Diagnosis of Sports-Related Concussion Using Symptom Report or Standardized Assessment of Concussion.

Importance: The Sports Concussion Assessment Tool-5 (SCAT5) has been recommended for concussion evaluation and utilizes both a subjective reported symptom grading scale and objective measures of concussion including a cognitive evaluation: the Standardized Assessment of Concussion (SAC). The SAC includes testing for orientation, immediate memory, concentration, and delayed recall; a 10-word list is used to assess immediate memory and delayed recall. Objective: To determine the diagnostic accuracy of components of the SCAT5 and to provide a framework for clinical interpretation. Design, Setting, and Participants: This prospective case-control study of National Collegiate Athletic Association Division I athletes from any sport was conducted from July 2020 to December 2022 at 4 universities. Athletes completed baseline SCAT5 testing using the 10-word list. When an athlete presented acutely with suspected concussion (sideline or within 2 days), the tests were repeated. If a concussion was diagnosed, a control athlete underwent the same tests. Controls were identified and matched on comorbid conditions, sex and gender, sport, season, and baseline scores. Data analysis was conducted from August to October 2023. Main Outcomes and Measures: The primary outcomes were area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive and negative predictive value, and test-retest reliability of the symptom score; symptom severity score; the total SAC score; and the orientation, immediate memory, concentration, and delayed memory subcomponent scores on the SCAT5 compared with clinical diagnosis of concussion. Results: Baseline and postinjury data were collected on 92 athletes with concussion and 92 matched control athletes (96 men [52%] and 88 women [48%]; 110 who played a sport other than football [59%]). Diagnostic utility was considered excellent for symptom score (AUC, 0.93; 95% CI, 0.89-0.96) and symptom severity score (AUC, 0.94; 95% CI, 0.90-0.97). An increase of 2 points on the symptom score was associated with a sensitivity of 86% (95% CI, 78%-92%), specificity of 80% (95% CI, 70%-87I%), and positive predictive value of 81% (95% CI, 72%-88%). The total SAC score had poor to fair diagnostic utility (AUC, 0.70; 95% CI, 0.63-0.77); however, 41 athletes with concussion (45%) had a total SAC score at or above their baseline score (ie, within normal limits). The diagnostic utility was poor to fair for immediate memory (AUC, 0.68, 95%CI, 0.61-0.75) and delayed recall (AUC, 0.69; 95% CI, 0.62-0.77) and not useful for orientation (AUC, 0.49; 95% CI, 0.43-0.56) and concentration (AUC, 0.52 95% CI, 0.44-0.61). Test-retest reliability was fair for total SAC and poor for immediate memory and delayed recall, orientation, and concentration. Conclusions and Relevance: In this case-control study of the diagnostic accuracy of reported symptoms and the SAC, reported symptoms were the most accurate indicator of concussion while the 10-word SAC had limited sensitivity. These findings suggest that understanding the properties of the SAC is important when making the diagnosis of concussion.

Prevalence of covid-19 and long covid in collegiate student athletes from spring 2020 to fall 2021: a retrospective survey.

BACKGROUND: Symptomatic COVID-19 and Long COVID, also referred to as post-acute sequelae of SARS-CoV-2 (PASC) or post-COVID conditions, have been widely reported in young, healthy people, but their prevalence has not yet been determined in student athletes. We sought to estimate the prevalence of reported COVID-19, symptomatic COVID-19, and Long COVID in college athletes in the United States attending 18 schools from spring 2020 to fall 2021. METHODS: We developed an online survey to measure the prevalence of student athletes who tested positive for COVID-19, developed Long COVID, and did not return to their sport during the relevant time period. We surveyed a convenience sample of 18 collegiate school administrators, representing about 7,000 student athletes. Of those schools surveyed, 16 responded regarding the spring 2020 semester, and 18 responded regarding the full academic year of fall 2020 to spring 2021 (both semesters). RESULTS: According to the survey responses, there were 9.8% of student athletes who tested positive for COVID-19 in spring 2020 and 25.4% who tested positive in the academic year of fall 2020 to spring 2021. About 4% of student athletes who tested positive from spring 2020 to spring 2021 developed Long COVID, defined as new, recurring, or ongoing physical or mental health consequences occurring 4 or more weeks after SARS-CoV-2 infection. CONCLUSIONS: This study highlights that Long COVID occurs among young, healthy athletes and is a real consequence of COVID-19. Understanding the prevalence of Long COVID in this population requires longer follow-up and further study.

Effect of the 2018 NCAA Kickoff Rule Change on Concussion Rates in Collegiate Football: Results From a Division 1 Conference.

