Management Of Sport-related Concussion Research Articles

Concussion Management Practice Patterns Among Sports Medicine Physicians.

The primary purpose of this study was to examine concussion management practice patterns among sports medicine physicians in the United States. Cross-sectional study using a web-based survey. Members of the American Medical Society for Sports Medicine (AMSSM). We distributed a questionnaire to physician members of the AMSSM assessing the current practices for evaluating and managing concussions sustained during sports. Specifically, we asked respondents about their use of management guidelines, medications, balance assessments, neuropsychological tests, and return-to-play strategies. Of the 3591 members emailed, 425 (11.8%) respondents responded. Ninety-seven percent of respondents reported basing current management of sport-related concussion on a published set of criteria, with a majority (91.9%) following the guidelines provided by the Fourth International Conference on Concussion in Sport. Seventy-six percent of respondents reported using medication beyond 48 hours postinjury. Acetaminophen was reported as the most commonly administered medication, although tricyclic antidepressants and amantadine were also commonly administered. Vitamins, minerals, and dietary supplements were also reported as commonly administered. Most respondents reported using a form of neuropsychological testing (87.1%). A majority of respondents (88.6%) reported allowing athletes to return to competition after concussion only once the athlete becomes symptom free and completes a return-to-play protocol. Most sports medicine physicians seem to use recently developed guidelines for concussion management, regularly use medications and neuropsychological testing in management strategies, and follow established return-to-play guidelines. Sports medicine physicians seem to have clinical expertise in the management of sport-related concussion.

Long-term Stability and Reliability of Baseline Cognitive Assessments in High School Athletes Using ImPACT at 1-, 2-, and 3-year Test-Retest Intervals.

The ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) neurocognitive testing battery is a widely used tool used for the assessment and management of sports-related concussion. Research on the stability of ImPACT in high school athletes at a 1- and 2-year intervals have been inconsistent, requiring further investigation. We documented 1-, 2-, and 3-year test-retest reliability of repeated ImPACT baseline assessments in a sample of high school athletes, using multiple statistical methods for examining stability. A total of 1,510 high school athletes completed baseline cognitive testing using online ImPACT test battery at three time periods of approximately 1- (N=250), 2- (N=1146), and 3-year (N=114) intervals. No participant sustained a concussion between assessments. Intraclass correlation coefficients (ICCs) ranged in composite scores from 0.36 to 0.90 and showed little change as intervals between assessments increased. Reliable change indicesand regression-based measures (RBMs) examining the test-retest stability demonstrated a lack of significant change in composite scores across the various time intervals, with very few cases (0%-6%) falling outside of 95% confidence intervals. The results suggest ImPACT composites scores remain considerably stability across 1-, 2-, and 3-year test-retest intervals in high school athletes, when considering both ICCs and RBM. Annually ascertaining baseline scores continues to be optimal for ensuring accurate and individualized management of injury for concussed athletes. For instances in which more recent baselines are not available (1-2 years), clinicians should seek to utilize more conservative range estimates in determining the presence of clinically meaningful change in cognitive performance.

Preliminary results of residual deficits observed in athletes with concussion history: combined EEG and cognitive study.

Assessment, treatment, and management of sport-related concussions are a widely recognized public health issue. Although several neuropsychological and motor assessment tools have been developed and implemented for sports teams at various levels and ages, the sensitivity of these tests has yet to be validated with more objective measures to make return-to-play (RTP) decisions more confidently. The present study sought to analyze the residual effect of concussions on a sample of adolescent athletes who sustained one or more previous concussions compared to those who had no concussion history. For this purpose, a wide variety of assessment tools containing both neurocognitive and electroencephalogram (EEG) elements were used. All clinical testing and EEG were repeated at 8 months, 10 months, and 12 months post-injury for both healthy and concussed athletes. The concussed athletes performed poorer than healthy athletes on processing speed and impulse control subtest of neurocognitive test on month 8, but no alterations were marked in terms of visual and postural stability. EEG analysis revealed significant differences in brain activities of concussed athletes through all three intervals. These long-term neurocognitive and EEG deficits found from this ongoing sport-related concussion study suggest that the post-concussion physiological deficits may last longer than the observed clinical recovery.

