Access to athletic trainers and sex as modifiers of time to reach clinical milestones after sport-related concussion in collegiate athletes.

OBJECTIVE: Investigate whether an athlete's biological sex and exposure to a dedicated athletic trainer (AT) were related to clinical milestones after a sports-related concussion (SRC). DESIGN: Retrospective chart review. METHODS: Medical charts of collegiate athletes (n = 196 [70.9% female]) diagnosed with SRC were reviewed to extract: biological sex, dedicated AT exposure for their sport (yes/no), and time (days) to reaching clinical milestones (diagnosis, symptom resolution, unrestricted return to sport [RTS]). Mann-Whitney U tests were used to determine whether time to clinical milestones differed by sex, AT exposure, or their interaction. Proportions of same-day diagnoses and times to diagnosis, symptom resolution, and unrestricted RTS were evaluated with chi-squared and spearman's rank correlations, respectively. RESULTS: There were no significant differences in times to reaching any clinical milestone by sex, AT exposure, or their interaction (ps > 0.05). Forty-three percent of participants were diagnosed on the day of their SRC. This did not differ by sex or AT exposure (ps > 0.29). Longer times to SRC diagnosis were associated with more days to symptom resolution (ρ = 0.236, p = 0.001) and unrestricted RTS (ρ = 0.223, p < 0.001). CONCLUSIONS: Athlete sex and AT exposure were not associated with times to reach any clinical milestone; however, delayed diagnosis was associated with longer times to reach clinical recovery.

Sport-related concussion in para athletes: A scoping review of concussion incidence, assessment, and management.

ABSTRACT: Although research on sport-related concussion has grown substantially in the last decade, research on concussion in para sports remains limited. The aim of this scoping review is to synthesize and describe the current literature on the incidence, assessment, and management of sport-related concussion in para athletes. The literature search was conducted in CINAHL, Google Scholar, MEDLINE, SPORTDiscus, and Web of Science databases and identified 22 studies that addressed one of our research questions. A majority of studies addressed concussion in elite athletes; youth and collegiate para athletes were largely under-represented. Fewer studies addressed concussion assessment and management, in part due to limitations in accessibility of current assessment tools for athletes with varying disabilities. Moving forward, there is a need to capture a larger range of incidence data, create modified assessment tools with para-specific normative data, and develop risk prevention strategies for para athletes.

Reevaluating clinical assessment outcomes after unrestricted return to play following sport-related concussion.

PRIMARY OBJECTIVE: The objective of this study was to examine neurocognition, postural control, and symptomology at multiple timepoints following concussion. We hypothesized that collegiate athletes would perform similar to or better than their baseline in terms of each outcome at both timepoints. RESEARCH DESIGN: This was a retrospective study of 71 collegiate athletes (18.3 ± 0.89 years old; 182.2 ± 10.05 cm; 84.2 ± 20.07 kg) to observe changes in outcomes from a previously established clinical protocol. METHODS AND PROCEDURES: Participants were administered ImPACT™, the Sensory Organization Test (SOT), and the revised head injury scale (HIS-r) prior to their seasons (baseline); upon reporting symptom-free following concussion (post-injury); and approximately 8-months after return-to-play to establish a new baseline. MAIN OUTCOMES AND RESULTS: There were no changes in ImPACT scores or HIS-r reporting over time. ImPACT total symptom score (TSS) decreased over time (p = .002, ηp2 = 0.08). Significant main effects occurred for the SOT equilibrium score (p < .01, ηp2 = 0.34) and Vestibular sensory ratio (p < .001, ηp2 = 0.22). CONCLUSIONS: Our data suggest no decline in neurocognition, balance, or symptom burden approximately eight months post-injury. As clinicians continue to explore "best practices" for concussion management and potential long-term implications of these injuries it is important to monitor outcome measures longitudinally.

Factors Associated With Energy Expenditure and Energy Balance in Acute Sport-Related Concussion.

