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Objective To evaluate pre - to post-season differences in individual subtests of the Visio-Vestibular Examination (VVE) in healthy middle and high school athletes. Methods This prospective cohort study recruited participants from a private suburban United States secondary school. Participants completed a demographic questionnaire prior to the start of their season. A proxy for head impact exposure was estimated by incorporating previously published head impact frequencies by team and sport. The VVE was completed pre - and post-season and consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, and complex tandem gait. Generalized estimating equations were employed to assess the relative risk of an abnormal VVE outcome based on testing session (pre - vs. post-season). Results Participants included middle and high school athletes (n = 115; female = 59 (51.3%); median age at first assessment = 14.9 years, [IQR = 13.6, 16.0]) during 2017/18 - 2019/20 school years. During pre-season testing, accommodation (10.0%) and complex tandem gait (9.2%) had the largest proportion of abnormal outcomes, while smooth pursuits (10.6%) and convergence (9.5%) had the largest proportion of abnormal outcomes post-season. When assessing the effect of testing session on the relative risk of any abnormal VVE subtest, there were no significant findings (P ≥ 0.25). Additionally, there were no significant effects of testing session when adjusting for estimated head impact exposure for any VVE subtest (P ≥ 0.25). Conclusions Visio-vestibular function as measured by the VVE does not change from pre - to post-season in otherwise healthy adolescent athletes. Our findings suggest that the VVE may be stable and robust to typical neurodevelopment occurring in this dynamic age group and help inform post-injury interpretation of visio-vestibular impairments.

Visual and vestibular deficits, as measured by a visio-vestibular examination (VVE), are markers of concussion in youth. Little is known about VVE evolution post-injury, nor influence of age or sex on trajectory. The objective was to describe the time trend of abnormal VVE elements after concussion. Two cohorts, 11-18 years, were enrolled: healthy adolescents (in/i = 171) from a high school with VVE assessment before or immediately after their sport seasons and concussed participants (in/i = 255) from a specialty care concussion program, with initial assessment ≤28 days from injury and VVE repeated throughout recovery during clinical visits. The primary outcome, compared between groups, is the time course of recovery of the VVE examination, defined as the probability of an abnormal VVE (≥2/9 abnormal elements) and modeled as a cubic polynomial of days after injury. We explored whether probability trajectories differed by: age (lt;14 years vs. 14+ years), sex, concussion history (0 versus 1+), and days from injury to last assessment (≤28 days vs. 29+ days). Overall, abnormal VVE probability peaked at 0.57 at day 8 post-injury, compared with an underlying prevalence of 0.083 for uninjured adolescents. Abnormal VVE probability peaked higher for those 14+ years, female, with a concussion history and whose recovery course was longer than 28 days post-injury, compared with their appropriate strata subgroups. Females and thoselt;14 years demonstrated slower resolution of VVE abnormalities. VVE deficits are common in adolescents after concussion, and the trajectory of resolution varies by age, sex, and concussion history. These data provide insight to clinicians managing concussions on the timing of deficit resolution after injury.

Auditory and visually evoked potentials (EP) have the ability to monitor cognitive changes after concussion. In the literature, decreases in EP are commonly reported; however, a subset of studies shows increased cortical activity after injury. We studied auditory and visual EP in 4-week-old female Yorkshire piglets (N = 35) divided into anesthetized sham, and animals subject to single (sRNR) and repeated (rRNR) rapid non-impact head rotations (RNR) in the sagittal direction. Two-tone auditory oddball tasks and a simple white-light visual stimulus were evaluated in piglets pre-injury, and at days 1, 4- and 7 post injury using a 32-electrode net. Traditional EP indices (N1, P2 amplitudes and latencies) were extracted, and a piglet model was used to source-localize the data to estimate brain regions related to auditory and visual processing. In comparison to each group’s pre-injury baselines, auditory Eps and brain activity (but not visual activity) were decreased in sham. In contrast, sRNR had increases in N1 and P2 amplitudes from both stimuli. The rRNR group had decreased visual N1 amplitudes but faster visual P2 latencies. Auditory and visual EPs have different change trajectories after sRNR and rRNR, suggesting that injury biomechanics are an important factor to delineate neurofunctional deficits after concussion.

Increased sensitivity to light is common after concussion. Viewing a flickering light can also produce uncomfortable somatic sensations like nausea or headache. We examined effects evoked by viewing a patterned, flickering screen in a cohort of 81 uninjured youth athletes and 84 concussed youth. We used Multiple correspondence analysis and identified two primary dimensions of variation: the presence or absence of visually evoked effects and variation in the tendency to manifest effects that localized to the eyes (e.g., eye watering) versus more generalized neurological effects (e.g., headache). Based on these two primary dimensions, we grouped participants into three categories of evoked symptomatology: no effects, eye-predominant effects, and brain-predominant effects. A similar proportion of participants reported eye-predominant effects in the uninjured (33.3%) and concussed (32.1%) groups. By contrast, participants who experienced brain-predominant effects were almost entirely from the concussed group (1.2% of uninjured, 35.7% of concussed). The presence of brain-predominant effects was associated with a higher concussion symptom burden and reduced performance on visio-vestibular tasks. Our findings indicate that the experience of negative constitutional, somatic sensations in response to a dynamic visual stimulus is a salient marker of concussion and is indicative of more severe concussion symptomatology. We speculate that differences in visually evoked effects reflect varying levels of activation of the trigeminal nociceptive system.

