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Concussion education is widely mandated and largely ineffective. Recent consensus guidance on concussion education asserts the importance of (1) theory-driven programming that targets the team as a system and (2) working with end users throughout the development process, and considering issues such as feasibility, acceptability, and sustainability. Consistent with this guidance, and in collaboration with youth sport stakeholders in two regions of the United States, we developed a novel approach to concussion education: Pre-game safety huddles. Safety huddles have the following two core components: (1) athletes, coaches, and other stakeholders come together before the start of each game and (2) opinion leaders (coaches, referees) affirm the importance of care seeking for suspected concussion. The aim of this article is to provide an overview of the collaborative process through which we refined the safety huddle concept into an acceptable and feasible intervention with potential for sustainable implementation in diverse youth sports settings with minimal resource demands. In describing our process and discussing challenges and opportunities, we hope to provide an example for others seeking to develop and implement injury prevention interventions in youth sports settings.

To assess whether the King-Devick (KD) test is useful as a prognostic test for prolonged concussion symptoms by examining the relationship between a) change in performance on KD test from baseline to within two days post-injury and b) the absolute KD time at post-concussion testing, with an outcome of time to return to play (RTP).Prospective Cohort Study.Collegiate varsity athletes in the Concussion Assessment, Research, and Education (CARE) Consortium completed baseline and post-injury King-Devick tests from 2014 to 2018. Two exposures were evaluated: 1) change in KD score from baseline to within two days post-injury and 2) absolute KD score within two days post-injury, adjusted for baseline KD. We used Cox proportional hazards models to analyze the relationships between these exposures and time to RTP post-concussion.A total of 309 concussion injuries were included. Median baseline KD score was 40.0 s (IQR: 35.8, 45.2). Median post-injury KD score was 45.8 s (IQR: 39.8, 57.1). Median number of days until RTP in this cohort was 11 (IQR: 8, 17). Post-injury KD score adjusted for baseline KD had a stronger association with time to RTP duration (HR: 0.99 (0.98, 1.00), p = 0.03) than the difference in KD score from baseline to post-injury (HR: 0.99 (0.99, 1.00), p = 0.07).Higher post-injury KD scores are associated with longer RTP. The association between KD post-concussion test and longer RTP warrants further investigation to assess the utility of the KD for prognostication in a clinical setting.

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 to a control group of non-contact athletes.Generalized estimating equations were used to compare changes in annual, pre-season baseline measures of neurocognitive function, neurobehavioral and psychological symptoms, and postural stability between collegiate soccer players (n = 75; 51 [68%] female soccer players) and non-contact athletes (n = 210; 133 [63%] female non-contact athletes) across three consecutive years.Among all participants, the group-by-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% 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 (PCSS) Symptom Severity (p0.001, Exp(B) = 0.45 [95% CI 0.22-0.95]) scores than non-contact athletes. No other outcome measures were different between soccer players and non-contact athletes.Among collegiate athletes, soccer players report similar or better psychosocial functioning and symptom scores than non-contact athletes. Importantly, neurocognitive functioning, neurobehavioral and psychological symptoms, and postural stability does not worsen over time in collegiate soccer players relative to their non-contact counterparts. Our findings suggest that despite possible exposure to repetitive head impacts (RHIs), collegiate soccer players do not exhibit changes in observable function and symptoms across multiple seasons.

ObjectivesDetermine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes.MethodsA cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9–14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season.ResultsOf 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen’s d=0.35).Conclusions and relevancePre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting.Trial registration numberNCT04099329.

Background: The prevalence of unreported concussions is high, and undiagnosed concussions can lead to worse postconcussion outcomes. It is not clear how those with a history of undiagnosed concussion perform on subsequent standard concussion baseline assessments. Purpose: To determine if previous concussion diagnosis status was associated with outcomes on the standard baseline concussion assessment battery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Concussion Assessment, Research, and Education (CARE) Consortium participants (N = 29,934) self-reported concussion history with diagnosis status and completed standard baseline concussion assessments, including assessments for symptoms, mental status, balance, and neurocognition. Multiple linear regression models were used to estimate mean differences and 95% CIs among concussion history groups (no concussion history [n = 23,037; 77.0%], all previous concussions diagnosed [n = 5315; 17.8%], ≥1 previous concussions undiagnosed [n = 1582; 5.3%]) at baseline for all outcomes except symptom severity and Brief Symptom Inventory–18 (BSI-18) score, in which negative binomial models were used to calculate incidence rate ratios (IRRs). All models were adjusted for sex, race, ethnicity, sport contact level, and concussion count. Mean differences with 95% CIs excluding 0.00 and at least a small effect size (≥0.20), and those IRRs with 95% CIs excluding 1.00 and at least a small association (IRR, ≥1.10) were considered significant. Results: The ≥1 previous concussions undiagnosed group reported significantly greater symptom severity scores (IRR, ≥1.38) and BSI-18 (IRR, ≥1.31) scores relative to the no concussion history and all previous concussions diagnosed groups. The ≥1 previous concussions undiagnosed group performed significantly worse on 6 neurocognitive assessments while performing better on only 2 compared with the no concussion history and all previous concussions diagnosed groups. There were no between-group differences on mental status or balance assessments. Conclusion: An undiagnosed concussion history was associated with worse clinical indicators at future baseline assessments. Individuals reporting ≥1 previous undiagnosed concussions exhibited worse baseline clinical indicators. This may suggest that concussion-related harm may be exacerbated when injuries are not diagnosed.

