Sport Concussion Assessment Tool Research Articles

Cerebral Blood Flow Alterations in Acute Sport-Related Concussion.

Sport-related concussion (SRC) is a major health problem, affecting millions of athletes each year. While the clinical effects of SRC (e.g., symptoms and functional impairments) typically resolve within several days, increasing evidence suggests persistent neurophysiological abnormalities beyond the point of clinical recovery after injury. This study aimed to evaluate cerebral blood flow (CBF) changes in acute SRC, as measured using advanced arterial spin labeling (ASL) magnetic resonance imaging (MRI). We compared CBF maps assessed in 18 concussed football players (age, 17.8 ± 1.5 years) obtained within 24 h and at 8 days after injury with a control group of 19 matched non-concussed football players. While the control group did not show any changes in CBF between the two time-points, concussed athletes demonstrated a significant decrease in CBF at 8 days relative to within 24 h. Scores on the clinical symptom (Sport Concussion Assessment Tool 3, SCAT3) and cognitive measures (Standardized Assessment of Concussion [SAC]) demonstrated significant impairment (vs. pre-season baseline levels) at 24 h (SCAT, p < 0.0001; SAC, p < 0.01) but returned to baseline levels at 8 days. Two additional computerized neurocognitive tests, the Automated Neuropsychological Assessment Metrics and Immediate Post-Concussion and Cognitive Testing, showed a similar pattern of changes. These data support the hypothesis that physiological changes persist beyond the point of clinical recovery after SRC. Our results also indicate that advanced ASL MRI methods might be useful for detecting and tracking the longitudinal course of underlying neurophysiological recovery from concussion.

The Concussion Toolbox: The Role of Vision in the Assessment of Concussion.

Concussion may lead to subtle changes in brain function, and tests involving the visual system probe higher cortical functioning and increase our sensitivity in detecting these changes. Concussions are acutely and sometimes more persistently associated with abnormalities in balance, cognition, and vision. The visual system involves roughly half of the brain's circuits, including many regions susceptible to head impacts. After a concussion, the neuro-ophthalmologic exam commonly detects abnormalities in convergence, accommodation, the vestibulo-ocular reflex, ocular muscle balance, saccades, and pursuit. The King-Devick (K-D) test is a visual performance measure that may increase the sensitivity of detecting concussions on the sideline when used in combination with tests of cognition and balance that are part of the Sports Concussion Assessment Tool (3rd ed.; SCAT3). Portable eye movement trackers and pupillometry may in the future improve our neuro-ophthalmic assessment after concussions. Combining visual tasks with neuroimaging and neurophysiology has allowed subtle changes to be detected, may refine our ability to make appropriate return-to-play decisions, and could potentially determine susceptibility to long-term sequelae of concussion.

Sport concussion assessment tool - 3rd edition - normative reference values for professional ice hockey players.

To determine normative reference values for the Sport Concussion Assessment Tool-3rd Edition (SCAT3) using a large sample of professional male ice hockey players. A descriptive cross-sectional study. Preseason baseline testing was administered individually to 304 professional male ice hockey players. The participants were aged between 16 and 40 with a mean (M) age of 25.3 years. Over 60% of the athletes reported previous concussion, almost 20% had been hospitalized or medically imaged following a head trauma. Of the players, 48% reported no symptoms. The symptom score median (Md) was 1.0 (M=1.5) and severity median was 1.0 (M=2.3). The median of the SAC score was 27.0 (M=27.0). The median of the M-BESS was 1.0 (M=2.0). The Tandem gait median was 10.9s (M=10.8s). The most common baseline symptom was neck pain (24%). Delayed recall was the most difficult component of the SAC (Md=4); only 24% performed it flawlessly. All athletes completed the double-leg stance of the M-BESS without errors, but there was performance variability in the tandem stance (Md=0, M=0.6, range=0-10) and single-leg stance (Md=1.0, M=1.4, range=0-10). Representative normative reference values for the SCAT3 among professional male ice hockey players are provided.

Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes.

