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To assess whether padded headgear was associated with incidence of suspected sports-related concussion, non-sports-related concussion head injury, and injuries to other body regions in junior Australian football.Prospective cohort injury surveillance.There were 400 junior players (42.5% female) enrolled across two seasons. Suspected sports-related concussion was defined by detection of observable signs on the field and medical assessment or missed match(es) due to suspected sports-related concussion. Non-sports-related concussion head injury and injuries to other body regions were defined as those that received medical assessment or resulted in a missed match.There were 20 teams monitored over 258 matches. 204 players (2484 player hours) wore mandated headgear throughout the season and 196 (2246 player hours) did not. The incidence rate of suspected sports-related concussion was 3.17 (95% confidence interval: 3.04-3.30) per 1000 player-hours and no differences were observed between males and females (risk ratio 1.11; 95% confidence interval: 0.40-3.06). Headgear use was not associated with suspected sports-related concussion (risk ratio 1.09; 95% confidence interval: 0.41-2.97), non-sports-related concussion head injury (risk ratio 0.27; 95% confidence interval: 0.06-1.31), or injuries to other body regions (risk ratio 1.41; 95% confidence interval: 0.79-2.53).Headgear use was not associated with reduced risk of suspected sports-related concussion, non-sports-related concussion head injury or injuries to other body regions. There was no difference in the rate of suspected sports-related concussion in female compared to male players, however, rates of non-sports-related concussion head injury and injuries to other body regions were higher in male players.

Video surveillance and detection of players with visible signs of concussion by experienced medical staff facilitates rapid on-field screening of suspected concussion in professional sports. This method, however has not been validated in community sports where video footage is unavailable. This study aimed to explore the utility of visible signs of concussion to identify players with decrements in performance on concussion screening measures. In this observational prospective cohort study, personnel with basic training observed live matches across a season (60 matches) of community male and female Australian football for signs of concussion outlined in the community-based Head Injury Assessment form (HIAf). Players identified to have positive signs of concussion (CoSign+) following an impact were compared with players without signs (CoSign-). Outcome measures, the Sport Concussion Assessment Tool (SCAT3) and Cogstate, were administered at baseline and post-match. CoSign+ (

IntroductionDue to the increase in participation and risk of anterior cruciate ligament (ACL) injuries and concussion in women’s Australian Football, an injury prevention programme (Prep-to-Play) was codesigned with consumers (eg, coaches, players) and stakeholders (eg, the Australian Football League). The impact of supported and unsupported interventions on the use of Prep-to-Play (primary aim) and injury rates (secondary aim) will be evaluated in women and girls playing community Australian Football.Methods and analysisThis stepped-wedge, cluster randomised controlled trial will include ≥140 teams from U16, U18 or senior women’s competitions. All 10 geographically separated clusters (each containing ≥14 teams) will start in the control (unsupported) phase and be randomised to one of five dates (or ‘wedges’) during the 2021 or 2022 season to sequentially transition to the intervention (supported Prep-to-Play), until all teams receive the intervention. Prep-to-Play includes four elements: a neuromuscular training warm-up, contact-focussed football skills (eg, tackling), strength exercises and education (eg, technique cues). When transitioning to supported interventions, study physiotherapists will deliver a workshop to coaches and player leaders on how to use Prep-to-Play, attend team training at least two times and provide ongoing support. In the unsupported phase, team will continue usual routines and may freely access available Prep-to-Play resources online (eg, posters and videos about the four elements), but without additional face-to-face support. Outcomes will be evaluated throughout the 2021 and 2022 seasons (~14 weeks per season). Primary outcome: use of Prep-to-Play will be reported via a team designate (weekly) and an independent observer (five visits over the two seasons) and defined as the team completing 75% of the programme, two-thirds (67%) of the time. Secondary outcomes: injuries will be reported by the team sports trainer and/or players. Injury definition: any injury occurring during a football match or training that results in: (1) being unable to return to the field of play for that match or (2) missing ≥ one match. Outcomes in the supported and unsupported phases will be compared using a generalised linear mixed model adjusting for clustering and time. Due to the type III hybrid implementation-effectiveness design, the study is powered to detect a improvement in use of Prep-to-Play and a reduction in ACL injuries.Ethics and disseminationLa Trobe University Ethics Committee (HREC 20488) approved. Coaches provided informed consent to receive the supported intervention and players provided consent to be contacted if they sustained a head or knee injury. Results will be disseminated through partner organisations, peer-reviewed publications and scientific conferences.Trial registration numberNCT04856241.

