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Objectives: The purpose of this study was to determine sex differences in recovery trajectories of assessments for sport-related concussion using Concussion Assessment, Research and Education (CARE) Consortium data. Methods: National Collegiate Athletic Association athletes (N = 906; 61% female) from sex-comparable sports completed a pre-season baseline assessment and post-sport-related concussion assessments within 6 h of injury, 24–48 h, when they initiated their return to play progression, when they were cleared for unrestricted return to play, and 6 months post-injury. Assessments included the Standardized Assessment of Concussion, Balance Error Scoring System, Brief Symptom Inventory-18, Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Sport Concussion Assessment Tool-3 symptom evaluation, Clinical Reaction Time, King–Devick test, Vestibular Ocular Motor Screen, 12-item Short-Form Health Survey, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale. Results: Only the Vestibular Ocular Motor Screen Total Symptom Score at the 24–48 h timepoint (p = 0.005) was statistically significantly different between sexes. Specifically, female athletes (mean = 60.2, 95% confidence interval [CI] 51.5–70.4) had higher Vestibular Ocular Motor Screen Total Symptom Scores than male athletes (mean = 36.9, 95% CI 27.6–49.3), but this difference resolved by the time of return-to-play initiation (female athletes, mean = 1.8, 95% CI 1.1–2.9; male athletes, mean = 4.1, 95% CI 1.5–10.9). Conclusions: Sport-related concussion recovery trajectories for most assessments were similar for female and male National Collegiate Athletic Association athletes except for Vestibular Ocular Motor Screen symptoms within 48 h of sport-related concussion, which was greater in female athletes. Female athletes had a greater symptom burden across all timepoints, suggesting that cross-sectional observations may indicate sex differences despite similar recovery trajectories. [ABSTRACT FROM AUTHOR]

Multiple clinical evaluation tools exist for adolescent concussion with various degrees of correlation, presenting challenges for clinicians in identifying which elements of these tools provide the greatest diagnostic utility. To determine the combination of elements from 4 commonly used clinical concussion batteries that maximize discrimination of adolescents with concussion from those without concussion. Cross-sectional study. Suburban school and concussion program of a tertiary care academic center. A total of 231 participants with concussion (from a suburban school and a concussion program) and 166 participants without concussion (from a suburban school) between the ages of 13 and 19 years. Individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, fifth edition (SCAT5; including the modified Balance Error Scoring System), King-Devick test (K-D), and Postconcussion Symptom Inventory (PCSI) were evaluated. The 24 subcomponents of these tests were grouped into interpretable factors using sparse principal component analysis. The 13 resultant factors were combined with demographic and clinical covariates into a logistic regression model and ranked by frequency of inclusion into the ideal model, and the predictive performance of the ideal model was compared with each of the clinical batteries using the area under the receiver operating characteristic curve (AUC). A cluster of 4 factors (factor 1 [VVE saccades and vestibulo-ocular reflex], factor 2 [modified Balance Error Scoring System double-legged stance], factor 3 [SCAT5/PCSI symptom scores], and factor 4 [K-D completion time]) emerged. A model fit with the top factors performed as well as each battery in predicting concussion status (AUC = 0.816 [95% CI = 0.731, 0.889]) compared with the SCAT5 (AUC = 0.784 [95% CI = 0.692, 0.866]), PCSI (AUC = 0.776 [95% CI = 0.674, 0.863]), VVE (AUC = 0.711 [95% CI = 0.602, 0.814]), and K-D (AUC = 0.708 [95% CI = 0.590, 0.819]). A multifaceted assessment for adolescents with concussion, comprising symptoms, attention, balance, and the visio-vestibular system, is critical. Current diagnostic batteries likely measure overlapping domains, and the sparse principal component analysis demonstrated strategies for streamlining comprehensive concussion assessment across a variety of settings. [ABSTRACT FROM AUTHOR]

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery. [ABSTRACT FROM AUTHOR]

