Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement.

Selected Issues in Sport-Related Concussion (SRC|Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus documents written for the practicing team physician. This document provides an overview of selected medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement.

ABSTRACT: Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus articles written for the practicing team physician. This document provides an overview of select medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

International consensus definitions of video signs of concussion in professional sports.

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

International study of video review of concussion in professional sports.

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

National Football League Head, Neck and Spine Committee's Concussion Diagnosis and Management Protocol: 2017-18 season.

One of the National Football League's (NFL) Head, Neck and Spine Committee's principal goals is to create a 'best practice' protocol for concussion diagnosis and management for its players. The science related to concussion diagnosis and management continues to evolve, thus the protocol has evolved contemporaneously. The Fifth International Conference on Concussion in Sport was held in Berlin in 2016, and guidelines for sports concussion diagnosis and management were revised and refined. The NFL Head, Neck and Spine Committee has synthesised the most recent empirical evidence for sports concussion diagnosis and management including the Berlin consensus statement and tailored it to the game played in the NFL. One of the goals of the Committee is to provide a standardised, reliable, efficient and evidence-based protocol for concussion diagnosis and management that can be applied in this professional sport during practice and game day. In this article, the end-of-season version of the 2017-18 NFL Concussion Diagnosis and Management Protocol is described along with its clinical rationale. Immediate actions for concussion programme enhancement and research are reviewed. It is the Committee's expectation that the protocol will undergo refinement and revision over time as the science and clinical practice related to concussion in sports crystallise.

What domains of clinical function should be assessed after sport-related concussion? A systematic review.

BACKGROUND: Sport-related concussion (SRC) is a clinical diagnosis made after a sport-related head trauma. Inconsistency exists regarding appropriate methods for assessing SRC, which focus largely on symptom-scores, neurocognitive functioning and postural stability. DESIGN: Systematic literature review. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, Cochrane-DSR, Cochrane CRCT, CINAHL, SPORTDiscus (accessed July 9, 2016). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Original (prospective) studies reporting on postinjury assessment in a clinical setting and evaluation of diagnostic tools within 2 weeks after an SRC. RESULTS: Forty-six studies covering 3284 athletes were included out of 2170 articles. Only the prospective studies were considered for final analysis (n=33; 2416 athletes). Concussion diagnosis was typically made on the sideline by an (certified) athletic trainer (55.0%), mainly on the basis of results from a symptom-based questionnaire. Clinical domains affected included cognitive, vestibular and headache/migraine. Headache, fatigue, difficulty concentrating and dizziness were the symptoms most frequently reported. Neurocognitive testing was used in 30/33 studies (90.9%), whereas balance was assessed in 9/33 studies (27.3%). SUMMARY/CONCLUSIONS: The overall quality of the studies was considered low. The absence of an objective, gold standard criterion makes the accurate diagnosis of SRC challenging. Current approaches tend to emphasise cognition, symptom assessment and postural stability with less of a focus on other domains of functioning. We propose that the clinical assessment of SRC should be symptom based and interdisciplinary. Whenever possible, the SRC assessment should incorporate neurological, vestibular, ocular motor, visual, neurocognitive, psychological and cervical aspects.

Use of Publicly Obtained Data in Sports Medicine Research: A Systematic Review and Bibliometric Analysis.

BACKGROUND: Publicly obtained data (POD) have recently been utilized frequently by sports medicine researchers to describe injury patterns, risk factors, and outcomes in elite athletes. The relative ease of this type of research that is based solely on internet and media sources has resulted in a near exponential increase in the number of these POD studies. PURPOSE: To systematically review the sports medicine literature for studies based solely on POD. STUDY DESIGN: Systematic review and bibliometric analysis; Level of evidence, 4. METHODS: A systematic review of POD studies published since 2000 was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies of interest were those relying on publicly available injury reports or online media for data acquisition in collegiate, semiprofessional, and professional athletes. RESULTS: There were 209 POD studies published between 2000 and 2022, with 173 (82.8%) of these studies published after 2016. Studies were published most frequently on athletes participating in North American professional leagues: National Football League (n = 69 [28.4%]), Major League Baseball (n = 56 [23.0%]), National Basketball Association (n = 37 [15.2%]), and National Hockey League (n = 33 [13.6%]). The most common injuries assessed were head injuries/concussions (n = 43 [21.1%]), anterior cruciate ligament injuries (n = 33 [16.2%]), and ulnar collateral ligament injuries (n = 23 [11.3%]). One-quarter of the studies (n = 53 [25.4%]) reported only 1 POD source, and 1 study (0.5%) reported no source. Additionally, 65 studies (31.1%) listed nonspecific POD resources or solely cited previous literature to describe the POD search methodology and data acquisition. CONCLUSION: POD studies are exponentially increasing in number, particularly across major North American professional sports leagues, with significant variability in the injury of interest, search methodology, and number of data sources. The accuracy of the conclusions reached based on the POD methodology appears highly variable. Given the potential impact of these publications as both contributors to current knowledge and drivers of future research, the sports medicine community should be aware of the inherent biases and limitations of POD injury studies.