There is limited long-term data on the course of school-related problems and academic needs for youth with persistent post-concussive symptoms (PPCS).This was a randomized trial comparing collaborative care to usual care for 200 youth 11-18 years of age with PPCS. In this report, the main outcomes were academic functioning, GPA, school absences, date of return to school, and school days missed.Youth were mean age of 14.7 (SD = 1.7), 62.0% female. New or worsening academic problems occurred in half of participants in both groups at 12 months after injury. Students were most concerned about grades and falling behind. There were no significant differences by study group on school problems or GPA, but number of days missed was lower in the collaborative care group compared at 3 months (12.5 [SD = 14.5] vs 16.1 days [20.4] adjusted relative risk [aRR] 0.67 [95% CI: 0.61, 0.74; p .001]), 6 months (14.5 [22.1] vs 19.3 [26.6] aRR 0.77 [95% CI: 0.71, 0.84; p .001]), and 12 months (16.9 [25.4] vs 19.6 [27.7], aRR 0.68 [95% CI: 0.62, 0.74; p .001]).Youth with PPCS are at high risk of school problems in the year after injury.

Research suggests coaches play a central role in establishing a context conducive to concussion reporting, particularly via direct verbal communication about concussion. Informed by qualitative int...

Objective: Acknowledging that coach communication about concussion increases the likelihood of athletes reporting concussive symptoms, the goal of this study was to examine factors affecting such communication, in order to develop a conceptual model that would inform the design of future educational interventions.Participants: Division I contact sport coaches.Methods: We conducted structured qualitative interviews with coaches and analyzed interviews using Thematic Analysis, viewed through the lens of the Theory of Planned Behavior nested within the Social Ecological Model.Results: Coaches had good knowledge of concussion and understood the dangers of playing with symptoms. However, they also discussed the lack of objective criteria for concussion diagnosis, and pressure to win in order to remain employed, both of which created barriers to concussion communication. Ultimately, most coaches reported not engaging in significant concussion communication as they did not feel this was their role, instead deferring to medical staff.Conclusions: Educational interventions might benefit from a focus on the importance of coach concussion safety-supportive coach communication, with a goal of increasing the likelihood of athlete concussion reporting.

The purpose of this study was to describe the mechanism of injury (MOI) and examine factors associated with greater risk for specific MOIs involving concussions in collegiate soccer players.Participants included 3,288 collegiate soccer players from 28 institutions across four competitive seasons, 2014-17. MOIs were documented for 262 soccer-related concussions during the study and placed into one of four categories: collisions, unintentional contact, aerial challenges, and others.70% of the concussions occurred in DI soccer players. Collisions and unintentional contact were the MOIs that resulted in 66.5% of all concussions. DI and DIII soccer players sustained more concussions by unintentional contact versus collisions and aerial challenges when compared to their DII counterparts. Defenders were more likely than midfielders to sustain concussions by aerial challenges than collisions. As expected, the field players experienced more concussions as a result of collisions, unintentional contact, and aerial challenges when compared to goalkeepers.Future research should explore preventive strategies for decreasing collisions, especially during aerial challenges while heading the soccer ball, and unintentional contacts from errant balls in soccer in order to decrease concussion risk.

Challenges with school learning following a concussion have become recognized more so over the past decade. Evidence-based assessment tools to identify these clinical problems and needs can facilitate critical supports for the recovering student. The Concussion Learning Assessment & School Survey, 3rd Edition (CLASS-3), developed to address this need, was administered to student participants (n = 390, ages 10–18 years) and their parents (n = 132, ages 5–18 years). We present sources of psychometric evidence regarding the reliability/precision and validity/accuracy in support of the interpretation of the four CLASS-3 scale scores (General Academic Concern, Academic Problems, School Stresses, Academic Subjects). For self- and parent-report versions, each scale presents strong evidence of internal consistency, moderate relationships between parent and child ratings, and adequate stability of the scores over time for a clinically recovering sample. Exploratory factor analysis of each scale reveals a strong unidimensional structure while patterns of intercorrelations of the CLASS-3 scales with other measures demonstrate evidence of logical relationships with post-concussion symptoms and executive functions. Sensitivity of the scale scores to change over time is demonstrated as well as differentiating recovered from non-recovered patients. Overall, the self- and parent-report versions of the CLASS-3 scales provide reasonable psychometric evidence to consider it as a clinical measure to define and track the academic needs of the student following concussion.

ObjectiveTo examine the association between estimated age at first exposure (eAFE) to American football and clinical measures throughout recovery following concussion.MethodsParticipants were recruited across 30 colleges and universities as part of the National Collegiate Athletic Association (NCAA)–Department of Defense Concussion Assessment, Research and Education Consortium. There were 294 NCAA American football players (age 19 ± 1 years) evaluated 24–48 hours following concussion with valid baseline data and 327 (age 19 ± 1 years) evaluated at the time they were asymptomatic with valid baseline data. Participants sustained a medically diagnosed concussion between baseline testing and postconcussion assessments. Outcome measures included the number of days until asymptomatic, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) composite scores, Balance Error Scoring System (BESS) total score, and Brief Symptom Inventory 18 (BSI-18) subscores. The eAFE was defined as participant's age at the time of assessment minus self-reported number of years playing football.ResultsIn unadjusted regression models, younger eAFE was associated with lower (worse) ImPACT Visual Motor Speed (R2 = 0.031, p = 0.012) at 24–48 hours following injury and lower (better) BSI-18 Somatization subscores (R2 = 0.014, p = 0.038) when the athletes were asymptomatic. The effect sizes were very small. The eAFE was not associated with the number of days until asymptomatic, other ImPACT composite scores, BESS total score, or other BSI-18 subscores.ConclusionEarlier eAFE to American football was not associated with longer symptom recovery, worse balance, worse cognitive performance, or greater psychological distress following concussion. In these NCAA football players, longer duration of exposure to football during childhood and adolescence appears to be unrelated to clinical recovery following concussion.

Purpose: Assess whether athletes with a prior concussion diagnosis are more likely to continue play with a possible concussion. Additionally, explore whether reasons for concussion under-reporting are different among athletes with a prior concussion when compared to other athletes. Methods: Cross-sectional survey of 328 collegiate athletes. Results: Athletes with a prior concussion diagnosis had significantly greater relative risk of continuing play while symptomatic of a possible concussion during their most recent season compared to athletes without prior concussion diagnosis. Significant differences exist in the reasons that athletes provided for not reporting by history of concussion. Conclusions: Findings suggest that learning may have occurred as a result of the prior diagnosis; however, this learning did not appear to result in safer reporting behavior. Additional research is necessary to clarify why athletes who have been previously diagnosed with a concussion are more likely to continue playing while experiencing concussion symptoms.