CONTEXT: Sport-related concussion (SRC) is characterized by a pathologic neurometabolic cascade that results in an increased intracranial energy demand and a decreased energy supply. Little is known about the whole-body energy-related effects of SRC. OBJECTIVE: To examine factors associated with whole-body resting metabolic rate (RMR), total energy expenditure (TEE), energy consumption (EC), and energy balance (EBal) in student-athletes acutely after SRC and healthy matched control individuals. DESIGN: Case-control study. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Student-athletes diagnosed with SRC (n = 28, 50% female, age = 18.4 ± 1.8 years, body mass index [BMI] = 24.1 ± 4.1 kg/m2) assessed ≤72 hours postinjury and a matched control group (n = 28, 50% female, age = 19.4 ± 2.9 years, BMI = 24.7 ± 4.78 kg/m2). MAIN OUTCOME MEASURE(S): Resting metabolic rate was measured via indirect calorimetry. Participants reported their physical activity and dietary intake for 3 days, which we used to estimate TEE and EC, respectively, and to calculate EBal (EC:TEE ratio). Resting metabolic rate, TEE, and EC were normalized to body mass. Group and group-by-sex comparisons were conducted for RMR·kg-1, TEE·kg-1, EC·kg-1, and EBal using independent t tests with the a priori α = .05. Associations of age, sex, concussion history, BMI, and symptom burden with RMR·kg-1 and EBal were explored with linear regression models. RESULTS: Total energy expenditure·kg-1 was lower (P < .01; mean difference ± SD = -5.31 ± 1.41 kcal·kg-1) and EBal was higher (P < .01; 0.28 ± 0.10) in SRC participants than in control participants. Both sexes with SRC had lower TEE·kg-1 than did the control participants (P values ≤ .04); females with SRC had higher EBal than controls (P = .01), but male groups did not differ. Higher RMR·kg-1 was associated with history of concussion (adjusted R2 = .10, ß = 0.65). Younger age (ß = -0.35), fewer concussions (ß = -0.35), lower BMI (ß = -0.32), greater symptom duration (ß = 1.50), and lower symptom severity (ß = -1.59) were associated with higher EBal (adjusted R2 = .54). CONCLUSIONS: Total energy expenditure·kg-1 and EBal appeared to be affected by acute SRC, despite no differences in RMR·kg-1. Sex, concussion history, BMI, and symptom burden were associated with acute energy-related outcomes.

Direct and indirect costs associated with stereotactic radiosurgery or open surgery for medial temporal lobe epilepsy: Results from the ROSE trial.

OBJECTIVE: To determine whether a less-invasive approach to surgery for medically refractory temporal lobe epilepsy is associated with lower health care costs and costs of lost productivity over time, compared to open surgery. METHODS: We compared direct medical costs and indirect productivity costs associated with treatment with stereotactic radiosurgery (SRS) or anterior temporal lobectomy (ATL) in the ROSE (Radiosurgery or Open Surgery for Epilepsy) trial. Health care use was abstracted from hospital bills, the study database, and diaries in which participants recorded health care use and time lost from work while seeking care. Costs of use were calculated using a Medicare costing approach used in a prior study of the costs of ATL. The power of many analyses was limited by the sample size and data skewing. RESULTS: Combined treatment and follow-up costs (in thousands of US dollars) did not differ between SRS (n = 20, mean = $76.6, 95% confidence interval [CI] = 50.7-115.6) and ATL (n = 18, mean = $79.0, 95% CI = 60.09-103.8). Indirect costs also did not differ. More ATL than SRS participants were free of consciousness-impairing seizures in each year of follow-up (all P < 0.05). Costs declined following ATL (P = 0.005). Costs tended to increase over the first 18 months following SRS (P = 0.17) and declined thereafter (P = 0.06). This mostly reflected hospitalizations for SRS-related adverse events in the second year of follow-up. SIGNIFICANCE: Lower initial costs of SRS for medial temporal lobe epilepsy were largely offset by hospitalization costs related to adverse events later in the course of follow-up. Future studies of less-invasive alternatives to ATL will need to assess adverse events and major costs systematically and prospectively to understand the economic implications of adopting these technologies.

