Standardized Assessment Of Concussion Research Articles

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

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

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

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

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

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

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

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

Research Letter: Relationship of Blood Biomarkers of Inflammation With Acute Concussion Symptoms and Recovery in the CARE Consortium.

Determine the association of inflammatory biomarkers with clinical measures and recovery in participants with concussion. Multicenter study in National Collegiate Athletic Association member institutions including military service academies. Four hundred twenty-two participants with acute concussion. Clinical visits and blood draws were completed preinjury and at multiple visits postconcussion (0-12hours, 12-36hours, and 36-60hours postinjury). Clinical measures included Sport Concussion Assessment Tool (SCAT) symptom severity, Balance Error Scoring System, Standardized Assessment of Concussion (SAC), Brief Symptom Inventory-18 (BSI-18) scores, time to initiation of graduated return-to-play (RTP) protocol, and time to RTP. Interleukin (IL)-6, IL-10, IL-8, IL-1 receptor antagonist (RA), tumor necrosis factor (TNF), c-reactive protein, and vascular endothelial growth factor (VEGF) were measured in serum. Prespecified analyses focused on IL-6 and IL-1RA at 0 to 12hours; exploratory analyses were conducted with false discovery rate correction. For prespecified analyses, IL-1RA at 0 to 12hours in female participants was positively associated with more errors on the SAC (B(standard error, SE)=0.58(0.27), P <.05) and worse SCAT symptom severity (B(SE)=0.96(0.44), P <.05). For exploratory analyses, higher levels of IL-1RA at 12 to 36hours were associated with higher global (B(SE)=0.55(0.14), q<0.01), depression (B(SE)=0.45(0.10), q <0.005), and somatization scores on the BSI (B(SE)=0.46(0.12), q <0.01) in participants with concussion; Higher TNF at 12 to 36hours was associated with fewer errors on the SAC (B(SE)=-0.46(0.14), q <0.05). Subanalyses showed similar results for male participants and participants who were athletes. No associations were discovered in nonathlete cadets. Higher IL-8 at 0 to 12hours was associated with slower RTP in female participants (OR=14.47; 95% confidence interval, 2.96-70.66, q <0.05); no other associations with recovery were observed. Peripheral inflammatory markers are associated with clinical symptoms following concussion and potentially represent one mechanism for psychological symptoms observed postinjury. Current results do not provide strong support for a potential prognostic role for these markers.

The Effect of Exercise on a Novel Dual-Task Assessment for Sport Concussion.

To determine the effect of exercise on cognitive and motor performance and the subsequent test-retest reliability of a novel dual-task (DT) assessment in non-concussed college students. Sixty (53.3% female) non-concussed college students with an average age (+standard deviation) of 20.5 ± 1.34 years, height = 171.7 ± 9.33 cm, mass = 69.3 ± 12.23 kg). Participants were assigned to an exercise (n = 30) or rest (n = 30) intervention group and completed two study visits that were separated by a two-week test-retest interval. At each visit, participants completed a novel DT assessment that consisted of the concurrent administration of the Standardized Assessment of Concussion (SAC) and tandem gait (TG) prior to the exercise or rest intervention. Following the DT assessment at the first visit, participants in the exercise group performed moderate intensity exercise while the rest group sat quietly for 30 minutes. Following the intervention, both groups were readministered the DT assessment. At the second visit, the same procedures were followed except for each group was administered the opposite intervention (e.g., the exercise group completed the rest intervention). A composite TG (cTG) score was calculated by summing the average time to complete the TG pattern during each SAC domain (immediate memory, digits backwards, months in reverse order, delayed recall). A one-way analysis of covariance (ANCOVA) was conducted to assess post-intervention differences while controlling for pre-intervention performance. Test-retest reliability was assessed using intraclass correlation coefficients (ICC3,2) with 95% confidence intervals with all analyses performed with α = 0.05. SAC and cTG performance was similar (p's > 0.05) from pre- to post-intervention for the rest or exercise protocols. Good (rest:ICC = 0.77[0.62,0.87]; exercise: ICC = 0.84[0.73,0.90]) and excellent (rest: ICC = 0.97[0.94,0.98]; exercise: ICC = 0.93[0.88,0.96]) test-retest reliability were observed for the SAC composite score and cTG score, respectively. Our DT assessment was robust to the influence of moderate intensity exercise and demonstrated good-to-excellent test-retest reliability in a healthy collegiate sample.

