Multidomain Predictors of Protracted Recovery following Concussion Among 5- to 9-Year-Old Patients: A Preliminary Study.

OBJECTIVE: To determine which components from a multidomain assessment best predict protracted recovery in pediatric patients with a concussion. STUDY DESIGN: A prospective cohort of patients aged 5-9 years who presented within 21 days of concussion to a specialty clinic were categorized into normal (≤30 days) and protracted (>30 days) recovery. Participants provided demographic and medical history information, and completed the Child Sport Concussion Assessment Tool-5 symptom report and balance assessment, the Vestibular/Ocular Motor Screen-Child (VOMS-C), and the Pediatric Immediate Post-concussion Assessment and Cognitive Testing. Univariate logistic regressions (LR) were used to inform a follow-up forward stepwise LR to identify the best predictors of protracted recovery. Receiver operating characteristic analysis of the area under the curve (AUC) was used to identify which predictors retained from the LR model best discriminated recovery. RESULTS: The final sample included 68 patients (7.52 ± 2.3 years; 56% male), 36 (52.9%) with normal and 32 (47.1%) with protracted recovery. Results of the LR to identify protracted recovery were significant (P < .001) and accounted for 39% of the variance. The model accurately classified 78% of patients, with days to first clinic visit (OR, 1.2; 95% CI, 1.1-1.4; P = .003) and positive VOMS-C findings (OR, 8.32; 95% CI, 2.4-28.8; P < .001) as significant predictors. A receiver operating characteristic analysis of the AUC of this 2-factor model discriminated protracted from normal recovery (AUC, 0.82; 95% CI, 0.71-0.92; P < .001). CONCLUSIONS: Days to first clinic visit and positive findings on the VOMS-C were the most robust predictors of protracted recovery after concussion in young pediatric patients.

Evaluating Recovery After Two and Three Repeated Concussions Using Growth Curves.

The results of prior research concerning the effects of repeated concussions have been mixed. The aim of this study was to evaluate how concussion outcomes and presentation changed within patients who were evaluated at a concussion specialty clinic multiple times with a concussion. Subjects included 202 patients (54% male) aged 10-21 years (M = 13.17) who presented to a specialty concussion clinic for two and three concussions (77% sport-related) and were followed through formal clearance. First, growth curve models were estimated to determine recovery time and initial symptom burden across the multiple injuries. Second, covariates were added to these models to evaluate which demographic, risk factor, or injury variables predicted any change that did occur in evaluation or outcome variables. Models indicated that each subsequent concussion linearly resulted in significantly fewer days to recovery (-4.62 days, p < 0.047) across three concussions, and significantly lower (and linear) symptom scores on the post-concussion symptom scale (PCSS) (-2.16, p = 0.05). More severe presentation (i.e., days to recovery; higher symptom score) was significantly associated (-.62, p = 0.005) with greater improvement in recovery time (-.62, p = 0.005) and symptom burden (-.56, p < 0.001) at subsequent injuries. No covariates were significantly associated with improvement (or lack thereof) at subsequent injuries. This study adds to evidence suggesting multiple injuries is not associated with protracted recovery at subsequent injuries, in the context of treatment and full clearance for each injury at a multi-disciplinary clinic.

Impact of Sex and Pubertal Development on Anxiety in Adolescents After Concussion.

Concussion often results in psychological symptoms, including anxiety. Post-concussion anxiety has been well documented, although much of this research has focused on collegiate athletes. The purpose of this study was to compare (1) anxiety symptoms in concussed and healthy controls over time and (2) to explore sex differences in post-concussion anxiety within the context of pubertal development. Participants (N = 126, mean age = 15.1 years old), including concussed (n = 86) and healthy adolescents (n = 40), completed the Pubertal Development Scale (PDS) and the Screen for Child Anxiety and Related Disorders (SCARED-C). The concussed groups completed SCARED-C at three visits (<10 days, 4 weeks, 3 months). Results of an analysis of covariance (ANCOVA) and multi-variate analysis of covariance (MANCOVA) found concussed adolescents reported higher SCARED-C total, generalized, and panic anxiety scores than healthy controls, after controlling for sex, age, and PDS score (PDSS). A three-way mixed ANCOVA examined the effects of sex, PDSS, time, and their interaction on SCARED-C total score in concussed adolescents while controlling for age. There was a significant three-way interaction between sex, age, and PDSS on SCARED-C total score while controlling for age. Overall, we observed increased anxiety in concussed adolescents, compared with controls, as well as greater post-concussion anxiety reported by females compared with males, including within PDSS groups. Concussion providers should be prepared to receive training to administer well-validated measures of psychopathology and should consider that female adolescents, compared with males, regardless of pubertal development, may be at greater risk for post-concussion anxiety.

