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1.  Management of Cerebral Concussion in Sports: The Athletic Trainer's Perspective 
Journal of Athletic Training  2001;36(3):257-262.
Objective:
To present a new approach in the evaluation and management of concussion from the athletic trainer's perspective.
Background:
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.
Recommendations:
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.
PMCID: PMC155416  PMID: 12937494
mild head injury; neuropsychological testing; postural stability testing; grading scales
2.  Evaluation and management of children and adolescents with sports-related concussion 
Paediatrics & Child Health  2012;17(1):31-32.
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.
PMCID: PMC3276525  PMID: 23277754
Adolescents; Children; Concussion; Return to play; Sport; Youth
3.  High School Coaches Perceptions of Physicians’ Role in the Assessment and Management of Sports-Related Concussive Injury 
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.
doi:10.3389/fneur.2012.00130
PMCID: PMC3464423  PMID: 23060851
sports; concussion; athlete; neurology
4.  Concussion History and Postconcussion Neurocognitive Performance and Symptoms in Collegiate Athletes 
Journal of Athletic Training  2008;43(2):119-124.
Context:
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.
Objective:
To determine the relationship between concussion history and postconcussion neurocognitive performance and symptoms in collegiate athletes.
Design:
Repeated-measures design.
Setting:
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).
Intervention(s):
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).
Results:
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).
Conclusions:
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.
PMCID: PMC2267331  PMID: 18345335
mild traumatic brain injury; ImPACT; memory; reaction time
5.  The ability of parents to accurately report concussion occurrence in their bantam-aged minor hockey league children 
Objective:
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.
Outcome Measures:
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.
Participants:
Parents of Bantam-aged minor hockey league athletes volunteered for the study.
Methods:
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.
Results:
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.
Conclusion:
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.
PMCID: PMC2796943  PMID: 20037689
hockey; bantam; concussion; chiropractic
6.  Supporting the Student-Athlete's Return to the Classroom After a Sport-Related Concussion 
Journal of Athletic Training  2010;45(5):492-498.
Abstract
Objective:
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.
Background:
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.
Description:
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.
Clinical Advantages:
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.
doi:10.4085/1062-6050-45.5.492
PMCID: PMC2938323  PMID: 20831397
athletic injuries; mild traumatic brain injuries; academic accommodations; school concussion programs
7.  Cerebral Concussion: Causes, Effects, and Risks in Sports 
Journal of Athletic Training  2001;36(3):307-311.
Objective:
To characterize the causes, effects, and risks associated with concussion in sports.
Background:
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.
Description:
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.
Conclusions/Recommendations:
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.
PMCID: PMC155423  PMID: 12937501
mild traumatic brain injury; head injury; injury prevention
8.  Principles of Liability for Athletic Trainers: Managing Sport-Related Concussion 
Journal of Athletic Training  2001;36(3):316-321.
Objective:
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.
Data Sources:
Case law dating back to 1976 and recent studies of sport-related concussion.
Summary:
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.
Conclusions/Recommendations:
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.
PMCID: PMC155425  PMID: 12937503
negligence; duty; breach; causation; damage; reasonable person standard
9.  Concussion in Sports 
Sports Health  2013;5(2):160-164.
Context:
Recently, concussion has become a topic of much discussion within sports. The goal of this review is to provide an overview of the literature concerning the definition of concussion, management of initial injury, return to play, and future health risks.
Evidence Acquisition:
This article reviews the most recent findings on recognizing and managing sports-related concussion, which has become a significant health risk. We reviewed articles from the literature discussing concussion and its effects.
Results:
Though concussion patients typically have negative head imaging, imaging is warranted in those with severe mechanism, significant loss of consciousness, focal neurologic deficit, or worsening symptoms. The existence of “second-impact syndrome,” whereby a first minor head injury predisposes an athlete to later catastrophic injury, remains controversial; however, it is clear that concussion has significant effects on a patient and should be considered carefully in return-to-play decisions.
Conclusions:
A comprehensive understanding of concussion and its related risks is important in making return-to-play decisions as well as health care and league policy.
doi:10.1177/1941738112462203
PMCID: PMC3658375  PMID: 24427385
concussion; sports concussion; return to play; mild traumatic brain injury
10.  Online training in sports concussion for youth sports coaches 
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.
doi:10.1260/1747-9541.5.1.1
PMCID: PMC2904626  PMID: 20640175
coaching; children; sports concussion; injury prevention
11.  Hypopituitarism After Multiple Concussions: A Retrospective Case Study in an Adolescent Male 
Journal of Athletic Training  2007;42(3):431-439.
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.
PMCID: PMC1978466  PMID: 18060001
neuroendocrinology; mild traumatic brain injury; sports
12.  Current Trends in Athletic Training Practice for Concussion Assessment and Management 
Journal of Athletic Training  2005;40(4):320-325.
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.
