Undiagnosed Concussions Research Articles

Sport-Related Concussions: Symptom Recurrence After Return to Exercise.

Background:Current guidelines dictate a gradual exercise progression after a concussion; however, it is unclear what proportion of athletes experience a recurrence of symptoms once they are symptom free at rest. Estimating the proportion of athletes and predictors of symptom recurrence would help shape return-to-play protocols.Purpose:To determine the proportion and associated risk factors of athletes who have a recurrence of concussion symptoms with exercise after being symptom free at rest.Study Design:Case-control study; Level of evidence, 3.Methods:Between October 1, 2009 and July 31, 2011, we studied patients from a sport concussion clinic located within a tertiary care regional children’s hospital. Patients were queried at every visit using a standardized questionnaire. Our main outcome variable was recurrence of symptoms with exercise after being symptom free at rest at some point in their recovery. Cofactors included age, sex, loss of consciousness with injury, prior concussion (diagnosed and undiagnosed), Post-Concussion Symptom Scale (PCSS) score, time until clinical presentation, and duration of symptoms.Results:Of the 217 patients included, 25 (12%) experienced a return of symptoms. Losing consciousness at the time of injury and a longer duration between injury and clinical presentation were associated with a decreased risk of symptoms recurring with exercise. Conversely, athletes who had sustained previously undiagnosed concussions and had suffered a longer duration of symptoms at rest were at an increased risk of symptom recurrence with exercise.Conclusion:Relatively few athletes who are symptom free at rest after a concussion will have a recurrence of symptoms when they resume exercise. The risk of symptoms recurring with exercise may be greater among those athletes who sustained previously undiagnosed concussions and had a longer period of symptoms at rest. The early identification of athletes who may be at risk of symptom recurrence will help mold treatment guidelines and exercise progression protocols.

Knowing What We Don't Know: Long-Term Psychiatric Outcomes following Adult Concussion in Sports.

Amidst a growing concern regarding concussion in sports, there is an emerging link between sport concussion and mental health outcomes. This review summarizes the current literature addressing long-term psychiatric sequelae associated with sport concussion in adults. Several databases were searched using a broad list of keywords for each of concussion, sports, and mental health, with a resultant 311 studies for initial review. After limiting studies based on duplication, appropriateness of data, and relevance, 21 studies remained pertaining to depression, anxiety, substance use, and behavioural changes, including those highlighting chronic traumatic encephalopathy (CTE). Most studies identified suggested an increased prevalence of depressive symptoms related to concussion history. A conference abstract and qualitative study suggested increasing anxiety related to concussion history; however, a PhD dissertation found no relationship. In reviewing substance use, several studies mentioned use in athletes suspected of having concussion histories, although no link was established, while another noted undiagnosed concussion as leading to current substance misuse. Regarding behavioural changes, all studies identified occurrences of behaviour and/or cognitive changes in participants, with 2 studies suggesting a link with concussion history. With respect to CTE, concerns with mood, behaviour, cognition, and substance use were consistently highlighted, suggesting relations to previous sport concussion; however, the notion of different CTE subtypes and clear aetiology behind concussion severity or frequency was not consistently elucidated. There appears to be a growing body of evidence supporting the presence of long-term psychiatric and psychological sequelae following sport concussion in adults.

Quantitative Assessment Of Parental Knowledge And Attitudes Toward Pediatric Sports-related Concussions

PURPOSE: Sports-related concussions are a growing concern in youth sports. Parents of young athletes play a major role in both identifying concussive symptoms and managing at-home recovery, but they are often unaware of the consequences of concussions and recommended management techniques. This study assessed the knowledge and attitudes toward sports-related concussions among parents living in Los Angeles, California. We expected to identify significant gaps in parental knowledge and characterize parent populations most in need of concussion-related education. We predicted that knowledge and attitudes would be better among parents with increased educational attainment and prior sports- and concussion-related experience. METHODS: Participants included parents and caregivers of children brought to Children’s Hospital Los Angeles and its four satellite clinics for evaluation of musculoskeletal or mild traumatic brain injuries. Participants completed a validated questionnaire that measured knowledge of concussion symptoms as well as attitudes regarding medical diagnosis and post-concussion sports participation. The survey also assessed previous sports- and concussion-related experience. RESULTS: 214 parents and caregivers were surveyed over an 8-month period. Participants scored an average of 18.4 (maximum=25) on the Concussion Knowledge Index and 63.1 (maximum=75) on the Concussion Attitude Index. Attitudes were significantly safer among Caucasian females, and knowledge increased with household income and education level. Previous experience playing sports did not affect knowledge or attitudes, but parents who reported suffering from an undiagnosed concussion during childhood had significantly better concussion knowledge than those who did not. CONCLUSION: The present study is the first to comprehensively examine parent knowledge and attitudes toward concussions using a validated assessment tool. Results suggest that parents with low income and education levels may benefit from additional concussion-related education. Ongoing efforts to understand parental knowledge and attitudes will inform the development of a strategic and tailored approach to the prevention and treatment of pediatric concussions.