Reliable Change Indices for the Serial Administration of the Concussion Clinical Profiles Screening Tool.

CONTEXT: The Concussion Clinical Profile Screening Tool (CP Screen) self-report concussion symptom inventory that is often administered at weekly intervals. However, 1-week reliable change indices (RCI) for clinical cutoffs and the test-retest reliability of the CP Screen is unknown. OBJECTIVE: Document RCI cutoff scores and 1-week test-retest reliability for each profile and modifier of the CP Screen for males and females. DESIGN: Case Series. SETTING: A large US university. PATIENTS OR OTHER PARTICIPANTS: 173 healthy college students. MAIN OUTCOME MEASURE(S): Participants completed two administrations of the CP Screen 7 days apart; CP Screen items yield five clinical profiles and two modifiers. Spearman rho coefficients (rs), intraclass correlation coefficients (ICCs) single measures and Unbiased Estimates of Reliability (UER) were used to assess test-retest reliability. Wilcoxon signed-rank tests assessed differences across time. RCI values and cutoff scores are provided at 90%/95% confidence intervals (CI). All analyses were performed for the total sample and separately for males and females. RESULTS: RCI cutoffs for clinically significant change (increase/decrease) at a 90% CI for males were as follows: Ocular, Vestibular >2/>4, Anxiety/Mood, Cognitive/Fatigue, Migraine>3/>3, Sleep >4/>6, and Neck>2/>2. RCI cutoffs for clinically significant change (increase/decrease) at a 90% CI for females were as follows: Anxiety/Mood≥2/≥4; Cognitive/Fatigue, Migraine, Ocular, Vestibular, Sleep≥3/≥3; and Neck≥1/≥1. Correlations for CP ranged from .51 (Migraine) to .79 (Anxiety/Mood) for the total sample, .48 (Migraine) to .84 (Vestibular) for males, and .51 (Migraine) to .77 (Ocular) for females. Test-retest indices for each profile and modifier were moderate to good for the total sample (ICC: .64-.82; UER: .79-.90), males (ICC: .60-.87; UER: .76-.94), and females (ICC: .64-.80; UER: .78-.89). CONCLUSION: The CP Screen is reliable and stable across a 1-week interval, and established RCIs for males and females can help identify meaningful change throughout recovery.

A Common Data Element-Based Adjudication Process for mTBI Clinical Profiles: A Targeted Multidomain Clinical Trial Preliminary Study.

INTRODUCTION: The primary purpose of this study was to examine the prevalence and percent agreement of clinician-identified mild traumatic brain injury (mTBI) clinical profiles and cutoff scores for selected Federal Interagency Traumatic Brain Injury Research common data elements (CDEs). A secondary purpose was to investigate the predictive value of established CDE assessments in determining clinical profiles in adults with mTBI. MATERIALS AND METHODS: Seventy-one (23 males; 48 females) participants (M = 29.00, SD = 7.60, range 18-48 years) within 1-5 months (M = 24.20, SD = 25.30, range 8-154 days) of mTBI completed a clinical interview/exam and a multidomain assessment conducted by a licensed clinician with specialized training in concussion, and this information was used to identify mTBI clinical profile(s). A researcher administered CDE assessments to all participants, and scores exceeding CDE cutoffs were used to identify an mTBI clinical profile. The clinician- and CDE-identified clinical profiles were submitted to a multidisciplinary team for adjudication. The prevalence and percent agreement between clinician- and CDE-identified clinical profiles was documented, and a series of logistic regressions with adjusted odds ratios were performed to identify which CDE assessments best predicted clinician-identified mTBI clinical profiles. RESULTS: Migraine/headache, vestibular, and anxiety/mood mTBI clinical profiles exhibited the highest prevalence and overall percent agreement among CDE and clinician approaches. Participants exceeding cutoff scores for the Global Severity Index and Headache Impact Test-6 assessments were 3.90 and 8.81 times more likely to have anxiety/mood and migraine/headache profiles, respectively. The Vestibular/Ocular Motor Screening vestibular items and the Pittsburgh Sleep Quality Index total score were predictive of clinician-identified vestibular and sleep profiles, respectively. CONCLUSIONS: The CDEs from migraine/headache, vestibular, and anxiety/mood domains, and to a lesser extent the sleep modifier, may be clinically useful for identifying patients with these profiles following mTBI. However, CDEs for cognitive and ocular may have more limited clinical value for identifying mTBI profiles.