PMCID: PMC1323294  PMID: 16404454
mild traumatic brain injury; mild brain injury; evaluation
13.  A Survey of Practice Patterns in Concussion Assessment and Management 
Journal of Athletic Training  2001;36(2):145-149.
Objectives:
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.”
Subjects:
A total of 339 valid surveys were returned by the attendees of the minicourse.
Measurements:
We used frequency analysis and descriptive statistics.
Results:
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.
Conclusions:
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.
PMCID: PMC155525  PMID: 12937455
mild brain injury; grading scales; head injury; evaluation
14.  Managing the health of the elite athlete: a new integrated performance health management and coaching model 
Elite athletes endeavour to train and compete even when ill or injured. Their motivation may be intrinsic or due to coach and team pressures. The sports medicine physician plays an important role to risk-manage the health of the competing athlete in partnership with the coach and other members of the support team. The sports medicine physician needs to strike the right ethical and operational balance between health management and optimising performance. It is necessary to revisit the popular delivery model of sports medicine and science services to elite athletes based on the current reductionist multispecialist system lacking in practice an integrated approach and effective communication. Athlete and coach in isolation or with a member of the multidisciplinary support team, often not qualified or experienced to do so, decide on the utilisation of services and how to apply the recommendations. We propose a new Integrated Performance Health Management and Coaching model based on the UK Athletics experience in preparation for the London Olympic and Paralympic Games. The Medical and Coaching Teams are managed by qualified and experienced individuals operating in synergy towards a common performance goal, accountable to a Performance Director and ultimately to the Board of Directors. We describe the systems, processes and implementation strategies to assist the athlete, coach and support teams to continuously monitor and manage athlete health and performance. These systems facilitate a balanced approach to training and competing decisions, especially while the athlete is ill or injured. They take into account the best medical advice and athlete preference. This Integrated Performance Health Management and Coaching model underpinned the Track and Field Gold Medal performances at the London Olympic and Paralympic Games.
doi:10.1136/bjsports-2013-093222
PMCID: PMC3963533  PMID: 24620040
Athletics; Elite Performance; Ethics
15.  Computerised cognitive assessment of concussed Australian Rules footballers 
Background—"Paper and pencil" neuropsychological tests play an important role in the management of sports related concussions. They provide objective information on the athlete's cognitive function and thus facilitate decisions on safe return to sport. It has been proposed that computerised cognitive tests have many advantages over such conventional tests, but their role in this domain is yet to be established.
Objectives—To measure cognitive impairment after concussion in a case series of concussed Australian Rules footballers, using both computerised and paper and pencil neuropsychological tests. To investigate the role of computerised cognitive tests in the assessment and follow up of sports related concussions.
Methods—Baseline measures on the Digit Symbol Substitution Test (DSST), Trail Making Test-Part B (TMT), and a simple reaction time (SRT) test from a computerised cognitive test battery (CogState) were obtained in 240 players. Tests were repeated in players who had sustained a concussive injury. A group of non-injured players were used as matched controls.
Results—Six concussions were observed over a period of nine weeks. At the follow up, DSST and TMT scores did not significantly differ from baseline scores in both control and concussed groups. However, analysis of the SRT data showed an increase in response variability and latency after concussion in the injured athletes. This was in contrast with a decrease in response variability and no change in latency on follow up of the control players (p<0.02).
Conclusion—Increased variability in response time may be an important cognitive deficit after concussion. This has implications for consistency of an athlete's performance after injury, as well as for tests used in clinical assessment and follow up of head injuries.
Key Words: concussion; football; neuropsychology; cognitive; head injury
doi:10.1136/bjsm.35.5.354
PMCID: PMC1724390  PMID: 11579074
16.  The cognitive effects and decrements following concussion 
Sports-related concussion is an injury that continues to receive attention from both the popular media and sports medicine community. The many different symptom presentations and cognitive decrements that follow concussions, have made this injury difficult to detect and manage. Furthermore, concussed athletes should not always be entrusted to appropriately self-report their concussion symptoms; therefore the burden falls on the clinician and coach. Recent management recommendations call for using a multi-faceted approach to managing concussion, which consists of neurocognitive testing before (ie, baseline/preseason) and after injury. In addition age, sex, and previous history of concussion have been found to influence the risk and recovery from this injury.
PMCID: PMC3781855  PMID: 24198543
cognitive function; neurocognitive testing; concussion
17.  Cognition in the days following concussion: comparison of symptomatic versus asymptomatic athletes 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1136/jnnp.2005.073155
PMCID: PMC2077582  PMID: 16421129
cognition; concussion; mild traumatic brain injury; neuropsychology; symptoms
18.  Examination of the Construct Validity of ImPACT™ Computerized Test, Traditional, and Experimental Neuropsychological Measures 
The Clinical neuropsychologist  2010;24(8):1309-1325.
