Epidemiologic studies have identified differences in concussion incidence between the sexes. However, few authors to date have updated injury rates (IRs) and time loss between male and female ...concussed athletes.
To examine sex differences in IRs and time loss in concussed National Collegiate Athletic Association (NCAA) athletes.
Descriptive epidemiologic study.
National Collegiate Athletic Association athletics.
A total of 1702 concusssed NCAA athletes, consisting of 903 females and 779 males participating in soccer, basketball, ice hockey, lacrosse, softball, or baseball over a 5-year period from 2004-2005 through 2008-2009.
Using the NCAA Injury Surveillance Program, athletic trainers reported concussions, athlete-exposures (AEs), and time loss across 10 NCAA sports. An IR is the number of injuries in a particular category divided by the number of AEs in that category.
During the study period, 1702 concussions were reported during 4 170 427 AEs for an overall total of 5.47 per 10 000 AEs. In sex-comparable sports, females had a 1.4 times higher overall concussion IR than males (IRs = 4.84 and 3.46, respectively), with greater rates in women's baseball/softball, basketball, ice hockey, and soccer than men. Female soccer and basketball players also displayed more time loss after concussion compared with male basketball and soccer players.
Female athletes sustained a higher rate of concussion and, in all sports except lacrosse, had greater time loss from concussion than male athletes. Additional research is needed on sex differences in time loss after concussions.
Background:
While a large number of studies have investigated the anatomic, hormonal, and biomechanical risk factors related to musculoskeletal (MSK) injury risk, there is growing evidence to suggest ...that cognition is an important injury contributor in the athletic population. A systematic review of the available evidence regarding the influence of cognitive performance on MSK injury risk has yet to be published in the sports medicine literature.
Purpose/Hypothesis:
The purpose was to determine the effects of cognition on (1) MSK biomechanics during sports-specific tasks and (2) MSK injury occurrence in the athletic population. It was hypothesized that athletes with lower cognitive performance would demonstrate biomechanical patterns suggestive of MSK injury risk and that injured athletes would perform worse on baseline measures of cognition as compared with their noninjured counterparts.
Study Design:
Systematic review.
Methods:
PubMed and SPORTDiscus were searched from January 2000 to January 2020. Manual searches were performed on the reference lists of the included studies. A search of the literature was performed for studies published in English that reported MSK biomechanics as a function of cognitive performance and MSK injury occurrence after baseline measures of cognition. Two independent reviewers extracted pertinent study data in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 guidelines and assessed study quality using the Quality Assessment Tool for Observational Cohort and Cross-sectional Studies from the National Institutes of Health. A meta-analysis was not performed, owing to the heterogeneous nature of the study designs.
Results:
Ten studies met inclusion criteria: 4 cognition–MSK biomechanics studies and 6 cognition–MSK injury studies. All 4 cognition–MSK biomechanics studies demonstrated that worse performance on measures of cognition was associated with lower extremity MSK biomechanical patterns suggestive of greater risk for MSK injury. The majority of the cognition–MSK injury studies demonstrated that injured athletes significantly differed on baseline cognition measures versus matched controls or that cognitive performance was a significant predictor for subsequent MSK injury.
Conclusion:
Although the literature exploring cognitive contributions to MSK injury risk is still in its infancy, it is suggested that sports medicine personnel conduct baseline assessments of cognition—in particular, reaction time and working memory—to identify which athletes may be at elevated risk for future MSK injury.
Background:
The Vestibular/Ocular Motor Screening (VOMS) measure is a newly developed vestibular and ocular motor symptom provocation screening tool for sport-related concussions. Baseline data, ...psychometric properties, and reliability of the VOMS are needed to further understand the applications of this tool, especially in the youth population, where research is scarce.
Purpose:
To establish normative data and document the internal consistency and false-positive rate of the VOMS in a sample of nonconcussed youth athletes.
Study Design:
Cross-sectional study; Level of evidence, 3.
Methods:
A total of 423 youth athletes (male = 278, female = 145) between the ages of 8 and 14 years completed baseline VOMS screening before the start of their respective sport seasons. Internal consistency was measured with Cronbach α and inter-item correlations.
Results:
Approximately 60% of youth athletes reported no symptom provocation on baseline VOMS assessment, with 9% to 13% scoring over the cutoff levels (score of ≥2 for any individual VOMS symptom, near point convergence distance of ≥5 cm). The VOMS displayed a high internal consistency (Cronbach α = .97) at baseline among youth athletes.
Conclusion:
The current findings provide preliminary support for the implementation of VOMS baseline assessment into clinical practice, due to a high internal consistency, strong relationships between VOMS items, and a low false-positive rate at baseline in youth athletes.
