Concussions are common sport injuries, and are particularly common among children and adolescents involved in organized sports and recreational activities. Symptoms of concussion can be subtle, and may be overlooked by athletes, coaches/trainers and parents. If a child or youth sustains a concussion, they should immediately be removed from play and assessed by a physician as soon as possible. The athlete should rest from physical and cognitive activities to allow for recovery from concussion. Once symptoms have completely resolved at rest, the athlete can progress through a medically supervised stepwise exertion protocol before being medically cleared to return to play. It is imperative that everyone involved in child and youth sports be aware of the signs and symptoms of concussion so that an accurate and timely diagnosis can be made, and proper evaluation and management instituted. The present position statement replaces the previous document published in 2006.
Adolescents; Children; Concussion; Return to play; Sport; Youth
To present a new approach in the evaluation and management of concussion from the athletic trainer's perspective.
The evaluation and management of concussion continues to be a controversial topic among sports medicine professionals. Inconsistent management, lack of objective data, and confusion concerning assessment techniques may lead to inappropriate decisions regarding when to return an athlete to competition after concussion. In this article, we provide recommendations and considerations for the certified athletic trainer in the management of concussion. We also present a quantifiable assessment technique that provides more information on which return-to-play decisions can be made; this technique can be used during the initial sideline examination as well as during subsequent follow-up examinations.
Certified athletic trainers and team physicians should consistently use appropriate grading scales. Assessment of concussion should include a symptom checklist, the Balance Error Scoring System, and the Standardized Assessment of Concussion, and the results should be compared with the athlete's normal baseline scores. Follow-up neuropsychological and postural stability testing is recommended. Return-to-play decisions should be based on the grade of concussion, scores on objective tests, and presence of concussive symptoms during exertional activities.
mild head injury; neuropsychological testing; postural stability testing; grading scales
Sports concussions are an increasingly recognized common type of mild traumatic brain injury (TBI) that affect athletes of all ages. The need for an increased involvement of trained physicians in the diagnosis and treatment of concussion has become more obvious as the pathophysiology and long-term sequelae of sports concussion are better understood. To date, there has been great variability in the athletic community about the recognition of symptoms, diagnosis, management, and physician role in concussion care. An awareness assessment survey administered to 96 high school coaches in a large metropolitan city demonstrated that 37.5% of responders refer their concussed players to an emergency department after the incident, only 39.5% of responders have a physician available to evaluate their players after a concussion, 71.6% of those who had a physician available sent their players to a sports medicine physician, and none of the responders had their player’s concussion evaluated by a neurologist. Interestingly, 71.8% of responders stated that their players returned to the team with “return to play” guidelines from their physician. This survey has highlighted two important areas where the medical community can better serve the athletic community. Because a concussion is a sport-inflicted injury to the nervous system, it is optimally evaluated and managed by a clinician with relevant training in both clinical neuroscience and sports medicine. Furthermore, all physicians who see patients suffering concussion should be educated in the current recommendations from the Consensus Statement on Concussion and provide return to play instructions that outline a graduated return to play, allowing the athlete to return to the field safely.
sports; concussion; athlete; neurology
Athletes are at an inherent risk for sustaining concussions. Research examining the long-term consequences of sport-related concussion has been inconsistent in demonstrating lingering neurocognitive decrements that may be associated with a previous history of concussion.
To determine the relationship between concussion history and postconcussion neurocognitive performance and symptoms in collegiate athletes.
Multi-center analysis of collegiate athletes.
Patients or Other Participants:
Fifty-seven concussed collegiate athletes (36 without concussion history, 21 with a history of 2 or more concussions).
All subjects were administered an Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) neurocognitive test battery, which measures verbal memory, visual memory, reaction time, and visual processing speed and 22 concussion symptoms.
Main Outcome Measure(s):
Subjects who sustained a concussion were administered 2 follow-up tests at days 1 and 5 postinjury. Independent variables were history of concussion (no history of concussion, 2 or more concussions) and time (baseline, day 1 postconcussion, or day 5 postconcussion).