Eye tracking assessments that include pupil metrics can supplement current clinical assessments of vision and autonomic dysfunction in concussed adolescents.This study aimed to explore the utility of a 220-second eye tracking assessment in distinguishing eye position, saccadic movement, and pupillary dynamics among uninjured adolescents, those with acute post-concussion symptoms (≤28 days since concussion), or those with persistent post-concussion symptoms (28 days since concussion).Two hundred fifty-six eye tracking metrics across a prospective observational cohort of 180 uninjured adolescents recruited from a private suburban high school and 224 concussed adolescents, with acute or persistent symptoms, recruited from a tertiary care subspecialty concussion care program, 13 to 17 years old, from August 2017 to June 2021 were compared. Kruskal-Wallis tests were used, and Bonferroni corrections were applied to account for multiple comparisons and constructed receiver operating characteristic curves. Principal components analysis and regression models were applied to determine whether eye tracking metrics can augment clinical and demographic information in differentiating uninjured controls from concussed adolescents.Two metrics of eye position were worse in those with concussion than uninjured adolescents, and only one metric was significantly different between acute cases and persistent cases. Concussed adolescents had larger left and right mean, median, minimum, and maximum pupil size than uninjured controls. Concussed adolescents had greater differences in mean, median, and variance of left and right pupil size. Twelve metrics distinguished female concussed participants from uninjured; only four were associated with concussion status in males. A logistic regression model including clinical and demographics data and transformed eye tracking metrics performed better in predicting concussion status than clinical and demographics data alone.Objective eye tracking technology is capable of quickly identifying vision and pupillary disturbances after concussion, augmenting traditional clinical concussion assessments. These metrics may add to existing clinical practice for monitoring recovery in a heterogeneous adolescent concussion population.

Repeated head loading in sports is associated with negative long-term brain health, and there is growing evidence of short-term neurophysiological changes after repeated soccer heading. The objective of this study was to quantify the head kinematics and effects of repetitive soccer headers in adolescents using an instrumented mouthguard. Adolescent soccer players aged 13–18 years were randomly assigned to a kicking control, frontal heading, or oblique heading group. Participants completed neurophysiological assessments at three-time points: immediately prior to, immediately after, and approximately 24 h after completing 10 headers or kicks. The suite of assessments included the Post-Concussion Symptom Inventory, visio-vestibular exam, King-Devick test, modified Clinical Test of Sensory Interaction and Balance with force plate sway measurement, pupillary light reflex, and visual evoked potential. Data were collected for 19 participants (17 male). Frontal headers resulted in significantly higher peak resultant linear acceleration (17.4 ± 0.5 g) compared to oblique headers (12.1 ± 0.4 g, p

The aim of this study was to compare demographic characteristics, medical care, and outcomes among patients with assault-related concussion (ARC) versus sports and recreation-related concussion (SRC).We conducted a retrospective chart review of 124 patients (62 ARC, 62 SRC) aged 8 to 17 years presenting to the care network of a large tertiary care pediatric hospital between July 1, 2012, and June 30, 2014 with a concussion diagnosis at time of presentation. We abstracted patient demographics, initial medical care visit characteristics, and outcome data, and compared proportions using χ2 testing and Fisher exact test and medians using Wilcoxon rank sum test.Patients with ARC were more likely to be Black, publicly insured, and present first for care to the emergency department. Significantly fewer patients with ARC received visio-vestibular testing at initial visit (27% vs 74%, P0.001). During recovery, the total number of reported physical, cognitive, emotional, and sleep symptoms did not differ between groups; however, more than twice as many patients with ARC reported decline in grades postinjury compared with patients with SRC (47% vs 20%, P = 0.012). There were trends toward prolonged symptom recovery and time to physician clearance for full return to activities among patients with ARC compared with SRC.This study highlights potential disparities in the initial evaluation and outcomes of pediatric concussion patients based on mechanism of injury. Patients with ARC were less likely to receive a concussion-specific diagnostic evaluation and reported a greater impact on educational outcomes, suggesting differences in concussion diagnosis and management among assault-injured patients. Further examination in larger populations with prospective studies is needed to address potential inequities in concussion care and outcomes among patients with ARC.

Current debate exists regarding the need for protective headwear in female lacrosse. To inform this issue, the current study quantified head impact exposure, mechanisms and kinematics in female lacrosse using instrumented mouthguards. A female high school varsity lacrosse team of 17 players wore the Stanford Instrumented Mouthguard (MiG) during 14 competitive games. Video footage was reviewed to remove false-positive recordings and verify head impacts, which resulted in a rate of 0.32 head impacts per athlete-exposure. Of the 31 video-confirmed head impacts, 54.8% were identified as stick contacts, 38.7% were player contacts and 6.5% were falls. Stick contacts had the greatest peak head kinematics. The most common impact site was the side of the head (35.5%), followed by the face/jaw (25.8%), forehead (6.5%), and crown (6.5%). Impacts to the face/jaw region of the head had significantly (p 0.05) greater peak kinematics compared to other regions of the head, which may have resulted from the interaction of the impacting surface, or the lower jaw, and the sensor. The current study provides initial data regarding the frequency, magnitude and site of impacts sustained in female high school lacrosse. A larger sample size of high quality head impact data in female lacrosse is required to confirm these findings.

