S.J. Sullivan

Self-report scales/checklists for the measurement of concussion symptoms: a systematic review

Objective: To identify self-reported sport concussion symptom scales and to describe the psychometric properties of these identified scales. Design: Systematic review. Intervention: PubMed, Medline, CINAHL, Scopus, Web of Science, Sport Discus, PsycINFO and AMED were searched from their establishment until December 2008. The medical subject heading terms “brain concussion”, “signs or symptoms” and “athletic injuries”. The search was limited to articles published in English. An additional search of the reference lists of the retrieved articles was conducted. Only full-text articles were considered for this study and these were retrieved to determine whether they met the inclusion criteria. Results: The initial search resulted in 421 articles, which were reduced to 290 articles after removing duplicates. The hand search resulted in 17 articles, thus giving a total of 307 articles. Full text was available for 295 articles of which 60 met the criteria for inclusion. The excluded 235 articles were case reports, reviews and guidelines on concussion management or studies that had not used a symptom scale or checklist. Conclusions: Six core scales were identified with a broad range of symptom items but with limited information on their psychometric properties. There were numerous derivative scales reported, most of which have not been methodically developed or subjected to scientific scrutiny. Despite this, they do make a contribution to the detection, assessment and return to play decisions but there is a need for the clinical user to be aware that many of these scales have “evolved” rather than being scientifically developed.

Sports concussion assessment: the effect of exercise on dynamic and static balance

This study determined the effect of exercise on measures of static and dynamic balance used in the assessment of sports‐related concussion (SRC). A balanced three‐group cross‐over randomized design was used with three levels of exercise verified by blood‐lactate, heart rate and “perceived‐exertion”: no exercise/rest (NE), moderate‐intensity exercise (ME), and high‐intensity exercise (HE). Participants performed two timed balance tasks: tandem gait (TG) and single‐leg stance (SLS); pre‐ and post‐exercise and 15 min after exercise. Linear mixed‐models with adjusted means and contrasts compared exercise effects. Ninety asymptomatic participants (45♂:45♀) were recruited. When times were contrasted with NE; HE resulted in a significant decrease in SLS (P<0.001) and TG (P<0.001) performance immediately following exercise. Fifteen minutes of recovery improved SLS (P<0.001) and TG (P=0.011) from post‐exercise performance. ME caused a significant decrease in performance in SLS (P=0.038) but not TG (P=0.428). No statistically significant change occurred following ME in any tasks after 15‐min recovery (SLS P=0.064; TG P=0.495). Test–retest reliability was considerably higher for the dynamic task compared with the static task. The reliability of static and dynamic balance tasks, and the change in performance following exercise, have implications for the immediate assessment of SRC, as these measures are utilized in concussion assessment instruments.

The effect of exercise on motor performance tasks used in the neurological assessment of sports-related concussion

Sports-related concussion is assessed using both cognitive and motor performance tasks. There is limited understanding of how exercise affects these measures. The purpose of this study was to investigate the effect of moderate-intensity exercise on three selected measures of motor performance. A repeated measures design was used to compare baseline motor performance scores with post-exercise scores with an exercise intervention modelled on the physiological demands of a team sport. 30 physically active subjects performed timed motor performance tasks: Finger-to-Nose (FTN), Tandem Gait (TG) and Single Leg Stance (SLS). The tasks were administered twice pre-exercise and twice post-exercise. FTN, TG and SLS demonstrated high test–retest reliability (ICC values >0.8). 15 minutes of moderate-intensity exercise caused a significant improvement in FTN (T2 = 2.66 (SD 0.38), T3 = 2.49 (0.32); p<0.001) and TG (T2 = 13.08 (2.84), T3 = 12.23 (2.22); p = 0.001), but not in SLS (T2 = 5.94 (4.99), T3 = 5.91 (5.54); p = 0.507). Improvement in the performance of motor tasks after exercise has implications for the immediate assessment of sports-related concussion, given that measures of motor performance are utilised in concussion assessment instruments.

Ethical Considerations in Using Facebook for Health Care Support: A Case Study Using Concussion Management

Social networking sites (SNS) are now part of everyday life, and SNSs such as Facebook, YouTube, and Twitter are among the most accessed Web sites on the Internet. Although SNSs are primarily used for staying in touch with friends and family, they are increasingly being used for health‐related purposes for a variety of conditions, including concussion awareness. As health interventions begin to be more commonly provided through SNSs (particularly Facebook), ethical issues have been raised with regard to confidentiality, privacy, and trust; these issues need to be addressed. This article outlines some of the key considerations when providing a concussion intervention through Facebook and discusses potential solutions to these issues.

