Female RNA concussion (FeRNAC) study: assessing hormone profiles and salivary RNA in females with concussion by emergency departments in New Zealand: a study protocol.

BACKGROUND: Females of reproductive age with concussion report a greater number of symptoms that can be more severe and continue for longer than age matched males. Underlying mechanisms for sex differences are not well understood. Short non-coding Ribonucleic Acids (sncRNAs) are candidate salivary biomarkers for concussion and have been studied primarily in male athletes. Female sex hormones influence expression of these biomarkers, and it remains unclear whether a similar pattern of sncRNA expression would be observed in females following concussion. This study aims to evaluate recovery time, the ratio of salivary sncRNAs and symptom severity across different hormone profiles in females presenting to emergency departments (ED) with concussion and, to investigate the presence of low energy availability (LEA) as a potential modifier of concussion symptoms. METHODS: This prospective cohort study recruits participants from New Zealand EDs who are biologically female, of reproductive age (16-50 years) and with a confirmed diagnosis of concussion from an ED healthcare professional. Participants are excluded by ED healthcare professionals from study recruitment as part of initial routine assessment if they have a pre-diagnosed psychiatric condition, neurological condition (i.e., epilepsy, cerebral palsy) or more than three previously diagnosed concussions. Participants provide a saliva sample for measurement of sncRNA's, and online survey responses relating to hormone profile and symptom recovery at 7-day intervals after injury until they report a full return to work/study. The study is being performed in accordance with ethical standards of the Declaration of Helsinki with ethics approval obtained from the Health and Disability Ethics Committee (HDEC #2021 EXP 11655), Auckland University of Technology Ethics Committee (AUTEC #22/110) and locality consent through Wellington hospital research office. DISCUSSION: If saliva samples confirm presence of sncRNAs in females with concussion, it will provide evidence of the potential of saliva sampling as an objective tool to aid in diagnosis of, and confirmation of recovery from, concussion. Findings will determine whether expression of sncRNAs is influenced by steroid hormones in females and may outline the need for sex specific application and interpretation of sncRNAs as a clinical and/or research tool. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) registration number ACTRN12623001129673.

Use of the concussion check protocol for concussion assessment in a female soccer team over two consecutive seasons in New Zealand.

AIM: Address deficiencies in access to sports sideline medical care by using a Concussion Check Protocol (CCP) for non-medically-trained people. METHOD: A prospective observational cohort study was undertaken on a single amateur female club-based soccer team over two consecutive years in New Zealand utilising a non-medically trained support person termed a Safety officer. CCP is an extension of the King-Devick test with features such as warning signs and symptoms of concussion built into the application. All players suspected of having a potential concussive injury were tested on the match sideline. RESULTS: The study overall incidence of match-related concussions was 20.8 (95% CI: 11.8 to 36.6) per 1000 match-hrs, with mean missed-match duration of 31 (95% CI: 27.9 to 34.1) days. Twelve players over the study had a significantly slower post-injury KD (49.9 [44.3 to 64.1]s; χ2(1) = 11.0; p = 0.0009; z = -2.9; p = 0.0033; d = 0.30) and/or reported symptoms, compared with their own baseline (47.2 [44.3 to 64.1]s). CCP had an overall sensitivity of 100% (95% CI: 73.5% to 100.0%), specificity of 100% (95% CI: 69.2% to 100.0%) and positive predictive value (PPV) of 100% (84.6% to 100.0%). CONCLUSION: Sideline use of CCP was undertaken successfully by non-medically trained people and provided a reliable platform for concussion identification.

Reliability of a Smooth Pursuit Eye-Tracking System (EyeGuide Focus) in Healthy Adolescents and Adults.

