Martin Mrazik

Sport concussion knowledge base, clinical practises and needs for continuing medical education: a survey of family physicians and cross-border comparison

Context Evolving concussion diagnosis/management tools and guidelines make Knowledge Transfer and Exchange (KTE) to practitioners challenging. Objective Identify sports concussion knowledge base and practise patterns in two family physician populations; explore current/preferred methods of KTE. Design A cross-sectional study. Setting Family physicians in Alberta, Canada (CAN) and North/South Dakota, USA. Participants CAN physicians were recruited by mail: 2.5% response rate (80/3154); US physicians through a database: 20% response rate (109/545). Intervention/instrument Online survey. Main and secondary outcome measures Diagnosis/management strategies for concussions, and current/preferred KTE. Results Main reported aetiologies: sports/recreation (52.5% CAN); organised sports (76.5% US). Most physicians used clinical examination (93.8% CAN, 88.1% US); far fewer used the Sport Concussion Assessment Tool (SCAT1/SCAT2) and balance testing. More US physicians initially used concussion-grading scales (26.7% vs 8.8% CAN, p=0.002); computerised neurocognitive testing (19.8% vs 1.3% CAN; p<0.001) and Standardised Assessment of Concussion (SAC) (21.8% vs 7.5% CAN; p=0.008). Most prescribed physical rest (83.8% CAN, 75.5% US), while fewer recommended cognitive rest (47.5% CAN, 28.4% US; p=0.008). Return-to-play decisions were based primarily on clinical examination (89.1% US, 73.8% CAN; p=0.007); US physicians relied more on neurocognitive testing (29.7% vs 5.0% CAN; p<0.001) and recognised guidelines (63.4% vs 23.8% CAN; p<0.001). One-third of Canadian physicians received KTE from colleagues, websites and medical school training. Leading KTE preferences included Continuing Medical Education (CME) courses and online CME. Conclusions Existing published recommendations regarding diagnosis/management of concussion are not always translated into practise, particularly the recommendation for cognitive rest; predicating enhanced, innovative CME initiatives.

Subjective, but not Objective, Lingering Effects of Multiple Past Concussions in Adolescents

The existing literature on lingering effects from concussions in children and adolescents is limited and mixed, and there are no clear answers for patients, clinicians, researchers, or policy makers. The purpose of this study was to examine whether there are lingering effects of past concussions in adolescent athletes. Participants in this study included 643 competitive Bantam and Midget hockey players (most elite 20% by division of play) between 13 and 17 years of age (mean age=15.5, SD=1.2). Concussion history at baseline assessment was retrospectively documented using a pre-season questionnaire (PSQ), which was completed at home by parents and players in advance of baseline testing. Players with English as a second language, self-reported attention or learning disorders, a concussion within 6 months of baseline, or suspected invalid test profiles were excluded from these analyses. Demographically adjusted standard scores for the five composites/domains and raw symptom ratings from the brief Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computerized battery were analyzed. Adolescent athletes with one or two or more prior concussions did not have significantly worse neurocognitive functioning on ImPACT than did those with no previous concussions. There were significantly more symptoms reported in those with two or more prior concussions than in those with no or one prior concussion. Adolescents with multiple previous concussions had higher levels of baseline symptoms, but there were not group differences in neurocognitive functioning using this brief computerized battery.

The Neurobiological Foundations of Giftedness

Case studies of extremely gifted individuals often reveal unique patterns of intellectual precocity and associated abnormalities in development and behavior. This article begins with a review of current neurophysiological and neuroanatomical findings related to the gifted population. The bulk of scientific inquiries provide evidence of unique patterns of right prefrontal cortex and inferior frontal activation implicated in gifted intelligence, although additional studies suggest enhanced neural processing and cerebral bilateralism. Geschwind, Behan, and Galaburda (GBG) first hypothesized the possible neurodevelopmental factors that account for unique brain development. This article explores more recent findings taken from the prenatal exposure literature and offers a proposed model for explaining aberrant developmental forces that may be at work in precocious individuals.

