Post-injury Assessments Research Articles

Influence of Self-reported Fatigue and Sex on Baseline Concussion Assessment Scores.

Background:Baseline concussion assessments are advocated to provide an objective preinjury point of comparison for determining the extent of postconcussion neurological deficits and to assist with return-to-activity decision making. Many factors, including testing environment, proctor availability, and testing group size, can influence test accuracy and validity; however, it is unknown how self-reported fatigue affects test scores.Purpose:To investigate the influence of self-reported fatigue and patient sex on baseline concussion assessment scores.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Participants included 494 healthy Division I college student-athletes (221 women, 273 men; mean ± SD age, 20.0 ± 1.3 years). During preseason baseline testing, participants were asked to rate their fatigue on a scale from 0 to 100 based on how they normally feel and function each day (0, completely exhausted; 100, completely awake and alert). Each participant then completed a multimodal baseline concussion assessment, including a graded symptom checklist (number of symptoms endorsed and total symptom severity score), Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and CNS Vital Signs computerized neurocognitive testing. Multiple linear regressions tested whether self-reported fatigue and sex predicted baseline concussion examination scores.Results:Athletes with higher self-reported fatigue levels (ß = –0.014, P < .01) and female athletes (ß = –0.216, P < .01) reported more total symptoms. Being male (ß = 0.856, P < .01) increased the likelihood of endorsing zero symptoms versus any symptoms by a factor of 2.40. Women also had significantly higher SAC scores (ß = 0.569, P < .001), BESS scores (ß = –2.747, P < .001), and CNS Vital Signs summary scores (ß = 4.506, P < .001). SAC, BESS, and CNS Vital Signs scores were not predicted by fatigue level (P > .05).Conclusion:Female athletes and fatigued athletes endorsed more symptoms and higher symptom severity at baseline. Using total symptom endorsement and total symptom severity scores as part of the postinjury management is a common practice. The current data suggest that levels of reported exhaustion can influence concussion assessment scores meant to represent a healthy baseline and likely would interfere with postinjury assessment scores.

Preinjury and Postinjury Factors That Predict Sports-Related Concussion and Clinical Recovery Time.

To evaluate the relationship between preinjury risk factors (RFs) and subsequent occurrence of concussion and examine whether preinjury RFs or postinjury assessments predict clinical recovery in collegiate athletes. Risk factors (sex, sport, and self-report history of concussion, migraine, attention-deficit disorder, learning disability, depression, and anxiety) and Sport Concussion Assessment Tool (SCAT), depression/anxiety screenings, and neuropsychological testing were obtained before the season. For athletes who sustained concussion, RFs, postinjury SCAT, neuropsychological assessment, and clinical recovery were assessed. We assessed 1152 athletes (69% male) at baseline and 145 (75% male) after subsequent concussion diagnosis. Only sport type (Wald = 40.29, P = 0.007) and concussion history (Wald = 9.91, P = 0.007) accounted for unique variance in subsequent concussion. Of athletes followed until full recovery, mean days until symptom-free (DUSF) was 9.84 ± 11.11 days (n = 138, median = 5 days, range = 1-86) and mean days until full return to play (DUFRTP) was 20.21 ± 19.17 (n = 98, median = 20.21, range = 4-150). None of the RFs or baseline testing measures were associated with DUSF or DUFRTP (P's > 0.05). After injury, athletes who reported more total symptoms (rs = 0.31, P < 0.001) and higher symptom severity (rs = 0.33, P < 0.001) exhibited longer DUSF. Days until symptom-free correlated with DUFRTP (rs = 0.75, P < 0.001). Among athletes assessed within 2 days after injury, DUSF was associated with Immediate Postconcussion Assessment and Cognitive Test visual motor (rs = -0.31, P = 0.004), reaction time (rs = 0.40, P < 0.001), and symptom score (rs = 0.54, P < 0.001). Only sport type and concussion history predicted subsequent occurrence of concussion, and none of the RFs or baseline measures predicted clinical recovery. Immediate postinjury assessments, including symptom number and severity, and select clinical measures predicted longer clinical recovery.

Health-Related Quality of Life Following Concussion in Collegiate Student-Athletes With and Without Concussion History.