Frequency and Outcomes of a Symptom-Free Waiting Period After Sport-Related Concussion

Background: Guidelines and practices for the management of sport-related concussion (SRC) have evolved swiftly over the past 2 decades. Despite common recommendations for a symptom-free waiting period (SFWP) before returning to sport, past reports have suggested poor utilization rates for this intervention. Purpose: To obtain current estimates of the utilization and characterization of SFWPs with high school and collegiate athletes. Study Design: Descriptive epidemiology study. Methods: Data were extracted from a larger prospective study that followed athletes with SRC across 13 institutions in southeastern Wisconsin from 2012 to 2014. Participants included 143 contact and collision sport athletes who were followed serially through their recoveries after SRCs. Results: In the current study sample, 99.3% of athletes used an SFWP. The mean self-reported symptom duration was 6.35 days (median, 5 days), with 72.7% reporting symptom recovery within 1 week of injury, 93.7% within 2 weeks, and 99.3% within 30 days. Rate of same-season repeat concussion was low (3.8%) and was similar to or lower than the overall rate of concussion (4.3%). Five same-season repeat concussions occurred at a range of 8 to 42 days after initial injuries. Conclusion: In comparison with prior published data collected from 1999 to 2004, utilization and duration of SFWPs were higher in the current study samples (99.3% vs 60.3% of athletes reported an SFWP; mean duration, 6.1 vs 3.2 days), and athletes were withheld from sports for more days than previously reported (12.3 vs 7.4 days). Rate of same-season repeat concussion was equivalent to that of prior published data. The findings support improved adherence to clinical management guidelines through increased utilization of SFWPs after SRC.

Test–retest, retest, and retest: Growth curve models of repeat testing with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

ABSTRACTComputerized neuropsychological testing has become an important tool in the identification and management of sports-related concussions; however, the psychometric effect of repeat testing has not been studied extensively beyond test–retest statistics. The current study analyzed data from Division I collegiate athletes who completed Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) baseline assessments at four sequential time points that varied over the course of their athletic careers. Administrations were part of a larger National Institutes of Health (NIH) study. Growth curve modeling showed that the two memory composite scores increased significantly with successive administrations: Change in Verbal Memory was best represented with a quadratic model, while a linear model best fit Visual Memory. Visual Motor Speed and Reaction Time composites showed no significant linear or quadratic growth. The results demonstrate the effect of repeated test administrations for memory composite scores, while speed composites were not significantly impacted by repeat testing. Acceptable test–retest reliability was demonstrated for all four composites as well.

Examining Computerized Neuropsychological Test Performance Scores Pre to Post Season Following a Season of Competitive Interscholastic Girls’ Soccer

Purposeful heading of a soccer ball is an inherent and strategic part of the sport. Recent neuroimaging evidence suggests that there may be detrimental effects of repetitive soccer heading on neurophysiology. With neuropsychological testing (NP) part of most sport-related concussion management programs, the ability to access this data and make reasonable conclusions even in the absence of concussion is advantageous. PURPOSE: To determine if differences in NP test performance exist pre to post season in a large cohort of female interscholastic soccer players. METHODS: A total of 707 interscholastic female soccer players from 19 different schools consented to participate in this study. Subjects were administered the computerized Automated Neuropsychological Assessment Metrics (ANAM) test battery prior to and at the conclusion of their playing season. Throughput scores (T-PUT) (measures of performance speed and accuracy) were taken from the ANAM test battery for the Simple Reaction Time (SRT), Math Processing Test (MTH), Continuous Performance Test (CPT), Matching to Sample (MSP), Sternberg Memory Test (ST6), Repeat Simple Reaction Time (RSRT), and Repeat Continuous Performance Test (RCPT); whereas higher scores are interpreted as better. Data were analyzed using a series of paired-samples t-tests. RESULTS: Significant (all p-values P < .000) improvements in T-PUT scores occurred in 6 of 7 of the NP variables [SRT 209.1 vs. 212.5, MTH 21.9 vs. 25.0, CPT 92.1 vs.103.4, MSP 31.0 vs. 33.6, ST6 75.4 vs. 82.7, RCPT 100.1 vs. 109.9]. The only pair that was not significant was RSRT (208.3 vs. 209.3). Calculated effect sizes ranged from small to medium. CONCLUSION: The SRT, RSRT, and MSP values reported here are lower than those previously reported in collegiate athletes. Practice effect improvements of +9 for SRT, +2 for MTH, +5 for MSP, and +10 for ST6 have been previously shown and compare favorably to what is demonstrated in our subject pool. Having hypothesized that we would find deficits in NP test performance, we unexpectedly report that in all NP variables this cohort actually improved performance. Our large scale research effort involving female interscholastic soccer players is important in providing evidence surrounding issues related to the subconcussive head impacts that take place during soccer competition.

