British Journal of Sports Medicine

Delasobera, Elizabeth; Shasteen, Mallory; Parsa, Keon; Wierenga, Justin

doi: 10.1136/bjsports-2016-097270.117pmid: N/A

ObjectiveThis study examines differences in baseline balance scores in order to establish normative data in college athletes, and also determine the potential effect of gender, sport, and concussion history on baseline performance.DesignRetrospective reviewSettingPre-participation evaluations of athletes at an American university.Participants961 varsity athletes, ages 17 to 21, both male and female from 2011 to 2015.Independent VariablesGender, sport, and history of prior concussions.Dependent VariableBaseline Balance Error Scoring System (BESS) scores.Main ResultsThe baseline BESS score for all athletes averaged 16.13 (range 2 to 40). Baseline BESS scores were significantly different in males (15.78) compared to females (16.84), with a difference of 1.056 (95% CI 0.233 to 1.890, P=0.013). Baseline scores averaged 17.40 in athletes with history of concussion compared to 16.45 in athletes with no prior concussion (CI 0.866 to 2.780, P=0.301). When comparing scores by sport, there were no significant differences in baseline scores between females who played field hockey, softball, volleyball, basketball, lacrosse, or soccer. There were no significant differences in baseline scores between males who played baseball, football, basketball, lacrosse, or soccer.ConclusionsWhen balance testing is used to assess an athlete after concussion injury, normative balance scores may be used in the absence of baseline scores. History of concussion and type of sport do not play a significant role in baseline balance assessment, however gender may alter the normative baseline data slightlyCompeting interestsNone.

Wright, Alexander D; Smirl, Jonathan D; Fraser, Sarah K; Bryk, Kelsey; Donkelaar, Paul van

doi: 10.1136/bjsports-2016-097270.60pmid: N/A

ObjectiveTo examine the effects of concussion history on an index of cerebral autoregulation in a healthy athlete population.DesignRetrospective Cohort.SettingLaboratory.Participants136 male contact sport athletes (19.1±1.4 years, 66 football, 70 hockey) were recruited; 39 presented with 0 previous concussions, 16 with 3+ previous concussions; exclusion criteria included history of concussion within 6 months.InterventionParticipants completed baseline testing prior to the athletic season. Squat-stand manoeuvres at 0.05 and 0.10 Hz were used to enhance blood pressure (BP) variation. BP and cerebral blood velocity (CBV) in the middle cerebral artery were indexed non-invasively via finger photoplethysmography and transcranial Doppler ultrasound, respectively. Independent variables included sport (2) and concussion history (2).OutcomesTransfer function analysis point estimates at 0.05 and 0.10 Hz characterised the coherence (correlation), phase (synchronisation), and gain (amplitude buffer) between BP and CBV waveforms during the squat-stand manoeuvres.ResultsThese findings suggest that, despite reductions in 0.10 Hz phase lead being reported acutely after concussion, multiple concussions do not appear to induce long-term impairments in dynamic cerebral autoregulation metrics. This is an important revelation as it indicates that the cerebrovasculature is able to adequately recover following the acutely diminished buffering capacity associated with a concussive injuryConclusionsThese findings suggest that, despite reductions in 0.10 Hz phase lead being reported acutely after concussion, multiple concussions do not appear to induce long-term impairments in dynamic cerebral autoregulation metrics. This is an important revelation as it indicates that the cerebrovasculature is able to adequately recover following the acutely diminished buffering capacity associated with a concussive injuryCompeting interestsNone.