The purpose of this study was to compare global and specific health-related quality of life (HRQOL) throughout concussion recovery between those with and without concussion history. Student-athletes diagnosed with concussion completed global (Short Form-12v2; SF-12) and specific (Hospital Anxiety and Depression Scale: HADS) HRQOL assessments at baseline, 24-48h, asymptomatic, return-to-play, and 6-months post-injury. Baseline scores were compared to post-injury time points for SF-12 subscores (physical and mental; PCS-12, MCS-12) and HADS subscores (depression and anxiety; HADS-D, HADS-A). We conducted a 2 × 5 mixed model ANOVA for group (with and without concussion history) and time (four post-injury assessments compared to baseline). We did not observe interaction or main effects for group, except those with concussion history had worse HADS-D subscores than those without concussion history. PCS-12 subscores were worse at 24-48h, asymptomatic, and return-to-play compared to baseline, but returned to baseline 6-months post-injury. MCS-12 subscores did not differ at any time points. HADS-D subscores worsened 24-48h post-injury, but improved for additional assessments compared to baseline. HADS-A improved post-injury compared to baseline at asymptomatic, return-to-play, and 6-month assessments, but was similar to baseline 24-48h post-injury. HRQOL physical aspects slightly worsened post-injury and restored to baseline after returning to play.

Neonatal Heart Regeneration: Comprehensive Literature Review.

The adult mammalian heart is incapable of meaningful functional recovery after injury, and thus promoting heart regeneration is 1 of the most important therapeutic targets in cardiovascular medicine. In contrast to the adult mammalian heart, the neonatal mammalian heart is capable of regeneration after various types of injury. Since the first report in 2011, a number of groups have reported their findings on neonatal heart regeneration. The current review provides a comprehensive analysis of heart regeneration studies in neonatal mammals conducted to date, outlines lessons learned, and poses unanswered questions. We performed a PubMed search using the keywords "neonatal" and "heart" and "regeneration." In addition, we assessed all publications that cited the first neonatal heart regeneration reports: Porrello et al, Science, Feb 2011 for apical resection injury; Porrello et al, PNAS, Dec 2012 for coronary ligation injury; and Mahmoud et al, Nature Methods, Jan 2014 for surgical methodology. Publications were examined for surgical models used, timing of surgery, and postinjury assessment including anatomic, histological, and functional assessment, as well as conclusions drawn. We found 30 publications that performed neonatal apical resection, 19 publications that performed neonatal myocardial infarction by coronary artery ligation, and 6 publications that performed cryoinjury using liquid nitrogen-cooled metal probes. Both apical resection and ischemic infarction injury in neonatal mice result in a robust regenerative response, mediated by cardiomyocyte proliferation. On the other hand, several reports have demonstrated that cryoinjury is associated with incomplete heart regeneration in neonatal mice. Not surprisingly, several studies suggest that injury size, as well as surgical and histological techniques, can strongly influence the observed regenerative response and final conclusions. Studies have utilized these neonatal cardiac injury models to identify factors that either inhibit or stimulate heart regeneration. Overall, there is consensus that both apical resection and coronary ligation injuries during the first 2 days of life result in heart regeneration in neonatal mammals, whereas cryoinjury was not associated with a similar regenerative response. This regenerative response is mediated by proliferation of preexisting cardiomyocytes, and is modifiable by injury size and surgical technique, as well as metabolic, immunologic, genetic, and environmental factors.

School Nurses' Management and Collaborative Practices for Student-Athletes Following Sport-Related Concussion.

The purpose of this study was to examine school nurses' management and collaboration with health-care providers (HCPs) for student-athletes following a concussion. Secondary school nurses accessed an online survey titled the Beliefs, Attitudes, and Knowledge of Pediatric Athletes with Concussions (access rate = 15.6%; n = 1,246/8,000). Approximately 40% of schools where nurses were employed administered baseline and postinjury concussion assessments. No significant differences were found between employment model (single vs. multiple sites) in regard to conducting baseline (p = .908) administration at their site; however, those employed at a single school more frequently offered postinjury assessments at their site than those at multiple sites (p = .019). School nurses most frequently reported relationships with an athletic trainer (38.8%, n = 483/1,246) compared to other HCPs. A concussion management team, including school nurses, and other recommended members should develop comprehensive concussion management plans. Plans should comprise of multiple concussion assessments to aid in the return-to-learn/play processes.

