Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.

BACKGROUND: Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE: To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS: On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS: A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION: Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS: ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

Vaccine Delays, Refusals, and Patient Dismissals: A Survey of Pediatricians.

BACKGROUND: Parental noncompliance with the American Academy of Pediatrics and Centers for Disease Control and Prevention immunization schedule is an increasing public health concern. We examined the frequency of requests for vaccine delays and refusals and the impact on US pediatricians' behavior. METHODS: Using national American Academy of Pediatrics Periodic Surveys from 2006 and 2013, we describe pediatrician perceptions of prevalence of (1) vaccine refusals and delays, (2) parental reasons for refusals and/or delays, and (3) physician dismissals. Questions about vaccine delays were asked only in 2013. We examined the frequency, reasons for, and management of both vaccine refusals and delays by using bivariate and multivariable analyses, which were controlled for practice characteristics, demographics, and survey year. RESULTS: The proportion of pediatricians reporting parental vaccine refusals increased from 74.5% in 2006 to 87.0% in 2013 (P < .001). Pediatricians perceive that parents are increasingly refusing vaccinations because parents believe they are unnecessary (63.4% in 2006 vs 73.1% in 2013; P = .002). A total of 75.0% of pediatricians reported that parents delay vaccines because of concern about discomfort, and 72.5% indicated that they delay because of concern for immune system burden. In 2006, 6.1% of pediatricians reported "always" dismissing patients for continued vaccine refusal, and by 2013 that percentage increased to 11.7% (P = .004). CONCLUSIONS: Pediatricians reported increased vaccine refusal between 2006 and 2013. They perceive that vaccine-refusing parents increasingly believe that immunizations are unnecessary. Pediatricians continue to provide vaccine education but are also dismissing patients at higher rates.

Rehabilitation of Musculoskeletal Injuries in Young Athletes.

Caring for young athletes challenges the physician to use primary preventive measures to prevent injury and to respond with secondary measures when injuries do occur. An enhanced knowledge of the rehabilitation process will assist the physician in making the appropriate referrals and in evaluating the patient's condition before clearing that athlete. Use of criteria-based testing may aid the primary care physician in determining an athlete's readiness for sport.

Eye Protection and Risk of Eye Injuries in High School Field Hockey.

OBJECTIVE: To determine if injury rates among female field hockey players differ before and after implementation of a national mandate for protective eyewear (MPE). METHODS: We analyzed girls' field hockey exposure and injury data collected from national (High School Reporting Information Online [RIO]) and regional (Fairfax County Public Schools) high school sports injury databases in 2 seasons before (2009/10 and 2010/11) and 2 seasons after (2011/12 and 2012/13) a national MPE. RESULTS: The incidence of eye/orbital injuries was significantly higher in states without MPE (0.080 injuries per 1000 athletic exposures [AEs]) than in states with MPE (before the 2011/12 mandate) and the postmandate group (0.025 injuries per 1000 AEs) (odds ratio 3.20, 95% confidence interval 1.47-6.99, P = .003). There was no significant difference in concussion rates for the 2 groups (odds ratio 0.77, 95% confidence interval 0.58-1.02, P = .068). After the 2011/12 MPE, severe eye/orbital injuries (time loss >21 days) were reduced by 67%, and severe/medical disqualification head/face injuries were reduced by 70%. Concussion rates for field hockey (0.335 per 1000 AEs) rank third among girls' sports included in the High School RIO surveillance program. CONCLUSIONS: Among female high school field hockey players, MPE is associated with a reduced incidence of eye/orbital injuries and fewer severe eye/orbital and head/face injuries. Concussion rates did not change as a result of the national MPE. Concussion remains the most common injury involving the head and face among female field hockey players, prompting further inquiry into potential effects of adopting protective headgear/helmets.

Video incident analysis of concussions in boys' high school lacrosse.

BACKGROUND: Boys' lacrosse has one of the highest rates of concussion among boys' high school sports. A thorough understanding of injury mechanisms and game situations associated with concussions in boys' high school lacrosse is necessary to target injury prevention efforts. PURPOSE: To characterize common game-play scenarios and mechanisms of injury associated with concussions in boys' high school lacrosse using game video. STUDY DESIGN: Descriptive epidemiological study. METHODS: In 25 public high schools of a single school system, 518 boys' lacrosse games were videotaped by trained videographers during the 2008 and 2009 seasons. Video of concussion incidents was examined to identify game characteristics and injury mechanisms using a lacrosse-specific coding instrument. RESULTS: A total of 34 concussions were captured on video. All concussions resulted from player-to-player bodily contact. Players were most often injured when contact was unanticipated or players were defenseless (n = 19; 56%), attempting to pick up a loose ball (n = 16; 47%), and/or ball handling (n = 14; 41%). Most frequently, the striking player's head (n = 27; 79%) was involved in the collision, and the struck player's head was the initial point of impact in 20 incidents (59%). In 68% (n = 23) of cases, a subsequent impact with the playing surface occurred immediately after the initial impact. A penalty was called in 26% (n = 9) of collisions. CONCLUSION: Player-to-player contact was the mechanism for all concussions. Most commonly, injured players were unaware of the pending contact, and the striking player used his head to initiate contact. Further investigation of preventive measures such as education of coaches and officials and enforcement of rules designed to prevent intentional head-to-head contact is warranted to reduce the incidence of concussions in boys' lacrosse.

