An examination of social relations and concussion management via the blue card.

Introduction: Initially developed by New Zealand Rugby in 2014, the Blue Card initiative in rugby enables match officials to remove athletes from play if they are suspected to have sustained a concussion. Considerable attention has been paid by sport and health advocates to the possibilities and limitations of this initiative in safeguarding athlete health. However, little if any attention has been paid to the well-being of those responsible for administering the Blue Card (i.e., match officials). The aim of this paper was to examine match officials' experiences with and perspectives on implementing the Blue Card initiative in Ontario, Canada, with focused attention on the tensions around their ability to manage games and participants (e.g., athletes, coaches) while attempting to safeguard athlete well-being. Methods: Using Relational Coordination Theory (RCT) as a guiding framework and qualitative research method, we highlight the rich accounts of 19 match officials' perspectives and experiences regarding sport-related concussion (SRC) management and the Blue Card protocol. Results: Four themes were derived from the data, reflecting latent assumptions embedded within the concussion management process, which include: assumptions of trust, respect, and cooperation; assumptions of shared responsibility; assumptions of shared understanding; and assumptions of harassment-free sport. Discussion: Our findings emphasize the need to attend to social relations in concussion management and provide insight into match officials' fraught experiences on the frontlines of concussion management. We identify factors affecting match official well-being and provide considerations for concussion management initiatives designed to improve athlete safety, such as the Blue Card.

A grounded theory of youth athlete concussion under-reporting decisions.

BACKGROUND: Sport-related concussions leave youth vulnerable to significant health, physical, social, and educational disruptions. Many youth athletes under-report concussions, but the scope of the issue for this population is not well understood, nor are the underlying motivations for (under)reporting. It is necessary to examine the relationship between sport-related concussion knowledge and reporting and invite athletes to share their decision-making processes. The purpose of the research was to understand how athletes' attitudes, experiences and beliefs regarding concussions influence their under-reporting decisions and behaviours. METHODS: We conducted semi-structured interviews with 17 elite athletes, aged 16-18 years, from individual and team sports. Data were analyzed using constructivist grounded theory and a substantive theoretical model of sport-related concussion under-reporting was developed. RESULTS: The model demonstrates personal, social, cultural, and biophysical processes that contribute to under-reporting decisions and identifies multiple interconnected processes that contribute to 'high-risk' situations of under-reporting. Youth athletes navigate various barriers and facilitators to under-reporting, including their own desire to play, perceived stigma, concussion sense-making, and social influences. Results suggest that under-reporting by youth athletes implicates a collective, rather than individual, responsibility. CONCLUSIONS: A theoretical grounded model for youth sport-related concussion under-reporting highlights the complexity of the decision-making process. This study offers a new framework for understanding why youth athletes may hide concussion symptoms. The model offers potential to be used to develop concussion interventions and tools for improved decision-making, and to address issues of risk and responsibility concerning concussion reporting.

Subconcussive head impacts in sport: A systematic review of the evidence.

PURPOSE: To identify and evaluate the evidence that examines subconcussive impacts in sport-specific settings, and address two objectives: a) to determine how 'subconcussion' is characterized in the current literature, and b) to identify directions for future research. RESEARCH DESIGN: Systematic review. METHODS AND PROCEDURES: CINAHL, EMBASE, MedLine, PsycINFO, SportDiscus, and Web of Science were searched for articles that sought to assess subconcussive impacts or outcomes related to non-concussive head impact exposure. Eligible articles were reviewed and evaluated with three quality assessment tools by rotating pairs of reviewers. RESULTS: A total of 1966 articles were screened. Fifty-six studies met the inclusion criteria. Studies were classified into three main categories based on primary focus: neurobiological, neuropsychological, and impact exposure metrics. The neurobiological studies suggested that in male athletes, functional and microstructural deterioration was associated with repetitive head impacts. There was insufficient to weak evidence for the relationship between repetitive hits to the head and deterioration in neurocognitive performance. Studies of impact exposure metrics examined various indices, including linear acceleration, rotational acceleration, and location and frequency of hits. Insufficient evidence was presented to determine a minimal injury threshold for repetitive hits to the head. Across all categories of studies there was a lack of consistency and clarity in defining and measuring variables related to the concept of 'subconcussion'. CONCLUSIONS: Evidence reviewed predominantly from studies of male athletes in contact and collision sports identifies that repetitive hits to the head are associated with microstructural and functional changes in the brain. Whether these changes represent injury is unclear. We determined the term 'subconcussion' to be inconsistently used, poorly defined, and misleading. Future research is needed to characterize the phenomenon in question.

