Concussion Management Guidelines Research Articles

Navigating concussion – community rugby players’ experiences of a concussion management initiative in New Zealand

ABSTRACT Objective Concussion is a serious concern in sport, with the potential to cause short- and long-term health consequences. These concerns highlight the need for the translation of concussion management guidelines into use in real-world sports settings. This qualitative study explores community rugby players’ concussion experiences as part of New Zealand Rugby’s concussion management pathway. Methods Semi-structured interviews were conducted with 36 rugby players (35 males and 1 female; 22 played at school and 14 at club-level; mean age 19.8 ± 4.8) Thematic analysis was utilized to analyze data. Results Four themes were identified i) the symptom journey, ii) the role of a dedicated concussion management pathway in shaping players' experiences, iii) the influence of coaches and physiotherapists, and iv) rugby culture. Support received as part of the concussion management pathway, and from individuals who were part of players’ concussion journey, deeply impacted their overall experience. However, players identified insufficient guidance while returning to school/work. At times, the sport’s collective cultural values made it difficult for players to enact positive concussion management behavior. Conclusion The findings highlight the importance of a defined management pathway to support players’ recovery. Addressing negative aspects of rugby’s collectivist culture remains critical for optimal concussion management and recovery.

A Framework for Concussion Management Strategies in Law Enforcement Officers.

Athletic trainers are increasingly utilized in non-traditional settings, such as in law enforcement, where they can contribute to healthcare management, including concussion management of law enforcement officers (LEOs). Despite the prevalence of concussions among LEOs, there is a notable gap in concussion management guidelines for this population. LEOs may lack the education and resources necessary for concussion recognition and proper management. Drawing on advancements in concussion management in athletes and military personnel, here we present a comprehensive framework for concussion management in LEOs encompassing concussion education, a graduated return to duty (RTD) protocol, and considerations for implementation and documentation specific to law enforcement. We also present several barriers and facilitators to implementation. Due to job requirements, it is critical for law enforcement organizations and their medical providers to adopt a concussion management strategy. Without proper concussion management, LEOs may risk subsequent injury and/or suffer from prolonged recovery and adverse long-term outcomes.

A comparison of public views about sports concussion recovery with current guidelines: where are the gaps and overlaps?

Background Sports concussion (SC) management guidelines have recently been updated. A key focus is the emphasis on rest (immediately postinjury) followed by gradual resumption of activity (active recovery). This study aimed to explore community views on SC management and compared these with the guidelines. Methods A total of 157 volunteers completed an online SC survey, including listing three pieces of advice for a concussed person immediately postinjury, and after 2weeks (subacute). Quantitative data were statistically compared, and qualitative data underwent content analysis. Results Almost all participants offered different immediate versus subacute advice; however, rest featured highly at both timepoints. Commonly expressed themes, consistent with guidelines were immediate rest; safety and reinjury prevention; and symptom monitoring. Two themes were identified in the community advice with limited emphasis in the guidelines: general health advice and psychological and social support. Expert clinical assessment was not always identified in community advice. Conclusion Community members hold some views that align with expert advice for SC, particularly the importance of immediate postinjury rest. However, there is scope to grow public awareness of some recommended practices, including expert clinical assessment following injury and when to engage in active recovery.

Sport-Related Concussion: A Cognitive Perspective.

The incidence of sport-related concussion (SRC) has been increasing in different sports and its impact on long-term cognitive function is increasingly recognized. In this study, we review the epidemiology, neuropathophysiology, clinical symptoms, and long-term consequences of SRC with a specific focus on cognition. Repeated concussions are associated with an increased risk of several neurologic diseases and long-term cognitive deficits. To improve cognitive outcomes in athletes with SRC, standardized guidelines for the assessment and management of SRC are vital. However, current concussion management guidelines lack procedures for rehabilitating acute and long-term cognitive symptoms. Increased awareness for the management and rehabilitation of cognitive symptoms in SRC is needed in all clinical neurologists treating professional and amateur athletes. We propose cognitive training as a prehabilitation tool to alleviate the severity of cognitive symptoms and as a rehabilitative tool to improve cognitive recovery postinjury.