Mild traumatic brain injury (mTBI) is the most common brain injury, seen in sports, fall, vehicle, or workplace injuries. Concussion is the most common type of mTBI. Assessment of impairments from concussion is evolving, with oculomotor testing suggested as a key component in a multimodality diagnostic protocol. The aim of this study was to evaluate the reliability of one eye-tracking system, the EyeGuide Focus. A group of 75 healthy adolescent and adult participants (adolescents: n = 28; female = 11, male = 17, mean age 16.5 ± 1.4 years; adults n = 47; female = 22; male = 25, mean age 26.7 ± 7.0 years) completed three repetitions of the EyeGuide Focus within one session. Intraclass correlation coefficient (ICC) analysis showed the EyeGuide Focus had overall good reliability (ICC 0.79, 95%CI: 0.70, 0.86). However, a familiarization effect showing improvements in subsequent trials 2 (9.7%) and 3 (8.1%) was noticeable in both cohorts (p < 0.001) with adolescent participants showing greater familiarization effects than adults (21.7% vs. 13.1%). No differences were observed between sexes (p = 0.69). Overall, this is the first study to address the concern regarding a lack of published reliability studies for the EyeGuide Focus. Results showed good reliability, suggesting that oculomotor pursuits should be part of a multimodality assessment protocol, but the observation of familiarization effects suggests that smooth-pursuit testing using this device has the potential to provide a biologically-based interpretation of the maturation of the oculomotor system, as well as its relationship to multiple brain regions in both health and injury.

Assessment of Somatosensory and Motor Processing Time in Retired Athletes with a History of Repeated Head Trauma.

Measurement of the adverse outcomes of repeated head trauma in athletes is often achieved using tests where the comparator is 'accuracy'. While it is expected that ex-athletes would perform worse than controls, previous studies have shown inconsistent results. Here we have attempted to address these inconsistencies from a different perspective by quantifying not only accuracy, but also motor response times. Age-matched control subjects who have never experienced head trauma (n = 20; 41.8 ± 14.4 years) where compared to two cohorts of retired contact sport athletes with a history of head trauma/concussions; one with self-reported concerns (n = 36; 45.4 ± 12.6 years), and another with no ongoing concerns (n = 19; 43.1 ± 13.5 years). Participants performed cognitive (Cogstate) and somatosensory (Cortical Metrics) testing with accuracy and motor times recorded. Transcranial magnetic stimulation (TMS) investigated corticospinal conduction and excitability. Results showed that there was little difference between groups in accuracy scores. Conversely, motor times in all but one test revealed that ex-athletes with self-reported concerns were significantly slower compared to other groups (p ranges 0.031 to <0.001). TMS latency showed significantly increased time (p = 0.008) in the group with ongoing concerns. These findings suggest that incorporating motor times is more informative than considering accuracy scores alone.

New Zealand cricket injury analysis based on 12 years of Accident Compensation Corporation data.

Objectives: To provide epidemiological data for cricket injuries in New Zealand. Methods: A retrospective analytical review using epidemiological cricket data obtained from the national Accident Compensation Corporation (ACC) for 2005-2016. Injury incidence was calculated per 1000 participants. Results: There were 86 562 injuries (77 212 males and 9350 females) during the 12 years with higher injury incidence for males (64.1) than females (36.1). While cricket-related injury claims increased by 42.6%, the injury incidence decreased from 59.0 in 2006 to 42.8 in 2016. The pooled injury rate per 1000 participants was highest for hand/fingers (9.2) and lumbar (8.1) body regions, and for contact (44.7) activities. Players aged 10-20 years were more likely to experience injury. Conclusions: Analysis of 12 years of ACC cricket-related injury claims showed only minimal reductions in injury incidence over the years. Therefore, cricket-related contact injuries to the hand/fingers and head need to be the focus of injury prevention programmes (eg, via promoting use of protective gear and correct technique), particularly in players aged 10-20 years.

Brain Injury Screening Tool (BIST): test-retest reliability in a community adult sample.

OBJECTIVE: To determine the test-retest reliability of the Brain Injury Screening Tool (BIST), which was designed to support the initial assessment of mild traumatic brain injury (mTBI) across a variety of contexts, including primary and secondary care. DESIGN: Test-retest design over a 2-week period. SETTING: Community based. PARTICIPANTS: Sixty-eight adults (aged 18-58 years) who had not experienced an mTBI within the last 5 years and completed the BIST on two different occasions. MEASURES: Participants were invited to complete the 15-item BIST symptom scale and the Depression, Anxiety and Stress Scale (DASS-21) online at two time-points (baseline and 2 weeks later). To account for large variations in mood affecting symptom reporting, change scores on the subscales of the DASS-21 were calculated, and outliers were removed from the analysis. RESULTS: The BIST total symptom score and subscale scores (physical-emotional, cognitive and vestibular) demonstrated moderate to good test-retest reliability with intraclass correlation coefficients ranging between 0.51 and 0.83. There were no meaningful differences between symptom reporting on the total scale or subscales of the BIST between time1 and time2 at the p<0.05 level when calculated using related samples Wilcoxon signed-rank tests. CONCLUSION: The BIST showed evidence of good stability of symptom reporting within a non-injured, community adult sample. This increases confidence that changes observed in symptom reporting in an injured sample are related to actual symptom change rather than measurement error and supports the use of the symptom scale to monitor recovery over time. Further research is needed to explore reliability of the BIST within those aged <16 years.