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.
doi:10.1080/13854046.2010.516072
PMCID: PMC3183488  PMID: 20924979
19.  Concussion Symptom Inventory: An Empirically Derived Scale for Monitoring Resolution of Symptoms Following Sport-Related Concussion 
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.
doi:10.1093/arclin/acp025
PMCID: PMC2800775  PMID: 19549721
Brain injury; Post-concussion; Scale
20.  TEST‐RETEST CONSISTENCY OF A POSTURAL SWAY ASSESSMENT PROTOCOL FOR ADOLESCENT ATHLETES MEASURED WITH A FORCE PLATE 
Purpose/Background:
Postural control assessments can provide a powerful means of detecting concussion‐related neurophysiological abnormalities and are considered an important part of the concussion management processes. Studies with college athletes indicate that postural sway analyzed using complexity metrics may provide a sensitive and novel way to detect post‐concussion postural control impairments. The purpose of this study was to determine if a postural sway assessment protocol (PSAP) measured using a force plate system can serve as a reliable assessment tool for adolescent athletes.
Methods:
The short‐term and long‐term test‐retest reliability of the PSAP was examined in a group of adolescent female athletes under eyes open and eyes closed conditions. Detrended fluctuation analysis was used to evaluate the complexity of the times series data (i.e., degree of self‐similarity across time scales). Conventional measures of standard deviation and total path length (distance traveled by the center‐of‐pressure) were also assessed.
Results:
The complexity and conventional measures generally demonstrated good reliability coefficients for short‐term and long‐term test‐retest reliability with both eyes open and eyes closed conditions. Intra‐class Correlation Coefficient (ICC) values ranged from .38‐.90 The highest ICC values corresponded with the short‐term reliability for the eyes open condition, while the lower ICC values corresponded with the long‐term reliability for the eyes closed condition.
Conclusions:
The results of this study indicate that the PSAP demonstrated good short‐term and long‐term test‐retest reliability. In addition, no evidence of learning effects was elicited through this study. Future studies should further explore the validity and feasibility of the use of this protocol for different age groups, different types of athletes, and longitudinal evaluations of post‐concussion impairments.
Clinical Relevance:
This study provides preliminary support for the utility of a postural sway assessment protocol measured using a force plate for use with adolescent athletes.
Level of Evidence:
Level III
PMCID: PMC3867067  PMID: 24377060
concussion; force plate; reliability; postural control
21.  Recovery from sports-related concussion: Days to return to neurocognitive baseline in adolescents versus young adults 
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
doi:10.4103/2152-7806.102945
PMCID: PMC3513851  PMID: 23227435
Age; concussion; immediate post-concussion assessment and cognitive testing; mild traumatic brain injury; sports
22.  MEDICAL SPORTS INJURIES IN THE YOUTH ATHLETE: EMERGENCY MANAGEMENT 
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.
PMCID: PMC3325640  PMID: 22530197
youth sports injuries; sudden cardiac death; concussion; heat related illness; hydration
23.  Between-Seasons Test-Retest Reliability of Clinically Measured Reaction Time in National Collegiate Athletic Association Division I Athletes 
Journal of Athletic Training  2011;46(4):409-414.
Context:
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.
Objective:
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).
Design:
Case series with repeated measures.
Setting:
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.
Interventions :
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.
Results:
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).
Conclusions:
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.
PMCID: PMC3419153  PMID: 21944073
intraclass correlation coefficient; concussions; traumatic brain injuries; assessment
24.  Investigation of Baseline Self-Report Concussion Symptom Scores 
Journal of Athletic Training  2010;45(3):273-278.
Abstract
Context:
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.
Objective:
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.
Design:
Cross-sectional study.
Setting:
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.
Results:
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.
Conclusions:
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.
doi:10.4085/1062-6050-45.3.273
PMCID: PMC2865966  PMID: 20446841
baseline evaluation; factorial validity; Postconcussion Symptom Scale
25.  Management of the Complicated Sports Concussion Patient 
Sports Health  2010;2(3):197-202.
Context:
Whereas the majority of sports concussions are isolated self-limited events, some patients have more complicated presentations and management needs. This review presents a framework for the management of these complicated concussion patients.
Evidence Acquisition:
A MEDLINE search for the years 1990 to 2009 was performed using the search terms concussion and athletic injuries. Secondary search terms included symptom, incidence, treatment, and risk factor. The Strength of Recommendation Taxonomy grading system was used for all clinical recommendations.
Results:
Patterns of complicated sports concussion presentations were identified from literature review, anecdote, and personal experience of the author and colleagues. All clinical recommendations carry a grade of C, unless otherwise noted.
Conclusion:
The sports medicine provider should be aware of certain patterns of complicated sports concussion presentations in order to use a patient-focused approach to management.
doi:10.1177/1941738109357305
PMCID: PMC3445107  PMID: 23015938
concussion; management; return-to-play; complicated

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