Longitudinal Alterations of Cerebral Blood Flow in High-Contact Sports.

Repetitive head trauma is common in high-contact sports. Cerebral blood flow (CBF) can measure changes in brain perfusion that could indicate injury. Longitudinal studies with a control group are necessary to account for interindividual and developmental effects. We investigated whether exposure to head impacts causes longitudinal CBF changes. We prospectively studied 63 American football (high-contact cohort) and 34 volleyball (low-contact controls) male collegiate athletes, tracking CBF using 3D pseudocontinuous arterial spin labeling magnetic resonance imaging for up to 4 years. Regional relative CBF (rCBF, normalized to cerebellar CBF) was computed after co-registering to T1-weighted images. A linear mixed effects model assessed the relationship of rCBF to sport, time, and their interaction. Within football players, we modeled rCBF against position-based head impact risk and baseline Standardized Concussion Assessment Tool score. Additionally, we evaluated early (1-5 days) and delayed (3-6 months) post-concussion rCBF changes (in-study concussion). Supratentorial gray matter rCBF declined in football compared with volleyball (sport-time interaction p = 0.012), with a strong effect in the parietal lobe (p = 0.002). Football players with higher position-based impact-risk had lower occipital rCBF over time (interaction p = 0.005), whereas players with lower baseline Standardized Concussion Assessment Tool score (worse performance) had relatively decreased rCBF in the cingulate-insula over time (interaction effect p = 0.007). Both cohorts showed a left-right rCBF asymmetry that decreased over time. Football players with an in-study concussion showed an early increase in occipital lobe rCBF (p = 0.0166). These results suggest head impacts may result in an early increase in rCBF, but cumulatively a long-term decrease in rCBF. ANN NEUROL 2023.

Baseline concussion assessment performance by sex in military service academy rugby players: findings from the CARE Consortium

BackgroundNormative student-athlete concussion assessment data may not be appropriate for service academy members (SAMs), particularly rugby players, because of the uniqueness of their academic/military training environment. Having accurate baseline data...

Examining Whether Loss of Consciousness is Associated with Worse Performance on the SCAT5 and Slower Clinical Recovery Following Concussion in Professional Athletes.

Video surveillance has almost universally been employed by professional sports to identify signs of concussion during competition. This study examined associations between video-identified possible loss of consciousness (LOC), acute concussion evaluation findings, and recovery time in concussed professional rugby league players. Medical personnel and sideline video operators identified head impact events sustained during three seasons of National Rugby League (NRL) matches to determine the need for further medical evaluation. If a concussion was suspected, players were removed from play and underwent a Head Injury Assessment, including the Sports Concussion Assessment Tool, 5th Edition (SCAT5). Video footage was later examined to identify signs of possible LOC (i.e., observed LOC, no protective action in the fall, and unresponsiveness or lying motionless). Possible LOC was identified in 99 of the 1,706 head impact events (5.8%). The median duration of apparent unresponsiveness was 4.2 seconds (M=7.4, SD=12.8, IQR=2.5-6.6). In the 661 athletes for whom SCAT5 data were available, those with possible LOC endorsed more SCAT5 symptoms and performed worse on Maddocks questions, Standardized Assessment of Concussion (SAC) total scores, orientation, immediate recall, concentration, and delayed recall. For the 255 players with medically diagnosed concussions, SCAT5 data were available for 245. Concussed players with possible LOC performed significantly worse on Maddocks questions. However, there were no group differences in SCAT5 symptom endorsement, SAC total scores, orientation, immediate recall, concentration, delayed recall, or mBESS total errors. Furthermore, the presence or absence of possible LOC was not associated with number of games missed or time to medical clearance for match play. The duration of possible LOC was not associated with the number of games missed or time to medical clearance for match play. According to video review in NRL players, brief LOC might be more common than previously thought. The present study reveals possible LOC is not predictive of missed games or time to recover following concussion.