A systematic review of mobile phone applications for concussion

Introduction: Effective concussion management is impeded by several factors, including: a wide range in symptomatology and recovery patterns among patients; notable disparities and inequities by ethnicity, gender, socioeconomic status, and geography; variation in concussion policies and management guidelines across jurisdictions; and ineffective communications among multidisciplinary healthcare providers and their patients. Modern technologies such as mobile phone applications have been proposed to remedy some of these issues and improve concussion management, but the current availability and evidence-base for mobile phone applications for concussion remain unclear.

Evaluating the Association of Sleep & Physical activity with Prolonged Concussion Symptoms

IntroductionAdolescents with concussion will typically experience symptom resolution within 4‐weeks of injury; however, persistent post‐concussion symptoms (PPCS) may develop in approximately 30% of adolescents. Concussion management guidelines currently recommend a brief (24‐48 hour) rest period followed by sub‐symptom exercise to facilitate recovery. Additionally, poor sleep is associated with longer recovery, and early physical activity (PA) may accelerate symptom resolution. By understanding the individual association of both sleep and PA with symptom recovery, a basis can be provided for future recommendations on concussion intervention. Therefore, the purpose of this study was to determine whether sleep characteristics (duration, timing) and/or PA (steps/day, exercise frequency, duration, exercise intensity) in the first month after concussion are associated with PPCS.MethodsWe performed a prospective study of adolescent athletes who sustained a concussion and were evaluated within 14 days of injury. Participants received a Fitbit Charge 3TM to track PA and sleep parameters during recovery. The Post‐Concussion Symptom Inventory (PCSI) was used to determine symptom severity at the initial visit and the clearance visit. Participants were followed until symptom resolution, and the main outcome interest was development of PPCS (symptom duration ≥ 28 days). We then used a logistic regression model to examine associations between PA and sleep parameters with PPCS.ResultsOf the 49 patients included in the analysis, 47% (n=23, symptom resolution=57±23 days post‐injury) developed PPCS and 53% (n=26, symptom resolution=15±7 days post‐injury) did not. There was a significant difference between the PPCS and no PPCS groups in three different variables: steps/day (7526±2975 vs. 9803±3786; p=0.02), exercise days/week (2.5±2.2 vs. 4.4±2.1; p=0.005), and time in bed awake (1.2±0.3 hours/night vs. 0.8±0.3 hours/night; p=0.03). In our multivariable model, the risk of developing PPCS decreased by 1.6x with each additional exercise session/week (adjusted odds ratio=0.616, 95% confidence interval=0.389, 0.974, p=0.038).ConclusionsThe results suggest that participating in multiple exercise sessions per week during concussion recovery is associated with a lower risk of developing PPCS. Furthermore, taking more steps/day and spending less time awake in bed are associated with a shorter recovery period. Counseling patients on optimizing sleep and PA during concussion recovery may be one method for clinicians to promote recovery for their patients.

Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League–Big Ten Epidemiology of Concussion Study

ObjectiveTo examine the progression of collegiate student athletes through five stages of a return-to-activity protocol following sport-related concussion (SRC).MethodsIn a multisite prospective cohort study, we identified the frequency of initial...

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

BackgroundHurling 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.MethodsInvestigators 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).ResultsA 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.ConclusionIn 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.