A within-subjects effect (time) on ImPACT performance (P < .001), a between-subjects multivariate effect of group (P < .001), and a group-by-time interaction (P = .034) were noted. Athletes with a concussion history performed significantly worse on verbal memory (P = .01) and reaction time (P = .023) at day 5 postconcussion compared with athletes who did not report a previous concussion. No significant group differences were seen at day 5 postinjury on visual memory (P = .167), processing speed (P = .179), or total concussion symptoms (P = .87).
Concussed collegiate athletes with a history of 2 or more concussions took longer to recover verbal memory and reaction time than athletes without a history of concussion.
mild traumatic brain injury; ImPACT; memory; reaction time
The purpose of this study was to evaluate ACTive: Athletic Concussion Training using Interactive Video Education, an interactive e-learning program designed to train community coaches of youth ages 10–18 in effective sports concussion prevention and management practices. Seventy-five youth sports coaches from across the country completed the study over the Internet. Results of a randomized control trial demonstrated significant differences between treatment and control participants on measures of (a) knowledge about sports concussion, management, and prevention; (b) attitudes about the importance of preventing sports concussion; and (c) intention and self-efficacy in sports concussion management and prevention. The results suggest that ACTive is an effective method of training youth sports coaches who are in an important position to reduce risks associated with sports concussion.
coaching; children; sports concussion; injury prevention
Context: Athletic trainers surveyed in 1999 demonstrated little consensus on the use of concussion grading scales and return-to-play criteria. Most relied on clinical examination or symptom checklists to evaluate athletes with concussion.
Objective: To investigate the current trends of certified athletic trainers in concussion assessment and management.
Design: Subjects were invited to participate in a 32-question Internet survey.
Setting: An Internet link to the survey was e-mailed to the subjects.
Patients or Other Participants: A total of 2750 certified athletic trainers and members of the National Athletic Trainers' Association were randomly e-mailed and invited to participate.
Main Outcome Measure(s): Survey questions addressed topics including years of certification, number of concussions evaluated each year, methods of assessing concussion, and guidelines used for return to play. Compliance with the recent position statement of the National Athletic Trainers' Association on sport-related concussion was also evaluated.
Results: Certified athletic trainers averaged 9.9 ± 7.3 years of certification and evaluated an average of 8.2 ± 6.5 concussions per year. To assess concussion, 95% reported using the clinical examination, 85% used symptom checklists, 48% used the Standardized Assessment of Concussion, 18% used neuropsychological testing, and 16% used the Balance Error Scoring System. The most frequently used concussion grading scale and return-to-play guideline belonged to the American Academy of Neurology (30%). When deciding whether to return an athlete to play, certified athletic trainers most often used the clinical examination (95%), return-to-play guidelines (88%), symptom checklists (80%), and player self-report (62%). The most important tools for making a return-to-play decision were the clinical examination (59%), symptom checklists (13%), and return-to-play guidelines (12%). Only 3% of certified athletic trainers surveyed complied with the recent position statement, which advocated using symptom checklists, neuropsychological testing, and balance testing for managing sport-related concussion.
Conclusions: Our findings suggest that only a small percentage of certified athletic trainers currently follow the guidelines proposed by the National Athletic Trainers' Association. Various assessment methods and tools are currently being used, but clinicians must continue to implement a combination of methods and tools in order to comply with the position statement.
mild traumatic brain injury; mild brain injury; evaluation
The objective of this study was to assess the ability of hockey parents/guardians to recognize concussion symptoms in their 13–14 year old (Bantam-aged) children.
The outcome measures were the ability to recognize different signs and symptoms listed on the Sport Concussion Assessment Tool (SCAT) as well as 8 detractors consisting of signs and symptoms not associated with post concussive syndrome. Additional questions assessing the parents’ knowledge of concussion management and recognition abilities were also posed.
Parents of Bantam-aged minor hockey league athletes volunteered for the study.
The study investigators distributed questionnaires during the warm up period or following their children’s games to the study participants. Following questionnaire completion, participants were provided with an information package outlining the correct signs and symptoms of concussion.
