Comparison of Urban versus Industry Normative Values of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT™).

Concussion baseline testing has been advocated for the assessment of pre-morbid function. When individual baseline scores are unavailable, utilizing normative values is recommended. However, the validity of generalizing normative data across multiple socioeconomic environments is unknown. OBJECTIVE: mimic the normative data creation of ImPACT™ to examine the effect of socioeconomic status (SES) on ImPACT™ composite scores. METHODS: A retrospective cross-sectional design analyzed completed computerized neuropsychological test data (ImPACT™) obtained to establish the baseline scores of cognitive function from males aged 13-15 years (n = 300) and 16-18 years (n = 331) from an urban high school system. Comparisons between baseline scores and normative ImPACT™ values were calculated utilizing t-tests with ImPACT™ composite scores serving as dependent variables. RESULTS: significant differences between age-dependent urban composite scores and ImPACT™ normative values for 13-15- and 16-18-year-olds were found for Composite Verbal Memory, Composite Visual Memory, Composite Motor and Composite Reaction Time (p < 0.01). CONCLUSIONS: Significant differences exist between urban high school athletes and ImPACT™-provided age-dependent normative scores, with urban participants performing below age-dependent normative values. These findings support establishing SES appropriate normative values when baseline test scores are not available for direct comparison in order to provide better evaluation and post-concussion management across diverse populations.

The Effect of Social Determinants of Health on Clinical Recovery Following Concussion: A Systematic Review.

CONTEXT: Concussion evaluations include a multifaceted approach; however, individual differences can influence test score interpretations and validity. Social determinants of health (SDoH) differentially affect disease risk and outcomes based upon social and environmental characteristics. Efforts to better define, diagnose, manage, and treat concussion have increased, but minimal efforts have focused on examining SDoH that may affect concussion recovery. OBJECTIVE: This review examined previous research that examined the effect of SDoH on concussion recovery of athletes. EVIDENCE ACQUISITION: CINAHL, MEDLINE, PsycInfo, and SPORTDiscus databases were used to search the terms "concussion" AND "recovery," "youth, adolescent, teen and/or adult," and "social determinants of health" and variations of these terms. The evidence level for each study was evaluated using the 2011 Oxford Center for Evidence-Based Medicine Guide. EVIDENCE SYNTHESIS: Seven thousand nine hundred and twenty-one articles were identified and screened for inclusion. Five studies met the inclusion criteria and were included in this systematic review. Using the Downs and Black Quality Index, the studies included in this review were deemed high quality. CONCLUSION: Though limited literature exists, there is preliminary evidence to suggest that SDoH (specifically, economic stability, education access and quality, and social and community context) may have an impact on the clinical recovery from concussion. The dimensions evaluated varied between studies and the results were inconsistent. No single factor consistently affected clinical recovery; however, private insurance and race appear to have an association with the speed of recovery. Unfortunately, the potential intersection of these variables and other preinjury factors limits the ability to make clear recommendations. While most of the studies in this review are retrospective in nature, future efforts should focus on training clinicians to prospectively evaluate the effect of SDoH on concussion recovery and injury outcomes. Funding and registration for this systematic review were not obtained nor required.

Postinjury Outcomes After Non-Sport-Related Concussion: A CARE Consortium Study.

