Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review.

OBJECTIVES: To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6). DATA SOURCES: Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation. ELIGIBILITY CRITERIA: (1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC. DATA EXTRACTION: Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool. RESULTS: Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children. CONCLUSION: Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes. PROSPERO REGISTRATION NUMBER: CRD42020154787.

Gaze stability in youth athletes: A normative observational study.

BACKGROUND: The Gaze Stabilization Test (GST) assesses vestibulo-ocular reflex (VOR) function by determining the maximum head velocity at which an individual can accurately perceive a fixed-size visual target. There is limited information about gaze stability performance in youth athletes. OBJECTIVE: The purpose of this study is to describe baseline performance of athletes ages 17 years and under on a computerized GST and explore the influence of demographic characteristics on performance. METHODS: Baseline GST and demographic data were acquired via retrospective chart review. RESULTS: The sample included 106 athletes aged 8 to 17 years (mean 13.9 years±1.79; 78% male). The median values for baseline GST function were 180 (IQR: 150-210) degrees per second (d/sec) in the leftward direction, and 190 d/sec (IQR: 160-220) in the rightward direction. There were no significant effects of sex/gender or concussion history on GST performance. CONCLUSIONS: The GST is one of many tools available for clinicians to use in a multi-modal approach to concussion management. Understanding how healthy young athletes perform can assist clinicians in determining vestibular impairment, formulating the exercise prescription, and estimating physiologic recovery.

Gaze stability in the elite athlete: A normative observational study.

BACKGROUND: The ability to clearly perceive an object while the head is in motion is important in athletics, as it relates to performance and potentially to injury prevention. Normative data for healthy adults on measures of gaze stability have been established. However, data for elite athletes is scarce. OBJECTIVE: To describe performance of elite athletes on computerized gaze stability testing and establish normative data for reference. METHODS: Data were acquired via retrospective chart review. 134 male professional baseball players completed computerized Visual Acuity, Visual Perception Time and Gaze Stability Tests as part of a multi-modal baseline testing session. RESULTS: Performance of all athletes was superior to general population norms reported in the literature. There were no significant differences between the optimal and suboptimal consistency groups or between English-speaking and non- or limited-English speaking players. CONCLUSIONS: Similar to prior studies with smaller samples that have examined GST in athletes, we found high levels of GST performance in professional baseball players relative to normative data for the general population. Normative data for elite athletes was established using this healthy sample. This study underscores the importance of understanding the unique abilities of elite athletes when providing therapy after injury.

Comparison of Uninjured and Concussed Adolecent Athletes on the Concussion Balance Test (COBALT).

BACKGROUND AND PURPOSE: Dizziness and balance problems are common symptoms following sports-related concussion (SRC). Most sports require high-level balance skills that integrate the sensory inputs used for balance. Thus, a comprehensive assessment of postural control following SRC is recommended as an integral part of evaluation and management of the injury. The purpose of this exploratory study was to examine performance differences between uninjured and concussed athletes on the Concussion Balance Test (COBALT), as well as complete preliminary analyses of criterion-related validity and reliability of COBALT. METHODS: COBALT is an 8 condition test developed for both preseason and postinjury assessment using force plate technology to measure sway velocity under dynamic postural conditions that challenge the vestibular system. Retrospective COBALT data obtained through chart review for 132 uninjured athletes and 106 concussed age-matched athletes were compared. RESULTS: All uninjured athletes were able to complete the assessment, compared with only 55% of concussed athletes. Concussed athletes committed significantly more errors than uninjured athletes. Sway velocity for concussed athletes was higher (worse) than that for uninjured athletes on 2 conditions in COBALT. DISCUSSION AND CONCLUSIONS: By examining an athlete's ability to complete the protocol, error rate, and sway velocity on COBALT postinjury, the clinician can identify balance function impairment, which may help the medical team develop a more targeted treatment plan, and provide objective input regarding recovery of balance function following SRC.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A204).

Fighting to keep a sport safe: toward a structured and sport-specific return to play protocol.

Combat sports are growing in popularity, viewership, and participation. The nature of these sports involves repetitive head contact, yet unlike most other professional contact sports, there are no endorsed guidelines or mandates for graduated and systematic return to play following concussion. Here, we review the literature related to concussion and fighting sports, and propose guidelines for concussion management and safe return to play following concussion.

Short-term neurocognitive outcomes following anterior temporal lobectomy.