The mean number of correct responses to signs and symptoms of concussion was 21.25/25 for the mothers and 20.41/25 for the fathers. The mean number of detractors identified as not associated with concussion was 5.93/8 for the mothers and 4.85/8 for the fathers, indicating that mothers were more capable of recognizing the signs and symptoms than fathers. An analysis of variance including sporting experience in the model did not strengthen the relationship between parent gender and test outcome.
This investigation revealed that there is still a disconnect in regards to key components of recognizing a concussion, such as difficulty with sleep, disorientation symptoms, and emotional irritability. Mothers have displayed an ability to better differentiate between true and false signs and symptoms of concussion as compared to fathers. Continued education and awareness of mild traumatic brain injury in athletes should address the misconceptions amongst parents in regards to the true signs and symptoms of a concussion.
hockey; bantam; concussion; chiropractic
To identify methods used by athletic trainers to assess concussions and the use of that information to assist in return-to-play decisions and to determine athletic trainers' familiarity with new standardized methods of concussion assessment.
Design and Setting:
A 21-item questionnaire was distributed to attendees of a minicourse at the 1999 National Athletic Trainers' Association Annual Meeting and Clinical Symposia entitled “Use of Standardized Assessment of Concussion (SAC) in the Immediate Sideline Evaluation of Injured Athletes.”
A total of 339 valid surveys were returned by the attendees of the minicourse.
We used frequency analysis and descriptive statistics.
Clinical examination (33%) and a symptom checklist (15.3%) were the most common evaluative tools used to assess concussions. The Colorado Guidelines (28%) were used more than other concussion management guidelines. Athletic trainers (34%) and team physicians (40%) were primarily responsible for making decisions regarding return to play. A large number of respondents (83.5%) believed that the use of a standardized method of concussion assessment provided more information than routine clinical and physical examination alone.
Athletic trainers are using a variety of clinical tools to evaluate concussions in athletes. Clinical evaluation and collaboration with physicians still appear to be the primary methods used for return-to-play decisions. However, athletic trainers are beginning to use standardized methods of concussion to evaluate these injuries and to assist them in assessing the severity of injury and deciding when it is safe to return to play.
mild brain injury; grading scales; head injury; evaluation
This article provides a framework for school athletic trainers to use in advising colleagues about the health and academic needs of student-athletes presenting with concussions.
Management of sport-related concussions has been an area of growing concern for school athletic programs. Recent work in this area has highlighted significant risks for student-athletes presenting with these mild traumatic brain injuries.
Topics covered include general teaching points for the athletic trainer to use with school colleagues. An integrated model for school management of sport concussion injuries is presented that includes involvement of the student's athletic trainer, school nurse, guidance counselor, teachers, social worker, psychologist, physicians, and parents.
Academic accommodations for specific postconcussion symptoms are proposed that may help the student-athlete strike an optimum balance between rest and continued academic progress during recovery.
athletic injuries; mild traumatic brain injuries; academic accommodations; school concussion programs
To characterize the causes, effects, and risks associated with concussion in sports.
Concussion is an injury associated with sports and is most often identified with boxing, football, ice hockey, and the martial arts. In addition, recent research has shown that concussion occurs in many different sports. In the decade of the 1990s, concussion became a primary issue for discussion among the media, sports sponsors, sports medicine professionals, and athletes.
Concussion is an injury that results from a wide variety of mechanisms and has numerous signs and symptoms that are common to different types of injury. Continued improvement in prevention and management strategies for concussion requires a strong body of research from a variety of different disciplines. It is essential that research efforts focus on both prevention and management and that researchers and clinicians work closely toward their common goals.
Until the research community is able to provide sound recommendations for the prevention and management of the concussion, the care of the injured player falls squarely on the clinician. It is important for sports medicine professionals to continue to stay up to date on the advances in understanding concussions and how to care individually for each player who sustains a concussion.
mild traumatic brain injury; head injury; injury prevention
To provide an overview of the general legal principles of negligence for sports medicine professionals and apply these principles to situations involving athletes with head injury.
Case law dating back to 1976 and recent studies of sport-related concussion.