Comparison of physiological outcomes after dynamic exertion between athletes at return to sport from concussion and controls: Preliminary findings.

OBJECTIVES: Compare physiological (heart rate, heart rate variability, and blood pressure), performance (change-of-direction task completion time and errors), and clinical (symptoms and rating of perceived exertion) outcomes during dynamic exertion between athletes at return to sport after concussion to healthy athlete controls. DESIGN: Case control. METHODS: A sample of 23 (Female = 10; 43.5 %) athletes at medical clearance to play/activity from concussion (CONCUSS) and 23 sex-, age-, and sport-matched healthy athletes (CONTROLS) completed a 5-min seated rest before and after the dynamic exertion test. Independent sample t-tests were used to compare CONCUSS and CONTROLS for completion time, heart rate, and blood pressure; and Mann-Whitney U tests for symptoms, perceived exertion, and errors. A series of ANOVAs were conducted to compare heart rate variability between groups across pre- and post-exercise rest periods. RESULTS: There were no differences in heart rate, blood pressure, symptoms, perceived exertion, and errors. CONCUSS were faster on Zig Zag (p = .048) and Pro Agility (p = .018) tasks, reported lower symptom severity (p = .019), and had lower post-EXiT HRV (p < .049) than CONTROLS. CONCLUSIONS: Performance, symptoms, perceived exertion, and blood pressure outcomes from dynamic exertion were equivocal between athletes at medical clearance from concussion and healthy controls, which provide empirical support for dynamic exercise to inform medical clearance clinical decision making for sport-related concussion. However, differences in autonomic nervous system functioning indicate that additional research is needed to examine temporal changes in heart rate variability and other physiological outcomes following dynamic exertion.

Targeted multidomain intervention for complex mTBI: protocol for a multisite randomized controlled trial in military-age civilians.

Background: Mild traumatic brain injury (mTBI) affects ~18,000 military personnel each year, and although most will recover in 3-4 weeks, many experience persisting symptoms and impairment lasting months or longer. Current standard of care for U.S. military personnel with complex mTBI involves initial (<48 h) prescribed rest, followed by behavioral (e.g., physical activity, sleep regulation, stress reduction, hydration, nutrition), and symptom-guided management. There is growing agreement that mTBI involves different clinical profiles or subtypes that require a comprehensive multidomain evaluation and adjudication process, as well as a targeted approach to treatment. However, there is a lack of research examining the effectiveness of this approach to assessing and treating mTBI. This multisite randomized controlled trial (RCT) will determine the effectiveness of a targeted multidomain (T-MD) intervention (anxiety/mood, cognitive, migraine, ocular, vestibular; and sleep, autonomic) compared to usual care (behavioral management) in military-aged civilians with complex mTBI. Methods: This study employs a single-blinded, two-group repeated measures design. The RCT will enroll up to 250 military-aged civilians (18-49 yrs) with a diagnosed complex mTBI within 8 days to 6 months of injury from two concussion specialty clinics. The two study arms are a T-MD intervention and a usual care, behavioral management control group. All participants will complete a comprehensive, multidomain clinical evaluation at their first clinical visit. Information gathered from this evaluation will be used to adjudicate mTBI clinical profiles. Participants will then be randomized to either the 4-week T-MD or control arm. The T-MD group will receive targeted interventions that correspond to the patient's clinical profile (s) and the control group will receive behavioral management strategies. Primary outcomes for this study are changes from enrollment to post-intervention on the Neurobehavioral Symptom Inventory (NSI), Patient Global Impression of Change (PGIC), and functional near-infrared spectroscopy (fNIRS). Time to return to activity (RTA), and healthcare utilization costs will also be assessed. Discussion: Study findings may inform a more effective approach to treat complex mTBI in military personnel and civilians, reduce morbidity, and accelerate safe return-to-duty/activity. Ethics and dissemination: The study is approved by the University of Pittsburgh Institutional Review board and registered at clinicaltrials.gov. Dissemination plans include peer-reviewed publications and presentations at professional meetings. Clinical Trial Registration: www.clinicaltrials.gov, identifier: NCT04549532.