Sports-related concussion commonly affects the visual pathways. Current sideline protocols test cognition and balance but do not include assessments of visual performance. We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels. Participants in this prospective study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Island University. Athletes underwent preseason baseline assessments using: 1) the King-Devick (K-D) test, a <2-minute visual performance measure of rapid number naming, 2) the Standardized Assessment of Concussion (SAC), a test of cognition, and 3) a timed tandem gait test of balance. The SAC and timed tandem gait are components of the currently used Sport Concussion Assessment Tool, 3rd Edition (SCAT3 and Child-SCAT3). In the event of a concussion during the athletic season, injured athletes were retested on the sideline/rink-side. Nonconcussed athletes were also assessed as control participants under the same testing conditions. Among 243 youth (mean age 11 ± 3 years, range 5-17) and 89 collegiate athletes (age 20 ± 1 years, range 18-23), baseline time scores for the K-D test were lower (better) with increasing participant age (P < 0.001, linear regression models). Among 12 athletes who sustained concussions during their athletic season, K-D scores worsened from baseline by an average of 5.2 seconds; improvement by 6.4 seconds was noted for the nonconcussed controls (n = 14). The vision-based K-D test showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury (receiver operating characteristic [ROC] curve areas from logistic regression models, accounting for age = 0.92 for K-D, 0.87 for timed tandem gait, and 0.68 for SAC; P = 0.0004 for comparison of ROC curve areas). Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment. This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision.

Sensitivity and specificity of an eye movement tracking-based biomarker for concussion.

Object:The purpose of the current study is to determine the sensitivity and specificity of an eye tracking method as a classifier for identifying concussion.Methods:Brain injured and control subjects prospectively underwent both eye tracking and Sport Concussion Assessment Tool 3. The results of eye tracking biomarker based classifier models were then validated against a dataset of individuals not used in building a model. The area under the curve (AUC) of receiver operating characteristics was examined.Results:An optimal classifier based on best subset had an AUC of 0.878, and a cross-validated AUC of 0.852 in CT- subjects and an AUC of 0.831 in a validation dataset. The optimal misclassification rate in an external dataset (n = 254) was 13%.Conclusion:If one defines concussion based on history, examination, radiographic and Sport Concussion Assessment Tool 3 criteria, it is possible to generate an eye tracking based biomarker that enables detection of concussion with reasonably high sensitivity and specificity.

The Child Sport Concussion Assessment Tool (Child SCAT3): normative values and correspondence between child and parent symptom scores in male child athletes

BackgroundChildren and youth are at increased risk of sustaining sport-related concussions. There is a need to develop age-specific tools to evaluate the effects of concussion. The objective of this study...

HeadCheck: A concussion app.

Increasing numbers of sports-related concussions have been reported in a number of countries.1, 2 Of several international guidelines to guide care after concussions,3-5 the Concussion in Sport Group consensus statement 20123 is the basis of many management recommendations and field side assessment tools propagated by sporting organisations in Australia and overseas. Some of the tools available to assist with recognising the symptoms of concussion have significant shortcomings: they are designed specifically for adults and elite sports professionals; they are paper based and do not necessarily provide a clear means of interpreting the information and guiding management; and are not always user friendly on the sidelines. Recent studies from Australia indicate that trainers and coaches have limited knowledge about concussion.6 Young athletes presenting to the emergency department did not follow head injury guidelines (e.g. were not taken off the field after a concussion, returned to play the same day), and parents and players were unaware of head injury guidelines from their sporting organisations.7 Based on reviews of the topic,8, 9 there was a need for an accessible, affordable, user-friendly, reliable and valid tool for use by those entrusted with the care of adult and child athletes at risk of concussive injuries. In a collaboration of child concussion experts at the Murdoch Childrens Research Institute (MCRI), the Royal Children's Hospital and the University of Melbourne, along with Curve Tomorrow, a software development and design company with expertise in the child health sector, a smartphone app, HeadCheck, was developed to help adults recognise the signs and symptoms of concussion in children. Although the primary focus of the app was for use in school-aged children and adolescents, the app is sufficiently robust for use in adult players as well. HeadCheck dynamically guides users through a series of concise questions to quickly assist in recognising symptoms of concussion ( Figure 1). The HeadCheck algorithm prioritises the information the user needs to understand, ensuring logical steps are followed in a potentially stressful situation. Depending on the severity of the individual's symptoms, the app may automatically re-direct the user to call the Australian emergency services phone number, ‘000’. Screen shot of HeadCheck concussion recognition app. The individual items examined in HeadCheck are consistent with the outcomes from deliberations at the 4th International Conference on Concussion in Sport,3 including the widely used and endorsed Sports Concussion Assessment Tool (SCAT-3), the ChildSCAT3 and the Pocket Concussion Recognition Tool (Pocket CRT). HeadCheck avoids medical jargon and uses plain and simple language. The smartphone format is more accessible and concise than the paper Pocket CRT currently used by coaches/parents to recognise concussive symptoms in children. HeadCheck is available as a free download from the Apple AppStore and is compatible with the iPhone (http://itunes.apple.com/au/app/headcheck/id887756402?mt=8). HeadCheck can easily be updated to incorporate future advances from concussion research and users can download updates to the app. User trials have been conducted for HeadCheck and researchers at MCRI (not involved in the project) also trialled the app while being observed by the software development and design team; their feedback was used to improve the functionality and usability of HeadCheck. HeadCheck has received endorsement from the Australian Football League; other national football codes have also shown interest in endorsing HeadCheck. An android version is being developed. Sideline validated, easy-to-use, interactive tools may improve concussion recognition and care. Ongoing collaboration between clinicians with expertise in concussion management and experts in technology, as well as feedback from the public, are instrumental in ensuring that such tools are of high quality and up to date.