Fatigue Influence On King-devick Test

One of current sideline, post-injury assessment tools used for screening concussion include the King-Devick Test (K-D) which measures cognitive processing speed, rapid eye movement, and visual tracking. As a post-exercise test it is unclear if the K-D is truly sensitive enough to rule-out concussion in the presence of fatigue. PURPOSE: To examine the impact of whole-body fatigue on King-Devick test performance. METHODS: The test was administered to 24 subjects (age = 23.2 ± 1.7 years, BMI = 24.9 ± 2.2 kg/m2) at baseline, after a fatigue protocol and on ensuing time at least 3 weeks later. The fatigue protocol was performed on a Concept 2 rower at an initial metronome pace of 75 bpm with an increase of one bpm every two minutes until the subject reached fatigue. Fatigue was determined when three of four criteria were met: 90% or higher of predicted MaxHR, inability to maintain metronome pace for three consecutive pulls to the abdomen, 17/20 or higher on the RPE scale, and inability to maintain proper form. RESULTS: Post-fatigue, 41.7% of the subjects were positive on the K-D test. Among subjects that reported a history of dizziness, 57.1 % were positive on the post-fatigue K-D test compared to 35.3% who did not reported dizziness (P = 0.2). The time spent on the rower was not different (P = 0.2) between subjects that were positive on the K-D test (14.8 ± 12.0 minutes) and the ones that were negative (44.8 ± 23.2 minutes). A positive K-D test is determination when the time to complete the test increases on a posttest or an error is recorded. Follow-up testing (3 weeks) showed that 20.8% of subjects had K-D scores indicative of further evaluation (P = 0.09). Of these, 60% K-D scores were positive by less than 1 second (0.64 sec.). If a positive K-D was defined as a score ≥1 second, only 8.3% of subjects will be categorized as positive for K-D (P = 0.01 compared to baseline). CONCLUSIONS: The present data demonstrate that whole-body fatigue may worsen the K-D scores, questioning its construct validity and limiting its use as a sideline screening for concussion. Scoring definitions can also be improved to better depict the positive results. The K-D test can show an improved validity when used in conjunction with pre-concussion symptom history.

Descriptive Analysis of a Baseline Concussion Battery Among U.S. Service Academy Members: Results from the Concussion Assessment, Research, and Education (CARE) Consortium.

The prevalence and possible long-term consequences of concussion remain an increasing concern to the U.S. military, particularly as it pertains to maintaining a medically ready force. Baseline testing is being used both in the civilian and military domains to assess concussion injury and recovery. Accurate interpretation of these baseline assessments requires one to consider other influencing factors not related to concussion. To date, there is limited understanding, especially within the military, of what factors influence normative test performance. Given the significant physical and mental demands placed on service academy members (SAM), and their relatively high risk for concussion, it is important to describe demographics and normative profile of SAMs. Furthermore, the absence of available baseline normative data on female and non-varsity SAMs makes interpretation of post-injury assessments challenging. Understanding how individuals perform at baseline, given their unique individual characteristics (e.g., concussion history, sex, competition level), will inform post-concussion assessment and management. Thus, the primary aim of this manuscript is to characterize the SAM population and determine normative values on a concussion baseline testing battery. All data were collected as part of the Concussion Assessment, Research and Education (CARE) Consortium. The baseline test battery included a post-concussion symptom checklist (Sport Concussion Assessment Tool (SCAT), psychological health screening inventory (Brief Symptom Inventory (BSI-18) and neurocognitive evaluation (ImPACT), Balance Error Scoring System (BESS), and Standardized Assessment of Concussion (SAC). Linear regression models were used to examine differences across sexes, competition levels, and varsity contact levels while controlling for academy, freshman status, race, and previous concussion. Zero inflated negative binomial models estimated symptom scores due to the high frequency of zero scores. Significant, but small, sex effects were observed on the ImPACT visual memory task. While, females performed worse than males (p < 0.0001, pη2 = 0.01), these differences were small and not larger than the effects of the covariates. A similar pattern was observed for competition level on the SAC. There was a small, but significant difference across competition level. SAMs participating in varsity athletics did significantly worse on the SAC compared to SAMs participating in club or intramural athletics (all p's < 0.001, η2 = 0.01). When examining symptom reporting, males were more than two times as likely to report zero symptoms on the SCAT or BSI-18. Intramural SAMs had the highest number of symptoms and severity compared to varsity SAMs (p < 0.0001, Cohen's d < 0.2). Contact level was not associated with SCAT or BSI-18 symptoms among varsity SAMs. Notably, the significant differences across competition level on SCAT and BSI-18 were sub-clinical and had small effect sizes. The current analyses provide the first baseline concussion battery normative data among SAMs. While statistically significant differences may be observed on baseline tests, the effect sizes for competition and contact levels are very small, indicating that differences are likely not clinically meaningful at baseline. Identifying baseline differences and significant covariates is important for future concussion-related analyses to inform concussion evaluations for all athlete levels.

