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Importance: Sport-related concussions (SRC) can significantly impact students' attendance and academic performance, highlighting the importance of gradual return-to-learn protocols for recovery. Understanding the association between missed school days and recovery, especially across genders, is vital for effective concussion management in high school athletes., Objectives: To describe missed school days in high school athletes with SRC and to determine associations between missed school days and authorized clearance to return to competition; secondarily, to determine whether school days missed differed by gender., Design, Setting, and Participants: Cohort study among student athletes participating in athletics sponsored by the Michigan High School Athletic Association (MHSAA) during academic years 2015 to 2023. SRC was a participant eligibility criterion and was defined as a head injury during participation in a MHSAA-sanctioned event. Data were analyzed from August 2015 to June 2023., Exposures: Primary exposure was missed school days; additional exposures included gender, year of season, concussion history, event type, sport level, contact level, and athletic trainer involvement., Main Outcome and Measure: The primary outcome was time to full unrestricted clearance following SRC., Results: The analysis included a total of 20 934 individuals with SRC (13 869 boys [66.25%]). Gender (χ23 = 167.40; P < .001), season (χ221 = 57.41; P < .001), event type (χ23 = 99.29; P < .001), sport level (χ29 = 68.15; P < .001), contact level (χ26 = 56.73; P < .001), and initial evaluation (χ23 = 147.13; P < .001) were independently associated with missed school days. Athletes took a median (IQR) of 11 (7-16) days to return to full unrestricted clearance. Relative to no missed school days, there was a significant mean increase of 57% (incidence rate ratio, 1.57; 95% CI, 1.52-1.62) in time to full unrestricted clearance for 3 or more missed school days. The estimated mean days to return to sport were 12.15 (95% CI, 12.00-12.30) for 0 missed school days, 12.68 (95% CI, 12.39-12.96) for 1 missed school day, 15.47 (95% CI, 15.06-15.87) for 2 missed school days, and 19.08 (95% CI, 18.55-19.62) for 3 or more missed school days., Conclusions and Relevance: This cohort study found that high school athletes typically missed 2 or fewer school days after SRC, suggesting that concussion management teams adhered to current recommendations of 24 to 48 hours of initial rest. The dose association, with more missed school days associated with slower return to play, suggests athletes' missing more school days (eg, ≥3) may be associated with severity of concussion and warrant additional support to return to school and/or sport.

The Vestibular/Ocular Motor Screening (VOMS) is a sport-related concussion screening tool that assesses vestibular ocular reflex (VOR) and oculomotor symptom provocation. Long-term test-retest reliability of the VOMS over multiple athletic seasons has not yet been established in a pediatric population. Fifty-one child athletes (females = 28, 54.9%) 8-13 years of age, completed a baseline VOMS assessment at two timepoints, 18 months apart. Cronbach's alpha was used to examine the internal consistency at both time points. Two-way mixed intra-class correlation coefficients and Cohen's Kappa statistics were used to evaluate test-retest reliability. High internal consistency existed at both initial ( α  = 0.91) and follow-up ( α  = 0.95) for VOMS symptom provocation items. Strong inter-item correlations were noted between vertical VOR ( r  = ≥0.70) and visual motion sensitivity (VMS) ( r  = ≥0.70). Fair agreement was produced for convergence ( κ  = 0.23, vertical VOR ( κ  = 0.25) and VMS ( κ  = 0.25), as well as reliability on NPC distance (ICC 2, k  = 0.31). All other VOMS scores yielded poor agreement between time points. Symptom provocation was the same for 49% of athletes between timepoints, while 31.4% had a decrease in scoring at follow-up. Symptom provocation from VOMS tasks lessened with increasing age and time; therefore, clinicians should consider annual baseline testing to improve accuracy for concussion evaluation and management in pediatrics.

Background: Growing interest has motivated recent studies to examine differences in recovery after sport-related concussion (SRC) by sex. However, heterogeneity in study design, participants, and recovery outcomes has led to mixed findings. Further work is needed to evaluate potential differences by sex and to investigate the role of related characteristics, such as sport contact-level, in recovery timelines. This study aimed to investigate whether concussion recovery trajectories differ by sex, considering a priori clinical and demographic covariates, and accounting for the sequence of recovery outcomes. Our secondary question was whether sport contact-level modifies the relationship between sex and time to outcomes. Using data from the Ivy League-Big Ten Epidemiology of Concussion Study, we included SRCs reported across five academic years; 2015-2020 (February 2020). We used Cox proportional hazards regressions to estimate associations between sex and time from injury to three outcomes: (1) symptom resolution, (2) return to academics, (3) return to full play, accounting for measured confounders., Results: Among 1160 SRCs (male, n = 667; female, n = 493) with complete data, median age overall was 20 years (25th-75th percentiles:19-21), and most occurred among athletes playing high-contact sports (78.0%). Males were slightly more likely to complete symptom resolution over time compared to females (HR = 1.18, 95%CI = 1.05-1.33), but results were attenuated in fully adjusted models (HR 1.13, 95%CI = 0.99-1.29). Similarly, the HR of full academic return for males compared to females was 1.22 (95%CI = 1.07-1.38), but was attenuated in fully adjusted models (HR = 1.11, 95%CI = 0.97-1.28). The HR of full return to play for males compared to females was 1.14 (95%CI = 1.02-1.28), and was attenuated after adjustment (HR = 1.06, 95%CI = 0.93-1.20) as well. The interaction between sex and playing a high/low-contact sport was not statistically significant across models, though differences were apparent., Conclusions: Among a cohort of collegiate athletes with SRC, recovery timelines appeared similar between male and female athletes, adjusting for measured confounders. Differences by sex, considering sport contact-level, were evident and may be important clinically and in future studies. This study used robust methods, accounting for nesting in the sequence of RTP outcomes. Results inform concussion management protocols and planned qualitative work to further elucidate how collegiate athletes experience concussion recovery., Key Points: Heterogeneity in study design, participants, and recovery outcomes has led to mixed findings in determining differences in recovery trajectories after concussion by sex. We found that having longer time to symptom resolution, and also the sequence of having academic return before symptoms resolve and longer time to academic return were confounders in the relationship between sex and RTP timelines. Time to sequential recovery outcomes appeared similar between male and female athletes, adjusting for observable confounders. Further differences by sex were evident when considering contact-level, and may be important to consider clinically and in future research. Results indicate that differences in concussion recovery trajectories by sex may be largely attributed to and driven by differences in sports with a men's or women's team only, such as football, and this should be explored further., (© 2024. The Author(s).)