Danielle, Salmon; Pinfold, Jayden; Sullivan, S John; Andrew, Gray; Lodge, Ed; Hamish, Osborne; Darryl, Tong

doi: 10.1136/bjsports-2016-097270.8pmid: N/A

ObjectiveThe tackle is a key component in rugby union and carries some of the highest risk for concussions. The purpose this study was to observe the acceleration profile of the head during a simulated tackle and to determine if these forces vary by playing position.DesignObservational.SettingLaboratory.ParticipantsMale rugby players (n=41) age 21.8±3.4 years.ProtocolParticipants were asked to perform 5 tackles with each shoulder. For each tackle the 50 kg bag was released on a pendulum and the players completed a 3 m run-up to make contact with the bag at its peak speed (4.3 ±.13 m/s). For each tackle the linear and rotational acceleration were captured using a head positioning system (HPS) anchored over the mastoid bone.Outcome measuresThe magnitude and variability of the mean resultant linear and rotational acceleration forces over the 10 tackles were examined using the peak acceleration values and were compared with Mann-Whitney-Wilcoxon tests.Main resultsThe overall mean peak linear force was 82.9 Gz with a range of 20.1–236.6 Gz. For the forwards (n=23) the peak linear and rotational accelerations were 83.0±36.3 Gz and 2537.8±477.7 m/s2, while for the backs (n=18) were 77.6±33.8 Gz and 2501.9±519.6 m/s2. There were no significant differences between forwards/backs, or those with a history of concussion (p≥0.054). ConclusionsWith growing evidence implicating the importance of sub-concussive impacts in later brain health, understanding the exposure load of players during trainings and games is essential. This is the first study to document the impact forces recorded at the head during a simulated rugby tackle.Competing interestsNone.Ed Lodge is CEO of CSx Concussion Management Systems, who developed and provided the Head positioning system that was used to measure head impact kinetics in real time.

Greenhow, Annette

doi: 10.1136/bjsports-2016-097270.181pmid: N/A

ObjectiveResponses to the harm caused by sports-related concussion constitute a new interdisciplinary field of research (Doherty, 2012). Regulatory theory and principles of what constitutes ‘good’ regulation can contribute to the discussion. The aim of this research is to present a typology of regulatory responses adopted by sports governing bodies in those sports with published injury surveillance data, and to classify the responses according to the regulatory methods used by the organisations.Sports governing bodies are voluntary self-regulated associations and custodians of their sport. As the dominant regulator responsible for the development of rules and standards, the organisation carries the responsibility to provide a safe system for participants within its regulatory field, focussing on precautionary-based approaches and risk reduction strategies to preserve the health, safety and welfare of participants. The expectation is that these interventions are based on well-defined objectives and an understanding of the variety of regulatory methods available to achieve the objectives.DesignThis presentation provides the results of a review of the regulatory activities of the sports governing bodies across contact and collision sport. By adopting a qualitative research method, the regulatory actions of the organisations are classified according to the four response areas of concussion management, concussion prevention, concussion research and concussion education.Main resultsA variety of regulatory methods were employed by the organisations across each of the four categories. Early interventions focus on concussion management and concussion prevention with more recent interventions focussed on concussion education and concussion research strategies.ConclusionsThose organisations with clearly defined objectives and comprehensive injury surveillance data reporting systems adopted regulatory methods across each of the four categories. Competing interestsNone

Wright, Alexander D; Smirl, Jonathan D; Jakovac, Michael; Fraser, Sarah K; Bryk, Kelsey; Grewal, Harjas S; Dierijck, Jill; Donkelaar, Paul van