Validity of Research Based on Publicly Obtained Data in Sports Medicine: A Quantitative Assessment of Concussions in the National Football League.

CONTEXT: Numerous researchers have leveraged publicly available internet sources to publish clinical research concerning incidence and recovery from injuries in National Football League (NFL) players. OBJECTIVE: This study aims to (1) provide a comprehensive systematic review of all publicly obtained data studies (PODS) regarding concussions in NFL athletes and (2) quantify the percentage of injuries identified by these studies in comparison with published concussion data from the NFL injury database. STUDY SELECTION: A systematic review was conducted in accordance with PRISMA guidelines to identify all published studies utilizing publicly obtained data regarding concussions in NFL athletes. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Manuscript details, factors related to the athletes of interest (eg, study period, positions included), and results (eg, concussion rate, number of total concussions, return-to-play data) were extracted independently by 2 authors. Results were compared with incident concussions reported from 2015 to 2019 by each medical staff member to the NFL database linked to the League's electronic health record (EHR). RESULTS: A total of 20 concussion-focused manuscripts based on PODS were identified from 2014 to 2020. PODS captured between 20% and 90% of concussions (mean, 70%) reported by medical staff to the injury database. PODS reported that 55% of concussions occurred on offensive plays, 45% on defensive plays and <1% occurred during special teams plays, compared with 44%, 37%, and 18%, respectively, as indicated by published data from the NFL injury database. When analyzed by position groups, running backs and quarterbacks comprised the most over-represented positions concussed in PODS, while offensive linemen, defensive backs, and linebackers comprised the most under-represented positions. CONCLUSION: PODS captured approximately 70% of concussions reported by NFL medical staff to the NFL injury database. There is heterogeneity in the degree to which PODS were able to identify concussions, with a bias toward concussions among players at higher profile positions.

Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League.

BACKGROUND: Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players. PURPOSE: To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams' medical staff to the NFL Injury Surveillance System database linked to the League's electronic health record. An ACL "capture rate" for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest. RESULTS: A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams' medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play. CONCLUSION: The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.

Disseminated superficial porokeratosis.

A 62-year-old woman with psoriasis and psoriatic arthritis presented for evaluation and treatment of a one-week history of pruritic, pink spots on her trunk and extremities. Several weeks prior, therapy with certolizumab pegol and methotrexate was started for her psoriatic arthritis. A biopsy specimen was consistent with the diagnosis of porokeratosis. Owing to the setting of immunosuppression and presence of symmetric pruritic lesions on non-sun exposed areas, the diagnosis of disseminated superficial porokeratosis was made.

Concussion Guidelines in National and International Professional and Elite Sports.

The Berlin statement on sport-related concussion was published in 2017 using evidence-based recommendations. We aimed to examine (1) the implementation of, distribution and education based on the Berlin recommendations, and the development of sport-specific protocols/guidelines among professional and elite sports, (2) the implementation of guidelines at the community level, (3) translation of guidelines into different languages, and (4) research activities. Senior medical advisers and chief medical officers from Australian Football League, All Japan Judo Federation, British Horseracing Authority, Cricket Australia, Fédération Equestre Internationale, Football Association, Gaelic Athletic Association, International Boxing Association, Irish Horseracing Regulatory Board, Major League Baseball, National Football League, National Hockey League, National Rugby League, and World Rugby completed a questionnaire. The results demonstrated that all 14 sporting organizations have published concussion protocols/guidelines based on the Berlin recommendations, including Recognize, Removal from play, Re-evaluation, Rest, Recovery, and Return to play. There is variable inclusion of Prolonged symptoms. Prevention and Risk reduction and Long-term effects are addressed in the guidelines, rules and regulations, and/or sport-specific research. There is variability in education programs, monitoring compliance with guidelines, and publication in other languages. All sporting bodies are actively involved in concussion research. We conclude that the Berlin recommendations have been included in concussion protocols/guidelines by all the sporting bodies, with consistency in the essential components of the recommendations, whilst also allowing for sport- and regional-specific variations. Education at the elite, community, and junior levels remains an ongoing challenge, and future iterations of guidelines may consider multiple language versions, and community- and junior-level guidelines.

Sport-related concussive convulsions: a systematic review.