Objective: The first objective was to establish the respective factor structures of a concussion perceptions inventory that was adapted for youth athletes (ages 8-14 years) and their parents from the Perceptions of Concussion Inventory for Athletes. The second objective was to understand the associations between the concussion perceptions of youth athlete-parent dyads., Method: In this cross-sectional study, 329 parent-youth athlete dyads completed a respective concussion perception inventory. Mean age of youth respondents was 10.9 ± 1.8 years (70.1% male) and mean age of parent respondents was 40.5 ± 13.6 years (60.9% female)., Results: Exploratory factor analyses revealed unique 7-factor structures for both the youth athlete and parent inventories (youth athlete: anxiety, clarity, treatment, permanent injury, symptom variability, long-term outcomes, and personal control; parent: anxiety, clarity, treatment, permanent injury, symptom variability, and long-term outcomes, and affect others). Weak associations were found between dyads on the 5 factors that were composed of identical items (anxiety, clarity, treatment, permanent injury, and symptom variability)., Conclusions: Findings suggest that this adapted inventory has adequate psychometric properties to be used in the study of the concussion perceptions of youth athletes and their parents. Weak correlations across the concussion perceptions in the dyads suggest that parents and children hold different concussion perceptions and this should be considered in instrument selection of future studies., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Epidemiology provides fundamental opportunities to protect student-athlete health. The goal of this study was to describe the epidemiology of sport-related concussion (SRC) across 8 years (2015/2016-2022/2023) and compare boys' and girls' sports for SRC incidence and SRC mechanisms., Methods: This was a retrospective cohort study performed using a statewide high school head injury surveillance system of high school student-athletes (n = 2,182,128; boys, n = 1,267,389; girls, n = 914,739). Exposures of interest included study year and boys and girls in comparable sports. Clinical incidence was calculated by dividing SRC counts in each sport by the number of participants per 100 player-seasons and presented with 95% CIs. The 2019/2020 and 2020/2021 data were included in the analysis, however caution is warranted due to the COVID-19 pandemic. Clinical incidence ratios (CIRs) were estimated for sex-comparable sports, and significance was determined if 95% CIs excluded 1.00. The authors compared mechanism of injury in boys' and girls' comparable sports with chi-square analyses (p < 0.05)., Results: Among 25,482 total SRCs, the overall clinical incidence of SRC for all boys and girls was 1.17 (95% CI 1.15-1.18) per 100 player-seasons across all years. Across all years, the overall clinical incidence in boys' sports was 1.34 (95% CI 1.32-1.36) per 100 player-seasons, and 0.93 (95% CI 0.91-0.95) per 100 player-seasons in girls' sports. Boys' sports with the highest clinical incidence included football, ice hockey, and wrestling. Girls' sports with the highest clinical incidence included basketball, soccer, lacrosse, competitive cheer, and gymnastics. Girls consistently had higher SRC rates relative to boys for baseball/softball, basketball, and soccer (CIR range 1.65 [95% CI 1.41-1.93] to 3.32 [95% CI 2.67-4.16]). Girls had lower SRC in lacrosse in 2015/2016 (CIR 0.63, 95% CI 0.40-0.97); no difference in 2016/2017-2020/2021, but had higher clinical incidence in 2021/2022 (CIR 1.69, 95% CI 1.18-2.44) relative to boys. In boys the most common mechanism of SRC occurred from person-to-person contact (n = 8752, 62.8%), whereas girls commonly sustained SRC from person-to-object contact (n = 2369, 33.4%) and from person-to-person contact (n = 2368, 33.4%). There were significant associations between boys' versus girls' sports and mechanism of injury within baseball/softball (χ2 = 12.71, p = 0.005); basketball (χ2 = 36.47, p < 0.001); lacrosse (χ2 = 185.15, p < 0.001); and soccer (χ2 = 122.70, p < 0.001)., Conclusions: These findings can help understand the potential impact of interventions aimed at preventing or reducing SRC. Including girls' sports within this study extends research for a largely underrepresented group.

Background: Headache is among the most common symptoms following concussion, yet headache after concussion (HAC) remains poorly characterized. This study describes headache characteristics over the first four weeks following pediatric sport-related concussion., Methods: This is a retrospective case series of 87 athletes (mean: 14.9 years; range: 8.4-18.8 years; 38% female) treated in a specialty sports concussion clinic within 28 days of injury. Primary outcomes of headache consistency, frequency, duration, and associated migrainous symptoms were assessed at immediate (0 to 48 h) and weekly time points over the first 28 days post-injury. Generalized mixed linear models compared headache characteristics across time points. Secondary analyses compared each outcome by as-needed analgesic use., Results: During the immediate post-injury period, headache was more often constant ( p = 0.002) and associated with migrainous symptoms ( p < 0.001). By the third week post-injury, episodic headache was more prevalent ( p < 0.001). Most patients (54%) transitioned from constant, migrainous headache to episodic, non-migrainous headache. This finding was uninfluenced by as-needed analgesic medication use., Conclusions: These findings document the trajectory of HAC. Future studies should assess relationships between initial headache characteristics and recovery.

Background: Traumatic brain injury (TBI) is an acute injury that is understudied in civilian cohorts, especially among women, as TBI has historically been considered to be largely a condition of athletes and military service people. Both the Centres for Disease Control and Prevention (CDC) and Department of Defense (DOD)/Veterans Affairs (VA) have developed case definitions to identify patients with TBI from medical records; however, their definitions differ. We sought to re-examine these definitions to construct an expansive and more inclusive definition among a cohort of women with TBI., Methods: In this study, we use electronic health records (EHR) from a single healthcare system to study the impact of using different case definitions to identify patients with TBI. Specifically, we identified adult female patients with TBI using the CDC definition, DOD/VA definition and a combined and expanded definition herein called the Penn definition., Results: We identified 4446 adult-female TBI patients meeting the CDC definition, 3619 meeting the DOD/VA definition, and together, 6432 meeting our expanded Penn definition that includes the CDC ad DOD/VA definitions., Conclusions: Using the expanded definition identified almost two times as many patients, enabling investigations to more fully characterise these patients and related outcomes. Our expanded TBI case definition is available to other researchers interested in employing EHRs to investigate TBI., Competing Interests: Competing interests: ALCS is an Associate Editor at Neurology. DJW provides consulting services on the topic of concussion/TBI epidemiology to the NCAA., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The current evidence for acute management practices of sport-related concussion (SRC) is often limited to in-clinic visits, with limited studies identifying professionals in early SRC care and the association with prolonged recovery outcomes., Purpose: To describe acute SRC management practices (ie, the personnel in the initial evaluations, removal from activity) and test the association with prolonged return to sport (RTS) time., Study Design: Descriptive epidemiology study., Methods: We conducted a retrospective cohort study of 17,081 high school SRCs accrued between the 2015-2016 and 2020-2021 academic years. We reported acute management practices and RTS time as frequencies stratified by sex, sport, and event type and compared athletic trainer (AT) access in initial evaluation with chi-square tests ( P < .05). Separate logistic regressions estimated odds ratios (ORs) and 95% CIs for removal from activity and prolonged RTS >21 days by acute management practices., Results: Most SRCs (n = 12,311 [72.1%]) had complete initial evaluation by an AT. Boys had an AT evaluation in 75.5% (n = 2860/3787) of practice-related and 74.8% (n = 5551/7423) of competition-related events. Girls had an AT evaluation in 61.3% (n = 1294/2110) of practice-related and 69.3% (n = 2606/3761) of competition-related events. In sex-comparable sports (n = 6501), there was no difference between boys (n = 1654/2455 [67.4%]) and girls (n = 2779/4046 [68.7%]) having an AT involved in the first evaluation (χ2 = 1.21; P = .27). Notably, 25.3% of girls' SRCs were evaluated by a coach alone, and we observed differences in personnel in initial evaluations by sport. The odds of immediate removal were higher when an AT made the initial evaluation (OR, 2.8 [95% CI, 2.54-3.08]). The odds of prolonged RTS >21 days was lower for those with an AT in the initial evaluation (OR, 0.74 [95% CI, 0.65-0.84]) adjusting for significant factors from univariate analyses, boys relative to girls (OR, 0.85 [95% CI, 0.76-0.96]), specialty care relative to PCP (OR, 2.16 [95% CI, 1.90-2.46]), specialty care relative to urgent or ready care (OR, 0.99 [95% CI, 0.82-1.22]) concussion history (OR, 1.41 [95% CI, 1.22-1.63]), and removal from activity (OR, 0.90 [95% CI, 0.78-1.05])., Conclusion: This study found variability in personnel involved in initial SRC evaluations, with higher percentages of athletes with SRCs having ATs make the initial evaluation during competitive events. There was no association between sex and AT involvement in comparable sports. There was an association between prolonged RTS and AT involvement, sex, concussion history, and location of follow-up care., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Funding for A.C.B. and D.J.W. is provided by the Training Program in Respiratory Neurobiology and Sleep (HL007713); funding for A.C.B. comes from the Penn Injury Science Center (CDC R49 CE 003083). D.J.W. serves as a consultant to the National Collegiate Athletic Association on matters of concussion and sports participation. This project was supported by the Michigan High School Athletic Association (MHSAA). The content of this report is solely the responsibility of the authors and does not necessarily reflect the views of the MHSAA. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Researchers often use publicly available data sources to describe injuries occurring in professional athletes, developing and testing hypotheses regarding athletic-related injury. It is reasonable to question whether publicly available data sources accurately indicate athletic-related injuries resulting from professional sport participation. We compared sport-related concussion (SRC) clinical incidence using data from publicly available sources to a recent publication reporting SRC using electronic health records (EHR) from the National Football League (NFL). We hypothesize publicly available data sources will underrepresent SRC in the NFL. We obtained SRCs reported from two publicly available data sources (NFL.com, pro-football-reference.com) and data reported from the NFL's published EHR. We computed SRC per 100 unique player signings from 2015-2019 and compared the clinical incidence from publicly available data sources to EHR rates using clinical incidence ratios (CIR) and 95% confidence intervals (CI)., Findings: From 2015-2019, SRC counts from published EHR record data ranged from 135-192 during the regular season, whereas SRC counts ranged from 102-194 and 69-202 depending on the publicly available data source. In NFL.com the SRC clinical incidence was significantly and progressively lower in 2017 (CIR: 0.73, 95% CI: 0.58-0.91), 2018 (CIR: 0.66, 95% CI: 0.50-0.87), and 2019 (CIR: 0.48, 95% CI: 0.35-0.64) relative to the gold-standard EHR. In the pro-football-reference.com data, the documented SRCs in publicly available data sources for other years were ~ 20-30% lower than the gold-standard EHR numbers (CIRs 0.70-0.81)., Conclusions: Publicly available data for SRCs per 100 unique player signings did not match published data from the NFL's EHR and in several years were significantly lower. Researchers should use caution before using publicly available data sources for injury research., (© 2024. The Author(s).)