Evidence-Based Management of Sport-Related Concussion: Completing the Puzzle

Concussion-related evidence is evolving at a rapid pace due to the complexity of concussive injury and the increased societal and medical attention around its potential consequences. Recent evidence and consensus suggests a multimodal assessment and management model that encompasses the various domains affected by concussion. The model is inclusive of a clinical evaluation, symptoms assessment, neurocognitive assessment, and balance assessment. However, new evidence also highlights additional diagnostic and prognostic factors that are important to understand in the concussion management process. With these advances, there is also increased consensus and evidence for a more active approach to management of the injury. As such, there are many new advances in the field that are key for clinicians to understand and utilize in clinical practice. This narrative review will provide an overview of recent evidence illustrating the necessity of multimodal concussion assessment and management best practices.

A pilot investigation of the Motivation Behaviors Checklist (MBC): An observational rating scale of effort towards testing for baseline sports-concussion assessment

ABSTRACTBackground: Baseline neuropsychological testing is commonly used in the management of sports-related concussion. However, underperformance due to poor effort could lead to invalid conclusions regarding postconcussion cognitive decline. We designed the Motivation Behaviors Checklist (MBC) as an observational rating scale to assess effort towards baseline neuropsychological testing. Here we present preliminary data in support of its reliability and validity. Method: MBC items were generated based on the consensus of a panel of graduate students, undergraduates, and a clinical neuropsychologist who conduct neuropsychological evaluations for a sports concussion management program. A total of 261 college athletes were administered a standard neuropsychological test battery in addition to the MBC. A subset of evaluations (n= 101) was videotape and viewed by a second rater. Exploratory factor analysis (EFA) was used to refine the scale, and reliability and validity were evaluated. Results: EFA revealed that the MBC items represent four latent factors—Complaints, Poor Focus, Psychomotor Agitation, and Impulsivity. Reliability analyses demonstrated that the MBC has good inter-rater reliability (intraclass correlation coefficient, ICC = .767) and internal consistency (α = .839). The construct validity of the MBC is supported by large correlations with examiners’ ratings of effort (ρ = –.623) and medium-sized relationships with cognitive performance and self-ratings of effort (|ρ| between .263 and .345). Discriminant validity was supported by nonsignificant correlations with measures of depression and postconcussion symptoms (ρ = .056 and .082, respectively). Conclusions: These findings provide preliminary evidence that the MBC could be a useful adjunct to baseline neuropsychological evaluations for sports-concussion management.

Sport-Related Concussion in Youth: A Curriculum for Advanced Practice Nurses

Sports-related concussions are a major public health concern for children, parents, and health care providers. Effective management of sports-related concussions in children and adolescents requires timely and accurate diagnosis and appropriate management. Advance practice nursing textbooks often do not address sport-related concussions. Although nurse practitioners routinely care for these patients, they may not have adequate education or training to diagnose and manage them. It is essential to close the gap in education by providing up-to-date recommendations and guidelines for diagnosis and management. Current research and recommendations are presented to facilitate nurse practitioner education about sport-related concussion.