Context Multiple clinical evaluation tools exist for adolescent concussion, with various degrees of correlation, presenting challenges for clinicians in identifying which elements of these tools provide the greatest diagnostic utility. Objective To determine the combination of elements from four commonly-used clinical concussion batteries that maximize discrimination of concussed from non-concussed participants. Design Cross-sectional study Setting Suburban school and concussion program of a tertiary care academic center Patients/Participants 166 non-concussed (from a suburban school) and 231 concussed (from the school and concussion program) participants aged 13–19 years Main Outcome Measures Individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, 5th Edition (SCAT-5, including the modified balance error scoring system [mBESS]), King-Devick test (K-D), and Post-Concussion Symptom Inventory (PCSI) were evaluated. The sub-components of these tests were grouped into interpretable factors using sparse principal component analysis (sPCA). The 13 resultant factors were combined with clinical covariates into a logistic regression and ranked by frequency of inclusion into the ideal model, and the predictive performance of the ideal model was compared to each of the individual batteries using the area under the receiving operating characteristic curve (AUC). Results A cluster of 4 factors (F1: VVE saccades and vestibulo-ocular reflex; F2: mBESS double leg stance; F3: SCAT-5/PCSI symptoms; F4: K-D completion time) emerged. A model fit with the top factors performed as well as each battery in predicting concussion status (AUC=0.816 [95% CI: 0.731–0.889]), compared to SCAT-5 (AUC=0.784 [95% CI: 0.692–0.866]), PCSI (AUC=0.776 [95% CI: 0.674–0.863]), VVE (AUC=0.711 [95% CI: 0.602–0.814]), and K-D (AUC=0.708 [95% CI: 0.590–0.819]). Conclusions A multifaceted assessment for concussed adolescents, comprised of symptoms, attention, balance, and the visio-vestibular system, is critical. It is likely that current diagnostic batteries measure overlapping domains, and our sPCA analysis demonstrated strategies for streamlining comprehensive concussion assessment across a variety of settings.

Characteristics of specific Automatic Emergency Braking (AEB) pulses can result in increased motion of the occupant, which can lead to the occupant being out-of-position such that when a crash occurs protection may be compromised. Quantifying these variations across the modern fleet is crucial to understand the loading environment to which vehicle occupants are exposed. Therefore, we categorized the AEB pulses based on acceleration pulse features such as deceleration magnitude, jerk, and ramp time.A total of 2278 AEB vehicle tests (years 2013-2019) were extracted from the Insurance Institute for Highway Safety (IIHS) database and analyzed. The following pulse characteristics were extracted: Jerk (g/s), Ramp-time (s), and Maximum deceleration (g). A subset of tests in which the tested vehicle did not contact the foam target (n = 1665) was analyzed further, with the following additional variables extracted: Deceleration time (s), Steady-state deceleration (g), and Duration (s). Other non-pulse related features were also considered: Test speed (20 and 40 km/h), Curb weight (Kg), and Vehicle Model Year. Using machine learning methods, the pulses were categorized into clusters. One-way ANOVAs for continuous variables and XUsing the entirety of the AEB vehicle tests extracted (n = 2278), a total of 3 clusters were selected. The three clusters showed significantly different Jerk, Ramp-time, and Maximum deceleration (p 0.001). Target contact decreased in AEB tests with more recent vehicle model years (rate of contact 66% in 2014 vs 1.7% in 2019). In one cluster, Jerk and Maximum deceleration increased with vehicle model year. Using the subset of tests in which there was no contact with the foam target (n = 1665), 4 categories of pulses were selected. In both sets of clusters, Ramp-time and Jerk showed moderate inverse correlation (r = -0.7), while all other features showed a low correlation.These results show that AEB technology improved over the years in obstacle avoidance. The identification of AEB pulse clusters is important in order to describe distinct approaches to achieving AEB and to be able to reproduce representative AEB pulses in the laboratory and understand the influences of those pulses on occupants' motion.

The Guardian Cap NXT (GC NXT) and the ProTech Helmet Cap (ProTech) are commercially available aftermarket products designed to augment the energy attenuation characteristics of American football helmets. The ability of these helmet shell add-on products to mitigate the severity of impacts typically experienced by professional offensive and defensive linemen was evaluated for seven helmet models using two test series. In linear impactor tests, the GC NXT reduced head impact severity as measured by the head acceleration response metric (HARM) by 9% relative to the helmets only, while the ProTech reduced HARM by 5%. While both products significantly improved the performance of the football helmets tested overall, effects varied by impact condition and helmet model with the add-ons worsening helmet performance in some conditions. The GC NXT had a strong effect size (Cohen’s d = 0.8) whereas the ProTech had a medium effect (Cohen’s d = 0.5). A second study investigated add-on performance for helmet-to-helmet impacts with eccentric impact vectors and resulted in a mixture of increased and decreased HARM when either add-on was placed on one or both helmets. Estimated risk for serious neck injury with add-ons and without differed by less than 4% for these eccentric impacts.

Objective To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries. Design Cross-sectional. Setting Suburban middle and high school. Patients One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020. Assessment of independent variables Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King-Devick (K-D), Postconcussion Symptom Inventory (PCSI). Main outcome measures Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait). Results Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini-Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K-D, or PCSI. Conclusions The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K-D.

