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Background: Former professional collision sport (CS) athletes, particularly American football players, are at risk of developing chronic health conditions; however, little is known about the health outcomes of amateur athletes. Methods: A 60-item health survey examined self-reported symptoms and diagnoses among former Division 1 Collegiate CS athletes and non- or limited-contact sport (non-CS) athletes. Binary logistic regressions tested the association between playing CS and health outcomes. Results: Five hundred and two (6.2%) participants completed the survey: 160 CS athletes (mean age: 59.2, SD = 16.0) and 303 non-CS athletes (mean age: 54.0, SD = 16.9). CS athletes had increased odds of reported cognitive complaints and neuropsychiatric symptoms including memory (Padj < 0.01), attention/concentration (Padj = 0.01), problem solving/multi-tasking (Padj = 0.05), language (Padj = 0.02), anxiety (Padj = 0.04), impulsivity (Padj = 0.02), short-fuse/rage/explosivity (Padj < 0.001), and violence/aggression (Padj = 0.02). CS athletes also reported higher rates of sleep apnea (Padj = 0.02). There were no group differences in cardiovascular and physical health outcomes. Conclusions: Former CS athletes reported more cognitive and neuropsychiatric complaints. The low response rate is a limitation of this study; however, over 500,000 athletes play college sports each year, thus research on long-term health outcomes in this population is critical. [ABSTRACT FROM AUTHOR]

Background: Wrestling is among the most common youth sports in the United States, with about 260,000 high school participants annually. There is a lack of literature investigating wrestling injury profiles and mechanisms of injuries. In the past 15 years, urgent care utilization has increased, and National Federation of State High School Associations (NFHS) concussion protocols have been developed and implemented. Purpose/Hypothesis: The purpose of this study was to analyze causes, diagnoses, body parts, and trends associated with wrestling injuries presenting to US emergency departments. It was hypothesized that there would be (1) decreased overall injuries presenting to emergency departments because of increased urgent care utilization and (2) decreased concussions because of the NFHS rule implementation and revision. Study Design: Descriptive epidemiology study; Level of evidence, 3. Methods: Youth wrestling injuries presenting to US emergency departments between January 1, 2013, and December 31, 2022, were queried from the National Electronic Injury Surveillance System database. The data included date of presentation, age, sex, race, body part, injury diagnosis, disposition, and a brief injury narrative. National estimates (NE) were calculated using the associated statistical weight of the reporting hospital. Linear regressions were performed to investigate the relationship between year and NE for overall injuries, diagnoses, body parts, mechanisms of injury, and other subanalyses. Statistical significance was set at P <.05. Results: A total of 8628 (NE = 296,502) wrestling injuries met the inclusion criteria for this study. The mean age at presentation was 14.3 ± 2.6 years (range, 3 to 18 years). The shoulder (NE = 43,207 [14.6%]), head (NE = 40,875 [13.8%]), and knee (NE = 30,218 [10.2%]) were the most injured body parts. The most common diagnoses were strain/sprain (NE = 91,924 [31%]), other/not stated (NE = 53,736 [18.1%]), and fracture (NE = 52,261 [17.6%]). Common mechanisms of injury included not specified (NE = 148,169 [50%]), impact with mat (NE = 61,557 [20.8%]), and abnormal rotation/strain (NE = 37,449 [12.6%]). Overall injuries (P =.01) (coefficient: –1763 [95% CI, –2963 to −563]) and concussions (P =.01) (coefficient: –178 [95% CI, –302 to −55]) statistically significantly decreased. Conclusions: Our study showed a trend in the decrease in overall injuries and concussions in high school wrestlers. Strains/sprains were the most common diagnoses with the shoulder being the most common site. Youth wrestlers would benefit from future research analyzing risks associated with these injuries as well as advances in protective gear. [ABSTRACT FROM AUTHOR]

Male lacrosse and female lacrosse have differences in history, rules, and equipment. There is current debate regarding the need for enhanced protective headwear in female lacrosse like that worn by male lacrosse players. To inform this discussion, 17 high school lacrosse players (6 female and 11 male) wore the Stanford Instrumented Mouthguard during 26 competitive games over the 2021 season. Time-windowing and video review were used to remove false-positive recordings and verify head acceleration events (HAEs). The HAE rate in high school female lacrosse (0.21 per athlete exposure and 0.24 per player hour) was approximately 35% lower than the HAE rate in high school male lacrosse (0.33 per athlete exposure and 0.36 per player hour). Previously collected kinematics data from the 2019 high school male and female lacrosse season were combined with the newly collected 2021 kinematics data, which were used to drive a finite element head model and simulate 42 HAEs. Peak linear acceleration (PLA), peak angular velocity (PAV), and 95th percentile maximum principal strain (MPS95) of brain tissue were compared between HAEs in high school female and male lacrosse. Median values for peak kinematics and MPS95 of HAEs in high school female lacrosse (PLA, 22.3 g; PAV, 10.4 rad/s; MPS95, 0.05) were lower than for high school male lacrosse (PLA, 24.2 g; PAV, 15.4 rad/s; MPS95, 0.07), but the differences were not statistically significant. Quantifying a lower HAE rate in high school female lacrosse compared to high school male lacrosse, but similar HAE magnitudes, provides insight into the debate regarding helmets in female lacrosse. However, due to the small sample size, additional video-verified data from instrumented mouthguards are required. [ABSTRACT FROM AUTHOR]

Background: Concussions make up a significant proportion of sports injuries. This study aimed to describe the mechanisms of injury and associated symptoms of pediatric patients diagnosed with concussions (age range, 4-17 years) from contact sports. Hypothesis: Mechanisms of injury would differ based on sex and age, with female athletes and younger athletes aged 4 to 11 years sustaining fewer concussions from player-to-player contact. Study Design: Descriptive epidemiology study. Methods: The National Electronic Injury Surveillance System was queried for all contact sport concussions presented to United States emergency departments. The sports analyzed included basketball, football, soccer, hockey, rugby, and lacrosse. Descriptive data, mechanisms of injury, and associated symptoms were analyzed for each sport. Differences in the number of concussions sustained by year and sport, the severity of the injury, and associated symptoms were compared using chi-square test, and differences in proportion were calculated for mechanisms of injury stratified by sex and age. Results: A total of 12,602 youth athletes sustained concussions between 2012 and 2021. Most patients were male (78.5%), with a mean age of 13.48 years. Football concussions were the most common, with 45.32% of the concussions. The mechanism of injury was largely sport-specific, with player-to-player contact the most common overall. Older male athletes were more likely to have concussions from player-to-player contact, whereas younger athletes were more impacted by head-to-ground mechanisms. Symptom presentation was not sport-specific, and headache and dizziness were the most common presentation at 41.2% and 26.2%, respectively. Conclusion: The most important overall mechanism of injury was player-to-player contact, especially in older male youth athletes, whereas younger athletes were more likely to be concussed due to head-to-ground injuries. [ABSTRACT FROM AUTHOR]

Background: Hormonal contraceptives (HCs) and the menstrual cycle have been suggested to affect symptom severity and postconcussion recovery. Additionally, hormones have been a suggested rationale for sex differences between female and male athletes on concussion assessment. Researchers have yet to explore the effects of HC use on baseline symptomatology, including symptom reporting and provocation. Purpose: To examine the influence of HC use on a baseline symptom reporting and vestibular/ocular provocation battery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 61 college-aged individuals (21 HC-using women, 21 non–HC-using women, 19 men) were administered a baseline symptom battery consisting of the Post-Concussion Symptom Scale (PCSS), Headache Impact Test-6 (HIT-6), Pediatric Vestibular Symptom Questionnaire (PVSQ), and Vestibular/Ocular Motor Screening (VOMS). The main outcome measures consisted of PCSS symptom reporting (total symptoms, symptom severity score, and symptom factors), HIT-6 and PVSQ total scores, and VOMS item (ie, saccades, convergence, or vestibular/ocular reflex) symptom provocation scores. Results: Significant differences were reported on HIT-6, with the highest headache reporting in the HC group (P =.026). On the PVSQ, the HC group also reported greater dizziness and unsteadiness symptoms than the non-HC group (P =.023). Similar findings existed on the PCSS, with the HC group reporting greater total symptoms (P <.001), symptom severity (P <.001), and vestibular-somatic (P =.024), cognitive-sensory (P =.004), sleep-arousal (P =.001), and affective (P <.001) factors compared with the non-HC group. Smooth pursuit (ie, following finger smoothly with eyes) was the only VOMS items with differences between groups (P =.003), with the HC group having greater provocation compared with non-HC users (P =.020). Conclusion: HC use was associated with overall symptomatology and worse self-reported symptoms on vestibular-related inventories and concussion symptom scales and factors when compared with non-HC users and male controls. Additionally, HC users reported higher VOMS provocation scores on the smooth pursuit item than non-HC users and male controls. [ABSTRACT FROM AUTHOR]