Concussion is common and subspecialty care can be essential to ensure recovery. However, barriers may exist to accessing care. This study aimed to assess disparities in subspecialty concussion care related to ethnicity, limited English proficiency (LEP), and insurance status. We utilized logistic regression to analyze 2010-2015 administrative data from four Sports Medicine clinics, comparing odds of being seen for concussion to odds of being seen for fracture by ethnicity, insurance type, and interpreter usage, controlling for demographic factors. ICD-9 codes were used to identify concussion and fracture. Our final sample contained 25,294 subjects: 5621 with concussion and 19,673 with fracture. In bivariate analysis, youth seen for concussion had 83% lower odds of being Hispanic compared with youth seen for fracture (95%CI: 75-92%). Due to interactions between ethnicity and interpreter use, we utilized a stratified multivariate model as our final model. Youth with concussion had 1.8× greater odds of having private insurance compared with youth with fracture (Hispanic OR 1.8, 95% CI 1.5-2.3; Non-Hispanic OR 1.8, 95% CI 1.7-2.0). Youth with concussion also had greater odds of not using an interpreter, though the strength of this association was weaker for Hispanic youth compared with non-Hispanic youth (Hispanic OR 1.68, 95% CI 1.30-2.17; Non-Hispanic OR 4.36, 95% CI 3.00-6.35). Age and sex were included as covariates. In conclusion, our analysis suggests disparities in subspecialty concussion care for Hispanic youth, as well as for individuals with LEP and non-private insurance. Further research should explore means for improving access to concussion care for all youth.

Context Comprehensive assessments are recommended to evaluate sport-related concussion (SRC). The degree to which the King-Devick (KD) test adds novel information to an SRC evaluation is unknown. Objective To describe relationships at baseline among the KD and other SRC assessments and explore whether the KD provides unique information to a multimodal baseline concussion assessment. Design Cross-sectional study. Setting Five National Collegiate Athletic Association institutions participating in the Concussion Assessment, Research and Education (CARE) Consortium. Patients or Other Participants National Collegiate Athletic Association student-athletes (N = 2258, age = 20 ± 1.5 years, 53.0% male, 68.9% white) in 11 men's and 13 women's sports. Main Outcome Measure(s) Participants completed baseline assessments on the KD and (1) the Symptom Inventory of the Sport Concussion Assessment Tool–3rd edition, (2) the Brief Symptom Inventory-18, (3) the Balance Error Scoring System, (4) the Standardized Assessment of Concussion (SAC), (5) the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test battery, and (6) the Vestibular/Ocular Motor Screening tool during their first year in CARE. Correlation coefficients between the KD and the 6 other concussion assessments in isolation were determined. Assessments with ρ magnitude >0.1 were included in a multivariate linear regression analysis to evaluate their relative association with the KD. Results Scores for SAC concentration, ImPACT visual motor speed, and ImPACT reaction time were correlated with the KD (ρ = −0.216, −0.276, and 0.164, respectively) and were thus included in the regression model, which explained 16.8% of the variance in baseline KD time (P < .001, Cohen f2 = 0.20). Better SAC concentration score (β = −.174, P < .001), ImPACT visual motor speed (β = −.205, P < .001), and ImPACT reaction time (β = .056, P = .020) were associated with faster baseline KD performance, but the effect sizes were small. Conclusions Better performance on cognitive measures involving concentration, visual motor speed, and reaction time was weakly associated with better baseline KD performance. Symptoms, psychological distress, balance, and vestibular-oculomotor provocation were unrelated to KD performance at baseline. The findings indicate limited overlap at baseline among the CARE SRC assessments and the KD.

ContextThe King-Devick (KD) test has received considerable attention in the literature as an emerging concussion assessment. However, important test psychometric properties remain to be addressed in large-scale independent studies.ObjectiveTo assess (1) test-retest reliability between trials, (2) test-retest reliability between years 1 and 2, and (3) reliability of the 2 administration modes.DesignCross-sectional study.SettingCollegiate athletic training facilities.Patients or Other ParticipantsA total of 3248 intercollegiate student-athletes participated in year 1 (male = 55.3%, age = 20.2 ± 2.3 years, height = 1.78 ± 0.11 m, weight = 80.7 ± 21.0 kg) and 833 participated in both years.Main Outcome Measure(s)Time, in seconds, to complete the KD error free. The KD test reliability was assessed between trials and between annual tests over 2 years and stratified by test modality (spiral-bound cards [n = 566] and tablet [n = 264]).ResultsThe KD test was reliable between trials (trial 1 = 43.2 ± 8.3 seconds, trial 2 = 40.8 ± 7.8 seconds; intraclass correlation coefficient [ICC] (2,1) = 0.888, P < .001), between years (year 1 = 40.8 ± 7.4 seconds, year 2 = 38.7 ± 7.7 seconds; ICC [2,1] = 0.827, P < .001), and for both spiral-bound cards (ICC [2,1] = 0.834, P < .001) and tablets (ICC [2,1] = 0.827, P < .001). The mean change between trials for a single test was −2.4 ± 3.8 seconds. Although most athletes improved from year 1 to year 2, 27.1% (226 of 883) of participants demonstrated worse (slower) KD times (3.2 ± 3.9 seconds) in year 2.ConclusionsThe KD test was reliable between trials and years and when stratified by modality. A small improvement of 2 seconds was identified with annual retesting, likely due to a practice effect; however, 27% of athletes displayed slowed performance from year 1 to year 2. These results suggest that the KD assessment was a reliable test with modest learning effects over time and that the assessment modality did not adversely affect baseline reliability.