One of the most difficult problems facing athletic trainers and team physicians is the recognition and treatment of sport-related concussion. Providing medical clearance for sports participation and treatment of athletic injuries involves legal as well as medical issues. The threat of lawsuits exists for the sports medicine professional, whether the athlete is allowed to play or not. In general, established medical malpractice principles govern claims by athletes for injury or death caused by improper treatment by health care providers. The elements of negligence are examined, as well as the primary defenses an athletic trainer would use in court and risk management techniques to avoid litigation.
Athletic trainers may protect themselves from liability by including standardized cognitive or postural stability testing in preparticipation examinations, using objective tests rather than subjective judgement to evaluate athletes who have sport-related concussion, working closely with physicians, and keeping excellent records.
negligence; duty; breach; causation; damage; reasonable person standard
Concussion is a common neurological injury occurring during contact sport. Current guidelines recommend that no athlete should return to play while symptomatic or displaying cognitive dysfunction. This study compared post‐concussion cognitive function in recently concussed athletes who were symptomatic/asymptomatic at the time of assessment with that of non‐injured (control) athletes.
Prospective study of 615 male Australian Rules footballers. Before the season, all participants (while healthy) completed a battery of baseline computerised (CogSport) and paper and pencil cognitive tasks. Sixty one injured athletes (symptomatic = 25 and asymptomatic = 36) were reassessed within 11 days of being concussed; 84 controls were also reassessed. The serial cognitive function of the three groups was compared using analysis of variance.
The performance of the symptomatic group declined at the post‐concussion assessment on computerised tests of simple, choice, and complex reaction times compared with the asymptomatic and control groups. The magnitude of changes was large according to conventional statistical criteria. On paper and pencil tests, the symptomatic group displayed no change at reassessment, whereas large improvements were seen in the other two groups.
Injured athletes experiencing symptoms of concussion displayed impaired motor function and attention, although their learning and memory were preserved. These athletes displayed no change in performance on paper and pencil tests in contrast with the improvement observed in asymptomatic and non‐injured athletes. Athletes experiencing symptoms of concussion should be withheld from training and competition until both symptoms and cognitive dysfunction have resolved.
cognition; concussion; mild traumatic brain injury; neuropsychology; symptoms
Although computerized neuropsychological screening is becoming a standard for sports concussion identification and management, convergent validity studies are limited. Such studies are important for several reasons: reference to established measures is needed to establish validity; examination of the computerized battery relative to a more traditional comprehensive battery will help understand the strengths and limitations of the computer battery; and such an examination will help inform the output of the computerized battery. We compared scores on the ImPACT™ battery to a comprehensive battery of traditional neuropsychological measures and several experimental measures used in the assessment of sports-related concussion in fifty-four healthy male athletes. Convergent validity was demonstrated for four of the five ImPACT™ domain scores. Two cognitive domains often compromised as a result of mild TBI were not directly identified by the ImPACT™ battery: sustained attention and auditory working memory. Affective symptoms correlated with performance on measures of attention and working memory. In this healthy sample, the correlations between the domains covered by ImPACT™ and the neuropsychological battery supports ImPACT™ as a useful screening tool for assessing many of the cognitive factors related to mTBI. However, the data suggest other sources of data need to be considered when identifying and managing concussions.
Self-report post-concussion symptom scales have been a key method for monitoring recovery from sport-related concussion, to assist in medical management, and return-to-play decision-making. To date, however, item selection and scaling metrics for these instruments have been based solely upon clinical judgment, and no one scale has been identified as the “gold standard”. We analyzed a large set of data from existing scales obtained from three separate case–control studies in order to derive a sensitive and efficient scale for this application by eliminating items that were found to be insensitive to concussion. Baseline data from symptom checklists including a total of 27 symptom variables were collected from a total of 16,350 high school and college athletes. Follow-up data were obtained from 641 athletes who subsequently incurred a concussion. Symptom checklists were administered at baseline (preseason), immediately post-concussion, post-game, and at 1, 3, and 5 days post-injury. Effect-size analyses resulted in the retention of only 12 of the 27 variables. Receiver-operating characteristic analyses were used to confirm that the reduction in items did not reduce sensitivity or specificity. The newly derived Concussion Symptom Inventory is presented and recommended as a research and clinical tool for monitoring recovery from sport-related concussion.