Biological sex and history of motion sickness are known modifiers associated with a false-positive baseline Vestibular/Ocular Motor Screening (VOMS). However, other factors may be associated with a false-positive VOMS in collegiate athletes. To identify contributing factors to false-positive VOMS assessments using population-specific criteria. We also critically appraised previously reported interpretation criteria. Descriptive laboratory study. Single-site collegiate athletic training clinic. National Collegiate Athletic Association Division I athletes (n = 462 [41% female]) aged 18.8 ± 1.4 years. Participants completed the Athlete Sleep Behavior Questionnaire, the 7-Item Generalized Anxiety Index, the Immediate Postconcussion Assessment and Cognitive Testing battery, the Patient Health Questionnaire-9, the Revised Head Injury Scale, the Sensory Organization Test, and the VOMS as part of a multidimensional baseline concussion assessment. Participants were classified into 2 groups based on whether they had a total symptom score of greater than or equal to 8 after VOMS administration, excluding the baseline checklist. We used χ2 and independent t tests to compare group demographics. A binary logistic regression with adjusted odds ratios (ORs) was used to evaluate the influence of sex, corrected vision, attention-deficit/hyperactivity disorder, Immediate Postconcussion Assessment and Cognitive Testing composite scores, concussion history, history of treatment for headache and/or migraine, Generalized Anxiety Index scores, Patient Health Questionnaire-9 scores, Athlete Sleep Behavior Questionnaire scores, and Sensory Organization Test equilibrium scores and somatosensory, visual, and vestibular sensory ratios on false-positive rates. Approximately 9.1% (42 of 462 [30 females]) met criteria for a false-positive VOMS. A significantly greater proportion of females had false positives (χ21 = 18.37, P <.001). Female sex (OR = 2.79; 95% CI = 1.17, 6.65; P =.02) and history of treatment for headache (OR = 4.99; 95% CI = 1.21, 20.59; P =.026) were the only significant predictors of false-positive VOMS. Depending on cutoff interpretation, false-positive rates using our data ranged from 9.1% to 22.5%. Our results support the most recent interpretation guidelines for the VOMS in collegiate athletes due to a low false-positive rate and ease of interpretation. Biological sex and history of headaches should be considered when administering the VOMS in the absence of a baseline. [ABSTRACT FROM AUTHOR]

Background: There is limited research examining whether mental health problems increase the risk for future concussions, even though these problems are highly prevalent in college-aged populations—including student-athletes. Purpose/Hypothesis: To examine whether affective disturbance (ie, depressive and anxiety symptoms) at baseline increases the risk for prospective concussion. It was hypothesized that athletes with co-occurring depressive/anxiety symptoms would incur the greatest risk for injury. Methods: A total of 878 collegiate athletes completed baseline neuropsychological testing. Athletes were separated into the following 4 groups based on self-reported anxiety and depressive symptoms at baseline: healthy controls; depressive symptoms alone; anxiety symptoms alone; and co-occurring depressive and anxiety symptoms. Of the 878 athletes, 88 sustained future concussions. Logistic regression was conducted with prospective concussion (yes/no) as the outcome and the affective group as the predictor. Sport was included as a covariate. Results: After controlling for sport, athletes in the co-occurring depressive/anxiety symptoms group were more than twice as likely to be diagnosed with a future concussion compared with healthy controls (odds ratio, 2.72 [95% CI, 1.33-5.57]; P =.01). The co-occurring depressive/anxiety symptoms group also showed an increased risk for prospective concussion compared with the depressive symptoms alone and anxiety symptoms alone groups, respectively. However, the results were not statistically significant. Athletes in the depressive symptoms alone and anxiety symptoms alone groups did not show a significantly increased risk for prospective concussion compared with healthy controls. Conclusion: Athletes with co-occurring depressive/anxiety symptoms at baseline showed a notably increased risk of being diagnosed with a future concussion, even after controlling for sport. This suggests that co-occurring depressive/anxiety symptoms infer a unique risk that is associated with a greater susceptibility to concussion diagnosis. [ABSTRACT FROM AUTHOR]

Background: There has been little focus on concussions in youth lacrosse players in the United States. Purpose: To provide a descriptive analysis of the epidemiology and incidence of concussions in youth lacrosse and compare the results with well-documented analyses of concussions in youth American football. Study Design: Descriptive epidemiology study. Methods: Data on concussions in pediatric patients playing lacrosse from 2006 to 2019 were collected using the National Electronic Injury Surveillance System (NEISS). Weighted calculations and combined participation data obtained from membership in USA Lacrosse were used to estimate injury incidence. A comparison dataset was created using the NEISS data on youth football-related concussions. The cause of concussion was categorized into player-to-player, player-to-stick, player-to-ball, or player-to-ground contact. Results: A total of 37,974 concussion injuries related to lacrosse were identified in players with a mean age of 14.5 ± 3.5 years; 70% of concussions occurred in boys. National participation in lacrosse increased from 2006 to 2011 by a mean of 10.3% annually, followed by a lower annual growth rate of 2.5% from 2012 to 2019. The overall incidence of concussion injuries increased over the study period (r = 0.314), with the incidence rate in boys being greater than that of girls from 2009 to 2013. The most common cause of concussion was player-to-ground contact for boys and player-to-ball or player-to-stick contact for girls. The mean annual concussion incidences in youth lacrosse and youth football were 443 and 355 per 100,000 participants, respectively. Conclusion: Over the study period, 16% of lacrosse injuries were diagnosed as concussions, a higher mean annual incidence per 100,000 participants than that of youth football (443 vs 355). The cause of concussion was different based on sex, with higher rates of player-to-ball or player-to-stick contact in female players versus player-to-ground contact in male players. [ABSTRACT FROM AUTHOR]

Background: Baseline concussion testing can be helpful to perform when providing concussion care for young athletes. To appropriately interpret these data, it is important to understand how certain factors may affect concussion testing. Purpose: To examine the relationship of sociodemographic and health variables with baseline concussion testing in young athletes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: High school and middle school athletes competing in sports or positions at high risk for concussion (football, soccer, ice hockey, wrestling, lacrosse, and pitchers/catchers in baseball/softball) during the 2020-2021 or 2021-2022 academic years completed annual baseline concussion testing and were included in the study. Baseline data included self-reported demographic and medical information, a graded symptom checklist, the Standardized Assessment of Concussion, and the King-Devick test. A validated measure, HOUSES (HOUsing-based index of SocioEconomic Status), was used to determine participants' socioeconomic status (SES) by linking personal address information to publicly available property data. Multivariable linear regression models were fit to analyze the relationship of concussion baseline testing to sociodemographic and health variables. Results: Among the eligible 2747 athletes (mean age, 15.4 ± 1.5 years; 73.6% male), the mean Standardized Assessment of Concussion score was 26.7 ± 2.0 and the mean best King-Devick test time was 50.3 ± 10.1 seconds. Higher baseline symptom severity scores were related to lower SES (P =.002). A lower (ie, poorer) mean Standardized Assessment of Concussion score was significantly associated with the following in the multivariable model: male sex (P <.001), younger age (P <.001), Black/African American race (P =.029), Hispanic ethnicity (P =.016), previous diagnosis of learning disorder or attention-deficit hyperactivity disorder (P <.001), and lower SES (P =.003). A higher (ie, poorer) mean King-Devick test time was related to younger age, previous diagnosis of a learning disorder or attention-deficit hyperactivity disorder, and lower SES (all P <.001). Conclusion: Baseline concussion testing was found to be associated with certain sociodemographic variables and underlying health conditions in high school and middle school athletes. [ABSTRACT FROM AUTHOR]