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

STUDY OBJECTIVE: Concussion is highly prevalent in adolescents and associated with a higher risk of substance use. With the rising use of opioids among adolescents, one form of substance use of concern is misuse of prescription opioids. This study aimed to examine the association between history of sports-related concussion in the past year and current prescription opioid misuse among high school students in the United States (US). SETTING: Secondary data analysis from the 2019 Youth Risk Behavior Survey. PARTICIPANTS: Nationally representative sample of high school students (n = 7,314). DESIGN: Cross-sectional study MAIN MEASURES: Participants were asked whether they experienced any concussions related to sports or being physically active during the past 12 months; and whether they had any prescription opioid misuse within the past 30 days. RESULTS: Amongst this cohort, 14.0% reported sustaining a concussion in the past 12 months and 6% reported current prescription opioid misuse. Prevalence of prescription opioid misuse was higher among those with history of concussion (9.9%) compared to those without concussion (5.5%, p = 0.0015). Controlling for covariates (sex, race/ethnicity, other substance use, depressive symptoms), the odds of prescription opioid misuse was 1.5 times higher for adolescents with concussion compared to those without (adjusted odds ratios [OR] = 1.5; 95% confidence interval 1.0, 2.3; p = 0.029). CONCLUSION: Concussion was associated with prescription opioid misuse among US youth, even after accounting for depressive symptoms and other substance use. Longitudinal studies are needed to test causal relationships and understand biobehavioral mechanisms that underlie associations between concussion and opioid misuse in adolescents.

Direct verbal communication from parents about concussion safety and parent pressure related to sport achievement may influence concussion risk-related behavior among youth athletes. This study assessed whether less parental pressure related to sport achievement and more parental communication about concussion safety were associated with lower intentions to continue sport participation while experiencing concussion symptoms. Participants were youth football players (ages 10-14) and their parents (n = 278 dyads, response rate = 45%). Structural equation modeling was used to predict the athlete's intention to continue play with concussive symptoms. One quarter of parents had never talked with their child about any concussion safety topic, and more than half had not talked about concussion safety within the past year. Greater parent communication about concussion and less pressure on sport achievement were both associated with lower child intention to continue playing while symptomatic post-concussion. Parents who placed more pressure on their child related to sport achievement were less likely to talk about concussion safety with their child. Determining how to shape parenting that is supportive of concussion safety is an important avenue for future health education program development work. This may include efforts to parenting behaviors in the sport context that reinforce effort rather than winning.

This study sought to identify factors that influence whether coaches support athletes struggling with depression and anxiety. Participants were U.S. public high school coaches who completed a written survey assessing their experiences, attitudes, and behaviors related to student-athlete mental health (n = 190 coaches, 92% response rate). Around two-thirds of coaches were concerned about mental health issues among the students they coached. They were more likely to extend help to a struggling athlete if they were aware of their school’s mental health plan and had greater confidence related to helping, including feeling confident in their ability to identify symptoms of mental health disorders. Mental health professionals, including sport psychologists who work with or consult with coaches, are well positioned to help provide coaches with the education necessary to be able to support and encourage care seeking by athletes who are struggling with anxiety or depression.

OBJECTIVE To examine variation in head impact exposure (HIE) by age and sex in youth soccer. DESIGN Prospective cohort study. SETTING AND PARTICIPANTS Youth soccer athletes (11-14 years old) in local clubs. EXPOSURES Age and sex. OUTCOME MEASURES Head impact exposure measured using adhesive-mounted accelerometers during 1 month of soccer. RESULTS Forty-six youth athletes (54% female) participated. No athlete reported a concussion during the study. More males than females had at least 1 head impact ≥15 g (P = 0.02). Of those who sustained a head impact above the 15-g threshold (57%), females sustained HIE of greater magnitude than males (median 47.4 g vs 33.3 g, P = 0.04). Eighty-five percent of athletes on U14 teams had at least 1 head impact ≥15 g compared with 15% of athletes on U12 teams (P < 0.001). Poisson regression stratified by sex and controlling for team-suggested age effects were significant only for females (P = 0.02). There was significant variation in HIE by team. There were no decrements in concussion symptoms, health-related quality of life, or neuropsychological testing after 1 month of soccer play. CONCLUSIONS There is significant variation in HIE in youth soccer, which seems to be influenced by age and sex. Further studies are needed to better understand potential significance for injury prevention.

ObjectiveTo assess diagnostic accuracy and reliability of sideline concussion tests in college athletes.MethodsAthletes completed baseline concussion tests including Post-Concussion Symptom Scale, Standardised Assessment of Concussion (SAC), modified Balance Error Scoring System (m-BESS), King-Devick test and EYE-SYNC Smooth Pursuits. Testing was repeated in athletes diagnosed acutely with concussion and compared to a matched teammate without concussion.ResultsData were collected on 41 concussed athletes and 41 matched controls. Test–retest reliability for symptom score and symptom severity assessed using control athletes was 0.09 (−0.70 to 0.88) and 0.08 (−1.00 to 1.00) (unweighted kappa). Intraclass correlations were SAC 0.33 (−0.02 to 0.61), m-BESS 0.33 (−0.2 to 0.60), EYE-SYNC Smooth Pursuit tangential variability 0.70 (0.50 to 0.83), radial variability 0.47 (0.19 to 0.69) and King-Devick test 0.71 (0.49 to 0.84). The maximum identified sensitivity/specificity of each test for predicting clinical concussion diagnosis was: symptom score 81%/94% (3-point increase), symptom severity score 91%/81% (3-point increase), SAC 44%/72% (2-point decline), m-BESS 40%/92% (5-point increase), King-Devick 85%/76% (any increase in time) and EYE-SYNC Smooth Pursuit tangential variability 48%/58% and radial variability 52%/61% (any increase). Adjusted area under the curve was: symptom score 0.95 (0.89, 0.99), symptom severity 0.95 (95% CI 0.88 to 0.99), SAC 0.66 (95% CI 0.54 to 0.79), m-BESS 0.71 (0.60, 0.83), King-Devick 0.78 (0.69, 0.87), radial variability 0.47 (0.34, 0.59), tangential variability 0.41 (0.30, 0.54)ConclusionTest–retest reliability of most sideline concussion tests was poor in uninjured athletes, raising concern about the accuracy of these tests to detect new concussion. Symptom score/severity had the greatest sensitivity and specificity, and of the objective tests, the King-Devick test performed best.