CONTEXT: Concussion research has primarily focused on sport-related mechanisms and excluded non-sport-related mechanisms. In adult populations, non-sport-related concussions (non-SRCs) demonstrated worse clinical outcomes compared with sport-related concussions (SRCs); however, investigations of non-SRCs in college-aged patients are limited. OBJECTIVES: To examine clinical outcomes in collegiate athletes with non-SRCs compared with SRCs and explore sex differences in outcomes among collegiate athletes with non-SRCs. DESIGN: Prospective cohort study. SETTING: Clinical setting. PATIENTS OR OTHER PARTICIPANTS: A total of 3500 athletes were included (n = 555 with non-SRCs, 42.5% female) from colleges or universities and service academies participating in the National Collegiate Athletic Association Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. MAIN OUTCOME MEASURE(S): Dichotomous outcomes (yes or no) consisted of immediate reporting, mental status alterations, loss of consciousness, posttraumatic amnesia, retrograde amnesia, motor impairments, delayed symptom presentation, and required hospital transport. Continuous outcomes were symptom severity, days with concussion symptoms, and days lost to injury. Data were collected within 24 to 48 hours of injury and at return to play. Adjusted relative risks (ARRs) compared the likelihood of dichotomous outcomes by mechanism and by sex within patients with non-SRCs. Multivariate negative binomial regressions were used to assess group differences in continuous variables. RESULTS: Athletes with non-SRCs were less likely to report immediately (ARR = 0.73, 95% CI = 0.65, 0.81) and more likely to report delayed symptom presentation (ARR = 1.17, 95% CI = 1.03, 1.32), loss of consciousness (ARR = 3.15, 95% CI = 2.32, 4.28), retrograde amnesia (ARR = 1.77, 95% CI = 1.22, 2.57), and motor impairment (ARR = 1.45, 95% CI = 1.14, 1.84). Athletes with non-SRCs described greater symptom severity, more symptomatic days, and more days lost to injury (P < .001) compared with those who had SRCs. Within the non-SRC group, female athletes indicated greater symptom severity, more symptomatic days, and more days lost to injury (P < .03) than male athletes. CONCLUSIONS: Athletes with non-SRCs had worse postinjury outcomes compared with those who had SRCs, and female athletes with non-SRCs had worse recovery metrics than male athletes. Our findings suggest that further investigation of individuals with non-SRCs is needed to improve concussion reporting and management.

Sex Differences in Recovery Trajectories of Assessments for Sport-Related Concussion Among NCAA Athletes: A CARE Consortium Study.

OBJECTIVES: The purpose of this study was to determine sex differences in recovery trajectories of assessments for sport-related concussion using Concussion Assessment, Research and Education (CARE) Consortium data. METHODS: National Collegiate Athletic Association athletes (N = 906; 61% female) from sex-comparable sports completed a pre-season baseline assessment and post-sport-related concussion assessments within 6 h of injury, 24-48 h, when they initiated their return to play progression, when they were cleared for unrestricted return to play, and 6 months post-injury. Assessments included the Standardized Assessment of Concussion, Balance Error Scoring System, Brief Symptom Inventory-18, Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Sport Concussion Assessment Tool-3 symptom evaluation, Clinical Reaction Time, King-Devick test, Vestibular Ocular Motor Screen, 12-item Short-Form Health Survey, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale. RESULTS: Only the Vestibular Ocular Motor Screen Total Symptom Score at the 24-48 h timepoint (p = 0.005) was statistically significantly different between sexes. Specifically, female athletes (mean = 60.2, 95% confidence interval [CI] 51.5-70.4) had higher Vestibular Ocular Motor Screen Total Symptom Scores than male athletes (mean = 36.9, 95% CI 27.6-49.3), but this difference resolved by the time of return-to-play initiation (female athletes, mean = 1.8, 95% CI 1.1-2.9; male athletes, mean = 4.1, 95% CI 1.5-10.9). CONCLUSIONS: Sport-related concussion recovery trajectories for most assessments were similar for female and male National Collegiate Athletic Association athletes except for Vestibular Ocular Motor Screen symptoms within 48 h of sport-related concussion, which was greater in female athletes. Female athletes had a greater symptom burden across all timepoints, suggesting that cross-sectional observations may indicate sex differences despite similar recovery trajectories.

Initial Mild Traumatic Brain Injury Characteristics and Recovery Patterns Among Females Across the United States Military Service Academies: A Report from the NCAA-DoD CARE Consortium.

Mild traumatic brain injury (mTBI) has been described in the United States (US) military service academy cadet population, but female-specific characteristics and recovery outcomes are poorly characterized despite sex being a confounder. Our objective was to describe female cadets' initial characteristics, assessment performance, and return-to-activity outcomes post-mTBI. Female cadets (n = 472) from the four US military service academies who experienced a mTBI completed standardized mTBI assessments from pre-injury to acute initial injury and unrestricted return-to-duty (uRTD). Initial injury presentation characteristics (e.g., delayed symptoms, retrograde amnesia) and return-to-activity outcomes [i.e., return-to-learn, initiate return-to-duty protocol (iRTD), uRTD] were documented. Descriptive statistics summarized female cadets' injury characteristics, return-to-activity outcomes, and post-mTBI assessment performance change categorization (worsened, unchanged, improved) relative to pre-injury baseline using established change score confidence rank criteria for each assessment score. The median (interquartile range) days to return-to-learn (n = 157) was 7.0 (3.0-14.0), to iRTD (n = 412) was 14.7 (8.6-25.8), and to uRTD (n = 431) was 26.0 (17.7-41.8). The majority experienced worse SCAT total symptom severity (77.8%) and ImPACT reaction time (97.0%) acutely < 24-h versus baseline, but unchanged BESS total errors (75.2%), SAC total score (72%), BSI-18 total score (69.6%), and ImPACT verbal memory (62.3%), visual memory (58.4%), and visual motor speed (52.5%). We observed similar return-to-activity times in the present female cadet cohort relative to the existing female-specific literature. Confidence ranks categorizing post-mTBI performance were heterogenous and indicate multimodal assessments are necessary. Our findings provide clinically relevant insights to female cadets experiencing mTBI across the US service academies for stakeholders providing healthcare.