Emotional Regulation and Adolescent Concussion: Overview and Role of Neuroimaging.

Emotional dysregulation symptoms following a concussion are associated with an increased risk for emotional dysregulation disorders (e.g., depression and anxiety), especially in adolescents. However, predicting the emergence or worsening of emotional dysregulation symptoms after concussion and the extent to which this predates the onset of subsequent psychiatric morbidity after injury remains challenging. Although advanced neuroimaging techniques, such as functional magnetic resonance imaging and diffusion magnetic resonance imaging, have been used to detect and monitor concussion-related brain abnormalities in research settings, their clinical utility remains limited. In this narrative review, we have performed a comprehensive search of the available literature regarding emotional regulation, adolescent concussion, and advanced neuroimaging techniques in electronic databases (PubMed, Scopus, and Google Scholar). We highlight clinical evidence showing the heightened susceptibility of adolescents to experiencing emotional dysregulation symptoms following a concussion. Furthermore, we describe and provide empirical support for widely used magnetic resonance imaging modalities (i.e., functional and diffusion imaging), which are utilized to detect abnormalities in circuits responsible for emotional regulation. Additionally, we assess how these abnormalities relate to the emotional dysregulation symptoms often reported by adolescents post-injury. Yet, it remains to be determined if a progression of concussion-related abnormalities exists, especially in brain regions that undergo significant developmental changes during adolescence. We conclude that neuroimaging techniques hold potential as clinically useful tools for predicting and, ultimately, monitoring the treatment response to emotional dysregulation in adolescents following a concussion.

Evidence for a multidomain clinical assessment of mild traumatic brain injury in older adults.

BACKGROUND: There are few guidelines on the appropriate clinical tools to evaluate mTBI in older adults. OBJECTIVE: We aimed to investigate the utility of a multidomain assessment to differentiate older adults with mTBI from controls. METHODS: Participants included 68 older adults (37% male) aged 60-76 (M = 66.24, SD = 4.50) years. Thirty-four patients were diagnosed with a mTBI at a specialty mTBI clinic within 90 days of injury, and age- and sex-matched to 34 community controls. Participants completed the following assessments: Post-Concussion Symptom Scale (PCSS), Short Fall Efficacy Scale-International (Short FES-I), Generalized Anxiety Disorder-7 Item Scale (GAD-7), Geriatric Depression Scale-5 Item (GDS-5), Wide Range Achievement Test-Fourth Edition (WRAT-4) reading subtest, subtests of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), clock drawing, and Vestibular/Ocular Motor Screening for Concussion (VOMS). Independent-samples t-tests or chi-squared analyses were used to compare assessment results between groups. A logistic regression (LR) was conducted to determine which combination of assessments best identified the mTBI group from controls. RESULTS: The mTBI group endorsed significantly more symptoms of concussion (p < .001), balance concerns (p < .001), anxiety (p < .001), and depression (p = 0.04), and performed worse on cognitive (p < .001), vestibular (p < .001), and oculomotor (p = .004) screening relative to controls. The LR (p < .001; r2 = 0.90) correctly identified 98.5% of older adults and retained concussion (p = .01) and depression (p = .02) symptoms, and cognitive (p = .03) and vestibular (p = .04) screening in the final model. DISCUSSION: The current findings support a multidomain assessment model of care for evaluating mTBI in older adults.

Factors associated with concussion management behavior in Ladies Gaelic Football players.