The Clinical Utility of the Child SCAT5 for Acute Concussion Assessment

BackgroundThe Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5 and 12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion.MethodsOur participants included 34 concussed (21 boys, 13 girls; age = 12.8 ± 0.86 years) and 44 non-concussed (31 boys, 13 girls; age = 12.4 ± 0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes (r=frac{Z}{sqrt{n}}) were calculated to assess the magnitude of difference for each comparison. The diagnostic properties (sensitivity, specificity, diagnostic accuracy, predictive values, likelihood ratios, and diagnostic odds ratio) of each Child SCAT5 score were also calculated.ResultsConcussed children endorsed more symptoms (p < 0.001, r=0.45), higher symptom severity (p < 0.001, r=0.44), and had higher double leg (p = 0.046, r=0.23), single leg (p = 0.035, r=0.24), and total scores (p = 0.022, r=0.26) for the mBESS than the non-concussed children. No significant differences were observed for the SAC-C scores (p’s ≥ 0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC = 0.76–0.77), negative predictive values (NPV = 0.84–0.88), and negative likelihood ratios (-LR = 0.22–0.31) of the Child SCAT5 scores.ConclusionsClinicians should prioritize interpretation of the symptom evaluation form of the Child SCAT5 as it was the most effective component for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion.

Relationship and Latent Factors Between Clinical Concussion Assessments and the Functional Standardized Assessment of Reaction Time (StART).

To examine the relationships and latent factors within the Standardized Assessment of Reaction Time (StART), and between StART and current clinical assessments. Cross-sectional study. Clinical medicine facility. Eighty-nine healthy collegiate student-athletes (63% male, age: 19.5 ± 0.9 years, 28% ≥1 concussion history). Student-athletes completed StART and clinical assessments during preinjury testing. Standardized Assessment of Reaction Time consisted of 3 conditions (standing, single-leg balance, cutting) under 2 cognitive states (single task and dual task) for 3 trials each condition. Clinical assessments were the Sport Concussion Assessment Tool (SCAT) symptom checklist, Standardized Assessment of Concussion (SAC), tandem gait (single task and dual task), and Immediate PostConcussion Assessment and Cognitive Testing (ImPACT). We used Pearson- r correlation coefficients and exploratory factor analysis (EFA) to examine relationships and latent factors between StART and clinical assessments. Null to moderate correlations presented among the StART outcomes (r range: 0.06-0.70), and null to small correlations between StART and clinical assessments (r range: -0.16 to 0.34). The three-factor EFA for solely StART explained 70.6% total variance: functional movement (cutting), static dual-task (standing and single-leg balance), and static single task (standing and single-leg balance). The five-factor EFA for StART and clinical assessments explained 65.8% total variance: gait (single-task and dual-task tandem gait), functional movement (StART single-task and dual-task cutting), static dual-task (StART standing, single-leg balance), neurocognitive (ImPACT verbal memory, visual memory, visual-motor speed), and static single task (StART standing, single-leg balance). No other outcomes met the factor loading threshold. StART displayed 3 distinct categories and had minimal redundancy within its subtests. StART did not meaningfully correlate with clinical assessments, suggesting that StART provides unique information by examining more functional, reactive movement.

SCAT5 Sex Differences: Normative Data, Clinical Thresholds, and Relevance for Identification of Concussion.

This study evaluated sex differences in performance on the Sport Concussion Assessment Tool-5 (SCAT5) Standardized Assessment of Concussion (SAC) and in baseline SCAT5 symptom reporting. It established clinically relevant cut points for low performance on the SAC based on both reliable chance indices (RCIs) and normative performance. This study also evaluated the diagnostic utility of the sex-adjusted SCAT5 SAC for identification of suspected concussion in collegiate athletes. In total, 671 uninjured collegiate athletes were administered the SCAT5 and 264 of these athletes also completed SCAT5 testing ~1year later. Fifty-four athletes were administered the SCAT5 after being removed from play due to suspected concussion. Sex differences in cognitive performance and symptom reporting at baseline were evaluated and sex-specific clinically relevant cut points were provided. Chi square and logistic regression models were used to evaluate if SAC performance was a significant predictor of concussion status. Female athletes outperformed male athletes on the SCAT 5 SAC and showed minimally higher symptom endorsement. Use of sex-corrected normative data improved performance of the SAC in identification of suspected concussion when a low score cut point was used. Logistic regression models showed that sex-corrected SAC change from baseline (RCI) improved the predictive value of the model after first accounting for other elements of the SCAT5. Present results support the use of sex-specific normative data for the SCAT5 SAC, particularly if using low performance without comparison to a baseline; however, reliable change from a pre-injury baseline may have somewhat higher diagnostic utility.

