Sara P. Chrisman

Risk factors for concussive symptoms 1 week or longer in high school athletes.

Objective: To identify risk factors for concussive symptoms ≥ 1 week. Methods: Retrospective cohort study of concussions in the RIO™ database 2006–2009 (n = 1412) analysing risk factors for concussive symptoms ≥ 1 week. This study examined athletes age, sex, weight, history of concussion, number of symptoms and specific symptoms. Data were stratified by football vs. non-football and analysed using Poisson regression to calculate relative risks and 95% confidence intervals. Results: Presenting with four or more symptoms was associated with double the risk for concussive symptoms ≥1 week for both football (95% CI = 1.3–3.5) and non-football players (95% CI = 1.4–4.6). History of prior concussion was associated with double the risk for concussive symptoms ≥1 week in football players only (95% CI = 1.3–3.5). Several symptoms were associated with concussive symptoms ≥1 week in all athletes: drowsiness, nausea and concentration difficulties. Sensitivity to light and noise was associated with concussive symptoms ≥1 week in non-football players only. Amnesia was associated with concussive symptoms ≥1 week in males, but not females. Loss of consciousness was not significant. Conclusions: Risk factors for concussive symptoms ≥1 week are identifiable and can potentially be used to prognosticate for athletes and design evidence-based return-to-play guidelines.

Physician Concussion Knowledge and the Effect of Mailing the CDC’s “Heads Up” Toolkit

Background. The Centers for Disease Control and Prevention’s (CDC) “Heads Up” toolkit was designed to educate physicians about concussion, but it has not been well studied. This study proposed to evaluate the effect of receiving the toolkit on physician concussion knowledge. Methods. The authors obtained a sample of physicians from the American Medical Association masterfile and randomly selected half to be mailed the CDC’s “Heads Up” toolkit. All physicians were then sent a survey on concussion knowledge. Data were analyzed to evaluate the effect of the toolkit on concussion knowledge. Results. The survey was completed by 414 physicians (183 intervention, 231 control). There were no differences in general concussion knowledge between intervention and control groups, but physicians in the intervention group were significantly less likely to recommend next day return to play after a concussion (adjusted odds ratio = 0.31, 95% confidence interval = 0.12-0.76). Conclusions. Mailing the CDC’s “Heads Up” toolkit appears to affect physicians’ recommendations regarding returning to play after a concussion.

The Effect of Coach Education on Reporting of Concussions Among High School Athletes After Passage of a Concussion Law

Background: Increasing attention has been paid to concussions and especially sports-related concussions in youth. To prevent an inappropriate return to play while symptomatic, nearly all states have now passed legislation on youth sports-related concussions. Purpose: To determine (1) the incidence of sports-related concussions in high school athletes using a unique system to collect reports on concussions, (2) the proportion of athletes with concussions who play with concussive symptoms, and (3) the effect of the type and modality of coach education on the likelihood of athletes reporting symptoms to the coach or playing with concussive symptoms. Study Design: Cohort study; Level of evidence, 2. Methods: This study was conducted with high school football and girls’ soccer athletes playing in fall 2012 and their coaches and parents in 20 urban or rural high schools in Washington State. The main outcome was the incidence of concussions per 1000 athlete-exposures (AEs), the proportion of concussed athletes who played with concussive symptoms, and the association of coach concussion education with coach awareness of athletes with concussive symptoms. Results: Among the 778 athletes, the rate of concussions was 3.6 per 1000 AEs and was identical for the 2 sports studied. The cumulative concussion incidence over the course of the season was similar in girls’ soccer (11.1%) and football (10.4%). Sixty-nine percent of concussed athletes reported playing with symptoms, and 40% reported that their coach was not aware of their concussion. Most measures of coach concussion education were not associated with coach awareness of concussions in their athletes, although the modalities of a video and quiz were associated with a lower likelihood of coach awareness. Conclusion: More objective and accurate methods are needed to identify concussions. Changes in athlete attitudes on reporting concussive symptoms will likely not be accomplished through legislation alone.

