Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports MEASUREMENT OF HEAD IMPACTS IN COLLEGIATE FOOTBALL PLAYERS: RELATIONSHIP BETWEEN HEAD IMPACT BIOMECHANICS AND ACUTE CLINICAL OUTCOME AFTER CONCUSSION Prevalence of neurocognitive and balance deficits in collegiate aged football players without clinically diagnosed concussion. Is neuropsychological testing useful in the management of sport-related concussion? Grade 1 or “Ding” Concussions in High School Athletes Detailed concussion symptom analysis in a paediatric ED population The “Value Added” of Neurocognitive Testing after Sports-Related Concussion The assessment of orientation following concussion in athletes. The reliability and validity of video analysis for the assessment of the clinical signs of concussion in Australian football. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Relation between subjective fogginess and neuropsychological testing following concussion. Immediate Neurocognitive Effects of Concussion Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion Reliability of a Graded Exercise Test for Assessing Recovery From Concussion Associations among self-reported balance problems, post-concussion symptoms and performance-based tests: a longitudinal follow-up study SEX DIFFERENCES IN NEUROPSYCHOLOGICAL FUNCTION AND POST‐CONCUSSION SYMPTOMS OF CONCUSSED COLLEGIATE ATHLETES Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: A pilot study
Context With increasing knowledge and research about concussion , there have been few objective studies that have used neuropsychological domain scores and postural stability to assess concussion . Objective To evaluate the recovery curve of athletes who incur sport-related concussion from repeated serial testing of neuropsychological and posturography testing . Design A prospect i ve epidemiological model was used for the course of the study . Setting Division I intercollegiate athletics . Participants Athletes participating in football , soccer , basketball , softball , and cheerleading . Main Outcome Measures  Neuropsychological scores and posturography measures  were obtained preseason and serially at day 1 , day 2 , day 3 , and day 10 postconcussion .  Control participants  were tested at the same intervals .  Neuropsychological scores were converted to st and ards score and then into domains of attention , learning , speed of information processing , concentration , memory , and verbal fluency . Analysis of covariance with the baseline test as the covariate was used to analyze the data with univariate post hoc tests performed . Results Significant group differences were found for self reported symptoms ( P = 0.001 ) , speed of information processing ( P = 0.005 ) , mean stability ( P = 0.002 ) , and vestibular function ( P = 0.003 ) between injured and control participants . A group , by day , planned comparison found that speed of information processing and composite balance measures demonstrated significant differences through day 10 postinjury , while symptoms and the vestibular ratio remained significant only through day 3 . Conclusions The concussion recovery curve demonstrated short-term neuropsychological and posturography deficits following injury . A comprehensive approach to concussion management should be used to assess the injury and make return-to-play decisions OBJECTIVE To determine the relationship between recorded head accelerations and impact locations and acute clinical outcome of symptomatology , neuropsychological , and postural stability tests after cerebral concussion in Division I collegiate football players . METHODS A prospect i ve field study was used in which accelerometers were embedded in the football helmets of 88 collegiate football players .  Linear and rotational accelerations of all head impacts sustained over the course of 2004 to 2006 National Collegiate Athletic Association football seasons were collected in real-time . Change scores were calculated on clinical measures from the players ' preseason baseline to postinjury ( within 48 h ) and regressed against the recorded linear and rotational accelerations of the head at the time of the concussion . RESULTS Thirteen concussions were recorded ranging in impact magnitudes of 60.51 to 168.71 g. Linear regression showed no significant relationships between impact magnitude ( linear or rotational acceleration ) or impact location and change scores for symptom severity , postural stability , or neurocognitive function ( P > 0.05 ) . CONCLUSION Our findings suggest that football players are concussed by impacts to the head that occur at a wide range of magnitudes and that clinical measures of acute symptom severity , postural stability , and neuropsychological function all appear to be largely independent of impact magnitude and location . Because of the varying magnitudes and locations of impacts result ing in concussion as well as other factors such as the frequency of subconcussive impacts and number of