STEP UP! LESS PHYSICAL ACTIVITY AFTER CONCUSSION IS ASSOCIATED WITH PROLONGED CLINICAL RECOVERY AMONG ADOLESCENTS

Background:While many adolescent athletes recover from concussion within one month, some will not recover within this timeframe. Concussion management guidelines have evolved to de-emphasize rest and promote early re-introduction of sub-symptomatic physical activity. However, the optimal levels of physical activity during concussion recovery have yet to be determined.Hypothesis/Purpose:To investigate the association between quantity, frequency and intensity of physical activity after concussion with clinical recovery, defined as return-to-play (RTP) clearance from their physician.Methods:We conducted an observational, prospective cohort study of 26 youth athletes who sustained a concussion and were evaluated at two time points: initial visit (<14 days post-injury) and RTP clearance visit. Participants reported concussion symptoms using the Post-Concussion Symptom Inventory (PCSI). Participants wore an activity tracking device for the first two weeks after initial visit. This allowed us to quantify average steps/day, exercise frequency (average workouts/week), exercise duration (average time/workout), and exercise intensity (average/maximum HR during workouts). We grouped participants by clinical recovery timing (RTP <28 days vs. ≥28 days post-injury) and compared physical activity measures using independent samples t-tests. We then identified the sensitivity, specificity, and classification accuracy of cutpoints for each exercise variable using a Receiver Operating Characteristic (ROC) and Area under the Curve (AUC) analysis.Results:Half (n=13) of the participants required ≥28 days to receive RTP clearance. The two groups were similar in age, proportion of females, and past concussion history (Table 1). Those who required ≥28 days for RTP clearance reported significantly greater symptom severity at the initial examination than the RTP <28 days group, despite similar initial visit timing (Table 1). During the two weeks after the initial visit, the RTP ≥28 days group took fewer steps/day, exercised fewer days/week, and exercised fewer total minutes/week (Table 2). Among the activity/exercise variables examined, the highest classification accuracy between groups consisted of ≥9,100 average steps/day, ≥4 sessions/week, and spending ≥135 total minutes/week exercising (Table 3).Conclusion:Higher daily step counts and more frequent/longer exercise sessions were associated with clearance for RTP within 28 days from concussion in adolescent athletes. These preliminary results further support the benefit of physical activity during concussion recovery. However, our study cannot assess the causal effect of these findings, given that those who felt better earlier may have been willing to participate in more physical activity. Further research is needed to develop duration-, frequency- and intensity-specific physical activity level guidelines to aid clinicians in concussion management.

Evaluation of Concussion Management Protocol in Adaptive Sports: The Guidelines for Conducting Proper Baselines

To discuss current concussion management guidelines in Adaptive Sports and educate clinicians on our Concussion Management Protocol (CMP).

Frequent but limited assessment of potentially concussed players in Gaelic Football: an opportunity to learn from other sports.

Sport-related concussion (SRC) is a potential issue within Gaelic Football. Therefore, it is essential that concussion management guidelines are adhered to. The aim of this study is to determine if potential concussive events (PCEs) in the Gaelic Athletic Association (GAA) National Football League (NFL) are assessed in accordance with GAA concussion guidelines and compare this to other sports. A descriptive video analysis approach was undertaken to identify PCEs throughout two seasons of play. Subsequent assessment, return to play (RTP) decisions, and signs of concussion were evaluated. A total of 242 PCEs were identified over 111 matches. Most PCEs (87.2%, n = 211) were assessed by medical personnel. However, 187 (88.6%) of assessments were under 2 min in duration. Of the 242 PCEs, 189 (78.1%) returned to play after on-pitch assessment, and 12 (5.0%) were removed following a PCE. Sixty-one (25.2%) players sustaining a PCE demonstrated one or more signs of concussion, of which 9 (14.8%) were removed from play. In the GAA NFL, PCEs are often briefly assessed but rarely result in player removal. Introduction of video incident analysis and concussion substitutions, as in other sports, may reduce the long-term burden of SRC on Gaelic Football players.

Quantifying Physical Activity After Concussion: The Relationship Between Sleep Quality, Symptoms, And Steps.