BACKGROUND: Sport-related concussion (SRC) management may be poor in community sports such as Ladies Gaelic Football (LGF). This study examined factors associated with SRC management behavior in adult LGF players. METHODS: Participants (n = 657) answered an online survey on demographic factors, concussion knowledge, attitudes, and education, and SRC management behavior. Data from participants who reported sustaining an LGF-related SRC during the previous year (n = 115) were further analyzed. RESULTS: Being diagnosed with SRC was the main factor influencing subacute management behavior. Players with diagnosed SRCs had increased odds of following a graded return-to-play (RTP) programme (OR = 4.89), following a medically supervised graded RTP programme (OR = 10.16), and being medically cleared before full RTP (OR = 13.45) compared with those with suspected SRCs. Concussion history was associated with increased odds of informing a coach of a possible SRC (OR = 2.86). Demographic factors, previous use of Ladies Gaelic Football Association concussion education resources, and concussion knowledge and attitudes had minimal or no influence on management behaviors. CONCLUSION: Greater access to medical personnel at LGF training and matches is recommended. Due to limited medical resources in community sport, a clear referral pathway for players with SRC and comprehensive SRC education should be introduced to ensure players receive adequate medical care.

Incidence of concussion and associated risk factors in collegiate soccer: findings from the NCAA-DoD CARE consortium.

This retrospective cohort study aims to examine concussion incidence rates (IR) in collegiate soccer players and compare IRs based on risk factors including sex, competition level, games/practices, history of concussion, and playing position. Collegiate soccer players were recruited (n = 2,471) from 23 institutions from the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium. Incidence rates for concussion per 1000 athlete exposures (AEs) were calculated across the 2015-16/2016-17 seasons. Incidence rates (IR) comparing risk factor groups were also calculated. A total of 162 concussions occurred during the study, for an IR of 0.08/1000 AEs. Females were more likely to have a concussion than males overall (IR = 1.47) and were more likely to have a concussion in games (IR = 1.42) and practices (IR = 2.91). Concussions were more likely during competition compared to practice (IR = 2.53), and less likely in Division III, compared to Divisions I and II, χ2 = 6.5, p > .05. In the concussed group, male sex was associated with 2.47 times higher odds of playing defender and 2.29 times higher odds of a collision mechanism. Results confirm previous findings that females and game exposures have higher concussion IR than males and practice exposures. Findings also supported sex differences in IRs based on exposure type, position, and mechanism.

Discriminating Young Children with Concussion in an Outpatient Specialty Clinic from Healthy Controls Using the Child Sports Concussion Assessment Tool-5.

OBJECTIVE: To evaluate the clinical utility of the Sports Concussion Assessment Tool-5 Child (Child SCAT5) in an outpatient specialty clinic sample of children aged 5-9 years. STUDY DESIGN: Ninety-six children within 30 days of a concussion (mean = 8.90 ± 5.78 days) and 43 age- and sex-matched healthy controls completed the Child SCAT5, including balance items, cognitive screening, parent and child symptom severity reports, as well as each individual parent- and child-rated symptom severity (0-3). A series of receiver operating characteristic curves with area under the curve (AUC) analysis were performed to evaluate the clinical utility of the Child SCAT5 components to discriminate concussion. RESULTS: The AUC values were nondiscriminate for cognitive screening (0.32) and poor for balance (0.61) items. The AUC values were acceptable for parent-reported symptoms worsening after physical activity (0.73) and mental activity (0.72). The AUCs for symptom severity items were excellent for parent (0.89) and child-reported (0.81) headaches, and were acceptable for parent-reported tired a lot (0.75) and both parent- (0.72) and child-reported (0.72) tired easily. CONCLUSION: With the exception of parent- and child-reported symptoms, the Child SCAT5 provides limited clinical utility for evaluating concussion in children aged 5-9 years seen at an outpatient concussion specialty clinic. The cognitive screening and balance testing items were not useful in discriminating concussion. Parent- and child-reported headache were the only Child SCAT5 items with excellent ability to differentiate concussion from controls in the age group.

The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients.

BACKGROUND: Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE: To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS: In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION: The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION: CRD42021253060 (PROSPERO).

Symptom Provocation Following Post-concussion Computerized Neurocognitive Testing and Its Relationship to Other Clinical Measures of Concussion.