PRIMARY OBJECTIVE: To compare child- and parent-report ratings on the Health Behavior Inventory, Revised Child Anxiety and Depression Scale-Short Version (anxiety subscale), Patient Health Questionnaire-9, and Pediatric Quality of Life Inventory™ among children with persistent post-concussive symptoms following a sports- or recreation-related concussion, overall and by child age and gender. RESEARCH DESIGN: Cross-sectional study examining baseline data from a randomized, comparative effectiveness trial. METHODS AND PROCEDURES: Inter-rater reliability was assessed using two-way random effects model (absolute agreement) intraclass correlations, correlations were examined using Spearman’s rho, mean differences were determined using paired t-tests, and agreement was examined using Bland-Altman plots. MAIN OUTCOMES AND RESULTS: The final analytic sample was 200 parent-child dyads [child M(age)=14.7 (95% CI: 14.5, 15.0)]. Reliability and correlations were modest overall. When considering child age and gender, reliability ranged from poor to excellent (−1.01–0.95) and correlations ranged from weak to strong (−0.64–0.94). Overall, children reported more symptoms but better functioning than parents, and mean differences in scores were greater among females (versus males) and ages 16–18 (versus younger groups). CONCLUSIONS: Findings should inform the use and interpretation of psychosocial measures when developing appropriate youth concussion treatment plans.

Key Points Question What factors are associated with recovery in pediatric patients with mild traumatic brain injury or concussion? Findings In this cohort study of 600 pediatric patients presenting to concussion clinics in 3 centers, girls and women experienced slower recovery and were more likely to have preexisting anxiety compared with boys and men. Independent of sex, patients with anxiety or depression or migraine recovered more slowly than those without these comorbidities. Meaning These findings suggest that factors, such as sex and comorbidities, in pediatric patients with mild traumatic brain injury are essential for accurate prognostic estimates and identifying targets for treatment., This cohort study examines patient characteristics associated with recovery time in pediatric patients with mild traumatic brain injury treated at concussion specialty clinics., Importance Pediatric mild traumatic brain injury (TBI) and concussion are a public health challenge with up to 30% of patients experiencing prolonged recovery. Pediatric patients presenting to concussion clinics often have ongoing impairments and may be at increased risk for persistent symptoms. Understanding this population is critical for improved prognostic estimates and optimal treatment. Objective To describe pediatric patients presenting to concussion clinics and characterize factors associated with their recovery. Design, Setting, and Participants This prospective cohort study included patients enrolled at multicenter concussion specialty clinics from the Four Corners Youth Consortium from December 2017 to July 2019, with up to 12-month follow-up. Patients were eligible if they were aged 5 to 18.99 years with a diagnosis of mild TBI or concussion presenting to participating clinics within 8 weeks of injury. Patients were excluded if the patient or their parents were unable to read or sign the consent document, or if the patient had a Glasgow Coma Scale score less than 13 or a penetrating injury. Data were analyzed from February 2019 to April 2020. Exposures Diagnosis of mild TBI or concussion. Main Outcomes and Measures This study used National Institute of Neurological Disorders and Stroke common data elements, including data on demographic characteristics, injury details, history, neurological and neuropsychological assessments, and treatment. Results A total of 600 patients were consecutively enrolled, among whom 324 (54.0%) were female and 435 (72.5%) were adolescents (ie, aged 13-18 years). A higher proportion of girls and women (248 patients [76.5%]) were adolescents compared with boys and men (187 patients [67.8%]) (P = .02), and girls and women reported significantly more preexisting anxiety compared with boys and men (80 patients [26.7%] vs 46 patients [18.7%]; P = .03). Significantly more adolescents reported preexisting migraines compared with preadolescents (82 patients [20.9%] vs 15 patients [10.9%]; P = .01). Girls and women recovered more slowly than boys and men (persistent symptoms after injury: week 4, 217 patients [81.6%] vs 156 patients [71.2%]; week 8, 146 patients [58.9%] vs 89 patients [44.3%]; week 12, 103 patients [42.6%] vs 58 patients [30.2%]; P = .01). Patients with history of migraine or anxiety or depression recovered more slowly than those without, regardless of sex. Conclusions and Relevance These findings suggest that identification of subgroups of pediatric patients with mild TBI or concussion at risk for prolonged recovery could aid in better prognostic estimates and more targeted treatment interventions.

Background: Identifying separate dimensions of concussion symptoms may inform a precision medicine approach to treatment. It was previously reported that a bifactor model identified distinct acute postconcussion symptom dimensions. Purpose: To replicate previous findings of a bifactor structure of concussion symptoms in the Concussion Assessment Research and Education (CARE) Consortium sample, examine measurement invariance from pre- to postinjury, and evaluate whether factors are associated with other clinical and biomarker measures. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Collegiate athletes were prospectively evaluated using the Sport Concussion Assessment Tool–3 (SCAT-3) during preseason (N = 31,557); 2789 were followed at Results: The optimal structure for each time point was a 7-factor bifactor model: a General factor, on which all items loaded, and 6 specific factors—Vestibulo-ocular, Headache, Sensory, Fatigue, Cognitive, and Emotional. The model manifested strict invariance across the 2 postinjury time points but only configural invariance from baseline to postinjury. From Conclusion: Bifactor modeling supported the predominant unidimensionality of concussion symptoms while revealing multidimensional properties, including a large dominant General factor and 6 independent factors: Headache, Vestibulo-ocular, Sensory, Cognitive, Fatigue, and Emotional. Unlike the widely used SCAT-3 symptom severity score, which declines gradually after injury, the bifactor model revealed separable symptom dimensions that have distinct trajectories in the acute postinjury period and different patterns of association with other markers of injury severity and outcome. Clinical Relevance: The SCAT-3 total score remains a valuable, robust index of overall concussion symptom severity, and the specific factors identified may inform management strategies. Because some symptom dimensions continue to worsen in the first 24 to 48 hours after injury (ie, Sensory, Fatigue, Emotional), routine follow-up in this time frame may be valuable to ensure that symptoms are managed effectively.