Implementation of Concussion Legislation and Extent of Concussion Education for Athletes, Parents, and Coaches in Washington State

Background: Most states in the United States have passed laws regarding concussions, but little is known regarding the implementation of these laws. Hypothesis/Purpose: The purpose of this study was to survey high school coaches 3 years after the passage of a concussion law to evaluate the variation in concussion education and knowledge in the context of this law as well as measure the effects of sport (football vs soccer) and urban versus rural locations. The hypothesis was that concussion education and knowledge would be more extensive in football compared with soccer and in urban locations compared with rural locations. Study Design: Descriptive epidemiology study. Methods: A mixed-methods (paper and online) survey was conducted in 2012 to 2013 on a random sample of public high school football, girls’ soccer, and boys’ soccer coaches in Washington State, stratified by urban and rural locality. The survey covered the extent of concussion education for coaches, athletes, and parents as well as coaches’ concussion knowledge and experience. Results: Of 496 coaches contacted, 270 responded (54.4%). Nearly all coaches answered concussion knowledge questions correctly, and nearly all coaches received education via ≥2 modalities (written, video, slide presentation, test, and in person). Athlete education was less extensive, with 34.7% exposed to ≥2 modalities and 29.5% only signing a concussion information form. Parent education was even more limited, with 16.2% exposed to ≥2 modalities and 57.9% only signing a concussion information form. Significantly more football than soccer coaches gave their athletes an in-person talk about concussions (59.1% vs 39.4%, respectively; P = .002) and provided concussion education to athletes via ≥2 modalities (44.1% vs 29.7%, respectively; P = .02). Concussion education for coaches and parents was similar between sports, and concussion education for all parties was similar in urban and rural localities. Conclusion: Three years after the passage of a concussion law in Washington State, high school football and soccer coaches are receiving substantial concussion education and have good concussion knowledge. Concussion education for athletes and parents is more limited. Football players receive more extensive concussion education than do soccer players. Clinical Relevance: Clinicians should be aware that athletes and parents may not be receiving significant concussion education.

Prevalence of diagnosed depression in adolescents with history of concussion.

PURPOSE Previous studies in adults have suggested concussion and other brain injury presents a risk factor for depression. The goal of our study was to analyze the association between previous concussion and current depression diagnosis in a large nationally representative adolescent data set. METHODS Retrospective cohort study using the National Survey of Childrens Health 2007-2008, a nationally representative survey conducted via random digit dialing. Data were obtained by parental report. We included youth 12-17 years old without a current concussion (N = 36,060), and evaluated the association between previous concussion (binary) and current depression diagnosis (binary) using multiple logistic regression to control for age, sex, parental mental health, and socioeconomic status. RESULTS After controlling for age, sex, parental mental health, and socioeconomic status, history of concussion was associated with a 3.3-fold greater risk for depression diagnosis (95% CI: 2.0-5.5). Other factors significantly associated with depression diagnosis included poor or fair parental mental health (OR: 3.7, 95% CI: 2.8-4.9), and older age (15-17 years vs. 12-14 years, OR: 1.4, 95% CI: 1.1-1.8). Sex of the subject was not significantly related to depression diagnosis. Being above 200% of the poverty level was associated with approximately a 50% decreased risk of depression diagnosis (95% CI: 35%-70%). CONCLUSIONS History of concussion was associated with a higher prevalence of diagnosed depression in a large nationally representative adolescent data set. Clinicians should screen for depression in their adolescent patients with concussion. Future studies should confirm this association using prospective methodology and examine potential treatment approaches.

Head Impact Exposure During a Weekend Youth Soccer Tournament

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 >15g measured (45% headers) and only 2 had a maximum peak linear acceleration >50g. 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.

Strength and Jump Biomechanics of Elite and Recreational Female Youth Soccer Players