Psychological Risk Factors and Outcomes of Dance Injury: A Systematic Review.

Historically, dance medicine and science has focused on the physical aspects rather than the psychological aspects of dance injury. Psychological variables, however, have been shown to influence the occurrence of injury and post-injury outcomes. The purpose of this review was to examine the dance psychology literature and determine the specific psychological factors reported to be associated with the incidence, frequency, and outcome of dance injuries. A systematic literature search was conducted using SPORTDiscus, MEDLINE, CINAHL, and PsycINFO. All retrieved articles were screened based on criteria developed a priori, and selected articles were subsequently assessed for quality. Thirteen studies met the inclusion and quality assessment criteria. Psychological factors associated with both risk and outcome of dance injury included the following: stress, psychological distress, disordered eating, and coping. Factors associated only with risk of injury were sleep, personality, and social support. The results suggest that psychological variables can affect both the incidence and outcome of dance injury among dancers. Therefore, it is critical to gain a well-rounded, thorough understanding of all the factors, including psychological, that have a negative impact on dancers with respect to dance injury. The findings are discussed in terms of the utility of including psychological assessment and intervention, such as cognitive behavioral therapy, when implementing preventative and treatment measures in dance schools and companies.

Heart Rate Variability of Athletes Across Concussion Recovery Milestones: A Preliminary Study.

OBJECTIVE: To assess heart rate variability (HRV) in athletes with concussion across three phases of recovery. DESIGN: A prospective matched control group design included the collection of HRV and symptoms measured by the Rivermead Post-Concussion Questionnaire. These measures were taken at 3 phases of recovery [(1) symptomatic; (2). asymptomatic; and (3) one-week after return-to-play (RTP)]. The same protocol was completed by noninjured athletes. SETTING: Interuniversity sports teams at a single institution. PARTICIPANTS: 11 athletes, across 7 sports, diagnosed with concussion, and 11 matched-athlete controls volunteered for the study. INTERVENTION: Physician diagnosed concussion and a sitting to standing protocol for HRV monitoring. MAIN OUTCOME MEASURES: The frequency, time, and nonlinear domains of HRV were assessed along with the absolute difference between sitting and standing for each. RESULTS: A 2 x 3 (group x phase) repeated-measures analysis of variance revealed significant interactions for sitting High Frequency (HF) norm, sitting Low Frequency (LF) norm, the difference between sitting and standing HF norm, and difference between sitting and standing LF norm. Acutely, athletes with concussion displayed increased LF norm and decreased HF norm while sitting and a decreased change in their HF and LF norm measures between sitting and standing. A significant group effect for sample entropy when standing was detected, with the concussed group displaying decreased values compared with the matched controls. CONCLUSIONS: Athletes with concussion displayed autonomic dysfunction in some measures of HRV that persisted beyond RTP and were related to a previous history of concussion.

Psychological and Physiological Markers of Stress in Concussed Athletes Across Recovery Milestones.

BACKGROUND: Sport-related concussions are associated with a range of physical, cognitive, and behavioral disturbances that are highly variable across individuals. Much remains unknown about the effects of sport concussion, and changes in markers of psychological and physiological stress over the recovery timeline. OBJECTIVE: To examine psychological (mood, stress, sleep quality, and symptoms) and physiological (heart rate variability and salivary cortisol) measures in concussed athletes over clinical recovery milestones. SETTING: University athletic program, sport medicine clinic, Canada. PARTICIPANTS: A sample of 52 interuniversity athletes (32 male and 20 female), 26 with concussion and 26 healthy controls. DESIGN: Case-control repeated measures study at 3 time points of the clinical recovery process. Measures were administered to a matched control sample of uninjured athletes as well. MAIN MEASURES: Physiological measures were heart rate variability and salivary cortisol; psychological measures were mood, perceived stress, and quality of sleep. RESULTS: Psychological measures were significantly worse for concussed athletes relative to controls at the symptomatic phase (acute injury), but significantly better at return-to-play (RTP). Multivariate analysis of heart rate variability identified main effects of sex and concussion, with reduced high-frequency heart rate variability for females and concussed athletes extending into the post-RTP phase. An interaction effect was also observed, showing the cardiac response of female athletes was more sensitive to concussion compared with males. Conversely, male athletes showed greater suppression of low-frequency heart rate variability associated with mood disturbances. CONCLUSION: This integrated study of psychological and physiological markers in concussed athletes confirmed the resolution of mood disturbances, symptoms, and sleep quality by RTP, but identified autonomic nervous system disturbances, as measured by depressed heart rate variability beyond RTP.

