models examined the relationship between factors associated with days to symptom resolution and days to FMC, and covariates were selected a priori based on previous literature. Hazard ratios with 95% CIs were reported for each predictor variable. Significant differences were found in SCAT5 concentration composite scores (p = 0.010) and SCAT5 delayed recall composite scores (p = 0.045) at the acute visit and near point of convergence average distance (cm; p = 0.005) at the FMC visit between the group who continued to play and those who were immediately removed. There were no differences between groups in days to symptom resolution (10 vs 7 days, p = 0.05) and days to clearance (13 vs 11.50 days, p = 0.13). The association between groups and days to symptom resolution (χ2[4] = 5.052, p = 0.282), and days to clearance (χ2[4] = 3.624, p = 0.459) were not significant when adjusting for covariates. Collegiate athletes who continued to play following concussion did not exhibit worse clinical outcomes or recovery times compared with athletes who were immediately removed. While the lack of differences found in this study could be supported by prior literature, including improved education, awareness, reporting attitudes, and concussion management at the collegiate level in recent years, the authors believe discrepancies are more likely due to study-specific differences (e.g., sample size, care setting, and timing). Therefore, these findings should not diminish the dangers of continued play and the importance of timely removal after concussion.

Examining for gender differences in return to learn following sport-related concussion in high school student athletes.

Prior studies have investigated associations between gender, symptom resolution, and time to return to play following sport-related concussion (SRC). However, there is a notable gap in research regarding the association between gender and return to learn (RTL) in adolescents. Therefore, this study 1) compared the patterns of RTL between boys and girls who are high school student athletes, and 2) evaluated the possible association between gender and time to RTL after adjusting for covariates. A retrospective cohort study of a prospective surveillance program that monitored concussion recovery of athletes in high schools throughout the state of Maine between February 2015 and January 2023 was performed. The primary independent variable was gender, dichotomized as boys and girls. The primary outcome was time to RTL, defined by the number of days for an athlete to return to school without accommodations. Mann-Whitney U-tests were used to compare RTL between the boys and girls. Each athlete's RTL status was dichotomized (i.e., returned vs had not returned) at several time points following injury (i.e., 1, 2, 3, and 4 weeks), and chi-square tests were performed to compare the proportions who achieved RTL between groups. Multivariable linear regression analyses were performed to evaluate the predictive value of gender on RTL. Covariates included age, number of previous concussions, history of learning disability or attention-deficit disorder or attention-deficit/hyperactivity disorder, history of a psychological condition, history of headaches or migraines, initial Sport Concussion Assessment Tool (SCAT3/SCAT5) score, and days to evaluation. Of 895 high school athletes, 488 (54.5%) were boys and 407 (45.5%) were girls. There was no statistically significant difference in median [IQR] days to RTL between genders (6.0 [3.0-11.0] vs 6.0 [3.0-12.0] days; U = 84,365.00, p < 0.375). A greater proportion of boys successfully returned to learn without accommodations by 3 weeks following concussion (93.5% vs 89.4%; χ2 = 4.68, p = 0.030), but no differences were found at 1, 2, or 4 weeks. A multivariable model predicting days to RTL showed that gender was not a significant predictor of RTL (p > 0.05). Longer days to evaluation (β = 0.10, p = 0.021) and higher initial SCAT3/SCAT5 scores (β = 0.15, p < 0.001) predicted longer RTL. In a cohort of high school athletes, RTL did not differ between boys and girls following SRC. Gender was not a significant predictor of RTL. Longer days to evaluation and higher initial symptom scores were associated with longer RTL.

Headache Characteristics of Pediatric Sport-Related Concussion.

Headache is among the most common symptoms following concussion, yet headache after concussion (HAC) remains poorly characterized. This study describes headache characteristics over the first four weeks following pediatric sport-related concussion. This is a retrospective case series of 87 athletes (mean: 14.9 years; range: 8.4-18.8 years; 38% female) treated in a specialty sports concussion clinic within 28 days of injury. Primary outcomes of headache consistency, frequency, duration, and associated migrainous symptoms were assessed at immediate (0 to 48 h) and weekly time points over the first 28 days post-injury. Generalized mixed linear models compared headache characteristics across time points. Secondary analyses compared each outcome by as-needed analgesic use. During the immediate post-injury period, headache was more often constant (p = 0.002) and associated with migrainous symptoms (p < 0.001). By the third week post-injury, episodic headache was more prevalent (p < 0.001). Most patients (54%) transitioned from constant, migrainous headache to episodic, non-migrainous headache. This finding was uninfluenced by as-needed analgesic medication use. These findings document the trajectory of HAC. Future studies should assess relationships between initial headache characteristics and recovery.

Sex differences in postconcussive symptom reporting in those with history of concussion: Findings from the federal interagency traumatic brain injury research (FITBIR) database

Objective: This study investigated influence of biological sex on postconcussive symptoms (PCS) following concussion using the Federal Interagency Traumatic Brain Injury Research (FITBIR) database. Method: All studies with publicly released data as of 4/7/21 that included both males and females, enough information to determine severity of injury consistent with concussion, a measure of PCS, and objective measures of neurocognitive functioning were used. This resulted in 6 studies with a total of 9890 participants (3206 females, 6684 males); 815 participants completed the Neurobehavioral Symptom Inventory (NSI), 471 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ), and 8604 completed the Sport Concussion Assessment Tool–3rd Edition (SCAT 3). Questionnaires were harmonized and the following symptom composite scores were computed: total score, somatic, cognitive, and affective. Data were analyzed using linear mixed-effects models. Results: Females endorsed higher total symptoms relative to males and that military personnel endorsed higher symptoms relative to civilians. Additionally, there was a small but significant interaction effect, such that female military personnel endorsed even higher symptoms than would be predicted by the main effects. Similar patterns were observed for somatic, cognitive, and affective symptom domains. Conclusions: Further understanding sex differences in PCS reporting is key to informing the most appropriate treatment options. Future work will need to examine whether sex differences in symptom reporting is due to sex differences in endorsement styles or genuine differences in symptom presentation, as well as the relationship between study population (e.g., military, civilian, sport) and sex on objective cognitive functioning and other functional outcomes.