Interdisciplinary Rehabilitation Referrals in a Concussion Clinic Cohort: An Exploratory Analysis

ObjectiveTo assess the frequency and spectrum of referrals to rehabilitation disciplines in a concussion clinic population and factors associated with need for referral. DesignRetrospective study. SettingConcussion clinic within the Physical Medicine and Rehabilitation Department of an academic medical center. ParticipantsPatients receiving physiatric management for concussion care. Main Outcome MeasuresReferral to physical therapy (PT), occupational therapy, speech therapy (ST), neuropsychology, or any referral (Any), and reasons for referral. InterventionsDemographic and clinical variables were analyzed for possible association with referral to rehabilitation disciplines. These independent variables included mechanism of injury, referral source, age, gender, provider, days since injury, presenting Sports Concussion Assessment Tool 2 (SCAT2) symptom score, insurance type, clinical risk factors, whether the injury was work related and whether the patient had been hospitalized. ResultsAmong 262 patients meeting inclusion criteria, the most commonly prescribed individual therapy was physical therapy (74 patients; 28%), followed by speech therapy (60 patients, 23%), neuropsychology (27 patients, 10.3%), and occupational therapy (19 patients, 7.2%). In all, 121 (46%) of patients were referred to one or more disciplines. The most common reasons for referral were cognitive strategies (54 patients, 21%), balance/vestibular therapy (50 patients,19%), and neck pain (32 patients, 12%). Per multivariate logistic regression analysis, covariates associated with PT: age, SCAT2 symptom score, gender, provider, and (inversely) cognitive/learning disorder; ST: time elapsed since injury, gender, and referral source of internal clinic; Any: SCAT2 symptom score. Referrals did not significantly vary by mechanism of injury (sports, fall, vehicular, etc), whether work-related, or whether the patient had been hospitalized. Insurance factors were significant for PT and Any on the univariate analysis but not logistic regression. ConclusionsRelatively little has been described about the typical rehabilitation requirements of individuals recovering from concussion. Although rest and guided return to usual activities have been emphasized as mainstays of management, a large number of patients in this concussion cohort were determined to require additional rehabilitation services to assist in recovery.

Baseline SCAT2 Assessment of Healthy Youth Student-Athletes: Preliminary Evidence for the Use of the Child-SCAT3 in Children Younger Than 13 Years.