Longitudinal Course and Predictors of Apathetic Symptoms after Severe Traumatic Brain Injury

Apathy is one of the most common behavioral symptoms encountered after traumatic brain injury (TBI). However, very little is known about the longitudinal course and predictors of apathetic manifestations. The aims of the present study were to examine how apathy changes and the predictive value of cognitive factors (memory, attention/executive mechanisms, and multitasking) and personal identity factors (self-esteem and self-efficacy beliefs) for apathy over a period of 10 months. To this end, 68 participants (32 patients with severe TBI matched with 36 control participants) living in the community were enrolled. At Time 1, participants were given three questionnaires to assess self-esteem, self-efficacy beliefs, anxiety and depression symptoms, and five tasks to assess cognitive processes. Simultaneously, a close relative of each participant completed a questionnaire that assessed lack of initiative/initiative. At Time 2, all questionnaires were re-administered to each patient and their relatives. Patients displayed a significant lack of initiative/interest at all post-injury assessments. At the individual level, the results revealed that a majority of patients had no change in their apathetic symptoms over the 10-month follow-up, whereas in the others, apathetic symptoms mostly increased. Furthermore, impaired memory was the only mechanism that significantly predicted later apathetic manifestations. Complementary profile analyses indicated that patients with worsening symptoms over the follow-up period showed higher inaccurate memory at Time 1 than patients with stable symptoms. These results provide valuable insight into the longitudinal evolution and predictors of apathy after TBI, which opens interesting prospects for psychological interventions.

Recovery progression and symptom resolution in sport-related mild traumatic brain injury

ABSTRACTObjective: To characterize the recovery progression of a group of athletes who participated in a concussion management program based on (1) group analysis and (2) individual analysis.Setting: Concussion management clinic.Participants: Thirty athletes (22 males, 8 females; baseline age = 16.23 ± 2.40 years) who had undergone four assessments: one baseline and three post-injury assessments at 3, 8, 15 days post-injury.Design: Retrospective clinical.Main Measures: Four neurocognitive scores of the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) including verbal memory, visual memory, speed of processing and reaction time and also a total symptom score.Results: Group-analysis showed a clear decline in verbal memory (F(3, 87) = 7.36, p < 0.000) and an increase in self-reported symptoms (χ2(3, N = 30) = 48.703, p < 0.000), 3 days post-injury. By day 8, athletes had returned to their baseline levels for verbal memory and were not experiencing symptoms. When athletes’ scores were examined individually, at 3 days post-injury, 60% of the athletes showed deficits on two or more of the ImPACT variables. This rate dropped to 23% at 8 days post-injury and remained the same (23%) 15 days post-injury.Conclusions: In concussion recovery, variability is the rule, rather than the exception, with regard to both impaired neurocognitive functions and recovery duration.

Change in KOOS and WOMAC Scores from Pre-injury Baseline in a Young Athletic Population with And without ACL Injury over FourYears of Follow-up