doi: 10.1136/bjsports-2016-097270.75pmid: N/A

ObjectiveTo examine the relationship between cerebral autoregulation changes and impact exposuresthroughout a season of contact sports (hockey or football).DesignProspective Cohort.SettingLaboratory.Participants40 male contact sport athletes (19.4±1.2 years); to date, 3 cross-country athletes (20.0±1.0 years) have completed testing (non-contact controls).InterventionParticipants completed testing prior to the start of their athletic seasons (T1), and again after the conclusion of each season (T2). Blood pressure (BP) oscillations were driven by stand-squat manoeuvres at 0.05 and 0.10 Hz. BP and cerebral blood velocity (CBV) in the middle cerebral artery were indexed non-invasively using finger photoplethysmography and transcranial Doppler ultrasound, respectively. RM-ANOVA independent variables included time (2) and frequency (2).Outcome measuresPoint-estimates of coherence (correlation), phase (synchronisation), and gain (amplitude buffer) transfer function analysis metrics were calculated. Biomechanical data on head-impact exposure was estimated in a subset of contact-sport athletes (n=29) using the xPatch (X2 Biosystems), affixed to the right mastoid.ResultsSignificant frequency-time interaction for gain in contact-sport athletes (p=0.048) but not controls (p=0.213). Simple effects analysis revealed a time effect at 0.10 Hz (p<0.001), whereby gain increased at T2 (95% CI: 0.070–0.229%/%). The Δgain T2-T1 at 0.10 Hz was correlated withestimated cumulativerotational acceleration exposure (r=0.462, p=0.015).ConclusionsThese findings suggest cumulative exposure to the rotational component of sustained head-impactsduring participation in a season of contact-sport (hockey or football) impairs the ability of the cerebrovasculature to buffer BP challenges experienced during everyday activities.Competing interestsNone.

Wilmott, Catherine; McIntosh, Andrew S; Howard, Teresa; Mitra, Biswadev; Dimech-Betancourt, Bleydy; Rosenfeld, Jeffrey V

doi: 10.1136/bjsports-2016-097270.198pmid: N/A

ObjectiveThis pilot study investigated SCAT3 from baseline to post-game among non-concussed amateur Australian Rules footballers, and association with game day head impacts.DesignPeak linear acceleration (PLA) of the head (>10 g) was measured by wearable impact sensor X2Biosytems xPatch. SCAT3 was administered at baseline and post-game.ParticipantsAmateur Australian Rules footballers n=68.Main resultsCommon symptoms at baseline: fatigue, trouble falling asleep & neck pain. N=57 sustained 2088 impacts>10 g (Mean PLA=14.40 g, range 10–115.78 g). Measured PLA among males (M=15.11g, SD 3.51) and females (M=16.60g, SD 4.04), U=288.00, z=−1.24, p=0.217 did not differ, however, males (M=46.13, SD=50.4) sustained significantly more impacts than females (M=17.63, SD=13.20), U=214.00, z=−2.46, p=0.013. Greater symptom severity was found post-game (M=6.16, SD=8.17) compared to baseline (M=4.04, SD=6.34), z=−0.32, p=0.001, along with greater symptom total (p=0.011). Those with higher mean PLA demonstrated slower tandem gait. A similar pattern of SCAT change was observed for the No Impact group, and there were no significant group differences in SCAT change scores.ConclusionsConsistent with previous findings players were not asymptomatic at baseline. Increase in symptom severity post-game was generally independent of head impact. Furthermore, the lack of association between PLA and SCAT3 change scores in this non-concussed Impact group suggests that other factors may contribute to such changes. Competing interestsNone.

