Concussion research: Moving beyond the natural history

The topic of sports-related concussion has been,and will likely continue to be,one of the most challenging topics in sports medicine.The last 2 decades of research has fundamentally altered clinician’s and the public’s view of concussions from a relatively minor“ding”to be shaken off with rapid return to play to the current realization that concussions are brain injuries with potential lifelong consequences.The National Collegiate Athletic Association(NCAA)and the Department of Defense(DoD)Concussion Assessment,Research and Education(CARE)Consortium Study1 currently elucidating the natural history of concussion will provide clinicians critical recommendations on the diagnosis and management;however,many neuropsychosocial questions remain unanswered.Thus,this special topic on Emerging Concussion Research of the Journal of Sport and Health Science(JSHS)is dedicated to addressing key concussion related questions that extend beyond typical clinical concussion management to include broad public health-related concerns.

Detailed description of Division I ice hockey concussions:Findings from the NCAA and Department of Defense CARE Consortium

Objective:Since concussion is the most common injury in ice hockey,the objective of the current study was to elucidate risk factors,specific mechanisms,and clinical presentations of concussion in men’s and women’s ice hockey.Methods:Ice hockey players from 5 institutions participating in the Concussion Assessment,Research,and Education Consortium were eligible for the current study.Participants who sustained a concussion outside of this sport were excluded.There were 332(250 males,82 females)athletes who participated in ice hockey,and 47(36 males,11 females)who sustained a concussion.Results:Previous concussion(odds ratio(OR)=2.00;95%confidence interval(95%CI):1.02‒3.91)was associated with increased incident concussion odds,while wearing a mouthguard was protective against incident concussion(OR=0.43;95%CI:0.22‒0.85).Overall,concussion mechanisms did not significantly differ between sexes.There were specific differences in how concussions presented clinically across male and female ice hockey players,however.Females(9.09%)were less likely than males(41.67%)to have a delayed symptom onset(p=0.045).Additionally,females took significantly longer to reach asymptomatic(p=0.015)and return-to-play clearance(p=0.005).Within the first 2 weeks post-concussion,86.11%of males reached asymptomatic,while only 45.50%of females reached the same phase of recovery.Most males(91.67%)were cleared for return to play within 3 weeks of their concussion,compared to less than half(45.50%)of females.Conclusion:The current study proposes possible risk factors,mechanisms,and clinical profiles to be validated in future concussions studies with larger female sample sizes.Understanding specific risk factors,concussion mechanisms,and clinical profiles of concussion in collegiate ice hockey may generate ideas for future concussion prevention or intervention studies.

Postural control deficits identify lingering post-concussion neurological deficits

Concussion,or mild traumatic brain injury,incidence rates have reached epidemic levels and impaired postural control is a cardinal symptom.The purpose of this review is to provide an overview of the linear and non-linear assessments of post-concussion postural control.The current acute evaluation for concussion utilizes the subjective balance error scoring system(BESS) to assess postural control.While the sensitivity of the overall test battery is high,the sensitivity of the BESS is unacceptably low and,with repeat administration,is unable to accurately identify recovery.Sophisticated measures of postural control,utilizing traditional linear assessments,have identified impairments in postural control well beyond BESS recovery.Both assessments of quiet stance and gait have identified lingering impairments for at least 1 month post-concussion.Recently,the application of non-linear metrics to concussion recovery have begun to receive limited attention with the most commonly utilized metric being approximate entropy(Ap En).Ap En,most commonly in the medial-lateral plane,has successfully identified impaired postural control in the acute post-concussion timeframe even when linear assessments of instrumented measures are equivalent to healthy pre-injury values;unfortunately these studies have not gone beyond the acute phase of recovery.One study has identified lingering deficits in postural control,utilizing Shannon and Renyi entropy metrics,which persist at least through clinical recovery and return to participation.Finally,limited evidence from two studies suggest that individuals with a previous history of a single concussion,even months or years prior,may display altered Ap En metrics.Overall,non-linear metrics provide a fertile area for future study to further the understanding of postural control impairments acutely post-concussion and address the current challenge of sensitive identification of recovery.

