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Concussion or mild traumatic brain injury (mTBI) is associated with long-term impairments in military personnel. Diagnosis of the condition remains clinically challenging. Neurological examination and cognitive symptoms may not accurately map the nature and severity of underlying brain injury. Neuroimaging techniques, such as diffusion tensor imaging (DTI), show promise as an effective tool in delineating the microstructural neural changes and corresponding clinical consequences following mTBI. This paper discusses the diagnosis and management of concussion, in the military context, using two cases of veterans who suffered blast-related mTBI. Insights on an integrated approach to concussion in the military, incorporating thorough neurological and neuropsychological examination and application of advanced neuroimaging are presented. [ABSTRACT FROM AUTHOR]

Background: Evidence-based clinical data are required for safe return to play after concussion in sport. Purpose: The objective of this study was to describe the natural history of concussion in sport and identify clinical features associated with more severe concussive injury, using return-to-sport decisions as a surrogate measure of injury severity. Study Design: Cohort study (prognosis); Level of evidence, 3. Methods: Male elite senior, elite junior, and community-based Australian Rules football players had preseason baseline cognitive testing (Digit Symbol Substitution Test, Trail-Making Test-Part B, and CogSport computerized test battery). Players were recruited into the study after a concussive injury sustained while playing football. Concussed players were tested serially until all clinical features of their injury had resolved. Results: Of 1015 players, 88 concussions were observed in 78 players. Concussion-associated symptoms lasted an average of 48.6 hours (95% confidence interval, 39.5-57.7 hours) with delayed return to sport correlated with ≥4 symptoms, headache lasting ≥60 hours, or self-reported ''fatigue/fogginess.'' Cognitive deficits using the Digit Symbol Substitution Test and Trail-Making Test-part B recovered concomitantly with symptoms, but computerized test results recovered 2 to 3 days later and remained impaired in 35% of concussed players after symptom resolution. Conclusion: Delayed return to sport was associated with initially greater symptom load, prolonged headache, or subjective concentration deficits. Cognitive testing recovery varied, taking 2 to 3 days longer for computerized tests, suggesting greater sensitivity to impairment. Therefore, symptom assessment alone may be predictive of but may underestimate time to complete recovery, which may be better estimated with computerized cognitive testing. [ABSTRACT FROM AUTHOR]

Studies have indicated that concussive and sub-concussive brain injuries that are frequent during collision sports may lead to long-term neurological abnormalities, however there is a knowledge gap on how biological sex modifies outcomes. Blood-based biomarkers can help to identify the molecular pathology induced by brain injuries and to better understand how biological sex affects the molecular changes. We therefore analyzed serum protein biomarkers in male (n = 50) and female (n = 33) amateur Australian rules footballers (i.e., Australia's most participated collision sport), both with a history of concussion (HoC) and without a history of concussion (NoHoC). These profiles were compared to those of age-matched control male (n = 24) and female (n = 20) athletes with no history of neurotrauma or participation in collision sports. Serum levels of protein markers indicative of neuronal, axonal and glial injury (UCH-L1, NfL, tau, p-tau, GFAP, BLBP, PEA15), metabolic (4-HNE) and vascular changes (VEGF-A, vWF, CLDN5), and inflammation (HMGB1) were assessed using reverse phase protein microarrays. Male, but not female, footballers had increased serum levels of VEGF-A compared to controls regardless of concussion history. In addition, only male footballers who had HoC had increased serum levels of 4-HNE. These findings being restricted to males may be related to shorter collision sport career lengths for females compared to males. In summary, these findings show that male Australian rules footballers have elevated levels of serum biomarkers indicative of vascular abnormalities (VEGF-A) and oxidative stress (4-HNE) in comparison to non-collision control athletes. While future studies are required to determine how these findings relate to neurological function, serum levels of VEGF-A and 4-HNE may be useful to monitor subclinical neurological injury in males participating in collision sports. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) resulting from episodes of domestic violence (DV) is a serious yet greatly underreported issue. Head injuries arising in these circumstances are often concussive or sub-concussive in nature, and are unlikely to be isolated incidents, with victims frequently suffering repetitive TBIs over time. Although men may also be victims of DV, women and children are most at risk of DV via intimate partners and parents, respectively. Due to the complexities of these interpersonal relationships, victims of DV are not always able to receive appropriate clinical diagnoses, care or follow-up after TBI. TBI arising from DV is also likely to occur in a complex milieu of fear, anxiety and depression, the physical and psychological consequences of which may worsen or perpetuate the pathology of TBI. This review examines the complexities of TBI arising from DV from several perspectives, with focus on three pertinent and interrelated topics: 1) pathobiology and complications of single and repetitive TBI, encompassing direct neural consequences, inflammation and hormonal changes; 2) behavioral, cognitive and psychosocial consequences of TBI; and 3) contributing factors to TBI and complications, including strategies to increase clinician recognition of TBI in DV patients, and programs and policies in place in Australia and abroad to decrease rates of offending. [ABSTRACT FROM AUTHOR]