The diagnostic accuracy of selected neurological tests

The diagnostic value and reliability of selected neurological clinical tests was studied in control subjects with normal neuroimaging (n=42), and subjects with a focal brain lesion (n=38). The items were studied by two examiners blinded to group membership and using standardized protocols, and subsequently by a neurologist who was not blinded to diagnosis. The positive likelihood ratios ranged from 1.06 (pronator drift) to 22.11 (single leg stance with eyes open, while the negative likelihood ratios ranged from 0.47 (tandem gait) to 0.97 (pupil symmetry). Three items (single leg stance - eyes closed - firm surface; single leg stance - eyes open - foam surface; and tandem gait) successfully distinguished between the two groups (odds ratio p<0.05). The inter-rater reliability was generally poor, with only tandem gait showing excellent agreement (kappa [K]=0.92). Tandem gait was the only item to show noteworthy agreement (K=0.93) between the examiners and the neurologist. The tests varied considerably in their ability to detect radiologically demonstrated structural brain lesions, and several items were poorly reproducible, questioning their value as part of a routine neurological examination.

Physiotherapists' use of information in identifying a concussion: an extended Delphi approach

Objective: To determine the relative importance of signs and symptoms that a selected cohort of sports physiotherapists use to identify a sports concussion. Methods: A two-round Delphi methodology was used to achieve consensus in a cohort of 21 sports physiotherapists. A subsequent round involving an educational intervention provided the participants with an opportunity to modify their knowledge base through the provision of a relevant resource article. Results: Participants provided 123 responses, which were grouped into eight descriptive categories with consensus (>80%) being reached for the importance of: cognition/orientation, memory, motor dysfunction and state of consciousness. The category “state of consciousness” remained the most important information source at the completion of the study. Conclusion: Participants placed considerable importance on the player’s level of consciousness in their decision making. This would appear to be in conflict with recent trends to place greater importance on the role of symptoms in identifying a concussion.

Reliability and diagnostic characteristics of clinical tests of upper limb motor function

There is a paucity of information on the inter-rater reliability and predictive value of components of the neurological examination. Selected tests of upper limb motor function were studied in 34 patients with Parkinsons disease, upper motor neuron disease or cerebellar disease and in 25 control participants. Video recordings were independently evaluated and scored by two clinicians to determine inter-rater reliability (kappa) and predictive values. Kappa values ranged from 0.00 to 0.73. Highest positive predictive values (PPV) were obtained for the Barré test, arm raise, forearm rolling and finger nose tests. Negative predictive values (NPV) were mostly low, with highest values for unimanual sequential finger tap and rhythmic tap. The combined tests had PPV of 0.58 and NPV of 0.73. This study demonstrates that these clinical tests have poor inter-rater reliability and low negative predictive value when used in isolation.

Training habits and injuries of masters' level football players: a preliminary report.

OBJECTIVE To profile training habits and injuries in football players participating in a national Masters tournament. METHODS A cross-sectional retrospective study design was used to survey male football players attending the 2008 New Zealand Masters Games. Information regarding player demographics, football injuries, football related training, and risk factors for injury were collected. RESULTS 199 Players were recruited, with a median age of 44 yrs (range 35-73) and a median football playing history of 15 yrs (range 0-66). Irrespective of age, 112 (84%) players included a warm-up and 104 (78%) included a stretching regime in their regular training programme. In the 12 months prior to the tournament, 128 football related injuries were reported by 93 players (64 injuries/100 players or 46 injured players/100 players). The most frequently injured region was the lower limb; specifically the lower leg (n=23), ankle (n=18), hamstring (n=17), knee (n=15), and Achilles tendon (n=15). CONCLUSION This study provides a preliminary insight into the training habits and injury profiles of Masters football players. Despite all players including some form of injury prevention strategy in their training, a significant number of players experienced an injury in the 12 months prior to the tournament.

Psychological and Lifestyle Factors That Influence the Serial Reporting of Postconcussion-like Symptoms in a Non-concussed Population

Symptoms related to concussion are generally nonspecific in nature, as they are also reported by non‐concussed individuals. What is currently not known is whether the symptoms vary over time, and whether they are also influenced by a multitude of factors.

Changes in the timed finger-to-nose task performance following exercise of different intensities

Objective The purpose of this study was to determine the effect of different levels of exercise intensity on the timed finger-to-nose (FTN) task, a measure of upper limb coordination included in the Sport Concussion Assessment Tool (SCAT2). Methods A three-group crossover randomised design was used to investigate changes in FTN times at three levels of exercise intensity; no exercise/rest (NE), moderate intensity exercise (ME) and high-intensity exercise (HE). Heart rates and a rating of perceived exertion (Borg Scale) were recorded to verify the level of exercise intensity. Participants performed three trials of the timed FTN task: pre-exercise, post-exercise and 15 min after the cessation of exercise. Linear mixed models were used to compare FTN change scores associated with exercise. Results Ninety asymptomatic participants (45♂:45♀) aged 18–32 years completed the study. Changes in FTN scores from pre-exercise showed that the HE condition was facilitated relative to NE at post-exercise (8% faster, 95% CI 5% to 10%, p<0.001) and at post-15 (3% faster, 95% CI 1% to 6%, p=0.005). ME did not show such a facilitation following exercise (2% faster, 95% CI 0% to 4%, p=0.081 and 1% faster, 95% CI 1% to 4%, p=0.225 respectively). Conclusions Performance on the FTN task is enhanced by a short period of HE, and this effect persists for at least 15 min. There was no evidence of such an effect with ME.