Concussion in Road Cycling: A Call to Action

The authors of an April 2019 paper that systematically reviewed all literature on concussion and concussion management in road cycling call for a cycling-specific concussion protocol. They call upon the Union Cycliste Internationale (UCI) to hold a consensus meeting with road cycling medical teams to develop this cycling-specific concussion protocol.

The Need for a Cycling-Specific Concussion Protocol

Cycling reportedly accounts for almost 20% of concussion cases in the U.S -- the highest percentage of any sport

Cycling reportedly accounts for almost 20% of concussion cases in the U.S -- the highest percentage of any sport (1). In an analysis of Tour de France races between 2010-2017, concussions accounted for just over 2% of the injuries suffered by professional cyclists (2). More generally, concussions account for 1.3-9.1% of all injuries in cycling events and this rate is increasing (3-6). Concussions in cycling not only place the injured athlete at risk of short and long term harms, but an undetected injured athlete may also cause an accident (for example, due to a lack of balance which is a common side-effect of concussion), thereby potentially harming other cyclists (7).

Current Cycling Guidelines

Unfortunately, there is no internationally agreed-upon protocol for concussion in cycling.

Given the prevalence and consequences of concussion in cycling, it would thus be expected that there are cycling-specific concussion diagnosis and management protocols, yet this is not the case. Unfortunately, there is no internationally agreed-upon protocol for concussion in cycling (8). The UCI and the American Cycling Association (ACA) recommend using the SCAT5 and SCAT2 respectively to diagnose concussion in road cycling. These recommendations are problematic (9). The SCAT2 is out-of-date (having been created in 2008) and the ACA guidelines are largely meant for education and providing a means in which a team can put in place SRC diagnosis and management processes that are “a bottom line of best practice on which team medical staff can build on.” While the SCAT5 is the latest concussion tool published by the Concussion in Sport Group in 2016, this UCI recommendation remains problematic because the SCAT5 requires modifications in order to be relevant and effective in cycling.

Further Cause for a Cycling-Specific Protocol

There are specific challenges that come with assessing concussion in cycling more generally, such as: the fast pace of the sport and the “remote nature of medical monitoring for cyclists” given that sometimes cyclists are in one country and the medical team is in another (10,11). Ultimately, simply using generic concussion tools is not adequate because they do not address the unique qualities of road cycling.

How to Move Forward

Very few studies have examined this issue and the two studies that were reviewed for this paper’s systematic review make broad statements that are not helpful in further developing a cycling-specific protocol (9,12,13).  Some specific recommended developments/changes that the authors of this paper have suggested are to:

  • Use real-time and replayed television images to create a concussion spotting system;
  • “Motor-pace” a cyclist back into position after they are assessed for concussion to reduce the negative impact a concussion assessment may have on the individual/team’s performance and position;
  • Change the Maddocks questions to include cycling-specific questions such as: what is the name of the race, how many kilometers are left in the race, who is the road captain, what was your last race, and what is your coach’s name; and
  • Create a central injury database to understand patterns of injuries which will, therefore, help develop methods to reduce concussion incidences in cycling.

Other changes that could be made are:

  • Adopt the saying ‘if in doubt, sit them out’ as per many other sports worldwide;
  • Provide the cycling concussion guidelines in multiple languages to reflect the internationality of the cycling community; and
  • Potentially consider an independent evaluation to ensure adherence to the concussion protocol (14).

Considerations also need to be made for both medical and non-medical roles -- such as neutral mechanics who may be the first responder at the scene of a concussion-inducing incident.

Any adaptations also need to be evidence-based which means more research must be done specifically on concussion in cycling and what changes will make: 1) the sport safer and 2) concussion diagnosis and management effective in the cycling environment.

The paper can be found here: https://bmjopensem.bmj.com/content/5/1/e000525.

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

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Equestrian Helmets May Be Too Stiff to Reduce Risk of TBI

Even in the Equestrian World, Helmets Do Not Prevent Concussions…But They Are Not Even Designed to Try

A recent study, published in Sports Medicine – Open in May 2019, retrospectively found that 70% (139/189) of reported equestrian fall accidents (seemingly focused on horse racing and jockeys’ injuries specifically) resulted in a head injury – 91% of which were concussions. Other head injuries included: skull fractures (4%); diffuse axonal injury (3.6%); subdural hematoma (1%); and cerebral edema (0.7%).

The Study

216 helmets were collected via a damaged helmet return scheme in the UK and USA. Of the 216, 189 accident report forms were provided by the rider or their doctor. These reports were not standardized and the details provided varied. In saying that, associated injuries from the fall were recorded. These helmets also were visually examined to identify damage (or lack thereof) as well as disassembled to inspect any internal damage; all of the helmets were certified.