CONTEXT Most researchers investigating soccer injuries have studied elite athletes because they have greater athletic-exposure hours than other athletes, but most youth participate at the recreational level. If risk factors for injury vary by soccer level, then recommendations generated using research with elite youth soccer players might not generalize to recreational players. OBJECTIVE To examine injury risk factors of strength and jump biomechanics by soccer level in female youth athletes and to determine whether research recommendations based on elite youth athletes could be generalized to recreational players. DESIGN Cross-sectional study. SETTING Seattle Youth Soccer Association. PATIENTS OR OTHER PARTICIPANTS Female soccer players (N = 92) aged 11 to 14 years were recruited from 4 randomly selected elite (n = 50; age = 12.5 years, 95% confidence interval [95% CI]) = 12.3, 12.8 years; height = 157.8 cm, 95% CI = 155.2, 160.3 cm; mass = 49.9 kg, 95% CI = 47.3, 52.6 kg) and 4 randomly selected recreational (n = 42; age = 13.2 years, 95% CI = 13.0, 13.5 years; height = 161.1 cm, 95% CI = 159.2, 163.1 cm; mass = 50.6 kg, 95% CI = 48.3, 53.0 kg) soccer teams. MAIN OUTCOME MEASURE(S) Players completed a questionnaire about demographics, history of previous injury, and soccer experience. Physical therapists used dynamometry to measure hip strength (abduction, adduction, extension, flexion) and knee strength (flexion, extension) and Sportsmetrics to measure vertical jump height and jump biomechanics. We compared all measurements by soccer level using linear regression to adjust for age and mass. RESULTS Elite players were similar to recreational players in all measures of hip and knee strength, vertical jump height, and normalized knee separation (a valgus estimate generated using Sportsmetrics). CONCLUSIONS Female elite youth players and recreational players had similar lower extremity strength and jump biomechanics. This suggests that recommendations generated from research with elite youth soccer players could be generalized to recreational players.

Threat, Pressure, and Communication about Concussion Safety: Implications for Parent Concussion Education.

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.

Influences of Mental Illness, Current Psychological State, and Concussion History on Baseline Concussion Assessment Performance:

Background: A student-athlete’s mental state, including history of trait anxiety and depression, or current psychological state may affect baseline concussion assessment performance. Purpose: (1) To determine if mental illness (anxiety, depression, anxiety with depression) influences baseline scores, (2) to determine if psychological state correlates with baseline performance, and (3) to determine if history of concussion affects Brief Symptom Inventory–18 (BSI-18) subscores of state anxiety, depression, and somatization. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A sample of 8652 collegiate student-athletes (54.5% males, 45.5% females) participated in the Concussion Assessment, Research and Education (CARE) Consortium. Baseline assessments included a demographic form, a symptom evaluation, Standardized Assessment of Concussion, Balance Error Scoring System, a psychological state assessment (BSI-18), and Immediate Post-concussion Assessment and Cognitive Test. Baseline scores were compared between individuals with a history of anxiety (n = 59), depression (n = 283), and anxiety with depression (n = 68) and individuals without a history of those conditions (n = 8242). Spearman’s rho correlations were conducted to assess the relationship between baseline and psychological state subscores (anxiety, depression, somatization) (α = .05). Psychological state subscores were compared between individuals with a self-reported history of concussions (0, 1, 2, 3, 4+) using Kruskal-Wallis tests (α = .05). Results: Student-athletes with anxiety, depression, and anxiety with depression demonstrated higher scores in number of symptoms reported (anxiety, 4.3 ± 4.2; depression, 5.2 ± 4.8; anxiety with depression, 5.4 ± 3.9; no anxiety/depression, 2.5 ± 3.4), symptom severity (anxiety, 8.1 ± 9.8; depression, 10.4 ± 12.4; anxiety with depression, 12.4 ± 10.7; no anxiety/depression, 4.1 ± 6.9), and psychological distress in state anxiety (anxiety, 3.7 ± 4.7; depression, 2.5 ± 3.6; anxiety with depression, 3.8 ± 4.2; no anxiety/depression, 0.8 ± 1.8), depression (anxiety, 2.4 ± 4.0; depression, 3.2 ± 4.5; anxiety with depression, 3.8 ± 4.8; no anxiety/depression, 0.8 ± 1.8), and somatization (anxiety, 2.3 ± 2.9; depression, 1.8 ± 2.8; anxiety with depression, 2.2 ± 2.4; no anxiety/depression, 0.9 ± 1.7). A moderate positive relationship existed between all BSI-18 subscores and total symptom number (n = 8377; anxiety: rs = 0.43, P < .001; depression: rs = 0.42, P < .001; somatization: rs = 0.45, P < .001), as well as total symptom severity (anxiety: rs = 0.43, P < .001; depression: rs = 0.41, P < .001; somatization: rs = 0.45, P < .001). Anxiety, depression, and somatization subscores were greater among student-athletes that self-reported more concussions. Conclusion: Clinicians should be cognizant that student-athletes with a history of trait anxiety, depression, and anxiety with depression may report higher symptom score and severity at baseline. Individuals with extensive concussion history may experience greater state anxiety, depression, and somatization.