Objectives: To examine sex differences in sport-related concussion (SRC) across comparable sports.Methods: Prospective cohort of collegiate athletes enrolled between 2014 and 2017 in the Concussion Assessment, Research and Education Consortium study.Results: Among 1071 concussions (females=615; 57.4%), there was no difference in recovery (median days to full return to play) (females=13.5 (IQR 9.0, 23.1) vs males=11.8 (IQR 8.1, 19.0), p=0.96). In subgroup analyses, female recovery was longer in contact (females=12.7 days (IQR 8.8, 21.4) vs males=11.0 days (IQR 7.9, 16.2), p=0.0021), while male recovery was longer in limited contact sports (males=16.9 days (IQR 9.7, 101.7) vs females=13.8 days (IQR 9.1, 22.0), p<0.0001). There was no overall difference in recovery among Division I schools (females=13.7 (IQR 9.0, 23.1) vs males=12.2 (IQR 8.2 19.7), p=0.5), but females had longer recovery at the Division II/III levels (females=13.0 (IQR 9.2, 22.7) vs males=10.6 (IQR 8.1, 13.9), p=0.0048).Conclusion: Overall, no difference in recovery between sexes across comparable women's and men's sports in this collegiate cohort was found. However, females in contact and males in limited contact sports experienced longer recovery times, while females had longer recovery times at the Division II/III level. These disparate outcomes indicate that, while intrinsic biological sex differences in concussion recovery may exist, important, modifiable extrinsic factors may play a role in concussion outcomes. [ABSTRACT FROM AUTHOR]

Head injuries in childhood can result in concussion. Families of a child with a head injury often seek medical advice through telephone triage call systems. It is important to understand if patients follow telephone triage recommendations and what proportion of triage calls result in subsequent concussion diagnosis. We used a one-year retrospective cohort of triage calls screened with the Barton Schmitt Pediatric Head Injury Telephone Triage Protocol. The objectives were to estimate the proportion who followed up with urgent recommendations to see a provider and determine prevalence of diagnoses of concussion. Out of 2,454 calls with recommendations to be seen urgently, the estimated proportion of being seen in the medical home network or an outside health care facility was 84.1%. Estimated overall diagnoses of concussion among those who were seen was 39.5%. These data can be used to improve patient education and follow-up, as well as the utility of the telephone triage system. [ABSTRACT FROM AUTHOR]

Objective: To determine the proportion of non-concussed, neurologically normal children with failures on a vestibular and oculomotor examination for concussion performed in an acute setting. Design: This was a cross-sectional study of subjects 6-18 years old presenting to a paediatric emergency department with non-neurologic chief complaints. The examination was administered by a paediatric emergency medicine physician, and includes assessments of dysmetria, nystagmus, smooth pursuits, saccades, gaze stability, near-point of convergence, and gait/balance testing. Results: Of the 295 subjects enrolled, 24% failed at least one element of testing. About 13% had >1 failed element and 5% had >2 failed elements. About 29% of females and 19% of males had failed examinations. By age, 15% of subjects 6-8 years old, 32% 9-11 years, 32% 12-14 years, and 26% 15-18 years had failed examinations. Overall, 10% were unable to complete the exam due to developmental age. Conclusions: The provider should be aware that a proportion of non-concussed children may demonstrate failure on a single element of the vestibular and oculomotor exam. While this testing is of benefit to the acute care provider in diagnosing paediatric concussion, its utility is greatest in the context of an injury history with acute onset of concussion symptoms. [ABSTRACT FROM AUTHOR]

Objectives. (1) Assess pediatric primary care providers’ understanding of cognitive rest for concussion and (2) describe their concussion management practices. Methods. This study included (1) a survey of general pediatric providers and (2) an electronic medical record (EMR) review of children 5 to 18 years old treated for concussion from September 1, 2010, to May 31, 2011. The survey asked about treatment recommendations for concussion, and results were coded to identify cognitive rest recommendations. The EMR review included the following: injury details, medical evaluation, and recommendations for resuming school and sports/recreation. Results. In all, 89 of 201 providers responded to the survey, and 52 of the 84 clinicians who included comments about concussion management mentioned cognitive rest (62%, 95% confidence interval [CI] = 51%-72%). Of the 91 EMRs reviewed for patients’ first visits following the concussion, only 10 (11%, 95% CI = 6%-19%) included written cognitive rest recommendations. Conclusions. Although the majority of pediatric providers identified cognitive rest as important in pediatric concussion management, few provided written recommendations in the EMR. [ABSTRACT FROM PUBLISHER]

OBJECTIVE: To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network. METHODS: A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried. RESULTS: There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval [CI]: 86%- 95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 "not a barrier" to 5 "significant barrier" was used to assess providers' barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%-23%), inadequate time to educate 15% (95% CI: 12%-24%), and not my role to educate 1% (95% CI: 0.4%-5%). Ninety-six percent (95% CI: 91%-98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%-100%) of providers without discharge instructions specific to concussion believed these resources would be helpful. CONCLUSIONS: Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and patient information could help enhance and standardize concussion management. [ABSTRACT FROM AUTHOR]

The article explores several aspects of concussion care for children. Topics discussed include pathophysiology of concussion, diagnosis of concussion based on Post-Concussion Symptom Scale, performing directed physical examination to assess deficits in balance and visual function, role of physical and cognitive rest in treatment of concussion, and rehabilitation therapies for oculomotor/vision deficits.

