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Objective: To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport., Background: Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice., Recommendations: These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies., (© by the National Athletic Trainers' Association, Inc.)

Selected Issues in Sport-Related Concussion (SRC|Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus documents written for the practicing team physician. This document provides an overview of selected medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC., Competing Interests: Competing interests: SH, MP, JJL and GS are members of the Concussion in Sport Group Expert Panel. SH and MP serve on the Center for Disease Control and Prevention and National Center for Injury Prevention and Control Board Pediatric Mild Traumatic Brain Injury Guideline Workgroup. SH serves on the NCAA Concussion Safety Advisory Group, is cofounder and Senior Medical Advisor for the Sports Institute at UW Medicine, and owns stock or stock options with Vicis. MP is a senior advisor to the NFL Head, Neck and Spine Committee, serves as the Chief Medical Officer for Major League Soccer, has received royalties from Up-To-Date and serves on the medical advisory board for US Soccer. GSS is Senior Medical Advisor for the NFL. KD has received grant funding from Children’s Hospital Foundation, and royalties from Up-To-Date. CRL has received grant funding from NOCSAE and received royalties from the AAP, and serves on medical advisory boards for Pop Warner Football, Illinois HS Association and US Soccer. JJL has received grant funding from the AMSSM, DoD and NIH, consulting fees from Neurolign and Stage 2 Contracting Engineering, participates on a Data Safety Monitoring Board or Advisory Board (Neuronasal) and has stock or stock options in Highmark Innovations. KMS is a consultant for Johnson & Johnson., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Abstract: Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus articles written for the practicing team physician. This document provides an overview of select medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC., (Copyright © 2021 by the American College of Sports Medicine.)

Objective: To describe the integration of neuropsychology services in a multidisciplinary concussion clinic and provide descriptive information on patients, services, and initial health status., Setting: A university-based outpatient sports medicine concussion clinic., Participants: A consecutive sample of 338 patients ages 8 to 84 years (median 23.5 years, 35% 13-18 years), 49.1% male, seen between 2014 and 2018. Patients' injuries included sports 42%, work 28.4%, and vehicular 12.1% and 48.5% were students., Design: Descriptive statistics with group comparisons., Main Measures: 12-Item Short Form Health Survey (SF-12) T scores (mean = 50, SD = 10) referenced to US population., Results: Half of the patients were seen within 24 days of their injury and showed reduced physical functioning (40.2) and average mental (emotional) functioning (48.8). Patients seen after 24 days showed even more reduced physical functioning (33.9) and reduced mental functioning (41.0), both P < .0001. Average treatment time was also longer, 88.1 (173.9) versus 186.8 (211.1) days, P < .0001. Two-thirds of patients were referred for cervical or vestibular physical therapy at their initial visit., Conclusion: Early referral for specialized care, including neuropsychology services, may be beneficial.

Sport-related concussion (SRC) is a common injury in recreational and organized sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment, and management of SRC. In addition to a growing need for knowledgeable health care professionals to provide evidence-based care for athletes with SRC, media attention and legislation have created awareness and, in some cases, fear about many issues and unknowns surrounding SRC. The American Medical Society for Sports Medicine formed a writing group to review the existing literature on SRC, update its previous position statement, and address current evidence and knowledge gaps regarding SRC. The absence of definitive outcomes-based data is challenging and requires relying on the best available evidence integrated with clinical experience and patient values. This statement reviews the definition, pathophysiology, and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short- and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The American Medical Society for Sports Medicine is committed to best clinical practices, evidence-based research, and educational initiatives that positively impact the health and safety of athletes.