Assessment of parental knowledge and attitudes toward pediatric sports-related concussions.

Background:Parents of young athletes play a major role in the identification and management of sports-related concussions. However, they are often unaware of the consequences of concussions and recommended management techniques.Hypothesis:This study quantitatively assessed parental understanding of concussions to identify specific populations in need of additional education. We predicted that parents with increased education and prior sports- and concussion-related experience would have more knowledge and safer attitudes toward concussions.Study Design:Cross-sectional survey.Level of Evidence:Level 5.Methods:Participants were parents of children brought to a pediatric hospital and 4 satellite clinics for evaluation of orthopaedic injuries. Participants completed a validated questionnaire that assessed knowledge of concussion symptoms, attitudes regarding diagnosis and return-to-play guidelines, and previous sports- and concussion-related experience.Results:Over 8 months, 214 parents completed surveys. Participants scored an average of 18.4 (possible, 0-25) on the Concussion Knowledge Index and 63.1 (possible, 15-75) on the Concussion Attitude Index. Attitudes were safest among white women, and knowledge increased with income and education levels. Previous sports experience did not affect knowledge or attitudes, but parents who reported experiencing an undiagnosed concussion had significantly better concussion knowledge than those who did not.Conclusion:Parents with low income and education levels may benefit from additional concussion-related education.Clinical Relevance:There exist many opportunities for improvement in parental knowledge and attitudes about pediatric sports-related concussions. Ongoing efforts to understand parental knowledge of concussions will inform the development of a strategic and tailored approach to the prevention and management of pediatric concussions.

Exploring the Culture of Concussion Safety in Major League Lacrosse: A Cross- Sectional Survey

Exploring the Culture of Concussion Safety in Major League Lacrosse: A Cross- Sectional Survey Objective: Lacrosse is one of the fastest growing sports in the United States, and concussion is among the most common athletic injuries. The purpose of this study was to explore concussion knowledge and culture of concussion safety among Major League Lacrosse (MLL) players, and to understand their concussion reporting behavior. Methods: Sixty-three male athletes, mean age 27 ± 3.45 years, participated. Subjects were all members of an MLL team during the 2014 season. Surveys regarding attitude toward concussion and perceived concussion norms were sent to these subjects. Subjects were excluded if they were not an MLL athlete or if they did not provide their informed consent to participate. Results: 39.7% of the participants reported at least one diagnosed concussion in their lifetime, while 55.6% reported at least one suspected but undiagnosed, concussion. Players felt that there was no significant difference between the likelihood of their current teammates or other male lacrosse players at various levels to report concussion symptoms. Participants felt that most National Football League players were less likely to report concussion symptoms, but female lacrosse players (at various levels) would report more. 83.33% of participants agreed that they should often or always set a good example about concussion safety for younger players. Finally, professional lacrosse players were willing to sustain an average of 3.02 and 4.58 concussions to earn $100,000 and $1,000,000, respectively. Conclusion: The culture of concussion safety and the symptom reporting behavior of MLL players may be influenced by the belief that professional players should act as role models for younger players. However, reports of multiple undiagnosed concussions and willingness to sustain multiple concussions for money may suggest that players lack complete understanding of concussion symptoms and consequences.

Frequency of head-impact-related outcomes by position in NCAA division I collegiate football players.

Concussions and subconcussive impacts sustained in American football have been associated with short- and long-term neurological impairment, but differences in head impact outcomes across playing positions are not well understood. The American Medical Society for Sports Medicine has identified playing position as a key risk factor for concussion in football and one for which additional research is needed. This study examined variation in head impact outcomes across primary football playing positions in a group of 730 National Collegiate Athletic Association Division I Football Championship Series athletes, using a self-report questionnaire. Although there were no significant differences between position groups in the number of diagnosed concussions during the 2012 football season, there were significant differences between groups in undiagnosed concussions (p=0.008) and "dings" (p<0.001); offensive linemen reported significantly higher numbers than most other positions. Significant differences were found between position groups in the frequencies of several postimpact symptoms, including dizziness (p<0.001), headache (p<0.001), and seeing stars (p<0.001) during the 2012 football season, with offensive linemen reporting significantly more symptoms compared to most other groups. There were also positional differences in frequency of returning to play while symptomatic (p<0.001) and frequency of participating in full-contact practice (p<0.001). Offensive linemen reported having returned to play while experiencing symptoms more frequently and participating in more full-contact practices than other groups. These findings suggest that offensive linemen, a position group that experiences frequent, but low-magnitude, head impacts, develop more postimpact symptoms than other playing positions, but do not report these symptoms as a concussion.