Objective To explore the potential utility of head acceleration event (HAE) measurements to augment identification of players for further concussion screening in non-helmeted contact sport. Design Prospective observational pilot study. Participants 210 (118 female) professional Australian football players in 2017 season. Methods Players wore the X-Patch® accelerometer for one match each with data collected across 14 matches. Players with HAEs above thresholds associated with concussion, 95 g (males) or 85.5 g (females), were compared to players identified to have suspected concussion by club personnel during the inspected matches. Video review of matches was undertaken by a physician blinded to HAEs to identify players with concussive signs. Results Among 26 players (50% female) with HAEs above threshold, two players were screened for concussion. Of the remaining 24 players, nine were not visible on video at the HAE time, six sustained verifiable head impacts, and nine sustained verifiable body impacts with no head impacts. Among 184 players with HAEs below threshold, five players were screened. Conclusion Players were identified to have head impacts and suspected concussion in the absence of HAEs above threshold. Use of X-Patch® was not sufficiently reliable for identifying players for further concussion screening in professional Australian football. Video review of head impacts remains essential in concussion screening.

Sports-related concussion, a form of mild traumatic brain injury, is characterized by transient disturbances of brain function. There is increasing evidence that functional brain changes may be driven by subtle abnormalities in white matter microstructure, and diffusion MRI has been instrumental in demonstrating these white matter abnormalities in vivo. However, the reported location and direction of the observed white matter changes in mild traumatic brain injury are variable, likely attributable to the inherent limitations of the white matter models used. This cross-sectional study applies an advanced and robust technique known as fixel-based analysis to investigate fibre tract-specific abnormalities in professional Australian Football League players with a recent mild traumatic brain injury. We used the fixel-based analysis framework to identify common abnormalities found in specific fibre tracts in participants with an acute injury (≤12 days after injury; n = 14). We then assessed whether similar changes exist in subacute injury (>12 days and

Background Up to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored. Methods Fifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews. Discussion Results from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes. Trial registration ANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118

AIM OR OBJECTIVE: The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC). DESIGN: Systematic review. DATA SOURCES: MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded. RESULTS: Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care. SUMMARY/CONCLUSIONS: A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2016:CRD42016039570.

We present a 23-year-old male professional Australian Football player who experienced a total of seven sports-related concussions between May-2015-March-2019, not associated with loss of consciousness (see supplementary materials for clinical details). Advanced brain imaging was performed after the latter four of these, revealing that his brain underwent a pattern of focal, but transient, increases in T2 relaxometry following concussive events.

Aim To determine whether acute sport-related concussion is associated with functional brain changes in Australian rules footballers. Methods Twenty acutely concussed professional Australian footballers were studied with 3 T magnetic resonance imaging and compared to 20 age-matched control subjects. We statistically compared whole-brain local functional magnetic resonance imaging connectivity between acutely concussed footballers and controls using voxel-wise permutation testing. Results The acutely concussed football players had significantly decreased local functional magnetic resonance imaging connectivity in the right dorsolateral prefrontal cortex, right inferior parietal lobe, and right anterior insula, compared to controls. No functional brain changes between groups within the default mode network were observed. Discussion Acutely concussed footballers had in common decreased functional connectivity within the right lateralized “cognitive control network” of the brain that is involved in executive functions, and the “salience network” involved in switching between tasks. Dysfunction of these brain regions is a plausible explanation for typical clinical features of concussion.

Objectives The objectives of the study were to assess the relationship between various player and game factors and risk of concussion; and to assess the reliability of video analysis for mechanistic assessment of concussion in Australian football. Design Prospective cohort study. Methods All impacts and collisions resulting in concussion were identified during the 2011 Australian Football League season. An extensive list of factors for assessment was created based upon previous analysis of concussion in Australian Football League and expert opinions. The authors independently reviewed the video clips and correlation for each factor was examined. Results A total of 82 concussions were reported in 194 games (rate: 8.7 concussions per 1000 match hours; 95% confidence interval: 6.9–10.5). Player demographics and game variables such as venue, timing of the game (day, night or twilight), quarter, travel status (home or interstate) or score margin did not demonstrate a significant relationship with risk of concussion; although a higher percentage of concussions occurred in the first 5 min of game time of the quarter (36.6%), when compared to the last 5 min (20.7%). Variables with good inter-rater agreement included position on the ground, circumstances of the injury and cause of the impact. The remainder of the variables assessed had fair-poor inter-rater agreement. Common problems included insufficient or poor quality video and interpretation issues related to the definitions used. Conclusions Clear definitions and good quality video from multiple camera angles are required to improve the utility of video analysis for concussion surveillance in Australian football.