Match and training injury incidence in rugby league: A systematic review, pooled analysis, and update on published studies.

In studies reporting rugby league injuries, match injuries varied depending upon participation level. To review and update pooled data estimates for rugby league injury epidemiology and add information for participation levels in match and training environments. A systematic review and pooled analysis for published studies reporting rugby league match and training injuries. Searches were performed in the PubMed, CINHAL, ScienceDirect, Scopus, SPORTDiscus, SpringerLink, and Wiley Online databases. Studies were considered if they reported on rugby league match or training injuries between Jan 1990 to June 2021. Two authors (DK, TC) extracted the study characteristics, numerical data and assessed the article quality, by adhering to the protocol for systematic review of observational studies (MOOSE) and the STrengthening and Reporting of OBservational studies in Epidemiology (STROBE) statement. The 46 studies included a combined exposure of 419,037 h and 18,783 injuries incorporating 158,003 match-hr and 15,706 match injuries (99.4 [95%CI: 97.9-101.0] per 1000 match-hr) and 264,033 training-hr and 3077 training injuries (11.8 [95%CI: 11.4-12.2] per 1000 training-hr). Of included studies, 47.9% utilised a medical attention/treatment injury definition. There was a five-fold difference in injuries for the semi-professional participation level (431.6 per 1000 match-hr) compared with professional (RR: 4.92; p < 0.001) and elite (RR: 3.77; p < 0.001) participation levels. The hooker recorded the highest pooled injury incidence (93.1 per 1000 match-hr). Compared to the 2014 analysis there was a 10-fold increase for head-neck region (RR: 10.7; p < 0.001) injury incidence, and more injuries for the ball carrier (RR: 1.1; p = 0.008) and tackler (RR: 1.2; p = 0.001). There was a three-fold decrease in injury incidence in the first half (RR: 2.9; p < 0.001) and a two-fold decrease in the second half (RR: 2.3; p < 0.001) of matches. While rugby league match and training injury incidence had decreased since 2014, the increase in head injuries, and greater injury rate at the semi-professional level, mean further injury prevention interventions are needed.

The Incidence, Cost, and Burden of Concussion in Women's Rugby League and Rugby Union: A Systematic Review and Pooled Analysis.

BACKGROUND: The extent of concussion injury in the rugby codes for women is unclear. OBJECTIVE: Our aim was to review all published studies reporting concussion injuries from match and training participation in rugby codes and report the pooled data estimates for rugby league and union concussion injury epidemiology. METHODS: We conducted a systematic literature analysis of concussion in rugby league and rugby union for published studies from January 1990 to July 2021. Data from 16 studies meeting the inclusion criteria were extracted for women's concussion injuries and were subsequently pooled. Costs from Accident Compensation Corporation (ACC) data were attributed to the results to provide cost estimates. RESULTS: The pooled analysis match injury incidence of women's concussion was higher for rugby league (10.3 per 1000 match hours) than rugby 15 s (2.8 per 1000 match hours) or rugby 7 s (8.9 per 1000 match hours). There was a fourfold difference in the pooled incidence of concussion in women's rugby league (risk ratio [RR] 4.53, 95% confidence interval [CI] 1.8-11.3]; p = 0.0001) when compared with rugby 15 s. There was also a ninefold higher risk of a concussion during match participation compared with training participation for women's rugby 15 s (RR 9.3, 95% CI 1.29-66.78; p = 0.0070). The total estimated costs for the concussions reported were NZ$1,235,101. For rugby 7 s, the pooled concussive injury burden was 33.2 days. CONCLUSIONS: Our pooled analysis clarified the extent of concussion injury and the possible associated costs at several levels of the game for women's rugby codes. The pooled mean days lost because of concussions was 33 days. As this was considerably longer than the 7- to 10-day expected timeframe outlined in the Concussion in Sport Consensus statement, these guidelines need to be updated to include sex-specific differences.

Profiling the tackle and its injury characteristics in premier New Zealand club rugby union players over a complete season.