To compare baseline scores of middle and high school students on the Sport Concussion Assessment Tool 2 (SCAT2) by sex and age. Cross-sectional study. Single private school athletic program. Three hundred sixty-one middle and high school student-athletes. Preseason SCAT2 was administered to student-athletes before athletic participation. Total SCAT2 score, symptoms, symptom severity, Glasgow coma scale, modified Balance Error Scoring System (BESS), coordination, and Standardized Assessment of Concussion (SAC) with subsections: Orientation, Immediate Memory, Concentration, and Delayed Recall. No differences were found in total SCAT2 scores between sex (P = 0.463) or age (P = 0.21). Differences were found in subcomponents of the SCAT2. Twelve year olds had significantly lower concentration scores (3.3 ± 1.2) than 15 and 18 year olds (3.9 ± 1.0 and 4.2 ± 1.0, respectively). The 12 year olds also had the lowest percentage of correct responses for the SAC's concentration 5-digit (46%), 6-digit (21%), and months' backward (67%) tasks. Females presented with more symptoms (20.0 ± 2.2 vs. 20.6 ± 2.1 P = 0.007) better immediate memory (14.6 ± 0.9 vs. 14.3 ± 1.0, P = 0.022) and better BESS scores (27.2 ± 2.3 vs. 26.6 ± 2.6, P = 0.043) than their male counterparts. Normative values for total SCAT2 and subscale scores show differences in concentration between ages, whereas symptoms, BESS, and immediate memory differed between sexes. We also found that 12 year olds have increased difficultly with the advanced concentration tasks, which lends support to the development of a separate instrument, such as the Child-SCAT3. The presence of developmental differences in the younger age groups suggests the need for annual baseline testing. Subtle differences between age and sex have been identified in many components of the SCAT2 assessment. These differences may support the current evolution of concussion assessment tools to provide the most appropriate test. Baseline testing should be used when available, and clinicians should be aware of potential differences when using normalized values.

Differences in Symptom Reporting Between Males and Females at Baseline and After a Sports-Related Concussion: A Systematic Review and Meta-Analysis.

Concussion literature and treatment guidelines are inconclusive regarding the role of sex in symptom reporting at baseline and post-concussion. Although empirical evidence is lacking, it is generally regarded that females have a more severe symptomatic presentation than males at all time-points on the concussion spectrum. Our objective was to determine whether differences exist between males and females at baseline (pre-season/before concussion) or post-concussion for self-reported (1) prevalence of individual symptoms and (2) total symptom scores in high school and college athletes. Systematic review and meta-analysis of observational cohort studies; level of evidence, 1. A computerized search of the PubMed, SPORTDiscus, CINAHL, and Scopus databases was performed. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines were followed. Criteria for inclusion were (1) self-report of symptoms at any time within the concussion spectrum, including baseline and after concussion, (2) study sample included high school and/or collegiate athletes aged 12-26 years, (3) concussions occurred during participation in sport, and (4) symptom reporting was separated by sex. The Quality Assessment Tool for Cohort Studies, Q-Coh, was utilized for quality assessment. Twenty-one studies met the criteria for inclusion: seventeen had good quality and four, acceptable quality. At baseline, females had significantly higher odds than males of reporting the individual symptoms of vision/hearing problems, headache/migraine, difficulty concentrating, energy/sleep disturbances, and emotional disturbances. Post-concussion, only one symptom demonstrated significant differences between males and females, with females demonstrating lower odds of reporting confusion than males. Statistically, at baseline and post-concussion, females had significantly higher total symptom scores on the Post-Concussion Scale (PCS) and the Sport Concussion Assessment Tool 2 (SCAT2), but when the standard mean difference was interpreted after back-transformation, these results were clinically insignificant. The symptomatic presentation of males and females, most notably the prevalence of specific symptoms, is very divergent. Females had higher total symptom scores at baseline and post-concussion, however, clinically this cannot be interpreted as a meaningful difference. It is possible that these differences can be explained by normal hormonal changes associated with the menstrual cycle. The implications of these findings are that symptomatic presentation during an individual female's menstrual cycle needs to be taken into consideration post-concussion when making return-to-play decisions, as returning to a completely asymptomatic level may not be a reasonable expectation.

Gender and age predict outcomes of cognitive, balance and vision testing in a multidisciplinary concussion center