More to the Story

Little has changed with helmet testing over the last 30 years despite an increased understanding of impact biomechanics

Out of the 139 helmets that also had a report of head injury, 75 (54%) of the helmets showed damage whereas 64 helmets (46%) showed no damage. In fact, the more stringent the certification (i.e. – the stiffer the helmet), the more likely the helmet was to show no damage.

On the one hand, helmets that are very stiff will very likely help protect against skull fracture, more serious brain injury, and death. On the other hand, the researchers of this study suggest that stiffer helmets may be less effective for lower-severity impacts. They argue that this is specifically the case because equestrian helmet certification tests currently do not test helmets under the conditions that falls in equestrian sport occur.

There is a tendency for equestrian falls to occur on softer, uneven surfaces which will ultimately create oblique hits with rotational acceleration and current tests focus on linear acceleration (1-3). In fact, little has changed with helmet testing over the last 30 years despite an increased understanding of impact biomechanics (4).

Finally, the researchers suggest that if helmet testing were to consider these components and helmets were designed with these factors in mind, equestrian helmets may be better suited at reducing incidences of concussion/head injury in low-severity impacts.

Further Considerations Need to Be Made Prior to These Claims

The researchers of this study strongly state that new helmets need to be created by examining detailed accident reconstruction, clinical outcome data, and the needs of helmet users

Yet, in concussion literature, it is widely stated that helmets do not prevent concussion but rather, protect the head against more serious injury. Certainly, ensuring that helmets are designed with the sport in mind is important as is ensuring that helmets are diffusing as much energy from the impact as possible so that they are most effective at preventing these more serious brain or structural injuries. The fact that the researchers of this study strongly state that new helmets need to be created by examining detailed accident reconstruction, clinical outcome data, and the needs of helmet users in a collaborative environment with engineers, clinicians, riders, and equestrian regulatory authorities is reasonable. Certainly, these conditions are vital to achieve this goal of creating a safer equestrian helmet. It may be unreasonable however, given that there is no threshold force to sustain a concussion and that concussion is not prevented in other sports with helmets, to suggest that improving helmets in this way will reduce incidences of concussion.

How to Move Forward

Equestrian sports are incredibly high risk with higher reported rates of concussion and mild traumatic brain injury (mTBI) than American football or boxing

In saying that, equestrian sports are incredibly high risk with higher reported rates of concussion and mild traumatic brain injury (mTBI) than American football or boxing and it is important to start exploring ways to reduce incidences of concussion (5-12). Perhaps exploring the circumstances in which head injuries are arising may lead to changes to the sport/environment/rules/etc. that will help reduce concussion.

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

Works Cited

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Hope on the Horizon: Progressing to a Better Concussion Assessment

Study shows concussion assessments comprising of multiple tools is the best method to assess concussion

It is well known that assessment tools are required to identify concussion. Most organizations promote the use of multiple tools to evaluate several domains known to be impacted by concussion (1-4). Yet few studies have examined which tool individually or which tools in combination best assess and most accurately identify concussion. A recent study -- which examined 22,057 player seasons collected during 2014-2017 for multiple sports from various NCAA and military schools -- has found that concussion assessments comprising of multiple tools, including a subjective symptom tool, is the best method to assess concussion.

One Assessment Tool to Rule Them All?

In the study, all “full models” -- meaning concussion assessments comprised of multiple tools -- outperformed all individual tools

Unfortunately, no singular tool that assesses concussion is more effective than a combination of tools. In the study, all “full models” -- meaning concussion assessments comprised of multiple tools -- outperformed all individual tools, suggesting that testing batteries are more effective at identifying the effects of concussion (5-9). Interestingly, removing the SCAT total symptoms from the full model resulted in the greatest reduction in a model’s performance. On the other hand, removing the BESS minimally impacted the model’s performance, highlighting the BESS assessment’s possible lack of utility in assessing concussion. Ultimately, these results suggest that symptoms better indicate concussion than neurological status and balance assessments. These results differ from other studies that suggest neurological assessment has the highest sensitivity, but this difference may be attributed to methodology and sample size (5,6,8-10).

Are Baseline Tests Necessary or Useful?

Completing baseline testing is becoming more common, but the presumed problem arises when the baseline data is not available to the medical professional assessing the concussed individual.

Some assessment tools use baseline tests to examine the difference between an athlete’s performance before and after the concussive injury. Completing baseline testing is becoming more common, but the presumed problem arises when the baseline data is not available to the medical professional assessing the concussed individual. Even when the data is available, the usefulness of this data remains questionable (11-13). The study found that while there is utility in baseline test scores for the SAC and SCAT (but not the BESS), it is still possible to adequately assess concussion without baseline tests and therefore baseline results may not be clinically valuable (7,10,12,13). In saying that, since this study examined only the assessment of acute concussion, it is possible that baseline information may be useful beyond this acute stage but research is needed to explore this train of thought.