previous concussions , it may be difficult to establish a threshold for concussive injury that can be applied to all football players STUDY DESIGN Prospect i ve cohort . OBJECTIVES To identify the prevalence of neurocognitive and balance deficits in collegiate football players 48 hours following competition . BACKGROUND Neurocognitive testing , balance assessment s , and subjective report of symptoms are a commonly used test battery in examining athletes when concussion is suspected . Previous literature suggests many concussions go unreported . Little research exists examining the prevalence of neurocognitive or balance deficits in athletes who do not report concussion-like symptoms to a health care provider . METHODS Forty-five Division IA collegiate football players participated in this study . Preseason baseline scores using the  Balance Error Scoring System , the Immediate Post-Concussion Assessment and Cognitive Testing , and the Postconcussion Symptom Scale  were compared to posttest results obtained 48 hours following a game . Prevalence of symptoms was analyzed and reported . RESULTS Thirty-two ( 71 % ) of the 45 athletes tested demonstrated at least 1 deficit in either the Postconcussion Symptom Scale , Balance Error Scoring System , or at least 1 composite score of the Immediate Post-Concussion Assessment and Cognitive Testing . Nineteen of the 32 subjects demonstrated a change in 2 or more categories of neurocognitive and balance function . CONCLUSION In a cohort of football players tested 48 hours following their last game of the season , who did not seek medical attention related to a concussion , a significant number demonstrated limitations in neurocognitive and balance performance , suggesting that further research may need to be performed to improve recognition of an athlete 's deficits and to improve the ability to assess concussion . LEVEL OF EVIDENCE Differential diagnosis/symptom prevalence , level 3b OBJECTIVE Neuropsychological ( NP ) testing has been used for several years as a way of detecting the effects of sport-related concussion in order to aid in return-to-play determinations . In addition to st and ard pencil- and -paper tests , computerized NP tests are being commercially marketed for this purpose to professional , collegiate , high school , and elementary school programs . However , a number of important questions regarding the clinical validity and utility of these tests remain unanswered , and these questions present serious challenges to the applicability of NP testing for the management of sport-related concussion . Our purpose is to outline the criteria that should be met in order to establish the utility of NP instruments as a tool in the management of sport-related concussion and to review the degree to which existing tests have met these criteria . DATA SOURCES A comprehensive literature review of MEDLINE and PsychLit from 1990 to 2004 , including all prospect i ve , controlled studies of NP testing in sport-related concussion . DATA SYNTHESIS The effects of concussion on NP test performance are so subtle even during the acute phase of injury ( 1 - 3 days postinjury ) that they often fail to reach statistical significance in group studies . Thus , this method may lack utility in individual decision making because of a lack of sensitivity . In addition , most of these tests fail to meet other psychometric criteria ( eg , adequate reliability ) necessary for this purpose . Finally , it is unclear that NP testing can detect impairment in players once concussion-related symptoms ( eg , headache ) have resolved . Because no current guideline for the management of sport-related concussion allows a symptomatic player to return to sport , the incremental utility of NP testing remains question able . CONCLUSIONS / RECOMMENDATIONS Despite the theoretic rationale for the use of NP testing in the management of sport-related concussion , no NP tests have met the necessary criteria to support a clinical application at this time . Additional research is necessary to establish the utility of these tests before they can be considered part of a routine st and ard of care , and concussion recovery should be monitored via the st and ard clinical examination and subjective symptom checklists until NP testing or other methods are proven effective for this purpose Background Recent concussion management guidelines have suggested that athletes with mild ( grade 1 ) concussions may be returned to play if asymptomatic for 15 minutes . The purpose of this study was to assess the utility of a current concussion management guideline in classifying and managing mild concussion . Hypothesis High school athletes diagnosed with a grade 1 concussion will demonstrate measurable decline in neuropsychological functioning that persists during the 1st week of recovery . Study Design Prospect i ve study design ed to evaluate neuropsychological functioning both prior to and following concussion . Methods Forty-three