Current debate exists regarding the need for protective headwear in female lacrosse. To inform this issue, the current study quantified head impact exposure, mechanisms and kinematics in female lacrosse using instrumented mouthguards. A female high school varsity lacrosse team of 17 players wore the Stanford Instrumented Mouthguard (MiG) during 14 competitive games. Video footage was reviewed to remove false-positive recordings and verify head impacts, which resulted in a rate of 0.32 head impacts per athlete-exposure. Of the 31 video-confirmed head impacts, 54.8% were identified as stick contacts, 38.7% were player contacts and 6.5% were falls. Stick contacts had the greatest peak head kinematics. The most common impact site was the side of the head (35.5%), followed by the face/jaw (25.8%), forehead (6.5%), and crown (6.5%). Impacts to the face/jaw region of the head had significantly (p < 0.05) greater peak kinematics compared to other regions of the head, which may have resulted from the interaction of the impacting surface, or the lower jaw, and the sensor. The current study provides initial data regarding the frequency, magnitude and site of impacts sustained in female high school lacrosse. A larger sample size of high quality head impact data in female lacrosse is required to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: There is a gap in the literature regarding musculoskeletal risk factors for concussion within the National Football League (NFL), which is an avenue that must be explored to promote player safety given the high incidence of both injury types. This study aims to observe if ankle injuries are associated with an increased risk of subsequent concussion in NFL players. Methods: The public online database ProFootballReference.com was used to identify ankle injuries and concussions in NFL players from the 2009-2010 to 2019-2020 seasons. Multivariable logistic regression for subsequent concussion and ankle injury was performed, adjusting for body mass index (BMI), age, and player position. For descriptive statistics, unpaired t tests with unequal variance were performed for continuous variables, including BMI and age. χ2 testing was performed for categorical variables, including player position, and whether the position was offensive, defensive, or on special teams. Results: Of the 5538 NFL players included in the study, 941 had an ankle injury, 633 had a concussion, and 240 had both an ankle injury and a subsequent concussion. The adjusted odds ratio (aOR) for concussion following a single ankle injury was 0.90 (95% CI 0.72-1.14, P =.387); however, the aOR for concussion following multiple ankle injuries was 2.87 (95% CI 1.23-6.75, P =.015). Special teams players had the lowest risk for concussion (aOR 0.17, 95% CI 0.069-0.36, P <.001) following ankle injury, and there was no significant difference in risk between offense and defense (aOR 0.91, 95% CI 0.77-1.08, P =.295). Conclusion: Multiple ankle injuries were associated with an increased risk of a subsequent concussion after adjusting for BMI; player position; and offense, defense, or special teams designation. These findings can inform injury prevention practices in the National Football League. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: Kickoff plays in American football are associated with an increased risk of concussion compared with other play types. In 2018, the National Collegiate Athletic Association (NCAA) Football Rules Committee altered the kickoff rules so a fair catch inside the 25-yard line results in a touchback, with the ensuing drive starting on the 25-yard line. The intention was to decrease the number of kickoff returns with a corresponding decrease in the rate of concussions on kickoff plays. Purpose: To determine whether the 2018 rule changes had the intended effects in an NCAA Division 1 Conference. Study Design: Cohort study; Level of evidence, 3. Methods: The study population included football athletes in the NCAA Pacific-12 (Pac-12) Conference. Data on the total number of plays, punts, kickoffs, touchbacks, and fair catches were obtained for all in-conference games from the 2016 to 2021 seasons. The number of game concussions and the play type were provided by each conference institution. Incidence of concussions occurring during kickoff plays before (2016-2017) and after (2018-2021) the rule change were compared with a difference-in-difference analysis using Poisson general linear models. Results: There were 242 concussions in 108,774 total plays in the study period, with an overall concussion rate of 2.2 per 1000 plays. The percentage of touchbacks increased significantly from 45% to 51% (P <.001) and the percentage of fair catches increased from 1% to 7% (P <.001) from before to after the rule change. Kickoffs accounted for 6% of plays both before and after the rule change and 11% of concussions before and 14% after the change. The mean annual concussion rate (per 1000 plays) on kickoffs was 3.42 before and 5.31 after the rule change (rate difference: 1.89; 95% confidence interval, -1.22 to 5.01). Conclusion: Touchbacks and fair catches increased after the kickoff rule change, but there was not a corresponding decrease in concussions during kickoff plays as anticipated. Concussions occurring during other football plays remained stable. [ABSTRACT FROM AUTHOR]

Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors. Data from patients aged 12–18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P = 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR] = 1.35, 95% CI 1.03–1.77, P = 0.030), which remained significant (HR = 1.32, 95% CI 1.002–1.73, P = 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR = 1.12, 95% CI 0.85–1.48, P = 0.410). Adding prior concussion history further reduced the association between race/recovery (HR = 1.01, 95% CI 0.77–1.34, P = 0.925). Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors. [ABSTRACT FROM AUTHOR]

Background: The Post-Concussion Symptom Scale (PCSS) is a self-report questionnaire measuring symptoms that commonly occur after a concussion; however, these symptoms are nonspecific and can be related to co-occurring orthopaedic injuries (eg, cervical strain) or patient characteristics and preexisting conditions, even in the absence of a recent injury. As such, clinicians may have difficulty determining whether symptom elevations are attributable to a recent concussion as opposed to a confounding injury or a preexisting condition, which may be especially difficult when preinjury baseline symptom data are unavailable. Purpose: This study aimed to further validate the 4-factor model of the PCSS (ie, cognitive, sleep-arousal, physical, and affective symptoms) with adolescent student-athletes and provide normative reference data for each factor and the total score, stratified by gender and preexisting health conditions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Participants were 9358 adolescent student-athletes who completed the PCSS during a preseason baseline evaluation (mean age, 14.9 years; SD, 1.3 years [range, 13-18 years]; 49.3% boys). The 4-factor model of the PCSS was tested for the full sample and separately for boys and girls using confirmatory factor analysis. Symptom severity percentiles were created for the PCSS total score and each factor, stratified by gender and preexisting conditions (ie, attention-deficit/hyperactivity disorder, mental health history, headache/migraine history, learning disability/dyslexia, academic problems, and concussion history). Results: The 4-factor model of the PCSS replicated in the full sample (comparative fit index [CFI] = 0.959) and in both gender groups (boys: CFI = 0.961; girls: CFI = 0.960). The total PCSS score at the 84th percentile varied by preexisting conditions as follows: healthy participants = 8, attention-deficit/hyperactivity disorder = 18, mental health history = 26, headache/migraine history = 18, learning disability = 19, and academic problems = 17. On all PCSS subscales, participants with a mental health history had the highest scores, and high scores were associated with having >1 preexisting condition. Girls had higher scores than boys for each stratification. Conclusion: The 4-factor model of the PCSS replicates for adolescent student-athletes. Gender, number of preexisting conditions, and mental health history are important factors to account for when interpreting PCSS symptom severity. The normative data provided herein could assist clinicians in determining whether an adolescent student-athlete is presenting with persistent postconcussion symptoms or a typical symptom experience based on their gender and personal health history. [ABSTRACT FROM AUTHOR]

Background: Concussion is a common injury among children and adolescents, with a growing body of literature supporting a variety of diagnostic and treatment modalities. Recovery is variable and depends on multiple factors that can be evaluated through a clinic visit: a thorough history, physical examination, and use of the Post-concussion Symptom Scale (PCSS). Purpose/Hypothesis: The purpose of this study was to evaluate factors associated with overall recovery from concussion in children and adolescents in the clinical setting. It was hypothesized that the presence of 1 of a number of pre- or postinjury characteristics will be associated with poor concussion recovery. Study Design: Case-control study; Level of evidence, 3. Methods: We conducted a retrospective chart review of adolescents and children aged 6 to 17 years with a diagnosis of concussion who were evaluated at a single sports medicine center between January 2015 and December 2019. Cases were categorized into recovered (PCSS <7) and poorly recovered (PCSS ≥7) cohorts based on the last PCSS scores during clinical follow-ups for concussion management. Results: Of the 162 charts reviewed, 110 cases met inclusion criteria. Significant statistical differences were found between the recovered and poorly recovered cohorts regarding mean days from injury to last clinic visit, previous migraine diagnosis, and emergency room (ER) visit before the first clinic visit (P <.01 for all). Binary logistic regression analysis revealed that the most predictive factors associated with poorer recovery were having an ER visit before the first clinic evaluation (P =.01) and previous migraine diagnosis (P =.04). Conclusion: While many factors may contribute to overall recovery from concussion in pediatric populations, our study suggested that a history of migraine and an ER visit before clinic evaluation may be associated with poor recovery of concussive symptoms. [ABSTRACT FROM AUTHOR]