Subjective vs. Objective Data

The underreporting of symptoms (at a rate as high as 50%) may greatly impact how effective concussion assessments are

Since the study showed that symptom scores have a higher sensitivity and specificity than objective measures, the underreporting of symptoms (at a rate as high as 50%) may greatly impact how effective concussion assessments are -- many concussions could go unidentified (14). Unfortunately, all objective assessment tools were outperformed. This raises the importance for developing better objective means in which to diagnose concussion. In saying that, it is possible that the objective tools play an important role once symptoms resolve; examining the utility of objective assessment tools beyond the acute stage is important.

Potential Areas of Improvement

The simultaneous use and interpretation of multiple tools with multiple domains is challenging especially when it does not have a method to combine the results into a single measure

The findings of this study provide some direction as to how to improve concussion assessments. For instance, since the BESS does not provide much value, it may be worth considering removing the tool from assessments; removing the tool would also reduce the time it takes to assess concussion. Furthermore, since this study combined risk modifiers and standard assessments into one score which can be gathered within the time constraints of most sports, there is potential for this to be applied to sideline concussion assessment/management. Indeed, the simultaneous use and interpretation of multiple tools with multiple domains is challenging especially when it does not have a method to combine the results into a single measure (1,3,4,15).

Finally, while the study did not find significant relationships in terms of age, sex, or previous numbers of concussion, it still may be important to incorporate modifying factors (the ones mentioned above as well as numerous others not examined in this study) into acute concussion assessments. Indeed, they can be important factors to consider. For instance, this study found that males were found to have an increased risk of acute concussion (25, 51-53). At first, it looks like this result is contradictory to many other studies that have found females experience more symptoms and a worse cognitive decline (24,26,50,53,54). However, this study’s finding seems to suggest that male athletes may still be concussed despite having fewer symptoms and closer-to-normal neurocognitive deficits compared with female athletes. This fact/trend would be worth knowing and considering when assessing concussion and should be built into the assessment.

Areas to Explore

While this study did find concrete ways in which to improve concussion assessment, it also highlighted areas that are certainly lacking in information and require more research.

  • First, similar research is needed for high school, recreational, and professional athletes to examine whether these findings are similar across all categories of athletes.
  • Second, this study has limitations in the fact that it only looked at specific concussion assessments -- examining both individual components of each assessment, as well as other assessments, will be important.
  • Third, as mentioned above, research on the usefulness of these tools, baseline scores, and objective data beyond the acute stage is required.

Finally, this study does highlight the need for research on other clinical measures that can be used when certain objective data is either unavailable or not as clinically valuable and self-reported symptoms are unreliable.

The study can be found here: https://www.ncbi.nlm.nih.gov/pubmed/29488165

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

Works Cited

  1. McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport: the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838–47.
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  8. Resch JE, Brown CN, Schmidt J, Macciocchi SN, Blueitt D, Cullum CM, et al. The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one. BMJ Open Sport Exerc Med. 2016;2:e000012.
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What Is Known About the Psychological and Social Impacts of Sports-Related Concussion in Youth

It is well-known that sports-related concussion (SRC) can produce a variety of physical, cognitive, and emotional symptoms (1-3). In comparison to neurocognitive outcomes of concussion, however, far less is known about the psychological and social consequences of SRC in youth athletes.

The Particular Importance of Understanding This Area for Youth

This is an incredibly important area to explore as youth typically have longer lasting symptoms – 14-20% of youth experience symptoms beyond 3 months and 12% beyond 12 months – which has a direct impact on multiple aspects of daily life including academic and social areas (4-7).

The Current State of Literature is Underwhelming

A review of the current state of literature on the social and psychological impacts of SRC in youth found 6 main domains that youth’s issues and struggles fall under: emotional and social dysfunction, behavioural problems, academic difficulties, sleep disturbance, headache, and quality of life (QoL). Unfortunately, as explored below, the amount of information specific to SRC is underwhelming. Oftentimes, the authors of this study had to extrapolate conclusions based on studies about general mild Traumatic Brain Injury (mTBI) (i.e. not sport-specific mTBI), but even that research leave questions unanswered.

The Six Domains Impacted by SRC

Emotional and Social Dysfunction: Changes in mood are well associated with SRC and it is hypothesized that the biochemical changes that occur after SRC may directly impact mood (8). Yet, there are other factors that also can compound or produce emotional or social disturbances, such as symptoms of SRC (concentration, headaches, sleep disturbance, etc.) and potential frustration or stress-inducing restrictions in sport (9).