Effectiveness of protective eyewear in reducing eye injuries among high school field hockey players.

OBJECTIVE: To determine if injury rates differ among high school field hockey players in states that mandated protective eyewear (MPE) versus states with no protective eyewear mandate (no MPE). METHODS: We analyzed field hockey exposure and injury data collected over the 2009-2010 and 2010-2011 scholastic seasons from national and regional databases. RESULTS: Incidence of all head and face injuries (including eye injuries, concussion) was significantly higher in no-MPE states compared with MPE states, 0.69 vs 0.47 injuries per 1000 athletic exposures (incidence rate ratio [IRR] 1.47; 95% confidence interval [CI]: 1.04-2.15, P = .048). Players in the no-MPE group had a 5.33-fold higher risk of eye injury than players in the MPE group (IRR 5.33; 95% CI: 0.71-39.25, P = .104). There was no significant difference in concussion rates for the 2 groups (IRR 1.04; 95% CI: 0.63-1.75, P = .857). A larger percentage of injuries sustained by athletes in the no-MPE group required >10 days to return to activity (32%) compared with athletes in the MPE group (17%), but this difference did not reach statistical significance (P = .060). CONCLUSIONS: Among high school field hockey players, playing in a no-MPE state results in a statistically significant higher incidence of head and face injuries versus playing in an MPE state. Concussion rates among players in MPE and no-MPE states were similar, indicating that addition of protective eyewear did not result in more player-player contact injuries, challenging a perception in contact/collision sports that increased protective equipment yields increased injury rates.

Video incident analysis of head injuries in high school girls' lacrosse.

BACKGROUND: Knowledge of injury mechanisms and game situations associated with head injuries in girls' high school lacrosse is necessary to target prevention efforts. PURPOSE: To use video analysis and injury data to provide an objective and comprehensive visual record to identify mechanisms of injury, game characteristics, and penalties associated with head injury in girls' high school lacrosse. STUDY DESIGN: Descriptive epidemiology study. METHODS: In the 25 public high schools of 1 school system, 529 varsity and junior varsity girls' lacrosse games were videotaped by trained videographers during the 2008 and 2009 seasons. Video of head injury incidents was examined to identify associated mechanisms and game characteristics using a lacrosse-specific coding instrument. RESULTS: Of the 25 head injuries (21 concussions and 4 contusions) recorded as game-related incidents by athletic trainers during the 2 seasons, 20 head injuries were captured on video, and 14 incidents had sufficient image quality for analysis. All 14 incidents of head injury (11 concussions, 3 contusions) involved varsity-level athletes. Most head injuries resulted from stick-to-head contact (n = 8), followed by body-to-head contact (n = 4). The most frequent player activities were defending a shot (n = 4) and competing for a loose ball (n = 4). Ten of the 14 head injuries occurred inside the 12-m arc and in front of the goal, and no penalty was called in 12 injury incidents. All injuries involved 2 players, and most resulted from unintentional actions. Turf versus grass did not appear to influence number of head injuries. CONCLUSION: Comprehensive video analysis suggests that play near the goal at the varsity high school level is associated with head injuries. Absence of penalty calls on most of these plays suggests an area for exploration, such as the extent to which current rules are enforced and the effectiveness of existing rules for the prevention of head injury.

Effectiveness of the women's lacrosse protective eyewear mandate in the reduction of eye injuries.