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5--12 years) and adolescents (13--18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [131] and Child SCOAT6 [8--12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: The purpose of this study was to determine if exercise-induced vision dysfunction [reduced performance and/or symptom exacerbation on a post-exercise King-Devick (KD) test] in adolescents early after sport-related concussion was associated with increased risk of persistent post-concussive symptoms (PPCS, recovery >28 days). We used exercise as a provocative maneuver before the KD test, hypothesizing that concussed adolescents with exercise-induced vision dysfunction would be more likely to develop PPCS. Design: Secondary analysis of data from a multi-center, randomized clinical trial comparing KD test performance before and after the Buffalo Concussion Treadmill Test in adolescents within 10 days of sport-related concussion who were randomized to aerobic exercise or placebo stretching program. Setting: Three university-associated sports medicine clinical programs. Participants: Ninety-nine adolescents with sport-related concussion (exercise group: n = 50, 15.3 ± 1 years, 60% M, 22% with PPCS; stretching group: n = 49, 15.9 ± 1 years, 65% M, 35% with PPCS) tested a mean of 6 ± 2 days from injury. Independent Variable: King-Devick test performed immediately before and 2 minutes after Buffalo Concussion Treadmill Test. Main Outcome Measure: Persistent post-concussive symptoms. Results: Adolescents who demonstrated exercise-induced vision dysfunction upon initial evaluation developed PPCS at a significantly greater rate when compared with adolescents who did not (71% vs 34%, P < 0.001). Exercise-induced vision dysfunction corresponded to a relative risk of 3.13 for PPCS. Conclusions: Adolescents with exercise-induced vision dysfunction had a 3-fold greater relative risk of developing PPCS than those without exercise-induced vision dysfunction. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries. Design: Cross-sectional. Setting: Suburban middle and high school. Patients: One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020. Assessment of Independent Variables: Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King–Devick (K–D), Postconcussion Symptom Inventory (PCSI). Main Outcome Measures: Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait). Results: Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini–Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K–D, or PCSI. Conclusions: The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K–D. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the discriminatory ability of different repetition increments of saccades and gaze stability testing for diagnosing concussion in adolescents. Design: Cross-sectional. Setting: Suburban high school and academic pediatric tertiary care center. Participants: Sixty-nine adolescent athletes within 28 days of a sports- or recreation-related concussion and 69 adolescent athletes without recent concussion. Assessment of Independent Variables: Symptom provocation with horizontal and vertical saccades and gaze stability testing performed up to 30 repetitions. Main Outcome Measures: Sensitivity and specificity at 10-repetition increments (<=10, <=20, <=30) and area under the receiver operating characteristic curves (AUC) of a visio-vestibular examination (VVE) subscore, scored 0 to 4 based on the number of assessments with symptom provocation, at each repetition increment. /=20,>/p> Results: Sensitivity improved when increasing from <=10 to <=20 to <=30 repetitions for horizontal (25% to 50% to 69%) and vertical (32% to 52% to 74%) saccades and horizontal (19% to 45% to 71%) and vertical (23% to 45% to 72%) gaze stability. Specificity was comparable at <=10 and <=20 repetitions, but decreased at <=30 repetitions across assessments. For a VVE subscore (0-4) based on the number of symptomatic assessments, the discriminatory ability of the test was highest at <=20 repetitions (AUC of 0.79) with an optimal subscore of one (sensitivity 59%, specificity 96%). /=20>/=10>/=30>/p> Conclusions: A VVE including a higher threshold level of repetitions for saccades and gaze stability has improved discriminatory ability for concussion, with an optimized AUC of 0.79 at <=20 repetitions. /p> Clinical Relevance: The findings in this study suggest that a higher threshold level of repetitions of 2 commonly used visio-vestibular assessments enables clinicians to more accurately diagnose youth concussion. [ABSTRACT FROM AUTHOR]