Acute Assessment of Traumatic Brain Injury and Post-Traumatic Stress After Exposure to a Deployment-Related Explosive Blast.

Introduction: Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are two of the signature injuries in military service members who have been exposed to explosive blasts during deployments to Iraq and Afghanistan. Acute stress disorder (ASD), which occurs within 2-30 d after trauma exposure, is a more immediate psychological reaction predictive of the later development of PTSD. Most previous studies have evaluated service members after their return from deployment, which is often months or years after the initial blast exposure. The current study is the first large study to collect psychological and neuropsychological data from active duty service members within a few days after blast exposure. Materials and Methods: Recruitment for blast-injured TBI patients occurred at the Air Force Theater Hospital, 332nd Air Expeditionary Wing, Joint Base Balad, Iraq. Patients were referred from across the combat theater and evaluated as part of routine clinical assessment of psychiatric and neuropsychological symptoms after exposure to an explosive blast. Four measures of neuropsychological functioning were used: the Military Acute Concussion Evaluation (MACE); the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS); the Headminder Cognitive Stability Index (CSI); and the Automated Neuropsychological Assessment Metrics, Version 4.0 (ANAM4). Three measures of combat exposure and psychological functioning were used: the Combat Experiences Scale (CES); the PTSD Checklist-Military Version (PCL-M); and the Acute Stress Disorder Scale (ASDS). Assessments were completed by a deployed clinical psychologist, clinical social worker, or mental health technician. Results: A total of 894 patients were evaluated. Data from 93 patients were removed from the data set for analysis because they experienced a head injury due to an event that was not an explosive blast (n = 84) or they were only assessed for psychiatric symptoms (n = 9). This resulted in a total of 801 blast-exposed patients for data analysis. Because data were collected in-theater for the initial purpose of clinical evaluation, sample size varied widely between measures, from 565 patients who completed the MACE to 154 who completed the CES. Bivariate correlations revealed that the majority of psychological measures were significantly correlated with each other (ps ≤ 0.01), neuropsychological measures were correlated with each other (ps ≤ 0.05), and psychological and neuropsychological measures were also correlated with each other (ps ≤ 0.05). Conclusions: This paper provides one of the first descriptions of psychological and neuropsychological functioning (and their inter-correlation) within days after blast exposure in a large sample of military personnel. Furthermore, this report describes the methodology used to gather data for the acute assessment of TBI, PTSD, and ASD after exposure to an explosive blast in the combat theater. Future analyses will examine the common and unique symptoms of TBI and PTSD, which will be instrumental in developing new assessment approaches and intervention strategies.

Tailored Educational Approaches for Consumer Health: A Model to Address Health Promotion in an Era of Personalized Medicine.

PURPOSE: To develop a model, based on market segmentation, to improve the quality and efficiency of health promotion materials and programs. DESIGN: Market segmentation to create segments (groups) based on a cross-sectional questionnaire measuring individual characteristics and preferences for health information. Educational and delivery recommendations developed for each group. SETTING: General population of adults in Virginia. PARTICIPANTS: Random sample of 1201 Virginia residents. Respondents are representative of the general population with the exception of older age. MEASURES: Multiple factors known to impact health promotion including health status, health system utilization, health literacy, Internet use, learning styles, and preferences. ANALYSIS: Cluster analysis and discriminate analysis to create and validate segments. Common sized means to compare factors across segments. RESULTS: Developed educational and delivery recommendations matched to the 8 distinct segments. For example, the "health challenged and hard to reach" are older, lower literacy, and not likely to seek out health information. Their educational and delivery recommendations include a sixth-grade reading level, delivery through a provider, and using a "push" strategy. CONCLUSION: This model addresses a need to improve the efficiency and quality of health promotion efforts in an era of personalized medicine. It demonstrates that there are distinct groups with clearly defined educational and delivery recommendations. Health promotion professionals can consider Tailored Educational Approaches for Consumer Health to develop and deliver tailored materials to encourage behavior change.