Physical Activity or Rest After Concussion in Youth: Questions About Timing and Potential Benefit

Mild traumatic brain injury, of which concussion is a subset, has garnered increasing attention in recent years due to the frequency of this injury and its potential for at least temporary disability. Much of the attention has focused on sportsand recreation-related concussions in youth, estimated to occur in 1.1 million to 1.9 million youth annually.1 Since the First International Conference on Concussion in Sport held in Vienna in 2001,2 consensus guidelines have recommended that athletes with concussion rest until they are completely asymptomatic, and then begin a graduated return to play over approximately 5 days. The rationale for this approach has been based on concerns about risk of second impact syndrome (ie, a superimposed traumatic brain injury) if athletes resume play while still symptomatic3 and laboratory data suggesting early physical activity prolongs recovery in animal models. There is also a sense that athletes should not be allowed to return to play too soon, or they might be tempted to play injured. However, the necessity of waiting until an athlete is completely asymptomatic has resulted in some athletes resting for weeks or months, at which point rest may be less helpful and perhaps even harmful.4 Recommendations regarding rest have also increased over the years to include not only physical rest but also cognitive rest—no schoolwork, no television or computer screen exposure, and even limits on social interaction. Four concussion consensus conferences have been held since 2001,5-7 and each has been accompanied by an increasing recognition that data regarding rest are limited and different approaches are needed. The 5th International Conference on Concussion in Sport took place in Berlin in October 2016, and questions about rest and the return to physical activity were the subject of much discussion. Several studies in the past few years have examined treating patients with physical activity if concussion symptoms last longer than 1 month.8,9 In parallel, other data suggest rest may not be as beneficial as previously thought, with 1 randomized clinical trial finding that 5 days of rest caused slightly worse outcomes than 2 days of rest for youth with concussion (greater daily symptoms and slower symptom resolution).10 When is it safe for children and adolescents with concussion to start physical activity or the inverse, ie, how much rest is necessary? In this issue of JAMA, Grool and colleagues11 report the findings from a prospective cohort study that examined the relationship between early physical activity and persistent symptoms after concussion. This multisite Canadian study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled 5to 17-year-old patients who had sustained an acute concussion and were evaluated in the emergency department.12,13 Data were analyzed to determine if early exposure to physical activity after concussion (<7 days) was associated with development of persistent postconcussive symptoms (PPCS; defined as presence of ≥3 new or worsened concussion symptoms 28 days after injury). The authors completed 3 different analyses (unadjusted, propensity score matching, and inverse probability of treatment weighting [IPTW]). Propensity scores included demographic variables such as age, sex, history and duration of previous concussions, and type and severity of concussion symptoms on presentation (measured with a standardized scale, the Postconcussion Symptom Inventory [PCSI]). The authors also conducted an analysis using IPTW to obtain theoretically unbiased estimates of average treatment effects using propensity scores. Among 2413 study participants, 30.4% developed PPCS (outcome) and 69.5% participated in some type of selfreported physical activity less than 7 days after injury (exposure). In unadjusted analyses, PPCS occurred in 24% in the early physical activity group vs 43.5% in the group that reported no early physical activity (relative risk [RR], 0.75 [95% CI, 0.7-0.8]). Similar results were observed with propensity matching (28.7% PPCS among those who reported early activity vs 41.1% among those who reported no physical activity; RR, 0.84 [95% CI, 0.77-0.92] and in the IPTW analysis with an RR for PPCS of 0.74 [95% CI, 0.65-0.84]) for the early activity group vs the no early activity group. Observational studies are always limited in that they cannot presume causality, and this is particularly true when the possibility of confounding by indication exists. A patient who is not feeling well 7 days after injury is less likely to be physically active (the exposure) and more likely to develop PPCS (the outcome). Factors associated with the exposure and the outcome are concerning because they cause confounding and if properly controlled for may eliminate evidence of an effect. Even though Grool et al have attempted to control for potential confounding using propensity matching and IPTW, these techniques are only able to control for measured factors and unmeasured variables could cause residual confounding. The authors measured many important factors such as severity of concussion symptoms, duration of previous concussions, and history of depression or anxiety, but did not control for depressive or anxious symptoms using standardized scales, which is concerning given that these are Related article page 2504 Opinion