This cross sectional investigation measured the agreement between parent report of their 8-14 year old child's sport-related concussion (SRC) history and their child's self-report of their own SRC history. Parent-child dyads ( n  = 405) within a youth contact sports (e.g., football, ice hockey, lacrosse, soccer) setting participated in the study. Parents (6.2%) and 8.6% of children self-reported a history of at least one diagnosed SRC. We observed substantial agreement between the number of parent-reported and child self-reported SRCs ( κ  = 0.613, p  ≤ .001). Partial agreement regarding the number of SRCs reported by both groups was also substantial (weighted κ  = 0.693, p  ≤ .001). Removing dyads where neither the parent nor the child reported a diagnosed SRC, sensitivity analyses revealed only fair agreement in parent-child SRC recall. These results indicate that parents and youth athletes overall accounts of their diagnosed SRC history correspond. However determining specifics (e.g., total concussion counts) may benefit from concurrent parent reports, or documented events in medical histories.

Purpose: The purpose of this study was to determine changes in neurocognitive, psychosocial, and balance functioning in collegiate male and female soccer players across three consecutive years of baseline testing compared with a control group of noncontact athletes., Methods: Generalized estimating equations were used to compare changes in annual, preseason baseline measures of neurocognitive function, neurobehavioral and psychological symptoms, and postural stability between collegiate soccer players ( n = 75; 51 [68%] female soccer players) and noncontact athletes ( n = 210; 133 [63%] female noncontact athletes) across three consecutive years., Results: Among all participants, the group-time interaction was not significant for any outcome measures. Overall, soccer players reported lower (better) Brief Symptom Inventory 18 Depression ( P = 0.004, Exp(B) = 0.36, 95% confidence interval [CI] = 0.18-0.73), Global Severity Index ( P = 0.006, Exp(B) = 0.53, 95% CI = 0.33-0.84), and Post-Concussion Symptom Scale Symptom Severity ( P < 0.001, Exp(B) = 0.45, 95% CI = 0.22-0.95) scores than noncontact athletes. No other outcome measures were different between soccer players and noncontact athletes., Conclusions: Among collegiate athletes, soccer players report similar or better psychosocial functioning and symptom scores than noncontact athletes. Importantly, neurocognitive functioning, neurobehavioral and psychological symptoms, and postural stability do not worsen over time in collegiate soccer players relative to their noncontact counterparts. Our findings suggest that despite possible exposure to repetitive head impacts, collegiate soccer players do not exhibit changes in observable function and symptoms across multiple seasons., (Copyright © 2022 by the American College of Sports Medicine.)

Soccer athletes experience repetitive head impacts (RHI) through purposeful heading and unintentional head impacts, which may be associated with acute and chronic brain injury. Previous soccer studies have sought to quantify and characterize RHI, but to-date no consistent, standardized methods exist. The Heads-Up Checklist (HUC), originally used for characterizing head impacts in hockey, was modified to be used in soccer (soccer HUC [SHUC]). Our aim was to determine the reliability of quantifying ball-to-head impacts using video verification and to develop and test the reliability of the SHUC to characterize RHI in soccer. Two trained reviewers used the SHUC to quantify ball-to-head impacts and characterize non-ball-to-head impacts in 38 male and female collegiate soccer matches. Intraclass correlation coefficient (ICC) and Cohen's Kappa were used to assess interrater reliability. Independent t -tests and chi-square analyses were used to examine sex differences. The interrater reliability for quantifying ball-to-head impacts was excellent (ICC = 0.97); however, only half of the non-ball-to-head impact characteristics had acceptable interrater reliability with two reviewers. The number of ball-to-head-impacts and RHI characteristics were consistent between males and females (ggg p > 0.05). Our results suggest that the SHUC is an applicable standardized method to quantify and characterize RHI from video footage of soccer matches; however, accurately characterizing some aspects of RHI is a challenging task that may be supplemented by head impact sensor data.

Context: Football continues to demonstrate the highest rate of sport-related concussion (SRC) in high school athletics. To mitigate the SRC risk, the Michigan High School Athletic Association (MHSAA) implemented rules aimed at reducing the number of collisions occurring in practices., Objective: To estimate the rates of SRC in MHSAA football programs and evaluate progressive limitations to collision practices over 5 consecutive seasons., Design: Retrospective cohort study., Setting: Michigan high school football., Patients or Other Participants: High school (9th-12th grade) football athletes (>99% male) participating in MHSAA-sanctioned events., Main Outcome Measure(s): Designated administrators at each school recorded the total number of participating athletes and SRCs (defined as head injuries resulting from athletic participation that required the student-athletes to be withheld from activity after exhibiting signs, symptoms, or behaviors consistent with an SRC) in the MHSAA injury-surveillance system each season (2015-2016 through 2019-2020). Progressive limitations to collision practices occurred across the study period. We estimated athlete-exposures (AEs) as the total number of players multiplied by the total number of possible practices (11 weeks, 4 days each) or competitions (9 weeks, 1 day each) during each season. Incidence rates and rate ratios (RRs) with 95% CIs were used to compare practice and competition SRCs and each season with the most recent season., Results: A total of 7755 football SRCs were diagnosed across the 5-year period. The overall SRC rate was 8.03 per 10 000 AEs (95% CI = 7.85, 8.21). The competition SRC rate (30.13/10 000 AEs) was higher than the practice rate (3.51/10 000 AEs; RR = 8.58; 95% CI = 8.19, 9.00). The practice SRC rate was lower in 2017-2018 (RR = 0.86; 95% CI = 0.77, 0.97), 2018-2019 (RR = 0.89; 95% CI = 0.79, 1.0), and 2019-2020 (RR = 0.83; 95% CI = 0.74, 0.94) relative to 2015-2016., Conclusions: We found that the progressive limitations to collision practices were protective against SRCs, as the rate of SRC was lower in the 3 most recent seasons relative to 2015-2016., (© by the National Athletic Trainers' Association, Inc.)