OBJECTIVES: RugbySmart is a safe tackle technique education programme. Our objective was to identify whether the RugbySmart-recommended safe tackle technique was exhibited by club rugby players and whether tackle-related injuries showed poor tackle technique characteristics. METHODS: The prospective cohort design enabled 28 senior club based amateur male rugby union players from New Zealand to be followed over 18 matches in the 2017 rugby season. Game video analysis by three analysts provided categorisation of tackle technique into type, approach, foot contact, leading foot and rear foot position, face and head position. Injuries were diagnosed by the same sports medicine physician. RESULTS: In the 18 matches, 28 players completed a combined total of 3006 tackles, with only six tackle-related injuries sustained. Notable findings included: (1) forwards complete more tackles than backs; (2) shoulder tackles were the most prevalent tackle; (3) good tackle technique as promoted by RugbySmart was demonstrated in 57.9% of all tackles and (4) of the six tackle-related injuries, two occurred despite RugbySmart desired tackle techniques. CONCLUSION: This is the first study to investigate whether players were performing the recommended 'safe tackle technique' proposed by New Zealand Rugby's RugbySmart programme. As two of six tackle-related injuries occurred despite the RugbySmart preferred technique being performed, further technique analysis and a larger sample are needed to determine what techniques reduce risk of injury during tackles. As only 57.9% of tackles were performed with RugbySmart head and foot positions, further research and education regarding tackle technique recommendations are needed.

Senior Club-Level Rugby Union Player's Positional Movement Performance Using Individualized Velocity Thresholds and Accelerometer-Derived Impacts in Matches.

ABSTRACT: Takamori, S, Hamlin, MJ, Kieser, DC, King, D, Hume, P, Yamazaki, T, Hachiya, M, and Olsen, PD. Senior club-level rugby union player's positional movement performance using individualized velocity thresholds and accelerometer-derived impacts in matches. J Strength Cond Res 36(3): 710-716, 2022-Game demands of professional rugby union players have been well documented; however, there is minimal game demand information using individualized velocity thresholds and collision loads, particularly for amateurs. This study investigated movement patterns of 20 male amateur rugby players during 16 senior premier division one matches using global positioning system (GPS) devices sampling at 10 Hz. Derived GPS variables included distances, velocities, sprinting, and impacts. Data files from 86 player games (≥60 minutes of play per game) were categorized into broad (forwards and backs) and specific (front row, second row, back row, half back, inside back, and outside back) positional groups for analysis. It was most likely that backs covered more distance in the high-speed running (>60% maximal velocity) zone (502 ± 157 m) compared with forwards (238 ± 147 m) (100/0/0%, chances of positive/trivial/negative differences, effect size [ES] = 1.3), performed more striding (backs 1,116 ± 240, forwards 954 ± 240 m, 96/4/0%, ES = 0.5), and sprinting (backs 121 ± 58, forwards 90 ± 65 m, 93/7/0%, ES = 0.5). However, forwards had higher collision loads (35 ± 12 arbitrary units) compared with backs (20 ± 6, 99.9/0.1/0%, ES = 1.3) with back row forwards completing the highest collision load of any playing position (40 ± 13). Our example match movement performance and impact information is valuable to coaches and support staff in preparing player profiles for similar-level rugby players to help manage their workloads.

Do Sideline Tests of Vestibular and Oculomotor Function Accurately Diagnose Sports-Related Concussion in Adults? A Systematic Review and Meta-analysis.

BACKGROUND: Sports-related concussion (SRC) assessment tools are primarily based on subjective assessments of somatic, cognitive, and psychosocial/emotional symptoms. SRC symptoms remain underreported, and objective measures of SRC impairments would be valuable to assist diagnosis. Measurable impairments to vestibular and oculomotor processing have been shown to occur after SRC and may provide valid objective assessments. PURPOSE: Determine the diagnostic accuracy of sideline tests of vestibular and oculomotor dysfunction to identify SRC in adults. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Electronic databases and gray literature were searched from inception until February 12, 2020. Physically active individuals (>16 years of age) who participated in sports were included. The reference standard for SRC was a combination of clinical signs and symptoms (eg, the Sport Concussion Assessment Tool [SCAT]), and index tests included any oculomotor assessment tool. The QUADAS tool was used to assess risk of bias, with the credibility of the evidence being rated according to GRADE. RESULTS: A total of 8 studies were included in this review. All included studies used the King-Devick test, with no other measures being identified. Meta-analysis was performed on 4 studies with a summary sensitivity and specificity of 0.77 and 0.82, respectively. The overall credibility of the evidence was rated as very low. CONCLUSION: Caution must be taken when interpreting these results given the very low credibility of the evidence, and the true summary sensitivity and specificity may substantially differ from the values calculated within this systematic review. Therefore, we recommend that clinicians using the King-Devick test to diagnose SRC in adults do so in conjunction with other tools such as the SCAT. PROSPERO REGISTRATION: CRD42018106632.