Objectives:Several studies have examined changes in patient reported outcome measures (PROMS) following ACL injury but no studies to date have prospectively evaluated changes from pre-injury baseline through injury and follow-up in ACL injured cases and uninjured controls. The purpose of this study was to examine changes in PROMS over time from pre-injury baseline to at least 2 years following ACL reconstruction and to compare this to changes in an uninjured control group with similar physical activity requirements.Methods:We conducted a prospective cohort study with a nested case-control analysis at a US service academy. All incoming freshmen were recruited to participate in this study. Within the first week of arrival all subjects completed a baseline questionnaire that contained information about demographics, injury history, and standardized PROMS including the KOOS, WOMAC, and Marx Activity Rating Scale (MARS). Subjects who subsequently sustained an ACL injury during their four years at the academy completed post injury assessments at the time of surgery and at 6-months, 12-months, and 24-months post-surgery. Controls with no history of knee joint injury at baseline, and no knee joint injury during the follow-up period, were recruited to repeat the baseline assessments within 1 year of graduation. Within group changes from pre-injury baseline to the final follow-up, and between group differences at these time points (baseline and final follow-up) were evaluated with dependent and independent t-tests, respectively. We also compared these results with established minimum clinically important difference (MCID) values.Results:Of the 1268 freshman entering the academy, 1177 consented to participate in this study. Males made up 82% of the cohort with an average age at enrollment of 19±1 years. Of those enrolled, 30 ACL injured cases with no history of injury at baseline met the inclusion criteria for this study. Ninety-two uninjured controls who also met the inclusion criteria completed follow-up assessments. There were no statistically significant pre-injury baseline differences between the ACL injured cases and uninjured controls on any of the PROMS except for the KOOS sports and recreation subscale, but this difference did not exceeded the MCID (Table 1). There were statistically significant differences across all KOOS and WOMAC subscales between ACL injured cases and uninjured controls at the time of the final follow-up assessment (Table 1). Four of the KOOS subscales (Pain, Symptoms, Sport, QOL) and the WOMAC stiffness subscale demonstrated greater than 8 point differences between groups, which exceeded the established MCID for these instruments (Figure 1A and 1B). There were no significant differences between ACL injured cases and uninjured controls on the MARS (p=0.635) at the time of the final follow-up. The ACL injured cases also reported significant deficits on the WOMAC stiffness (p=0.032) subscale, the MARS (p=0.030), and all KOOS subscales, with the exception of Function, at the time of final follow-up compared to their pre-injury baseline scores. These deficits exceeded the established MCID values for three of the KOOS subscales and the MARS.Conclusion:ACL injured cases reported significant deficits on PROMS at least 2 years following surgical reconstruction in relation to pre-injury baseline scores and uninjured controls. Many of these deficits exceeded established MCID values.Table 1:Between Group Differences at Pre-injury Baseline and Follow-up for ACL Injured Cases and Uninjured Controls. Pre-injury Baseline Follow-up ACL injured Cases Uninjured Controls ACL injured Cases Uninjured Controls Mean SD Mean SD p Mean SD Mean SD p KOOS Pain96.446.8097.255.070.41390.309.3498.864.45<0.001* Symptoms92.847.6194.347.240.25280.9314.8395.637.63<0.001* Function98.003.9698.642.720.27397.103.8499.522.79<0.001* Sports Function88.0019.8195.009.380.02977.8317.7597.457.72<0.001* QOL87.7412.7991.9111.340.06466.1722.2994.3414.47<0.001* WOMAC Pain97.116.0897.914.540.38495.506.8799.183.58<0.001 Stiffness90.3511.6890.8514.410.85683.1017.1693.8410.47<0.001* Function98.003.9698.662.680.25597.103.8499.522.79<0.001 MARS Activity12.533.7611.953.540.40610.304.7810.713.930.64*Between Group Difference Exceeds the Established Minimum Clinically Important Difference (MCID).

Correlates to concussion recovery in college athletes: prospective evaluation of pre-injury modifiers and post-injury clinical and neuropsychological assessments

Objectivevaluate relationships among pre-injury modifiers and post-injury assessments on sport-related concussion (SRC) recovery.DesignProspective-correlational.SettingSingle University.Participants208 SRCs; 173 athletes (males=132, females=41).Assessment of risk factorsBaseline modified sideline concussion assessment tool (m-SCAT):symptom checklist, Standardised Assessment of Concussion (SAC), modified-Balance Error Scoring System (m-BESS), Generalised Anxiety Disorder scale (GAD-7), Patient Health Questionnaire (PHQ-9), and history of concussion, learning disorder (LD), headaches/migraines, and depression/anxiety. m-SCAT and hybrid neuropsychological tests 48-hours post-injuryOutcome measuresDays to symptom free (DSF) and return to full play (DFP).Main resultsExpected concussion modifiers, (gender, prior concussion, LD, headaches/migraines, depression/anxiety, PHQ-9 or GAD-7) were NOT significantly associated with DSF or DFP (p &gt;.05). Although males (M=9.83, SD=12.22) became SF sooner (1.75 days) than females (M=11.58, SD=9.79), Mann-Whitney test indicated that differences for gender were not statistically significant, U=1249, p=0.11 and males (M=21.20,SD=20.75) and females (M=17.33, SD=14.86) didn’t differ significantly on DFP, U=613, p=0.25. ≤48-hours m-SCAT performance Athletes reporting more symptoms and higher symptom-severity score, took more DSF (rs=0.32, p&lt;0.01, rs=0.35, p&lt;0.01, respectively) and DFP (rs=0.19, p&lt;0.05, rs=0.20, p&lt;0.05, respectively). No statistically significant relationship between SAC or m-BESS and recovery existed. Four symptoms positively and significantly correlated with number of DSF and DFP: headache (SF:rs=0.27, p&lt;0.01; FP:rs=0.23, p&lt;0.05), neck-pain (SF:rs=0.36, p&lt;0.05; FP, rs=0.38, p&lt;0.05), feeling slowed down (SF:rs=0.21, p&lt;0.01; FP:rs=0.19, p&lt;0.05), and nervous/anxious (SF:rs=0.28, p&lt;0.01; FP:rs=0.21, p&lt;0.05). Athletes with slower RT on ImPACT took more DSF (rs=0.27, p&lt;0.01) and DFP (rs=0.25, p&lt;0.01). Athletes scoring lower/worse on ImPACT visual-motor speed composite had higher DSF (rs=-0.24, p&lt;0.01) and DFP (rs=-0.35, p&lt;0.01).ConclusionsWhile pre-injury “modifiers” aren’t correlated with clinical recovery, acute assessments after SRC may indicate prolonged recovery.Competing interestsNone.