An evaluation of Gaelic Athletic Association (GAA) athletes’ self-reported practice of playing while concussed, knowledge about and attitudes towards sports-related concussion

Sports-related concussions are now recognized as a major public health concern. However, despite the association of concussion with short- and long-term health consequences, many young athletes still lack basic knowledge about concussion and seem to believe that concussions may be "toughed out" and do not require medical attention. This study assessed self-reported practice of playing in training or a match while concussed among Gaelic Athletic Association (GAA) athletes in Ireland aged 13-25 years old (M=19.19, SD=3.54). This study also assessed knowledge about and attitudes towards sports-related concussion in GAA players in Ireland. Using a self-report questionnaire, data were captured electronically on GAA athletes aged 13-25 years old (n=80) regarding knowledge about the detection, assessment and management of sports-related concussion, as well as participant's attitudes towards concussion and self-reported practice of playing in training or a match while concussed. Data were collected from June to August 2013. This study revealed that approximately one in four athletes reported having played while concussed in practice or during a match. Males were significantly more likely to play while concussed than females (40.9% and 17.2%, respectively). Results from this study indicated participants lack a complete understanding of concussion, as common misconceptions about concussion prevailed. Analyses revealed that participants generally have safe attitudes towards concussion and concussion management. Generating awareness of the potential short- and long-term health consequences of concussion, coupled with the promotion of safer attitudes towards this injury, could minimize the number of players who return-to-play pre-maturely and promote a more safety-conscious sports culture in Ireland.

Policies, Procedures, and Practices Regarding Sport-Related Concussion in Community College Athletes

College sport organizations and associations endorse concussion-management protocols and policies. To date, little information is available on concussion policies and practices at community college institutions. To assess and describe current practices and policies regarding the assessment, management, and return-to-play criteria for sport-related concussion (SRC) among member institutions of the California Community College Athletic Association (CCCAA). Cross-sectional study. Web-based survey. A total of 55 head athletic trainers (ATs) at CCCAA institutions. Data about policies, procedures, and practices regarding SRC were collected over a 3-week period in March 2012 and analyzed using descriptive statistics, the Fisher exact test, and the Spearman test. Almost half (47%) of ATs stated they had a policy for SRC assessment, management, and return to play at their institution. They reported being in compliance with baseline testing guidelines (25%), management guidelines (34.5%), and return-to-play guidelines (30%). Nearly 31% of ATs described having an SRC policy in place for academic accommodations. Conference attendance was positively correlated with institutional use of academic accommodations after SRC (r = 0.44, P = .01). The number of meetings ATs attended and their use of baseline testing were also positively correlated (r = 0.38, P = .01). At the time of this study, nearly half of CCCAA institutions had concussion policies and 31% had academic-accommodation policies. However, only 18% of ATs at CCCAA institutions were in compliance with all of their concussion policies. Our findings demonstrate improvements in the management of SRCs by ATs at California community colleges compared with previous research but a need for better compliance with SRC policies.

Management of Sport-Related Concussion in the Pediatric and Adolescent Population.

Concussions make up nearly 10% of all high school athletic injuries. Recent changes in concussion management guidelines and legislation aim to make concussion care more standardized and safe but simultaneously pose a challenge for the primary care and sports medicine physician. Pediatric and adolescent concussions may cause anxiety for the treating physician due to concerns over return-to-play decisions, academic issues, and the potential for second impact syndrome. Determining when to refer a patient to an emergency department acutely, to an outpatient concussion clinic, or to other subspecialists may be a difficult decision for the primary care physician. The aim of this article is to review current evidence regarding concussion treatment and return-to-school and return-to-play recommendations to provide the primary care and sports medicine physician with practical guidelines for managing concussions.

Concussion-Related Protocols and Preparticipation Assessments Used for Incoming Student-Athletes in National Collegiate Athletic Association Member Institutions.