Mental Health and Wellbeing of Retired Elite and Amateur Rugby Players and Non-contact Athletes and Associations with Sports-Related Concussion: The UK Rugby Health Project.

BACKGROUND: Concerns have intensified over the health and wellbeing of rugby union and league players, and, in particular, about the longer-term effects of concussion. The purpose of this study was to investigate whether there were differences in mental health, sleep and alcohol use between retired elite and amateur rugby code players and non-contact athletes, and to explore associations with sports-related concussion. METHODS: 189 retired elite (ER, n = 83) and amateur (AR, n = 106) rugby code players (rugby union n = 145; rugby league n = 44) and 65 former non-contact athletes (NC) were recruited to the UK Rugby Health Project between 2016 and 2018. Details on sports participation and concussion history were obtained by questionnaire, which also included questions on mental health, anger, sleep, mood, alcohol use, social connections and retirement from injury. Data were compared between sports groups (ER, AR and NC), between exposure of three or more or five or more concussions and for years in sport. RESULTS: ER reported more concussions than AR (5.9 ± 6.3 vs. 3.7 ± 6.3, p = 0.022) and NC (0.4 ± 1.0, p < 0.001). ER had a higher overall negative mental health score (indicating poor mental health) than AR (10.4 ± 6.3 vs. 7.4 ± 6.5, d = 0.47, p = 0.003) and NC (7.1 ± 4.8, d = 0.57, p = 0.006) and a lower overall positive score (indicating good mental health) than NC (8.9 ± 4.1 vs. 10.7 ± 3.4, d = 0.46, p = 0.021). Negative scores were highest and positive scores lowest in those reporting three or more concussions (d = 0.36, p = 0.008; d = 0.28, p = 0.040, respectively) or five or more concussions (d = 0.56, p < 0.001; d = 0.325, p = 0.035, respectively). Reported symptoms for sleep disruption were more prevalent in ER than NC, and in former athletes with three or more concussions (d = 0.41-0.605, p < 0.05). There were no significant differences in alcohol score (p = 0.733). Global anger score and covert anger expression was higher in former athletes with five or more concussions (d = 0.32, p = 0.035; d = 0.37, p = 0.016). AR reported greater attachment to friends than NC (d = 0.46, p = 0.033) and 20% of ER reported that they would not turn to anyone if they had a problem or felt upset about anything. CONCLUSION: There was a significantly higher prevalence of adverse mental health and sleep disruption in ER and in former athletes who reported a higher number of concussions. Anger and irritability were more prevalent in former athletes with a history of five or more concussions. Strategies are needed to address mental health and sleep disturbance in elite rugby code athletes, who are also less likely to seek help should they need it. Further research is needed to elucidate causation, and the neurobiological connection between concussion, sub-concussions and longer-term psychological health and wellbeing.

Annual Baseline King-Devick Oculomotor Function Testing Is Needed Due to Scores Varying by Age.

OBJECTIVE: To document baseline King-Devick (K-D) oculomotor function scores for male and female participants aged between 4 and 20 years old. METHODS: Utilising a cross section of schools, rugby clubs and gymnastic clubs, 1936 participants (1300 male, 636 female) completed the spiral-bound K-D test for the identification of disturbed oculomotor function. RESULTS: This study identified that overall, the baseline scores of the K-D test became faster by 1.4 (0.3 to 4.5) s per year, when compared with the previous age group in the same number of reading card groups. When comparing normative values of the original K-D validation study with the same age groups of the current cohort, participants aged 6 to 11 years recorded a faster baseline time (range 3.5 to 8.6 s), while those in the 12 to 14 years. age group recorded slower baseline times (range -3.9 to -7.9 s). DISCUSSION: In general, there were age group differences, but not sex differences, for K-D test times in the current cohort. Analysis of single card times, across all age groups, showed changes likely due to improved reading time. CONCLUSION: The results support the need for individualised annual pre-injury baseline testing of the K-D test.