Background: Few studies have examined psychiatric symptoms during the acute phase following a concussion in adolescents. Thus, this study compares anxiety and depression in acutely concussed and nonconcussed adolescents. Hypothesis: Acutely concussed adolescents will report greater anxiety and depressive symptoms compared with nonconcussed adolescents. Study Design: Prospective cohort study. Level of Evidence: Level 3. Methods: Data were collected from 282 adolescents (111 concussed within 28 days of injury, 171 nonconcussed), 13 to 18 years of age, who completed Patient-Reported Outcome Measurement Information System (PROMIS) Anxiety and Depressive Symptoms measures. We calculated average T-scores for anxiety and depression across both groups and compared the proportion of those who scored above normal limits. Finally, we calculated risk ratios for anxiety and depression scores above normal limits. Results: Average T-scores for anxiety did not differ in concussed versus nonconcussed adolescents (mean: 45.9 [SD 10.84] vs 45.2 [8.1], respectively, P = 0.54), whereas average T-scores for depression were significantly higher in concussed versus nonconcussed adolescents (46.0 [10.88] vs 42.8 [8.48], respectively, P < 0.01). The proportion of concussed adolescents above normal limits for depression was greater than nonconcussed adolescents (32.4% vs 20.5%, respectively, P = 0.02). Post hoc sensitivity analyses excluding those with a history of anxiety or depression demonstrated a 1.45 (95% CI, 0.97, 2.01) and 1.56 (95% CI, 0.95, 2.56) increased risk of an above-normal anxiety and depression score for concussed compared with nonconcussed adolescents, respectively, although both were nonsignificant. Conclusion: Although we found few significant differences between the 2 groups, the results highlight that many concussed adolescents met the threshold for above-average symptoms on the depression and anxiety PROMIS measures. Clinical Relevance: In adolescents, there is increased risk for psychiatric sequalae in the acute period after a concussion. As such, we suggest that clinicians consider incorporating depression screening when caring for adolescents after a concussion.

The use of head kinematic measurement devices has recently proliferated owing to technology advances that make such measurement more feasible. In parallel, demand to understand the biomechanics of head impacts and injury in sports and the military has increased as the burden of such loading on the brain has received focused attention. As a result, the field has matured to the point of needing methodological guidelines to improve the rigor and consistency of research and reduce the risk of scientific bias. To this end, a diverse group of scientists undertook a comprehensive effort to define current best practices in head kinematic measurement, culminating in a series of manuscripts outlining consensus methodologies and companion summary statements. Summary statements were discussed, revised, and voted upon at the Consensus Head Acceleration Measurement Practices (CHAMP) Conference in March 2022. This manuscript summarizes the motivation and methods of the consensus process and introduces recommended reporting checklists to be used to increase transparency and rigor of future experimental design and publication of work in this field. The checklists provide an accessible means for researchers to apply the best practices summarized in the companion manuscripts when reporting studies utilizing head kinematic measurement in sport and military settings.

Understanding the size and shape variations of the head is important to the design of football helmets used to mitigate the risk of head injury. Current guidelines for selecting helmets use only the circumference of the player’s head to determine an appropriate size that may not offer the best fit and protection for every player. The goal of this study was to quantify key measurements of head shape to sufficiently characterize variability among players in the National Football League (NFL), focusing on the shape variation of the cranial region. Statistical shape analysis was performed on three-dimensional head scans of 87 contemporary NFL players to identify key features of head shape variability among the players’ heads. The principal component analysis revealed two factors that explained 87% of the head shape variance: (1) height and length of the head in the sagittal plane and (2) prominent back of the head with an oval shape in the transverse plane versus prominent forehead with a round shape. Four head shape measurements (circumference, length, breadth, and height) were then defined and quantified to describe the first two principal components. This information can facilitate improvements in the design of football helmets.

The Acoustic Startling Pre-stimulus (ASPS, i.e. a loud sound preceding a physical perturbation was previously found to accelerate take-over actions in adults but not teens in autonomous vehicle scenarios. It is not clear if the ASPS also influences the accuracy of the take-over response across ages and sexes. Therefore the aims of this study are: to characterize take-over accuracy across age/experience and sex and to examine the effect of the ASPS and a secondary task on steering wheel alignment in autonomous vehicle take-over scenarios. Fourteen adult (7 males and 13 teenage (6 males drivers volunteered for this study. Participants were instructed to align a marker on the steering wheel with a marker on a lateral post as fast as they could, when a sled perturbation started. Two of the conditions included the ASPS. Two of the conditions involved mobile texting while the sled started moving. The angle between the steering wheel and the lateral post was used to quantify overshooting, undershooting, or correct alignment during steering. Results showed that adult female subjects reached correct alignment slightly more frequently than any other group, while male adult drivers decreased their alignment error after the first trial. Both female and male adult drivers had a reduced alignment angle when the first trial had an ASPS compared to when the first trial had no ASPS while teen drivers performed similarly with ASPS or without. This study showed that take-over accuracy and steering control are influenced by sex, age/experience, and a startle-based warning.