Background:
Given the high participation of Black/African American individuals in high school sports, especially high-risk sports for concussion, it is important to note if racial and socioeconomic ...status (SES) differences exist in baseline performance on clinical measures of concussion.
Purpose:
To explore the association between race and SES on baseline concussion assessments of neurocognitive performance and oculomotor function in adolescent athletes.
Study Design:
Cohort study (Diagnosis); Level of evidence, 3.
Methods:
A total of 564 high school athletes (mean ± SD age, 15.33 ± 1.1 years) completed the baseline Immediate Post-Concussion Assessment and Cognitive Test and King-Devick (KD) battery before the start of their competitive season. Race was defined as either White/non-Hispanic or Black/African American. SES status was determined by whether the individual’s participating high school was a Title I or non–Title I school. A series of multivariable linear regression analyses were conducted to evaluate the association of computerized neurocognitive test scores (verbal memory, visual memory, motor processing speed, and reaction time), symptom severity scores, and KD scores by race and SES.
Results:
White/non-Hispanic individuals performed significantly better than Black/African American individuals on verbal memory (P < .01), visual memory (P < .01), visual motor processing speed (P < .01), and reaction time (P < .01) and had a lower symptom score (P < .01). Regarding SES, individuals from non–Title I schools performed better on visual memory (P = .05) and reaction time (P = .02) than individuals from Title I schools. Examination of cumulative KD test reading time revealed that there was no association between race on baseline reading times (P = .12). There was a significant association between cumulative reading time and SES (P = .02). Individuals from non–Title I schools performed significantly faster than individuals from Title I schools on KD test time.
Conclusion:
Overall, race and SES influence neurocognitive and oculomotor concussion baseline performance in high school athletes. These findings add to the growing literature on the influence of race and SES on neurocognitive and oculomotor function baseline concussion assessments; they highlight the necessity for individualized concussion baseline measurements or race-specific normative reference values.
Background:
Sports-related concussion (SRC) injury rates are well established in collegiate athletics through epidemiological studies using the National Collegiate Athletic Association Injury ...Surveillance System. However, few studies have examined sex differences, time loss, and missed school days in high school athletes, especially at the state level.
Purpose:
To identify sex differences in the clinical incidence of SRCs, missed school days, and time loss in high school student-athletes.
Study Design:
Descriptive epidemiological study.
Methods:
A total of 193,757 (116,434 male and 77,323 female) student-athletes (10th grade ± 1.1) participating in Michigan High School Athletic Association (MHSAA)–sponsored athletic activities were recorded in the Head Injury Reporting System. Certified athletic trainers, school athletic administrators, and coaches from MHSAA high schools reported SRC data and overall participation for the 2015-2016 academic year. Total concussive injuries, as well as missed school days and time loss for each concussive injury, were reported. The clinical incidence was calculated by dividing the number of SRCs in a particular category by the number of participants in that category and presented with 95% CIs. Relative risk ratios (RRs) were determined for sex-comparable sports.
Results:
The overall clinical incidence for all sports was 1.7 per 100 player-seasons (95% CI, 1.6-1.8) and 1.9 (95% CI, 1.8-2.0) for male sports and 1.5 (95% CI, 1.4-1.6) for female sports. Female athletes were at a 1.9 (95% CI, 1.8-2.2) times greater risk for enduring SRCs than male athletes in sex-comparable sports, with a greater risk in baseball/softball (RR, 2.7 95% CI, 1.9-3.8), basketball (RR, 2.5 95% CI, 2.1-2.9), and soccer (RR, 1.6 95% CI, 1.4-1.9). Female student-athletes had significantly longer time loss than male student-athletes (P < .001). The mean number of missed school days did not differ between sexes (P = .70).
Conclusion:
High school female student-athletes have a higher risk for an SRC in all sex-comparable sports except lacrosse. This may be because of biomechanical differences of the head-neck segment, hormonal differences, and the fact that female athletes are more likely to report symptoms after a suspected SRC.
Clinical Relevance:
Despite sex differences in the clinical incidence of SRCs and time loss from participation in high school sports, the numbers of missed school days are relatively similar between sexes.
To prospectively examine the relationship of sport-related concussion with depression and neurocognitive performance and symptoms among male and female high school and college athletes. A secondary ...objective was to explore age and sex differences.
Pretest, multiple posttest, repeated-measures design.
Laboratory.
High school and collegiate athletes (N=75) with a diagnosed concussion.
Not applicable.
Beck Depression Inventory-II and computerized neurocognitive test battery (Immediate Post-concussion Assessment and Cognitive Test), which includes concussion symptoms (Post-concussion Symptom Scale) at baseline and at 2, 7, and 14 days postinjury.