Many families are concerned about their child’s risk of concussion, and some seek counsel from clinicians about whether or not to return to contact sports participation postinjury. The present study sought to identify factors that parents weight most heavily in forming their preferences regarding whether their child should return to contact sport after recovering from a concussion. Survey data were collected from 568 parents of youth football players (aged 7–14 years) in the Pacific Northwest region of the United States (73% response rate). Approximately two thirds (63%) of parents preferred that their child retire from football after one or two concussions. Multivariable linear regression indicated parents above the sample mean in terms of how strongly they valued football participation preferred their child stop after more concussions than parents below the sample mean (β = .44, standard error [SE] = 0.06, p < .001). Factors endorsed by the most parents as making them “much more likely” to want their child to stop playing football included the belief that their child will experience cognitive issues later in life as a result of concussions (65.0%) and that their child will get another concussion while playing football (43.5%). Within the context of a clinical visit postconcussion, physicians may need to help families clarify their values related to football participation and provide information about the potential outcomes of returning to contact sport. A formalized shared decision aid could help support consistent implementation of this potentially challenging conversation.

Background: Organizations recommend that athletes should be asymptomatic or symptom-limited before initiating a graduated return-to-play (GRTP) protocol after sports-related concussion, although asymptomatic or symptom-limited is not well-defined. Hypotheses: (1) There will be a range (ie, beyond zero as indicator of “symptom-free”) in symptom severity endorsement when athletes are deemed ready to initiate a GRTP protocol. (2) Baseline symptom severity scores and demographic/preinjury medical history factors influence symptom severity scores at the commencement of the GRTP protocol. (3) Greater symptom severity scores at GRTP protocol initiation will result in longer protocol duration. (4) Symptom severity scores will not differ between those who did and did not sustain a repeat injury within 90 days of their initial injury. Study Design: Cohort study; Level of evidence, 2. Methods: Across 30 universities, athletes (N = 1531) completed assessments at baseline and before beginning the GRTP protocol, as determined by local medical staff. Symptom severity scores were recorded with the symptom checklist of the Sport Concussion Assessment Tool–3rd Edition. Nonparametric comparisons were used to examine the effect of medical, demographic, and injury factors on symptom endorsement at GRTP protocol initiation, as well as differences in symptom severity scores between those who did and did not sustain a repeat injury within 90 days. A Cox regression was used to examine the association between symptom severity scores at GRTP protocol initiation and protocol duration. Results: Symptom severity scores at the time when the GRTP protocol was initiated were as follows: 0 to 5 (n = 1378; 90.0%), 6 to 10 (n = 76; 5.0%), 11 to 20 (n = 42; 3.0%), and ≥21 (n = 35; 2.0%). Demographic (sex and age), medical (psychiatric disorders, attention-deficit/hyperactivity disorder, learning disorder), and other factors (baseline symptom endorsement and sleep) were significantly associated with higher symptom severity scores at the GRTP initiation ( P < .05). The 4 GRTP initiation time point symptom severity score groups did not significantly differ in total time to unrestricted RTP, χ2(3) = 1.4; P = .73. When days until the initiation of the GRTP protocol was included as a covariate, symptom severity scores between 11 and 20 ( P = .02; hazard ratio = 1.44; 95% CI, 1.06-1.96) and ≥21 ( P < .001; hazard ratio = 1.88; 95% CI, 1.34-2.63) were significantly associated with a longer GRTP protocol duration as compared with symptom severity scores between 0 and 5. Symptom severity scores at GRTP initiation did not significantly differ between those who sustained a repeat injury within 90 days and those who did not ( U = 29,893.5; P = .75). Conclusion: A range of symptom severity endorsement was observed at GRTP protocol initiation, with higher endorsement among those with higher baseline symptom endorsement and select demographic and medical history factors. Findings suggest that initiation of a GRTP protocol before an absolute absence of all symptoms is not associated with longer progression of the GRTP protocol, although symptom severity scores >10 were associated with longer duration of a GRTP protocol. Results can be utilized to guide clinicians toward optimal GRTP initiation (ie, balancing active recovery with avoidance of premature return to activity).

Background Individuals who sustain their first concussion during childhood may be at greater risk of sustaining multiple concussions throughout their lifetime because of a longer window of vulnerability. This article aims to estimate the association between age at first concussion and number of subsequent concussions. Patients and Methods A total of 23,582 collegiate athletes from 26 universities and military cadets from three military academies completed a concussion history questionnaire (65% males, age 19.9 ± 1.4 years). Participants self-reported concussions and age at time of each injury. Participants with a history of concussion (n = 3,647, 15.5%) were categorized as having sustained their first concussion during childhood (less than ten years old) or adolescence (≥10 and ≤18 years old). Poisson regression was used to model age group (childhood, adolescence) predicting the number of subsequent concussions (0, 1, 2+). A second Poisson regression was developed to determine whether age at first concussion predicted the number of subsequent concussions. Results Participants self-reporting their first concussion during childhood had an increased risk of subsequent concussions (rate ratio = 2.19, 95% confidence interval: 1.82, 2.64) compared with participants self-reporting their first concussion during adolescence. For every one-year increase in age at first concussion, we observed a 16% reduction in the risk of subsequent concussion (rate ratio = 0.84, 95% confidence interval: 0.82, 0.86). Conclusions Individuals self-reporting a concussion at a young age sustained a higher number of concussions before age 18. Concussion prevention, recognition, and reporting strategies are of particular need at the youth level.