National Collegiate Athletic Association (NCAA) legislation requires that member institutions have policies to guide the recognition and management of sport-related concussions. Identifying the nature of these policies and the mechanisms of their implementation can help identify areas of needed improvement. To estimate the characteristics and prevalence of concussion-related protocols and preparticipation assessments used for incoming NCAA student-athletes. Cross-sectional study. Web-based survey. Head athletic trainers from all 1113 NCAA member institutions were contacted; 327 (29.4%) completed the survey. Participants received an e-mail link to the Web-based survey. Weekly reminders were sent during the 4-week window. Respondents described concussion-related protocols and preparticipation assessments (eg, concussion history, neurocognitive testing, balance testing, symptom checklists). Descriptive statistics were compared by division and football program status. Most universities provided concussion education to student-athletes (95.4%), had return-to-play policies (96.6%), and obtained the number of previous concussions sustained by incoming student-athletes (97.9%). Fewer had return-to-learn policies (63.3%). Other concussion-history-related information (e.g., symptoms, hospitalization) was more often collected by Division I universities. Common preparticipation neurocognitive and balance tests were the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT; 77.1%) and Balance Error Scoring System (46.5%). In total, 43.7% complied with recommendations for preparticipation assessments that included concussion history, neurocognitive testing, balance testing, and symptom checklists. This was due to moderate use of balance testing (56.6%); larger proportions used concussion history (99.7%), neurocognitive testing (83.2%), and symptom checklists (91.7%). More Division I universities (55.2%) complied with baseline assessment recommendations than Division II (38.2%, χ2 = 5.49, P = .02) and Division III (36.1%, χ2 = 9.11, P = .002) universities. National Collegiate Athletic Association member institutions implement numerous strategies to monitor student-athletes. Division II and III universities may need additional assistance to collect in-depth concussion histories and conduct balance testing. Universities should continue developing or adapting (or both) return-to-learn policies.

Factors associated with delayed recovery in athletes with concussion treated at a pediatric neurology concussion clinic.

With the increase in knowledge and management of sport-related concussion over the last 15 years, there has been a shift from a grading scale approach to an individualized management approach. As a result, there is an increased need to better understand the factors involved in delayed recovery of concussion. The purpose of this retrospective study was to examine factors that may be associated with recovery from sport-related concussion in student athletes aged 11 to 18 years old. Of the 366 patients who met the inclusion criteria, 361 were included in our analysis. The primary dependent variable included days until athlete was able to return to play (RTP). Independent variables of interest included age, gender, academic performance, comorbid factors, sports, on-field markers, days until initial neurological evaluation, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) scores, acute headache rescue medications, chronic headache medication, sleep medication, and referral to concussion rehabilitation program. Variables associated with longer median RTP were being female (35 days), having a referral to concussion rehabilitation program (53 days), being prescribed acute headache rescue therapy (34 days), and having chronic headache treatment (53 days) (all p < 0.05). Variables associated with shorter RTP were on-field marker of headache (23 days) and evaluation within 1 week of concussion by a concussion specialist (16 days) (Both p < 0.05). This study supports the need for a concussed athlete to have access to a provider trained in concussion management in a timely fashion in order to prevent delayed recovery and return to play.

Normative Versus Baseline Paradigms for Detecting Neuropsychological Impairment Following Sports-Related Concussion

Objective: Obtaining baseline neuropsychological (NP) data to assist management of sports-related concussion has been considered the standard of care. The validity of this approach has been questioned, with suggestions that post-concussion testing alone will suffice. The present study compared the sensitivity of baseline and normative paradigms in the setting of sports-related concussion.Method: Baseline NP data were collected for 194 Australian rugby league athletes on a brief battery of paper-and-pencil NP tests. During competition, 27 athletes sustaining concussion referred from a sports physician were retested within two days of injury. Twenty-six uninjured controls were assessed at similar intervals. The baseline paradigm was assessed using a reliable change index for pre- and post-concussion scores. The normative paradigm was assessed comparing the post-concussion score to a normative mean.Results: The baseline paradigm was consistently more sensitive to negative change following concussion than the normative paradigm when using continuous data, despite reasonable agreement. However, when data were categorised as ‘impaired’ or ‘not-impaired’, using either 68% or 90% confidence intervals, the difference between paradigms failed to reach significance. Comparison of ROC curves for both paradigms found superior overall classification for one test and the composite score using baseline comparison data.Conclusions: Despite being a time and resource intensive process, the baseline paradigm as a repeated-measures design may be more sensitive than the between-subjects design of the normative paradigm for detecting changes following concussion. Further work is required to determine the validity of normative assessment in sports-related concussion.