Brain injury; Post-concussion; Scale
Sports-related concussions (SRC) among high school and collegiate athletes represent a significant public health concern. The Concussion in Sport Group (CIS) recommended greater caution regarding return to play with children and adolescents. We hypothesized that younger athletes would take longer to return to neurocognitive baseline than older athletes after a SRC.
Two hundred adolescent and young adult athletes who suffered a SRC were included in our clinical research cohort. Of the total participants, 100 were assigned to the 13-16 year age group and 100 to the 18-22 year age group and were matched on the number of prior concussions. Each participant completed baseline and postconcussion neurocognitive testing using the Immediate Post-Concussion assessment and Cognitive Testing (ImPACT) test battery. Return to baseline was defined operationally as post-concussion neurocognitive and symptom scores being equivalent to baseline using reliable change index (RCI) criteria. For each group, the average number of days to return to cognitive and symptom baseline were calculated. Independent sample t-tests were used to compare the mean number of days to return to baseline.
Significant differences were found for days to return to baseline between 13-16 year olds and 18-22 year olds in three out of four neurocognitive measures and on the total symptom score. The average number of days to return to baseline was greater for 13-16 year olds than for 18-22 year olds on the following variables: Verbal memory (7.2 vs. 4.7, P = 0.001), visual memory (7.1 vs. 4.7, P = 0.002), reaction time (7.2 vs. 5.1 P = 0.01), and postconcussion symptom scale (8.1 vs. 6.1, P = 0.026). In both groups, greater than 90% of athletes returned to neurocognitive and symptom baseline within 1 month.
Our results in this clinical research study show that in SRC, athletes 13-16 years old take longer to return to their neurocognitive and symptom baselines than athletes 18-22 years old.
Age; concussion; immediate post-concussion assessment and cognitive testing; mild traumatic brain injury; sports
As the number of youth sports participants continues to rise over the past decade, so too have sports related injuries and emergency department visits. With low levels of oversight and regulation observed in youth sports, the responsibility for safety education of coaches, parents, law makers, organizations and institutions falls largely on the sports medicine practitioner. The highly publicized catastrophic events of concussion, sudden cardiac death, and heat related illness have moved these topics to the forefront of sports medicine discussions. Updated guidelines for concussion in youth athletes call for a more conservative approach to management in both the acute and return to sport phases. Athletes younger than eighteen suspected of having a concussion are no longer allowed to return to play on the same day. Reducing the risk of sudden cardiac death in the young athlete is a multi‐factorial process encompassing pre‐participation screenings, proper use of safety equipment, proper rules and regulations, and immediate access to Automated External Defibrillators (AED) as corner stones. Susceptibility to heat related illness for youth athletes is no longer viewed as rooted in physiologic variations from adults, but instead, as the result of various situations and conditions in which participation takes place. Hydration before, during and after strenuous exercise in a high heat stress environment is of significant importance. Knowledge of identification, management and risk reduction in emergency medical conditions of the young athlete positions the sports physical therapist as an effective provider, advocate and resource for safety in youth sports participation. This manuscript provides the basis for management of 3 major youth emergency sports medicine conditions.
youth sports injuries; sudden cardiac death; concussion; heat related illness; hydration
Reaction time is typically impaired after concussion. A clinical test of reaction time (RTclin) that does not require a computer to administer may be a valuable tool to assist in concussion diagnosis and management.
To determine the test-retest reliability of RTclin measured over successive seasons in competitive collegiate athletes and to compare these results with a computerized measure of reaction time (RTcomp).
Case series with repeated measures.
Preparticipation physical examinations for the football, women's soccer, and wrestling teams at a single university.
Patients or Other Participants:
102 National Collegiate Athletic Association Division I athletes.
The RTclin was measured using a measuring stick embedded in a weighted rubber disk that was released and caught as quickly as possible. The RTcomp was measured using the simple reaction time component of CogState Sport.
Main Outcome Measure(s):
Data were collected at 2 time points, 1 season apart, during preparticipation physical examinations. Outcomes were mean simple RTclin and RTcomp.