Head impact exposure and time to recovery in youth american football players diagnosed with a concussion

ObjectiveTo compare head impact exposure (HIE) sustained by youth American football players on days of concussion with prior sessions, and to evaluate concussion resolution with objective assessments.DesignProspective,observational study.SettingYouth American football.ParticipantsYouth American football players (11-14 yr, n=57) who had head impact sensors embedded in their helmets; six were diagnosed with a concussion.InterventionsOver four consecutive seasons, baseline and post-injury concussion assessments were performed and HIE was monitored (Head Impact Telemetry system) for all practice/game sessions.Outcome measuresBaseline/Post-concussion assessments – symptoms, balance, reaction time, neurocognitive function (ImPACT), and oculomotor performance (King-Devick). HIE – location, frequency, and magnitude (linear acceleration [LA] and rotational acceleration [RA]).Main resultsFor concussive impacts, the average peak LA was 85.9g(39.7-156.8g) and average peak RA was 6918rad·sec-2(4508-8433rad·sec-2). On average, players sustained 21.3 impacts/session on days of concussion vs. 10.2 in previous sessions. Median LA and RA did not differ on days of concussion when compared to prior sessions (21.9 vs. 20.7g; 1480 vs. 1485 rad·sec-2). Average duration for a concussed player to have his assessment values return to baseline and be cleared for play was 32 days (17-53).ConclusionsConsiderable variation in magnitude existed between impacts that lead to concussion in this population. Players sustained more head impacts in sessions with a concussion compared to prior sessions. Frequency and magnitude of head impacts on the day of concussion did not correlate with time to recovery. Continued observation of a larger cohort is warranted.Competing interestsNone.

Impact of Diagnosed Sleep Disorder on Baseline Concussion Assessments in Collegiate Athletes

Research suggests at least 27% of college students are at risk for at least one sleep disorder. Adolescents with sleep-related symptoms and reduced sleep duration perform worse on baseline neurocognitive testing, although this effect size is small and samples have not included older or collegiate-level athletes. Previous research has not taken into consideration the effects of previously diagnosed sleep disorders on performance of preinjury baseline assessment. PURPOSE: The purpose of the current study was to compare athletes with and without a history of diagnosed sleep disorders on commonly used baseline concussion assessments. METHODS: All participants completed baseline testing including: the Balance Error Scoring System (BESS), Brief Symptom Inventory (BSI), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Post-Concussion Symptom Score (PCSS), Standardized Assessment of Concussion (SAC) and Vestibular/Ocular Motor Screening (VOMS). A total of 632 NCAA student-athletes participated in the study including 316 with previously diagnosed sleep disorders and 316 with no history of sleep disorder, matched for age, sex, sport, concussion history and race. Both groups were 19.87 years old (SD = 1.36), consisted of 176 males (55.7%), with 119 athletes (37.7%) previously having sustained a concussion, and represented a multitude of sports. RESULTS: A series of one-way ANOVAs with Bonferroni corrections revealed significant differences between groups on BESS (F(1, 535) = 4.02, p = .045), BSI somatization (F(1,623) = 11.41, p < .01), BSI depression (F(1, 623) = 13.59, p < .01), BSI anxiety (F(1, 623) = 20.97, p < .01), BSI global severity index (F(1, 623), p < .01) and PCSS (F(1, 396) = 22.86, p < .01). Specifically, the diagnosed sleep disorder group scored worse on the BESS and reported higher BSI and PCSS symptoms. No differences were noted between groups on VOMS, ImPACT neurocognitive measures, and SAC. CONCLUSION: Collegiate student-athletes with sleep disorders may have elevated affective and concussion symptoms at baseline that could affect interpretation of post-injury impairment and symptoms. Clinicians should assess diagnosed sleep disorders during pre-participation sport physicals and consider them when interpreting post-injury assessments.