The Prevalence of Undiagnosed Concussions in Athletes

Previous studies suggest athletes underreport concussions. We sought to determine whether athletes in our clinics have sustained previous concussions that went undiagnosed. Multicentered cross sectional study. Two sport concussion clinics. Patients diagnosed with sport-related concussions or concussions with injury mechanisms and forces similar to those observed in sports were included. The proportion of patients who answered "yes" to the following question were defined as having a previously undiagnosed concussion: "Have you ever sustained a blow to the head which was NOT diagnosed as a concussion but was followed by one or more of the signs and symptoms listed in the Post Concussion Symptom Scale?" Of the 486 patients included in the final analysis, 148 (30.5%) patients reported a previously undiagnosed concussion. Athletes reporting previously undiagnosed concussions had a higher mean Post Concussion Symptom Scale (PCSS) score (33 vs 25; P < 0.004) and were more likely to have lost consciousness (31% vs 22%; P = 0.038) with their current injury than athletes without previously undiagnosed concussions. Nearly one-third of athletes have sustained previously undiagnosed concussions, defined as a blow to the head followed by the signs and symptoms included in the PCSS. Furthermore, these previously undiagnosed concussions are associated with higher PCSS scores and higher loss of consciousness rates when future concussions occur. Many athletes have sustained previous blows to the head that result in the signs and symptoms of concussion but have not been diagnosed with a concussion. These injuries are associated with increased rates of loss of consciousness and higher symptom scale scores with future concussions.

Shake, Rattle, and Roll: The Impact of Undiagnosed Concussions in Pediatrics

Shake, Rattle, and Roll: The Impact of Undiagnosed Concussions in Pediatrics

Injury, pain, and prescription opioid use among former National Football League (NFL) players

BackgroundAthletes with injury-related pain, especially National Football League (NFL) players, are at increased risk for opioid use and misuse which may result in medical, psychiatric and social problems. This is the first study to evaluate the intersection of sports pain and opioid use and misuse among former NFL players. MethodsA telephone survey of 644 retired NFL players from the 2009 Retired Players Association Directory was conducted (53.4% completion rate) from March to August 2010. ResultsOver half (52%) used opioids during their NFL career with 71% reporting misuse. Additionally, 15% of NFL misusers currently misused vs. 5% among players who used just as prescribed during their NFL career. Prevalence of current opioid use was 7%—3 times the rate of the general population. Multivariate analyses indicated that significant NFL pain increased the adjusted odds (AOR) of any current opioid use vs. non-use (AOR 6.76, 95%CI 2.88–15.87), as did moderate to severe mental impairment (AOR 1.88, 95%CI 1.19–2.98) and heavy drinking in the past week (AOR 2.15, 95%CI 1.17–3.98). Undiagnosed concussions singly predicted current misuse vs. use just as prescribed (AOR 4.25, 95%CI 1.12–16.22). Three variables predicted current misuse vs. non-use: significant pain (AOR 8.33, 95%CI 1.98–35.04), undiagnosed concussions (AOR 3.51, 95%CI 1.98–35.04) and heavy drinking (AOR 3.48, 95%CI 1.63–7.41). ConclusionsPlayers who misused during their NFL career were most likely to misuse currently compared to others. Current misuse was associated with more NFL pain, undiagnosed concussions and heavy drinking. Longitudinal studies are needed to determine the long term effects of opioid misuse among athletes.

Poster 60: Challenges in the Diagnosis of Concussion in the Emergency Department

Objective: To determine the frequency of undiagnosed concussion in the emergency department (ED) in persons meeting the U.S. Centers for Disease Control and Prevention (CDC) operational definition of concussion. Design: Retrospective review of medical records of patients identified in the ED by study personnel as meeting CDC concussion criteria. Charts were reviewed for clinical diagnosis of concussion and key terms used in concussion epidemiologic studies. Setting: Urban academic level I trauma center ED.