Prevalence of Heading in Middle School American Youth Club Soccer Players

Research Objectives To find out the frequency of heading event occurrence in the youth club soccer season. Design Observational study. Setting Community setting at the soccer match playground. Participants Player on an “Oceanside Breakers Competitive male soccer team” composed of 6th-grade middle school players and their opponents’ team. Interventions No interventions. Main Outcome Measures Number of heading occurrence in the participants and opposite team observer by the research team. Results The mean standardized assessment of concussion (SAC) score for the observed soccer team was 24.9±2.6 (out of 30). The number of heading occurrences in the consecutive 11 matches in both teams are 47, 34, 26, 23, 33, 29, 45, 31, 32, 40, 51. The average heading occurrence is 35.5 times/ match in a season. The observed team showed that the frequency of heading is more in the middle location 18.72±8.79 compared to the forward location (14.34±8.51) and the defense (10.34±7.1). However, there is no significant difference between the number of heading events at different locations of the play level (forward, middle, and defense) F2,10=1.097; p=.372. Conclusions Independent of the player's location, all players are susceptible to heading occurrence in the soccer game. With the high frequency of this occurrence, there is a need to address this problem at the level of the soccer federation and policymakers of the soccer game. The players, coaches, family members need to be educated to decrease the heading occurrence in the soccer game since the repetitive heading occurrence may have a negative influence on the developing brain. Author(s) Disclosures None of the authors have conflicts of interest. To find out the frequency of heading event occurrence in the youth club soccer season. Observational study. Community setting at the soccer match playground. Player on an “Oceanside Breakers Competitive male soccer team” composed of 6th-grade middle school players and their opponents’ team. No interventions. Number of heading occurrence in the participants and opposite team observer by the research team. The mean standardized assessment of concussion (SAC) score for the observed soccer team was 24.9±2.6 (out of 30). The number of heading occurrences in the consecutive 11 matches in both teams are 47, 34, 26, 23, 33, 29, 45, 31, 32, 40, 51. The average heading occurrence is 35.5 times/ match in a season. The observed team showed that the frequency of heading is more in the middle location 18.72±8.79 compared to the forward location (14.34±8.51) and the defense (10.34±7.1). However, there is no significant difference between the number of heading events at different locations of the play level (forward, middle, and defense) F2,10=1.097; p=.372. Independent of the player's location, all players are susceptible to heading occurrence in the soccer game. With the high frequency of this occurrence, there is a need to address this problem at the level of the soccer federation and policymakers of the soccer game. The players, coaches, family members need to be educated to decrease the heading occurrence in the soccer game since the repetitive heading occurrence may have a negative influence on the developing brain.

Utility of VOMS, SCAT3, and ImPACT Baseline Evaluations for Acute Concussion Identification in Collegiate Athletes: Findings From the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium

Background: The Vestibular/Ocular-Motor Screening (VOMS) is a valuable component of acute (<72 hours) sports-related concussion (SRC) assessments and is increasingly used with the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) instrument and the third edition of the Sport Concussion Assessment Tool (SCAT3). Research has suggested that VOMS acute postinjury scores are useful in identifying acute concussion. However, the utility of preseason baseline measurements to improve diagnostic accuracy remains ambiguous. To this end, there is a need to determine how reliable VOMS baseline assessments are across years and whether incorporating individuals’ baseline performance improves diagnostic yield for acute concussions. Purpose: To analyze VOMS, SCAT3, and ImPACT to evaluate the test-retest reliability of consecutive-year preseason baseline assessments to directly compare the diagnostic utility of these tools when incorporating baseline assessments versus using postinjury data alone to identify acute SRC. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Preseason and postinjury VOMS, SCAT3, ImPACT Post-Concussion Symptom Scale (PCSS), and ImPACT composite scores were analyzed for 3958 preseason (47.7% female) and 496 acute (≤48 hours) SRC (37.5% female) collegiate athlete evaluations in the National Collegiate Athletic Association—Department of Defense Concussion Assessment Research and Education Consortium. Descriptive statistics, Kolmogorov-Smirnov significance, and Cohen d effect size were calculated. Consecutive-year baseline reliability was evaluated for a subset of 447 athlete encounters using Pearson r, Cohen κ, Cohen d, and 2-way mixed intraclass correlation coefficients (ICCs). Wilcoxon signed rank tests were used to determine the statistical significance between population performances, and the 90% reliable change index (RCI) was calculated from the test-retest results. Preseason to postinjury change scores were then calculated from each tool’s RCI. Finally, receiver operating characteristic (ROC) curve analyses were conducted, and DeLong method was used to compare the area under the curve (AUC) of raw postinjury scores versus change scores from preseason baseline assessments. Potential effects of sex, medical history (learning disorders or attention-deficit/hyperactivity disorder), and outlier data were also explored. Results: Effect sizes were large, and overall predictive utilities were clinically useful for postinjury VOMS Total (d = 2.44; AUC = 0.85), the SCAT3 Symptom Evaluation total severity score (d = 1.74; AUC = 0.82), and the ImPACT PCSS total severity score (d = 1.67; AUC = 0.80). Comparatively, effect sizes were small and predictive utilities were poor for Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (mBESS), and all ImPACT composites (d = 0.11-0.46; AUC = 0.48-0.59). Preseason baseline test-retest reliability was poor to moderate (r = 0.23-0.52; κ = 0.32-0.36; ICC = 0.36-0.68) for all assessments except ImPACT Visual Motion Sensitivity (r = 0.73; ICC = 0.85). Incorporating baseline scores for VOMS Total, SCAT3 (Symptom Evaluation, SAC, mBESS), ImPACT PCSS, or ImPACT composites did not significantly improve AUCs. Conclusion: VOMS Total and symptom severity (SCAT3, PCSS) total scores had large effect sizes and clinically useful AUCs for identifying acute concussion. However, all tools demonstrated high within-patient test-retest variability, resulting in poor reliability. The findings in this sample of collegiate athletes suggest that incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion.

Effects of Pre-Collegiate Sport Specialization on Cognitive, Postural, and Psychological Functions: Findings from the NCAA-DoD CARE Consortium.

Background: Early sport specialization has been associated with an increased risk of musculoskeletal injuries and unfavorable psychological outcomes; however, it is unknown whether sport specialization is associated with worse cognitive, postural, and psychological functions in first-year collegiate student-athletes. Methods: First-year collegiate multisport (MA) and single-sport (SA) student-athletes were identified using a pre-collegiate sport experience questionnaire. The cognitive, postural, and psychological functions were assessed by the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and Brief Symptom Inventory 18 (BSI-18). Results: MA student-athletes performed higher in cognitive outcomes (e.g., higher ImPACT visual memory composite scores [ß = 0.056, p < 0.001]), but had higher psychological distress (e.g., higher BSI-18 global severity index [ß = 0.057, p < 0.001]) and no difference in postural stability (p > 0.05) than SA student-athletes. Conclusions: This study indicated first-year collegiate athletes with a history of sport specialization demonstrate lower cognitive performance but decreased psychological distress and no differences in static postural stability as compared to their MA counterparts. Future studies should consider involving different health measures to better understand the influence of sport specialization on overall physical and mental health.