The Influence of Athletic Identity on Mental Health Symptoms During Retirement From Sport.

CLINICAL SCENARIO: Athletic identity (AI) can be defined as, "the degree to which an individual identifies with an athlete role, and the values, and social networks associated with that identity," and can pose a problem when athletes do not explore themselves outside of sport. This lack of identity development beyond athletics has the potential to lead to the development of a high AI. High AI in athletes can have positive effects in areas such as performance, however, high AI may also pose negative consequences. The development of such an identity can limit the adaptive responses to substantial life changes such as retirement from sport. This inability to adapt may thereby contribute to mental health problems during the transition. Therefore, the purpose of this study is to better understand the relationship between athletic identity and mental health symptoms so clinicians may provide support to enable positive outcomes after retirement from sport. CLINICAL QUESTION: What is the influence of athletic identity on mental health symptoms in athletes retiring from sports? SUMMARY OF KEY FINDINGS: (1) High athletic identity contributes to increased mental health symptoms following retirement. (2) Athletic identity had no relationship to mental health symptoms during the preretirement phase of an athlete's career Clinical Bottom Line: The findings suggest that there is high-quality evidence to support that AI has no relationship with mental health symptoms during the preretirement phase and that athletes with high AI are more likely to experience mental health symptoms during their transition out of or retirement from sport. STRENGTH OF RECOMMENDATION: The grade of B is recommended by the Strength of Recommendation taxonomy for consistent, limited-quality, patient-oriented evidence that high AI has a strong relationship to mental health symptoms following retirement in athletes.

Concussion education for youth athletes using Pre-Game Safety Huddles: a cluster-randomised controlled trial.

OBJECTIVES: Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes. METHODS: A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9-14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season. RESULTS: Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen's d=0.35). CONCLUSIONS AND RELEVANCE: Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting. TRIAL REGISTRATION NUMBER: NCT04099329.

Stakeholder-Engaged Development of a Theory-Driven, Feasible, and Acceptable Approach to Concussion Education.

Concussion education is widely mandated and largely ineffective. Recent consensus guidance on concussion education asserts the importance of (1) theory-driven programming that targets the team as a system and (2) working with end users throughout the development process, and considering issues such as feasibility, acceptability, and sustainability. Consistent with this guidance, and in collaboration with youth sport stakeholders in two regions of the United States, we developed a novel approach to concussion education: Pre-game safety huddles. Safety huddles have the following two core components: (1) athletes, coaches, and other stakeholders come together before the start of each game and (2) opinion leaders (coaches, referees) affirm the importance of care seeking for suspected concussion. The aim of this article is to provide an overview of the collaborative process through which we refined the safety huddle concept into an acceptable and feasible intervention with potential for sustainable implementation in diverse youth sports settings with minimal resource demands. In describing our process and discussing challenges and opportunities, we hope to provide an example for others seeking to develop and implement injury prevention interventions in youth sports settings.

Development of a scale to measure expected concussion reporting behavior.

BACKGROUND: Most concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes. METHODS: A mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9-16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155). RESULTS: Internal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to "always" tell their coach about symptoms of a suspected concussion. CONCLUSIONS: The CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.

Increasing the Availability of Automated External Defibrillators at Sporting Events: A Call to Action from the American College of Sports Medicine.

ABSTRACT: Given that most sudden cardiac arrests (SCAs) occur outside of a medical facility, often in association with exercise and sporting events, and given that early cardiopulmonary resuscitation (CPR) plus defibrillation is the strongest predictor of survival from SCA, this Call to Action from the American College of Sports Medicine recommends increasing the availability and effectiveness of early CPR plus defibrillation so that the time from collapse-to-first automated external defibrillator shock is less than 3 min.

Factors Influencing Concussion Reporting Intention in Adolescent Athletes.