Concussed athletes exhibited significantly higher levels of depression from baseline at 2 days (P≤.001), 7 days (P=.006), and 14 days postconcussion (P=.04). Collegiate athletes demonstrated a significant increase in depression at 14 days postconcussion than did high school athletes (P=.03). There were no sex differences in depression levels. Neurocognitive decrements at 14 days were supported for reaction time (P=.001) and visual memory (P=.001). Somatic depression at 7 days postconcussion was related to slower reaction time at 7 days postconcussion. Somatic depression at 14 days postinjury was related to lower visual memory scores at 14 days postinjury.
Although not clinically significant, athletes experienced increased depression scores up to 14 days after concussion that coincided with neurocognitive decrements in reaction time and visual memory. Somatic depression appears to be most salient with regard to lower neurocognitive performance. Mood assessments after concussion are warranted to help monitor and enhance recovery.
Previous literature on sport-related concussion (SRC) knowledge and reporting behaviors has been limited to high school and National Collegiate Athletic Association collegiate athletes; however, ...knowledge regarding collegiate club-sport athletes is limited.
To determine the level of SRC knowledge and reporting behaviors among collegiate club-sport athletes and to investigate differences between athletes in traditional and nontraditional sports.
Cross-sectional study.
Survey.
A total of 410 athletes (247 males, 163 females) involved in traditional (n = 244) or nontraditional (n = 165) collegiate club sports.
The survey consisted of demographics, recognition of SRC signs and symptoms, general SRC knowledge, and reasons why athletes would not report SRCs. The independent variable was sport type. Sport-related concussion signs and symptoms and general knowledge were assessed by the frequency of correct answers to SRC signs and symptoms and general knowledge questions. Sport-related concussion-reporting behavior frequencies were evaluated by asking participants to indicate reasons why they did not or would not report an SRC.
The SRC signs and symptoms knowledge score was 23.01 ± 3.19 and general SRC knowledge score was 36.49 ± 4.16 (maximal score = 43). No differences were present for SRC signs and symptoms knowledge ( F
= 1.99, P = .16) or general SRC knowledge ( F
= 3.28, P = .07) between athletes in traditional and nontraditional collegiate club sports. The most common reason for not reporting an SRC was not recognizing it as a serious injury (n = 165, 40.3%). Chi-square tests demonstrated significant relationships between sport type and 5 reasons for not reporting an SRC.
The participants displayed moderate to high levels of knowledge of SRCs but indicated they had failed to or would fail to report SRCs for a variety of reasons. The lack of sports medicine coverage and disconnect between knowledge and injury recognition may make collegiate club-sport athletes more likely to participate while concussed.
To our knowledge, little research has examined concussion across the youth/adolescent spectrum and even less has examined concussion-related outcomes (ie, symptoms and return to play).
To examine and ...compare sport-related concussion outcomes (symptoms and return to play) in youth, high school, and collegiate football athletes.
Athletic trainers attended each practice and game during the 2012 to 2014 seasons and reported injuries. For this descriptive, epidemiological study, data were collected from youth, high school, and collegiate football teams, and the analysis of the data was conducted between July 2015 and September 2015. The Youth Football Surveillance System included more than 3000 youth football athletes aged 5 to 14 years from 118 teams, providing 310 team seasons (ie, 1 team providing 1 season of data). The National Athletic Treatment, Injury, and Outcomes Network Program included 96 secondary school football programs, providing 184 team seasons. The National Collegiate Athletic Association Injury Surveillance Program included 34 college football programs, providing 71 team seasons.
We calculated the mean number of symptoms, prevalence of each symptom, and the proportion of patients with concussions that had long return-to-play time (ie, required participation restriction of at least 30 days). Generalized linear models were used to assess differences among competition levels in the mean number of reported symptoms. Logistic regression models estimated the odds of return to play at less than 24 hours and at least 30 days.
Overall, 1429 sports-related concussions were reported among youth, high school, and college-level football athletes with a mean (SD) of 5.48 (3.06) symptoms. Across all levels, 15.3% resulted return to play at least 30 days after the concussion and 3.1% resulted in return to play less than 24 hours after the concussion. Compared with youth, a higher number of concussion symptoms were reported in high school athletes (β = 1.39; 95% CI, 0.55-2.24). Compared with college athletes, the odds of return to play at least 30 days after injury were larger in youth athletes (odds ratio, 2.75; 95% CI, 1.10- 6.85) and high school athletes (odds ratio, 2.89; 95% CI, 1.61-5.19). The odds of return to play less than 24 hours after injury were larger in youth athletes than high school athletes (odds ratio, 6.23; 95% CI, 1.02-37.98).
Differences in concussion-related outcomes existed by level of competition and may be attributable to genetic, biologic, and/or developmental differences or level-specific variations in concussion-related policies and protocols, athlete training management, and athlete disclosure. Given the many organizational, social environmental, and policy-related differences at each level of competition that were not measured in this study, further study is warranted to validate our findings.