ObjectiveThis study examined components of the Sports Concussion Assessment Tool, 3rd Edition (SCAT3) and a vision-based test of rapid number naming (King–Devick [K-D]) to evaluate sports and non-sports concussion patients in an outpatient, multidisciplinary concussion center. While the Symptom Evaluation, Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (BESS), and K-D are used typically for sideline assessment, their use in an outpatient clinical setting following concussion has not been widely investigated. MethodsK-D, BESS, SAC, and SCAT3 Symptom Evaluation scores were analyzed for 206 patients who received concussion care at the Concussion Center at NYU Langone Medical Center. Patient age, gender, referral data, mechanism of injury, time between concussive event and first concussion center appointment, and the first specialty service to evaluate each patient were also analyzed. ResultsIn this cohort, Symptom Evaluation scores showed a higher severity and a greater number of symptoms to be associated with older age (r=0.31, P=0.002), female gender (P=0.002, t-test), and longer time between the concussion event and first appointment at the concussion center (r=0.34, P=0.008). Performance measures of K-D and BESS also showed associations of worse scores with increasing patient age (r=0.32–0.54, P≤0.001), but were similar among males and females and across the spectrum of duration since the concussion event. Patients with greater Symptom Severity Scores also had the greatest numbers of referrals to specialty services in the concussion center (r=0.33, P=0.0008). Worse Immediate Memory scores on SAC testing correlated with slower K-D times, potentially implicating the dorsolateral prefrontal cortex as a commonly involved brain structure. ConclusionThis study demonstrates a novel use of sideline concussion assessment tools for evaluation in the outpatient setting, and implicates age and gender as predictors of outcomes for these tests.

Utilization of a text-messaging robot to assess intraday variation in concussion symptom severity scores.

To determine the amount of within-day variation of Concussion Symptom Severity Scores (CSSSs) in athletes with a clinically diagnosed concussion. This prospective cohort study used a text-messaging robot to survey concussed athletes using the CSSS 5-times daily while they remained symptomatic. Academic sports concussion clinic at a large tertiary care medical center. Fourteen 14- to 22-year-old athletes with clinically diagnosed concussions were enrolled. All were injured in sport, still in season, English speaking, and used a cellular telephone to text message on a regular basis. This study did not collect any demographic or other information about the subjects. The only data collected were the individual responses to the questions in the Post Concussion Symptom Score (PCSS). The only aim of this study was to evaluate the variability in responses to the CSSS, which is calculated from the PCSS. The primary outcome measure was a repeatability coefficient from a random-effects model. Concussion Symptom Severity Score, mean daily CSSS, and standard deviation of CSSS differences from the mean were also calculated. Mean follow-up was 23.9 days. A total of 24 180 text messages were received from subjects. Eight hundred four complete surveys were analyzed. Repeatability coefficient was ±23.1. When surveyed frequently by a text-messaging robot, concussed athletes report poorly repeatable Sport Concussion Assessment Tool 2 (SCAT2) Symptom Severity Scores. The SCAT2 Symptom Severity Score may be an invalid method of tracking concussion severity and resolution over time.

Detection of concussion using cranial accelerometry.

To determine whether skull motion produced by pulsatile cerebral blood flow, as measured by cranial accelerometry, is altered during concussion. In phase 1, to identify a specific pattern indicative of concussion, cranial accelerometry of subjects who sustained a concussion underwent analysis of waveforms, which was compared with accelerometry from subjects without a concussion (baseline). In phase 2, this concussion pattern was tested against prospectively acquired, blinded data. High school tackle football practice and game play. Eighty-four football players. Subjects had accelerometry measurements and concurrent 2-lead electrocardiograms. In players with a concussion, multiple sequential measurements were obtained. Sport Concussion Assessment Tool 2 was used to assist clinical determination of concussion. Whether a characteristic waveform pattern of cranial accelerometry occurs in subjects with concussion. Phase 1 demonstrated a consistent pattern correlated to concussion. Phase 2 found this pattern in 10 of 13 subjects with concussion (76.9% sensitivity). Seventy-nine of 82 baseline plus nine postseason (total = 91) recordings from nonconcussed subjects did not show the concussion pattern (87% specificity). In subjects with concussion, we observed a unique pattern determined by cranial accelerometry. This may provide a method to noninvasively detect and longitudinally observe concussion. There is no objective, real-time, noninvasive, and easily accessible measure for concussion. If accelerometry is validated, it could provide a critical diagnostic tool for sports medicine physicians.

Diagnostic tests for concussion: is vision part of the puzzle?