The influence of musculoskeletal injury on cognition: implications for concussion research.

BACKGROUND: Safe return-to-play decisions after concussion can be challenging for sports medicine specialists. Neuropsychological testing is recommended to objectively measure concussion-related cognitive impairments. PURPOSE: The objective of this study was to measure cognitive functioning among 3 specific athletic groups: (1) athletes with no injuries (n = 36), (2) athletes with musculoskeletal injuries (n = 18), and (3) athletes with concussion (n = 18). STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Seventy-two intercollegiate athletes completed preseason baseline cognitive testing and follow-up assessment using the Automated Neuropsychological Assessment Metrics (ANAM) test battery. Injured athletes were tested within 72 hours of injury. A 1-way analysis of covariance adjusted for baseline scores was performed to determine if differences existed in cognitive test scores among the 3 groups. RESULTS: A group of athletes with concussion performed significantly worse than a group of athletes with no injuries on the following subtests of the ANAM at follow-up: Code Substitution Learning, Match to Sample, and Simple Reaction. Athletes with musculoskeletal injuries performed significantly worse than those with no injury on the Match to Sample subtest. No significant differences between athletes with concussion and athletes with musculoskeletal injuries were found on all ANAM subtests. CONCLUSION: Concussion produces cognitive impairment in the acute recovery period. Interestingly, athletes with musculoskeletal injuries also display a degree of cognitive impairment as measured by computerized tests. CLINICAL RELEVANCE: Although these findings support previous research that neuropsychological tests can effectively measure concussion-related cognitive impairment, this study provides evidence that athletic injury, in general, also may produce a degree of cognitive disruption. Therefore, a narrow interpretation of scores of neuropsychological tests in a sports concussion context should be avoided.

Evaluating the methodological quality of sports neuropsychology concussion research: a systematic review.

PRIMARY OBJECTIVE: Sports-related concussion is a frequently-occurring, serious neurological event that can produce a spectrum of potentially debilitating primary and secondary problems. Many investigators-particularly neuropsychologists-have focused their efforts on identifying cognitive changes that accompany such injuries. As such, the present review evaluated the methodological quality of neuropsychological sports-related concussion research using a comprehensive, systematic method. RESEARCH DESIGN: Of 349 studies initially selected by search criteria, a total of 43 studies were evaluated using a Cochrane-style review format. RESEARCH METHODS: Studies were assigned a Level of Evidence using the Centre for Evidence-based Medicine (CEMB) framework. Relevant information related to the methods of each study were extracted and rated for methodological quality using a standardized form-based evaluation tool. RESULTS: The review revealed heterogeneity among the studies in terms of research design, as well as a number of methodological weaknesses and inconsistencies. CONCLUSION: Despite the proliferation of neuropsychological research on sports-related concussion over the past decade, the methodological quality of studies appears to be highly variable, with many lacking proper scientific rigour. Future research in this area needs to be carefully controlled, repeatable and generalizable, which will contribute to developing practical, evidence-based guidelines for concussion management.

Emotional response to sport concussion compared to ACL injury.