Highlighting the prevalence of emotional and social impacts of SRC, one study found that 50% of children with SRC experience emotional symptoms (10). In the same study, poorer psychiatric outcomes was associated with symptom burden at the time of injury as well as post-concussive syndrome (PCS), highlighting the importance of properly managing symptoms right from the start (10). A concerning statistic in this study is that a new or worsening psychiatric disorder occurred in 10% of the group with 25% of those children being left untreated (10). Another interesting find is that in comparison to other injuries, youth with SRC had more pronounced maladaptive coping (11).

Depression: In regards to depression, no SRC-specific studies have examined depression in youth. In saying that, depressive symptoms appear in youth with mTBI but often are at the subclinical level meaning that the child would not be diagnosed with depression. In one study, criteria for major depressive disorder were met by 4-6% of patients with uncomplicated mTBI (12). In another study, youth were 9x more likely to have a new mood diagnosis at 6 months (13). A third study found that youth with mTBI experience greater mood swings and withdrawal – but not necessarily clinical depression – 2 years after concussion (14). These statistics may highlight the fact that healthcare professionals managing concussion cases should be aware of the possibility that depression and other mood disorders may arise – potentially at the subclinical level – and regardless, should be addressed. One reason youth may experience depressive symptoms is that other symptoms and academic or QoL outcomes may produce or exacerbate low mood, suggesting that addressing these areas may help manage or resolve depressive symptoms (15).

Anxiety: Similarly, anxiety-related symptoms have not been explored in pediatric SRC. One study in pediatric mTBI literature suggests that around 10% of youth with mTBI develop “a new anxiety disorder within a year” and another study found that concussed children were “4x more likely to have a new anxiety diagnosis within 6 months” (16, 17). Fortunately in the latter study, in comparison with orthopaedic controls, the anxiety symptoms in mTBI youth were comparable 1 and 2 years later (18,19).

Social Functioning: There is a void of information in this area regarding pediatric SRC. The authors of this literature review suggest “it could be” that an extended disruption in a concussed child’s integration back into school and sports may “temporarily interfere with social relationships at a critical time in personal development.” One study examined uninjured, moderate/severe TBI, and mTBI children, finding that the mTBI group had the poorest social competence (20). These difficulties emerged after 2 years and are likely representative of the fact that children with mTBI receive less support because mTBI is an invisible, and not as severe, head injury in comparison to other traumatic brain injuries (19,21). Social support after traumatic brain injury aids in improving physical health and overall QoL and any negative impacts on social functioning due to concussion should be adequately addressed, but more information is required (22).

Behavioural Problems: Following the trend, there is very little research investigating behavioural disorders following pediatric concussion, sport-related or otherwise. In a New Zealand study, children with a history of mTBI during preschool years were at a greater risk of “attention-deficit/hyperactivity, conduct, or oppositional defiant disorder during adolescence” (23). Once again, this may be as a result of a disruption in the child acquiring behaviour skills during a “critical development period” (23, 24). In saying that, in one study, behavioural problems were either an issue or not present depending on who was asked about child conduct (parent vs. teacher) (25). Regardless, more research on this topic specific to SRC and mTBI generally is necessary.

Academic Difficulties: It is well-known that the symptoms of concussion can have negative impacts in the school environment, such as challenges with learning new material or difficulties concentrating, especially if one returns to school too soon which exacerbates symptoms (26). One study found that 45% of concussed students returned to school too early and suffered from worse symptoms (27, 28). Cognitive rest and slowly returning to school via a step-by-step program is important. Yet, it is important to find a balance between mental rest and activity as cognitive stimulation is important in recovery and there is a concern that the student may suffer from social isolation if withdrawn from school for too long (29).

Sleep Disturbance: Much like cognitive stimulation, it is important to find a balance between too much and too little sleep. Sleeping patterns often change immediately after a concussion -- 33% of concussed youth claimed they slept too much or had troubles sleeping (30, 31). Excessive sleep – identified in one study as longer than 9 hours – was associated with “reduced visual memory, visual motor speed, and reaction time” and prolonged symptoms (32,33). On the other end of the spectrum, sleep difficulties are associated with poorer functional, social, and emotional outcomes ( but these difficulties are not necessarily associated to concussion) (34,35). Sleep is an important restorative measure for the brain after concussive injury and these side-effects should be acknowledged and addressed for the most effective recovery (31, 32, 36, 37).