Changes in cognitive function are a well established risk of anterior temporal lobectomy (ATL). Deficits in verbal memory are a common postoperative finding, though a small proportion of patients may improve. Postoperative evaluation typically occurs after six to 12months. Patients may benefit from earlier evaluation to identify potential needs; however, the results of a formal neuropsychological assessment at an early postoperative stage are not described in the literature. We compared pre- and postoperative cognitive function for 28 right ATL and 23 left ATL patients using repeated measures ANOVA. Changes in cognitive function were compared to ILAE seizure outcome. The mean time to postoperative neuropsychological testing was 11.1weeks (SD=6.7weeks). There was a side×surgery interaction for the verbal tasks: immediate memory recall (F(1,33)=20.68, p<0.001), short delay recall (F(1,29)=4.99, p=0.03), long delay recall (F(1,33)=10.36, p=0.003), recognition (F(1,33)=5.69, p=0.02), and naming (F(1,37)=15.86, p<0.001). This indicated that the left ATL group had a significant decrement in verbal memory following surgery, while the right ATL group experienced a small but significant improvement. For the right ATL group, there was a positive correlation between ILAE outcome and improvement in immediate recall (r=-0.62, p=0.02) and long delay recall (r=-0.57, p=0.03). There was no similar finding for the left ATL group. This study demonstrates that short-interval follow-up is effective in elucidating postoperative cognitive changes. Right ATL was associated with improvement in verbal memory, while left ATL resulted in a decrement in performance. Improvement in the right ATL group was related to improved seizure outcome. Short-interval follow-up may lend itself to the identification of patients who could benefit from early intervention.

A refractory arachnoid cyst presenting with tremor, expressive dysphasia, and cognitive decline.

BACKGROUND: Arachnoid cysts are common incidental findings on intracranial imaging, although they are rarely symptomatic. CASE DESCRIPTION: We present a case of a 49 year-old woman with a recurrent left supraorbital arachnoid cyst who developed staring spells, expressive dysphasia, and tremor after cyst fenestration and cystoperitoneal shunting. Her symptoms resolved after removing the shunt valve and creating a valveless system. The case is discussed and the literature reviewed. CONCLUSION: We present a case of a recurrent arachnoid cyst that developed worsening and new symptoms after cysto-peritoneal shunting with a programmable valve, which reducing the pressure in the cyst resulted in remarkable resolution of her symptoms.

The multidisciplinary concussion management program.

Over the past decade, research has increased scientific and public knowledge about the importance of identification and proper management of concussion. These concerns have prompted many state, regional, and private organizations to mandate the creation of, and strict adherence to, concussion management protocols, particularly with regard to sport-related concussion and subsequent return to play. Because of the individualized nature of the concussive injury and its recovery, a multidisciplinary approach provides comprehensive patient care that best addresses treatment and management of changing symptoms and their impact on multiple aspects of a patient's life and overall function. The current report will explore a model of multidisciplinary concussion management from program establishment and baseline testing to recovery from chronic postconcussion symptoms.

Do manualized treatments for depression reduce insomnia symptoms?

OBJECTIVE: Researchers evaluated the effect of manualized treatments for depression on comorbid symptoms of insomnia. METHOD: Hierarchical linear modeling was used to analyze archival data collected from 14 studies (N = 910) examining the efficacy of psychological treatments for depression in adults. RESULTS: Participants receiving a psychological treatment for depression experienced significantly more relief from symptoms of insomnia with overall, early-, middle-, and late-night sleep than those not receiving such treatment. CONCLUSION: Symptoms of insomnia in those with an average (or lower) level of depression can be reduced through psychological treatment for depression. However, more severe depressive symptoms do not receive great relief from sleep disturbance and may require an additional treatment component targeting symptoms of insomnia.

Efficacy and process of cognitive bibliotherapy for the treatment of depression in jail and prison inmates.