Background: Investigations of estimated age of first exposure to repetitive head impacts from collision and contact sports have shown no associations with neurocognitive or neurobehavioral function at the collegiate level, but the effect of career duration may be a more comprehensive factor. Understanding whether longer career duration influences gait performance would provide insights into potential neurological impairment. Purpose: To examine the relationship between career duration of collision sports and single/dual-task gait performance in collegiate student-athletes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We recruited 168 male student-athletes from collision sports: football, lacrosse, ice hockey, and wrestling (mean ± SD age, 19.2 ± 1.3 years; height, 184.5 ± 7.2 cm; mass, 94.3 ± 15.9 kg; estimated age of first exposure, 8.6 ± 3.1 years; career duration, 10.6 ± 3.0 years). All participants completed a baseline single- and dual-task gait assessment before the start of their athletic season. Inertial measurement units were used to measure gait speed and stride length. During the dual task, participants were asked to perform working memory cognitive tasks while walking. The dependent variables were single/dual-task gait speed and stride length, cognitive accuracy, and dual-task cost. The relationship between career duration, analyzed as a continuous variable, and the dependent variables was analyzed using a linear regression. Results: There were no significant associations between career duration and single-task gait speed (1.16 ± 0.16 m/s; β = −0.004; P =.35; 95% CI = −0.012 to 0.004; η2 = 0.005) or dual-task gait speed (1.02 ± 0.17 m/s; β = −0.003; P =.57; 95% CI = −0.011 to 0.006; η2 = 0.002). There were also no significant associations between career duration and single/dual-task stride length, cognitive accuracy, or dual-task cost. Conclusion: Career duration among collegiate collision sport athletes was not associated with single- or dual-task gait performance, suggesting that a greater exposure to repetitive head impacts is not detrimental to dynamic postural control at the college level. However, the effects of diminished gait performance over the lifetime remain to be elucidated. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Objective: Although the word recall component of the Sport Concussion Assessment Tool (SCAT) was updated from 5-to-10 words, its clinical utility across athletic populations remains unknown. The purpose of this study was to provide normative data on the SCAT-5 10-word test and examine its discriminative ability between healthy university level athletes and those with sport-related concussion (SRC). Design: Cross-sectional. Setting: University. Participants: Three hundred sixty-three (363, M = 220, F = 153) healthy athletes and 49 (M = 30, F = 19) athletes following SRC. Independent Variable: Healthy athletes measured preseason were compared with athletes following an SRC (median = 4.0 days postinjury). Main Outcome Measure: Ten-word list performance from the SCAT-5. Results: There were no significant differences in either immediate (P = 0.228, Cohen's D = 0.18) or delayed (P = 0.908, Cohen's D = 0.02) recall tests between athletes with SRC and healthy athletes; the null findings extended to both the male and female subset comparisons. Among healthy athletes, females outperformed males on both immediate (mean difference = 1.0, P < 0.001) and delayed (mean difference = 0.5, P = 0.006) recall tasks. Conclusion: Concussion does not seem to impact immediate or delayed recall of the 10-word list in the subacute period following injury. Practitioners should be mindful of sex differences and the time point of administration following injury. [ABSTRACT FROM AUTHOR]

Background: Sleep issues are commonly reported in athletes after a sport-related concussion (SRC). Further studies are needed to evaluate screening methods for sleep disturbances and the risk of persisting symptoms after an SRC. Purpose: To evaluate the association between the Sport Concussion Assessment Tool 5 (SCAT5) symptoms of trouble falling asleep, fatigue (or low energy), and drowsiness and the risk of persisting symptoms (≥28 days to recovery) in adolescent athletes. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 519 athletes aged 13 to 18 years reported any sleep-related symptoms with an SRC, scored as none (0), mild (1-2), moderate (3-4), or severe (5-6), at their initial office visit (median, 5.4 days after an SRC). Scores were correlated with the risk of persisting symptoms. A composite "sleep cluster" score (range, 0-18) was calculated by summing the SCAT5 component items for trouble falling asleep, fatigue, and drowsiness. Results: The results indicated that, compared with athletes who reported that they did not have each symptom, (1) athletes who reported mild, moderate, or severe trouble falling asleep were 3.0, 4.6, and 6.7 times more likely to have persisting symptoms, respectively; (2) athletes reporting mild, moderate, or severe fatigue (or low energy) were 2.6, 4.8, and 7.6 times more likely to have persisting symptoms, respectively; and (3) athletes reporting mild, moderate, or severe drowsiness were 1.9, 4.6, and 6.8 times more likely to have persisting symptoms, respectively (P <.001 for all). For every 1-point increase in the sleep cluster score, there was a 1.2-fold increased risk of persisting symptoms and an additional 2.4 days of recovery required (P <.001 for both). Conclusion: Athletes who reported mild, moderate, or severe sleep-related symptoms on the SCAT5 were at a proportionally increased risk of persisting symptoms at the initial office visit. [ABSTRACT FROM AUTHOR]

Purpose: Contact sport athletes are exposed to a unique environment where they sustain repeated head impacts throughout the season and can sustain hundreds of head impacts over a few months. Accordingly, recent studies outlined the role that head impact exposure (HIE) has in concussion biomechanics and in the development of cognitive and brain-based changes. Those studies focused on time-bound effects by quantifying exposure leading up to the concussion, or cognitive changes after a season in which athletes had high HIE. However, HIE may have a more prolonged effect. This study identified associations between HIE and concussion incidence during different periods of the college football fall season. Methods: This study included 1120 athlete seasons from six National Collegiate Athletic Association Division I football programs across 5 yr. Athletes were instrumented with the Head Impact Telemetry System to record daily HIE. The analysis quantified associations of preseason/regular season/total season concussion incidence with HIE during those periods. Results: Strong associations were identified between HIE and concussion incidence during different periods of the season. Preseason HIE was associated with preseason and total season concussion incidence, and total season HIE was associated with total season concussion incidence. Conclusions: These findings demonstrate a prolonged effect of HIE on concussion risk, wherein elevated preseason HIE was associated with higher concussion risk both during the preseason and throughout the entire fall season. This investigation is the first to provide evidence supporting the hypothesis of a relationship between elevated HIE during the college football preseason and a sustained decreased tolerance for concussion throughout that season. [ABSTRACT FROM AUTHOR]

Objective: To investigate the incidence of youth ice hockey-related concussions preceding and following the implementation of new body-checking and head contact rules by USA hockey in 2011. We hypothesized a decrease in concussions after the rule change. Design: Retrospective analysis. Setting: United States emergency department (ED) data queried in the National Electronic InjurySurveillance System (NEISS). Patients: National Electronic Injury Surveillance System reported male youth (<=18 years) ice hockey concussion cases from January 1, 2002, to December 31, 2016. In total, 848 players were diagnosed with concussion, representing a national estimate of 17 374 cases. /p> Independent Variables: Time, specifically years. Main Outcome Measures: Incidences and incidence rates (measured per 10 000 person-years) of male youth ice hockey concussions. Annual trends were analyzed using descriptive and linear or polynomial regression analysis. Results: The national estimate of youth ice hockey-related concussions seen in US emergency departments (EDs) increased significantly from 656 in 2007 to 2042 in 2011 (P < 0.01). During the same period, their respective incidence increased significantly from 21.8 to 66.8 per 10 000, before dropping through 2016 (P < 0.05). After 2011, concussions decreased from 1965 in 2012 to 1292 in 2016 (P = 0.055). The gap in concussion incidence between the 11 to 12 and 13 to 14 divisions widened after 2011 (before 2011: 41 vs 49 per 10 000 person-years [ P = 0.80]; after 2011: 45 and 89, respectively [ P < 0.01]). Conclusions: US EDs experienced a significant increase in youth ice hockey concussion visits from 2007 to 2011. After the 2011 rule changes, concussion visits decreased significantly from 2012 to 2016. Key Point [ABSTRACT FROM AUTHOR]