high school athletes completed  neuropsychological test performance  and  symptom ratings  prior to the season and at two times during the 1st week following  mild concussion . Results Thirty-six hours after injury , mildly concussed high school athletes demonstrated a decline in memory ( P < 0.003 ) and a dramatic increase in self-reported symptoms ( P < 0.00001 ) compared to baseline performance . Conclusions Athletes with grade 1 concussion demonstrated memory deficits and symptoms that persisted beyond the context in which they were injured . These data suggest that current grade 1 return-to-play recommendations that allow for immediate return to play may be too liberal . Clinical Relevance A reconsideration of current concussion grading systems appears to be warranted Primary objective : To examine the frequency of acute mild traumatic brain injury ( mTBI ) symptoms in children using a concussion symptom inventory  and to identify which symptoms are most useful in identifying mTBI . It was hypothesized that symptoms associated with mTBI are more common in children with head injury than orthopaedic injury and certain symptoms are more useful than others in identifying mTBI . Research design : Prospect i ve case-control study conducted in a paediatric trauma centre emergency department . Methods and procedures : Children of 6–18 years old with head injury or a minor extremity injury were enrolled .  Symptoms were assessed using a grade d symptom checklist .  Symptom frequency was compared using a chi-square test . The association between individual symptoms with AMS was evaluated with logistic regression analysis . Main outcomes and results : Children with head injury displayed more frequent symptoms than controls . Head-injured cases with altered mental status ( AMS ) demonstrated the most frequent and severe symptoms ( median symptom scores : control = 1 , cases without AMS = 5 , cases with AMS = 10 ; p < 0.001 ) . Headache , nausea , dizziness , blurred/double vision and not feeling ‘ sharp ’ were associated with AMS . Conclusions : Symptoms associated with mTBI are more frequent in children with head injury . AMS magnifies this effect . A symptom inventory is integral to the evaluation of mTBI in children ; a smaller set of dichotomized symptoms may be as useful as and more easily administered than lengthier symptom scales Background Neurocognitive testing has been endorsed as a “ cornerstone ’ of concussion management by recent Vienna and Prague meetings of the Concussion in Sport Group . Neurocognitive testing is important given the potential unreliability of athlete self-report after injury . Relying only on athletes'ormalities after injury . Study Design Case control study ; Level of evidence , 3 . Methods High school and college athletes with a diagnosed concussion were tested 2 days after injury . Postinjury neurocognitive performance ( Immediate Postconcussion Assessment and Cognitive Testing ) and symptom ( postconcussion symptom ) scores were compared with preinjury ( baseline ) scores and with those of an agex and education-matched noninjured athlete control group . “ Abnormal ” test performance was determined statistically with Reliable Change Index scores . Results Sixty-four percent of concussed athletes reported a significant increase in symptoms , as judged by postconcussion symptom scores , compared with preinjury baseline at 2 days after injury . Eighty-three percent of the concussed sample demonstrated significantly poorer neurocognitive test results relative to their own baseline performance . The addition of neurocognitive testing result ed in a net increase in sensitivity of 19 % . Ninety-three percent of the sample had either abnormal neurocognitive test results or a significant increase in symptoms , relative to their own baseline ; 30 % of a control group demonstrated either abnormalities in neurocognitive testing or elevated symptoms , as judged by postconcussion symptom scores . For the concussed group , use of symptom and neurocognitive test results result ed in an increased yield of 29 % overreliance on symptoms alone . In contrast , 0 % of the control group had both symptoms and abnormal neurocognitive testing . Conclusion Reliance on patients ’ self-reported symptoms after concussion is likely to result in underdiagnosis of concussion and may result in premature return to play . Neurocognitive testing increases diagnostic accuracy when used in conjunction with self-reported symptoms The purpose of this study was to investigate the sensitivity of  orientation and recent memory questions  in the diagnosis of concussion . In a prospect i ve study over 7 consecutive years ( 1985 - 1991 ) , all players at a professional Australian Rules Football club who sustained a concussive injury ( n = 28 ) were administered a set of questions evaluating orientation and recent memory .  