The intraclass correlation coefficient estimates from season 1 to season 2 were 0.645 for RTclin (n = 102, entire sample) and 0.512 for RTcomp (n = 62 athletes who had 2 consecutive valid baseline CogState Sport test sessions).
The test-retest reliability of RTclin over consecutive seasons compared favorably with that of a concurrently tested computerized measure of reaction time and with literature-based estimates of computerized reaction time measures. This finding supports the potential use of RTclin as part of a multifaceted concussion assessment battery. Further prospective study is warranted.
intraclass correlation coefficient; concussions; traumatic brain injuries; assessment
Self-reported symptoms (SRS) scales comprise one aspect of a multifaceted assessment of sport-related concussion. Obtaining SRS assessments before a concussion occurs assists in determining when the injury is resolved. However, athletes may present with concussion-related symptoms at baseline. Thus, it is important to evaluate such reports to determine if the variables that are common to many athletic environments are influencing them.
To evaluate the influence of a history of concussion, sex, acute fatigue, physical illness, and orthopaedic injury on baseline responses to 2 summative symptom scales; to investigate the psychometric properties of all responses; and to assess the factorial validity of responses to both scales in the absence of influential variables.
Athletic training facilities of 6 National Collegiate Athletic Association institutions.
Patients or Other Participants:
The sample of 1065 was predominately male (n = 805) collegiate athletes with a mean age of 19.81 ± 1.53 years.
Main Outcome Measure(s):
Participants completed baseline measures for duration and severity of concussion-related SRS and a brief health questionnaire.
At baseline, respondents reporting a previous concussion had higher composite scores on both scales (P ≤ .01), but no sex differences were found for concussion-related symptoms. Acute fatigue, physical illness, and orthopaedic injury increased composite SRS scores on both duration and severity measures (P ≤ .01). Responses to both scales were stable and internally consistent. Confirmatory factor analysis provided strong evidence for the factorial validity of the responses of participants reporting no fatigue, physical illness, or orthopaedic injury on each instrument.
A history of concussion, acute fatigue, physical illness, and orthopaedic injury increased baseline SRS scores. These conditions need to be thoroughly investigated and controlled by clinicians before baseline SRS measures are collected.
baseline evaluation; factorial validity; Postconcussion Symptom Scale
Computerized neurocognitive testing is becoming popular among clinicians evaluating sport-related concussions across all levels of sport. Baseline neurocognitive testing has been recommended to provide more accurate representation of the preconcussion cognitive status of individual athletes. However, little is known about the use of baseline neurocognitive testing in concussion assessment and management.
To examine implementation and practice trends of sports medicine professionals using baseline neurocognitive testing at the high school and collegiate levels.
Quantitative survey research.
Patients or Other Participants:
Certified athletic trainers (ATs) from approximately 1209 US institutions listed on the ImPACT Web site were recruited. A total of 399 ATs completed the survey, for a response return rate of 32.7%.
Main Outcome Measure(s):
Survey questions addressed educational level, years of certification, employment setting, percentage of athletes baseline tested, and accuracy of baseline tests. Other items addressed postconcussive neurocognitive testing protocols and scenarios for return-to-play decisions based on neurocognitive testing.
Nearly all ATs (94.7%) administered baseline computerized neurocognitive testing to their athletes. However, only 51.9% examined these baseline tests for validity. The majority of ATs indicated that they administer baseline neurocognitive tests most frequently to football players (88.4%), followed by women's soccer players (78.8%) and men's soccer players (71.2%). Nearly all respondents (95.5%) stated that they would not return a symptomatic athlete to play if the athlete's neurocognitive scores were back to baseline. However, when asked if they would return an athlete who is symptom free but who scores below his or her baseline, 86.5% responded no, 9.8% responded yes, and 3.8% indicated that it depended on the importance of the competition.