Clinical Scenario: Concussions are severely underreported, with only 47.3% of high school athletes reporting their concussion. The belief was that athletes who were better educated on the signs and symptoms and potential dangers of concussion would be more likely to report. However, literature has shown inconsistent evidence on the efficacy of concussion education, improving reporting behaviors. Factors such as an athlete's attitude, subjective norms, and perceived behavioral control have shown promise in predicting intention to report concussions in athletes. Focused Clinical Question: Do attitudes, subjective norms, and perceived behavioral control influence adolescent athletes' intention to report? Summary of Key Findings: Three studies (1 randomized control and 2 cross-sectional surveys) were included. Across the 3 studies, attitudes, subjective norms, and perceived behavioral control positively influenced athletes' reporting intention. The studies found that attitude toward concussion reporting and perceived behavioral control were the most influential predictors of reporting intention. Clinical Bottom Line: There is moderate evidence to suggest that positive attitudes, supportive subjective norms, and increased perceived behavioral control influence reporting intention in secondary school athletes. Strength of Recommendation: Grade B evidence exists that positive attitudes, supportive subjective norms, and increased perceived behavioral control positively influence concussion reporting intention in secondary school athletes.

Does Anxiety Affect Neuropsychological Assessment in College Athletes?

Clinical Scenario: Anxiety is a mental disorder that affects a large portion of the population and may be problematic when evaluating brain injuries such as concussion. The reliance of cognitive testing in concussion protocols call for the examination of potential cognitive alterations commonly seen in athletes with anxiety. Focused Clinical Question: Does anxiety affect neuropsychological assessments in healthy college athletes? Summary of Key Findings: Three studies were included: 1 cross-sectional study and 2 prospective cohort studies. One study examined the effect of a range of psychological issues on concussion baseline testing in college athletes. Another study examined the effect of anxiety on reaction time both before and after sport competition in college-aged athletes. The final study examined the effects of psychosocial issues on reaction time during demanding tasks in college athletes. The first study reported slower simple and complex reaction times in athletes with anxiety. The second study found that athletes with high trait anxiety have slower reaction times both before and after competition. The third study reported that demanding tasks led to increased state anxiety which slowed reaction time. Overall, all 3 studies support the adverse effect anxiety can have on cognitive testing in athletes. Clinical Bottom Line: College athletes who present with anxiety at baseline may be susceptible to decreased performance on neuropsychological assessments. Strength of Recommendation: There is level B evidence that anxiety in healthy college athletes can impact neuropsychological assessments, and level C evidence that anxiety at baseline concussion assessment impacts neuropsychological testing in college athletes.

The effect of acute pain on executive function.

BACKGROUND AND AIM: Executive functions are high-level cognitive processes that allow a person to success-fully engage in an independent and self-fulfilling life. Previous literature indicates that chronic pain can affect executive function, but there are limited studies that investigate the effect of acute pain on executive function. The purpose of this study was to determine if acute pain affects executive function in recreationally active indi-viduals who sustained a musculoskeletal injury. METHODS: Twenty-four recreationally active participants who presented with acute pain following a muscu-loskeletal injury underwent a neuropsychological battery within 72 hours of injury. Follow up testing occurred within two weeks from the initial testing session when participants were pain free. Pain intensity was measured using the Visual Analog Scale (VAS). The neuropsychological battery consisted of the following tests: Digit Span (DS), Rey Auditory Verbal Learning Test (RAVLT), and Trail Making Test B (TMT-B). The DS was bro-ken into two separate scores, the RAVLT four scores, and TMT-B one score. Seven paired samples t-tests were conducted using an adjusted alpha level of 0.007. RESULTS: Participants had significantly improved scores when pain free in DS forwards (p < 0.007) and TMT-B (p < 0.007). No significant difference was observed for the DS backward (p = 0.023), RAVLT A1 (p = 0.563), RAVLT sum A1 to A5 (p = 0.953), RAVLT A6 (p = 1.0), RAVLT recognition list A (p = 0.009). These results suggest that immediate recall and complex attention may be diminished in individ-uals who experience acute pain due to a musculoskeletal injury. CONCLUSIONS: Results from this study suggest acute pain from musculoskeletal injuries may disrupt executive function. RELEVANCE FOR PATIENTS: Patients should be aware that there may be cognitive changes after a musculoskeletal injury. Knowing which cognitive domains may be impaired during acute pain could impact clinical practice and further benefit patients suffering from pain and its associated symptoms.