Concussion was diagnosed independently on the basis of loss or disturbance of consciousness and clinical symptoms . A control group of age-matched nonconcussed players was administered the same set of questions . The results showed that items evaluating recently acquired information were more sensitive in the assessment of concussion than st and ard orientation items . The relative sensitivity of orientation questions must be considered when they are used in the clinical diagnosis of concussion in sport OBJECTIVES The objective of this study was to determine the reliability and validity of identifying clinical signs of concussion using  video analysis in Australian football . DESIGN Prospect i ve cohort study . METHODS All impacts and collisions potentially result ing in a concussion were identified during 2012 and 2013 Australian Football League seasons . Consensus definitions were developed for clinical signs associated with concussion . For intra- and inter-rater reliability analysis , two experienced clinicians independently assessed 102 r and omly selected videos  on two occasions . Sensitivity , specificity , positive and negative predictive values were calculated based on the diagnosis provided by team medical staff . RESULTS 212 incidents result ing in possible concussion were identified in 414 Australian Football League games . The intra-rater reliability of the  video-based identification of signs associated with concussion was good to excellent . Inter-rater reliability was good to excellent for impact seizure , slow to get up , motor incoordination , ragdoll appearance ( 2 of 4 analyses ) , clutching at head and facial injury . Inter-rater reliability for loss of responsiveness and blank and vacant look was only fair and did not reach statistical significance . The feature with the highest sensitivity was slow to get up ( 87 % ) , but this sign had a low specificity ( 19 % ) . Other video signs had a high specificity but low sensitivity . Blank and vacant look ( 100 % ) and motor incoordination ( 81 % ) had the highest positive predictive value . CONCLUSIONS Video analysis may be a useful adjunct to the side-line assessment of a possible concussion . Video analysis however should not replace the need for a thorough multimodal clinical assessment This study explored the diagnostic utility of the composite scores of Immediate Post-Concussion Assessment and Cognitive Testing ( ImPACT ) and Post Concussion Symptom Scale scores ( PCSS ) . Recently concussed high school athletes ( N=72 ) were tested within 72 h of sustaining a concussion , and data were compared to non-concussed high school athletes with no history of concussion ( N=66 ) . Between-groups MANOVA revealed a significant multivariate effect of concussion on test performance ( p<.001 ) ; univariate ANOVAS revealed all six measures contributed to the between-groups differences . A discriminant function analyses was conducted to measure the ability of the five ImPACT composite scores , as well as the PCSS to classify concussion status . One discriminant function was identified that consisted of the Visual Memory , Processing Speed , and Impulse Control composite scores PCSS , which correctly classified 85.5 % of the cases . Approximately 82 % of participants in the concussion group and 89 % of participants in the control group were correctly classified . Using these data , the sensitivity of ImPACT was 81.9 % , and the specificity was 89.4 % . As part of a formal concussion management program , ImPACT is a useful tool for the assessment of the neurocognitive and neurobehavioral sequelae of concussion , and can also provide post-injury cognitive and symptom data that can assist a practitioner in making safer return to play decisions The purpose of this study was to examine the relation between the subjective report of feeling foggy at one-week post concussion and acute neuropsychological outcome . The outcome variables were derived from a computerized neuropsychological screening battery , Immediate Post-Concussion Assessment and Cognitive Testing ( ImPACT ) . Participants were 110 high school students who sustained a sports-related concussion and were evaluated 5 - 10 days post injury ( M = 6.8 days ) . Athletes were divided into two groups on the basis of self-reported fogginess . The first group reported no fogginess ( n = 91 ) , whereas the second group reported experiencing some degree of fogginess ( n = 19 ) on a 6-point scale . The athletes with persistent fogginess experienced a large number of other post-concussion symptoms , compared to the athletes with no reported fogginess . In addition , the athletes with persistent fogginess had significantly slower reaction times , reduced memory performance , and slower processing speed . Thus , athletes with any degree of self-reported fogginess at one-week post injury are likely to have adverse effects from their concussions in multiple domains OBJECTIVE To prospect ively measure the immediate neurocognitive effects and early course of recovery from concussion and to examine the effects of loss of