Background: There is growing awareness and clinical interest in athletes with affective symptoms after sport-related concussion (SRC), as these symptoms may contribute to overall symptoms and represent a modifiable risk factor of longer recovery. However, evidence of their effects on the entire return-to-play (RTP) trajectory, particularly among women and men, is limited., Purpose/hypothesis: To examine the relationship between affective symptom reporting and RTP progression after SRC among a cohort of Division 1 student-athletes. We hypothesized that those endorsing affective symptoms, specifically nervous-anxious symptoms, spend more time in RTP progression and recovery., Study Design: Cohort study; Level of evidence, 3., Methods: Using SRC data from the Ivy League-Big Ten Epidemiology of Concussion Study among varsity athletes through February 2020, we identified the 4 affective symptoms from the Sport Concussion Assessment Tool symptom inventory. We modeled the relationship between a 4-category affective symptom variable and time to symptom resolution, RTP, and RTP progression, adjusting for nonaffective symptom prevalence and concussion history. Cox regressions were used to estimate hazard ratios for time to event outcomes, and linear regressions were used to evaluate mean differences for continuous outcomes., Results: Among 2077 student-athletes (men, 63.5%) with SRC symptoms, affective symptom prevalence was 47.6% and 44.3% in women and men, respectively, and nervous-anxious prevalence was 24.2% and 22.5%, respectively. When comparing women with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with affective symptoms, and women with nervous-anxious symptoms spent significantly longer in RTP progression. When comparing men with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with co-occurring affective symptoms, and affective symptoms were not associated with time in RTP progression., Conclusion: Student-athletes with affective symptoms and nervous-anxious symptoms exhibited delayed clinical recovery and RTP timelines, particularly for time in RTP. Symptom prevalence and concussion history contributed to this; however, unmeasured confounding remains, as indicated by the poor model fit. This study motivates future work to explore affective symptoms and RTP timelines, considering anxiety and risk/protective factors over time.

Context: Researchers conducting studies about sport-related concussion (SRC) reporting behaviors and reasons for nondisclosure primarily focus on older athletic populations. Youth athletes participating in contact sports are also at risk for SRC; however, little is known about their SRC disclosure patterns and reasons for nondisclosure., Objective: To examine the self-reported SRC history and reasons for SRC nondisclosure of youth athletes aged 8-14 years., Design: Cross-sectional study., Setting: Youth athletes in organized football, ice hockey, lacrosse, or soccer., Patients or Other Participants: A total of 411 youth athletes (boys = 70.0% [n = 287/410]; median age = 11 [interquartile range = 10-13] years)., Main Outcome Measure(s): A 15-minute survey including self-reported demographics, diagnosed and nondisclosed SRC history, and reasons for nondisclosure of suspected SRCs., Results: Ten percent of respondents (n = 41/411) recounted ≥1 diagnosed SRC, 12.7% (n = 52/411) did not report a suspected SRC, 13.1% (n = 53/404) indicated they continued to practice, and 12.3% (n = 50/406) reported they continued to play in a game after a suspected SRC. Significant associations between sport and nondisclosure existed (P values < .001) but not with self-reported concussion history (P = .14). In sex-comparable analyses, boys' lacrosse players had a higher frequency of nondisclosure than girls (P = .05). The most common reasons for nondisclosure were not wanting to lose playing time (66.7%, n = 32/48), miss a game (56.3%, n = 27/48), and let the team down (43.8%, n = 21/48) and uncertainty over injury severity and the presence of SRC (43.8%, n = 21/48)., Conclusions: Ten percent of youth athletes self-reported at least 1 diagnosed SRC. However, they also described continuing to practice or play in a game after a suspected SRC. Reasons for nondisclosure at this age were similar to those reported in high school and collegiate athletes. Recent researchers suggested negative consequences of continued play with SRC, especially in the acute stages. Anyone conducting future educational initiatives should emphasize these risks and focus on reasons why athletes of both sexes withhold reporting., (© by the National Athletic Trainers' Association, Inc.)

Objective: To examine the progression of collegiate student athletes through five stages of a return-to-activity protocol following sport-related concussion (SRC)., Methods: In a multisite prospective cohort study, we identified the frequency of initial 24-48 hours physical and cognitive rest, and the sequence of (1) symptom resolution and return to (2) exertion activity, (3) limited sport, (4) full sport and (5) full academics. In resulting profiles we estimated the likelihood of return to full sport ≤14 days or prolonged >28 days and tested for variability based on timing of the stages., Results: Among 1715 athletes with SRC (31.6% females), 67.9% had 24-48 hours initial physical and cognitive rest. The median was 6 days to return to full academics, 8 days to symptom resolution and 9 days to exertion. Three profiles emerged; all had the same sport-specific return progression, but varied in the relative timing of full academics. In unadjusted analyses, full academics as the first stage corresponded to the longest time to return to full sport, and initiating exertion the same day as symptom resolution resulted in the shortest time. In adjusted regression analyses, athletes initiating full academics while still symptomatic were 21.5% less likely (95% CI -27.4% to -15.5%) to return to full sport ≤14 days and, analogously, 19.1% more likely (95% CI 13.4% to 24.7%) to have prolonged return >28 days. While additionally controlling for initial rest, sex, symptom count and concussion history, the likelihood of prolonged return >28 days was 37.0% (95% CI 25.2% to 48.8%) in athletes initiating exertion considerably before symptoms resolved (ie, 7+ days), but only 3.6% (95% CI -1.4% to 8.6%) in athletes initiating exertion shortly before achieving symptom resolution (ie, 3-4 days)., Conclusion: We found evidence that sequential progressions were consistent with current recommendations including brief initial rest, and the initiation and relative timing of each stage impacted the final return-to-sport outcome., Competing Interests: Competing interests: This research was conducted as an activity of the Ivy League–Big Ten Epidemiology of Concussion Study, which is an initiative of the Big Ten–Ivy League Traumatic Brain Injury Research Collaboration. DJW is Principal Investigator of the Concussion Study, BAD is a PhD student, and ACB is a postdoctoral fellow involved with study management and research. Ivy League and Big Ten University and Conference leadership played no role in approving, interpreting, or permitting the present analysis to be conducted or published. DJW has consulted for the National Collegiate Athletic Association (NCAA)., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Context: Researchers have identified sex differences in sport-related concussion incidence and recovery time; however, few have examined sex differences in specific recovery trajectories: time to symptom resolution, return to academics, and return to athletic activity across collegiate sports., Objective: To examine sex differences in sport-related concussion recovery trajectories across a number of club and varsity sports with different levels of contact., Design: Descriptive epidemiology study., Setting: Collegiate varsity and club sports., Patients or Other Participants: Sport-related concussions sustained by student-athletes (n = 1974; women = 38.8%) participating in Ivy League sports were monitored between 2013-2014 and 2018-2019., Main Outcome Measure(s): Athletic trainers collected concussive injury and recovery characteristics as part of the Ivy League-Big Ten Epidemiology of Concussion Study's surveillance system. Time to symptom resolution, return to academics, and return to limited and full sport participation were collected. Survival analyses determined the time from injury to each recovery outcome for male and female athletes by sport. Peto tests were used to compare recovery outcomes between men's and women's sports and by sport., Results: The median (interquartile range [IQR]) was 9 days (IQR = 4-18 days) for time to symptom resolution overall, 8 days (IQR = 3-15 days) for return to academics, 12 days (IQR = 8-23 days) for return to limited sport participation, and 16 days (IQR = 10-29 days) for return to full sport participation. We observed differences overall between sexes for median time to symptom resolution (men = 8 days [IQR = 4-17 days], women = 9 days [IQR = 5-20 days]; P = .03) and return to academics (men = 7 days [IQR = 3-14 days], women = 9 days [IQR = 4-17 days]; P < .001) but not for median time to return to athletics (limited sport participation: P = .12, full sport participation: P = .58). Within-sport comparisons showed that women's lacrosse athletes had longer symptom resolution (P = .03) and return to academics (P = .04) compared with men's lacrosse athletes, whereas men's volleyball athletes took longer to return to limited (P = .02) and full (P = .049) sport participation than women's volleyball athletes., Conclusions: Recovery timelines between sexes were different. Athletes in women's sports experienced longer symptom durations and time to return to academics compared with men's sports, but athletes in men's and women's sports presented similar timelines for return to athletics., (© by the National Athletic Trainers' Association, Inc.)