Background: While concussions are common pediatric injuries, a lack of agreement on a standard definition of recovery creates multiple challenges for clinicians and researchers alike. Hypothesis: The percentage of concussed youth deemed recovered as part of a prospective cohort study will differ depending on the recovery definition. Study Design: Descriptive epidemiologic study of a prospectively enrolled observational cohort Level of Evidence: Level 3. Methods: Participants aged 11 to 18 years were enrolled from the concussion program of a tertiary care academic center. Data were collected from initial and follow-up clinical visits ≤12 weeks from injury. A total of 10 recovery definitions were assessed: (1) cleared to full return to sports; (2) return to full school; (3) self-reported return to normal; (4) self-reported full return to school; (5) self-reported full return to exercise; (6) symptom return to preinjury state; (7) complete symptom resolution; (8) symptoms below standardized threshold; (9) no abnormal visio-vestibular examination (VVE) elements; and (10) ≤1 abnormal VVE assessments. Results: In total, 174 participants were enrolled. By week 4, 63.8% met at least 1 recovery definition versus 78.2% by week 8 versus 88.5% by week 12. For individual measures of recovery at week 4, percent recovered ranged from 5% by self-reported full return to exercise to 45% for ≤1 VVE abnormality (similar trends at 8 and 12 weeks). Conclusion: There is wide variability in the proportion of youth considered recovered at various points following concussion depending on the definition of recovery, with higher proportions using physiologic examination-based measures and lower proportions using patient-reported measures. Clinical Relevance: These results further emphasize the need for a multimodal assessment of recovery by clinicians as a single and standardized definition of recovery that captures the broad impact of concussion on a given patient continues to be elusive.

Introduction Repetitive head impacts in soccer have been linked to short-term neurophysiological deficits, and female soccer players have higher concussion rates than males. These findings have inspired investigation into gender differences in head impact exposure and how head impact rate contributes to the cumulative effect of head impact exposure on neurological outcomes. Various periods of exposure have been used to calculate head impact rates, including head impacts per season, game, and player-hour. Purpose The aim of this study was to apply different methodological approaches to quantify and compare head impact rates by gender for two seasons of high school varsity soccer. Methods Video review was used to confirm all events recorded by a headband-mounted impact sensor and calculate playing time for all players. Impact rates were calculated per athlete exposure (presence and participation) and per player-hour (scheduled game time, individual play time, and absolute time). Results Impact rates per athlete exposure ranged from 2.5 to 3.2 for males and from 1.4 to 1.6 for females, and impact rates per player-hour ranged from 2.7 to 3.8 for males and from 1.0 to 1.6 for females. The exposure calculation method significantly affected head impact rates; however, regardless of approach, the head impact rate for males was higher, up to threefold, than for females. Individual head impact exposure varied substantially within a team with one in five players experiencing no impacts. Conclusions Overall, the gender differences found in this study indicate that males experience higher head impact exposure compared with females. Future studies are needed to understand potential clinical implications of variability in head impact exposure and reconcile higher female concussion rates with the reduced head impact rates presented herein.

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

Wearable sensors that accurately record head impacts experienced by athletes during play can enable a wide range of potential applications including equipment improvements, player education, and rule changes. One challenge for wearable systems is their ability to discriminate head impacts from recorded spurious signals. This study describes the development and evaluation of a head impact detection system consisting of a mouthguard sensor and machine learning model for distinguishing head impacts from spurious events in football games. Twenty-one collegiate football athletes participating in 11 games during the 2018 and 2019 seasons wore a custom-fit mouthguard instrumented with linear and angular accelerometers to collect kinematic data. Video was reviewed to classify sensor events, collected from instrumented players that sustained head impacts, as head impacts or spurious events. Data from 2018 games were used to train the ML model to classify head impacts using kinematic data features (127 head impacts; 305 non-head impacts). Performance of the mouthguard sensor and ML model were evaluated using an independent test dataset of 3 games from 2019 (58 head impacts; 74 non-head impacts). Based on the test dataset results, the mouthguard sensor alone detected 81.6% of video-confirmed head impacts while the ML classifier provided 98.3% precision and 100% recall, resulting in an overall head impact detection system that achieved 98.3% precision and 81.6% recall.

Consideration of position-specific features of the NFL concussion environment could enable improved risk mitigation through the design of position-specific helmets to improve self-protection as well as protection for the other player with whom the contact occurs. The purpose of this paper is to quantify position-specific features of scenarios resulting in concussions to NFL players, and the players they contact, by reviewing all game footage (broadcast and non-broadcast) over 4 seasons. Position-specific features were documented for 647 concussions in which a primary exposure could be visualized, including impact source, helmet impact location, activity, and the other player with whom the contact occurred. Findings include the over-representation of helmet-to-ground impacts to the rear of the quarterback's helmet, the high frequency of impacts to the side (upper) location of both concussed players and the players they contacted regardless of position, and distinct differences in the circumstances of concussions to cornerbacks and safeties. The study shows that some features of concussion scenarios are common to all positions, but several position-specific features exist and can inform the design of position-specific helmets for NFL players.

To further the understanding of long-term sequelae as a result of repetitive head impacts in sports, in vivo head impact exposure data are critical to expand on existing evidence from animal model and laboratory studies. Recent technological advances have enabled the development of head impact sensors to estimate the head impact exposure of human subjects in vivo. Previous research has identified the limitations of filtering algorithms to process sensor data. In addition, observer and/or video confirmation of sensor-recorded events is crucial to remove false positives. The purpose of the current study was to conduct a systematic review to determine the proportion of published head impact sensor data studies that used filtering algorithms, observer confirmation and/or video confirmation of sensor-recorded events to remove false positives. Articles were eligible for inclusion if collection of head impact sensor data during live sport was reported in the methods section. Descriptive data, confirmation methods and algorithm use for included articles were coded. The primary objective of each study was reviewed to identify the primary measure of exposure, primary outcome and any additional covariates. A total of 168 articles met the inclusion criteria, the publication of which has increased in recent years. The majority used filtering algorithms (74%). The majority did not use observer and/or video confirmation for all sensor-recorded events (64%), which suggests estimates of head impact exposure from these studies may be imprecise.