PRIMARY OBJECTIVES: To ascertain and compare the nature of emotional response of athletes to concussion and to anterior cruciate ligament (ACL) injury. RESEARCH DESIGN: Pre-injury, post-injury and longitudinal emotional functioning of athletes with concussion (n = 16), athletes with ACL injuries (n = 7) and uninjured athletes (n = 28) were compared in a prospective repeated-measures design. METHODS AND PROCEDURES: Participants completed the short version of the Profile of Mood States (POMS). ANOVAs and trend analysis were used to examine between and within group differences across time on two sub-scales, Total Mood Disturbance and Depression. MAIN OUTCOMES AND RESULTS: Athletes with ACL injury reported higher levels of depression for a longer duration than athletes with concussion. Relative to un-injured controls, athletes with concussion reported significant changes in Total Mood Disturbance and Depression post-injury, whereas athletes with ACL injuries reported significant changes in Depression scores only. Different patterns of post-injury emotional disturbance for the injured groups were observed by trend analyses. CONCLUSIONS: Concussed athletes do not report as much emotional disturbance as athletes with ACL injuries. Differential patterns of emotional disturbance were detected between injured groups. The authors recommended that clinical protocols and educational programmes address emotional sequelae associated with sport concussion and ACL injury.

Differential emotional responses of varsity athletes to concussion and musculoskeletal injuries.

OBJECTIVE: To determine if athletes with concussion and those with minor musculoskeletal injuries experienced differential emotional response to injury. DESIGN: A prospective longitudinal cohort study. SETTING: University of Toronto, Ontario, Canada. PARTICIPANTS: Thirty-four injured athletes from Canadian Interuniversity Sport (CIS) and 19 healthy, physically active undergraduate students participated in the study. INTERVENTION: All participants completed the Profile of Mood States (POMS; short version) on 3 nonconsecutive days during a 2-week period after a baseline test. MAIN OUTCOME MEASURES: Emotional responses were assessed using the POMS. The 7 main outcome measures assessed by POMS were tension, depression, anger, vigor, fatigue, confusion, and total mood disturbance. RESULTS: After injury, concussion produced an emotional profile characterized by significantly elevated fatigue and decreased vigor. In contrast, athletes with musculoskeletal injuries displayed a significant increase in anger that resolved to a pre-injury level within 2 weeks. CONCLUSIONS: The results revealed that both injured groups experienced emotional disturbance after injury. More importantly, the findings strongly suggest that the emotional reaction after concussion is different from that of musculoskeletal injury. Therefore, we concluded that assessing emotional reactions to concussion is particularly important and recommend that sports medicine professionals assess and monitor emotional functioning as well as somatic complaints and neurocognitive changes during recovery.

Does the apolipoprotein epsilon 4 allele predispose varsity athletes to concussion? A prospective cohort study.

OBJECTIVE: To determine the association between the apolipoprotein epsilon 4 allele and concussion. We hypothesized that apolipoprotein epsilon 4 carriers may be more likely to sustain a concussion. DESIGN: Prospective cohort study. SETTING: University of Toronto varsity athletics. PARTICIPANTS: Included 318 of 822 collegiate student athletes who participated in University of Toronto varsity sports from September 2002 to April 2006. ASSESSMENT OF RISK FACTORS: The presence of apolipoprotein epsilon 4 was described dichotomously after genotyping blood samples collected from participants. MAIN OUTCOME MEASUREMENTS: Concussions were identified by sport-medicine professionals present on the sidelines using on-field assessment forms. All concussion diagnoses were verified by a sports medicine physician. Survival analysis was used to determine the association between apolipoprotein epsilon 4 and first concussion. RESULTS: The unadjusted hazard ratio for concussion in the apolipoprotein epsilon 4 carriers was 1.18 (95% CI: 0.52, 2.69) compared to noncarriers. Adjustment for sex, weight, height, and team type resulted in a hazard ratio of 1.06 (95% CI: 0.41, 2.72), indicating little effect from confounding factors. CONCLUSIONS: There is no important association between carrying the apolipoprotein epsilon 4 allele and sustaining a concussion. At this time, we do not recommend preseason genetic testing for varsity athletes as a mechanism for targeting prevention strategies.

The functional repertoire of the hand and its application to assessment.

Functional assessment of the hand typically involves evaluation of proficiency using a test battery rather than identifying the range of hand skills available to a client. Establishing a clients hand function by reference to the movement repertoire of his or her fully-functioning hand offers numerous benefits for clinicians and researchers. A functional repertoire model of the hand is proposed as a framework for guiding assessment and therapy. The model identifies four main components relating to hand function: personal constraints, hand roles, hand actions, and task parameters. The model provides a common language for assessment, program development, and research across populations. Application here is to hand-injured clients, but the framework is equally valuable for hand function assessment of developmentally and physically challenged individuals, persons with neuromuscular disorders, or geriatric populations.