An Examination of Adolescent Athletes and Nonathletes on Baseline Neuropsychological Test Scores.

CONTEXT: An estimated 15.3 million adolescent students are enrolled in US high schools, with approximately 7.8 million participating in athletics. Researchers have examined various demographics in high school athletes; however, athletic participation may play a larger role in test performance than previously thought. Currently, investigations of concussion assessment may rely on uninjured athletes as controls. However, due to the intense nature of athletics, this may not be an appropriate practice. OBJECTIVE: To examine differences between athletes and nonathletes using a common computerized neuropsychological test. DESIGN: Retrospective cross-sectional study. SETTING: High schools from a school district in Columbus, Ohio. PATIENTS OR OTHER PARTICIPANTS: A total of 662 adolescent high school students (athletes: n = 383, female n = 18; nonathletes: n = 279, female n = 193). MAIN OUTCOME MEASURE(S): Participants were administered a computerized neuropsychological test battery (Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]) during baseline concussion assessment. Differences between groups were established for output composite scores. RESULTS: Differences were found between athletes and nonathletes in composite reaction time ( F1,522 = 14.855, P < .001) and total symptom score ( F1,427 = 33.770, P < .001). Nonathletes reported more symptoms, whereas athletes had faster reaction times. No differences were present in composite verbal memory, composite visual memory, composite visual motor speed, or composite impulse control ( P > .05). CONCLUSIONS: Symptom reporting and reaction time differed between high school athletes and nonathletes. Participation in extracurricular activities may lead to cognitive differences in adolescents that can influence performance on the Immediate Post-Concussion Assessment and Cognitive Test battery. Researchers should account for these differences in baseline performance when making concussion diagnostic and management decisions.

The Role of Gender in Neuropsychological Assessment in Healthy Adolescents.

CONTEXT: Research in college athletes has revealed significant gender differences in areas of verbal memory, visual memory, and reaction time. Additionally, research has focused on differences in neuropsychological components and gender in college populations; however, such differences in gender have not been documented in healthy adolescent populations. PURPOSE: To identify potential differences between males and females using different components of a common computerized neuropsychological test. METHODS: A computerized neuropsychological test battery (ImPACT®) was administered to 662 high-school age adolescent athletes (male: n = 451 female: n = 262). Differences between genders were calculated using a 1-way ANOVA. All statistical analyses were conducted using SPSS 23.0. Significance levels were set a priori at P < .05. RESULTS: A 1-way ANOVA revealed statistically significant differences between males and females for composite reaction time (F1,660 = 10.68, P = .001) and total symptom score (F1,660 = 81.20, P < .001). However, no statistically significant differences were found between males and females in composite verbal memory, visual memory, visual motor, or impulse control (P > .05). CONCLUSIONS: Significant differences between males and females were discovered for composite reaction time and total symptom scores, with females reporting more symptoms and slower reaction times at a baseline assessment. Increased symptom reporting by females may be attributed to both hormonal differences and increased honesty. Quicker reaction times in males may support theories that repetition of activities and quicker muscle contraction are gender dependent. However, additional research is necessary to understand gender differences in adolescent athletes during periods of cognitive and physical maturation.

Psychological Impact of Cognitive Rest Following Sport-Related Concussion on Low Socioeconomic Status Adolescent Patients.

PURPOSE: Describe the psychological impact of cognitive rest in adolescents recovering from concussion from sport-related concussion. METHODS: Eight male football players with a previous sport concussion and full recovery completed semi-structured interviews during focus group sessions. Using content analysis, the researchers independently analyzed notes and transcriptions to identify themes associated with the psychological impact of cognitive rest. RESULTS: Common themes included: 1) sport as social support, and 2) boredom-complicated recovery following cognitive rest. CONCLUSIONS: The current treatment protocol indicating cognitive rest and removal from school and sport may be detrimental in a population that is peer-dependent. Future research should explore generalizability and additional factors that may complicate psychological recovery of adolescent athletes following concussive injuries.

The Effectiveness of Cervical Strengthening in Decreasing Neck-Injury Risk in Wrestling.