OBJECTIVE: The objective of this study was to document the prevalence of post-computerized neurocognitive test (post-CNT) increases in symptoms in athletes with sport-related concussion, and to examine the effect of post-CNT symptom increases on concussion neurocognitive and vestibular/ocular motor clinical outcomes. METHODS: This was a retrospective analysis of medical records from a concussion specialty clinic. Two hundred and three athletes (M = 16.48 ± 1.97 years; 44% [90/203] female) completed a clinical visit for concussion within 30 days of injury (M = 7.73 ± 5.54 days). Computerized neurocognitive testing (the Immediate Post-concussion Assessment and Cognitive Testing: ImPACT), the Post-Concussion Symptom Scale (PCSS), and the Vestibular Ocular Motor Screening (VOMS) were the main outcome measures for the current study. RESULTS: Sixty-nine percent (141/203) of the sample did not report significant increases in PCSS scores following post-concussion CNT and were classified into a No Provocation (NO PROV) group. Thirty-one percent (62/203) of participants did report a significant increase in symptoms following post-concussion CNT and were classified into a Provocation (PROV) group. Neurocognitive performance was similar between groups. However, the PROV group reported significantly higher scores on the VOMS symptom items than the NO PROV group. CONCLUSIONS: The majority of adolescent athletes can complete a post-concussion CNT without experiencing significant increases in concussion symptoms. Individuals that report symptom increases from completing a post-concussion CNT are more likely to exhibit increased vestibular/ocular motor symptoms. These findings underscore the relationship between the clinical findings from both CNT and vestibular/ocular motor measures following concussion.

Multidomain concussion symptoms in adolescents: A network analysis.

Concussion is a heterogeneous injury involving symptoms and impairment that represent multiple domains (e.g., anxiety, cognitive, vestibular). Network analysis, a modeling technique that estimates relationships among symptoms, provides a statistically sound and clinically practical method for evaluating these interrelationships. The purpose of this study was to examine, using network analysis, relationships among clinical assessments and multidomain symptom report within a sample of adolescent patients following a concussion. Participants included 326 patients (49.7% female) aged 10-21 years presenting to a concussion specialty clinic within 28 days of a diagnosed concussion. Participants completed the Post-Concussion Symptom Scale (PCSS) and Vestibular-Ocular Motor Screening (VOMS) tool at initial visit. Network models were applied to PCSS symptoms initially, and then applied to VOMS and PCSS symptom data together. Dizziness (Expected influence (EI) = 1.10) and sadness (EI = 1.91) were most central (i.e., highest cumulative partial correlations) to the symptom network. Numerous interdomain relationships were supported, including irritability with mental fogginess (edgeweight = 0.12), dizziness with headache (edgeweight = 0.16), and dizziness with vision problems (edgeweight = 0.13). Community analyses resulted in VOMS groupings by domain (e.g., vestibular) and symptom (e.g., dizziness). The findings suggest a more direct focus on symptom interrelationships, such as how dizziness contributes to emotional symptoms, may help guide and better target treatments. Also, results suggest grouping VOMS assessment by symptom (e.g., dizziness) and item (e.g., vestibular-ocular reflex) may better reflect underlying impairments reflected by these symptom-item combinations.

Test-Retest, Interrater Reliability, and Minimal Detectable Change of the Dynamic Exertion Test (EXiT) for Concussion.

