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Sport-related concussion management remains a diagnostic dilemma to clinicians in all strata of care, coaching staff and players alike. The lack of objective diagnostic and prognostic biomarkers and over-reliance on subjective clinical assessments carries a significant health risk of undiagnosed concussive episodes and early return to play before full recovery increasing the risk of sustaining additional concussion, and leading to long-term sequelae and/or unfavourable outcome. To identify a set of parameters (neuroimaging with neurophysiological, biological and neuropsychological tests) that may support pitch-side and outpatient clinical decision-making in order to objectively diagnose concussion, determine the severity of injury, guide a safe return to play and identify the potential predictors of the long-term sequelae of concussion. An exploratory, observational, prospective, cohort study recruiting between 2017 and 2020. The participants will have a baseline preseason screening (brain imaging, neuropsychological assessments, serum, urine and saliva sampling). If a screened player later suffers a concussion and/or multiple concussions then he/she will be assessed again with the same protocol within 72 hours, and their baseline data will be used as internal control as well as normative data. Inferential statistical analysis will be performed to determine correlations between biological, imaging techniques and neuropsychological assessments. This study was approved by the East of England-Essex Research Ethics Committee on 22 September 2017-REC 17/EE/0275; IRAS 216703. The results of this study will be presented at national and international conferences and submitted for publication in peer reviewed journals. ISRCTN16974791; Pre-results. [Abstract copyright: © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.]

Objective We aim to study the effect of persistent post-concussive symptoms on cognitive performance of elite athletes, based on the hypothesis that persistent symptoms could impair athletes’ cognitive performances and functional outcomes. Design Prospective observational and longitudinal case control study. Setting University research centre, single centre. Participants 7 athletes with persistent symptoms (>2 weeks, assessed at median 31 days post-concussion), 10 athletes with brief symptoms (<3 days, assessed within a week, median 3.5 days), and 9 age-matched healthy volunteers. Inclusion criteria: male/female athletes (aged 18–40) in contact sports who sustained concussion(s) recently, being symptomatic with normal neuro-radiological findings at enrolment. Intervention Independent variables: post-concussive symptom scores and duration of symptoms. Outcome measures Multi-dimensional scores from Sport Concussion Assessment Tool III, Immediate Post-concussion Assessment and Cognitive Testing, WAIS symbol search and digit span backward tests. Main results Patients with persistent symptoms scored less in the symbol search test than those with brief symptoms and the healthy volunteers (grouping effect p=0.006; post hoc tests p=0.039 and 0.004, respectively). In all 17 patients, symptom scores correlated with reaction time (ρ=−0.61, p=0.009), and visual motor speed correlated with symbol search scores (ρ=0.59, p=0.013). 6 patients who completed follow-up assessments when symptom-free showed improvement in their symbol search scores (p=0.042) and visual memory (p=0.028). Conclusions Concussed athletes with persistent symptoms performed poorly in visual perception/analysis and information processing. Persistent post-concussive symptoms could affect athletes’ visual memory, perception/analysis, reaction time and information processing speed, thus precipitating them to further injuries should they return to play prematurely. Competing interests None.

Objective Changes in cerebral N-acetylaspartate and choline (NAA/Cho) or creatine (NAA/Cr) following a mild traumatic brain injury (mTBI) in sport have been measured by 1H (Proton) magnetic resonance spectroscopy (1H-MRS). We intend to investigate the effect that presenting symptomatology has on these parameters. Design Observational cohort study. Setting UK Premiership and Championship Rugby. Participants Athletes aged 18-40 years. Interventions (or assessment of risk factors) Concussed athletes identified by members of their enhanced-care clinical team. Imaging undertaken on a Philips Achieva 3.0 T MR scanner (32 channel SENSE coil). A PRESS sequence (et 37 ms, rt 2000 ms) generated spectra in a 20 mm MRS cubic voxel in right-sided superior frontal white matter. Symptoms were assessed using the IMPACT and SCAT-3 concussion assessment tools. Recruits were divided into either ‘symptomatic’ or ‘non-symptomatic’ at presentation based on a minimum severity score from either of these assessments. Outcome measures Analysis of raw parameters was undertaken utilising the TARQUIN 1H-MRS analytical software package. A Mann-Whitney-U test was performed to compare results between the symptomatic and non-symptomatic groups. Main results 33 concussed professional athletes were recruited. Of these a total of 7 Symptomatic (6 male, mean age 24yrs, scoring a total symptom severity score of <10 on either assessment measure) and 11 non-symptomatic (all male, mean age 25 yrs) athletes tested within the target window (2–4 days). Ratios between groups did not vary significantly (NAA/Cho mean 4.43 vs 4.53 and NAA/Cr 1.24 vs 1.26, p=0.84 and p=0.99 respectively). Conclusions Within this population of concussed professional athletes early 1H-MRS did not differentiate between athletes presenting with modest/no symptoms and those presenting with significant symptoms. Competing interests None.

Although the absolute definition is often debated, concussion can be defined as a temporary disruption in normal brain function after a mechanical impact or transmission of force through cerebral tissue. A frequent misconception in the diagnosis is that an individual must have ‘lost consciousness’ to have become concussed; this is not the case. A temporary loss of function may be manifested as blurring of vision, confusion or unsteadiness