Objectives: Several iterations of the Sport Concussion Assessment Tool (SCAT) have been published over the past 16 years. Our goal was to systematically review the literature related to the SCAT and provide recommendations for improving the tool. To achieve this goal, five separate but related searches were conducted and presented herein., Design: Systematic literature review., Data Sources: Medline, Embase, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, SPORTDiscus and PubMed., Eligibility Criteria: Original, empirical, peer-reviewed findings published in English and included sports-related concussion (SRC). Review papers, case studies, editorials and conference proceedings/abstracts were excluded. The age range for the ChildSCAT was 5-12 years and for the Adult SCAT was 13 years and above., Results: Out of 2961 articles screened, a total of 96 articles were included across the five searches. Searches were not mutually exclusive. The final number of articles included in the qualitative synthesis for each search was 21 on Adult SCAT, 32 on ChildSCAT, 21 on sideline, 8 on video/observation and 14 on oculomotor., Summary/conclusions: The SCAT is the most widely accepted and deployable sport concussion assessment and screening tool currently available. There is some degree of support for using the SCAT2/SCAT3 and ChildSCAT3 in the evaluation of SRC, with and without baseline data. The addition of an oculomotor examination seems indicated, although the most valid method for assessing oculomotor function is not clear. Video-observable signs of concussion show promise, but there is insufficient evidence to warrant widespread use at this time., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: The Ottawa ankle rule (OAR) is a clinical decision rule used in emergency departments to identify which patients with acute ankle/midfoot injury require radiography. The purpose of this study was to implement the OAR, with a modification to improve the specificity for identifying malleolar fractures (the "Buffalo rule"), in a sports medicine center and measure impact on physician practice and cost savings., Methods: All pediatric and adult patients presenting to a university sports medicine walk-in clinic with acute (< or = 10 d old) ankle/midfoot injury had the rule applied by primary care providers. Exclusion criteria included pregnancy, isolated skin injury, > 10 d since injury, second evaluation for same injury, obvious deformity of ankle or foot, or altered sensorium., Results: In 217 patients (mean age, 23.3 +/- 8.5 yr; range, 10-64 yr) there were 24 clinically significant (i.e., nonavulsion) fractures (fracture rate 3.7% per year for 3 yr), all of which were identified by the rule (100% sensitivity). In 193 patients with malleolar pain, the sensitivity for malleolar fracture (with 95% confidence intervals) was 100% (78-100%) and specificity was 45% (43-46%). In 24 patients with midfoot pain, sensitivity was 100% (65-100%) and specificity was 35% (21-49%). Thirty-five percent of radiographic series (76 of 217) were foregone for a cost savings of almost $6000. One hundred percent follow-up on those patients for whom x-rays were obtained found no missed fractures and they were subjectively satisfied with their care., Conclusion: The OAR reduced radiography in acute ankle/midfoot injury and saved money in relatively younger patients in the outpatient sports urgent care setting without missing any clinically significant fractures. The specificity of the Buffalo malleolar rule in the present implementation study, however, was not a significant improvement over the OAR malleolar rule. Widespread application of the OAR could save substantial resources without compromising quality of care.

Concussion and persistent postconcussive symptoms (PPCS) are encountered by clinicians in sports medicine, pediatrics, neurology, physiatry, emergency medicine, and primary care. Clinical management may require a multidisciplinary approach. This article presents a structured method for the diagnosis of concussion and PPCS in the outpatient setting, which includes a history, physical examination, and additional tests as clinically indicated to help identify underlying symptom generators. Treatment for concussion and PPCS should be individualized, based on predominant signs and symptoms, and can include subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and some symptom-specific pharmacological therapies. [ABSTRACT FROM AUTHOR]

Abstract Background Most individuals at risk for developing cardiovascular disease (CVD) can reduce risk factors through diet and exercise before resorting to drug treatment. The effect of a combination of resistance training with vegetable-based (soy) versus animal-based (whey) protein supplementation on CVD risk reduction has received little study. The study's purpose was to examine the effects of 12 weeks of resistance exercise training with soy versus whey protein supplementation on strength gains, body composition and serum lipid changes in overweight, hyperlipidemic men. Methods Twenty-eight overweight, male subjects (BMI 25–30) with serum cholesterol >200 mg/dl were randomly divided into 3 groups (placebo (n = 9), and soy (n = 9) or whey (n = 10) supplementation) and participated in supervised resistance training for 12 weeks. Supplements were provided in a double blind fashion. Results All 3 groups had significant gains in strength, averaging 47% in all major muscle groups and significant increases in fat free mass (2.6%), with no difference among groups. Percent body fat and waist-to-hip ratio decreased significantly in all 3 groups an average of 8% and 2%, respectively, with no difference among groups. Total serum cholesterol decreased significantly, again with no difference among groups. Conclusion Participation in a 12 week resistance exercise training program significantly increased strength and improved both body composition and serum cholesterol in overweight, hypercholesterolemic men with no added benefit from protein supplementation.

Abstract Background Our purpose was to determine the relationship between energy intake, energy availability, dietary fat and lower extremity injury in adult female runners. We hypothesized that runners who develop overuse running-related injuries have lower energy intakes, lower energy availability and lower fat intake compared to non-injured runners. Methods Eighty-six female subjects, running a minimum of 20 miles/week, completed a food frequency questionnaire and informed us about injury incidence over the next year. Results Injured runners had significantly lower intakes of total fat (63 ± 20 vs. 80 ± 50 g/d) and percentage of kilocalories from fat (27 ± 5 vs. 30 ± 8 %) compared with non-injured runners. A logistic regression analysis found that fat intake was the best dietary predictor, correctly identifying 64% of future injuries. Lower energy intake and lower energy availability approached, but did not reach, a significant association with overuse injury in this study. Conclusion Fat intake is likely associated with injury risk in female runners. By documenting these associations, better strategies can be developed to reduce running injuries in women.