Background: Previous studies have found that injury rates are slightly higher in children who play flag football versus tackle football. It is unclear if this difference is due to the way each type is played or taught or whether there are intrinsic differences in attitudes or neuropsychological characteristics in children and their parents. Purpose: To determine whether children who play flag football score differently from those who play tackle football on validated neuropsychological tests. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Each participating athlete (aged 8-12 years) was recruited in 2018 and 2019 by email through local youth football leagues and the local university. Each athlete was administered a 1-time multidimensional assessment battery. The battery included the Wechsler Abbreviated Scale of Intelligence-2nd Edition, the children's version of the Trail Making Test, the Integrated Digit Span and Spatial Span subtests of the Wechsler Intelligence Scale for Children-4th Edition (WISC-IV), and the Beck Self-Concept Inventory for Youth. The parent/guardian of each athlete completed the Achenbach Child Behavior Checklist-Parent Report Form, the Behavior Rating Inventory of Executive Function (BRIEF)-Parent Form, and a custom survey. These tests were used to determine IQ estimates and standardized scores, measuring verbal comprehension, matrix reasoning, mental set-shifting, attention, cognitive processing speed, working memory, spatial processing, perception of self-concept, behavioral regulation index, metacognition index, and global executive composite. Scores were compared between flag football and tackle football groups by 2-sample t test, with the Wilcoxon rank-sum test used for nonparametric data. Results: A total of 64 athletes (41 tackle football, 23 flag football) were enrolled from youth football leagues (grades 4-6). Flag players scored significantly higher on the WISC-IV Spatial Span-Backward subtest (scaled mean, 12.0 vs 10.6; P =.046), while tackle players had significantly higher BRIEF-Inhibit subscores (mean t -score, 45 vs 42; P =.026). There were no significant differences in any of the other tests, including socioeconomic status and perceived concussion risks. Conclusion: Concerns that injury epidemiologic studies comparing flag with tackle football could be confounded by intrinsic differences in the children who choose to play each type seem to be unfounded. [ABSTRACT FROM AUTHOR]

Background: The targeting rule was adopted by the National Collegiate Athletic Association (NCAA) in 2008 to discourage dangerous contact during collegiate American football competition. Although targeting rules have been emphasized as a means to reduce concussion rates, there is currently no evidence that targeting plays are higher risk for concussion than other plays in American football. Purpose: To compare the rate of concussion occurring during targeting versus nontargeting plays in American collegiate football. Study Design: Cross-sectional study. Methods: Concussions occurring in games in the 2016-2019 Pac-12 Conference were classified as having occurred during either (1) a play where a targeting penalty was called or (2) all other plays. Targeting plays were further categorized to either those in which the call was upheld or those overturned by the on-field official after replay review. The number of targeting plays and the total number of plays during games were also recorded. Concussion incidence (per 1000 plays) and risk ratios were calculated. Results: Overall, 538 games with 68,670 plays were reviewed, during which 213 concussions occurred (15 during plays where targeting was called and 198 on other plays) and 141 targeting penalties were called. The incidence of concussion was 106.4/1000 plays for targeting plays (including 141.2/1000 upheld targeting fouls and 53.6/1000 overturned targeting fouls) and 2.9/1000 plays for nontargeting plays. The risk of concussion during targeting plays was 36.9 (95% CI, 22.4-60.7) times greater than that for all other plays. The risk of concussion during targeting plays upheld was 49.0 (95% CI, 28.5-84.2) times greater than that for all other plays. Conclusion: Concussion risk was significantly higher during plays in which targeting was called, especially those in which targeting fouls were upheld. Clinical Relevance: This study supports eliminating or reducing targeting from American football. The results of this study suggest that players should be screened for concussion after targeting plays are called. [ABSTRACT FROM AUTHOR]

Background: Sports-related concussion (SRC) is a common injury mostly in contact sports. Specifically, it is a public health concern for collegiate rugby athletes because at least one concussion is reported in every two games and concussion has been reported to increase the risk of developing neuro-degenerative disorders later in life. Aim: To clinically audit concussions to examine commonly reported signs/symptoms in the Sports Concussion Assessment Tool (SCAT). Materials and methods: Retrospective audit of a South African University health services medical electronic records database for all concussion International Classification of Diseases 10 (ICD10) diagnoses codes: S06.0, S06.00 and S06.01 in 367 rugby players (age 24.6 ± 4.3, height 1.8 ± 0.1 and weight; 90.7 ± 14.4) for the period 2013–2018. Results: SCAT data was obtained for 70% of the 434 concussions. Headache (57%), "pressure in head" (56%), feeling slowed down (55%) and fatigue/low energy (54%) were the most frequently reported concussion symptoms on the SCAT. A significant reduction in the serial SCAT symptom (p < 0.001) and severity (p < 0.001) scores was observed in a sub-set of the rugby players. The concussion incidence proportion was 7%; this was obtained from an annual estimate of the University rugby club's registered players and concussion count (n = 87) during the five-year period. Discussion and conclusions: The initial SCAT sub-domain scores following a SRC in this collegiate cohort were consistent with other elite adult male sport cohorts in endorsing many symptoms and showing low-concentration scores. A unique feature of this study was the tracking of serial symptoms in a sub-set of this cohort. These players showed a clear reduction in symptom endorsement, but were still not symptom-free by their third SCAT. The collegiate student population should be educated regarding symptoms, including headache, which might be indicative of concussion following a head injury. [ABSTRACT FROM AUTHOR]

Introduction: Repetitive head impacts in soccer have been linked to short-term neurophysiological deficits, and female soccer players have higher concussion rates than males. These findings have inspired investigation into gender differences in head impact exposure and how head impact rate contributes to the cumulative effect of head impact exposure on neurological outcomes. Various periods of exposure have been used to calculate head impact rates, including head impacts per season, game, and player-hour. Purpose: The aim of this study was to apply different methodological approaches to quantify and compare head impact rates by gender for two seasons of high school varsity soccer. Methods: Video review was used to confirm all events recorded by a headband-mounted impact sensor and calculate playing time for all players. Impact rates were calculated per athlete exposure (presence and participation) and per player-hour (scheduled game time, individual play time, and absolute time). Results: Impact rates per athlete exposure ranged from 2.5 to 3.2 for males and from 1.4 to 1.6 for females, and impact rates per player-hour ranged from 2.7 to 3.8 for males and from 1.0 to 1.6 for females. The exposure calculation method significantly affected head impact rates; however, regardless of approach, the head impact rate for males was higher, up to threefold, than for females. Individual head impact exposure varied substantially within a team with one in five players experiencing no impacts. Conclusions: Overall, the gender differences found in this study indicate that males experience higher head impact exposure compared with females. Future studies are needed to understand potential clinical implications of variability in head impact exposure and reconcile higher female concussion rates with the reduced head impact rates presented herein. [ABSTRACT FROM AUTHOR]

Background: Vestibular and ocular symptoms in sport-related concussions are common. The Vestibular/Ocular-Motor Screening (VOMS) tool is a rapid, free, pen-and-paper tool that directly assesses these symptoms and shows consistent utility in concussion identification, prognosis, and management. However, a VOMS validation study in the acute concussion period of a large sample is lacking. Purpose: To examine VOMS validity among collegiate student-athletes, concussed and nonconcussed, from the multisite National Collegiate Athletic Association–Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. A secondary aim was to utilize multidimensional machine learning pattern classifiers to deduce the additive power of the VOMS in relation to components of the Sport Concussion Assessment Tool 3 (SCAT3). Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Preseason and acute concussion assessments were analyzed for 419 student-athletes. Variables in the analysis included the VOMS, Balance Error Scoring System, Standardized Assessment of Concussion, and SCAT3 symptom evaluation score. Descriptive statistics were calculated for all tools, including Kolmogorov-Smirnov significance and Cohen d effect size. Correlations between tools were analyzed with Spearman r, and predictive accuracy was evaluated through an Ada Boosted Tree machine learning model's generated receiver operating characteristic curves. Results: Total VOMS scores and SCAT3 symptom scores demonstrated significant increases in the acute concussion time frame (Cohen d = 1.23 and 1.06; P <.0001), whereas the Balance Error Scoring System lacked clinical significance (Cohen d = 0.17). Incorporation of VOMS into the full SCAT3 significantly boosted overall diagnostic ability by 4.4% to an area under the curve of 0.848 (P <.0001) and produced a 9% improvement in test sensitivity over the existing SCAT3 battery. Conclusion: The results from this study highlight the relevance of the vestibular and oculomotor systems to concussion and the utility of the VOMS tool. Given the 3.8 million sports-related and 45,121 military-related concussions per year, the addition of VOMS to the SCAT3 is poised to identify up to an additional 304,000 athletes and 3610 servicemembers annually who are concussed, thereby improving concussion assessment and diagnostic rates. Health care providers should consider the addition of VOMS to their concussion assessment toolkits, as its use can positively affect assessment and management of concussions, which may ultimately improve outcomes for this complex and common injury. [ABSTRACT FROM AUTHOR]