Introduction: On-site health care providers are not routinely present at all youth sport events. Therefore, parents and youth athletes are often responsible for identifying and making appropriate immediate care decisions regarding concussions, which may be influenced by their injury health literacy. Previous studies have investigated the level of concussion knowledge of parents and athletes, but few have investigated factors associated with greater awareness at the youth sport level specifically., Method: A total of 466 parents and 390 youth contact sport athletes from Pennsylvania and Michigan completed separate surveys of concussion knowledge and personal and family demographic information., Results: Parents had a mean concussion knowledge score of 39.3 ± 4.6 out of a possible 47 points. Having a medical occupation (p = .04) and being older in age (p = .03) were associated with higher concussion knowledge scores in parents (R 2  = 0.018; 95% CI = 32.77-38.99). Youth athletes had a mean concussion knowledge score of 35.0 ± 5.7 out of 47. Having learned about concussion previously (p < .001), having a history of diagnosed concussion(s) (p = .01), sport type (relative to girls' ice hockey, p < .001), older age (p < .001), and parent concussion knowledge (p = .04) were associated with higher youth athlete concussion knowledge (R 2  = 0.176; 95% CI = 19.08-31.72)., Conclusions: More evidence-based concussion awareness resources are needed at the youth sport level. While it did not significantly influence concussion knowledge for parents, concussion education is a modifiable factor that may be essential for improving concussion knowledge of youth athletes, thus warranting further study into effective awareness strategies for this population. Practical Applications: The factors found to influence concussion knowledge in this study could be considered in future educational concussion initiatives for youth athletes and their parents in order to increase awareness regarding the potential dangers of participating in sport while concussed., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Objective: Postpartum depression (PPD) remains an understudied research area despite its high prevalence. The goal of this study is to develop an ontology to aid in the identification of patients with PPD and to enable future analyses with electronic health record (EHR) data., Methods: We used Protégé-OWL to construct a postpartum depression ontology (PDO) of relevant comorbidities, symptoms, treatments, and other items pertinent to the study and treatment of PPD., Results: The PDO identifies and visualizes the risk factor status of variables for PPD, including comorbidities, confounders, symptoms, and treatments. The PDO includes 734 classes, 13 object properties, and 4,844 individuals. We also linked known and potential risk factors to their respective codes in the International Classification of Diseases versions 9 and 10 that would be useful in structured EHR data analyses. The representation and usefulness of the PDO was assessed using a task-based patient case study approach, involving 10 PPD case studies. Final evaluation of the ontology yielded 86.4% coverage of PPD symptoms, treatments, and risk factors. This demonstrates strong coverage of the PDO for the PPD domain., Conclusion: The PDO will enable future researchers to study PPD using EHR data as it contains important information with regard to structured (e.g., billing codes) and unstructured data (e.g., synonyms of symptoms not coded in EHRs). The PDO is publicly available through the National Center for Biomedical Ontology (NCBO) BioPortal ( https://bioportal.bioontology.org/ontologies/PARTUMDO ) which will enable other informaticists to utilize the PDO to study PPD in other populations., Competing Interests: None declared., (Thieme. All rights reserved.)

Determining the sensitivity and specificity of short neurocognitive assessments to objectively detect concussion will help clinicians more confidently integrate such tools in clinical management decisions. This study quantified the sensitivity and specificity of a computerized cognitive flexibility task isolating shifts of visuospatial attention in combination with clinical symptoms acutely (< 72 h) following concussion. A total of 100 athletes (53 concussed; 47 non-injured control; 42% female) completed computerized neurocognitive testing and clinical symptom reports (Sport Concussion Assessment Tool 3rd edition: SCAT3). Separate discriminant function analyses were performed for individual, combination, and stepwise inclusion of neurocognitive and clinical symptomology assessments. Findings revealed the combination of neurocognitive outcomes (i.e., mean reaction time, response accuracy, and response accuracy cost) with clinical symptom factor scores exhibited the greatest sensitivity (95.7%) and specificity (88.7%) as well as the highest positive predictive value (95.9%) and negative predictive value (88%) relative to other approaches. Further, a stepwise approach predicting concussion status using the discriminant functions improved detection of concussion (98.2% sensitivity, 95.7% specificity, 96.4% positive predictive value, and 97.8% negative predictive value) when clinical symptom factors failed to indicate the presence of a concussion. Incorporating a cognitive flexibility task involving shifts of visuospatial attention combined with clinical symptom factor scores may improve clinical decision-making as this approach exceeds the sensitivity and specificity of widely popular neurocognitive test batteries and takes less than 10 min to administer., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Context: Return to play after sport-related concussion (SRC) requires authorized clearance from a health care provider (HCP). The variability in HCPs and facilities where athletes seek care may influence return time., Objective: To identify the initial examiner, HCPs who authorize clearance to return to play, and medical facilities that authorize clearance to return to play for high school student-athletes after SRC and compare authorized clearance time by HCPs and medical facilities., Design: Prospective cohort study., Setting: High school., Patients or Other Participants: Student-athletes (n = 16 001) with SRC participating in athletics sponsored by the Michigan High School Athletic Association., Main Outcome Measure(s): Frequencies of initial examiner and authorized clearance for each HCP (doctor of osteopathic medicine, medical doctor, nurse practitioner, physician assistant) and medical facility (neurologist's office; team physician, primary care physician or pediatrician's office [PCP]; hospital; urgent/ready care) for each case of SRC. We calculated Kaplan-Meier curves and Peto tests to evaluate differences in the median time to authorized clearance between HCPs and facilities. Only cases with a date on which clearance to return to play was authorized (80.3%; n = 12 856) were included in the authorized clearance and time-to-return analyses., Results: An athletic trainer was at least 1 of the initial examiners in 71.3% (n = 11 404) of SRC cases; 81.2% (n = 12 990) had only 1 initial examiner. We observed an association between the initial examiner and the medical facility providing clearance for athletic director (χ2 = 52.6, P < .001, V = .06), athletic trainer (χ2 = 172.0, P < .001, V = .12), coach (χ2 = 161.5, P < .001, V = .11), doctor of osteopathic medicine (χ2 = 59.4, P < .001, V = .07), and nurse practitioner (χ2 = 10.0, P = .04, V = .12). Clearance was authorized most frequently by a medical doctor (63.9%, n = 8218) and at a PCP (70.8%, n = 9099). Median (interquartile range) time to authorized clearance varied by facility (urgent/ready care = 7 days [4-11 days], hospital = 9 days [6-14 days], PCP = 10 days [6-14 days], team physician = 12 days [8-16 days], neurologist's office = 13 days [9-20 days]; P < .001). An athletic trainer was the initial examiner more often for males (74.1%) than for females (65.8%). The medical facility where clearance to return to play was authorized also differed between males (PCP = 69.3%, team physician = 11.3%, neurologist's office = 8.4%) and females (PCP = 73.6%, team physician = 8.5%, neurologist's office = 8.3%)., Conclusions: Clearance to return to play after SRC was frequently provided by a medical doctor and at a PCP. The median time to return to unrestricted participation after SRC varied by HCP and medical facility. Future researchers should elucidate the reasons for these differences and determine why athletes seek care at different types of medical facilities., (© by the National Athletic Trainers' Association, Inc.)

Context: Lacrosse is an increasingly popular sport; the number of teams participating in collegiate women's lacrosse has increased by 21.4% in the past 5 years., Background: The growth of National Collegiate Athletic Association women's lacrosse, coupled with the ongoing discussions surrounding protective equipment, necessitates further epidemiologic studies in this population., Methods: Exposure and injury data collected in the National Collegiate Athletic Association Injury Surveillance Program during 2014-2015 through 2018-2019 were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios with 95% CIs were used to examine differential injury rates., Results: The overall injury rate was 4.99 per 1000 athlete exposures. Less than 30% of injuries were time-loss injuries; injuries were most commonly attributed to noncontact (26.6%) and overuse (25.2%) mechanisms. The most commonly reported specific injuries were lateral ligament complex tears (ankle sprains; 9.1%), concussions (7.2%), and hamstring tears (3.8%)., Summary: Findings from this study were consistent with the existing epidemiologic evidence in previous studies. Injury incidence in practices, in preseason, and as a result of player contact warrant further attention in this population., (© by the National Athletic Trainers' Association, Inc.)