This article presents a brief, focused physical examination [PE, the Buffalo Concussion Physical Examination (BCPE)] for sport-related concussion (SRC) to be considered for use in the outpatient setting by sports medicine physicians, pediatricians, and primary-care physicians. This companion paper describes how to perform the PE, which was derived in a separate study presented in this journal. It is envisioned for use at the initial and follow-up outpatient visits both for acute concussions and in patients with prolonged symptoms. A pertinent PE, combined with other assessments, can help identify specific treatment targets in those with persistent symptoms after SRC. The BCPE includes orthostatic vital signs and examinations of the cranial nerves, oculomotor/ophthalmologic, cervical, and vestibular systems. Supplementary tests, including testing for exercise tolerance and neurocognitive function, may be performed if indicated. It is recommended that a PE be performed at the initial visit and every 1 to 2 weeks after SRC. On return of symptoms, cognition, and the PE to baseline, as well as normalization of any supplementary tests, patients can begin a return to play program. [ABSTRACT FROM AUTHOR]

Objective: To study the effect of early prescribed aerobic exercise versus relative rest on rate of recovery in male adolescents acutely after sport-related concussion (SRC). Design: Quasi-experimental design. Setting: University sports medicine centers. Participants: Exercise group (EG, n = 24, 15.13 +/- 1.4 years, 4.75 +/- 2.5 days from injury) and rest group (RG, n = 30, 15.33 +/- 1.4 years, 4.50 +/- 2.1 days from injury). Interventions: Exercise group performed a progressive program of at least 20 minutes of daily subthreshold aerobic exercise. Rest group was prescribed relative rest (no structured exercise). Both groups completed daily online symptom reports (Postconcussion Symptom Scale) for 14 days. Main Outcome Measures: Days to recovery after treatment prescription. Recovery was defined as return to baseline symptoms, exercise tolerant, and judged recovered by physician examination. Results: Recovery time from initial visit was significantly shorter in EG (8.29 +/- 3.9 days vs 23.93 +/- 41.7 days, P = 0.048). Mixed-effects linear models showed that all symptom clusters decreased with time and that there was no significant interaction between treatment group and time. No EG participants experienced delayed recovery (>30 days), whereas 13% (4/30) of RG participants experienced delayed recovery. Conclusions: These preliminary data suggest that early subthreshold aerobic exercise prescribed to symptomatic adolescent males within 1 week of SRC hastens recovery and has the potential to prevent delayed recovery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate (1) systematic assessment of exercise tolerance in adolescents shortly after sport-related concussion (SRC) and (2) the prognostic utility of such assessment. Design: Prospective randomized controlled trial. Setting: University and community sports medicine centers. Participants: Adolescents with SRC (1-9 days from injury). Sixty-five were randomized and 54 completed the study (mean age 15 years, 4 days after injury). Interventions: Buffalo Concussion Treadmill Test (BCTT, = 5 27) or not (controls, n = 27) on visit day #1. Heart rate threshold (HRt) at symptom exacerbation represented level of exercise tolerance. Participants reported symptoms daily for 14 days and then had follow-up BCTT (n = 54). Recovery was defined as returning to normal level of symptoms and exercise tolerance, verified by independent physician examination. Main Outcome Measures: Days to recovery and typical (≤21 days) versus prolonged recovery (>21 days). Mixed effects linear models and linear regression techniques examined symptom reports and time to recovery. Linear regression assessed the association of HRt with recovery time. Results: Days to recovery (P = 0.7060) and typical versus prolonged recovery (P = 0.1195) were not significantly different between groups. Symptom severity scores decreased in both groups over 14 days (P,0.0001), were similar (P=0.2984), and did not significantly increase the day after the BCTT (P = 0.1960). Lower HRt on visit day #1 was strongly associated with prolonged recovery time (P = 0.0032). Conclusions: Systematic evaluation of exercise tolerance using the BCTT within 1 week after SRC did not affect recovery. The degree of early exercise intolerance after SRC was important for prognosis. This has implications for school academic and team preparation. [ABSTRACT FROM AUTHOR]

Objective: Investigate the reliability of concussion symptoms captured through ecological momentary assessment (EMA) and compare time with recovery based on 3 definitions of symptomatic recovery and the date of clinical clearance to begin the return-to-play (RTP) process. Design: We used a mobile app with EMA to monitor concussion symptoms as part of a multicenter randomized controlled trial. Setting: Three sports medicine practices. Participants: Patients between 13 and 18 years old with sport-related concussion were prompted to complete the Post-Concussion Symptom Inventory daily over 4 weeks. Interventions: None. Main Outcome Measures: We compared the elapsed days to reaching the 4 outcomes using scatterplots and Kaplan–Meier curves. Results: Among 118 participants, symptoms reported into the app had excellent agreement with symptoms reported at a clinical visit on the same day (intraclass correlation coefficient = 0.97). Most (>50%) participants reached "specific symptom return to preinjury levels," "overall symptom return to preinjury levels," and "current symptom resolution" based on EMA symptom reports between several days and 1 week before achieving "clinical clearance to RTP" determined at a clinical visit, which had 100% sensitivity, but between 56.3% and 78.1% specificity, relative to the app-measured symptom outcomes. Conclusions: Time until symptom recovery varies based on the chosen definition of symptomatic recovery but is a more precise correlate with clinical clearance to begin the RTP process when defining symptom recovery as a return to a preinjury baseline level of symptomatology. Real-time symptom monitoring may be beneficial clinically, allowing providers to assess patients' recovery status and make more timely and remote treatment recommendations. [ABSTRACT FROM AUTHOR]