A qualitative review of sports concussion education: prime time for evidence-based knowledge translation

Background Educating athletes, coaches, parents and healthcare providers about concussion management is a public health priority. There is an abundance of information on sports concussions supported by position statements from governing sport and medical organisations. Yet surveys of athletes, parents, coaches and healthcare providers continue to identify multiple barriers to the successful management of sports concussion. To date, efforts to provide education using empirically sound methodologies are lacking. Purpose To provide a comprehensive review of scientific research on concussion education efforts and make recommendations for enhancing these efforts. Study design Qualitative literature review of sports concussion education. Methods Databases including PubMed, Sport Discus and MEDLINE were searched using standardised terms, alone and in combination, including ‘concussion’, ‘sport’, ‘knowledge’, ‘education’ and ‘outcome’. Results Studies measuring the success of education interventions suggest that simply presenting available information may help to increase knowledge about concussions, but it does not produce long-term changes in behaviour among athletes. Currently, no empirical reviews have evaluated the success of commercially available sports concussion applications. The most successful education efforts have taken steps to ensure materials are user-friendly, interactive, utilise more than one modality to present information and are embedded in mandated training programmes or support legislation. Psychosocial theory-driven methods used to understand and improve ‘buy in’ from intended audiences have shown promise in changing behaviour. Conclusions More deliberate and methodologically sound steps must be taken to optimise education and knowledge translation efforts in sports concussion.

Assessment of symptoms in a concussion management programme: Method influences outcome

Context: Monitoring of subjective symptoms is the foundation of all sport concussion management programmes. The purpose of this study is to examine methodological variables that impact symptom reporting during baseline testing. Objective: To investigate how the administration method of a concussion assessment tool (self-report vs interview) affects the report of symptoms. Design, setting and participants: This was a cross-sectional, semi-randomized study of 117 athletes. Main outcome measurements: Subjects completed the Post-Concussion Scale during pre-season evaluations. Results: A two-factor ANOVA revealed a significant difference in total symptom scores (p = 0.02) and number of endorsed symptoms (p = 0.02) across administration modes. Athletes had a greater total symptom score and reported a greater number of symptoms in the self-administration condition than in the interview condition. Furthermore, there was a significant difference in symptom reporting across interviewer gender. Athletes endorsed more symptoms when the interviewer was a woman. Conclusions: Because the method of collecting symptoms, as well as interviewer gender, can impact test results, self-report measures may be a better way of obtaining consistent results. Clinicians and researchers should be aware that both the nature and extent of symptom reporting is greater when using questionnaires than when athletes are interviewed.

Absence of differences between male and female adolescents with prior sport concussion.

Objective:Sex differences following concussion are poorly understood. The purpose of this study was to examine whether male and female adolescent athletes with prior concussions differ regarding neurocognitive function and symptom reporting. Setting:Community-based hockey teams. Participants:Participants included 615 elite hockey players 13 to 17 years old (mean = 15.5, 95% confidence interval [CI] = 15.4-15.6). There were 517 males and 98 females. Players with English as a second language, attention or learning problems, a concussion within 6 months of baseline, or suspected invalid test profiles were excluded from these analyses. Design:Cross-sectional. Main Measure:Domain scores and symptom ratings from the ImPACT computerized battery. Results:There were no significant neurocognitive differences between males and females with (F5,227 = 1.40, P = .227) or without (F5,376 = 1.33, P = 0.252) a prior history of concussion. Male and female athletes with a history of concussion reported higher raw symptom scores than those without a prior concussion; however, sex differences disappear when symptom scores are adjusted for known sex differences in controls (total score, F2,230 = 0.77, P = .46; Cohen d = 0.01 or domain scores (F4,227 = 1.52, P = .197; Cohen d = 0.07-0.18). Conclusions:Although those with prior concussions report more symptoms (but do not differ on neurocognition), this study does not support sex differences with cognition or symptoms in adolescent athletes with prior concussions.

Does an individual's fitness level affect baseline concussion symptoms?