Study Design Cross-sectional study. Background Functional task performance in patients with chondrolabral pathology following hip arthroscopy is unknown. Objectives To investigate in people with chondrolabral pathology following hip arthroscopy (1) the bilateral differences in functional task performance compared to controls, (2) the association of hip muscle strength with functional task performance, and (3) the association of functional task performance scores with good outcome, as measured by International Hip Outcome Tool score. Methods Seventy-one patients who had unilateral hip arthroscopy for hip pain and 60 controls were recruited. Patient-reported outcomes included the 4 subscales of the International Hip Outcome Tool. Hip muscle strength measures included abduction, adduction, extension, flexion, external rotation, and internal rotation. Functional tasks assessed included the single hop test, the side bridge test, and the single-leg rise test. For aim 1, analyses of covariance tests were used. For aim 2, stepwise multiple linear regression analyses were used. For aim 3, receiver operating characteristic curve analyses were used. Results Compared to controls, the chondrolabral pathology group had significantly worse performance on both legs for each of the functional tasks (P

Objectives The objective of this study was to determine the reliability and validity of identifying clinical signs of concussion using video analysis in Australian football. Design Prospective cohort study. Methods All impacts and collisions potentially resulting in a concussion were identified during 2012 and 2013 Australian Football League seasons. Consensus definitions were developed for clinical signs associated with concussion. For intra- and inter-rater reliability analysis, two experienced clinicians independently assessed 102 randomly selected videos on two occasions. Sensitivity, specificity, positive and negative predictive values were calculated based on the diagnosis provided by team medical staff. Results 212 incidents resulting in possible concussion were identified in 414 Australian Football League games. The intra-rater reliability of the video-based identification of signs associated with concussion was good to excellent. Inter-rater reliability was good to excellent for impact seizure , slow to get up , motor incoordination , ragdoll appearance (2 of 4 analyses), clutching at head and facial injury . Inter-rater reliability for loss of responsiveness and blank and vacant look was only fair and did not reach statistical significance. The feature with the highest sensitivity was slow to get up (87%), but this sign had a low specificity (19%). Other video signs had a high specificity but low sensitivity. Blank and vacant look (100%) and motor incoordination (81%) had the highest positive predictive value. Conclusions Video analysis may be a useful adjunct to the side-line assessment of a possible concussion. Video analysis however should not replace the need for a thorough multimodal clinical assessment.

BackgroundThe use of video to assist professional sporting bodies with the diagnosis of sport-related concussion (SRC) has been well established; however, there has been little consistency across sporting codes with regards to which video signs should be used, and the definitions of each of these signs.AimThe aims of this study were to develop a consensus for the video signs considered to be most useful in the identification of a possible SRC and to develop a consensus definition for each of these video signs across the sporting codes.MethodsA brief questionnaire was used to assess which video signs were considered to be most useful in the identification of a possible concussion. Consensus was defined as >90% agreement by respondents. Existing definitions of these video signs from individual sports were collated, and individual components of the definitions were assessed and ranked. A modified Delphi approach was then used to create a consensus definition for each of the video signs.ResultsRespondents representing seven sporting bodies (Australian Football League, Cricket Australia, Major League Baseball, NFL, NHL, National Rugby League, World Rugby) reached consensus on eight video signs of concussion. Thirteen representatives from the seven professional sports ranked the definition components. Consolidation and refinement of the video signs and their definitions resulted in consensus definitions for six video signs of possible concussion: lying motionless, motor incoordination, impact seizure, tonic posturing, no protective action—floppy and blank/vacant look.ConclusionsThese video signs and definitions have reached international consensus, are indicated for use by professional sporting bodies and will form the basis for further collaborative research.

In the original article [1] reference was made to the Hawk-Eye system having been used as the sideline operating system during the 2015 season.