The effect of an exertional field-test on sport concussion assessment tool 5 subcomponents in University rugby and wrestling athletes: A pilot prospective case series

ObjectivesTo evaluate how an exertional field-test impacts the Sport Concussion Assessment Tool 5 (SCAT5) subcomponents in uninjured athletes. DesignProspective case-series. SettingSports medicine setting. ParticipantsA total of 37 rugby and wrestling athletes (76% female) with a median age of 19 years (range: 18–23). Twenty-one (57%) had a history of concussion. Main outcome measuresThe SCAT5 was administered prior-to and following a volitionally fatiguing, field-based 30-15 Intermittent Fitness Test. The primary outcome measures included: total symptom scores and severity, standardized assessment of concussion, neurological screening, and balance errors during the modified balance error scoring system. Wilcoxon signed-rank tests examined differences in ordinal data between pre- and post-exertion with Bonferroni corrections (alpha = 0.006). Data were also stratified into time to SCAT5 administration post-exertion and compared via Cliff's Delta (d). ResultsThe SCAT5 was administered a median of 20-min (interquartile range: 14-26-min) following exertion. No differences were found pre- and post-exertion across all SCAT5 metrics (p > 0.048). Within the post-exertion 0-10-min stratification, total symptoms and severity scores appeared to be elevated with a large effect size (d ≥ 0.64). ConclusionsWhile SCAT5 metrics were not statistically altered when quantified a median of 20-min following high-intensity exertion; greater symptom reporting may occur 10-min following exertion.

Validation of a Multimodal EEG-Based Index to Aid in Diagnosing and Tracking Concussion Among Athletes

The goal of this study was to validate an EEG based multimodal index to aid in the assessment of concussion at time of injury, severity of concussion, and aid in evaluating readiness to return to play/activity. The absence of a gold standard for diagnosis of concussion results in reliance on subjective self-report of symptoms. EEG has been demonstrated to be sensitive to changes in brain function following head injury, especially in connectivity. Using machine learning with inputs primarily from EEG measures, and including multimodal inputs, an objective marker of the likelihood of concussion (Concussion Index, CI) was derived. Male and female concussed athletes and controls ages of 13-25 years, represented a convenience sample (n = 580), enrolled from US High School, Colleges, and Concussion Clinics. Concussed subjects had a witnessed head impact and were removed from play by site guidelines. Assessments were performed within 72 hours of injury, at clinically determined return to play (RTP), 45 days following RTP, and included EEG (frontal and frontotemporal regions), neurocognitive performance, and standard concussion assessments. Sensitivity = 85.99%, Specificity = 70.78%, NPV = 90.10% and PPV = 62.02, were obtained. Results demonstrated significance: (1) between CI at injury compared to RTP (p < 0.0001); (2) between CI in patients with rapid (<14 days) compared with those with prolonged recovery (=14 days), (p = 0.0038); (3) stability over time in controls (p < 0.0001); and (4) between CI and total symptom burden (correlation coefficient 0.8031, p < 0.0001). This study independently validated a multimodal, EEG-based, objective index of concussion (CI). The neurotechnology platform incorporating this capability is handheld, rapid to use, and lends itself to incorporation into the standard assessment of concussion to aid in clinical diagnosis and assessment of readiness to RTP. This data supported the FDA clearance for the Concussion Index (embedded in the BrainScope medical device).

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

BackgroundHurling is a fast-paced contact sport that places players at risk of concussion. Given the consequences of repeated concussive impacts, it is imperative that concussion management guidelines are followed.Hypothesis/Purpose.The aim of this study is to determine if potential concussive events (PCEs) in elite Hurling are assessed in accordance with league management guidelines. The secondary objective is to investigate the effectiveness of current concussion training programs.MethodsInvestigators used a video analysis approach to identify PCEs throughout the 2018 and 2019 inter-county Hurling seasons and championships. Subsequent assessment, return to play (RTP) decision, and signs of concussion were evaluated based on previously validated methods. The results were then compared year-over-year with previous research in Gaelic Football (GF).ResultsA total of 183 PCEs were identified over 82 matches. PCEs were frequently assessed (86.3%, n = 158) by medical personnel. The majority of assessments were less than 1 min in duration (81.0%, n = 128). Thirteen (7.1%) players were removed following a PCE. There were 43 (23.5%) PCEs that resulted in one or more signs of concussion, of which 10 (23.3%) were removed from play. There was no difference in rate of assessment, duration of assessment, or rate of RTP between 2018 and 2019 in both Hurling and GF, suggesting that current concussion training programs have had limited success.ConclusionIn Hurling, players suspected of having sustained a concussion are frequently subject to a brief assessment, and are rarely removed from play. Affirmative action is needed to ensure the consistent application of standardized concussion assessment across the Gaelic Games.