Are psychotropic medications associated with differences in baseline neurocognitive assessment scores for young athletes? A pilot study

Objectives. Baseline and post-concussive neurocognitive testing is useful in managing concussed athletes. The Concussion in Sport Group has postulated that the use of psychotropic medications is a modifying factor in the management of sport-related concussion. About 7% of US adolescents are prescribed psychotropics in a given year. Our aim was to investigate whether psychotropic medication use or psychiatric illness is associated with differences in baseline neurocognitive test scores. Methods. From 2007 to 2012, over 7000 athletes underwent pre-participation baseline neurocognitive testing using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery. Following application of inclusion and exclusion criteria, athletes’ self-reported medication lists were reviewed and: 1) classified as psychotropic or not and 2) subclassified. Group subclassification yielded: 1) use of any psychotropic medication, 2) psychostimulant use, 3) antidepressant use and 4) self-reported history of depression and/or anxiety without psychotropic use. Each group was matched, by sex, age, body mass index, education level and concussion history with athletes who were not reportedly prescribed psychotropic medications or did not report a depression/anxiety history, respectively. Each group’s baseline ImPACT scores were compared to matched controls. Results. The use of prescribed psychotropic medications without regard to subclass had no effect on baseline ImPACT composite scores among athletes ages 13–25. However, athletes reportedly prescribed psychostimulants displayed significantly lower visual motor speed scores (32.8 vs 37.1, p = 0.030) and slower reaction times (0.65 vs 0.60, p = 0.044) than non-users. In contrast, antidepressant users displayed significantly faster reaction times (0.58 vs 0.61, p = 0.029). Those reporting a history of depression/anxiety, not treated with psychotropics, displayed significantly lower visual memory (70.4 vs 75.2, p = 0.010) and higher symptom scores (8.83 vs 4.72, p = 0.005). Conclusions. This pilot study suggests that self-reported psychotropic medications are associated with differences in baseline ImPACT test scores, which appear dependent on medication subclass. Our preliminary results support the inclusion of psychotropic medications, specifically psychostimulants and antidepressants, as well as history of depression/anxiety as potential concussion modifiers.

Reliability of a Computerized Neurocognitive Test in Baseline Concussion Testing of High School Athletes.

Baseline assessments using computerized neurocognitive tests are frequently used in the management of sport-related concussions. Such testing is often done on an annual basis in a community setting. Reliability is a fundamental test characteristic that should be established for such tests. Our study examined the test-retest reliability of a computerized neurocognitive test in high school athletes over 1 year. Repeated measures design. Two American high schools. High school athletes (N = 117) participating in American football or soccer during the 2011-2012 and 2012-2013 academic years. All study participants completed 2 baseline computerized neurocognitive tests taken 1 year apart at their respective schools. The test measures performance on 4 cognitive tasks: identification speed (Attention), detection speed (Processing Speed), one card learning accuracy (Learning), and one back speed (Working Memory). Reliability was assessed by measuring the intraclass correlation coefficient (ICC) between the repeated measures of the 4 cognitive tasks. Pearson and Spearman correlation coefficients were calculated as a secondary outcome measure. The measure for identification speed performed best (ICC = 0.672; 95% confidence interval, 0.559-0.760) and the measure for one card learning accuracy performed worst (ICC = 0.401; 95% confidence interval, 0.237-0.542). All tests had marginal or low reliability. In a population of high school athletes, computerized neurocognitive testing performed in a community setting demonstrated low to marginal test-retest reliability on baseline assessments 1 year apart. Further investigation should focus on (1) improving the reliability of individual tasks tested, (2) controlling for external factors that might affect test performance, and (3) identifying the ideal time interval to repeat baseline testing in high school athletes. Computerized neurocognitive tests are used frequently in high school athletes, often within a model of baseline testing of asymptomatic individuals before the start of a sporting season. This study adds to the evidence that suggests in this population such testing may lack sufficient reliability to support clinical decision making.