Concussion is a common injury among adolescents. It is unknown how a concussion affects driving behavior and performance in adolescents. Although there are guidelines for return to learn, exercise, and sports that school nurses can help support in school, little is known about return to driving after concussion. The goal of this integrative review was to summarize the current literature on return to driving after concussion in adolescents. Six articles published between 2016 and 2020 were included in the review. Physicians and nurse practitioners find providing driving recommendations to adolescents to be appropriate; however, they are unclear what metrics to use to determine whether a patient is fit to drive. Future studies should explore clinical predictors of readiness to return to driving in adolescents. School nurses have an opportunity to support adolescents in their resumption of typical activities after concussion including school, sports, and, as more evidence becomes available, driving.

The relationship between laboratory and on-field performance of football helmets was assessed for 31 football helmet models selected from those worn by players in the 2015–2019 National Football League (NFL) seasons. Linear impactor tests were conducted with helmets placed on an instrumented Hybrid III head and neck assembly mounted on a sliding table. Based on impacts to each helmet at six impact locations and three velocities, a helmet performance score (HPS) was calculated using a linear combination of the head injury criterion (HIC) and the diffuse axonal multi-axis general evaluation (DAMAGE). To determine the on-field performance of helmets, helmet model usage, player participation, and incident concussion data were collected from the five NFL seasons and used to calculate helmet model-specific concussion rates. Comparison of laboratory HPS to the helmet model-specific concussion rates on a per play basis showed a positive correlation (r2 = 0.61, p

As more is learned about injury mechanisms of concussion and scenarios under which injuries are sustained in football games, methods used to evaluate protective equipment must adapt. A combination of video review, videogrammetry, and laboratory reconstructions was used to characterize concussive impacts from National Football League games during the 2015-2017 seasons. Test conditions were generated based upon impact locations and speeds from this data set, and a method for scoring overall helmet performance was created. Head kinematics generated using a linear impactor and sliding table fixture were comparable to those from laboratory reconstructions of concussive impacts at similar impact conditions. Impact tests were performed on 36 football helmet models at two laboratories to evaluate the reproducibility of results from the resulting test protocol. Head acceleration response metric, a head impact severity metric, varied 2.9–5.6% for helmet impacts in the same lab, and 3.8–6.0% for tests performed in a separate lab when averaged by location for the models tested. Overall inter-lab helmet performance varied by 1.1 ± 0.9%, while the standard deviation in helmet performance score was 7.0%. The worst helmet performance score was 33% greater than the score of the best-performing helmet evaluated by this study.

Public concern is growing about the short- and long-term effects of pediatric mild traumatic brain injury (mTBI). This concern is amplified because pediatric mTBI has the potential to go undiagnosed in acute care settings, placing children at increased risk for reinjury prior to complete recovery. The management of mTBI can be particularly challenging due to the lack of validated biomarkers that clinicians can use to objectively diagnose pediatric mTBI, predict risk for prolonged recovery, or demonstrate mTBI recovery. Fluid-based biomarkers have drawn increased attention as an objective measure to diagnose and manage pediatric mTBI, but investigations of promising biomarkers may pose unique challenges in pediatric populations. Our systematic review confirms the relative paucity of high-quality, clinically impactful diagnostic or prognostic fluid biomarker studies, on samples representing only a small fraction of pediatric mTBI. Ultimately, well-designed longitudinal studies across diverse points of care are needed to truly characterize the utility of fluid biomarkers of injury and recovery for the pediatric mTBI patient.

Seventeen concussive helmet-to-helmet impacts occurring in National Football League (NFL) games were analyzed using video footage and reconstructed by launching helmeted crash test dummies into each other in a laboratory. Helmet motion on-field and in the laboratory was tracked in 3D before, during, and after impact in multiple high frame rate video views. Multiple (3-10) tests were conducted for each of the 17 concussive cases (100 tests total) with slight variations in input conditions. Repeatability was assessed by duplicating one or two tests per case. The accuracy of the input conditions in each reconstruction was assessed based on how well the closing velocity, impact locations, and the path eccentricity of the dummy heads matched the video analysis. The accuracy of the reconstruction output was assessed based on how well the changes in helmet velocity (translational and rotational) from the impact matched the video analysis. The average absolute error in helmet velocity changes was 24% in the first test, 20% in the tests with the most accurate input configuration, and 14% in the tests with minimal error. Coefficients of variation in 22 repeated test conditions (1-2 per case) averaged 3% for closing velocity, 7% for helmet velocity changes, and 8% for peak head accelerations. Iterative testing was helpful in reducing error. A combination of sophisticated video analysis, articulated physical surrogates, and iterative testing was required to reduce the error to within half of the effect size of concussion.

This paper reports the development of a test device for replicating unique features of concussion-causing helmet-to-ground impacts. Helmet-to-ground impacts are characterized by an oblique impact velocity vector, preimpact rotational motion of the helmeted head, and an impact into a compliant frictional surface of unknown effective mass. No helmet assessment testing program replicates these impact characteristics, yet they influence brain injury risk and therefore may influence helmet design priorities. To replicate these mechanics, the carriage of a drop tower was modified by the addition of a curvilinear bearing track and a hinged torso-neck fixture to which a helmeted head of a Hybrid III anthropomorphic test device was mounted. Preimpact rotational motion of the head was imparted by forcing a link arm to follow the curvilinear path as the carriage fell under gravity. At impact, the rotating helmeted head struck a vertically mounted surface. The ground impact features of head kinematics are illustrated by comparing rear impacts into a rigid, low-friction surface against those into a compliant frictional surface simulating turf. With the rigid, low-friction surface, the head experienced a change in rotational rate of approximately 40 rad/s, which corresponded to a peak rotational acceleration of approximately αy = − 4000 rad/s2. In contrast, peak rotational acceleration with the compliant frictional surface was approximately αy = − 1000 rad/s2 while the helmet was in contact with the surface. Neck loads were significantly greater with the compliant frictional surface. Translational head acceleration was less sensitive to the surface characteristics, with the peak of the anterior-posterior component essentially unchanged.