Gardner, Andrew J; Levi, Christopher R; Iverson, Grant L

doi: 10.1136/bjsports-2016-097270.214pmid: N/A

ObjectiveA video analysis of 201 National Rugby League (NRL) matches to document all signs of possible concussion during the 2014 season.SettingAll match play from the 2014 NRL season.ParticipantsAll professional players participating in the 2014 seasonOutcome measuresThe total frequency of six concussion signs (unresponsiveness/loss of consciousness, slow to get up, clutching head, unsteadiness of gait, vacant stare, and seizure). Main resultsThe concussion interchange rule was used 156 times, with 60 medically diagnosed concussions. The incidence rate for concussion was 17.26 (95% CI=13.44–22.16) per 1,000 player match hours, or approximately one concussion every 3.35 games. There were 127,062 tackles reviewed in the 201 matches, for an average of 632.1 tackles per match. Being slow to get up was observed 2,240 times, clutching the head 361 times, unsteadiness of gait 102 times, vacant stare 98 times, possible loss of consciousness (LOC) 52 times, and a seizure 4 times. Of the 2,240 instances of being slow to get up following a tackle, only 2.7% of those cases involved a medically diagnosed concussion. Of the 52 instances in which a player appeared to have brief LOC, 50 players were removed under the concussion interchange rule (96.2%). Of those 50, 24 were medically diagnosed as having sustained a concussion (48%).ConclusionsReviewing match video footage can be a useful addition to the sideline assessment of concussion.Competing interestsAndrew Gardner has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He serves, in a voluntary capacity, as a member of the Australia Rugby Union (ARU) concussion advisory group. He has received travel funding from the Australian Football League (AFL) to present at the Concussion in Football Conference in 2013. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas. He is currently funded through the HMRI, supported by Anne Greaves.Grant Iverson has been reimbursed by the government, professional scientific bodies, and commercial organisations for discussing or presenting research relating to mild TBI and sport-related concussion at meetings, scientific conferences, and symposiums. He has a clinical and consulting practice in forensic neuropsychology involving individuals who have sustained mild TBIs (including professional athletes).Christopher Levi none.

Lebrun, Constance M; Martin, Mrazik; Abhaya S, Prasad; Taryn, Taylor; Tatiana, Jevremovic

doi: 10.1136/bjsports-2016-097270.110pmid: N/A

ObjectiveTo examine knowledge base/practice patterns regarding sport concussion in two physician populations.DesignOn-line survey.SettingOntario, Canada.ParticipantsPhysicians from Ontario Medical Association, Sections of: Sport & Exercise Medicine (SEM), General & Family Practice (SGFP).InterventionEmailed survey, 2 reminders.Outcome measuresKnowledge base/practice patterns; learning methods: current/preferred.Main resultsParticipantsSEM 92/594 (15.5%), SGFP 270/12,168 (2.2%); 51 (13.4%) members of both. More SEM physicians saw >5 children (<18 years) with concussions/month (40.2% SEM, 9.5% SGFP; p =< 0.001).ToolsClinical examination; Sport Concussion Assessment Tool (SCAT/SCAT2) (68.4% SEM, 34.1% SGFP; p<0.001); balance testing (56.5% SEM, 37.4% SGFP; p=0.001); computerised neurocognitive testing (23.9% SEM, 1.9% SGFP; p<0.001); concussion grading scales (9.8% SEM, 14.1% SGFP; p<0.001). Management: Physical rest (65.2% SEM, 68.5% SGFP); modified school/work until symptom resolution (50.0% SEM, 38.5% SGFP; p=0.026); no cognitive rest (3.2% SEM, 9.6% SGFP; p=0.026).Return-to-play: Clinical examination; SCAT/SCAT2 (60.8% SEM, 29.6% SGFP; p<0.001); balance testing (56.5% SEM, 37.4% SGFP; p<0.001); computerised neurocognitive testing (35.9% SEM, 2.2% SGFP; p<0.001); concussion grading scales (7.6% SEM, 9.6% SGFP).Learning sourcescolleagues (55.4% SEM, 27.8% SGFP; p<0.001); specialists (33.7% SEM, 23.7% SGFP; p=0.030); continuing medical education (CME) courses/conferences (67.4% SEM, 54.7% SGFP; p=0.017; preferred: 85.9% SEM, 73.9% SGFP; p=0.006); journals/publications (48.9% SEM, 25.2% SGFP; p<0.001); websites (35.8% SEM, 32.2% SGFP; preferred: 35.9% SEM, 47.8% SGFP; p=0.024); medical school/residency training (19.6% SEM, 17.4% SGFP; preferred: 37.0% SEM, 47.8% SGFP).ConclusionsGaps exist between consensus-based recommendations and current practice patterns. Enhanced medical school/residency training and additional CME initiatives are recommended.Competing interestsNone.