The use of baseline testing, baseline testing readministration, and postconcussion protocols among ATs is increasing. However, the ATs in this study reported that they relied more on symptoms than on neurocognitive test scores when making return-to-play decisions.
concussions; baseline testing; computerized neurocognitive testing
The purpose of the study was to investigate concussion history, knowledge, injury identification, and management strategies among athletes, coaches, and medical staff in Italian club level football (soccer) clubs. Surveys (N=727) were distributed among Italian football clubs. Athletes’ surveys were designed to evaluate athlete knowledge of concussive signs and symptoms and injury reporting. Coaches’ surveys explored the understanding of concussive signs and symptoms and management practices. Medical staff surveys explored the standard of care regarding concussions. A total of 342 surveys were returned, for a 47% response rate. Descriptive analyses indicated 10% of athletes sustaining a concussion in the past year and 62% of these injuries were not reported, primarily due to the athletes not thinking the injury was serious enough. Coaches consistently identified non-concussion related symptoms (98.7%), but were unable to identify symptoms associated with concussion (38.9%). Most understood that loss of consciousness is not the sole indicator of injury (82.6%). Medical staff reported a heavy reliance on the clinical exam (92%) and athlete symptom reports (92%) to make the concussion diagnosis and return to play decision, with little use of neurocognitive (16.7%) or balance (0.0%) testing. Italian football athletes appear to report concussions at a rate similar to American football players, with a slightly higher rate of unreported injuries. Most of these athletes were aware they were concussed, but did not feel the injury was serious enough to report. Although coaches served as the primary person to whom concussions were reported, the majority of coaches were unable to accurately identify concussion related symptoms. With little use for neurocognitive and postural control assessments, the medical personnel may be missing injuries or returning athletes to play too soon. Collectively, these findings suggest that athletes, coaches, and medical personnel would benefit from concussion based educational materials on the signs, symptoms, and evaluative techniques of concussion.
Italian football (soccer) athletes report less than 40% of concussions.
Injuries are most commonly reported to coaches, who may not be fully aware of concussive signs and symptoms.
International educational measures on concussion awareness and management may be of use.
Mild traumatic brain injury; symptoms
Objective: To describe the development of hypopituitarism in an adolescent athlete after multiple concussions and to raise awareness among sports medicine clinicians concerning the growing concern of hypopituitarism in concussion injury surveillance and management.
Background: A 14-year-old, previously healthy male athlete suffered 4 head traumas over a 4-month period. The first 3 traumas were considered by the athlete to be minor and were not reported to medical personnel. The fourth trauma was a medically diagnosed concussion suffered during soccer play. Over the next year, the patient noted a decline in strength and conditioning and a failure to grow.
Differential Diagnosis: After physical examination and a full battery of endocrine tests, the patient, then 16.5 years old, was diagnosed with hypopituitarism. Follow-up interviews provided evidence that at least 2 of the 3 head injuries suffered before the last concussion could also be considered concussions, which may have contributed to the severity of the last head injury.
Treatment: The patient is currently being treated with physiologic replacement hormones (growth hormone, cortisol, and thyroxine), with resumption of linear growth and strength. He is progressing well.
Uniqueness: In the past few years in the medical literature, increased attention has been drawn to the occult occurrence of hypopituitarism after traumatic brain injury in adults. Initial reports indicate that children are also at risk. To our knowledge, this is the first reported case of hypopituitarism after mild traumatic brain injury in the sports medicine literature.
Conclusions: Symptoms of hypopituitarism are often masked by trauma and postconcussion symptoms and may not appear until months or years after the trauma incident, which can lead to significant delay in proper diagnosis and treatment. We urge greater vigilance by, and training of, sports medicine clinicians toward the goal of recognizing the possibility of pituitary disorders after sports concussion.
neuroendocrinology; mild traumatic brain injury; sports
To review models for the use of neuropsychological testing in the management of sport-related concussion at various levels of competition.
As we come to understand the natural history of sport-related concussive brain injury, it is increasingly evident that significant neurologic risks are associated with this type of injury. These risks include (1) acute intracranial pathology, (2) catastrophic brain swelling from second-impact syndrome, and (3) the potential risk for markedly prolonged recovery or permanent cognitive dysfunction associated with multiple concussions.
Neuropsychological testing has proved to be a useful tool in the medical management of sport-related concussion. In this paper, I describe a systematic model for the implementation of neuropsychological assessment of athletes at various levels of competition.