BackgroundVideo review has become an important tool in professional sporting codes to help sideline identification and management of players with a potential concussion.AimTo assess current practices related to video review of concussion in professional sports internationally, and compare protocols and diagnostic criteria used to identify and manage potential concussions.MethodsCurrent concussion management guidelines from professional national and international sporting codes were reviewed. Specific criteria and definitions of video signs associated with concussion were compared between codes. Rules and regulations adopted across the codes for processes around video review were also assessed.ResultsSix sports with specific diagnostic criteria and definitions for signs of concussion identified on video review participated in this study (Australian football, American football, world rugby, cricket, rugby league and ice hockey). Video signs common to all sports include lying motionless/loss of responsiveness and motor incoordination. The video signs considered by the majority of sports as most predictive of a diagnosis of concussion include motor incoordination, impact seizure, tonic posturing and lying motionless. Regulatory requirements, sideline availability of video, medical expertise of video reviewers and use of spotters differ across sports and geographical boundaries. By and large, these differences reflect a pragmatic approach from each sport, with limited underlying research and development of the video review process in some instances.ConclusionsThe use of video analysis in assisting medical staff with the diagnosis or identification of potential concussion is well established across different sports internationally. The diagnostic criteria used and the expertise of the video review personnel are not clearly established, and research efforts would benefit from a collaborative harmonisation across sporting codes.

Background Sideline video review has been increasingly used to evaluate risk of concussive injury during match play of a number of collision sports, with the view to reducing the incidence of match play concussion injuries. The purpose of this study was to evaluate the effectiveness of sideline video review for identifying and evaluating head impact events in Rugby Union. Methods All Australian teams’ 2015 Super Rugby season matches were studied. Meaningful head impact events (HIEs) were identified, comprising events identified and acted upon during matches and events identified through a post-season retrospective review. Video footage of each HIE was coded by two experienced independent sports medicine clinicians to evaluate management decisions made by match-day (MDD) and team doctors (TD). HIE incidences for matches with and without sideline video were compared, and the agreement between game-day video interpretation and the independent clinician opinion calculated. Results Seventy HIEs were identified in 83 matches (47 identified during matches and 23 identified post-season), equating to 42.5 HIEs per 1000 player match hours. When video review was available, an unnoticed HIE occurred once every 4.3 matches, compared to once every 2.3 matches when the sideline video review was unavailable. Of the 47 identified in-match HIEs evaluated by TD and MDD during the season, 18 resulted in an immediate and permanent removal, 28 resulted in temporary removal for an off-field assessment, and one resulted in the player continuing the game. Game-day head injury assessment process video decisions agreed with the independent clinician view in 72% of cases, κ = 0.49 (95% CI 0.38–0.59, weak agreement). Conclusions These findings suggest that access to sideline video review is an important supplementary component to identify potential concussions; however, there is a critical need for improved systems and processes to reduce the likelihood of missing an incident.

To conduct the first video analysis of concussion in the Australian National Rugby League (NRL) and describe player and injury characteristics, situational factors and time to return to play.Descriptive, observational case series.Video analysis of 20 medically diagnosed concussions for three consenting clubs during the 2013 NRL season.Most concussions (83%) occurred during a high tackle, and all injured ball carriers were hit high. Loss of consciousness was observed in 30% of cases. Common observable signs of injury included clutching of the head, balance problems or wobbly legs and a blank or vacant state. There were no post-concussive seizures. All players with loss of consciousness were removed from play. However, only half of the total sample was removed from play and one athlete who was removed returned to play in the same match. Of the players who were removed from play, the large majority returned the following week. Illegal play accounted for 25% of all concussions.Video analysis may be a useful method to study the incidence, mechanism and management of concussion in sports such as Rugby League. Future studies may include larger numbers to validate this preliminary data and may also investigate other levels of play and age ranges.

OBJECTIVE: To conduct a systematic review of the literature regarding assessment and treatment modalities in patients with persistent symptoms following sport-related concussion (SRC). DATA SOURCES: We searched Medline, Embase, SPORTSDiscus, PsycINFO, CINAHL, Cochrane library and ProQuest Dissertation & Theses Global electronic databases. STUDY ELIGIBILITY CRITERIA: Studies were included if they were original research, reported on SRC as the primary source of injury, included patients with persistent postconcussive symptoms (>10 days) and investigated the role of assessment or treatment modalities. RESULTS: Of 3225 articles identified in the preliminary search, 25 articles met the inclusion criteria. 11 articles were concerned with assessment and 14 articles with treatment of persistent symptoms following SRC. There were three randomised control trials and one quasi-experimental study. The remainder consisting of cross-sectional studies, historical cohorts and case series. SUMMARY: 'Persistent symptoms' following SRC can be defined as clinical recovery that falls outside expected time frames (ie, >10-14 days in adults and >4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding pathologies. A detailed multimodal clinical assessment is required to identify specific primary and secondary processes, and treatment should target specific pathologies identified. There is preliminary evidence supporting the use of symptom-limited aerobic exercise, targeted physical therapy and a collaborative approach that includes cognitive behavioural therapy. Management of patients with persistent symptoms is challenging and should occur in a multidisciplinary collaborative setting, with healthcare providers with experience in SRC.