BACKGROUND: The Dynamic Exertion Test (EXiT) was developed to inform return-to-play (RTP) decision-making following clinical recovery from sport-related concussion (SRC). The purpose of the current study was to document intrarater and test-retest reliability and minimal detectable change (MDC) scores for physiological [heart rate (HR) and blood pressure], performance (change-of-direction task completion time and errors), and clinical outcomes (endorsed symptoms, perceived exertion) of EXiT, and interrater reliability of performance outcomes. HYPOTHESIS: Healthy athletes would exhibit stable physiological responses to the EXiT across visits, demonstrate consistent change-of-direction task completion time between consecutive trials at each visit, and the fastest time (of 2 trials) across visits, and endorse equivocal symptoms and effort across visits. STUDY DESIGN: Cross-sectional, test-retest. LEVEL OF EVIDENCE: Level 3. METHODS: Seventy-nine (female: 34 [43%], 19.6 ± 5.0 years) athletes completed the EXiT at 2 study visits (8.7 ± 4.7 days between visits). Two-way, mixed, intraclass correlation coefficients (ICCs) were used to evaluate intrarater and test-retest reliability. Cronbach's alpha was used to document the internal consistency of symptoms at each visit, and MDC scores were calculated on the physiological, performance, and clinical outcomes. RESULTS: Measured and percentage of age-estimated maximum HR were reliable following EXiT (ICC = 0.579-0.618). Change-of-direction task completion time (MDC range = 0.75-8.70 s) had good-to-excellent test-retest (ICC = 0.703-0.948) and interrater (ICC = 0.932-0.965) reliability. Symptoms had a high internal consistency at visits 1 (α = 0.894) and 2 (α = 0.805) and were reliable across visits (ICC = 0.588). CONCLUSION: The current investigation established test-retest reliability in addition to MDC scores of an objective dynamic exercise assessment among healthy adolescent and adult athletes. The EXiT may be an objective approach to inform RTP decision-making following SRC recovery. CLINICAL RELEVANCE: The EXiT is a clinically feasible exertion-based assessment that can be readily administered in a variety of outpatient clinical settings.

Concussion in Ladies Gaelic Football: Self-reported History, Clinical Profiles, and Management Behavior.

OBJECTIVE: To describe the prevalence, characteristics, and management behavior of self-reported sport-related concussion (SRC) in Ladies Gaelic Football (LGF) players. DESIGN: Cross-sectional study. SETTING: Online survey distributed to LGF clubs throughout Ireland. PARTICIPANTS: Elite and nonelite adult LGF players (n = 657). INTERVENTIONS: Participants were recruited by convenience sampling and answered an online survey. Questions on demographic characteristics, SRC history, symptoms, injury characteristics, and management behavior after SRCs that occurred while playing LGF during the previous season were included. MAIN OUTCOME MEASURES: Overall concussion history, occurrence of an SRC during the previous LGF season, clinical profile scores, characteristics (eg mechanism and setting), and management behavior (eg following a graded RTP program) after SRCs that occurred during the previous season. RESULTS: Approximately one-fifth (17.5%) of participants sustained a suspected or diagnosed SRC during the previous season, which was higher among elite (26.1%) than nonelite (15.3%) players ( P < 0.01). The highest scoring clinical profiles were the ocular and migraine profiles. Only 3.5% of respondents adhered to all SRC management recommendations. Although players who reported a medically diagnosed versus a suspected SRC more often followed these guidelines, SRC management beyond the initial phase of injury remained inadequate. CONCLUSION: SRC is common in LGF; however, adherence to recommended management guidelines is poor, even among players who receive medical assistance. In particular, few LGF athletes receive clinical concussion care beyond the initial diagnosis and acute management phase. Further research is needed to examine the underlying reasons for poor SRC management in LGF, which will guide the development of future sport-specific interventions.

Sex Differences on the Concussion Clinical Profiles Screening in Adolescents With Sport-Related Concussion.

CONTEXT: Sex differences influence symptom presentations after sport-related concussion and may be a risk factor for certain concussion clinical profiles. OBJECTIVE: To examine sex differences on the Concussion Clinical Profile Screen (CP Screen) in adolescents after sport-related concussion. DESIGN: Cross-sectional study. SETTING: A concussion specialty clinic. PATIENTS OR OTHER PARTICIPANTS: A total of 276 adolescent (age = 15.02 ± 1.43 years; girls = 152 [55%]) athletes with a recently diagnosed concussion (≤30 days). MAIN OUTCOME MEASURE(S): The 5 CP Screen profiles (anxiety mood, cognitive fatigue, migraine, vestibular, ocular) and 2 modifiers (neck, sleep), symptom total, and symptom severity scores were compared using a series of Mann-Whitney U tests between boys and girls. RESULTS: Girls (n = 152) scored higher than boys (n = 124) on the cognitive fatigue (U = 7160.50, z = -3.46, P = .001) and anxiety mood (U = 7059, z = -3.62, P < .001) factors but not on the migraine (U = 7768, z = -2.52, P = .01) factor. Girls also endorsed a greater number of symptoms (n = 124; U = 27233, z = -3.33, P = .001) and scored higher in symptom severity (U = 7049, z = -3.60, P < .001) than boys. CONCLUSIONS: Among adolescents, symptom endorsement on the CP Screen varied based on sex, and clinicians need to be aware of these differences, especially when evaluating postconcussion presentation in the absence of baseline data.