BACKGROUND: In an effort to minimize the risk of catastrophic eye injury, US Lacrosse initiated mandatory use of protective eyewear in women's lacrosse in the 2004-2005 season. PURPOSE: The authors compared eye injury rates in girls' scholastic lacrosse before and after implementation of protective eyewear. They also compared head/face injury rates, concussion rates, and overall injury rates before and after the rule change to assess possible unintended consequences of the change. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study group included female scholastic lacrosse players in the 25 public high schools in Fairfax County, Virginia, during the 2004-2009 spring seasons. Injury rates were compared with those from the same data source for the 2000-2003 seasons. Premandate versus postmandate injury rates were adjusted for athlete exposures, or total opportunities for injury throughout the season. RESULTS: The rate of eye injuries was reduced from 0.10 injuries per 1000 athlete exposures (AEs) in 2000 through 2003 before the use of protective eyewear to 0.016 injuries per 1000 AEs in 2004 through 2009 (incident rate ratio [IRR], 0.16; 95% confidence interval [CI], 0.06-0.42). The rate ratio of head/face injuries excluding concussion also decreased (IRR, 0.44; 95% CI, 0.26-0.76). There was no change in the rate ratio of total injuries involving all body parts (IRR, 0.93; 95% CI, 0.82-1.1) after introduction of protective eyewear. However, the rate ratio of concussion increased (IRR, 1.6; 95% CI, 1.1-2.3). CONCLUSION: The use of protective eyewear in women's lacrosse was associated with a reduction in the number of eye injuries. The number of head/face injuries decreased in this study group after introduction of protective eyewear, and there was no change in overall injury rates. The reason for the increase in concussion rate cannot be determined conclusively based on this study, but the authors speculate that this increase resulted largely from increased recognition and diagnosis because overall injury rates do not indicate rougher play with introduction of protective equipment.

Trends in concussion incidence in high school sports: a prospective 11-year study.

BACKGROUND: Understanding the risk and trends of sports-related concussion among 12 scholastic sports may contribute to concussion detection, treatment, and prevention. PURPOSE: To examine the incidence and relative risk of concussion in 12 high school boys' and girls' sports between academic years 1997-1998 and 2007-2008. STUDY DESIGN: Descriptive epidemiology study. METHODS: Data were prospectively gathered for 25 schools in a large public high school system. All schools used an electronic medical record-keeping program. A certified athletic trainer was on-site for games and practices and electronically recorded all injuries daily. RESULTS: In sum, 2651 concussions were observed in 10 926 892 athlete-exposures, with an incidence rate of 0.24 per 1000. Boys' sports accounted for 53% of athlete-exposures and 75% of all concussions. Football accounted for more than half of all concussions, and it had the highest incidence rate (0.60). Girls' soccer had the most concussions among the girls' sports and the second-highest incidence rate of all 12 sports (0.35). Concussion rate increased 4.2-fold (95% confidence interval, 3.4-5.2) over the 11 years (15.5% annual increase). In similar boys' and girls' sports (baseball/softball, basketball, and soccer), girls had roughly twice the concussion risk of boys. Concussion rate increased over time in all 12 sports. CONCLUSION: Although the collision sports of football and boys' lacrosse had the highest number of concussions and football the highest concussion rate, concussion occurred in all other sports and was observed in girls' sports at rates similar to or higher than those of boys' sports. The increase over time in all sports may reflect actual increased occurrence or greater coding sensitivity with widely disseminated guidance on concussion detection and treatment. The high-participation collision sports of football and boys' lacrosse warrant continued vigilance, but the findings suggest that focus on concussion detection, treatment, and prevention should not be limited to those sports traditionally associated with concussion risk.

Summary statement: appropriate medical care for the secondary school-aged athlete.

OBJECTIVE: To present the recommendations made by the Appropriate Medical Care for Secondary School-Aged Athletes Task Force and to summarize the subsequent monograph developed around 11 consensus points. DATA SOURCES: The MEDLINE, CINAHL, and SportDiscus databases were searched for relevant literature regarding secondary school-aged athletes; health care administration; preparticipation physical examination; facilities; athletic equipment; emergency action planning; environmental conditions; recognition, evaluation, and treatment of injuries; rehabilitation and reconditioning; psychosocial consultation; nutrition; and prevention strategies. CONCLUSIONS AND RECOMMENDATIONS: Organizations that sponsor athletic programs for secondary school-aged athletes should establish an athletic health care team to ensure that appropriate medical care is provided to all participants. The 11 consensus points provide a framework-one that is supported by the medical literature and case law-for the development of an athletic health care team and for assigning responsibilities to the team, administrators, and staff members of institutions sponsoring secondary school and club-level athletic programs.

Understanding organization structures of the college, university, high school, clinical, and professional settings.

Athletes participate at many different levels of competition--from amateur to professional, from backyard sandlot to Yankee Stadium. There are as many different organized structures involved in providing medical care to athletes as there are types of athletes themselves. Although the organizational structures involved in providing medical care for a little league team in a small town are different from those involved in providing care for a professional baseball team, the mission is the same-caring for athletes. This is the central theme of this article. Though there are different organizational structures, there are more common threads than differences in the mission of those who provide medical care for athletes at any level.

The prevalence of overweight in participants in high school extramural sports.