The systematic model was designed to incorporate state-of-the-art techniques for the detection and tracking of neurocognitive deficits associated with concussion into recently formulated guidelines for the medical management of sport-related concussion. Current applications of the model are discussed, as well as ongoing studies designed to elaborate the empirical underpinnings of the model and refine clinical decision making in this area.
concussion; sports; brain injury
Despite negative neuroimaging findings many athletes display neurophysiological alterations and post-concussion symptoms that may be attributable to neurometabolic alterations.
The present study investigated the effects of sports concussion on brain metabolism using 1H-MR Spectroscopy by comparing a group of 10 non-concussed athletes with a group of 10 concussed athletes of the same age (mean: 22.5 years) and education (mean: 16 years) within both the acute and chronic post-injury phases. All athletes were scanned 1-6 days post-concussion and again 6-months later in a 3T Siemens MRI.
Concussed athletes demonstrated neurometabolic impairment in prefrontal and motor (M1) cortices in the acute phase where NAA:Cr levels remained depressed relative to controls. There was some recovery observed in the chronic phase where Glu:Cr levels returned to those of control athletes; however, there was a pathological increase of m-I:Cr levels in M1 that was only present in the chronic phase.
These results confirm cortical neurometabolic changes in the acute post-concussion phase as well as recovery and continued metabolic abnormalities in the chronic phase. The results indicate that complex pathophysiological processes differ depending on the post-injury phase and the neurometabolite in question.
MRI spectroscopy; sports concussion; recovery; metabolism
Massage is a popular treatment choice of athletes, coaches, and sports physical therapists. Despite its purported benefits and frequent use, evidence demonstrating its efficacy is scarce.
To identify current literature relating to sports massage and its role in effecting an athlete's psychological readiness, in enhancing sports performance, in recovery from exercise and competition, and in the treatment of sports related musculoskeletal injuries.
Electronic databases were used to identify papers relevant to this review. The following keywords were searched: massage, sports injuries, athletic injuries, physical therapy, rehabilitation, delayed onset muscle soreness, sports psychology, sports performance, sports massage, sports recovery, soft tissue mobilization, deep transverse friction massage, pre-event, and post exercise.
Research studies pertaining to the following general categories were identified and reviewed: pre-event (physiological and psychological variables), sports performance, recovery, and rehabilitation.
Despite the fact clinical research has been performed, a poor appreciation exists for the appropriate clinical use of sports massage.
Additional studies examining the physiological and psychological effects of sports massage are necessary in order to assist the sports physical therapist in developing and implementing clinically significant evidence based programs or treatments.
sports massage; sports rehabilitation; sports performance; sports recovery
Background and Purpose:
Rehabilitation and strength and conditioning are often seen as two separate entities in athletic injury recovery. Traditionally an athlete progresses from the rehabilitation environment under the care of a physical therapist and/or athletic trainer to the strength and conditioning coach for specific return to sport training. These two facets of return to sport are often considered to have separate goals. Initial goals of each are often different due to the timing of their implementation encompassing different stages of post-injury recovery. The initial focus of post injury rehabilitation includes alleviation of dysfunction, enhancement of tissue healing, and provision of a systematic progression of range-of-motion and strength. During the return to function phases, specific return to play goals are paramount. Understanding of specific principles and program parameters is necessary when designing and implementing an athlete's rehabilitation program. Communication and collaboration amongst all individuals caring for the athlete is a must. The purpose of this review is to outline the current evidence supporting utilization of training principles in athletic rehabilitation, as well as provide suggested implementation of such principles throughout different phases of a proposed rehabilitation program.
The following electronic databases were used to identify research relevant to this clinical commentary: MEDLINE (from 1950–June 2011) and CINAHL (1982–June 2011), for all relevant journal articles written in English. Additional references were accrued by independent searching of references from relevant articles.
Currently evidence is lacking in the integration of strength and conditioning principles into the rehabilitation program for the injured athlete. Numerous methods are suggested for possible utilization by the clinician in practice to improve strength, power, speed, endurance, and metabolic capacity.
Despite abundance of information on the implementation of training principles in the strength and conditioning field, investigation regarding the use of these principles in a properly designed rehabilitation program is lacking.
periodization; program design; rehabilitation; strength; training