Context: The popularity of National Collegiate Athletic Association (NCAA) men's lacrosse has been steadily increasing since the early 1980s., Background: Injury surveillance is an important tool to aid in identifying emerging patterns of sport-related injury in NCAA men's lacrosse., Methods: Injury data collected from a sample of men's lacrosse teams through the NCAA Injury Surveillance Program for the academic years 2014-2015 through 2018-2019 were analyzed. Athlete exposures were estimated and computed based on collected exposure data. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated to estimate differences in injury rates., Results: The overall injury rate was 4.90 per 1000 athlete exposures (AEs), and the competition injury rate was higher than the practice injury rate (IRR = 2.59; 95% CI = 2.35, 2.84). The overall preseason injury rate was higher than the regular and postseason injury rates. The most reported injuries were concussions (8.0%), ankle sprains (7.7%), and hamstring tears (6.9%)., Conclusions: Study findings were comparable with existing epidemiological evidence. The overall burden of concussions and lower extremity injuries warrant further attention in this population., (© by the National Athletic Trainers' Association, Inc.)

Importance: Because of the negative consequences of concussion, considerable research efforts have been directed toward understanding the risk factors for sport-related concussion (SRC) and its outcomes to better inform strategies for risk reduction. Girls are suggested to have an increased risk of concussion, warranting exploration into sex-dependent variations in concussion presentation and management, with the potential that this information might inform sex-specific rules directed toward risk reduction within sports., Objective: To compare sex-associated differences in epidemiology and concussion management in adolescent soccer players within a prospective, longitudinal high school injury surveillance project., Design, Setting, and Participants: This prospective, longitudinal cohort study assessed male and female soccer athletes from all high schools in the Michigan High School Athletic Association (MHSAA) during academic years 2016-2017 to 2018-2019., Exposures: Sport-related concussion captured in the MHSAA Head Injury Reporting System., Main Outcomes and Measures: Outcomes included details regarding each documented SRC event, including injury mechanism, immediate management, and return-to-play time. Multiple comparisons were made between male and female athletes regarding SRC risk, mechanism, short-term management, and outcomes., Results: A total of 43 741 male and 39 637 female soccer athletes participated in MHSAA soccer during the 3 consecutive academic years of study (2016-2017: n = 751 schools; 2017-2018: n = 750 schools; and 2018-2019: n = 747 schools). During the 3 years of surveillance, 1507 of the 83 378 soccer athletes (1.8%) were reported to have SRC during soccer participation, including 557 boys (37.0%) and 950 girls (63.0%). Documented SRC risk in female soccer participants was greater than in male soccer participants (risk ratio, 1.88; 95% CI, 1.69-2.09; P < .001). Male soccer athletes most often sustained SRC from contact with another player (48.4%), whereas SRCs in female soccer players recorded in the Head Injury Reporting System were most often from nonplayer contact events (41.9%; P < .001). Adolescent male soccer players with a documented SRC were more likely to be removed from play on the day of injury (odds ratio, 1.54; 95% CI, 1.15-2.06; P = .004). Although the overall median time to return to play was 11 days (interquartile range [IQR], 7-15 days), male athletes typically returned 2 days earlier than female athletes (median, 10 [IQR, 7-14] days vs 12 [IQR, 7-16] days; Peto test P < .001)., Conclusions and Relevance: In this cohort study, sex-associated differences were revealed among adolescent soccer athletes in SRC risk, mechanism of injury, immediate management, and outcomes in injuries documented in a statewide injury reporting system. Thus, consideration might be given to sex-specific approaches to participation and concussion management in the sport.

Context: Understanding time loss resulting from sport-related concussion (SRC) within individual sports allows high school athletic trainers to provide accurate and evidence-based clinical information. Currently, research regarding patterns of clinical recovery outcomes in high school student-athletes across sports is lacking., Objective: To describe the time to authorized unrestricted return to participation (RTP) after SRC in a large cohort of high school student-athletes in a variety of sports using a time-to-event analysis., Design: Descriptive epidemiology study., Setting: Aggregate injury and player exposure data from the Michigan High School Athletic Association Head Injury Reporting System., Patients or Other Participants: High school student-athletes., Main Outcome Measure(s): Dates for SRC injury events and authorized unrestricted RTP were entered into the Head Injury Reporting System for each case and were used to calculate time to unrestricted RTP. Survival analysis indicated the time to authorized RTP for males and females in weekly increments across sports and academic years. Separate Kaplan-Meier analyses adjusted for SRC cases with a history of concussion also identified the proportions of student-athletes who obtained authorized medical clearance in weekly increments., Results: A total of 15 821 SRCs, 10 375 (65.6%) in males and 5446 (34.4%) in females, were reported during the 2015-2016 through 2018-2019 academic years. The median time to authorized unrestricted RTP was 11 days for all patients. Approximately 30% of concussed student-athletes were not cleared for unrestricted RTP by 14 days after their SRC diagnosis, with 13% taking longer than 21 days to return to unrestricted RTP after SRC., Conclusions: The results from this multisite, state-based injury surveillance system indicated that it is not abnormal for high school student-athletes to take longer than 14 days to fully recover from an SRC. This information may be useful for educating high school student-athletes and sport stakeholders, normalizing SRC recovery trajectory perceptions, and establishing realistic RTP timeline expectations., (© by the National Athletic Trainers' Association, Inc.)

Context: Understanding time-loss resulting from sport-related concussion (SRC) within individual sports allows high school athletic trainers to provide accurate and clinically evidence-based information. Currently there is a lack of research regarding patterns of clinical recovery outcomes in high school student-athletes across sports., Objective: To describe the time to authorized unrestricted RTP following SRC in a large cohort of high school student-athletes in variety of sports using a time-to-event analysis., Design: Descriptive Epidemiology Study., Setting: Aggregate injury and player exposure data from the STATE-XXX High School Athletic Association (XHSAA) Head Injury Reporting System (HIRS)., Patients or Other Participants: High school student-athletes., Main Outcome Measure(s): Dates for SRC injury events and authorized unrestricted RTP were entered into the HIRS for each case, and were used to calculate time to unrestricted RTP. Survival analysis determined time to authorized RTP for males and females in weekly increments across sports and academic years. Separate Kaplan-Meier analyses adjusted for SRC cases with a history of concussion also identified the proportions of student-athletes that obtained authorized medical clearance in weekly increments., Results: There was a total of 15,821 SRC cases, 10,375 (65.6%) male and 5,446 (34.4%) female, reported during the 2015-16 through 2018-19 academic years. The median time to authorized unrestricted RTP was 11 days for all cases. Approximately, 30% of concussed student-athletes were not cleared for unrestricted RTP by 14 days following their SRC diagnosis, with 13% taking longer than 21 days to unrestricted RTP after SRC., Conclusions: The results from this multi-site, State-based injury surveillance system indicate that it is not abnormal for high school student-athletes to take longer than 14 days to fully recovery from a SRC. This information may be useful for educating high school student-athletes and sport stakeholders, normalizing SRC recovery trajectory perceptions, and establishing realistic RTP timeline expectations., (© by the National Athletic Trainers' Association, Inc.)

Objective : The primary purpose of this study was to examine the longitudinal effects of sports-related concussion (SRC) on a multi-faceted assessment battery which included neuropsychological testing, symptom reporting, and enhanced brain function index (eBFI) among athletes with and without SRC. A secondary purpose was to explore longitudinal sex differences among these measures in athletes with and without SRC. Methods : A case-control, repeated-measures design was used for this study. A total of 186 athletes (concussed group: n = 87 controls: n = 99) participated in the study. A repeated-measures design was used in which each athlete was tested at four time points following an SRC: within 72 h of injury (Day 0; 2.0 ± 0.9 days following injury), 5 days following injury (Day 5; 5.0 ± 0.0), at return to play (RTP; 18.3 ± 13.8 days following injury), and within 45 days following RTP (RTP45; 66.2 ± 19.0 days following injury). All analyses were conducted separately using a 2 (Group: concussed, control) × 2 (Sex: male, female) × 4 (Time:Day 0, Day 5, RTP, RTP45) univariate multi-level model including the random intercept for each participant. A higher eBFI score indicates a better performance. Alpha level was set aprior at .05. This study was registered on clinicaltrials.gov (Objective Brain Function Assessment of mTBI/Concussion in College/high school Athletes NCT02477943, NCT02661633, CAS 13-25 NCT03963804). Results : Concussed athletes exhibited impaired eBFI within 72 h of SRC and at Day 5 compared to controls ( p <.001). Analysis of eBFI scores between male and female athletes revealed a main effect of sex ( p =.05), with female athletes exhibiting lower eBFI (33.9 ± 30.7) relative to male athletes (40.4 ± 33.0), however, it did not indicate interactions between sex, group, and time ( p's ≥ 0.786). Conclusion : The eBFI appears to be a useful tool in determining concussed athletes during the acute stages of an SRC. However, this index may lack the sensitivity to detect sex-related differences between groups at various time points during recovery.