Headache: Chronic headaches are a common symptom after concussion, reported in more than 90% of high school concussions (31). The prevalence of chronic headache in youth 3 months after injury range from 8%-31% depending on the study (38, 39). Headaches, and pain in general, can have a negative impact on daily activities, mental health, sleep, and personal relationships (40). Interestingly, in one study that looked at post-injury headache in mTBI compared to arm fractures, more concussed females suffered from headache, highlighting that there are differences in concussion symptomatology and severity between males and females (41). More research is required in this area, particularly to understand the prevalence and duration of chronic headache in youth suffering from SRC as well as to understand the transition of acute post-concussion headache to chronic headache pain.

Quality of Life (QoL): The impact concussion has on overall QoL is up for debate. Some studies have found that athletes with greater post concussive symptoms or longer recovery had reduced QoL (42, 43) One study even found that QoL remained “significantly below normative levels even after symptom resolution” in 11% of children at 3 months and 13% at 12 months (44-47). This may be an important finding because it reinforces the idea that just because concussion symptoms are resolved does not mean all of concussion’s effects are resolved. This fact ultimately should have an impact on return to play (RTP) and treatment decisions. On the other hand, there are studies that also have mixed findings (48). Ultimately, QoL impairments seem to be minimal, with symptom burden likely being the cause of a lower QoL (46).

Final Conclusions

Ultimately, more information is required on these topics to fully understand what psychological and social components youth with SRC suffer from as well as to understand how to address these side-effects to most effectively manage concussion and promote recovery. Regardless, for the time being, it could be suggested that medical professionals managing concussion cases consider these 6 areas as potential areas that may be impacting the youth’s recovery.

The original review can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383087/

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

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  9. Meehan WP., III Medical therapies for concussion. Clin Sports Med. 2011;30:115–124, ix.
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  11. Covassin T, Elbin RJ, Beidler E, Lafevor M, Kontos AP. A review of psychological issues that may be associated with a sport-related concussion in youth and collegiate athletes. Sport Exerc Perform. 2017;6:220–229.
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  13. Luis CA, Mittenberg W. Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study. J Clin Exp Neuropsychol. 2002;24:270–279.
  14. Hawley CA, Ward AB, Magnay AR, Long J. Outcomes following childhood head injury: a population study. J Neurol Neurosurg Psychiatry. 2004;75:737–742.
  15. Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med. 2011;39:1209–1216.
  16. Max JE, Lopez A, Wilde EA, et al. Anxiety disorders in children and adolescents in the second six months after traumatic brain injury. J Pediatr Rehabil Med. 2015;8:345–355.
  17. Luis CA, Mittenberg W. Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study. J Clin Exp Neuropsychol. 2002;24:270–279.
  18. Hawley CA, Ward AB, Magnay AR, Long J. Outcomes following childhood head injury: a population study. J Neurol Neurosurg Psychiatry. 2004;75:737–742.
  19. Anderson V, Beauchamp MH, Yeates KO, et al. Social competence at two years after childhood traumatic brain injury. J Neurotrauma. 2017;34:2261–2271
  20. Anderson V, Beauchamp MH, Yeates KO, Crossley L, Hearps SJ, Catroppa C. Social competence at 6 months following childhood traumatic brain injury. J Int Neuropsychol Soc. 2013;19:539–550.
  21. Kennedy JE, Cullen MA, Amador RR, Huey JC, Leal FO. Symptoms in military service members after blast mTBI with and without associated injuries. Neurorehabilitation. 2010;26:191–197.
  22. Lumba-Brown A, Yeates KO, Gioia G, et al. Report from the pediatric mild traumatic brain injury guideline workgroup: systematic review and clinical recommendations for healthcare providers on the diagnosis and management of mild traumatic brain injury among children.
  23. McKinlay A, Grace R, Horwood J, Fergusson D, MacFarlane M. Adolescent psychiatric symptoms following preschool childhood mild traumatic brain injury: evidence from a birth cohort. J Head Trauma Rehabil. 2009;24:221–227.
  24. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2006;117:1359–1371.
  25. Taylor HG, Orchinik LJ, Minich N, et al. Symptoms of persistent behavior problems in children with mild traumatic brain injury. J Head Trauma Rehabil. 2015;30:302–310
  26. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132:948–957.
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Important Factors to Consider When Returning Concussed Youth to School

Study Shows Returning to School is a Unique Consideration for Concussed Youth

In comparison to adults, youth who suffer a sport-related concussion have to manage different factors, such as returning to school (RTS). Therefore, a 2018 study systematically reviewed academic literature concerning concussions in youth and RTS (1). Specifically, the study examined two questions: 1) what factors must be considered in RTS following concussion, and 2) what strategies or accommodations should be recommended following concussion?