The objective of this study was to characterize how pediatric primary care and emergency medicine health care providers and trainees engage in injury prevention counseling and assess perceptions toward injury prevention resources. We surveyed physicians, advanced practice providers, and trainees in the Emergency Department, Primary Care Network, and Pediatric Residency Program at Children’s Hospital of Philadelphia from September to November 2019. Of the 578 eligible participants, 208 (36.0%) completed the survey. When asked to rank the suitability of alternative personnel for providing counseling, 63.0% of the participants selected an injury prevention specialist as best suited. Seventy-six percent of the providers considered a tablet or mobile device used before a patient encounter to be a helpful resource. Variability existed in provider comfort, knowledge, and frequency of counseling by injury topic. Free-text responses cited time as a barrier to counseling. Opportunities exist to improve the provision of injury education through the utilization of novel resources and personnel.

Background Concussion prognosis is a challenging clinical task. Identification of measures useful for persistent symptom risk can help optimize treatment pathways and allow clinicians to offer appropriate anticipatory guidance. Research Question Can a multifaceted single/dual-task postural control assessment within one week of a diagnosed concussion identify the odds of developing persistent post-concussion symptoms (PPCS; symptoms that persist for more than 28 days post-concussion)? Methods We conducted a prospective cohort study of youth and young adult athletes who were evaluated within 7 days of injury, and followed until they no longer reported concussion symptoms. Participants were grouped into those who developed PPCS and those who did not. During the initial evaluation, participants completed a postural control evaluation in single/dual-task conditions. We calculated six gait performance variables (in single/dual-task conditions), nine quiet stance performance variables, and three cognitive task performance (standing and walking) variables. We conducted between-group comparisons to identify candidate PPCS prognostic variables, and multivariable models to adjust for covariates (age, post-injury evaluation time, history of concussion, and BMI). Results Sixty-six participants completed the study: 24% reported PPCS (mean age = 16.9 ± 3.5 years; 50% female; evaluated 4.2 ± 1.9 days post-injury) and 74% (mean age = 18.3 ± 3.0 years; 52% female; evaluated 3.5 ± 1.6 days post-injury) did not. Between-group comparisons indicated greater dual-task transverse plane center-of-mass (COM) range of motion (ROM) (13.1 ± 4.3 vs. 9.9 ± 2.5 degrees; p = 0.013) and lateral step variability (5.1 ± 1.4 vs. 4.0 ± 1.2 cm; p = 0.003) for the PPCS group relative to the no PPCS group. After multivariable modeling, dual-task transverse plane COM ROM (adjusted odds ratio = 1.34, 95% CI = 1.07, 1.68) and lateral step variability (adjusted odds ratio = 1.85, 95% CI = 1.13, 3.05) were significantly associated with PPCS. Significance Dual-task transverse plane movement and lateral step variability demonstrate viable prognostic ability for PPCS among youth and young adult athletes and, along with other established factors, may add incremental value to PPCS prognosis models.

Seating configurations for autonomous driving will include reclined front seated occupants, which may expose child occupants seated directly behind to head impacts even in pre-crash scenarios. This study used mathematical modelling to investigate head contact for second-row child occupants seated behind a reclined front-seat during an automatic emergency braking (AEB) scenario. Although characterized by low speed (1 m/s), head contacts were observed for a seatbelt-restrained 10-year-old and a 6-year-old in a low-back booster when the front-seat was reclined and in an aftward track position. Future seating configurations should consider the potential for head contact by second-row child occupants during crash-avoidance scenarios.

Ergonomic design of child restraint systems (CRS) may facilitate optimal travel behavior and crash protection of child passengers during motor vehicle trips. However there have been few studies examining the relationship between CRS design and child passenger travel behavior. The aim of this study was to examine whether associations between CRS design features and child passenger behavior exist during real-world, everyday vehicle trips. Video from a naturalistic driving study (NDS) was analyzed in this study. Families drove an instrumented study vehicle for approximately two weeks with at least one child aged between one and eight years traveling in their own forward-facing (FF) CRS or belt positioning booster (BPB). Video for one child passenger was randomly selected from each trip for analysis. Video was coded for five-second epochs at nine time points (5%, 17%, 25%, 30%, 50%, 53%, 75%, 89% and 95% of trip length). Two types of child passenger travel behaviors were identified by manual review of the video and audio recordings: (i) optimal/suboptimal head position and (ii) correct/incorrect use of the internal harness/shoulder belt. Video screenshots were used to characterize CRS design features. Random effects logistic regression models were used to examine the associations between specific CRS design features and the travel behaviors of interest, whilst accounting for clustering of data by child and trip. Suboptimal head position was associated with the absence of a height adjustable headrest and a narrow headrest wing width in FFCRS. Incorrect harness use in a FFCRS was associated with the absence of an adjustable headrest, in addition to headrest features such as wing width and depth. In BPBs, a reduction in suboptimal head position was associated with the absence of a sash belt guide, however no restraint design features were associated with incorrect shoulder belt use. Some CRS design features may influence undesirable child passenger travel behavior. These early findings support enhanced and user-centric CRS design as a likely important mechanism to improve child passenger safety.