This paper presents the Sport Concussion Assessment Tool 5th Edition (SCAT5), which is the most recent revision of a sport concussion evaluation tool for use by healthcare professionals in the acute evaluation of suspected concussion. The revision of the SCAT3 (first published in 2013) culminated in the SCAT5. The revision was based on a systematic review and synthesis of current research, public input and expert panel review as part of the 5th International Consensus Conference on Concussion in Sport held in Berlin in 2016. The SCAT5 is intended for use in those who are 13 years of age or older. The Child SCAT5 is a tool for those aged 5-12 years, which is discussed elsewhere.

With growing concerns about long-term complications and expert consensus that premature return to play may increase the risk of adverse outcomes, there has been an increased emphasis on accurate diagnosis and a conservative management approach to concussion in sport.1 The diagnosis and clinical assessment of concussion, however, remains challenging. In addition to the variability in clinical presentation and the absence of a reliable direct biomarker of injury and recovery,2 the evolution of concussion symptoms is unpredictable, complicating the clinical assessment. While some athletes demonstrate the symptoms and signs of concussion immediately following impact, in many the symptoms evolve over minutes, and in some, over days. This is particularly common in younger athletes. Thus, concussion assessment performed too early, or using a single diagnostic modality, frequently fails to accurately diagnose concussion. Consequently, a multimodal approach is currently recommended for the assessment of concussion to maximize the sensitivity of the clinical evaluation.1

Sports injuries are a significant clinical and public health concern. There is a growing call to improve the translation of available evidence-based and expert-informed sports injury prevention interventions into sustained use in practice by physicians and others (eg, athletic trainers, coaches, and parents) who care for injured athletes. This article provides a brief overview of the current sport injury prevention implementation literature before focusing specifically on the translation of guidelines (including consensus and position statements) developed to assist physicians and others diagnose and manage athletes with sport-related concussion and the associated return-to-play decisions. The outcomes of more than 20 published studies indicate that physician, athletic trainer, coach, parent, and athlete knowledge, use of, and compliance with sport-related concussion guidelines are limited. More concerted, coordinated, and theory-informed efforts are required to facilitate the widespread dissemination, translation, and implementation of such guidelines. An example is provided of how implementation drivers could be used to inform the development of a comprehensive, multilevel implementation strategy targeting the individual, organizational, and system-level changes necessary to support the translation of available sport-related concussion guidelines in both the clinical and sports settings.

Sports-related concussion (SRC) is one of the most important medical issues in contact and collision sports around the world. The NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocols, published in this edition of the BJSM , represent a comprehensive approach to concussion management in professional sport.1 The protocols highlight how much the approach to SRC has evolved, particularly since the first International Conference on Concussion in Sport held in Vienna in November 2001.2 This evolution has been driven largely by concerns (both medical and public) regarding potential short-term and long-term adverse outcomes following SRC, and have been underpinned by evolving concepts from five international consensus meetings, and an explosion of research on SRC over the past decade. The fifth International Conference on Concussion in Sport was held in Berlin in October 2016. The meeting involved more than 18 months of active planning, 10 scientific committee members, 23 additional expert panellists and 420 participants representing 24 countries.3 The output included 12 comprehensive systematic reviews (which collectively screened nearly 60 000 articles), 202 additional conference scientific abstracts, a consensus paper4 and revised standardised concussion recognition and assessment tools (SCAT5, ChildSCAT5 and CRT5). The output from the Berlin meeting provides a blueprint of 11 key principles of concussion management (the 11 ‘R’s’).4 Translation and implementation of these principles …

Aim The need for accurate diagnosis and appropriate return-to-play decisions following a concussion in sports has prompted the dissemination of guidelines to assist managing this condition. This study aimed to assess whether key messages within these guidelines are reflected in the knowledge of coaches and sports trainers involved in community sport. Methods An online knowledge survey was widely promoted across Australia in May–August 2012 targeting community Australian Football (AF) and Rugby League (RL) coaches and sports trainers. 260 AF coaches, 161 AF sports trainers, 267 RL coaches and 228 RL sports trainers completed the survey. Knowledge scores were constructed from Likert scales and compared across football codes and respondent groups. Results General concussion knowledge did not differ across codes but sports trainers had higher levels than did coaches. There were no significant differences in either concussion symptoms or concussion management knowledge across codes or team roles. Over 90% of respondents correctly identified five of the eight key signs or symptoms of concussion. Fewer than 50% recognised the increased risk of another concussion following an initial concussion. Most incorrectly believed or were uncertain that scans typically show damage to the brain after a concussion occurs. Fewer than 25% recognised, and >40% were uncertain that younger players typically take longer to recover from concussion than adults. Conclusions The key messages from published concussion management guidelines have not reached community sports coaches and sports trainers. This needs to be redressed to maximise the safety of all of those involved in community sport.