Student athletes who continued to play after injury took twice as long to recover and were 9x more likely to have prolonged recovery

Factors To Consider

This study identified elements that tend to negatively impact a student’s ability to RTS. The list below summarizes these factors.

  1. Number of Symptoms or Symptom Severity: a higher number of symptoms or greater symptom severity indicated there was a greater chance of youth missing more days of school and having challenges RTS (2-6).
  2. Types of Symptoms: specific symptoms, such as: headache, fatigue, visual disturbances, memory deficits, difficulty concentrating, executive dysfunction, and vestibular abnormalities, negatively impacted a student’s ability to RTS (2-4,6-8).
  3. Duration of Symptoms: symptoms that lasted longer meant the students had more difficulty with RTS (2,5)
  4. Age/Grade: adolescents/high school students tended to suffer from: a) more symptoms, and b) more severe symptoms which was associated with taking longer to, and having more difficulty in, RTS in comparison to younger children (3-6,9-10). In one study, youth aged 13 years and older was a predictor of persistent symptoms (11). These trends may reflect increased academic and social demands, greater challenges to coordinate management strategies across multiple classes, and “greater independence and decreased supervision in compliance with medical recommendations” (1).
  5. Courses: math caused the most problems for students RTS followed by reading/language, arts, science, and social studies classes (5).
  6. Rest: youth who did not immediately rest after injury took longer to RTS (12). In fact, increased school attendance and higher cognitive loads after injury were associated with persistent or exacerbated symptoms (12-15). Student athletes who continued to play after injury took twice as long to recover and were 9x more likely to have prolonged recovery (16).
  7. Socioeconomic Status: youth with private insurance missed more days of school after a concussion than youth with public insurance (17).

What Accommodations Can Be Made?

Three interesting trends were found that could be helpful in developing specific accommodations other than increased school absence. First, most students were able to RTS after 2-5 days (14,18-19). Second, 45% of students may experience exacerbation or recurrence of symptoms when RTS (9). Third, anywhere from 17-73% of students received accommodations and/or experienced difficulty at school (2-4,7,10,18,20). Most interestingly, schools that had concussion policies were more likely to provide concussed students with accommodations in comparison to schools who did not have a policy (21). Similarly, students who had a medical RTS letter or received outpatient medical follow-ups were also more likely to be provided with accommodations (10,18).

More Research Needed

Due to the study’s reasonable inclusion criteria, only 17 studies were assessed for this systematic review. Ultimately, more research is needed in order to establish RTS processes and accommodations that are guided by clinical evidence.

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

References

  1. Purcell LK, Davis GA, Gioia GAWhat factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic reviewBritish Journal of Sports Medicine 2019;53:
  2. Baker JG , Leddy JJ , Darling SR , et al. Factors associated with problems for adolescents returning to the classroom after sport-related concussion. Clin Pediatr 2015;54:961–8.
  3. Corwin DJ, Wiebe DJ, Zonfrillo MR, et al. Vestibular deficits following youth concussion. J Pediatr 2015;166:1221–5
  4. Purcell L, Harvey J, Seabrook JA. Patterns of recovery following sport-related concussion in children and adolescents. Clin Pediatr 2016;55:452–8.
  5. Ransom DM, Vaughan CG, Pratson L, et al. Academic effects of concussion in children and adolescents. Pediatrics 2015;135:1043–50.
  6. Ransom DM, Burns AR, Youngstrom EA, et al. Applying an evidence-based assessment model to identify students at risk for perceived academic problems following concussion. J Int Neuropsychol Soc 2016;22:1038–49
  7. Darling SR, Leddy JJ, Baker JG, et al. Evaluation of the Zurich Guidelines and exercise testing for return to play in adolescents following concussion. Clin J Sport Med 2014;24:128–33.
  8. Lovell MR, Collins MW, Iverson GL, et al. Recovery from mild concussion in high school athletes. J Neurosurg 2003;98:296–301.
  9. Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: physician’s chart review. Can Fam Physician 2014;60:e310–e12-5
  10. Zuckerbraun NS, Atabaki S, Collins MW, et al. Use of modified acute concussion evaluation tools in the emergency department. Pediatrics 2014;133:635–42
  11. Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA 2016;315:1014–25
  12. Taubman B, Rosen F, McHugh J, et al. The timing of cognitive and physical rest and recovery in concussion. J Child Neurol 2016;31:1555–60.
  13. Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014;133:e299–304.
  14. Makki AY, Leddy J, Hinds A, et al. School attendance and symptoms in adolescents after sport-related concussion. Glob Pediatr Health 2016;3:1–3.
  15. Silverberg ND, Iverson GL, McCrea M, et al. Activity-related symptom exacerbations after pediatric concussion. JAMA Pediatr 2016;170:946–53
  16. Elbin RJ, Sufrinko A, Schatz P, et al. Removal from play after concussion and recovery time. Pediatrics 2016;138:e20160910.
  17. Zuckerman SL, Zalneraitis BH, Totten DJ, et al. Socioeconomic status and outcomes after sport-related concussion: a preliminary investigation. J Neurosurg Pediatr 2017;19:652–61.
  18. Grubenhoff JA, Deakyne SJ, Comstock RD, et al. Outpatient follow-up and return to school after emergency department evaluation among children with persistent postconcussion symptoms. Brain Inj 2015;29:1186–91.
  19. Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015;135:213–23.
  20. Corwin DJ, Zonfrillo MR, Master CL, et al. Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population. J Pediatr 2014;165:1207–15.
  21. Glang AE, Koester MC, Chesnutt JC, et al. The effectiveness of a web-based resource in improving postconcussion management in high schools. J Adolesc Health 2015;56:91–7.