Background: Timely removal from activity after concussion symptoms remains problematic despite heightened awareness. Previous studies indicated potential adverse effects of continuing to participate in physical activity immediately after sustaining a concussion. Hypothesis/Purpose: The purpose was to determine the effect of timing of removal from play after concussion on clinical outcomes. It was hypothesized that immediate removal from activity after sport-related concussion (SRC) would be associated with less time missed from sport, a shorter symptomatic period, and better outcomes on acute clinical measures. Study Design: Cohort study; Level of evidence, 3. Methods: Data were reported from the National Collegiate Athletic Association and Department of Defense Grand Alliance: Concussion Awareness, Research, and Education (CARE) Consortium. Participants with 506 diagnosed SRCs from 18 sports and 25 institutions and military service academies were analyzed and classified as either immediate removal from activity (I-RFA) or delayed removal from activity (D-RFA). Outcomes of interest included time missed from sport attributed to their SRC, symptom duration, and clinical assessment scores. Results: There were 322 participants (63.6%) characterized as D-RFA. I-RFA status was associated with significantly less time missed from sport ( R2 change = .022-.024, P < .001 to P = .001) and shorter symptom duration ( R2 change = .044-.046, P < .001 [all imputations]) while controlling for other SRC recovery modifiers. These athletes missed approximately 3 fewer days from sport participation. I-RFA athletes had significantly less severe acute SRC symptoms and were at lower risk of recovery taking ≥14 days (relative risk = .614, P < .001, small-medium effect size) and ≥21 days (relative risk = .534, P = .010, small effect size). Conclusion: I-RFA is a protective factor associated with less severe acute symptoms and shorter recovery after SRC. Conveying this message to athletes, coaches, and others involved in the care of athletes may promote timely injury reporting.

Background. Parental communication about the importance of reporting concussion symptoms can influence a child’s attitudes about such reporting, and is likely related to perceived threat of concussion. However, parental investment in child sport achievement might impede this communication. Purpose. To examine the relationship between perceived threat of concussion and parent–child communication regarding concussion symptom reporting, and the potential interaction with parental pressure regarding child sport achievement. Method. A total of 236 parents of youth soccer players completed an anonymous online survey. Results. There were greater odds of encouraging concussion reporting among parents who perceived that their child had a greater likelihood of sustaining a concussion ( OR = 1.03, 95% CI [1.01, 1.04]) and lower odds among parents who exhibited greater parental sport pressure ( OR = 0.88, 95% CI [0.78, 0.99]). Parents whose child had a prior concussion were much more likely to communicate with their child about concussion reporting ( OR = 7.86, 95% CI [3.00, 20.55]). Conclusion. Initiatives are needed to support healthy sport parenting, particularly focusing on parental encouragement of concussion reporting. Possible directions for concussion education for parents based on the results of this study include providing parents with concrete guidance about the important role they can play in encouraging their child to report symptoms of a concussion, communicating the athletic consequences of continued sport involvement while experiencing symptoms of a concussion, and using narrative messaging with exemplars to personalize the information for parents of youth who have not previously sustained a concussion.

Background Prior studies suggest potential benefit using monitored aerobic exercise to treat youth with persistent concussion symptoms, but these studies have been small. Objectives To explore the safety and potential benefits of a rehabilitative exercise intervention, the Sub-symptom Threshold Exercise Program (SSTEP), for treating youth with persistent concussion symptoms >1 month. Methods We conducted a retrospective cohort study of 83 youth who participated in SSTEP, completing trajectory analysis of concussion symptoms using the symptom subscale of the Sport Concussion Assessment Tool, version 2 (SCAT-2). Results The average age of patients was 14.9+/-2.3 years and 54% were female. Most concussions (76%) were due to sports, the majority from football and girls' soccer, and 55% had a previous concussion. Comorbidity was not uncommon: 14% had history of ADHD and 16% history of depression and/or anxiety. Most patients improved following the intervention, and none reported worsening. Symptoms decreased exponentially following initiation of SSTEP, and trajectory did not differ by duration of symptoms at presentation ( 12 weeks). Conclusions Monitored exercise programs appear to be safe and potentially beneficial for youth with persistent concussive symptoms. Large-scale controlled studies are needed to examine efficacy, ideal timing and duration.

The objective of this study was to assess the beliefs of parents of youth soccer players about Chronic Traumatic Encephalopathy (CTE), concussion, and retirement from sport decisions and compare them to those of concussion-specialized clinicians. An electronic survey was completed by parents of youth club soccer players (n=247/1600, 15.4% response rate) and concussion-specialized clinicians (n=18/47, 38.3% response rate) located in a large U.S. urban center. Parents believed more strongly in the causal relationship between concussions and CTE, and between CTE and harm than did clinicians. Parents who themselves had participated in sport at a high level had more conservative beliefs than other parents about the number of concussions after which an athlete should retire from contact or collision sport. Results are discussed in the context of ethical risk communication between clinicians and parents. This includes the importance of communicating information about CTE to parents and youth athletes in an understandable way so that they can make informed choices about contact and collision sport participation. Further research is encouraged to evaluate approaches of communicating evidence about CTE to a diverse population of families of youth athletes.

Despite state laws requiring concussion education for youth sport stakeholders and a proliferation of educational programs, there has been little demonstrated impact on concussion reporting behaviors. We propose that this is because of four key limitations to existing approaches to concussion education: (1) deliberative decision making by the injured athlete is assumed, (2) interventions are often targeted at individuals rather than social systems, (3) education occurs once during preseason and is forgotten, and (4) dissemination challenges exacerbate health inequalities. Addressing these limitations, we propose a novel theoretic framework that situates individual behavior within a sport system’s culture and their broader structural context. Concussion education programs should seek to facilitate safety-supportive interpersonal communication within and between stakeholder groups and influence attributes of groups that drive behavior, including shared values. Addressing the limitations outlined and drawing on the proposed conceptual framework, we describe a novel approach to concussion education: pregame safety huddles.