Concussion, particularly in relation to sports and combat activities, is increasingly recognized as a potential cause of both short- and long-term neurologic sequelae. This review will focus on the neuro-ophthalmologic findings associated with concussion, the current tests for concussion, and the potential for visual performance measures to improve our detection and assessment of concussions. A PubMed search using the specific key words "concussion," "mild traumatic brain injury," "neuro-ophthalmological findings," and "diagnostic and management tests" was performed. An emphasis was placed on articles published during the past 5 years, but additional articles referenced within recent publications were obtained. Concussion is frequently associated with abnormalities of saccades, pursuit eye movements, convergence, accommodation, and the vestibular-ocular reflex. Current sideline testing for athletes includes the Sports Concussion Assessment Tool, Third Edition (SCAT3) incorporates cognitive and balance testing. The King-Devick (K-D) test is a rapid visual performance measures that can be used on sidelines by nonmedical personnel, including parents of youth athletes. The K-D test complements components of the SCAT3 and improves the detection of concussions. Other vision-based tools for diagnosing and for managing concussion include eye movement tracking devices, pupillary assessment, computerized testing, imaging modalities, and eletrophysiologic testing. Many of the imaging modalities and electrophysiological studies have been combined with vision-based tests. Concusssion is associated with many neuro-ophthalmologic signs and symptoms. Visual performance measures enhance the detection and management of concussion, and future studies are under way to further incorporate vision-based testing into sideline diagnosis and long-term clinical assessments.

Eye tracking detects disconjugate eye movements associated with structural traumatic brain injury and concussion.

Disconjugate eye movements have been associated with traumatic brain injury since ancient times. Ocular motility dysfunction may be present in up to 90% of patients with concussion or blast injury. We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 sec and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen. We prospectively eye tracked 64 normal healthy noninjured control subjects and compared findings to 75 trauma subjects with either a positive head computed tomography (CT) scan (n=13), negative head CT (n=39), or nonhead injury (n=23) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion. Tracking metrics were then correlated to the clinical concussion measure Sport Concussion Assessment Tool 3 (SCAT3) in trauma patients. Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to noninjured control subjects. Only one of five vertical disconjugacy measures was significantly increased in brain-injured patients relative to controls. Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total Standardized Assessment of Concussion score. Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects observed in follow-up. Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury.

Oculomotor and Neurocognitive Assessment of Youth Ice Hockey Players: Baseline Associations and Observations After Concussion

Baseline scores on the King-Devick (K-D) Test, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Sport Concussion Assessment Tool 3 (SCAT3), and convergence were evaluated in youth hockey players. Worse K-D times were associated with worse ImPACT visual motor speed and reaction time. Eleven concussed athletes were retested, and there was a trend toward improved ImPACT and K-D times compared to baseline.

Influence of factors within the context of daily life on the reporting of post concussion-like symptoms in university students

Background: Concussions commonly occur in contact and collision sports. Following a concussion, serial assessments of symptoms are conducted to track recovery of a concussed athlete for 7–10 days and beyond to assist in making decisions on return-to-play. Several studies have reported the presence of baserates of postconcussion-like symptoms in normal (non-concussed) individuals. However, factors within the context of daily life that canpotentially influence the reportingof thesepostconcussion-like symptoms in a non-concussed cohort are yet to be explored. Thus, the purpose of this study was to explore the natural variation of postconcussion-like symptoms and also investigate factors within the context of daily life that influence the symptoms reported over a definitive period of time (7 days) in university students. Methods: University students aged 18–30 years were recruited to participate in this time series study. The symptoms experienced by participants on a daily basis were sampled by adopting an ecological momentary approach using the Sport Concussion Assessment Tool 2 (SCAT2) postconcussion symptom scale. Each participant was signaled randomly each day via text message to complete a mini online questionnaire which lasted for seven consecutive days. In this questionnaire, theywere asked to report their symptoms experienced at that moment they were texted along withother factors (predictors) suchas stress, anxiety and their location at a time of reporting etc. The effect of predictors on the total symptom score (TSS) was estimated using a mixed-effects model with the level of significance set at p<0.05. Results: 110 university students (26males and 84 females) consented to participate in this 7-day study. On average, each student had their TSS decrease (Estimate =−0.29) on each day across the 7-dayperiod.Out of the10predictors included in the stepwisemultivariate mixed-effects model, 3 predictors that include location at the time of reporting, physical fatigue (Estimate =−0.98) andmental fatigue (Estimate =−0.53) contributed to the prediction of TSS. Post-hoc analysis for the predictor of location at the time of reporting revealed that, students reported increased TSS at university or a cafe/restaurant compared to their flat/college of residence. Discussion: This daily variation and the influence of potential factors within the context of daily life on these symptoms in non-concussed individuals serve as a forewarning for clinicians to account for these factors while interpreting symptom scores associated with making decisions on return-to-play of a concussed athlete.