Quantitative Pupillometry Predicts Return to Play and Tracks the Clinical Evolution of Mild Traumatic Brain Injury in US Military Academy Cadets: A Military Traumatic Brain Injury Initiative Study.

The objective of this study was to determine the utility of the pupillary light reflex use as a biomarker of mild traumatic brain injury (mTBI). This prospective cohort study was conducted at The US Military Academy at West Point. Cadets underwent a standard battery of tests including Balance Error Scoring System, Sports Concussion Assessment Tool Fifth Edition Symptom Survey, Standard Assessment of Concussion, and measure of pupillary responses. Cadets who sustained an mTBI during training events or sports were evaluated with the same battery of tests and pupillometry within 48 hours of the injury (T1), at the initiation of a graded return to activity protocol (T2), and at unrestricted return to activity (T3). Pupillary light reflex metrics were obtained in 1300 cadets at baseline. During the study period, 68 cadets sustained mTBIs. At T1 (<48 hours), cadets manifested significant postconcussion symptoms (Sports Concussion Assessment Tool Fifth Edition P < .001), and they had decreased cognitive performance (Standardized Assessment of Concussion P < .001) and higher balance error scores (Balance Error Scoring System P < .001) in comparison with their baseline assessment (T0). The clinical parameters showed normalization at time points T2 and T3. The pupillary responses demonstrated a pattern of significant change that returned to normal for several measures, including the difference between the constricted and initial pupillary diameter (T1 P < .001, T2 P < .05), dilation velocity (T1 P < .01, T2 P < .001), and percent of pupillary constriction (T1 P < .05). In addition, a combination of dilation velocity and maximum constriction velocity demonstrates moderate prediction ability regarding who can return to duty before or after 21 days (area under the curve = 0.71, 95% CI [0.56-0.86]). This study's findings indicate that quantitative pupillometry has the potential to assist with injury identification and prediction of symptom severity and duration.

Diagnosis of Sports-Related Concussion Using Symptom Report or Standardized Assessment of Concussion

The Sports Concussion Assessment Tool-5 (SCAT5) has been recommended for concussion evaluation and utilizes both a subjective reported symptom grading scale and objective measures of concussion including a cognitive evaluation: the Standardized Assessment of Concussion (SAC). The SAC includes testing for orientation, immediate memory, concentration, and delayed recall; a 10-word list is used to assess immediate memory and delayed recall. To determine the diagnostic accuracy of components of the SCAT5 and to provide a framework for clinical interpretation. This prospective case-control study of National Collegiate Athletic Association Division I athletes from any sport was conducted from July 2020 to December 2022 at 4 universities. Athletes completed baseline SCAT5 testing using the 10-word list. When an athlete presented acutely with suspected concussion (sideline or within 2 days), the tests were repeated. If a concussion was diagnosed, a control athlete underwent the same tests. Controls were identified and matched on comorbid conditions, sex and gender, sport, season, and baseline scores. Data analysis was conducted from August to October 2023. The primary outcomes were area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive and negative predictive value, and test-retest reliability of the symptom score; symptom severity score; the total SAC score; and the orientation, immediate memory, concentration, and delayed memory subcomponent scores on the SCAT5 compared with clinical diagnosis of concussion. Baseline and postinjury data were collected on 92 athletes with concussion and 92 matched control athletes (96 men [52%] and 88 women [48%]; 110 who played a sport other than football [59%]). Diagnostic utility was considered excellent for symptom score (AUC, 0.93; 95% CI, 0.89-0.96) and symptom severity score (AUC, 0.94; 95% CI, 0.90-0.97). An increase of 2 points on the symptom score was associated with a sensitivity of 86% (95% CI, 78%-92%), specificity of 80% (95% CI, 70%-87I%), and positive predictive value of 81% (95% CI, 72%-88%). The total SAC score had poor to fair diagnostic utility (AUC, 0.70; 95% CI, 0.63-0.77); however, 41 athletes with concussion (45%) had a total SAC score at or above their baseline score (ie, within normal limits). The diagnostic utility was poor to fair for immediate memory (AUC, 0.68, 95%CI, 0.61-0.75) and delayed recall (AUC, 0.69; 95% CI, 0.62-0.77) and not useful for orientation (AUC, 0.49; 95% CI, 0.43-0.56) and concentration (AUC, 0.52 95% CI, 0.44-0.61). Test-retest reliability was fair for total SAC and poor for immediate memory and delayed recall, orientation, and concentration. In this case-control study of the diagnostic accuracy of reported symptoms and the SAC, reported symptoms were the most accurate indicator of concussion while the 10-word SAC had limited sensitivity. These findings suggest that understanding the properties of the SAC is important when making the diagnosis of concussion.