Increased sensitivity to light is common following concussion. Viewing a flickering light can also produce uncomfortable somatic sensations like nausea or headache. Here we examined effects evoked by viewing a patterned, flickering screen in a cohort of 81 uninjured youth athletes and 84 youth with concussion. We used exploratory factor analysis and identified two primary dimensions of variation: the presence or absence of visually evoked effects, and variation in the tendency to manifest effects that localized to the eyes (e.g., eye watering), versus more generalized neurologic symptoms (e.g., headache). Based on these two primary dimensions, we grouped participants into three categories of evoked symptomatology: no effects, eye-predominant effects, and brain-predominant effects. A similar proportion of participants reported eye-predominant effects in the uninjured (33.3%) and concussion (32.1%) groups. By contrast, participants who experienced brain-predominant effects were almost entirely from the concussion group (1.2% of uninjured, 35.7% of concussed). The presence of brain-predominant effects was associated with a higher concussion symptom burden and reduced performance on visio-vestibular tasks. Our findings indicate that the experience of negative constitutional, somatic sensations in response to a dynamic visual stimulus is a salient marker of concussion and is indicative of more severe concussion symptomatology. We speculate that differences in visually evoked effects reflect varying levels of activation of the trigeminal nociceptive system.

To assess if abnormalities on visio-vestibular examination (VVE) are associated with concussion history (first vs. repeat) or age of first concussion in acutely concussed adolescents.Cross-sectional.Data were queried from the Children's Hospital of Philadelphia Minds Matter concussion registry. Patients aged 14-18 years old presenting for their initial visit to the specialty care concussion program within 28 days of injury were included. Demographics, including age, sex, concussion history, and age of first concussion, were collected before the exam. The VVE consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and vestibulo-ocular reflex (VOR), binocular convergence, left/right monocular accommodation, and complex tandem gait. Primary outcomes included VVE subtests (normal/abnormal), and total VVE score (abnormal = 2+ abnormal subtests).Among 1051 patients included (female = 604(57.5 %); age = 15.6 ± 1.2; median lifetime concussions = 1 [IQR = 1,3]), 518 had repeat concussion. Controlling for age and sex, first vs. repeat concussion was not associated with any VVE subtest or total score (Total VVE Score RR = 1.35, 99.5%CI = 0.70,2.61). Of those with repeat concussion, 190 had valid age of first concussion data. Controlling for age, sex, and number of lifetime concussions, age of first concussion was not significantly associated with any VVE subtest or total score (Total VVE Score RR = 1.11, 99.5%CI = 0.78,1.57).Adolescents with concussion history present with similar visio-vestibular function to those with no concussion history. Additionally, clinical effects of early age of first concussion may not be evident in children. This study provides foundational data regarding potential cumulative effects of concussion in younger athletes.

Previous studies of support legs in rearward-facing infant CRS models have focused on frontal impacts and have found that the presence of a support leg is associated with a reduction in head injury metrics. However, real-world crashes often involve an oblique principal direction of force. The current study used sled tests to evaluate the effectiveness of support legs in rearward-facing infant CRS models for frontal and frontal-oblique impacts with and without a simulated front row seatback. Frontal and frontal-oblique impact sled tests were conducted using the simulated Consumer Reports test method with and without the blocker plate, which was developed to represent a front row seatback. The Q1.5 anthropomorphic test device (ATD) was seated in rearward-facing infant CRS models, which were tested with and without support legs. The presence of a support leg was associated with significant reductions of head injury metrics below injury tolerance limits for all tests, which supports the findings of previous studies. The presence of a support leg was also associated with significant reductions of peak neck tensile force. The presence of the blocker plate resulted in greater head injury metrics compared to tests without the blocker plate, but the result was non-significant. However, the fidelity of the interaction between the CRS and blocker plate as an adequate representation of the interaction that would occur in a real vehicle is not well understood. The findings from the current study continue to support the benefit of support legs in managing the energy of impact for a child in a rearward-facing CRS.

Field studies have evaluated the accuracy of sensors to measure head impact exposure using video analysis, but few have studied false negatives. Therefore, the aim of the current study was to investigate the proportion of potential false negatives in high school soccer head impact data. High school athletes (23 females and 31 males) wore headband-mounted Smart Impact Monitor-G impact sensors during competitive soccer games. Video footage from 41 varsity games was analyzed by 2 independent reviewers to identify head contact events, which were defined as visually observed contact to the head. Of the 1991 video-identified head contact events for which sensors were functioning and worn by the players, 1094 (55%) were recorded by the sensors. For female players, 45% of video-identified head contact events were recorded by the sensor compared with 59% for male players. For both females and males, sensitivity varied by impact mechanism. By quantifying the proportion of potential false negatives, the sensitivity of a sensor can be characterized, which can inform the interpretation of previous studies and the design of future studies using head impact sensors. Owing to the difficulty in obtaining ground truth labels of head impacts, video review should be considered a complementary tool to head impact sensors.

Objective: Emergency braking can potentially generate precrash occupant motion that may influence the effectiveness of restraints in the subsequent crash, particularly for rear-seated occup...