Moving to 7-Day Disabled List Improves Major League Baseball Concussion Reporting

Major League Baseball’s (MLB) change from a concussion-specific mandatory 15-day disabled list (DL) rule to a 7-day DL rule in 2011 seemingly has improved concussion reporting amongst the league’s athletes.

Study’s Statistics

This study, published in The Orthopaedic Journal of Sports Medicine, examined 112 players between 2005-2016. The average number of concussions increased from 3.7 concussions/year prior to 2011 when the mandatory 15-day DL was enforced to 13.0 concussions/year after the mandatory 7-day DL rule was implemented.

The Importance

There are numerous benefits of this increased reporting of concussion. Most generally, concussion is traditionally underreported and increasing reporting rates is an important improvement in the area of concussion management. More specifically, given the potential harms of inadequately diagnosed and managed concussions, increased reporting and subsequent concussion care benefits the injured player’s health. Specifically to baseball, since a professional baseball player’s career trajectory significantly changes for the worse if a concussion is left unreported, increased reporting and subsequent appropriate concussion care is beneficial for both player and team success.

While concussions are prominent topics in sport leagues such as the National Football League (NFL) and National Hockey League (NHL), baseball is often overlooked. Thus, this study provides valuable insight into concussion identification and management trends in professional baseball. In fact, this study examined which positions had the highest rates of concussion. The top three positions were outfielders (34%), catchers (33%), and infielders (20%) followed by pitchers (8%) and basemen (4%). Pitchers however, had the highest number of days on the DL as well as the highest concussion-associated costs, followed by fielders and catchers.

Financial Benefits

This study also examined the total cost of the player’s injury to the team. The cost per concussed player before 2011 was $1.1 million and that total decreased to $565,000 after the 7-day DL rule change. This decreased cost occurred despite an increase in reported incidents of concussion and an increase in player salaries. This decrease may be partially explained by the decreased average number of days that concussed athletes spend on the DL (from 38.8 days during the 15-day DL rule to 29.2 during the 7-day DL rule) although the study did not speculate as to why the total cost of an injured player to a team decreased by almost 50%.

Cause for Concern

Many studies and concussion protocols, including this one, cite the fact that most concussions typically resolve between 7-10 days [1][2]. The most recent protocols and guidelines however, state that concussions resolve anywhere from 10-14 days to 4 weeks (the latter time period being most relevant for youth) [3][4]. It is thus initially concerning that the MLB reduced the mandatory sit-out period from 15 days to 7 days which may mean players are returning to play too early.

There are two pieces of evidence that may suggest there is no need for worry. First, this study examined average performance metrics between injured players before and after the 2011 rule change – including earned run average, walks plus hits per inning pitched, batting average, and on-base percentage – and found that there were no significant differences. This means that players before and after the 2011 rule were returning to the game at a similar skill level. It would be important and more valuable however, to examine the performance metrics of the specific injured player before and after his concussion to truly assess whether the player is returning at an appropriate time or too early.

Second, the fact that the average number of days an athlete stayed on the DL after a concussion decreased from 38.1 to 29.2 after 2011 but remained around the 4 week mark suggests that players still are taking significant time off to appropriately recover. In short, simply because the rule mandates a 7-day sit-out period does not mean that immediately after 7 days the player is back on the field.

Conclusion

Ultimately, one cannot conclude that the 7-day DL rule increased the reporting rates of concussion amongst MLB athletes as the trend may be attributable to a general increase in awareness and understanding of concussive injuries which positively correlates with increased reporting [5]. However, it can be said that decreasing the mandatory days on the DL from 15-days to 7-days creates an environment where MLB athletes may be more likely to report concussions. This change is beneficial both physically and financially.