Evidence of a conservative gait strategy in athletes with a history of concussions

Background：A history of 3 or more concussions is frequently associated with numerous short-and long-term neuropathologies.Impairments in postural control are a known acute consequence of concussion;however,limited evidence exists on the effects of multiple concussions on gait.The purpose of this study was to assess gait stepping characteristics in collegiate aged student-athletes based on concussion history.Methods：There were 63 participants divided into 3 even groups based on concussion history：≥3 concussions,1–2 concussions,and 0 concussion.All participants completed 10 trials of gait on a 4.9 m instrumented walkway.The dependent variables of interest included both gait stepping characteristics（step velocity,length,and width,double support time,and the percentage of the gait cycle in stance） and coefficien of variability（CoV） measures（step length,time,and width）.The gait stepping characteristics were compared firs with a MANOVA with follow-up 1-way ANOVAs and Tukey post hoc tests as appropriate.The Co V measures were compared with 1-way ANOVAs and Tukey post hoc tests.Results：There were main effects for group for step velocity,length,width,and double support time.Overall,the 0 concussion group displayed typical healthy young gait parameters and performed significant y better than either concussion group.The 0 concussion group had a significant y greater step length Co V,but there were no differences in the step time or width Co V.Conclusion：This findin provides evidence of subtle impairments in postural control during gait among individuals with prior history of concussion which could be an early indicator of future neurological deficiencies The limited difference in the variability measures is consistent with prior static stance studies and could suggest the individuals constrain their motor systems to reduce variability.Taken together,these findi gs suggest a conservative gait strategy which is adopted by individuals with a history of concussions.

English professional football players concussion knowledge and attitude

Background： Concussions are a common pathology in football and multiple misconceptions exist amongst the players and managers. To address these misconceptions, and potentially reduce concussion associated sequela, effective educational interventions need to be developed. However, the current knowledge and attitude status must be ascertained to appropriately develop these interventions. The purpose of this study was to assess the concussion knowledge and attitude of English professional footballers. Methods： Twenty-six participants from one English Football League Championship club completed the study. A mixed methods approach included the Rosenbaum Concussion Knowledge and Attitudes Survey （RoCKAS） and a semi-structured interview. The RoCKAS contains separate knowledge （055） and attitude （15-75） scores and was followed by a semi-structured interview consisting of concussion knowledge, attitude, and behavior related questions. Results： The mean score on the RoCK.AS knowledge was 16.4± 2.9 （range 11-22） and the attitude score was 59.6 ± 8.5 （range 41-71）. The interview responses identified inconsistencies between the RoCKAS and the intended behaviors, endorsing multiple concussion misconceptions, and revealed barriers to concussion reporting. Conclusion： The results of this study suggest that Championship Level English footballers have moderate concussion knowledge, safe attitudes, and good concussion symptom recognition when assessed with pen and paper questionnaires. However, within the semi-structured interview many respondents reported unsafe concussion behaviors despite accurately identifying the potential risks. Further, multiple barriers to concussion reporting were identified which included perceived severity of the injury, game situations, and the substitution rule. These findings can help form the foundation of educational interventions to potentially improve concussion reporting behaviors amongst professional footballers.

Effects of contact/collision sport history on gait in early-to mid-adulthood

Background:To determine the effect of contact/collision sport participation on measures of single-task(ST)and dual-task(DT)gait among early-to middle-aged adults.Methods:The study recruited 113 adults(34.88±11.80 years,(mean±SD);53.0%female)representing 4 groups.Groups included(a)former non-contact/collision athletes and non-athletes who are not physically active(n=28);(b)former non-contact/collision athletes who are physically active(n=29);(c)former contact/collision sport athletes who participated in high-risk sports and are physically active(n=29);and(d)former rugby players with prolonged repetitive head impact exposure history who are physically active(n=27).Gait parameters were collected using inertial measurement units during ST and DT gait.DT cost was calculated for all gait parameters(double support,gait speed,and stride length).Groups were compared first using one-way analysis of covariance.Then a multiple regression was performed for participants in the highrisk sport athletes and repetitive head impact exposure athletes groups only to predict gait outcomes from contact/collision sport career duration.Results:There were no significant differences between groups on any ST,DT,or DT cost outcomes(p>0.05).Contact/collision sport duration did not predict any ST,DT,or DT cost gait outcomes.Conclusion:Years and history of contact/collision sport participation does not appear to negatively affect or predict neurobehavioral function in early-to mid-adulthood among physically active individuals.