Rasch analysis of the Brain Injury Screening Tool (BIST) in mild traumatic brain injury.

OBJECTIVE: To evaluate the psychometric properties of the Brain Injury Screening Tool (BIST) symptom scale in a sample of people with a mild Traumatic Brain Injury (mTBI) through Rasch analysis, and to obtain an interval level measurement score for potential clinical use. MATERIALS AND METHODS: Data were obtained from 114 adults aged over 16 years, who had experienced at least one mTBI in the past 10 years. Participants were recruited via social media, concussion clinics and sports organisations over a 4-month period between May and September 2020. Participants were asked to compete the symptom scale of the BIST tool via an anonymous online questionnaire. Internal construct validity, dimensionality, person separation index, and differential item functioning of the BIST were examined with Rasch analysis. RESULTS: BIST in its original form produced a satisfactory item-trait interaction, and good reliability, but was found to be multi-dimensional. Rasch analysis of the full scale with three domains as subtests resulted in acceptable model fit (χ2(6) =3.8, p >  0.05), with good reliability (Person Separation Index = 0.84), and uni-dimensionality. Differential Item Functioning (DIF) analysis displayed no significant DIF effects for sex or age revealing that people responded consistently and similarly to the individual BIST items based on severity of symptom burden. CONCLUSIONS: The 15-item symptom scale of the BIST tool is a psychometrically sound measure of symptom burden following mTBI. The findings provide support for use of both total and sub scale scores for clinical use. Ordinal to interval score conversions are recommended for use when using the scores for research purposes in mTBI.

Preliminary Evidence for the Clinical Utility of Tactile Somatosensory Assessments of Sport-Related mTBI.

OBJECTIVES: To evaluate the clinical utility of tactile somatosensory assessments to assist clinicians in diagnosing sport-related mild traumatic brain injury (SR-mTBI), classifying recovery trajectory based on performance at initial clinical assessment, and determining if neurophysiological recovery coincided with clinical recovery. RESEARCH DESIGN: Prospective cohort study with normative controls. METHODS: At admission (n = 79) and discharge (n = 45/79), SR-mTBI patients completed the SCAT-5 symptom scale, along with the following three components from the Cortical Metrics Brain Gauge somatosensory assessment (BG-SA): temporal order judgement (TOJ), TOJ with confounding condition (TOJc), and duration discrimination (DUR). To assist SR-mTBI diagnosis on admission, BG-SA performance was used in logistic regression to discriminate cases belonging to the SR-mTBI sample or a healthy reference sample (pooled BG-SA data for healthy participants in previous studies). Decision trees evaluated how accurately BG-SA performance classified SR-mTBI recovery trajectories. RESULTS: BG-SA TOJ, TOJc, and DUR poorly discriminated between cases belonging to the SR-mTBI sample or a healthy reference sample (0.54-0.70 AUC, 47.46-64.71 PPV, 48.48-61.11 NPV). The BG-SA evaluated did not accurately classify SR-mTBI recovery trajectories (> 14-day resolution 48%, ≤14-day resolution 54%, lost to referral/follow-up 45%). Mann-Whitney U tests revealed differences in BG-SA TOJc performance between SR-mTBI participants and the healthy reference sample at initial clinical assessment and at clinical recovery (p < 0.05). CONCLUSIONS: BG-SA TOJ, TOJc, and DUR appear to have limited clinical utility to assist clinicians with diagnosing SR-mTBI or predicting recovery trajectories under ecologically valid conditions. Neurophysiological abnormalities persisted beyond clinical recovery given abnormal BG-SA TOJc performance observed when SR-mTBI patients achieved clinical recovery.

Effects of Stricter Management Guidelines on Return-to-Competition Timeframes Following Concussion in Professional Australian Rules Football: An Exploratory Analysis.