CONTEXT Variables that may influence baseline concussion symptoms should be investigated. OBJECTIVE To evaluate the effect of physical fitness on self-report of baseline concussion symptoms in collegiate athletes and students. DESIGN Controlled laboratory study. PATIENTS OR OTHER PARTICIPANTS A total of 125 undergraduates, including 95 collegiate athletes and 30 recreational athletes (83 males, 42 females). INTERVENTION(S) Participants completed the Standardized Concussion Assessment Tool 2 (SCAT2; symptom report) at baseline, within 10 minutes of completing the Leger test, and within 24 hours of the initial baseline test. The Leger (beep) test is a shuttle-run field test used to predict maximal aerobic power. MAIN OUTCOME MEASURE(S) The total symptom score on the SCAT2 was calculated and analyzed with a repeated-measures analysis of variance. A linear regression analysis was used to determine if 3 variables (sport type, sex, or fitness level) accounted for a significant amount of the variance in the baseline symptom report. RESULTS Participants reported more symptoms postactivity but fewer symptoms at 24 hours compared with baseline, representing a time effect in our model (F2,234 = 47.738, P < .001). No interactions were seen among the independent variables. We also found an effect for fitness level, with fitter individuals reporting fewer symptoms at all 3 time intervals. The regression analysis revealed that fitness level accounted for a significant amount of the variance in SCAT2 symptoms at baseline (R (2) = 0.22, F3,121 = 11.44, P < .01). CONCLUSIONS Fitness level affected the baseline concussion symptom report. Exercise seems to induce concussion symptom reporting, and symptom severity may be a function of an athletes level of conditioning. Sports medicine professionals should consider an athletes level of fitness when conducting baseline concussion symptom assessments.

Baseline Evaluation in Youth Ice Hockey Players: Comparing Methods for Documenting Prior Concussions and Attention or Learning Disorders

STUDY DESIGN Cross-sectional. OBJECTIVE To examine differences in concussion history and attention or learning disorders reported by elite youth ice hockey players, using a questionnaire that allows parental input compared to a clinic-based test battery that does not. BACKGROUND A history of previous concussion and the presence of attention or learning disorders can affect concussion-management decisions; however, youth athletes may not accurately report their medical history because they may not know or recall important details. METHODS The sample included 714 Bantam (ages 12-14 years) and Midget (ages 15-17 years) ice hockey players (601 male, 113 female) from the most elite divisions of play (AA and AAA). Players completed a take-home preseason questionnaire (PSQ) with the input of a parent/guardian, and also independently completed the baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) at the beginning of the 2011-2012 hockey season. RESULTS In 21.1% (95% confidence interval: 18.1%, 24.1%) of cases, there was disagreement between the PSQ and ImPACT in the number of previous concussions reported. Among those who reported an attention disorder on the PSQ, 85.7% also reported an attention disorder on the ImPACT. Only 9.5% of those who reported a learning disorder on the PSQ also reported a learning disorder on the ImPACT. CONCLUSION In 1 of 5 players, reported concussion history differed between the PSQ and ImPACT, and there was substantial disagreement between instruments for those reporting learning disorders. The method of obtaining medical history may, therefore, affect baseline and postconcussion evaluations.

Administration and Scoring Errors of Graduate Students Learning the WISC-IV: Issues and Controversies

A total of 19 graduate students enrolled in a graduate course conducted 6 consecutive administrations of the Wechsler Intelligence Scale for Children, 4th edition (WISC-IV, Canadian version). Test protocols were examined to obtain data describing the frequency of examiner errors, including administration and scoring errors. Results identified 511 errors on 94% of protocols with a mean of 4.48 errors per protocol. The most common errors were identified on the Vocabulary, Similarities, and Comprehension subtests, which comprised 80% of all errors. A repeated-measures ANOVA (analysis of variance) was not significant across six administrations, F(5, 90) = 1.609, p = .166, eta2 = .082, although there was a trend in the data for a reduced number of errors with successive administrations. Results were consistent with other studies that have determined graduate student administration and scoring errors do not improve with repeated administrations. Implications and recommendations to reduce administration and scoring errors among graduate students were discussed.

Psychometric Properties and Reference Values for the ImPACT Neurocognitive Test Battery in a Sample of Elite Youth Ice Hockey Players

This cross-sectional study aimed to determine psychometric properties and reference values for ImPACT in a sample of 704 elite ice hockey players aged 13-17. Baseline ImPACT tests were completed at the beginning of the 2011-2012 season. Players aged 16-17 had better visual motor processing speed, adjusted R(2) = .0522, F(2, 45) = 10.79, β = 2.87, p < .001, and impulse control, adjusted R = .0185, F(2,45) = 7.46, β = -1.35, p = .001, than younger players, and girls had greater total symptom ratings than boys (z = -3.47, p = .0005). There were no other sex- or age-related differences in neurocognitive performance, and no effect of previous concussion on ImPACT scores. Reference values with cut-off scores are presented.