Context: Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days-3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors., Objective: The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items., Design: Case series., Setting: High school and college., Patients or Other Participants: A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes., Main Outcome Measure(s): Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted., Results: A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive-fatigue (eg, feeling "in a fog" and "don't feel right"), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine-fatigue (eg, headache and "pressure in the head"), affective (eg, sadness and more emotional), and cognitive-ocular (eg, difficulty remembering and balance problems) symptom factors., Conclusions: The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acutely concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor., (© by the National Athletic Trainers' Association, Inc.)

Despite the clinical utility of baseline comparisons during concussion assessments, little evidence exists on long-term test-retest reliability of baseline tests in youth athletes. In addition, sex differences in baseline performance are inconsistent in youth athletes, warranting further research. The purpose was to examine sex differences, prevalence of false-positive scores, and long-term test-retest reliability of the King-Devick (KD) test. Healthy youth athletes (23 males, 28 females) completed the KD test prior to the Spring 2016 and Fall 2017 seasons. Two-way random-effects intraclass correlation coefficients (ICCs) were utilized to determine test-retest reliability. A mixed between-within ANOVA with post-hoc t-tests were used to identify the interaction between sex and season, and frequencies were used to determine abnormal test score prevalence. The KD test demonstrated good test-retest reliability (0.77[95% CI, 0.43-0.89]), with 11.8% of youth athletes having clinically meaningful improvements between Season 1 to Season 2. There was a significant sex*season interaction (F (1,49)  = 4.67, p = .04), with significantly greater improvements between seasons in male youth athletes compared to female youth athletes. However, 33-35% of youth athletes displayed abnormal test scores in Season 2 relative to Season 1. The KD test demonstrated good reliability and only a small percentage had clinically meaningful changes, however a high prevalence of false-positive scores were observed in this sample., (Published by Elsevier B.V.)

Context: Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days-3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors., Objective: The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items., Design: Case series., Setting: High school and college., Patients or Other Participants: A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes., Main Outcome Measure(s): Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted., Results: A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive fatigue (eg, feeling "in a fog" and "don't feel right"), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine fatigue (eg, headache and "pressure in the head"), affective (eg, sadness and more emotional), and cognitive ocular (eg, difficulty remembering and balance problems) symptom factors., Conclusions: The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acute concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor., (© by the National Athletic Trainers' Association, Inc.)

The purpose of this study was to report baseline values for the SCAT5 in NCAA Division I collegiate student-athletes, while also evaluating if sex, health diagnoses, or sport type influenced baseline performance. A sample of 462 collegiate student-athletes (212 females, 250 males, (19.21±1.32 years)) completed the SCAT5 prior to the 2017-18, 2018-19 or 2019-20 athletic seasons. Descriptive statistics were reported for symptom total (22 possible), symptom severity (132 possible), orientation (5 possible), immediate memory (30 possible), concentration (5 possible), delayed recall (10 possible), total SAC score (50 possible), 3 mBESS stances (10 possible), and mBESS score (30 possible). Separate Mann-Whitney U tests were conducted to identify sex, health diagnoses (concussion history, ADD/ADHD, depression/anxiety), and sport type (contact, non-contact) differences for all SCAT5 components. Alpha level was set a priori <.05. Student-athletes reported 1.96± 3.37 symptoms with a severity of 3.43±7.63, and an overall SAC score of 35.14±5.23 (orientation 4.96±0.20, immediate memory 20.18±3.40, concentration 3.60±1.14, delayed recall 6.41±1.94). Student-athletes participating in contact sports, had ADD/ADHD, or depression/anxiety reported more symptoms and at greater severity ( p =<.001-.01). Those with ADD/ADHD performed worse on mBESS ( p =.01-.03). No sex differences were found for any SCAT5 components ( p =.08-.90). This study presents reference values for the SCAT5 by sex, health diagnoses, and sport type. Healthcare professionals may utilize these normative values when individual baseline references are unavailable.

Extant evidence demonstrates disruptions to inhibitory control from as little as six months to as long as several years following sports-related concussion. However, the sensitivity of tasks requiring inhibitory control for detecting disruptions to cognition during the acute, subacute, and protracted phases of recovery remains in question. Accordingly, the purpose of this study was to examine concussion-related disruptions to inhibitory control across recovery. Athletes with sports-related concussion (n = 55; 22 female) completed an inhibitory control task within 72 h of injury, after returning to play, and within one month following return to play. Matched control athletes (n = 55; 22 female) were tested at similar intervals. Behavioral indices of performance were analyzed using univariate multi-level modeling. Findings indicated that the concussion group exhibited decrements to inhibitory control immediately after injury and up to one month following return to play, with no such observable differences at the return to play period. In addition to being sensitive to detecting chronic cognitive deficits resulting from sports-related concussion, these findings suggest that inhibitory control measures have the requisite sensitivity to identify the immediate and protracted signs of neurocognitive dysfunction following sports-related concussion. Accordingly, integrating assessments of inhibitory control into baseline, post-injury, and post-season measurement of cognitive function may prove useful for tracking the acute and persistent effects of sports-related concussion across an athlete's career. Athletes exhibiting impaired inhibitory control across the phases of recovery may be at greater risk of reinjury, thereby suggesting that integrating inhibitory control assessments into existing clinical measures may be of interest for informing concussion management and return-to-play decisions., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Approximately 1.6 to 3.8 million recreational and sports-related concussions (SRC) occur each year in the Unites States. Research suggest that female athletes are at a greater risk for a SRC compared to male athletes competing in comparable sports (i.e., soccer, basketball). Moreover, female athletes have reported more total symptoms and greater neurocognitive impairments following a SRC. Female athletes have been found to report greater symptom provocation as measured by the Vestibular/Ocular Motor Screening (VOMS), and increased brain activation compared to males. There is a scarcity of research on long-term effects of SRC in male and female athletes. Therefore, the aim of this review article is to summarize the existing literature on sex differences in acute and sub-acute SRC outcomes., (Copyright © 2017. Published by Elsevier B.V.)

Context:: Previous literature on sport-related concussion (SRC) knowledge and reporting behaviors has been limited to high school and National Collegiate Athletic Association collegiate athletes; however, knowledge regarding collegiate club-sport athletes is limited., Objective:: To determine the level of SRC knowledge and reporting behaviors among collegiate club-sport athletes and to investigate differences between athletes in traditional and nontraditional sports., Design:: Cross-sectional study., Setting:: Survey., Patients or Other Participants:: A total of 410 athletes (247 males, 163 females) involved in traditional (n = 244) or nontraditional (n = 165) collegiate club sports., Main Outcome Measure(s):: The survey consisted of demographics, recognition of SRC signs and symptoms, general SRC knowledge, and reasons why athletes would not report SRCs. The independent variable was sport type. Sport-related concussion signs and symptoms and general knowledge were assessed by the frequency of correct answers to SRC signs and symptoms and general knowledge questions. Sport-related concussion-reporting behavior frequencies were evaluated by asking participants to indicate reasons why they did not or would not report an SRC., Results:: The SRC signs and symptoms knowledge score was 23.01 ± 3.19 and general SRC knowledge score was 36.49 ± 4.16 (maximal score = 43). No differences were present for SRC signs and symptoms knowledge ( F 1,408 = 1.99, P = .16) or general SRC knowledge ( F 1,408 = 3.28, P = .07) between athletes in traditional and nontraditional collegiate club sports. The most common reason for not reporting an SRC was not recognizing it as a serious injury (n = 165, 40.3%). Chi-square tests demonstrated significant relationships between sport type and 5 reasons for not reporting an SRC., Conclusions:: The participants displayed moderate to high levels of knowledge of SRCs but indicated they had failed to or would fail to report SRCs for a variety of reasons. The lack of sports medicine coverage and disconnect between knowledge and injury recognition may make collegiate club-sport athletes more likely to participate while concussed.