Sports-Related Concussion.

Sports-related concussions (SRC) are common in all ages and occur in all sports. The diagnosis based on clinical suspicion after more serious injury is ruled out. Symptoms of concussion are due to a temporary and reversible neurometabolic cascade resulting in blood flow changes, neuronal excitotoxicity, ionic shifts, and mitochondrial changes. Symptoms are nonspecific, and commonly include headache, cognitive complaints, photophobia, and phonophobia. Loss of consciousness is rare in SRC and has limited influence on recovery and prognosis. Imaging has a limited role in the management of concussion and should be used to evaluate for more serious intracranial pathology. Treatment is based on symptoms and an understanding of the typical, rapid (7-10days) recovery. No athlete should return to play until their symptoms have resolved and they have completed a supervised, step-wise return to play protocol. The article covers the most recent literature on the diagnosis and management of SRC, including evidence-based recommendations and expert-based consensus opinion. The article will also discuss issues regarding medical retirement, legislation, and future concepts in concussion diagnosis and management.

Test-Retest Reliability of a Computerized Concussion Test: CNS Vital Signs.

Background:Neurocognitive testing is an important concussion evaluation tool, but for neurocognitive tests to be useful, their psychometric properties must be well established. Test-retest reliability of computerized neurocognitive tests can influence their clinical utility. The reliability for a commonly used computerized neurocognitive test, CNS Vital Signs, is not well established. The purpose of this study was to examine test-retest reliability and reliable change indices for CNS Vital Signs in a healthy, physically active college population.Hypothesis:CNS Vital Signs yields acceptable test-retest reliability, with greater reliability between the second and third test administration compared with between the first and second administration.Study Design:Cohort study.Level of Evidence:Level 3.Methods:Forty healthy, active volunteers (16 men, 24 women; mean age, 21.05 ± 2.17 years) reported to a clinical laboratory for 3 sessions, 1 week apart. At each session, participants were administered CNS Vital Signs. Outcomes included standard scores for the following CNS Vital Signs domains: verbal memory, visual memory, psychomotor speed, cognitive flexibility, complex attention, processing speed, reaction time, executive functioning, and reasoning.Results:Participants performed significantly better on the second session and/or third session than they did on the first testing session on 6 of 9 neurocognitive domains. Pearson r test-retest correlations between sessions ranged from 0.11 to 0.87. Intraclass correlation coefficients ranged from 0.10 to 0.86.Conclusion:Clinicians should consider using reliable change indices to account for practice effects, identify meaningful score changes due to pathology, and inform clinical decisions.Clinical Relevance:This study highlights the importance of clinicians understanding the psychometric properties of computerized neurocognitive tests when using them in the management of sport-related concussion. If CNS Vital Signs is administered twice within a small time frame (such as 1 week), athletes should be expected to improve between the first and second administration.

Clinical Management of Sport-Related Concussion: Developing a Roadmap to a Successful Outcome

In order to promote the most successful outcomes following concussion, a multifaceted team of individuals is required for appropriate injury diagnosis and management. This review explores the primary roles of sports medicine personnel in the concussion diagnosis and management process. We will discuss the psychometric properties, including sensitivity, specificity, and clinical utility, of on-field/sideline, laboratory, and neurophysiological assessment tools. Additionally, we will discuss the roles of other kinesiology experts in concussion management and recovery, and their importance to concussion research. By developing a thorough and consistent roadmap for concussion management, clinicians and researchers will be capable of providing athletes with the most successful outcomes.