a b s t r a c t Objectives: This study investigated tests of hip muscle strength and functional performance. The spe- cific objectives were to: (i) establish intra- and inter-rater reliability; (ii) compare differences between dominant and non-dominant limbs; (iii) compare agonist and antagonist muscle strength ratios; (iv) com- pare differences between genders; and (v) examine relationships between hip muscle strength, baseline measures and functional performance. Design: Reliability study and cross-sectional analysis of hip strength and functional performance. Methods: In healthy adults aged 18-50 years, normalised hip muscle peak torque and functional per- formance were evaluated to: (i) establish intra-rater and inter-rater reliability; (ii) analyse differences between limbs, between antagonistic muscle groups and genders; and (iii) associations between strength and functional performance. Results: Excellent reliability (intra-rater ICC = 0.77-0.96; inter-rater ICC = 0.82-0.95) was observed. No difference existed between dominant and non-dominant limbs. Differences in strength existed between antagonistic pairs of muscles: hip abduction was greater than adduction (p < 0.001) and hip ER was greater than IR (p < 0.001). Men had greater ER strength (p = 0.006) and hop for distance (p < 0.001) than women. Strong associations were observed between measures of hip muscle strength (except hip flexion) and age, height, and functional performance. Conclusions: Deficits in hip muscle strength or functional performance may influence hip pain. In order to provide targeted rehabilitation programmes to address patient-specific impairments, and determine when individuals are ready to return to physical activity, clinicians are increasingly utilising tests of hip strength and functional performance. This study provides a battery of reliable, clinically applicable tests which can be used for these purposes.

This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus questions discussed at this meeting; 4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT …

The Sport Concussion Assessment Tool 2 (SCAT2), which evolved from the 2008 Concussion in Sport Group (CISG) Consensus meeting, has been widely used internationally for the past 4 years. Although the instrument is considered very practical and moderately effective for use by clinicians who manage concussion, the utility and sensitivity of a 100-point scoring system for the SCAT2 has been questioned. The 2012 CISG Consensus Meeting provided an opportunity for several of the world's leading concussion researchers and clinicians to present data and to share experiences using the SCAT2. The purpose of this report is to consider recommendations by the CISG, and to review the current literature to identify the most sensitive and reliable concussion assessment components for inclusion in a revised version-the SCAT3. Through this process, it was determined that important clinical information can be ascertained in a streamlined manner through the use of a multimodal instrument such as the SCAT3. This test battery should include an initial assessment of injury severity using the Glasgow Coma Scale, immediately followed by observing and documenting concussion signs. Once this is complete, symptom endorsement and symptom severity, neurocognitive function and balance function should be assessed in any athlete suspected of sustaining a concussion. There is no evidence to support the use of a composite/total score; however, there is good evidence to support the use of each component (scored independently) in a revised assessment tool.

Background Concussion in sport typically recovers clinically within 10 days of injury. In some cases, however, symptoms may be prolonged or complications may develop. The objectives of the current paper are to review the literature regarding the difficult concussion and to provide recommendations for an approach to the investigation and management of patients with persistent symptoms. Methods A qualitative review of the literature on concussion in sport was conducted with a focus on prolonged recovery, long-term complications and management including investigation and treatment strategies. MEDLINE and Sports Discus databases were reviewed. Results Persistent symptoms (>10 days) are generally reported in 10–15% of concussions. This figure may be higher in certain sports (eg, ice hockey) and populations (eg, children). In general, symptoms are not specific to concussion and it is important to consider and manage coexistent pathologies. Investigations may include formal neuropsychological testing and conventional neuroimaging to exclude structural pathology. Currently, there is insufficient evidence to recommend routine clinical use of advanced neuroimaging techniques or genetics markers. Preliminary studies demonstrate the potential benefit of subsymptom threshold activity as part of a comprehensive rehabilitation programme. Limited research is available on pharmacological interventions. Conclusions Cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion. Important components of management, after the initial period of physical and cognitive rest, include associated therapies such as cognitive, vestibular, physical and psychological therapy, assessment for other causes of prolonged symptoms and consideration of a graded exercise programme at a level that does not exacerbate symptoms.