Cognitive Deficits Post-Traumatic Brain Injury and Their Association with Injury Severity and Gray Matter Volumes.

Traumatic brain injury (TBI) is known to have a substantial though highly variable impact on cognitive abilities. Due to the wide range of cognitive abilities among healthy individuals, an objective assessment of TBI-related cognitive loss requires an accurate measurement of pre-morbid cognitive performance. To address this problem, we recruited 50 adults who sustained a TBI and had performed a cognitive baseline assessment in adolescence as part of the aptitude tests mandated by the Israeli Defense Forces. This group was matched with non-injured controls (n = 35). Pre- and post-injury cognitive assessments consisted of three domains-namely, verbal abstraction, mathematical reasoning, and non-verbal abstract reasoning (from the Wechsler Adult Intelligence Scale-Third Edition). The difference between post- and pre-injury scores was calculated as a measure of domain-specific cognitive decline. Voxel-based regression was used to correlate cognitive decline with modulated gray matter probability maps controlling for age, Glasgow Coma Scale, and total intracranial volume. Using objectively assessed cognitive scores, we found that abstract reasoning declined in both moderate-severe and mild TBI patients, whereas verbal abstraction declined only in the moderate-severe group. Mathematical reasoning was not affected by TBI. In the TBI patients, non-verbal abstract reasoning post-pre-injury change scores were negatively correlated with the volume of the insula. We conclude that access to pre-morbid neuropsychological data may have facilitated the discovery of the effects of mild TBI on abstract reasoning, as well as a significant correlation between TBI-related decline in this cognitive domain and the volume of the bilateral insula, both of which had not been appreciated in the past.

377 Four Year Post-injury Assessment of Functional Outcome Using GOSE at In-Patients With Moderate and Severe Trauma: Prospective Multicentre Cohort Study in Hong Kong

377 Four Year Post-injury Assessment of Functional Outcome Using GOSE at In-Patients With Moderate and Severe Trauma: Prospective Multicentre Cohort Study in Hong Kong

Changes in baseline concussion assessment scores following a school bus crash

ABSTRACTObjective: The objective of this article is to present concussion assessment data for 30 male athletes prior to and after being involved in a large school bus crash. The athletes on the bus, all male and aged 14–18 years, were participants in their school's concussion management program that included baseline and postinjury testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).Methods: This case study described changes in concussion assessment scores for 30 male athletes following a primarily frontal school bus crash. Data from the school's concussion management program, including baseline test data and postinjury assessment data, were reviewed. Athletes who required multiple postinjury assessments by the program were identified as having had significant cognitive changes as a result of the bus crash.Results: Twenty-nine of 30 athletes were injured. One had lumbar compression fractures; others had various lacerations, abrasions, contusions, sprains, and nasal fractures. ImPACT data (postcrash) were available for all 30 athletes and 28 had available precrash baseline data. A total of 16 athletes (53.3%) had significant cognitive changes indicated by changes in their concussion assessment scores, some of which took months to improve.Conclusion: This case study highlights a unique opportunity to evaluate concussion assessment data from 30 male athletes involved in a high-speed school bus crash. Further, these data provide additional insight into assessing the effectiveness of current school bus occupant protection systems.