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.

Risk of Concussion After a Targeting Foul in Collegiate American Football.

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.

Diagnostic accuracy and reliability of sideline concussion evaluation: a prospective, case-controlled study in college athletes comparing newer tools and established tests.

OBJECTIVE: To assess diagnostic accuracy and reliability of sideline concussion tests in college athletes. METHODS: Athletes completed baseline concussion tests including Post-Concussion Symptom Scale, Standardised Assessment of Concussion (SAC), modified Balance Error Scoring System (m-BESS), King-Devick test and EYE-SYNC Smooth Pursuits. Testing was repeated in athletes diagnosed acutely with concussion and compared to a matched teammate without concussion. RESULTS: Data were collected on 41 concussed athletes and 41 matched controls. Test-retest reliability for symptom score and symptom severity assessed using control athletes was 0.09 (-0.70 to 0.88) and 0.08 (-1.00 to 1.00) (unweighted kappa). Intraclass correlations were SAC 0.33 (-0.02 to 0.61), m-BESS 0.33 (-0.2 to 0.60), EYE-SYNC Smooth Pursuit tangential variability 0.70 (0.50 to 0.83), radial variability 0.47 (0.19 to 0.69) and King-Devick test 0.71 (0.49 to 0.84). The maximum identified sensitivity/specificity of each test for predicting clinical concussion diagnosis was: symptom score 81%/94% (3-point increase), symptom severity score 91%/81% (3-point increase), SAC 44%/72% (2-point decline), m-BESS 40%/92% (5-point increase), King-Devick 85%/76% (any increase in time) and EYE-SYNC Smooth Pursuit tangential variability 48%/58% and radial variability 52%/61% (any increase). Adjusted area under the curve was: symptom score 0.95 (0.89, 0.99), symptom severity 0.95 (95% CI 0.88 to 0.99), SAC 0.66 (95% CI 0.54 to 0.79), m-BESS 0.71 (0.60, 0.83), King-Devick 0.78 (0.69, 0.87), radial variability 0.47 (0.34, 0.59), tangential variability 0.41 (0.30, 0.54) CONCLUSION: Test-retest reliability of most sideline concussion tests was poor in uninjured athletes, raising concern about the accuracy of these tests to detect new concussion. Symptom score/severity had the greatest sensitivity and specificity, and of the objective tests, the King-Devick test performed best.

Comparison of cardiovascular screening in college athletes by history and physical examination with and without an electrocardiogram: Efficacy and cost.

BACKGROUND: Preparticipation screening for conditions associated with sudden cardiac death (SCD) is required in college athletes. Previous cost analyses used theoretical models based on variable assumptions, but no study used real-life outcomes. OBJECTIVE: The purpose of this study was to compare disease prevalence, positive findings, and costs of 2 different screening strategies: history and physical examination alone (H&P) or with an electrocardiogram (H&P+ECG). METHODS: De-identified preparticipation data (2009-2017) from Pacific-12 Conference institutions were abstracted for cardiovascular history questions, cardiovascular physical examination, and ECG result. Secondary testing, cardiac diagnoses, return to play outcomes, and complications from testing were recorded. The costs of screening and secondary testing were based on the Centers for Medicare & Medicaid Services Physician Fee Schedule. RESULTS: A total of 8602 records (4955 H&P, 3647 H&P+ECG) were included. Eleven conditions associated with SCD were detected (2 H&P only, 9 H&P+ECG). The prevalence of cardiovascular conditions associated with SCD discovered with H&P alone was 0.04% (1/2454) compared to 0.24% (1/410) when ECG was added (P = .01) (odds ratio 5.17; 95% confidence interval 1.28-20.85; P = .02). Cost of screening and secondary testing with H&P alone was $130 per athlete and in the ECG-added group was $152 per athlete. The cost per diagnosis was $312,407 in the H&P group and $61,712 in the ECG-added group. There were no adverse outcomes from secondary testing or treatment. CONCLUSION: H&P with the addition of ECG is 6 times more likely to detect a cardiovascular condition associated with SCD than without. The addition of ECG improves the cost efficiency per diagnosis by 5-fold and should be considered at college institutions with appropriate resources.

Concussion Management in the Collegiate Athlete.

Concussions have always been common in sports, but the awareness and associated diagnosis of the condition have been trending upward, gaining significant attention through medical literature, news media, and entertainment. Concussion management in the collegiate athlete is of specific concern, as over 460,000 young adults compete in collegiate athletics annually. The NCAA and other groups have strived to provide consensus guidelines, but many student-athletes still are not being managed as recommended. The return to play process should begin only after a student-athlete is symptom free and has returned to his or her baseline functioning. Return to play should follow a progressive, stepwise approach, using uniform steps that have been established through association recommendations. Returning to academics, or return to learn, often proves to be more challenging, as this process requires a multidisciplinary approach involving academic and administrative representatives in addition to the medical team. As further scientific evidence comes out, is it imperative that professionals providing concussion care remain up-to-date on this ever-evolving topic.