Background Arthroscopy is increasingly used to improve pain and function in athletes with hip joint pathology. Surgical techniques have evolved to utilise arthroscopic femoral osteoplasty to address potential morphological contributors to pathology. Purpose Investigate pain and function outcomes following hip arthroscopy with and without femoral osteoplasty in individuals with intra-articular hip pathology. Study design Systematic review. Methods A comprehensive search strategy identified studies that evaluated the outcome over at least 3 months following arthroscopy for intra-articular hip pathology, using patient-reported outcomes of pain and/or function. Methodological quality was evaluated (Downs and Black scale), and effect sizes calculated when sufficient data were available. Results Twenty-nine studies of moderate methodological quality were included. Of 16 studies investigating arthroscopy alone, two studies showed large effects (3.12–5.46) at 1–2 years. Pain reduction and functional improvement (median 47%) were consistently reported by the remaining 14 studies up to 10 years postsurgery. Of 15 studies investigating arthroscopy with osteoplasty, nine papers showed mostly large effects (0.78–2.93) over 6–28 months. Adverse events were minimal (7% of participants, 12 studies, predominantly transient neuropraxia (83%)). Conclusion Current evidence indicates that hip arthroscopy can significantly reduce pain and improve function in patients with intra-articular hip pathology. While benefits of arthroscopy alone can persist up to 10 years postsurgery, effects of osteoplasty beyond 3 years need to be established. Future studies should investigate rehabilitation in this population, and the impact of surgery on development of osteoarthritis. Refereed/Peer-reviewed

Background Hamstring strains remain one of the most prevalent injuries in Australian Rules football. The authors prospectively examined the relationship between musculotendinous stiffness of the hamstring and leg stiffness with hamstring injury in professional Australian Rules footballers during the 2006 season. Hypothesis Higher hamstring stiffness and leg stiffness are related to noncontact, soft tissue hamstring injury risk in professional Australian Rules footballers. Study Design Case-control study; Level of evidence, 3. Methods Unilateral hamstring stiffness and leg stiffness were assessed in 136 professional footballers in the month before the commencement of the competitive season. This information was then investigated relative to players who suffered noncontact, soft tissue hamstring injuries during either matches or training throughout the season to identify whether preseason stiffness was related to injury occurrence. Results Fourteen tested players recorded acute, noncontact hamstring injuries, resulting in 3.3 ± 2.8 weeks of missed match play per injury. At preseason testing, the players who ended up sustaining a hamstring injury during the season recorded significantly higher mean hamstring stiffness (11%, P = .04) and leg stiffness (5%, P = .03). When considering the injured players, the leg stiffness of the involved limb was significantly higher than the noninjured players (P = .02), whereas hamstring stiffness was significantly higher on the noninvolved limb (P = .01). Further, those players who suffered a hamstring injury were significantly older than the noninjured players (P = .01). Conclusion It appears that a high bilateral hamstring stiffness and leg stiffness may be a determinant in the risk of sustaining a hamstring injury. Further, relatively lower hamstring stiffness in the involved limb of injured players appears to be associated with increased injury and may be related to a lack of strength. The information from stiffness assessment may allow medical staff to determine the hamstring risk status for individual players in team sports.

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.

Background: At the Second International Conference on Concussion in Sport, concussion was classified as “simple” or “complex” based largely on duration of clinical features. The purpose of the classification system was to assist clinicians in identifying higher grades of injury severity and guide injury management. The aim of the current paper is to review the validity and clinical usefulness of the simple versus complex classification system. Study design: Qualitative review of the literature on concussion in sport, with a focus on time course of clinical recovery and prognostic factors. Intervention: Pubmed, Medline and Sport Discus databases were reviewed. Fifty journal articles were included in the review. Results: Prospective studies support the recovery of symptoms, balance deficits and cognitive impairment in the majority of concussed athletes within 10 days of injury. However, clinical factors that predict higher grades of injury severity or poor outcome following concussion remain unclear. At present, concussion severity can only be accurately determined in retrospect after all clinical features have resolved. Conclusion: It is recommended that concussion in sport be considered as a single entity. Clinical factors that have demonstrated to be associated with longer duration of symptoms (for example, post-traumatic amnesia) or poor outcome (for example, repetitive head injury) may serve as “modifying” factors to assist the treating practitioner in identifying potential for higher grades of injury severity or adverse outcomes.

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.