BACKGROUND: Management of concussion remains a serious issue for professional sports, particularly with the growing knowledge on the consequences of repetitive concussion. One primary concern is the subjective assessment of recovery that dictates the time until a concussed athlete is returned-to-competition. In response to this concern, the Australian Football League (AFL) changed its policy in 2020 such that medical clearance for return-to-competition was extended from 1 day, to a minimum of 5 days, prior to the next scheduled match. OBJECTIVE: We sought to explore the impact of the AFL policy change by asking whether time to return-to-competition after concussion was increased in the 2020 season relative to previous years. METHODS: Retrospective data on injury and return-to-competition were sourced from publicly available tables published by the AFL. Our primary exploration compared the number of matches missed and the number of days missed in concussed players across 2017-2020 inclusive, with secondary exploration analysing the proportion of players returning to play 12 days or longer. RESULTS: Analysis of data from 166 concussed players revealed no increase in the number of matches missed in 2020 relative to previous years as would have been expected from an extended recovery protocol. Comparing 2020 relative to 2017-2019, we found that there was an overall moderate reduction in median time to return-to-competition (RTC) in 2020 (10 vs 13 days, respectively d = - 0.345) and a significant reduction in players taking more than 12 days to RTC (p = 0.046). CONCLUSION: This exploratory study demonstrates that clubs may not have followed policy change around concussion management designed to increase time to RTC. Ongoing auditing is required to ensure player clearance meets policy goals, highlighting the need for objective measures for RTC after concussion.

The Brain Injury Screening Tool (BIST): Tool development, factor structure and validity.

Currently health care pathways (the combination and order of services that a patient receives to manage their injury) following a mild traumatic brain injury vary considerably. Some clinicians lack confidence in injury recognition, management and knowing when to refer. A clinical expert group developed the Brain Injury Screening Tool (BIST) to provide guidance on health care pathways based on clinical indicators of poor recovery. The tool aims to facilitate access to specialist services (if required) to improve longer term prognosis. The tool was developed using a three-step process including: 1) domain mapping; 2) item development and 3) item testing and review. An online retrospective survey of 114 adults (>16 years) who had experienced a mild brain injury in the past 10 years was used to determine the initial psychometric properties of the 15-item symptom scale of the BIST. Participants were randomised to complete the BIST and one of two existing symptom scales; the Rivermead Post-concussion Symptom Questionnaire (RPQ) or the Sports Concussion Assessment Test (SCAT-5) symptom scale to determine concurrent validity. Participant responses to the BIST symptom scale items were used to determine scale reliability using Cronbach's alpha. A principal components analysis explored the underlying factor structure. Spearman's correlation coefficients determined concurrent validity with the RPQ and SCAT-5 symptom scales. The 15 items were found to require a reading age of 6-8 years old using readability statistics. High concurrent validity was shown against the RPQ (r = 0.91) and SCAT-5 (r = 0.90). The BIST total symptom scale (α = 0.94) and the three factors identified demonstrated excellent internal consistency: physical/emotional (α = 0.90), cognitive (α = 0.92) and vestibular-ocular (α = 0.80). This study provides evidence to support the utility, internal consistency, factor structure and concurrent validity of the BIST. Further research is warranted to determine the utility of the BIST scoring criteria and responsiveness to change in patients.

A systematic review of the effects of educational interventions on knowledge and attitudes towards concussion for people involved in sport - Optimising concussion education based on current literature.

Educational interventions aimed at increasing concussion knowledge and attitudes are designed according to different frameworks. The aim of this systematic review of the literature was to determine the effects of educational interventions on concussion knowledge and attitudes, while providing recommendations for future research in the area of concussion education interventions. Data were extracted from 25 papers following a systematic search of the CINAHL, PubMed/Medline, Science Direct, SPORTDiscus and Web of Science scientific databases. Interventions were designed according to expert opinion and recommendations from previous research, such as knowledge transfer frameworks, the Health Belief Model, Theory of Planned Behaviour or by unknown means. Interventions were presented using PowerPoint presentations, videos, interactive computer modules, tool-kits, games and as guidelines. Interventions designed according to expert opinion increased concussion knowledge during post-intervention testing up to 2 weeks after intervention administration, and occasionally increased attitudes, with both knowledge and attitude improvements tending to return to baseline levels over-time. Interventions designed according to recommendations from previous research tend to increase both knowledge and attitudes with lack of follow-up data to determine long-term effects. Future concussion educational interventions should be designed according to expert opinion and using a knowledge transfer framework. The long-term effects of interventions require more research in order to design more effective educational tools.

Correction to: Quantifying the Collision Dose in Rugby League: A Systematic Review, Meta-analysis, and Critical Analysis.

An amendment to this paper has been published and can be accessed via the original article.