The effects of two therapeutic patellofemoral taping techniques on strength, endurance, and pain responses.

OBJECTIVE: To compare the effects of taping techniques on clinical measures in patellofemoral pain syndrome (PFPS) patients. DESIGN: Crossover experimental design. SETTING: Controlled laboratory. PARTICIPANTS: Twenty physically active PFPS patients. MAIN OUTCOME MEASURES: Isokinetic strength and endurance, and perceived pain. RESULTS: Bilateral baseline differences existed for strength (involved = 1.8 ± 0.5 Nm/kg; uninvolved = 2.1 ± 0.5 Nm/kg; p = 0.001) and endurance (involved = 35.6 ± 14.0 J/kg; uninvolved = 40.2 ± 12.9 J/kg; p = 0.013). Strength (McConnell = 2.1 ± 0.6 Nm/kg, 95% SCI = (1.1, 4.2); Spider(®) = 2.1 ± 0.5 Nm/kg, 95% SCI = (0.9, 4.0)) and endurance (McConnell = 42.9 ± 13.8 J/kg, 95% SCI = (2.9, 11.6); Spider(®) = 42.5 ± 11.0 J/kg, 95% SCI = (2.6, -11.3)) increased when taped compared to baseline. Pain decreased during strength (baseline = 3.0 ± 2.2 cm; McConnell = 1.9 ± 1.7 cm, 95% SCI = (-1.8, -0.4); Spider(®) = 1.6 ± 2.0 cm, 95% SCI = (-2.0, -0.5)) and endurance (baseline = 2.5 ± 2.0 cm; McConnell = 1.5 ± 1.8 cm, 95% SCI = (-1.6, -0.4); Spider(®) = 1.1 ± 0.8 cm, 95% SCI = (-1.7, -0.5)) measurements when taped. Differences between taping techniques were insignificant. CONCLUSIONS: Taping improved clinical measures in PFPS patients. No differences existed between Spider(®) and McConnell techniques.

Clinical inquiries. What is the most effective management of acute fractures of the base of the fifth metatarsal?

For acute Jones' fractures in recreationally active patients, early intramedullary screw fixation results in lower failure rates and shorter times to both clinical union and return to sports than non-weightbearing short leg casting (strength of recommendation [SOR]: A, based on 2 randomized controlled trials [RCT]). Non-weightbearing short leg casting achieves union in 56% to 100% of patients but can require prolonged casting (SOR: B, based on 2 prospective cohorts and multiple retrospective, follow-up studies). Stress fractures were not included in this review. For avulsion fractures of the fifth metatarsal tuberosity, a soft Jones' dressing allows earlier return to pre-injury levels of activity than rigid short leg casting (SOR: B, based on a lower-quality RCT).

Medical coverage of high school athletics in North Carolina.

BACKGROUND: A significant percentage of high school students participate in athletics, and of those participating, at least one third will experience a sport-related injury. Despite the high risk of injury, there are few guidelines on what type of medical coverage should be provided for high school athletics. Although vague recommendations are present, it is not known to what extent high schools comply with these guidelines. The primary objective of this cross-sectional study was to assess the quality and extent of medical coverage at high school athletic events in North Carolina. METHODS: A questionnaire, mailed to all athletic directors at public and private North Carolina high school members of the North Carolina High School Athletic Association, was used to assess medical coverage. RESULTS: Only 56% of the schools had coverage by either nationally or state certified athletic trainers. Although 71% of schools had physician coverage at some athletic events, less than 10% of physician coverage included monitoring of athletic practices. Only 27% of the schools surveyed felt that their existing medical coverage of athletic events could be considered adequate. CONCLUSIONS: These preliminary findings suggest that medical coverage of high school athletics in North Carolina, as in other states, is lacking and inconsistent.

Clinical inquiries. How does tissue adhesive compare with suturing for superficial lacerations?

Tissue adhesives are effective and yield results comparable to those with conventional suturing of superficial, linear, and low-tension lacerations. The cosmetic outcome is similar; wound complications, such as infection and dehiscence, may be lower with tissue adhesives. Wound closure of superficial lacerations by tissue adhesives is quicker and less painful compared with conventional suturing (strength of recommendation: A, systematic reviews of randomized trials).