Association of Multidomain Assessment Outcomes With Referral for Vestibular Therapy After Concussion.

CONTEXT: Multiple aspects of a multidomain assessment have been validated for identifying concussion; however, researchers have yet to determine which components are related to referral for vestibular therapy. OBJECTIVE: To identify which variables from a multidomain assessment were associated with receiving a referral for vestibular therapy after a concussion. DESIGN: Retrospective chart review, level of evidence 3. PATIENTS OR OTHER PARTICIPANTS: Participants (n = 331; age = 16.9 ± 7.2 years; 39.3% female) were diagnosed with a concussion per international consensus criteria by a clinical neuropsychologist after presenting to a concussion specialty clinic. MAIN OUTCOME MEASURE(S): Medical chart data were extracted from the first clinical visit regarding preinjury medical history, computerized neurocognition, Post-Concussion Symptom Scale, Concussion Clinical Profiles Screen, and Vestibular Ocular Motor Screening within 16.2 ± 46.7 days of injury. We built 5 backwards logistic regression models to associate the outcomes from each of the 5 assessments with referral for vestibular therapy. A final logistic regression model was generated using variables retained in the previous 5 models as potential predictors of referral for vestibular therapy. RESULTS: The 5 models built from individual components of the multidomain assessment predicted referral for vestibular therapy (R2 = 0.01-0.28) with 1 to 6 statistically significant variables. The final multivariate model (R2 = 0.40) retained 9 significant variables, represented by each of the 5 multidomain assessments except neurocognition. Variables that had the strongest association with vestibular therapy referral were motor vehicle accident mechanism of injury (odds ratio [OR] = 15.45), migraine history (OR = 3.25), increased headache when concentrating (OR = 1.81), and horizontal vestibular ocular reflex (OR = 1.63). CONCLUSIONS: We demonstrated the utility of a multidomain assessment and identified outcomes associated with a referral for vestibular therapy after a concussion.

Comparison of Clinical Outcomes Between Athletes With Immediate and Delayed Onset of Symptoms Following Sport-Related Concussion.

OBJECTIVE: To compare characteristics and clinical outcomes of adolescent athletes with immediate and delayed onset of symptoms following sport-related concussion (SRC). A secondary objective was to describe the symptoms that are delayed and the timing of symptom onset. DESIGN: Prospective, repeated measures study. SETTING: Concussion Specialty Clinic. PARTICIPANTS: One hundred fifty-two participants (63.3% men) aged 11 to 24 (15.78 ± 3.47) evaluated within 7 days (3.47 ± 1.66) of sustaining an SRC. INDEPENDENT VARIABLE: Group classification of immediate (IMMEDIATE) or delayed onset of symptoms (DELAYED; >60 seconds following mechanism of injury) through structured clinical interview. MAIN OUTCOME MEASURES: Group comparisons on demographic and medical history factors, concussion and clinical profile symptom scores, computerized neurocognitive test scores, vestibular/oculomotor screening scores, and days to medical clearance. RESULTS: 24.3% of athletes in the sample were DELAYED. The groups did not differ on demographics and medical history. The DELAYED group had increased likelihood of posttraumatic migraine (PTM) as a primary/secondary clinical profile ( P = 0.03). Groups did not differ on any other clinical profiles ( P > 0.05). Groups did not differ on recovery time ( P = 0.47), the IMMEDIATE group higher dizziness on vestibular/ocular motor screening ( P = 0.016) and increased likelihood of dizziness being the initial symptom experienced ( P < 0 .001). CONCLUSIONS: The results indicated that delayed onset of symptoms in athletes were relatively common following SRC, supporting continued evaluation of athletes for several days following suspected injuries. Delayed onset of symptoms was associated with PTM, whereas immediate onset was associated with more pronounced vestibular dysfunction, suggesting that clinicians should consider the timing of symptom onset when assessing and treating athletes following SRC.