Objective: A critical barrier to the understanding of disruptions to cognitive flexibility following sports-related concussion is the use of assessments that conflate shifts of visuospatial attention and contextual rules. Because these dissociable forms of cognitive flexibility are subserved by distinct neural networks, the utility of a cognitive flexibility assessment following concussion may be reduced, depending upon the extent to which the task requires shifting visuospatial attention relative to shifting contextual rules. Accordingly, the current investigation examined the extent to which these aspects of cognitive flexibility exhibit differential trajectories of recovery following a sports-related concussion., Method: Twenty-two athletes with sports-related concussions were assessed on a cognitive flexibility task with 2 switch conditions (i.e., perceptual-based and contextual rule-based) within 72 hr of injury, after return to play, and within 1 month following return to play. Thirty-three healthy control athletes were tested at the same intervals., Results: Findings revealed that concussed athletes demonstrated protracted disruptions in task performance on a visuospatial attention-based cognitive flexibility task relative to healthy controls, whereas disruptions in task performance on a contextual rule-based cognitive flexibility task resolved after the acute phase of injury. These findings suggest that dissociable forms of cognitive flexibility exhibit differential trajectories of recovery., Conclusions: Therefore, evaluations detecting sports-related concussion disruptions in cognitive flexibility may be reduced depending on the extent to which they rely on contextual rule-based decisions. Test batteries focusing on visuospatial attention-based demands may be useful additions to aid in the objective assessment and follow-up management of athletes following the acute phase of injury. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Background: Sports-related concussion (SRC) injury rates, and identifying those athletes at the highest risk, have been a primary research focus. However, no studies have evaluated at which time point during an athletic event athletes are most susceptible to SRCs., Purpose: To determine the clinical incidence of SRCs during the start, middle, and end of practice and competition among high school male and female athletes in the state of Michigan., Study Design: Descriptive epidemiological study., Methods: There were 110,774 male and 71,945 female student-athletes in grades 9 through 12 (mean time in high school, 2.32 ± 1.1 years) who participated in sponsored athletic activities (13 sports) during the 2015-2016 academic year. An SRC was diagnosed and managed by a medical professional (ie, MD, DO, PA, NP). SRC injuries were reported by certified athletic trainers, athletic administrators, and coaches using the Michigan High School Athletic Association Head Injury Reporting System. Time of SRC was defined as the beginning, middle, or end of practice/competition. Clinical incidence was calculated by dividing the number of SRCs in a time point (eg, beginning) by the total number of participants in a sport per 100 student-athletes (95% CI). Risk ratios were calculated by dividing one time point by another time point., Results: There were 4314 SRCs reported, with the highest in football, women's basketball, and women's soccer. The total clinical incidence for all sports was 2.36 (95% CI, 2.29-2.43) per 100 student-athletes. The most common time for SRCs was the middle, followed by the end of all events. Athletes had a 4.90 (95% CI, 4.44-5.41) and 1.50 (95% CI, 1.40-1.60) times greater risk during the middle of all events when compared with the beginning and end, respectively. There was a 3.28 (95% CI, 2.96-3.63) times greater risk at the end of all events when compared with the beginning., Conclusion: Athletes were at the greatest risk for SRCs at the middle of practice and competition when compared with the beginning and end., Clinical Relevance: The current study suggests that medical attention is particularly important during the middle of all athletic events. Intervention measures to limit SRCs may be most beneficial during the middle of athletic events.

Background: Sports-related concussion (SRC) injury rates are well established in collegiate athletics through epidemiological studies using the National Collegiate Athletic Association Injury Surveillance System. However, few studies have examined sex differences, time loss, and missed school days in high school athletes, especially at the state level., Purpose: To identify sex differences in the clinical incidence of SRCs, missed school days, and time loss in high school student-athletes., Study Design: Descriptive epidemiological study., Methods: A total of 193,757 (116,434 male and 77,323 female) student-athletes (10th grade ± 1.1) participating in Michigan High School Athletic Association (MHSAA)-sponsored athletic activities were recorded in the Head Injury Reporting System. Certified athletic trainers, school athletic administrators, and coaches from MHSAA high schools reported SRC data and overall participation for the 2015-2016 academic year. Total concussive injuries, as well as missed school days and time loss for each concussive injury, were reported. The clinical incidence was calculated by dividing the number of SRCs in a particular category by the number of participants in that category and presented with 95% CIs. Relative risk ratios (RRs) were determined for sex-comparable sports., Results: The overall clinical incidence for all sports was 1.7 per 100 player-seasons (95% CI, 1.6-1.8) and 1.9 (95% CI, 1.8-2.0) for male sports and 1.5 (95% CI, 1.4-1.6) for female sports. Female athletes were at a 1.9 (95% CI, 1.8-2.2) times greater risk for enduring SRCs than male athletes in sex-comparable sports, with a greater risk in baseball/softball (RR, 2.7 [95% CI, 1.9-3.8]), basketball (RR, 2.5 [95% CI, 2.1-2.9]), and soccer (RR, 1.6 [95% CI, 1.4-1.9]). Female student-athletes had significantly longer time loss than male student-athletes ( P < .001). The mean number of missed school days did not differ between sexes ( P = .70)., Conclusion: High school female student-athletes have a higher risk for an SRC in all sex-comparable sports except lacrosse. This may be because of biomechanical differences of the head-neck segment, hormonal differences, and the fact that female athletes are more likely to report symptoms after a suspected SRC., Clinical Relevance: Despite sex differences in the clinical incidence of SRCs and time loss from participation in high school sports, the numbers of missed school days are relatively similar between sexes.

Background: Soccer players head the ball repetitively throughout their careers; this is also a potential mechanism for a concussion. Although not all soccer headers result in a concussion, these subconcussive impacts may impart acceleration, deceleration, and rotational forces on the brain, leaving structural and functional deficits. Stronger neck musculature may reduce head-neck segment kinematics., Hypothesis: The relationship between anthropometrics and soccer heading kinematics will not differ between sexes. The relationship between anthropometrics and soccer heading kinematics will not differ between ball speeds., Study Design: Pilot, cross-sectional design., Level of Evidence: Level 3., Methods: Division I soccer athletes (5 male, 8 female) were assessed for head-neck anthropometric and neck strength measurements in 6 directions (ie, flexion, extension, right and left lateral flexions and rotations). Participants headed the ball 10 times (25 or 40 mph) while wearing an accelerometer secured to their head. Kinematic measurements (ie, linear acceleration and rotational velocity) were recorded at 2 ball speeds., Results: Sex differences were observed in neck girth ( t = 5.09, P < 0.001), flexor and left lateral flexor strength ( t = 3.006, P = 0.012 and t = 4.182, P = 0.002, respectively), and rotational velocity at both speeds ( t = -2.628, P = 0.024 and t = -2.227, P = 0.048). Neck girth had negative correlations with both linear acceleration ( r = -0.599, P = 0.031) and rotational velocity at both speeds ( r = -0.551, P = 0.012 and r = -0.652, P = 0.016). Also, stronger muscle groups had lower linear accelerations at both speeds ( P < 0.05)., Conclusion: There was a significant relationship between anthropometrics and soccer heading kinematics for sex and ball speeds., Clinical Relevance: Neck girth and neck strength are factors that may limit head impact kinematics.