The relationship between the Neuro-Quality of Life Depression and Anxiety Measures and the Personality Assessment Inventory in persons with epilepsy.

BACKGROUND: To investigate the associations between the Neuro-Quality of Life (NQOL) Depression and Anxiety measures with an objective emotional inventory (Personality Assessment Inventory; PAI), and demonstrate the clinical utility of the NQOL as screening measures for depression and anxiety in persons with epilepsy (PWE). METHODS: PWE (N=72) were concurrently administered the NQOL Depression and Anxiety measures and the PAI. Pearson product moment correlations were used to determine the relationships between the NQOL measures and the respective PAI scales (i.e., depression, anxiety). One-way ANOVAs were conducted comparing NQOL scores between patients with elevated levels of depression and anxiety (T-score≥65 on the PAI) to profiles that were within normal limits. Using sensitivity and specificity analyses, optimal cut-scores on the NQOL measures were determined. RESULTS: Participants were primarily Caucasian (89%), female (60%), and ~35 years old. The NQOL Depression measure was significantly correlated with the PAI Depression total score (r=.747; p<0.001) and its subscales (p's<0.001). Similarly, the NQOL Anxiety measure was significantly correlated with the PAI Anxiety total score (r=.750; p<0.001) and its subscales (p's<0.001). Compared to profiles that were within normal limits, individuals with elevated depressive symptoms on the PAI had significantly higher NQOL Depression scores (F(1,71)=48.2, p<0.001, d=1.6). Similarly, those who endorsed elevated anxiety on the PAI had significantly higher NQOL Anxiety scores (F(1,71)=32.2, p<0.001, d=1.5). Cut-off scores of 19 on the NQOL Depression and 24 on the NQOL Anxiety measures adequately detected depression (sensitivity=0.67; specificity=0.93; PPV=0.91; NPV=0.74) and anxiety symptoms (sensitivity=0.77; specificity=0.82; PPV=0.81; NPV=0.78) in PWE. CONCLUSIONS: The NQOL Depression and Anxiety measures evidenced strong associations with the PAI Depression and Anxiety scales and may be effective in detecting depressive and anxiety symptoms in PWE using the provided cut-scores.

Baseline SCAT2 Assessment of Healthy Youth Student-Athletes: Preliminary Evidence for the Use of the Child-SCAT3 in Children Younger Than 13 Years.

OBJECTIVE: To compare baseline scores of middle and high school students on the Sport Concussion Assessment Tool 2 (SCAT2) by sex and age. DESIGN: Cross-sectional study. SETTING: Single private school athletic program. PARTICIPANTS: Three hundred sixty-one middle and high school student-athletes. INTERVENTION: Preseason SCAT2 was administered to student-athletes before athletic participation. MAIN OUTCOME MEASURES: Total SCAT2 score, symptoms, symptom severity, Glasgow coma scale, modified Balance Error Scoring System (BESS), coordination, and Standardized Assessment of Concussion (SAC) with subsections: Orientation, Immediate Memory, Concentration, and Delayed Recall. RESULTS: No differences were found in total SCAT2 scores between sex (P = 0.463) or age (P = 0.21). Differences were found in subcomponents of the SCAT2. Twelve year olds had significantly lower concentration scores (3.3 ± 1.2) than 15 and 18 year olds (3.9 ± 1.0 and 4.2 ± 1.0, respectively). The 12 year olds also had the lowest percentage of correct responses for the SAC's concentration 5-digit (46%), 6-digit (21%), and months' backward (67%) tasks. Females presented with more symptoms (20.0 ± 2.2 vs. 20.6 ± 2.1 P = 0.007) better immediate memory (14.6 ± 0.9 vs. 14.3 ± 1.0, P = 0.022) and better BESS scores (27.2 ± 2.3 vs. 26.6 ± 2.6, P = 0.043) than their male counterparts. CONCLUSIONS: Normative values for total SCAT2 and subscale scores show differences in concentration between ages, whereas symptoms, BESS, and immediate memory differed between sexes. We also found that 12 year olds have increased difficultly with the advanced concentration tasks, which lends support to the development of a separate instrument, such as the Child-SCAT3. The presence of developmental differences in the younger age groups suggests the need for annual baseline testing. CLINICAL RELEVANCE: Subtle differences between age and sex have been identified in many components of the SCAT2 assessment. These differences may support the current evolution of concussion assessment tools to provide the most appropriate test. Baseline testing should be used when available, and clinicians should be aware of potential differences when using normalized values.