Clinical Practices in Collegiate Concussion Management

Background: In recent years, sports leagues and sports medicine experts have developed guidelines for concussion management. The extent to which current clinical practice is consistent with guideline recommendations is unclear. At the collegiate level, there have been few examinations of concussion management practices and the extent to which meaningful differences across divisions of competition exist. Purpose: The purposes of this study were to (1) examine current practices in concussion diagnosis and management at National Collegiate Athletic Association (NCAA) member colleges, (2) explore the extent to which current practices reflect current recommendations for concussion diagnosis and management, and (3) determine whether there are differences in management patterns across divisions of competition. Design: Descriptive epidemiology study. Methods: An electronic questionnaire was sent to sports medicine clinicians at all NCAA member colleges during September and October 2013. Clinicians were asked about baseline assessments, diagnosis and management practices, return-to-play protocols, the perceived prevalence of underdiagnosis, and basic demographic information. Results: Approximately 30% (n = 866) of contacted clinicians, representing nearly 50% (n = 527) of NCAA member colleges, responded to the questionnaire. Preparticipation baseline examinations were administered at the majority of schools (95%), but most (87.5%) administered baseline assessments only to selected high-risk athletes. Computerized neurocognitive testing and balance assessments were most commonly used as preseason baseline and postinjury assessments. Multimodal examination in line with NCAA and other guidance was used only at a minority of institutions. Athletic trainers most commonly administered and interpreted the preseason baseline examination. Most clinicians reported that their institutions’ practices were in line with NCAA guidelines during the first 24 hours of an athlete’s concussion diagnosis, with exact percentages varying across measures. Differences across divisions of competition included shorter return-to-play time at Division I schools than Division III schools (9.13 vs 10.31 days, respectively) and more frequently referring concussed athletes to a physician within 24 hours of diagnosis at Division I schools. Conclusion: Concussion management at many colleges in the United States incorporates elements recommended by current guidelines; however, there is room to improve. Increasing the use of a multimodal baseline and postinjury examination will elevate the concussion care provided to college athletes and better align with best practice guidance.

Effects of quercetin on chronic constriction nerve injury in an experimental rat model.

Flavonoids are popular substances in the literature, with proven effects on cardiovascular, neoplastic and neurodegenerative diseases. Antioxidant effect is the most pronounced and studied one. Among thousands of flavonoids, quercetin (QUE) is a prototype with significant antioxidant effects. This study aims to demonstrate the effects of QUE in an experimental rat model of chronic constriction injury (CCI). A two-level study was designed with 42 adult Wistar rats that were randomly assigned to different groups. In the first part, animals in sham, control, quercetin, morphine and gabapentine groups received chronic constriction injury to their sciatic nerves and received a single dose of QUE, morphine and gabapentine. In the second part, different dose regimens of QUE were administered to different groups of animals. Pre-injury and post-injury assessments for mechanical hypersensitivity, thermal sensitivity, locomotor activity and anxiety were recorded and statistical comparisons were performed between different groups. Comparison of QUE with morphine and gabapentine has revealed significant effects of this agent in the current chronic constriction injury model. QUE was significantly superior to Gabapentine and morphine in terms of alleviating mechanical and thermal hypersensitivity. Additionally, pre-injury administration of QUE for 4 days demonstrated long-term effectiveness on mechanical hypersensitivity. This preliminary report the on effects of QUE in a chronic constriction injury model proved significant effects of the agent, which should be supplemented with different studies using different dose regimens.

Screening for Substance Use Disorders Following Traumatic Brain Injury

To examine the validity of the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST)--2 widely recommended rating scales--in a traumatic brain injury (TBI) population at 24 months following injury. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders was used as the gold standard criterion. TBI rehabilitation program at Epworth Hospital, Victoria, Australia. A total of 113 individuals, 87 males and 26 females, with complicated mild to severe TBI. Prospective study documenting substance use following TBI. AUDIT, DAST, and Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. In individuals with TBI, a cutoff score of 11 on the AUDIT may be the most appropriate indicator of an alcohol use disorder whereas a cutoff score of 6 on the DAST may be the most appropriate indicator of drug use disorder. Both screening measures demonstrated excellent diagnostic accuracy at 24 months following injury. The optimal cutoff score for the AUDIT may need to be elevated for use following TBI. Nevertheless, both the AUDIT and the DAST are suitable measures for assessing substance use following TBI. Given the importance of uniformity in postinjury assessment, the AUDIT and the DAST may serve as future screening standards in TBI research.

The Return-to-Play Incentive and the Effect of Motivation on Neuropsychological Test-Performance: Implications for Baseline Concussion Testing

Athletes may be less engaged in baseline cognitive testing in the absence of a powerful return-to-play incentive. The present study sought to evaluate whether athletes’ level of motivation (1) influences baseline test performance and (2) changes across pre- and post-injury assessments. We found a significant relationship between examiners’ ratings of athletes motivation toward testing and baseline cognitive test performance. Athletes, but not controls, demonstrated increased motivation between tests. These findings suggest that baseline test performance may underestimate true premorbid abilities for a subset of athletes.