Objective: Many schools and sports leagues provide preseason concussion education to parents/guardians, and in some jurisdictions, it is required for interscholastic sports participation. However, directives about content are absent or vague. The purpose of this study was to obtain expert consensus about what parents/guardians need to know to about concussion. Design: A modified Delphi process with nationally recognized expert panel members was used to obtain consensus about parent/guardian behaviors relevant to concussion prevention, identification, and management and knowledge domains relevant to performance of those behaviors. Results: Sixteen parent/guardian behaviors and 24 knowledge domains were identified. However, consensus was not achieved regarding whether it is realistic to expect parents/guardians to perform approximately one-third of the behaviors that experts agreed mattered. This variability may reflect underlying uncertainty about the capacities of some parents/guardians to put knowledge into action or the belief that there are other barriers to action. Furthermore, for most knowledge domains, there was a lack of agreement about whether or not there could be a "correct" answer on the basis of current scientific knowledge. Conclusions: These findings raise practical and ethical questions: how can we expect parents/guardians to help prevent, identify, or manage concussion if they cannot have all the information required to engage in these behaviors due to lack of scientific consensus? This issue is not unique to concussion. Best practices for risk communication and shared decision-making can inform how we think about educating parents/guardians about concussion inside and outside of the health care setting. [ABSTRACT FROM AUTHOR]

Purpose: Evaluate the discriminatory ability of two clinical measures and one device-based measure of gait and balance for concussed youth. Methods: We enrolled 81 cases and 90 controls age 14–18 yr old from August 2017 to June 2018. Controls were recruited from a suburban high school, and cases were recruited from the concussion program of an academic pediatric tertiary care center. Tests included two clinical measures: 1) complex tandem gait, scored as sway/errors walking forward and backward eyes open and closed; 2) Modified Balance Error Scoring System (mBESS), scored as total number of errors on three standing tasks; and one device-based measure; 3) Modified Clinical Test of Sensory Interaction and Balance (mCTSIB) using the Biodex Biosway Balance System, scored as a sway index. Sensitivity, specificity, ideal cutpoint, and area under the receiver operating characteristic curve (AUC) were calculated for all test components. Results: Ideal cutpoint for total number of sway/errors for tandem gait = 5, sensitivity 41%, specificity 90%. Ideal cutpoint for total mBESS errors = 4, sensitivity 55%, specificity 75%. Ideal cutpoint for mCTSIB = 1.37, sensitivity 37%, specificity 88%. Among each test, some individual components outperformed overall composites, in particular tandem gait (specificity forward eyes open = 99%, sensitivity backward eyes closed = 81%). Among the 40 cases and 65 controls with all three assessments, AUC (95% CI) for tandem gait = 0.63 (0.52,0.75), mBESS = 0.70 (0.60,0.81), and mCTSIB = 0.54 (0.42,0.66). Conclusions: A device-based measure of balance did not produce better discriminatory ability than two clinical assessments. Complex tandem gait has the additional benefit of being an easy-to-perform and graded test with highly sensitive and specific individual components. [ABSTRACT FROM AUTHOR]

Objectives: (1) To examine how age influences initial symptom presentation following concussion; and (2) to determine whether specific symptom profiles are associated with duration of postconcussion symptoms, and whether they vary by age group. Design: A total of 689 patients (20% children 7-12 years of age, 69% adolescents 13-18 years of age, and 11% young adults 19-30 years of age) were seen and diagnosed with a concussion within 21 days after injury. Patients completed the Post-Concussion Symptom Scale (PCSS) and were followed until they no longer required care. Setting: Two specialty care sport concussion clinical practices. Main outcome measures: Overall PCSS score was obtained, as well as severity ratings from somatic, vestibular-ocular, cognitive, sleep, and emotional symptom domains. We also calculated total symptom duration time. Results: No significant main effect of age, or age by sex associations were identified among the symptom domains. Females endorsed a higher somatic symptom severity rating than males (9.8 +/- 6.7 vs 8.1 +/- 6.7; P = 0.03). For patients between 7 and 12 years of age, higher somatic [[beta]-coefficient = 1.57, 95% confidence interval (CI), 1.47-1.67] and cognitive ([beta]-coefficient = 2.50, 95% CI, 2.32-2.68) symptom severities were associated with longer duration of concussion symptoms. Among adolescents, longer total symptom duration was associated with more severe somatic ([beta]-coefficient = 1.25, 95% CI, 0.34-2.15) and vestibular-ocular ([beta]-coefficient = 2.36, 95% CI, 1.49-3.23) symptoms. Conclusions: Within 21 days after concussion, symptom-reporting behavior seems to be similar across the age spectrum, but the relationship between symptom profiles and time to symptom resolution varies by age. Although overall symptom ratings are beneficial in determining clinical pathways, symptom domain use may provide a beneficial method to determine individualized patient care that differs between children and adolescents after concussion. [ABSTRACT FROM AUTHOR]