Background There is growing research finding associations between adolescents' concussion and negative outcomes, including violence, rarely however are the experiences of community-based early adolescents considered. Methods This study examined associations between reports of concussion (Time-1) and reports of violence 1-year later (Time-2). Australian adolescents from 13 high-schools completed two identical surveys administered 12-months apart (n = 734 retained, initial mean age = 13.45). Results At the first survey, 91 students (13%) reported they had a concussion, and of these students, 40% reported seeing a doctor/attending hospital during the prior 3 months. Both self-reported experience of violent injury (from getting in a fight) and violent behaviour (getting in a fight) were predicted by reports of concussion in Year 9. This prediction held, when adding sex, Year 9 reports of violence, alcohol use, truancy and engagement in passenger and driving risk-taking to logistic regression models. Year 9 concussion was not predictive of later injury in other contexts, including transportation, falls or sports. Conclusion The study highlights the need to understand concussion among community-based early adolescents including consider associations with violence. [ABSTRACT FROM AUTHOR]

Purpose: This study developed standardized vignettes that depict a mild traumatic brain injury (TBI) from one of several causes and subjected them to formal expert review. Method: A base vignette was developed using the World Health Organization operational criteria for mild TBI. Eight specific causes (e.g. sport vs assault) were examined. A convenience sample of mild TBI experts with a discipline background of Neuropsychology from North America, Australasia and Europe (n= 21) used an online survey to evaluate the vignettes and rated the role of cause on outcome. Results: The vignette suite was rated as fitting the mild TBI WHO operational diagnostic criteria at least moderately well. When compared to other factors, cause was not rated as significantly contributing to outcome. When evaluated in isolation, approximately half of the sample rated cause as important or very important and at least two of three clinical outcomes were associated with a different cause. Discussion: The vignettes may be useful in experimental mild TBI research. They enable the injury parameters to be controlled so that the effects of cause can be isolated and examined empirically. Such studies should advance understanding of the role of this factor in mild TBI outcome. [ABSTRACT FROM PUBLISHER]

The National Rugby League (NRL) in Australia introduced a new 'concussion interchange rule' (CIR) in 2014, whereby a player suspected of having sustained a concussion can be removed from play, and assessed, without an interchange being tallied against the player's team. We conducted a video analysis, describing player and injury characteristics, situational factors, concussion signs, and return to play for each "CIR" event for the 2014 season. There were 167 reported uses of the CIR. Apparent loss of consciousness/unresponsiveness was observed in 32% of cases, loss of muscle tone in 54%, clutching the head in 70%, unsteadiness of gait in 66%, and a vacant stare in 66%. More than half of the players who were removed under the CIR returned to play later in the same match (57%). Most incidences occurred from a hit up (62%) and occurred during a tackle where the initial contact was with the upper body (80%). The new concussion interchange rule has been used frequently during the first season of its implementation. In many cases, there appeared to be video evidence of injury but the athlete was cleared to return to play. More research is needed on the usefulness of video review for identifying signs of concussive injury. [ABSTRACT FROM AUTHOR]

Professional sports with high rates of concussion have become increasingly concerned about the long-term effects of multiple head injuries. In this context, return-to-play decisions about concussion generate considerable ethical tensions for sports physicians. Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning. At times, a team's interest in winning may not accord with the welfare of an injured player, particularly when it comes to decisions about returning to play after injury. Australia's two most popular professional football codes-rugby league and Australian Rules football-have adopted guidelines that prohibit concussed players from continuing to play on the same day. I suggest that conflicts of interest between doctors, patients, and teams may present a substantial obstacle to the proper adherence of concussion guidelines. Concussion management guidelines implemented by a sport's governing body do not necessarily remove or resolve conflicts of interest in the doctor-patient-team triad. The instigation of a concussion exclusion rule appears to add a fourth party to this triad (the National Rugby League or the Australian Football League). In some instances, when conflicts of interest among stakeholders are ignored or insufficiently managed, they may facilitate attempts at circumventing concussion management guidelines to the detriment of player welfare. [ABSTRACT FROM AUTHOR]

Background: Decisions regarding safe return to play after concussion in sport remain difficult. Objective: To determine whether a concussed player returned to play using an individual clinical management strategy is at risk of impaired performance or increased risk of injury or concussion. Study Design: Cohort study; Level of evidence, 3. Methods: All elite Australian football players were followed for 4 seasons. Players were recruited into the study after sustaining a concussive injury. Outcome measures included performance statistics (disposals per hour match-time), injury rates, and recurrence of concussion on return to play. A subset of players had brief screening cognitive tests performed at baseline and after their concussion. Noninjured players matched for team, position, age, and size were chosen as controls. Results: A total of 199 concussive injuries were observed in 158 players. Sixty-one concussive injuries were excluded from analysis because of incomplete data (45 players) or presence of concurrent injury (16 players). Of the 138 concussive injuries assessed, 127 players returned to play without missing a game (92%). The remainder of concussed players returned to play after missing a single game (8%). Overall, there was no significant decline in disposal rates in concussed players on return to competition. Furthermore, there were no significant differences in injury rates between concussed and team, position, and game-matched controls. In the subset of players who had completed screening cognitive tests, all had returned to their individual baseline performance before being returned to play. Conclusion: Return to play decisions based on individual clinical assessment of recovery allows safe and appropriate return to sport following a concussive injury. [ABSTRACT FROM AUTHOR]