BACKGROUND: Concussion management guidelines have evolved over recent years to include earlier introduction of physical activity. Determining optimal post-concussion physical activity levels with objective methods will further aid clinicians in counseling patients on the role of physical activity in concussion recovery. PURPOSE: Our aim was to investigate the relationship of physical activity, as measured by daily step count, with post-injury sleep quality, symptom rating, and dual-task gait measures among youth athletes with concussion. METHODS: We conducted a longitudinal investigation of youth athletes who sustained a concussion and were evaluated at 2 time points: within 2 weeks of injury and at clearance for return-to-play. Following the initial visit, athletes wore an activity tracking device (Fitbit Charge 3). Dual-task gait, Post-Concussion Symptom Inventory, and Pittsburgh Sleep Quality Index values were collected at both visits. We compared outcomes between those who recorded an average of ≥10,000 steps/day (high physical activity) and <10,000 steps day (low physical activity) between initial and return-to-play clearance visits. RESULTS: Six concussed athletes were classified as having high physical activity (33% female; 14.9±2.0 years of age; 13,900±3,390 steps/day), and five were classified as having low physical activity (40% female; 15.8±1.7 years of age; 8,415±1,775 steps/day). There were no significant differences found at initial visit for total symptom severity (44.3±30.8 vs. 58.2±28.4; p=0.46), sleep quality (6.8±4.4 vs. 8.8±2.0; p=0.38), or dual-task gait cost (-22.4±7.9% vs. -20.1±13.5%; p=0.73) between the high and low physical activity groups. At the time of return-to-play clearance, however, the high physical activity group reported significantly better sleep quality (1.3 ±1.9 vs. 6.7±1.5; p=0.009) and lower symptom severity (0.3±0.8 vs. 3.0±2.0; p=0.02) than the low physical activity group. CONCLUSIONS: Adolescents with a concussion who participated in more physical activity after their initial clinical visit reported better sleep quality and lower symptom severity at return-to-play clearance than the low physical activity group. These preliminary results further support the utility of physical activity in concussion management.

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

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. 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. Qualitative document analysis. High school athletics. 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. 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. 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.

Sleep Symptoms Predict School Attendance After Pediatric Concussion.

This study examined the relationship between postconcussive symptom domain and school attendance. Retrospective chart review was completed for 88 children aged 6 to 18 years who were evaluated within 30 days postinjury. Hierarchical multiple regression was used to assess the association of physical, cognitive, emotional, and sleep symptoms with extent of school attendance. A subgroup multiple regression analysis was conducted to evaluate whether age affected the relationship of symptoms to school attendance. After controlling for demographic variables and total number of symptoms, a higher number of postconcussive sleep symptoms strongly predicted less school attendance. Specifically, older children (≥14 years old) with more sleep symptoms demonstrated less school attendance. For children presenting for specialty care after concussion, sleep symptoms are unfavorably associated with return to school. Future work aimed at optimizing sleep regulation following concussion may assist with early reengagement in school as recommended by current concussion management guidelines.

International study of video review of concussion in professional sports

BackgroundVideo review has become an important tool in professional sporting codes to help sideline identification and management of players with a potential concussion.AimTo assess current practices related to video review...

Concussion in Children.

Concussions are common in pediatric athletes, but they often go underreported. The topic of concussions has garnered much attention from the media recently, and this attention has resulted in the development of stricter guidelines for management of concussion by professional sporting leagues such as the National Football League and the National Hockey League. It is important to establish a clear understanding of the definitions, signs, and symptoms of concussion so that teachers, families, coaches, and physicians can better recognize it when it occurs. A concussion can interfere with school performance and interpersonal relationships, and the knowledge about long-term consequences of pediatric concussion is evolving. Proper management of concussion is critical to reduce the long-term sequelae, especially because there are no current means for prevention of concussion. [Pediatr Ann. 2019;48(4):e182-e185.].

Rest Evaluation for Active Concussion Treatment (ReAct) Protocol: a prospective cohort study of levels of physical and cognitive rest after youth sports-related concussion

IntroductionAlthough current guidelines for the early clinical management of sports-related concussion (SRC) call for a gradual return-to-activity, the optimal level of rest needed to promote recovery remains unknown. This paper...

National Football League Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol: 2017-18 season

One of the National Football League’s (NFL) Head, Neck and Spine Committee’s principal goals is to create a ‘best practice’ protocol for concussion diagnosis and management for its players. The...