The full study can be read here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383093/

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

References

  1. Belanger HG, Vanderploeg RD. The neuropsychological impact of sports-related concussion: a meta-analysis. J Int Neuropsychol Soc. 2005;11(4):345-357.
  2. Karr JE, Areshenkoff CN, Garcia-Barrera MA. The neuropsychological outcomes of concussion: a systematic review of meta-analyses on the cognitive sequelae of mild traumatic brain injury. Neuropsychology. 2014;28(3):321-336.
  3. “Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms.” Ontario Neurotrauma Foundation, 6 July 2018, www.braininjuryguidelines.org/concussion.
  4. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5thinternational conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.
  5. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495-503.

 


Increase in Diagnosed Concussions Following Mandated Concussion Policy

Study shows there is still room for improvement in documenting suspected concussions.

A study examining the effect of Ontario’s Policy/Program Memorandum #158 (PPM #158) – a policy requiring each publicly funded school board in the province to create and implement a concussion policy – has found that there has been a 30% increase in diagnosed concussions in school children after policy was implemented.[1]

Comparing Trends

The study, published in the November 2018 issue of BMC Public Health, examined 21,094 head injuries in youth aged 4-18 between 2009-2016 from five hospitals across Ontario. The purpose being to compare trends of the 8,935 diagnosed and 12,159 suspected concussions in youth before and after PPM #158 was established in March 2014.

In the 5 years prior to PPM #158, the average number of diagnosed concussions in school children was 89 concussions/month. That number increased to 117 diagnosed concussions/month after the policy was established. Similarly, there was an “almost twofold” increase in the number of diagnosed concussions where the concussion-inducing incident happened at school. Before March 2014, school-incurred concussions accounted for 28% of all diagnosed concussions. This rate increased to almost 50% in 2016. The most common places of injury at school were the playground (24%), gymnasium (22%), or sports field (20%).

The Gender Equation

Finally, there was also an increase of diagnosed concussions in females, growing from 38% in 2013 to 46% in 2016 after PPM #158. This increase in the number of confirmed concussions in women is important.[2] Some studies have suggested that female head injuries are more often overlooked despite the fact that women may receive more concussions – with longer recoveries – than their male counterparts.[3],[4],[5],[6],[7]

Is the policy truly effective?

It is important to note that the total number of identified head injuries (comprising of both suspected and diagnosed concussions) did not increase after the policy. Given the trends of under-reporting for concussion, this circumstance raises questions as to whether PPM # 158 was indeed effective at increasing concussion awareness and reporting at schools. In fact, the increase in only diagnosed concussions may suggest that there was an improvement in emergency department doctors’ knowledge and confidence in diagnosing concussion – an increase that would be unrelated to the policy.

More Research and More Policies

The study concludes that “ongoing research into the effectiveness of PPM 158 in terms of prevention of concussions and student, teacher, and parental awareness is required.” This call for research should also extend to examining the effectiveness of the Ontario government’s latest concussion safety bill: Bill 193, Rowan’s Law (Concussion Safety), 2018. Further research will help support the direction of changes made to concussion policy and legislation in Ontario as well as push other provinces to develop and implement effective concussion policy and legislation.

You can read the full study here: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6232-9

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

 

Footnotes

[1] Ministry of Education of Ontario. Policy/Program memorandum no. 158. 2014. http://www.edu.gov.on.ca/extra/eng/ppm/158.pdf. Accessed 9 Feb 2017.

[2] Zhang AL, et al. The rise of concussions in the adolescent population. Orthopaedic journal of sports medicine. 2016;4(8):2325967116662458.

[3] Snyder M. Girls Suffer Sports Concussions at a Higher Rate than Boys. Why Is That Overlooked? The Washington Post. 2015. https://www.washingtonpost.com/posteverything/wp/2015/02/10/our-effort-to-reduce-concussions-inyouth-sports-overlooks-the-biggest-victims-girls/?utm_term=.29b684e6a9a9.Accessed 14 Feb 2017.

[4] Abrahams S, et al. Risk factors for sports concussion: an evidence-based systematic review. Br J Sports Med. 2014;48(2):91–7.

[5] Schallmo MS, Joseph AW, Wellington KH. Sport and sex-specific reporting trends in the epidemiology of concussions sustained by high school athletes. JBJS. 2017;99(15):1314–20.

[6]Resch JE, et al. Sport concussion and the female athlete. Clin Sports Med. 2017;36(4):717–39.

[7] Covassin T, Moran R, Elbin RJ. Sex differences in reported concussion injury rates and time loss from participation: an update of the National Collegiate Athletic Association Injury Surveillance Program from 2004–2005 through 2008–2009. J Athl Train. 2016;51(3):189–94.