Figler, Rick; Linder, Susan; Russman, Andrew; Cruickshank, Jason; Grey, Bob; Ozinga, Sarah; Lally, Maureen; Day, Tanujit; Alberts, Jay

doi: 10.1136/bjsports-2016-097270.17pmid: N/A

ObjectiveThe utilisation of a multi-factorial approach to evaluating relevant neuro-cognitive and motor function is a critical element in effective and comprehensive concussion management. In this project, normative data were gathered utilising the Cleveland Clinic Concussion (C3) iPad Application in youth, high school and college athletes. DesignProspective normative study. SettingField-based.ParticipantsPre-season C3 data were collected in more the 6,500 youth (N=607), high school (N=5415) and college (N=744) athletes; approximately 32% females. Data were collected between Fall 2014 and Spring 2015. InterventionsNA. Outcome measuresNeurocognitive assessment modules of C3 include information processing (simple and choice reaction time), attention and working memory (Trail Making Test) and postural stability. Balance is quantified through biomechanical processing of accelerometer and gyroscope data gathered from the iPad during performance of the BESS. Main resultsNo gender effects were present for performance on the neurocognitive modules; however, postural stability was significantly worse for youth males compared to female peers (P<0.01). Youth were significantly slower in performance of neurocognitive modules (simple and choice reaction time and Trails; (P<0.0001)). Neurocognitive and postural stability measures were similar across high school and college athletes. ConclusionsSlower neurocognitive performance in youth relative to older athletes underscores the need to utilise age appropriate normative data in the management of concussion, particularly if no baseline is acquired. The control of postural stability develops at different rates as a function of age and gender, therefore balance assessment across the injury spectrum must utilise specific age-gender normative values.Competing interestsJLA, SML and SBO have authored intellectual property associated with the mobile application presented in this study.

Gardner, Andrew J; Kay-Lambkin, Frances; Shultz, Sandy R; Iverson, Grant L

doi: 10.1136/bjsports-2016-097270.176pmid: N/A

ObjectiveTo investigate attitudes and knowledge of concussion.DesignOnline survey.SettingOnline questionnaire for the general public.ParticipantsAthletes, coaches, parents, sports administrators, and fans, aged 18–80 years.AssessmentA 75 question survey about the respondents’ concussion knowledge, sources of that knowledge, and attitudes toward injury.Outcome measuresFrequency of responses.Main resultsOf the 210 respondents who initiated the survey, there were 146 complete datasets. Respondents identified themselves as fans (46%), athletes (43%), coaches (20%), parents (18%), and administrators (13%). Most (85%) claimed to have little to average level of knowledge regarding concussion, the main source of knowledge for 26% of respondents was the media, and 59% had no knowledge of concussion guidelines (only 21% of respondents had heard of the Consensus Statement on Concussion in Sport), although 74% claimed to have knowledge of return-to-play guidelines. When considering reporting a concussion during a game, 77% considered it to be important, 77% beneficial, 74% valuable, 49% brave, and 21% easy. Most respondents indicated that it was extremely serious to experience headaches or dizziness after a blow to the head (54%), extremely important not to participate in physical activity when experiencing signs of concussion (67%), and extremely important to report concussion signs (77%). Respondents’ indicated that it was extremely important for players to be informed about: how concussions occur (67%), concussion prevention (67%), and what to do following concussion (82%). Some respondents (34%) strongly agreed that athletes are undereducated about concussion.ConclusionsPublic knowledge about concussion is modest.Competing interestsAndrew Gardner has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He serves, in a voluntary capacity, as a member of the Australia Rugby Union (ARU) concussion advisory group. He has received travel funding from the Australian Football League (AFL) to present at the Concussion in Football Conference in 2013. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas. He is currently funded through the HMRI, supported by Anne Greaves.Frances Kay-Lambkin: None.Sandy Shultz: None.Grant Iverson has been reimbursed by the government, professional scientific bodies, and commercial organisations for discussing or presenting research relating to mild TBI and sport-related concussion at meetings, scientific conferences, and symposiums. He has a clinical and consulting practice in forensic neuropsychology involving individuals who have sustained mild TBIs (including professional athletes).