Background:
The current evidence for acute management practices of sport-related concussion (SRC) is often limited to in-clinic visits, with limited studies identifying professionals in early SRC ...care and the association with prolonged recovery outcomes.
Purpose:
To describe acute SRC management practices (ie, the personnel in the initial evaluations, removal from activity) and test the association with prolonged return to sport (RTS) time.
Study Design:
Descriptive epidemiology study.
Methods:
We conducted a retrospective cohort study of 17,081 high school SRCs accrued between the 2015-2016 and 2020-2021 academic years. We reported acute management practices and RTS time as frequencies stratified by sex, sport, and event type and compared athletic trainer (AT) access in initial evaluation with chi-square tests (P < .05). Separate logistic regressions estimated odds ratios (ORs) and 95% CIs for removal from activity and prolonged RTS >21 days by acute management practices.
Results:
Most SRCs (n = 12,311 72.1%) had complete initial evaluation by an AT. Boys had an AT evaluation in 75.5% (n = 2860/3787) of practice-related and 74.8% (n = 5551/7423) of competition-related events. Girls had an AT evaluation in 61.3% (n = 1294/2110) of practice-related and 69.3% (n = 2606/3761) of competition-related events. In sex-comparable sports (n = 6501), there was no difference between boys (n = 1654/2455 67.4%) and girls (n = 2779/4046 68.7%) having an AT involved in the first evaluation (χ2 = 1.21; P = .27). Notably, 25.3% of girls’ SRCs were evaluated by a coach alone, and we observed differences in personnel in initial evaluations by sport. The odds of immediate removal were higher when an AT made the initial evaluation (OR, 2.8 95% CI, 2.54-3.08). The odds of prolonged RTS >21 days was lower for those with an AT in the initial evaluation (OR, 0.74 95% CI, 0.65-0.84) adjusting for significant factors from univariate analyses, boys relative to girls (OR, 0.85 95% CI, 0.76-0.96), specialty care relative to PCP (OR, 2.16 95% CI, 1.90-2.46), specialty care relative to urgent or ready care (OR, 0.99 95% CI, 0.82-1.22) concussion history (OR, 1.41 95% CI, 1.22-1.63), and removal from activity (OR, 0.90 95% CI, 0.78-1.05).
Conclusion:
This study found variability in personnel involved in initial SRC evaluations, with higher percentages of athletes with SRCs having ATs make the initial evaluation during competitive events. There was no association between sex and AT involvement in comparable sports. There was an association between prolonged RTS and AT involvement, sex, concussion history, and location of follow-up care.
Background:
Research has demonstrated that female athletes are more likely to report their sports-related concussion (SRC) symptoms compared with male athletes; however, it is unknown if these ...reporting behaviors correspond to immediate removal from activity in sex-comparable sports.
Purpose:
To compare the incidence of high school student-athletes removed and not removed from activity after SRC in sex-comparable sports in Michigan.
Study Design:
Descriptive epidemiology study.
Methods:
Participants included student-athletes diagnosed with SRC participating in Michigan High School Athletic Association–sponsored athletic activities (22 sex-comparable sports) between 2016 and 2019. All SRCs were recorded in the association’s Head Injury Reporting System (HIRS) by certified athletic trainers, administrators, or coaches. Removal from activity indicated that the student-athlete was removed from play at the time of an injury event. If the student-athlete reported that his or her suspected injury event occurred earlier during activity or if symptom onset was delayed, “not removed from activity” was entered into the HIRS. Incidence proportions were calculated by dividing SRCs not removed by total SRCs in each sport. Risk ratios were calculated by dividing the incidence proportions of girls not removed by boys not removed in each sport.
Results:
A total of 4418 (2773 female, 1645 male) SRCs were reported, with the most occurring in female soccer players (n = 1023). Overall, 515 girls and 243 boys were not removed from activity, resulting in incidences of 0.19 (95% CI, 0.17-0.20) and 0.15 (95% CI, 0.13-0.17), respectively. Across all sports, girls were 1.26 (95% CI, 1.09-1.45) times as likely to not be removed from activity compared with boys. Of the sports with the most SRCs—soccer, basketball, baseball/softball, and lacrosse—girls had 1.37 (95% CI, 1.09-1.72), 1.15 (95% CI, 0.89-1.47), 1.19 (95% CI, 0.77-1.84), and 1.35 (95% CI, 0.94-1.95) times the risk of not being removed, respectively.
Conclusion:
Girls were at greater risk of not being removed from activity compared with boys in sex-comparable sports. Results from this study should be incorporated into SRC education in Michigan and potentially elsewhere to inform affiliated personnel of potential sex differences and protect female student-athletes from further harm.
PDF