The purpose of this two-study project was to determine the effects of cognitive bibliotherapy for the treatment of depressive symptoms in jail and prison inmates. Participants in both samples were randomly assigned to either a treatment group that received the 4-week bibliotherapy program or a delayed-treatment control group. In the jail sample, which served as a pilot study for the more detailed prison study, the treatment group showed greater improvement on the A. T. Beck and R. A. Steer Beck Depression Inventory, 1993, Psychological Corporation, San Antonio, TX and the DAS (M. M. Weissman, & A. T. Beck Development and validation of the Dysfunctional Attitudes Scale: A preliminary investigation; paper presented at the meeting of the American Educational Research Association, November, 1978, Toronto, ON, Canada). In the prison sample, results indicated that the treatment group showed greater improvement on the HRSD (M. Hamilton, Development of a rating scale for primary depressive illness, British Journal of Social & Clinical Psychology, Vol. 6, 1967, pp. 278-296) and the A. T. Beck, R. A. Steer, & G. K. Brown Beck Depression Inventory (2nd ed.), 1996, Psychological Corporation, San Antonio, TX. Approximately half of the treated participants achieved clinically significant change. Analyses of the follow-up data revealed maintenance of treatment gains in the prison and jail samples. In the prison study, significant changes were also observed on a general measure of psychological distress. Overall, results suggest that cognitive bibliotherapy may be efficacious for depressed inmates.

A revised factor structure for the post-concussion symptom scale: baseline and postconcussion factors.

BACKGROUND: Symptom reports play a critical role in the assessment and management of concussions. Symptoms are often conceptualized as factors comprising several related symptoms (eg, somatic factor = headache, nausea, vomiting). Previous research examining the factor structure of the 22-item Post-Concussion Symptom Scale (PCSS) has been limited to small samples and has not adequately evaluated factor loadings at both baseline and postconcussion for male and female athletes at the high school and collegiate levels. PURPOSE: To examine the factor structure of the 22-item PCSS in independent samples of high school and collegiate athletes reported at baseline and postconcussion, and to evaluate sex and age differences in the resulting baseline and postconcussion symptom factor scores. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Exploratory factor analytic (EFA) methods were applied to 2 separate samples of athletes who completed the PCSS at baseline (n = 30,455) and 1 to 7 days after a sport-related concussion (n = 1438). The baseline sample (mean ± standard deviation) was 15.74 ± 1.78 years, with a range of 13 to 22 years, and the postconcussion sample was 17.14 ± 2.25 years, with a range of 13 to 24 years. RESULTS: A 4-factor solution accounting for 49.1% of the variance at baseline included a cognitive-sensory, sleep-arousal, vestibular-somatic, and affective factor structure. A 4-factor solution that included cognitive-fatigue-migraine, affective, somatic, and sleep was revealed for the postconcussion EFA. High school athletes reported higher baseline levels of the cognitive-sensory and vestibular-somatic symptom factors and lower levels of the sleep-arousal factor than college athletes. Female participants reported higher symptoms on all postconcussion factors than male participants. CONCLUSION: The current findings reveal different symptom factors at baseline and postinjury and several age and sex differences on the symptom factors. At postconcussion, symptoms aggregated into a global concussion factor including cognitive, fatigue, and migraine symptoms. Symptoms reported at baseline are not the same as those reported after injury. The presence of a global postconcussion symptom comprising the fatigue factor highlights the importance of physical and cognitive rest during the first week after a concussion. Although headache was the most commonly reported symptom, it was not the greatest contributor to the global postconcussion symptom factor.

Postconcussive symptoms are associated with compensatory cortical recruitment during a working memory task.

BACKGROUND: The severity of sports-related concussion is often characterized by the number and severity of postconcussive symptoms (eg, headache, dizziness, difficulty concentrating). Although the level of postconcussive symptoms after injury is believed to index the severity of the neurological insult sustained, studies examining the relationship between symptom severity and neural functioning in concussed athletes remain rare. OBJECTIVE: This exploratory study examined the association between self-reported symptom severity and functional activation on a working memory task in a group of 16 recently concussed student athletes. METHODS: Functional magnetic resonance imaging was used to examine the relationship of symptom severity to brain activation during a working memory task in 16 concussed subjects. RESULTS: Findings indicated that symptom severity was associated with regionally specific hyperactivation during a working memory task, even though symptom severity was not significantly related to task accuracy. CONCLUSION: The results add to a growing body of literature that demonstrates that functional neuroimaging may have the potential to serve as a sensitive biomarker of the severity of concussion and mild traumatic brain injury.

Neurocognitive and symptom predictors of recovery in high school athletes.