This study examines the body mass index (BMI) percentiles for age of 3970 male high school athletes. Overall, boys participating in sports had BMI percentiles similar to the general population. However, the prevalence of overweight in boys playing certain sports, particularly football, but also wrestling and crew, was higher than the general population.

Head, face, and eye injuries in scholastic and collegiate lacrosse: a 4-year prospective study.

BACKGROUND: Risks and mechanisms of head, face, and eye injuries in high school and college lacrosse are not well documented. PURPOSE: To identify (1) primary mechanisms of head, face, and eye injuries in lacrosse and (2) differences in injury risk between the men's and women's game and between high school and collegiate levels. STUDY DESIGN: Descriptive epidemiological study. METHODS: The authors gathered data on 507,000 girls' and boys' high school and 649,573 women's and men's college lacrosse athletic exposures using sport-specific injury surveillance systems over 4 seasons. They identified the most common scenarios for head, face, and eye injuries. RESULTS: The high school girls' head, face, and eye injury rate (0.54 per 1000 athletic exposures) was significantly higher (incident rate ratio, 1.42; 95% confidence interval, 1.09-1.86) than that for boys (0.38 per 1000 athletic exposures); college women (0.77 per 1000 athletic exposures) sustained a higher rate of injuries (incident rate ratio, 1.76; 95% confidence interval, 1.42-2.19) than did men (0.44 per 1000 athletic exposures). Concussions constituted a higher percentage of injuries among boys (73%) and men (85%) than among girls (40%) and women (41%). Men sustained few facial injuries, whereas a substantial proportion of women's injuries involved the face and orbital area. CONCLUSION: Although permitting only incidental contact, women's lacrosse had higher rates of head, face, and eye injuries at both the high school and collegiate levels. Concussion was the most common injury. For men, the primary injury mechanism was player-to-player contact; women's injuries primarily resulted from stick or ball contact. High school injury rates were lower than were college rates, but the nature of injuries, body parts affected, and mechanisms were similar.

Epidemiology of lacrosse injuries in high school-aged girls and boys: a 3-year prospective study.

OBJECTIVE: To report the types, mechanisms, and circumstances of lacrosse injuries incurred by high school-aged girls and boys during organized interscholastic and summer camp games. STUDY DESIGN: Descriptive epidemiology study. METHODS: For 3 years, the authors gathered data on girls' and boys' lacrosse injuries for 359 040 high school and 28 318 summer camp athletic exposures using a lacrosse-specific computerized injury surveillance system. The most prevalent injuries were organized into multifactorial injury scenarios. RESULTS: In high school play, the injury rate for adolescent boys (2.89 per 1000 athletic exposures) was slightly higher than that for girls (2.54 per 1000 athletic exposures) (incidence rate ratio = 1.14; 95% confidence interval, 1.00-1.30). The most prevalent injuries for adolescent girls and boys were knee and ankle sprains resulting from noncontact mechanisms. Male players had significantly higher rates of shoulder, neck, trunk, and back injuries and higher game-to-practice injury ratios. In addition, they had higher rates of concussive events from player-to-player contact. Female players had higher rates of overall head injuries, many involving contusions and abrasions from stick and ball contact. CONCLUSIONS: The overall injury rates for boys' and girls' high school lacrosse were significantly lower than those for collegiate play. Significant differences existed between adolescent boys and girls with respect to injury mechanisms, body parts injured, and player and team activity at the time of injury.

Monitoring Resolution of Postconcussion Symptoms in Athletes: Preliminary Results of a Web-Based Neuropsychological Test Protocol.

OBJECTIVE: A new Web-based neuropsychological test was field tested to determine usefulness in detecting and monitoring resolution of symptoms after sport-related concussions and in providing objective information for return-to-play decisions. DESIGN AND SETTING: We obtained neuropsychological baseline data on all subjects. After concussion, subjects were administered alternate, equivalent follow-up tests until symptoms resolved. Follow-up testing typically occurred at 1- to 2-day intervals after the concussion. SUBJECTS: Baseline testing was obtained for 834 athletes as part of ongoing field trials. Subsequently, 26 athletes sustained concussions and were studied. MEASUREMENTS: We administered The Concussion Resolution Index (CRI) at baseline and alternate forms posttrauma. Follow-up tests included a self-report inventory of neurophysiologic symptoms. RESULTS: A total of 88% of patients were identified as symptomatic on initial postconcussion testing. The CRI appeared relatively resistant to retest effects, and multiple administrations tracked resolution of symptoms over short and extended time periods. CONCLUSIONS: Although the CRI is still in field trials, preliminary data indicate that the CRI may be a useful method for athletic trainers and other professionals to expeditiously track resolution of symptoms after sport-related concussion.