Clinical Scenario: In wrestling, athletes often support a large amount of weight on their heads or are forced into extreme ranges of motion. These suboptimal movement conditions lead to a high prevalence of neck injuries in wrestlers. A large portion of the work done by the cervical musculature in wrestling is theorized to be eccentric or isometric types of contractions. Strengthening of these cervical muscles is clinically considered to play a vital role in being competitive on the wrestling mat. The cervical stability provided by strengthening these muscles may also play a part in injury prevention among wrestlers. Focused Clinical Question: Does increased cervical strength lead to a decreased risk of injury in wrestling? Summary of Search, "Best Evidence" Appraised, and Key Findings: The literature was searched for studies of level 4 evidence or higher using the Oxford Centre for Evidence-Based Medicine level of evidence system that investigated the relationship between cervical strength and injury risk in wrestling. No studies were found comparing cervical strength to injury risk in wrestling, but 2 related studies were found and have been included in this critically appraised topic. Clinical Bottom Line: There is poor evidence to support a relationship between cervical strength and injury risk in wrestling. Strength of Recommendation: There is grade C evidence to indicate that increased cervical strength decreases the risk of injury in wrestling.

Concussion assessment and management.

Sport-related concussions are becoming common place in athletics and daily activity. Proper assessment and management of concussions are crucial, as repeat concussion can result in prolonged symptoms and catastrophic outcomes. New research is changing the way concussions are managed. The previously used systems have been abandoned in favor of individualized assessment and management using a multidisciplinary approach to include clinical signs, neuropsychological assessment, and postural stability. Transitioning the new evidence to clinical practice is the future of diagnosis, management, and safe return to play following sport-related concussions. This article aims to bridge this gap and provide a systematic, easy-to-use methodology in the management of sport-related concussions.

The reliability of the modified Balance Error Scoring System.

OBJECTIVE: Study 1 investigated the intraclass reliability and percent variance associated with each component within the traditional Balance Error Scoring System (BESS) protocol. Study 2 investigated the reliability of subsequent modifications of the BESS. DESIGN: Prospective cross-sectional examination of the traditional and modified BESS protocols. SETTING: Schools participating in Georgia High School Athletics Association. INTERVENTION: The modified BESS consisted of 2 surfaces (firm and foam) and 2 stances (single-leg and tandem-leg stance) repeated for a total of three 20-second trials. PARTICIPANTS: Participants consisted of 2 independent samples of high school athletes aged 13 to 19 years. MAIN OUTCOME MEASURES: Percent variance for each condition of the BESS was obtained using GENOVA 3.1. An intraclass reliability coefficient and repeated measures analysis of variance were calculated using SPSS 13.0. RESULTS: Study 1 obtained an intraclass correlation coefficient (r = 0.60) with stance accounting for 55% of the total variance. Removing the double-leg stance increased the intraclass correlation coefficient (r = 0.71). Study 2 found a statistically significant difference between trials 1 and 2 (F(1.65,286) = 4.890, P = 0.013) and intraclass reliability coefficient of r = 0.88 for 3 trials of 4 conditions. CONCLUSIONS: The variance associated with the double-leg stance was very small, and when removed, the intraclass reliability coefficient of the BESS increased. Removal of the double-leg stance and addition of 3 trials of 4 conditions provided an easily administered, cost-effective, time-efficient tool that provides reliable objective information for clinicians to base clinical decisions upon.

Age-related differences in neuropsychological testing among high school athletes.

CONTEXT: Clinicians have questioned the need to obtain annual baseline neuropsychological tests in high school athletes. If no difference among academic grades exists, annual baseline testing may not be necessary. OBJECTIVE: To examine differences at baseline testing on pencil-and-paper neuropsychological tests among grade levels in high school athletes. DESIGN: Cross-sectional, between-groups design. SETTING: Schools participating in a Georgia high school athletics association. PATIENTS OR OTHER PARTICIPANTS: High school football players (n = 198) in the 9th through 12th grades, with a mean age of 15.78 +/- 1.16 years. MAIN OUTCOME MEASURE(S): Participants were divided into 4 groups by grade and were administered a symptom checklist and brief neuropsychological test battery. Grade level served as the independent variable. Symptom and individual test scores within the neuropsychological test battery served as dependent variables. RESULTS: Differences were noted among grades on the Trail Making Test A (F(3,194) = 3.23, P = .024, eta(2) = 0.048), Trail Making Test B (F(3,194) = 3.93, P = .009, eta(2) = 0.057), Symbol Digit Modalities Test (F(3,194) = 4.38, P = .005, eta(2) = 0.064), dominant tap (F(3,194) = 3.14, P = .026, eta(2) = 0.046), and nondominant tap (F(3,194) = 4.902, P = .003, eta(2) = 0.070). Using the Bonferroni correction (P