Multicenter cohort study on association of genotypes with prospective sports concussion: methods, lessons learned, and recommendations.

Approximately 3.8 million sports related TBIs occur per year. Genetic variation may affect both TBI risk and post-TBI clinical outcome. Limited research has focused on genetic risk for concussion among athletes. We describe the design, methods, and baseline characteristics of this prospective cohort study designed to investigate a potential association between genetic polymorphisms of apolipoprotein E gene, APOE promoter G-219T, and Tau gene exon 6 polymorphisms (Ser53 Pro and Hist47Tyr) with: 1) the risk of prospective concussion; 2) concussion severity; and 3) postconcussion neurocognitive recovery. The prospective cohort study included a final population of 2947 college, high school, and professional athletes. Baseline data collection included a concussion/medical history questionnaire, neuropsychological (NP) testing, and genetic sampling for the genetic polymorphisms. Data collection on new concussions experienced utilized post-concussion history/mental status form, Lovell post-concussion symptom score, Standardized Assessment of Concussion (SAC) and/or the Sports Concussion Assessment Tool (SCAT)-1/SCAT-2, and post-concussion NP testing. This paper is focused on discussing the important methodological considerations, organizational challenges and lessons learned in the completion of a multi-center prospective cohort study. A total of 3740 subjects enrolled, with a total of 335 concussions experienced. Of critical importance to the success of a study of this type is to successfully recruit committed institutions with qualified local study personnel, obtain "buy-in" from study sites, and cultivate strong working relationships with study sites. The use of approved incentives may improve study site recruitment, enhance retention, and enhance compliance with study protocols. Future publications will detail the specific findings of this study. Collaborative research is very likely needed given the nature of this study population.

A Normative Study of the Sport Concussion Assessment Tool (SCAT2) in Children and Adolescents

Recent clinical practice parameters encourage systematic use of concussion surveillance/management tools that evaluate participating athletes at baseline and after concussion. Office-based tools (Sports Concussion Assessment Tool; SCAT2) require accurate baseline assessment to maximize utility but no normative data exist for children on the SCAT2, limiting identification of “normal” or “impaired” score ranges. The purpose of this study was to develop child and adolescent baseline norms for the SCAT2 to provide reference values for different age groups. A community-based approach was implemented to compile baseline performance data on the SCAT2 in 761 children aged 9 to 18 to create age- and sex-graded norms. Findings indicate a significant age effect on SCAT2 performance such that older adolescents and teenagers produced higher (better) total scores than younger children (ages 9 to 11) driven by age differences on individual components measuring cognition (SAC), postural stability (BESS), and symptom report. Females endorsed greater numbers of symptoms at baseline than males. Normative data tables are presented. Findings support the SCAT2 as a useful clinical tool for assessing baseline functioning in teenagers, but suggest clinical utility may be limited in children under age 11. Follow-up studies after incident concussion are needed to confirm this assumption.

Assessment of mild traumatic brain injury with the King-Devick Test® in an emergency department sample

Objective: The King-Devick Test® (K-D) is a brief measure of cognitive processing speed and rapid gaze shifting that appears sensitive to the effects of sport-related concussion. This study evaluated its diagnostic and incremental validity in civilian patients with mild traumatic brain injury (MTBI).Methods: Participants with MTBI (n = 26) and controls with non-head injuries (n = 33) were prospectively recruited from an Emergency Department (ED). They underwent a clinical evaluation including the K-D test and the Sport Concussion Assessment Tool 2 (SCAT2). Magnetic resonance imaging (MRI) was conducted within 10 days post-injury.Results: The patients with MTBI differed from those without MTBI on components of the SCAT2, including the Symptom Scale (Cohen’s d = 1.02–1.15, p < 0.001) and Standardized Assessment of Concussion (d = 0.81, p = 0.004), but not the K-D test (d = 0.40, p = 0.148). In a logistic regression analysis, the K-D Test did not contribute over and above these two measures in predicting group membership (MTBI vs. control), p = 0.191. Low K-D Test scores in the MTBI group (<1 SD below controls) were not associated with poor SCAT2 performance, loss of consciousness or traumatic abnormalities on MRI, suggesting these cases may have been false positives.Conclusions: The present findings do not support the K-D Test for the assessment of civilian MTBI in an ED setting.