Neuroradiologic Evaluation of MRI in High-Contact Sports.

Background and Purpose: Athletes participating in high-contact sports experience repeated head trauma. Anatomical findings, such as a cavum septum pellucidum, prominent CSF spaces, and hippocampal volume reductions, have been observed in cases of mild traumatic brain injury. The extent to which these neuroanatomical findings are associated with high-contact sports is unknown. The purpose of this study was to determine whether there are subtle neuroanatomic differences between athletes participating in high-contact sports compared to low-contact athletic controls.Materials and Methods: We performed longitudinal structural brain MRI scans in 63 football (high-contact) and 34 volleyball (low-contact control) male collegiate athletes with up to 4 years of follow-up, evaluating a total of 315 MRI scans. Board-certified neuroradiologists performed semi-quantitative visual analysis of neuroanatomic findings, including: cavum septum pellucidum type and size, extent of perivascular spaces, prominence of CSF spaces, white matter hyperintensities, arterial spin labeling perfusion asymmetries, fractional anisotropy holes, and hippocampal size.Results: At baseline, cavum septum pellucidum length was greater in football compared to volleyball controls (p = 0.02). All other comparisons were statistically equivalent after multiple comparison correction. Within football at baseline, the following trends that did not survive multiple comparison correction were observed: more years of prior football exposure exhibited a trend toward more perivascular spaces (p = 0.03 uncorrected), and lower baseline Standardized Concussion Assessment Tool scores toward more perivascular spaces (p = 0.02 uncorrected) and a smaller right hippocampal size (p = 0.02 uncorrected).Conclusion: Head impacts in high-contact sport (football) athletes may be associated with increased cavum septum pellucidum length compared to low-contact sport (volleyball) athletic controls. Other investigated neuroradiology metrics were generally equivalent between sports.

One-year stability of preseason Sport Concussion Assessment Tool 5 (SCAT5) values in university level collision and combative sport athletes

ABSTRACT Objectives To determine the stability of the Sport Concussion Assessment Tool (SCAT) 5 between consecutive seasons in uninjured collision and combative varsity athletes. Methods Thirty-six athletes (19 females) were recruited to participate (wrestling [n = 12], rugby [n = 14], and hockey [n = 10]). The SCAT5 was administration at the start of the 2017 and 2018 seasons. Median baseline demographics for 2017 were as follows: age (19 years [range: 17–24 years]), height (174 cm [range: 149–195 cm]), and weight (76 kg [range: 57–118 kg]). Outcome metrics included subcomponents of the SCAT5: symptom reporting, standardized assessment of concussion (SAC), neurological screening, and balance performance measured with the modified balance error scoring system (mBESS). Wilcoxon signed-rank tests and Cronbach’s alpha (α) values were calculated to determine the stability between consecutive years for the SCAT5 variables in the same cohort of athletes. Bonferroni corrections were applied for Wilcoxon signed-rank tests, where alpha = 0.006 (0.05/9). Results Between the 2017 and 2018 seasons, no differences were noted in symptom reporting (p = 0.14), SAC (p = 0.32), neurological screening (p = 0.98), and balance performance on the mBESS (p = 0.01). The Cronbach’s alpha displayed unacceptable to questionable levels of within-subject stability (range: α = 0.34–0.70) for all subcomponents, except months in reverse order (α = 0.92). Conclusions While no statistical differences were present for all SCAT5 subcomponent metrics between 2017 and 2018 baselines, all but one displayed unacceptable to questionable stability (α ≤ 0.70) when retested one year later. Further research is needed to understand the appropriate time duration baseline SCAT5 values can reliably be utilized within longitudinal studies; as well as the normal variation of SCAT5 reporting/scoring.