A systems approach to understanding the identification and treatment of sport-related concussion in community rugby union

AimThe aim of the present study was to utilise a systems thinking approach to explore the perceived responsibilities for identifying and treating concussion held by different actors across the community rugby system (e.g., players, coaches, parents, medics, referees, and management), as well as their role-specific concussion management strategies. MethodsA systems approach was taken to assess what different stakeholders within rugby systems perceive their roles to be regarding concussion identification and treatment. Through an online survey, 118 members of the amateur (community) rugby union system were asked about their role-specific concussion management responsibilities and strategies. Respondents included players, parents, medics, coaches, club managers, administrators, and volunteers. ResultsThe majority of respondents indicated that they were able to identify the symptoms of rugby-related concussion, however, only medics stated their responsibility to use formal concussion assessments (e.g., SCAT2). A smaller number of the respondents indicated that they were involved in treating concussion within their current role/s (majority of which were medics). ConclusionsThis study illustrated that the current challenges in the identification and treatment of rugby-related concussion in community sport may be due to role/responsibility confusion and possible overreliance on field-side medics. These findings offer insight into the possible limitations of the current concussion management guidelines and may offer empirically based direction for future revisions.

Sport concussion knowledge base and current practice: a survey of selected physician sections from the ontario medical association

ObjectiveTo examine knowledge base/practice patterns regarding sport concussion in two physician populations.DesignOn-line survey.SettingOntario, Canada.ParticipantsPhysicians from Ontario Medical Association, Sections of: Sport &amp; Exercise Medicine (SEM), General &amp; Family Practice (SGFP).InterventionEmailed survey, 2 reminders.Outcome measuresKnowledge base/practice patterns; learning methods: current/preferred.Main resultsParticipantsSEM 92/594 (15.5%), SGFP 270/12,168 (2.2%); 51 (13.4%) members of both. More SEM physicians saw &gt;5 children (&lt;18 years) with concussions/month (40.2% SEM, 9.5% SGFP; p =&lt; 0.001).ToolsClinical examination; Sport Concussion Assessment Tool (SCAT/SCAT2) (68.4% SEM, 34.1% SGFP; p&lt;0.001); balance testing (56.5% SEM, 37.4% SGFP; p=0.001); computerised neurocognitive testing (23.9% SEM, 1.9% SGFP; p&lt;0.001); concussion grading scales (9.8% SEM, 14.1% SGFP; p&lt;0.001).Management:Physical rest (65.2% SEM, 68.5% SGFP); modified school/work until symptom resolution (50.0% SEM, 38.5% SGFP; p=0.026); no cognitive rest (3.2% SEM, 9.6% SGFP; p=0.026).Return-to-play:Clinical examination; SCAT/SCAT2 (60.8% SEM, 29.6% SGFP; p&lt;0.001); balance testing (56.5% SEM, 37.4% SGFP; p&lt;0.001); computerised neurocognitive testing (35.9% SEM, 2.2% SGFP; p&lt;0.001); concussion grading scales (7.6% SEM, 9.6% SGFP).Learning sourcescolleagues (55.4% SEM, 27.8% SGFP; p&lt;0.001); specialists (33.7% SEM, 23.7% SGFP; p=0.030); continuing medical education (CME) courses/conferences (67.4% SEM, 54.7% SGFP; p=0.017; preferred: 85.9% SEM, 73.9% SGFP; p=0.006); journals/publications (48.9% SEM, 25.2% SGFP; p&lt;0.001); websites (35.8% SEM, 32.2% SGFP; preferred: 35.9% SEM, 47.8% SGFP; p=0.024); medical school/residency training (19.6% SEM, 17.4% SGFP; preferred: 37.0% SEM, 47.8% SGFP).ConclusionsGaps exist between consensus-based recommendations and current practice patterns. Enhanced medical school/residency training and additional CME initiatives are recommended.Competing interestsNone.