Vani J Sabesan,1 Beau Prey,2 Ryan Smith,3 Daniel J Lombardo,3 Wilfredo J Borroto,4 James D Whaley5 1Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA; 2Western Michigan University School of Medicine, Kalamazoo, MI, USA; 3Department of Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, MI, USA; 4Ponce School of Medicine and Health Sciences, Ponce, PR, USA; 5Beaumont Health System, Detroit, MI, USA Background: Major League Baseball (MLB) players are throwing the ball faster and hitting harder than ever before. Although some safety measures have been implemented, by decreasing the 15 days on the disabled list (DL) to the 7 days on the DL, concussion rates remain high across positions and may impact player performance. Our hypothesis was, there would be an increase in concussion incidence following implementation of the 7 day DL, but this would not have a negative impact on player’s postconcussion performance.Study design: This is a descriptive epidemiology study.Methods: The concussed players from 2005 to 2016 were identified from the MLB DL and verified using established new sources. Position-specific performance metrics from before and after injuries were gathered and compared to assess effects of the injury. Postconcussion performance metrics were compared before and after the 7-day DL rule implementation.Results: A total of 112 concussed players were placed on the DL. For all position players, the batting average (BA) and on-base percentage (OBP) showed a nonsignificant decline after injury (P=0.756). Although performance statistics for pitchers declined on average, the trend was not statistically significant. Postinjury BA and OBP did not significantly change before (0.355) and after (0.313) the 7-day DL rule change in 2011 (P=0.162).Conclusion: The incidence of reported concussion has increased with the 7-day DL rule change. Concussion incidence was highest in catchers and pitchers compared with all other players. The most common causes identified as being hit by pitch or struck by a foul ball or foul tip. While new league rules prevent collisions with catchers at home plate, injury by a foul tip was the most common cause for concussion. The shortened time spent on the DL did not negatively impact player’s performance. Further research on protective helmets for catchers may reduce concussion incidence. Keywords: baseball, epidemiology, head injuries/concussion, MLB, performance

To further the understanding of long-term sequelae as a result of repetitive head impacts in sports, in vivo head impact exposure data are critical to expand on existing evidence from animal model and laboratory studies. Recent technological advances have enabled the development of head impact sensors to estimate the head impact exposure of human subjects in vivo. Previous research has identified the limitations of filtering algorithms to process sensor data. In addition, observer and/or video confirmation of sensor-recorded events is crucial to remove false positives. The purpose of the current study was to conduct a systematic review to determine the proportion of published head impact sensor data studies that used filtering algorithms, observer confirmation and/or video confirmation of sensor-recorded events to remove false positives. Articles were eligible for inclusion if collection of head impact sensor data during live sport was reported in the methods section. Descriptive data, confirmation methods and algorithm use for included articles were coded. The primary objective of each study was reviewed to identify the primary measure of exposure, primary outcome and any additional covariates. A total of 168 articles met the inclusion criteria, the publication of which has increased in recent years. The majority used filtering algorithms (74%). The majority did not use observer and/or video confirmation for all sensor-recorded events (64%), which suggests estimates of head impact exposure from these studies may be imprecise. [ABSTRACT FROM AUTHOR]

Background: Recent advances in technology have enabled the development of head impact sensors, which provide a unique opportunity for sports medicine researchers to study head kinematics in contact sports. Studies have suggested that video or observer confirmation of head impact sensor data is required to remove false positives. In addition, manufacturer filtering algorithms may be ineffective in identifying true positives and removing true negatives. Purpose: To (1) identify the percentage of video-confirmed events recorded by headband-mounted sensors in high school soccer through video analysis, overall and by sex; (2) compare video-confirmed events with the classification by the manufacturer filtering algorithms; and (3) quantify and compare the kinematics of true- and false-positive events. Study Design: Cohort study; Level of evidence, 2. Methods: Adolescent female and male soccer teams were instrumented with headband-mounted impact sensors (SIM-G; Triax Technologies) during games over 2 seasons of suburban high school competition. Sensor data were sequentially reduced to remove events recorded outside of game times, associated with players not on the pitch (ie, field) and players outside the field of view of the camera. With video analysis, the remaining sensor-recorded events were identified as an impact event, trivial event, or nonevent. The mechanisms of impact events were identified. The classifications of sensor-recorded events by the SIM-G algorithm were analyzed. Results: A total of 6796 sensor events were recorded during scheduled varsity game times, of which 1893 (20%) were sensor-recorded events associated with players on the pitch in the field of view of the camera during verified game times. Most video-confirmed events were impact events (n = 1316, 70%), followed by trivial events (n = 396, 21%) and nonevents (n = 181, 10%). Female athletes had a significantly higher percentage of trivial events and nonevents with a significantly lower percentage of impact events. Most impact events were head-to-ball impacts (n = 1032, 78%), followed by player contact (n = 144, 11%) and falls (n = 129, 10%) with no significant differences between male and female teams. The SIM-G algorithm correctly identified 70%, 52%, and 66% of video-confirmed impact events, trivial events, and nonevents, respectively. Conclusion: Video confirmation is critical to the processing of head impact sensor data. Percentages of video-confirmed impact events, trivial events, and nonevents vary by sex in high school soccer. Current manufacturer filtering algorithms and magnitude thresholds are ineffective at correctly classifying sensor-recorded events and should be used with caution. [ABSTRACT FROM AUTHOR]

Objectives: To assess the reliability and effect of exercise on sideline dynamic visual performance measures of ocular-motor function using a portable visual assessment system (EYE-SYNC®).Design: Prospective cohort study.Methods: Healthy student athletes, ages 18-25 years, performed eye-tracking six times-three times consecutively prior to and after practice-using EYE-SYNC® goggles. Ocular-motor performance was assessed by calculating five gaze error outcomes between target position and actual gaze position to inform dynamic visual synchronization. We assessed reliability by calculating the intraclass correlation coefficient (ICC) for each outcome (we defined the standard deviation of tangential error (SDTE) as our primary outcome) and calculated differences in mean pre- and post-practice scores.Results: ICCs for the SDTE score were 0.86 (95% confidence interval, CI: 0.82-0.9) and 0.88 (0.84-0.91) at pre- and post-practice, respectively. 133 (89%) and 135 (90%) of 150 athletes had at least one measurement at pre- and post-practice, respectively. 117 (78%) and 122 (81%) athletes had more than one SDTE score at pre- and post-practice, respectively. The absolute mean (SD) differences between pre- and post-practice mean scores ranged from 0.02 (0.05) for horizontal gain to 0.1 (0.5) for SDTE.Conclusions: We observed high ICC scores indicating excellent reliability of visual synchronization measurements, suggesting that one measurement would be sufficient. Most athletes had similar scores before and after practice, indicating little change in visual performance following exercise. EYE-SYNC® goggles have the potential for use in obtaining objective visual performance measures of ocular-motor function for sideline assessment of concussion and return to play decisions. [ABSTRACT FROM AUTHOR]

Background: Concussion in collegiate athletics is one of the most prevalent sport-related injuries in the United States, with recent studies suggesting persistent deficits in neuromuscular control after a concussion and an associated increase in risk of lower extremity injury. Purpose: To expand on the relationship between concussion and lower extremity injury by examining the effect of multiple concussions (MC) on rate and odds of future lower extremity injury in collegiate athletes after return to play (RTP) compared with matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: From 2001 to 2016, 48 National Collegiate Athletic Association Division I athletes sustaining multiple concussions at a single institution were identified. Athletes with multiple concussions (MC) were matched directly to athletes with a single concussion (SC) and to athletes with no concussion history (NC) by sex, sport, position, and games played. Incidence of, time to, and location of lower extremity injury were recorded for each group after RTP from their first reported concussion until completion of their collegiate career. Logistic regression was used to analyze odds ratios (ORs) for sustaining lower extremity injury, whereas time to injury was summarized by use of Kaplan-Meier curves and log rank test analysis. Results: The incidence of lower extremity injury after RTP was significantly greater (P =.049) in the MC cohort (36/48, 75%) than in SC athletes (25/48 = 52%) and NC athletes (27/48 = 56%). Similarly, odds of lower extremity injury were significantly greater in the MC cohort than in SC athletes (OR, 3.00; 95% CI, 1.26-7.12; P =.01) and NC athletes (OR, 1.66; 95% CI, 1.07-2.56; P =.02). Time to lower extremity injury was significantly shorter in the MC group compared with matched controls (P =.01). No difference was found in odds of lower extremity injury or time to lower extremity injury between SC and NC athletes. Conclusion: Collegiate athletes with MC were more likely to sustain a lower extremity injury after RTP in a shorter time frame than were the matched SC and NC athletes. This may suggest the presence of a cohort more susceptible to neuromuscular deficits after concussion or more injury prone due to player behavior, and it may imply the need for more stringent RTP protocols for athletes experiencing MC. [ABSTRACT FROM AUTHOR]