Sports concussion assessment and management: future research directions.

Over the past 2 decades, major progress has been achieved toward advancing the translational science of sport-related concussion (SRC), paving the way for evidence-based guidelines for injury diagnosis, evaluation and management. Several key empirical questions on the basic and clinical science of SRC, however, remain unanswered. The aim of this summary article is to highlight gaps in the existing science of SRC and to propose a platform for the next generation of SRC research. The article is framed around addressing two key questions that have major significance to protecting the health and safety of athletes affected by SRC, including: (a) Who is at risk of slow recovery or poor outcome after SRC, and why? (b) How does one modify the risks of slow recovery and poor outcome after SRC? Another aim of this article is to stimulate thought among researchers who will carry the science of SRC into the future, including neuropsychology leaders in the field. Implications for the broader science of traumatic brain injury are also discussed.

Role of neuropsychologists in the evaluation and management of sport-related concussion: an inter-organization position statement.

Over the past 20 years, clinical neuropsychologists have been at the forefront of both scientific and clinical initiatives aimed at developing evidence-based approaches to the evaluation and management of sport-related concussion (SRC). These efforts have directly impacted current policy on strategies for injury assessment and return-to-play by athletes after concussion. Many states are considering legislation requiring (a) education of athletes, parents, coaches, and school/organization officials on the recognition, evaluation, and management of SRCs; (b) removal from play of any youth athlete that is suspected of having sustained a concussion; and (c) not allowing the student to return to participation until the student is evaluated and cleared for return to participation in writing by an appropriate healthcare professional. It is the official position of the American Academy of Clinical Neuropsychology (AACN), American Board of Professional Neuropsychology (ABN), Division 40 (Neuropsychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN) that neuropsychologists should be included among the licensed healthcare professionals authorized to evaluate, clinically manage, and provide return to play clearance for athletes who sustain a SRC.

Symptom-based assessment of the severity of a concussion.

OBJECT: Current grading systems of concussion and return-to-play guidelines have little empirical support. The authors therefore examined the relationships of the characteristics and symptoms of concussion and the history of concussion to three indicators of concussion severity-number of immediate symptoms, number of symptoms at the initial follow-up examination, and duration of symptoms--to establish an empirical basis for grading concussions. METHODS: Forty-seven athletes who sustained concussions were administered alternate forms of an Internet-based neurocognitive test until their performances were within normal limits relative to baseline levels. Assessments of observer-reported and self-reported symptoms at the sideline of the playing field on the day of injury, and at follow-up examinations were also obtained as part of a comprehensive concussion management protocol. Although loss of consciousness (LOC) was a useful indicator of the initial severity of the injury, it did not correlate with other indices of concussion severity, including duration of symptoms. Athletes reporting memory problems at follow-up examinations had significantly more symptoms in general, longer durations of those symptoms, and significant decreases in scores on neurocognitive tests administered approximately 48 hours postinjury. This decline of scores on neurocognitive testing was significantly associated with an increased duration of symptoms. A history of concussion was unrelated to the number and duration of symptoms. CONCLUSIONS: This paper represents the first documentation of empirically derived indicators of the clinical course of postconcussion symptom resolution. Self-reported memory problems apparent 24 hours postconcussion were robust indicators of the severity of sports-related concussion and should be a primary consideration in determining an athlete's readiness to return to competition. A decline on neurocognitive testing was the only objective measure significantly related to the duration of symptoms. Neither a brief LOC nor a history of concussion was a useful predictor of the duration of postconcussion symptoms.