OBJECTIVES: The purpose of this study was to identify specific symptom and neuropsychological test patterns that might serve as prognostic indicators of recovery in concussed high school football players. The recently proposed simple versus complex concussion classification was examined and specific symptom clusters were identified. DESIGN: Case-control study. SETTING: High school football. PARTICIPANTS: Subjects were 108 recently concussed male high school football athletes between the ages of 13 and 19 (mean, 16.01) years. ASSESSMENT OF RISK FACTORS: Participants were evaluated by utilizing the Immediate Postconcussion Assessment and Cognitive Testing computer-based neurocognitive test battery at before injury and within an average of 2.23 days of injury. All athletes were followed until they met criteria for clinical recovery. MAIN OUTCOME MEASURES: Symptom ratings and neurocognitive test performance. RESULTS: Both neurocognitive test results and self-reported symptom data had prognostic value in determining time to clinical recovery. Self-reported cognitive decline, Immediate Postconcussion Assessment and Cognitive Testing reaction time, and migraine headache symptoms were associated with longer time to clinical recovery. Overall, these difficulties were predictive of concussions that were retrospectively classified as complex. CONCLUSIONS: Specific symptom clusters and neurocognitive test results may have predictive value to classifying and managing concussions.

The relation between post concussion symptoms and neurocognitive performance in concussed athletes.

The objective of this study was to examine differences in neurocognitive performance between symptomatic concussed athletes, a group of concussed athletes with no subjective symptoms, and a non-concussed control group of athletes. All concussed athletes were evaluated within one week of injury using the ImPACT computerized test battery. Results indicate that concussed athletes who denied subjective symptoms demonstrated poorer performance than control subjects on all four composite scores of the ImPACT test batters (Verbal Memory, Visual Memory, Reaction Time and Processing Speed However, the concussed but asymptomatic group demonstrated significantly better performance than did the concussed and symptomatic group. Thus, concussed athletes who did not report subjective symptoms were not fully recovered based on neurocognitive testing. This study underscores the importance of neurocognitive testing in the assessment of concussion sequelae and recovery.

Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes.

OBJECTIVE: The relationship between athlete reports of symptoms, neurophysiological activation, and neuropsychological functioning is investigated in a sample of high school athletes. METHODS: All athletes were evaluated using functional magnetic resonance imaging (fMRI), a computer-based battery of neurocognitive tests, and a subjective symptom scale. Athletes were evaluated within approximately 1 week of injury and again after clinical recovery using all assessment modalities. RESULTS: This study found that abnormal fMRI results during the first week of recovery predicted clinical recovery. As a group, athletes who demonstrated hyperactivation on fMRI scans at the time of their first fMRI scan demonstrated a more prolonged clinical recovery than athletes who did not demonstrate hyperactivation at the time of their first fMRI scan. CONCLUSION: These results demonstrate the relationship between neurophysiological, neuropsychological, and subjective symptom data in a relatively large sample composed primarily of concussed high school athletes. fMRI represents an important evolving technology for the understanding of brain recovery after concussion and may help shape return-to-play guidelines in the future.

Effectiveness of mouthguards in reducing neurocognitive deficits following sports-related cerebral concussion.

Although it is widely accepted that mouthguards decrease the incidence of dental injuries, there is a controversy among sports medicine professionals as to the effectiveness of mouthguards in decreasing the incidence or severity of sports-related cerebral concussion (SRCC). While some experimental data suggest that this may be the case, there exist a number of reports suggesting that mouthguards do not serve this purpose. These conclusions have been drawn, however, without actually measuring the extent of neurocognitive dysfunction in athletes following sports-related concussion. The purpose of this study was to determine whether mouthguard use reduces the neurocognitive and symptomatic impairments that follow an injurious episode of SRCC. Preseason baseline data were collected as part of an ongoing clinical program that uses a computerized neurocognitive test to assess various faculties of brain function and symptoms reported at the time of testing. Follow-up testing from 180 student-athletes who had sustained an SRCC was analyzed for the purpose of this study. These athletes were separated into one of two groups: those who reported using mouthguards and those who did not. Neurocognitive testing was accomplished using the Immediate Post-Concussion and Assessment Test (ImPACT). Results suggest that neurocognitive deficits at the time of the athletes' first follow-up assessment did not differ between mouthguard users and non-users, suggesting that mouthguard use does little to reduce the severity of neurocognitive dysfunction and onset of symptoms following sports-related head trauma. However, an interesting finding in this study was that athletes experienced significantly lower neurocognitive test scores and reported higher symptom scores following SRCC regardless of mouthguard use. This emphasizes a thorough clinical evaluation of athletes that have sustained an SRCC. Although it was found in this study that mouthguard use does not decrease the severity of concussion, it is important to note that the use of mouthguards is paramount in reducing maxillofacial and dental trauma and their use should continue to be mandated by athletic associations and supported by all dental and sports medicine professionals.