IMPORTANCE: Sport-related concussion (SRC) is a significant public health problem without an effective treatment. OBJECTIVE: To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC. DESIGN, SETTING, AND PARTICIPANTS: This multicenter prospective randomized clinical trial was conducted at university concussion centers. Male and female adolescent athletes (age 13-18 years) presenting within 10 days of SRC were randomly assigned to aerobic exercise or a placebo-like stretching regimen. INTERVENTIONS: After systematic determination of treadmill exercise tolerance on the first visit, participants were randomly assigned to a progressive subsymptom threshold aerobic exercise or a progressive placebo-like stretching program (that would not substantially elevate heart rate). Both forms of exercise were performed approximately 20 minutes per day, and participants reported daily symptoms and compliance with exercise prescription via a website. MAIN OUTCOMES AND MEASURES: Days from injury to recovery; recovery was defined as being asymptomatic, having recovery confirmed through an assessment by a physician blinded to treatment group, and returning to normal exercise tolerance on treadmill testing. Participants were also classified as having normal (

Key Points Question What is the effectiveness of collaborative care with cognitive behavioral therapy for treating adolescents with persistent postconcussive symptoms? Findings In this randomized clinical trial of 200 adolescents, those who received collaborative care reported fewer postconcussive symptoms at 3 and 12 months and higher health-related quality of life at 12 months compared with a control group receiving usual care. Meaning These findings suggest that collaborative care with cognitive behavioral therapy is a promising treatment to alleviate symptoms and improve functioning for adolescents with persistent postconcussive symptoms., This randomized clinical trial examines whether collaborative care treatment for adolescents with persistent postconcussive symptoms is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care., Importance Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. Objective To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. Design, Setting, and Participants The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreational-related concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. Interventions The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. Main Outcomes and Measures Primary outcomes were adolescents’ reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parent-reported symptoms. Results Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3- to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, −6.6 to −0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, −7.7 to −0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes. Conclusions and Relevance Although both groups improved over time, youth receiving the collaborative care intervention had fewer symptoms and better quality of life over 1 year. Intervention delivery through telehealth broadens the reach of this treatment. Trial Registration ClinicalTrials.gov Identifier: NCT03034720

An enhanced understanding of agreement levels between adolescents and parents for reporting athletic events and symptoms can help inform surveillance systems as well as clinical and epidemiological investigations of sports-related concussions. We sought to quantify agreement levels between high school athletes and parents for reporting: (1) number of games; (2) number of practices; (3) occurrence of an injury resulting in any concussion symptoms; and (4) presence of each specific symptom on the date of that injury among high school boys' football and girls' soccer athletes playing in Autumn 2012 in Washington State. There was substantial agreement on reporting the number of athletic events. Agreement levels were greater for games (kappa = 0.82; 95% confidence interval [CI]: 0.79-0.85 in boys' football; kappa = 0.75; 95% CI: 0.72-0.79 in girls' soccer) than for practices (kappa = 0.64; 95% CI: 0.62-0.67 in boys' football; kappa = 0.65; 95% CI: 0.62-0.67 in girls' soccer). There was moderate to substantial agreement on the occurrence of injury resulting in any concussion symptoms; however, agreement on the presence and severity of each symptom varied from poor to almost perfect. Overall, athletes reported greater severity of symptoms than parents did; notably, no difference in mean symptom scores was found when the athlete had a history of concussion. Agreement levels were greater when information was ascertained within 1 week of injury than when it was obtained later than 1 week. Including both athletes' and parents' reports of sports-related events and ascertaining information as soon as possible after injury are important considerations in designing injury surveillance systems.

Concussion is a known risk in youth soccer, but little is known about subconcussive head impacts. The authors provided a prospective cohort study measuring frequency and magnitude of subconcussive head impacts using accelerometry in a middle school–age soccer tournament, and association between head impacts and changes in (1) symptoms, (2) cognitive testing, and (3) advanced neuroimaging. A total of 17 youth completed the study (41% female, mean 12.6 years). There were 73 head impacts >15 g measured (45% headers) and only 2 had a maximum peak linear acceleration >50 g. No youth reported symptoms consistent with concussion. After correction for multiple comparisons and a sensitivity analysis excluding clear outliers, no significant associations were found between head impact exposure and neuropsychological testing or advanced neuroimaging. The authors conclude that head impacts were relatively uncommon and low in acceleration in youth playing a weekend soccer tournament. This study adds to the limited data regarding head impacts in youth soccer.

OBJECTIVE To explore differences in baseline King-Devick Test (KD) completion time between 2 testing modalities: (1) spiral-bound paper cards (cards) and (2) iPad application (iPad). DESIGN Cross-sectional cohort analysis. SETTING National Collegiate Athlete Association (NCAA) institutions. PARTICIPANTS Student athletes from 13 women's and 11 men's collegiate sports who completed KD baseline testing as part of their first year in the Concussion Assessment, Research and Education (CARE) Consortium from 2014 to 2016 (n = 2003, 52.2% male). INDEPENDENT VARIABLES King-Devick Test modalities; cards or iPad. MAIN OUTCOME MEASURE Baseline KD completion time (seconds). RESULTS Mean baseline KD completion time of the iPad modality group [42.8 seconds, 95% confidence interval (CI), 42.1-43.3] was 2.8 seconds (95% CI, 2.1-3.4) greater than the cards group (40.0 seconds, 95% CI, 39.7-40.3) (t(1, 1010.7) = -8.0, P < 0.001, Cohen's d = 0.41). CONCLUSIONS Baseline KD performance is slower when tested on an iPad than when tested on spiral-bound paper cards. The 2 KD modalities should not be used interchangeably in concussion assessments because differences in the modalities can lead to time differences similar in magnitude to those used to indicate concussion. From a research perspective, modality may influence interpretation and/or synthesis of findings across studies.