Objective: Depression, neuropathology, and cognitive decline are commonly observed with repetitive head injuries (RHIs).We examined whether in boxers (a) clinically significant depression is associated with structural brain changes and cognition; (b) minimal symptoms of depression moderate the relations among RHI and brain volumes and cognition; and (c) baseline depression is associated with longitudinal cognitive changes. Setting: Clinical Research Center. Participants: A total of 205 male professional boxers. Design: Cross-sectional and longitudinal (subsample: n = 45; first visit to follow-up range = 1-6 years; mean = 2.61 years).Main Measures: Patient Health Questionnaire- 9 depression; CNS Vital Signs cognitive battery; brain imaging. Results: Clinically significant depression was associated with smaller regional volumes in insula, cingulate, orbitofrontal cortex, thalami, and middle corpus-callosum subregions; and with poorer verbal memory and psychomotor speed performance. Depression symptoms moderated the relations between RHI and bilateral thalami, left hippocampus, left medial orbitofrontal cortex, and bilateral insula volumes; but not cognition. Baseline depression was associated with poorer psychomotor speed and reaction time longitudinally and improved verbal memory performance longitudinally. Conclusion: Clinical depression is associated with volumetric and cognitive changes occasioning RHI exposure, and even minimal depressive symptoms may moderate the relations between exposure and brain volumes in key regions. Longitudinally, there is preliminary evidence that depression precedes cognitive changes. [ABSTRACT FROM AUTHOR]

Background:: Cheerleading is a specialized athletic activity that can lead to catastrophic injuries. Cheerleading rules are in place to maximize safety of participants. The purpose of this study was to describe catastrophic cheerleading injuries among high school and collegiate-level participants in the United States and to explore whether the 2006-2007 basket toss rule change was effective at reducing the number of catastrophic injuries.Hypothesis:: The 2006-2007 basket toss rule change contributed to a reduction in the number of catastrophic injuries among high school and collegiate cheerleaders.Study Design:: Case series.Level Of Evidence:: Level 4.Methods:: Data on catastrophic cheerleading injuries were collected by the National Center for Catastrophic Sport Injury Research from July 2002 to June 2017. Information collected included cheerleader, event, and injury characteristics. The impact of the 2006-2007 rule change banning the basket toss on any hard surfaces was assessed by comparing injury rates and 95% CIs before and after the rule change.Results:: There were 54 catastrophic cheerleading injuries, or 3.6 injuries per year. From July 2002 through June 2017, the injury rate was 2.12 per 1,000,000 cheerleaders (95% CI, 1.56-2.69). Most cheerleaders sustained serious injuries (n = 27; 50%) during practice (n = 37; 69%) to the head (n = 28; 52%) and cervical spine (n = 17; 32%). From July 2002 through June 2017, basket tosses were the stunt that accounted for the highest proportion of injuries (n = 19; 35%). The basket toss injury rate decreased from 1.55 to 0.40 per 1,000,000 cheerleaders among both high school and collegiate cheerleaders after the rule change.Conclusion:: Catastrophic injury rates in cheerleading decreased dramatically after the 2006-2007 rule change banning basket tosses from being performed on any hard surfaces. In particular, there was a nearly 4-fold reduction in the rate of catastrophic basket toss injuries. [ABSTRACT FROM AUTHOR]

Background: Concussions in American football remain a high priority of sports injury prevention programs. Detailed video review provides important information on causation, the outcomes of rule changes, and guidance on future injury prevention strategies. Purpose: Documentation of concussions sustained in National Football League games played during the 2015-2016 and 2016-2017 seasons, including consideration of video views unavailable to the public. Study Design: Descriptive epidemiology study. Methods: All reported concussions were reviewed with all available video footage. Standardized terminology and associated definitions were developed to describe and categorize the details of each concussion. Results: Cornerbacks sustained the most concussions, followed by wide receivers, then linebackers and offensive linemen. Half (50%) of concussions occurred during a passing play, 28% during a rushing play, and 21% on a punt or kickoff. Tackling was found to be the most common activity of concussed players, with the side of the helmet the most common helmet impact location. The distribution of helmet impact source—the object that contacted the concussed player's helmet—differed from studies of earlier seasons, with a higher proportion of helmet-to-body impacts (particularly shoulder) and helmet-to-ground impacts and with a lower proportion of helmet-to-helmet impacts. Helmet-to-ground concussive impacts were notable for the high prevalence of impacts to the back of the helmet and their frequency during passing plays. Conclusion: Concussion causation scenarios in the National Football League have changed over time. Clinical Relevance: The results of this study suggest the need for expanded evaluation of concussion countermeasures beyond solely helmet-to-helmet test systems, including consideration of impacts with the ground and with the body of the opposing player. It also suggests the possibility of position-specific countermeasures as part of an ongoing effort to improve safety. [ABSTRACT FROM AUTHOR]

Many studies have focused on the long-term impact of concussions in professional sports, but few have investigated short-term effects. This study examines concussion effects on individual players in the National Hockey League (NHL) by assessing career length, performance, and salary. Contracts, transactions, injury reports, and performance statistics from 2008–17 were obtained from the official NHL online publication. Players who sustained a concussion were compared with the 2008–17 non-concussed player pool. Career length was analyzed using Kaplan-Meier survival curves and stratification of player age, experience, and longevity. Player performance and salary changes were evaluated between the years before versus after concussion. Performance and salary changes were compared against non-concussed NHL athletes before/after their career midpoints. Of the 2194 eligible NHL players in the 9-year period, 309 sustained 399 concussions resulting in injury protocol. The probability of playing a full NHL season post-concussion was significantly decreased compared with the non-concussed pool (p < 0.05), specifically 65.0% versus 81.2% at 1 year into a player's career, 49.8% versus 67.4% at 2 years, and 14.6% versus 43.7% at 5 years. Performance was reduced at all non-goalie positions post-concussion (p < 0.05). Players scored 2.5 points/year less following a concussion. The total annualized financial impact from salary reductions after 1 concussion was $57.0 million, with a decrease of $292,000 per year in contract value per athlete. This retrospective study demonstrates that NHL concussions resulting in injury protocol activation lead to shorter career lengths, earnings reductions, and decreased performance when compared with non-concussed controls. [ABSTRACT FROM AUTHOR]

Objectives: To investigate changes from baseline on SCAT3 as a result of football game exposure, and association with X2 Patch measured head acceleration events in amateur Australian footballers.Design: Prospective cohort.Methods: Peak linear acceleration (PLA) of the head (>10 g) was measured by wearable head acceleration sensor X2 Biosystems X-Patch in male (n=34) and female (n=19) Australian footballers. SCAT3 was administered at baseline (B) and post-game (PG).Results: 1394 head acceleration events (HEA) >10 g were measured. Mean and median HEA PLA were recorded as 15.2 g (SD=9.2, range=10.0-115.8) and 12.4 g (IQR=11.0-15.6) respectively. No significant difference in median HEA PLA (g) was detected across gender (p=0.55), however, more HEAs were recorded in males (p=0.03). A greater number (p=0.004) and severity (p<0.001) of symptoms were reported PG than at B. No significant association between number of HEA or median PLA, and SCAT3 change scores (p>0.05 for all), was identified for either gender.Conclusions: Increase in symptom severity post game was not associated with X2 measured HEA. Males sustained more HEA, however HEA PLA magnitude did not differ across gender. Further work on the validation of head acceleration sensors is required and their role in sports concussion research and medical management. [ABSTRACT FROM AUTHOR]