Objectives Video analysis can provide critical information to improve diagnostic accuracy and speed of clinical decision-making in potential cases of concussion. The objective of this study was to validate a hierarchical flowchart for the assessment of video signs of concussion, and to determine whether its implementation could improve the process of game day video assessment. Design Prospective cohort study. Methods All impacts and collisions potentially resulting in a concussion were identified during 2012 and 2013 Australian Football League (AFL) seasons. Consensus definitions were developed for clinical signs associated with concussion. A hierarchical flowchart was developed based on the reliability and validity of the video signs of concussion. Ninety videos were assessed, with 45 incidents of clinically confirmed concussion, and 45 cases where no concussion was sustained. Each video was examined using the hierarchical flowchart, and a single response was given for each video based on the highest-ranking element in the flowchart. Results N o protective action , impact seizure, motor incoordination or blank/vacant look were the highest ranked video signs in almost half of the clinically confirmed concussions, but in only 8.8% of non-concussed individuals. The presence of facial injury, clutching at the head and slow to get up were the highest ranked sign in 77.7% of non-concussed individuals. Conclusions This study suggests that the implementation of a flowchart model could improve timely assessment of concussion, and it identifies the video signs that should trigger automatic removal from play.

If physical impairments that are associated with poorer outcomes can be identified in people with chondrolabral hip pathology, then rehabilitation programmes that target such modifiable impairments could potentially be established to improve quality of life. The aim of this study was to examine the relationship between quality-of-life PROs and physical impairment measurements in people with chondrolabral pathology post-hip arthroscopic surgery. This was a cross-sectional study where multiple stepwise linear regression analyses were conducted to determine which physical impairment measurements were most associated with poorer quality-of-life patient-reported outcomes (PROs). Eighty-four patients (42 women; all aged 36 ± 10 years) with hip chondrolabral pathology 12- to 24-month post-hip arthroscopy were included. The Hip disability and Osteoarthritis Outcome Score Quality-of-life (HOOS-Q) subscale and International Hip Outcome Tool (IHOT-33) PROs were collected. Measurements of active hip ROM and strength were assessed. Modifiable post-surgical physical impairments were associated with PRO in patients with chondrolabral pathology. Greater hip flexion ROM was independently associated with better scores in both HOOS-Q and IHOT-33 (adjusted r 2 values ranged from 0.249 to 0.341). Greater hip adduction strength was independently associated with better HOOS-Q and IHOT-33 (adjusted r 2 0.227–0.317). Receiver Operator Curve analyses determined that the limit value for hip flexion ROM was 100° (sensitivity 92 %, specificity 75 %), and hip adduction strength was 0.86 Nm/kg (sensitivity 96 %, specificity 70 %). Hip flexion ROM and adduction strength were associated with better quality-of-life PRO scores in patients with chondrolabral pathology 12- to 24-month post-hip arthroscopy. These impairments could be targeted by clinicians designing rehabilitation programmes to this patient group. Cross-sectional study, Level IV.

Second impact syndrome is a condition that is believed by some people to be a consequence of recurrent sports concussion. The only evidence to support its existence is anecdotal and, if it does exist, it is rare. The fear of this condition has driven the promulgation of concussion management guidelines and, more worryingly, the recent trend towards government regulation of the clinical management of concussion in the United States. Diffuse brain swelling following a single head injury, a well-recognized condition, is more common in children than in adults and usually has a poor outcome. It is posited that the so-called second impact syndrome simply represents diffuse brain swelling mistakenly attributed to repeated concussion.

Objective: To compare the long term outcomes of the two treatment options for navicular stress fractures: non-weightbearing cast immobilisation and surgical fixation. Design: Retrospective case study. Participants: Subjects aged 18 years and older who had been treated for a navicular stress fracture more than two years previously. Main outcome measures: Questionnaire based analogue pain score and function score; tenderness on palpation; abnormality detected on computed tomography (CT). Results: In all, 32 fractures in 26 subjects were investigated. No significant differences were found between surgical and conservative management for current pain (p = 0.984), current function (p = 0.170), or abnormality on CT (p = 0.173). However, surgically treated patients more often remained tender over the “N spot” (p = 0.005), even after returning to competition for two years or more. Conclusions: Surgical fixation of navicular stress fractures appears to be as effective as conservative management over the longer term. However, there remains a small but measurable degree of pain and loss of function over this period. The value of using “N spot” tenderness as the sole clinical predictor of treatment success requires further investigation, as some patients remained tender despite successful completion of treatment and return to competition.