OBJECTIVES: The incidence of sport-related concussion (SRC) continues to rise. Presentations of concussed athletes vary from subtle symptoms to notable signs. Between the 4th and 5th iterations of the Concussion in Sport Group (CISG) guidelines, concussive convulsions were removed as a modifying factor, but little evidence or discussion supported this change. While considerable research exists regarding post-traumatic epilepsy in moderate to severe traumatic brain injury, convulsions following SRC are relatively understudied. There is no clear consensus on the prevalence of convulsions, seizures, or the management of these entities following SRC. The aim of this review was to assess the state of the literature, describe the management trends of concussive convulsions and post-traumatic epilepsy in the SRC population, and provide evidence and guidance for the management of these athletes. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adapted for a review of heterogeneous literature. English-language titles and abstracts published prior to June 2017 were searched systematically across four electronic databases. Primary peer-reviewed journal articles were included if they reported individuals of any age or gender who suffered a concussion or mild traumatic brain injury that was associated with seizure activity during a sports/recreational event. RESULTS: Of 852 records screened for review, 58 full-text articles were assessed for eligibility. Eight studies with 130 athletes total met the inclusion criteria. Of these individuals suffering a SRC convulsion or a post-concussive seizure, 0.8% received antiepileptic medications, 24.6% underwent electroencephalography, and 30.8% underwent brain imaging. The mean time until the participant returned to play was 14.8 days. Only 6.9% developed long-term sequelae over a mean follow-up time of 3.3 years. CONCLUSIONS: The current literature describing concussive convulsions and post-concussion seizure in sports is limited. A void of primary literature concerning the management of patients with concussive convulsions or seizures and the long-term sequelae among this population remains. However, the evidence available suggests that concussive convulsions do not need to be a primary modifying factor in the management of SRC.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.

BACKGROUND: Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE: To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS: On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS: A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION: Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS: ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

Talking with parents of high school football players about chronic traumatic encephalopathy: a concise summary.

Over the past decade, athletic-related chronic traumatic encephalopathy (CTE) has garnered a great deal of attention in the popular press and, more recently, in the scientific press. With increasing frequency, sports medicine practitioners and providers are faced with questions from the parents of high school football players about CTE and the risk posed to children who participate in this or other contact or collision sports. The purpose of this review was to summarize the research on CTE in an attempt to provide some evidence-based answers to frequently asked questions in clinics from parents. Addressed are (1) the definitions of CTE and its symptoms, (2) the evidence for CTE in football, (3) abnormal tau protein, (4) the use of neuroimaging in CTE diagnosis, (5) risk for CTE, (6) CTE diagnosis in youth, (7) CTE and its relationship to suicide, and (8) contact and collision sports as a risk factor for permanent brain injury or death.

Supervision and computerized neurocognitive baseline test performance in high school athletes: an initial investigation.

CONTEXT: Computerized neuropsychological testing batteries have provided a time-efficient and cost-efficient way to assess and manage the neurocognitive aspects of patients with sport-related concussion. These tests are straightforward and mostly self-guided, reducing the degree of clinician involvement required by traditional clinical neuropsychological paper-and-pencil tests. OBJECTIVE: To determine if self-reported supervision status affected computerized neurocognitive baseline test performance in high school athletes. DESIGN: Retrospective cohort study. SETTINGS: Supervised testing took place in high school computer libraries or sports medicine clinics. Unsupervised testing took place at the participant's home or another location with computer access. PATIENTS OR OTHER PARTICIPANTS: From 2007 to 2012, high school athletes across middle Tennessee (n = 3771) completed computerized neurocognitive baseline testing (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]). They reported taking the test either supervised by a sports medicine professional or unsupervised. These athletes (n = 2140) were subjected to inclusion and exclusion criteria and then matched based on age, sex, and number of prior concussions. MAIN OUTCOME MEASURE(S): We extracted demographic and performance-based data from each de-identified baseline testing record. Paired t tests were performed between the self-reported supervised and unsupervised groups, comparing the following ImPACT baseline composite scores: verbal memory, visual memory, visual motor (processing) speed, reaction time, impulse control, and total symptom score. For differences that reached P < .05, the Cohen d was calculated to measure the effect size. Lastly, a χ(2) analysis was conducted to compare the rate of invalid baseline testing between the groups. All statistical tests were performed at the 95% confidence interval level. RESULTS: Self-reported supervised athletes demonstrated better visual motor (processing) speed (P = .004; 95% confidence interval [0.28, 1.52]; d = 0.12) and faster reaction time (P < .001; 95% confidence interval [-0.026, -0.014]; d = 0.21) composite scores than self-reported unsupervised athletes. CONCLUSIONS: Speed-based tasks were most affected by self-reported supervision status, although the effect sizes were relatively small. These data lend credence to the hypothesis that supervision status may be a factor in the evaluation of ImPACT baseline test scores.