The purpose of this study was to (a) assess the feasibility of recruitment/retention of participants, protocol/resource management, and participant safety, and (b) estimate the size of the effect between the experimental and control groups. This was a feasibility study conducted as a prospective pilot double-blind randomized clinical trial. Subjects aged 10-23 years old with acute concussion and dizziness were enrolled from sports medicine centers. Forty-one participants were randomized into treatment and were seen for physical therapy beginning at 10 days post-concussion. Subjects in the experimental group received individually tailored, pragmatically delivered progressive interventions. Subjects in the control received prescriptive sham to minimally progressive interventions. The two primary outcomes were medical clearance for return-to-play and symptomatic recovery. The median number of days to medical clearance for the experimental group was 15.5 and for the control was 26. The median number of days to symptomatic recovery was 13.5 for the experimental group and was 17 for the control. According to Cox proportional hazards regression for time to medical release for return-to-play, the experimental group demonstrated a hazard ratio of 2.91 (95% CI: 1.01, 8.43) compared to the control. For time-to-symptomatic recovery, those in the experimental group demonstrated a hazard ratio of 1.99 (95% CI: 0.95, 4.15) compared to the control. The results indicate that it is feasible and safe to complete this type of intervention study. The results provide strong support for the allocation of resources to conduct well-powered randomized clinical trials of this intervention. [ABSTRACT FROM AUTHOR]

Background: Sensitive and specific screening methods are needed to identify athletes at risk of prolonged recovery after sport-related concussion (SRC). Convergence insufficiency (CI) is a common finding in concussed athletes. Purpose: To assess the relationship between CI and recovery after SRC at the initial office visit. Study Design: Case-control study; Level of evidence, 3. Methods: In this retrospective cohort study, 270 athletes (147 male, 123 female), mean ± SD age 14.7 ± 2.0 years (range, 10-21 years), with the diagnosis of SRC who presented for initial office visit between January 2014 and January 2016 were evaluated for near point of convergence (NPC). The athletes were categorized into 2 groups: normal near point of convergence (NPC ≤6 cm), and convergence insufficiency (NPC >6 cm). These athletes were then followed to determine recovery time. Results: Athletes presented for initial office visit at a mean of 5.2 ± 4.2 days (range, 1-21 days) after SRC. Half of the athletes had CI after SRC (50.4%; n = 136). Athletes with CI (NPC 12.3 ± 4.7 cm) took significantly longer to recover after SRC, requiring 51.6 ± 53.9 days, compared with athletes with normal NPC (4.1 ± 1.3 cm), who required 19.2 ± 14.7 days (P < .001). After controlling for potential confounding variables, CI significantly increased the odds of prolonged recovery (≥28 days from injury) by 12.3-fold (P < .001; 95% confidence interval, 6.6-23.0). CI screening correctly classified 75.2% of our sample with 84.2% sensitivity and 70.0% specificity. The positive predictive value for CI and prolonged recovery was 62.5%, and the negative predictive value was 88.1%. Conclusion: CI at the initial office visit identified athletes at increased risk of prolonged recovery after SCR. Clinicians should consider measuring NPC in concussed athletes as a quick and inexpensive prognostic screening method. [ABSTRACT FROM AUTHOR]

Background: Soccer players head the ball repetitively throughout their careers; this is also a potential mechanism for a concussion. Although not all soccer headers result in a concussion, these subconcussive impacts may impart acceleration, deceleration, and rotational forces on the brain, leaving structural and functional deficits. Stronger neck musculature may reduce head-neck segment kinematics.Hypothesis: The relationship between anthropometrics and soccer heading kinematics will not differ between sexes. The relationship between anthropometrics and soccer heading kinematics will not differ between ball speeds.Study Design: Pilot, cross-sectional design.Level Of Evidence: Level 3.Methods: Division I soccer athletes (5 male, 8 female) were assessed for head-neck anthropometric and neck strength measurements in 6 directions (ie, flexion, extension, right and left lateral flexions and rotations). Participants headed the ball 10 times (25 or 40 mph) while wearing an accelerometer secured to their head. Kinematic measurements (ie, linear acceleration and rotational velocity) were recorded at 2 ball speeds.Results: Sex differences were observed in neck girth ( t = 5.09, P < 0.001), flexor and left lateral flexor strength ( t = 3.006, P = 0.012 and t = 4.182, P = 0.002, respectively), and rotational velocity at both speeds ( t = -2.628, P = 0.024 and t = -2.227, P = 0.048). Neck girth had negative correlations with both linear acceleration ( r = -0.599, P = 0.031) and rotational velocity at both speeds ( r = -0.551, P = 0.012 and r = -0.652, P = 0.016). Also, stronger muscle groups had lower linear accelerations at both speeds ( P < 0.05).Conclusion: There was a significant relationship between anthropometrics and soccer heading kinematics for sex and ball speeds.Clinical Relevance: Neck girth and neck strength are factors that may limit head impact kinematics. [ABSTRACT FROM AUTHOR]

Background: Concussion and repetitive head impact in sports has increased interest and concern for clinicians, scientists, and athletes. Lacrosse is the fastest growing sport in the United States, but the burden of head impact in lacrosse is unknown. Purpose: The goal of this pilot study was to quantify head impact associated with practicing and playing collegiate lacrosse while subjects were fitted with wearable accelerometers. Study Design: Descriptive epidemiology study. Methods: In a single year, a collegiate cohort of 14 women’s and 15 men’s lacrosse players wore mastoid-patch accelerometers to measure the frequency and severity of head impacts during official practices and games. Average impact severity, mean number of impacts, and cumulative acceleration were evaluated, stratified by sport and event type. Results: Men’s and women’s collegiate lacrosse players did not significantly differ in the number of head impacts received during games (11.5 for men vs 9.2 for women) or practices (3.1 vs 3.1). Men’s lacrosse players had significantly higher average head acceleration per impact during games compared with women (21.1g vs 14.7g) but not during practices (21.3g vs 18.1g). For both men and women, more impacts occurred during games than during practices (men, 11.5 vs 3.1; women, 9.2 vs 3.1), but impact severity did not significantly differ between events for either sport (men, 21.1g vs 21.3g; women, 14.7g vs 18.1g). Conclusion: The study data suggest a higher impact burden during games compared with practices, but this effect is driven by the quantity rather than severity of impacts. In contrast, sex-based effects in impact burden are driven by average impact severity rather than quantity. Data collected from larger multisite trials and/or different age groups could be used to inform ongoing debates, including headgear and practice regulations, that might appreciably affect the burden of head impacts in lacrosse. Clinical Relevance: While most head impacts do not result in a clinical diagnosis of concussion, evidence indicates that subconcussive head impacts may increase susceptibility to concussion and contribute to long-term neurodegeneration. [ABSTRACT FROM AUTHOR]

Background: Concussions impair balance, visual acuity, and reaction time—all of which are required for high-level batting performance—but the effects of concussion on batting performance have not been reported. The authors examined this relationship between concussion and batting performance among Major League Baseball (MLB) players. Hypothesis: Batting performance among concussed MLB players will be worse upon return to play than batting performance among players missing time for noninjury reasons. Study Design: Cohort study; Level of evidence, 3. Methods: The authors identified MLB players who sustained a concussion between 2007 and 2013 through league disabled-list records and a Baseball Prospectus database. For a comparison group, they identified players who went on paternity or bereavement leave during the same period. Using repeated-measures generalized linear models, the authors compared 7 batting metrics between the 2 groups for the 2 weeks upon return, as well as 4 to 6 weeks after return, controlling for pre-leave batting metrics, number of days missed, and position. Results: The authors identified 66 concussions and 68 episodes of bereavement/paternity leave to include in the analysis. In the 2 weeks after return, batting average (.235 vs .266), on-base percentage (.294 vs .326), slugging percentage (.361 vs .423), and on-base plus slugging (.650 vs .749) were significantly lower among concussed players relative to the bereavement/paternity leave players (time 3 group interaction, P\.05). In weeks 4 to 6 after leave, these metrics were slightly lower in concussed players but not statistically significantly so. Conclusion: Although concussed players may be asymptomatic upon return to play, the residual effects of concussion on the skills required for batting may still be present. Further work is needed to clarify the mechanism through which batting performance after concussion is adversely affected and to identify better measures to use for return-to-play decisions. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the effects of neck muscle strength and anticipatory cervical muscle activation on the kinematic response of the head to impulsive loads. In the study, multivariate linear mixed models were utilized. Based on the results, neck strength and impact anticipation are potentially modifiable risk factors for concussion.