consciousness ( LOC ) and posttraumatic amnesia ( PTA ) on the severity of neurocognitive impairment immediately after concussion . METHODS A sports-related concussion research model was used to allow prospect i ve immediate evaluation of concussion . A total of 2385 high school and college football players were studied . Ninety-one players ( 3.8 % ) sustained concussions during the study . A brief neurocognitive and neurological screening measure , the St and ardized Assessment of Concussion  , was used to assess cognitive functioning before the football season , immediately after injury , and 15 minutes , 48 hours , and 90 days after injury . RESULTS St and ardized Assessment of Concussion scores immediately after concussion were significantly lower than the preseason baseline score and the noninjured population baseline mean , even for injured subjects without LOC or PTA . Subjects with LOC were most severely impaired immediately after injury , whereas those without LOC or PTA were least impaired . Significant impairment was also detected 15 minutes after injury , but all three groups returned to baseline levels of cognitive functioning within 48 hours . CONCLUSION These findings are the first to demonstrate not only that a gradient of increasing concussion severity is represented by PTA and LOC but also that measurable neurocognitive abnormalities are evident immediately after injury without PTA or LOC Background Concussion is one of the most commonly occurring injuries in sport today . The Sport Concussion Assessment Tool ( SCAT ) is a commonly used paper neurocognitive tool . To date , little is known about SCAT baseline normative values in youth athletes . Objective The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players . Methods This is a secondary data analysis of pooled data from three prospect i ve cohort studies examining the risk of injury in paediatric ice hockey players aged 9–17 years . A preseason baseline demographic and injury history question naire was completed by each player . Results A total of 4193 players completed SCATs at baseline and were included in the analysis . 781 players ( 18.6 % ) reported a previous history of concussion . Fatigue and low energy followed by headache were the most commonly reported symptoms in all players . The majority of youth players could recite all five words immediately but only three words when delayed . A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age . The median number of digits recited in reverse order was 4 . Conclusions Youth ratings varied between age groups , gender and from previously reported ratings of varsity athletes , possibly reflecting developmental and gender differences . An underst and ing of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion Objective : To evaluate a grade d treadmill test for retest reliability ( RTR ) and interrater reliability ( IRR ) in the evaluation of the physiologic effects of symptom exacerbation from concussion . Design : Prospect i ve case series ( RTR ) and blinded rater assessment of 10 actors portraying patients with and without symptom exacerbation ( IRR ) . Setting : University Sports Medicine Concussion Clinic . Participants : For RTR , 21 refractory concussed patients ( 11 athletes and 10 nonathletes ) and 10 healthy subjects ; for IRR , 32 raters representing a variety of health care disciplines . Intervention : For RTR , a Balke protocol treadmill test to symptom exacerbation before and after 2 to 3 weeks . For IRR , video recordings of actors during the treadmill test viewed by raters blinded to condition . Main Outcome Measures : For RTR , agreement of the tests for maximal heart rate ( HR ) , systolic blood pressure , diastolic blood pressure , and rating of perceived exertion . For IRR , presence or absence of symptom exacerbation and the symptom exacerbation HR . Results : Raters achieved a sensitivity of 99 % for identifying actors with symptom exacerbation and a specificity of 89 % for ruling out concussion symptoms and agreed on 304 of 320 observations ( accuracy of 95 % ) . The intraclass correlation coefficient for the symptom exacerbation HR was large at 0.90 ( 95 % confidence interval , 0.78 - 0.98 ) . The treadmill test had good RTR for maximum HR ( intraclass correlation coefficient , 0.79 ) but not for systolic blood pressure , diastolic blood pressure , or rating of perceived exertion . Conclusions : The Balke exercise treadmill protocol has very good IRR and sufficient RTR for identifying patients with symptom exacerbation from concussion Purpose : The main objectives of this study were to describe long-term self-reported balance problems  and to explore their associations with post-concussion symptoms and performance-based tests . Method : Prospect i ve study of patients with mild traumatic brain injury ( MTBI ) .  Self-reported balance problems and post-concussion symptoms were measured with the Rivermead Post-concussion Symptoms Question naire at 1 and 4 years after injury . Performance-based tests were performed 4 years after injury and included  posturography , the Dynamic Gait Index ( DGI ) , walking speed tests , and the six-minute walk test . Results : Self-reported balance problems were reported in 31 % of patients 4 years after injury and correlated significantly with post-concussion symptoms . The correlations with performance-based tests varied from ρ = 0.18 to ρ = 0.70 and were strongest for the maximum walking speed test ( ρ = 0.70 ) and a dual-task test ( ρ = 0.43 ) . The DGI had a considerable ceiling effect . Conclusions : Balance problems were long-term consequences of MTBI in one third of this study sample . Self-reported balance problems correlated with post-concussion symptoms and some of the performance-based tests . Future research needs to develop and evaluate appropriate rehabilitation strategies that also address the balance problems . Implication s for Rehabilitation Balance problems may persist several years after a mild traumatic brain injury . We need to develop and evaluate appropriate rehabilitation strategies that also address the balance problems OBJECTIVE Our purpose was to determine whether sex differences exist with respect to post-concussion symptoms and neurocognitive function in concussed collegiate athletes . METHODS A prospect i ve dependent- sample cohort design was used to compare baseline and post-concussion neuropsychological test scores and endorsed symptoms as functions of serial post-concussion assessment with respect to time and sex . The Immediate Post-concussion Assessment and Cognitive Testing ( ImPACT ) battery was administered to a multicenter analysis group of 79 concussed athletes . This computerized neuropsychological test was given to the athletes during the preseason and , on average , 2 and 8 days postinjury . RESULTS Multivariate analyses revealed no significant between-group differences on baseline test performance with respect to sex on any of the ImPACT composite scores or on the total symptom score . Multivariate analyses of post-concussion data revealed a significant main effect of time on ImPACT scores , but no main effect of sex was identified , and no time-by-sex interaction existed . Post hoc analysis revealed that concussed female athletes performed significantly worse than concussed male athletes on visual memory tasks ( P = 0.001 ) , and analysis of endorsed post-concussion symptoms revealed that concussed men were significantly more likely than concussed women to report post-concussion symptoms of vomiting ( P = 0.001 ) and sadness ( P = 0.017 ) . Athletes ' scores were examined individually using the reliable-change methodology . At 2 days post-injury , 58 % of concussed athletes had one or more reliable incidents of performance decline or increases in symptom reporting . At 8 days post-concussion , 30 % of concussed athletes were still showing one or more reliable change from preseason values . CONCLUSIONS College athletes exhibit differences on visual memory composite scores and symptoms post-concussion as a function of sex . These data support the importance of evaluating neuropsychological status and post-concussion symptoms in concussed athletes . In addition , these data illustrate the importance of analyzing an individual athlete 's recovery pattern , because individual differences in recovery trajectories may be overshadowed by global norm-group comparisons AIM This study undertook to use the K-D sideline test with the SCAT2 to see if concussions could be identified in amateur rugby league players over a representative competition period . METHOD A prospect i ve cohort study was conducted on two teams participating in an amateur rugby league . All players were tested for signs of concussion utilising the K-D test and players with longer times than their baseline scores undertook a further concussion assessment with the SCAT2 . RESULTS Five athletes with suspected concussion were evaluated by K-D testing .  Three concussions were associated with witnessed events during the matches and two athletes were identified by the team medic as having longer K-D time scores incidentally post-match compared to baseline . Post-match K-D scores for all concussed athletes were worse than baseline for those with reported or witnessed concussion events ( 7s ; 5.0 - 7.1 ; p=0.025 ) and for those identified incidentally ( > 5s ; 8.9 - 9.1s ) . Both groups also reported more symptoms on the PCSS ( a part of the SCAT2 ) post-match . DISCUSSION In this rugby cohort , the K-D test was not only useful in identifying changes in players with witnessed head trauma , but in identifying changes in players with an un-witnessed suspected concussion
Six core scales were identified with a broad range of symptom items but with limited information on their psychometric properties .
OBJECTIVE To identify  self-reported sport concussion symptom scales  and to describe the psychometric properties of these identified scales .