Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, Davis GA, Echemendia RJ, Makdissi M, McNamee M, Broglio S, Emery CA, Feddermann-Demont N, Fuller GW, Giza CC, Guskiewicz KM, Hainline B, Iverson GL, Kutcher JS, Leddy JJ, Maddocks D, Manley G, McCrea M, Purcell LK, Putukian M, Sato H, Tuominen MP, Turner M, Yeates KO, Herring SA, Meeuwisse W.
Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022.
Br J Sports Med. 2023 Jun;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
Abstract/Text
For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.
© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.
Silverberg ND, Iverson GL; ACRM Brain Injury Special Interest Group Mild TBI Task Force members:; Cogan A, Dams-O-Connor K, Delmonico R, Graf MJP, Iaccarino MA, Kajankova M, Kamins J, McCulloch KL, McKinney G, Nagele D, Panenka WJ, Rabinowitz AR, Reed N, Wethe JV, Whitehair V; ACRM Mild TBI Diagnostic Criteria Expert Consensus Group:; Anderson V, Arciniegas DB, Bayley MT, Bazarian JJ, Bell KR, Broglio SP, Cifu D, Davis GA, Dvorak J, Echemendia RJ, Gioia GA, Giza CC, Hinds SR 2nd, Katz DI, Kurowski BG, Leddy JJ, Sage NL, Lumba-Brown A, Maas AI, Manley GT, McCrea M, Menon DK, Ponsford J, Putukian M, Suskauer SJ, van der Naalt J, Walker WC, Yeates KO, Zafonte R, Zasler ND, Zemek R.
The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury.
Arch Phys Med Rehabil. 2023 Aug;104(8):1343-1355. doi: 10.1016/j.apmr.2023.03.036. Epub 2023 May 19.
Abstract/Text
OBJECTIVE: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings.
DESIGN: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus.
PARTICIPANTS: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations.
RESULTS: The first 2 Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.'
CONCLUSIONS: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.
Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Echemendia RJ, Brett BL, Broglio S, Davis GA, Giza CC, Guskiewicz KM, Harmon KG, Herring S, Howell DR, Master C, McCrea M, Naidu D, Patricios JS, Putukian M, Walton SR, Schneider KJ, Burma JS, Bruce JM.
Sport concussion assessment tool™ - 6 (SCAT6).
Br J Sports Med. 2023 Jun;57(11):622-631. doi: 10.1136/bjsports-2023-107036.
Abstract/Text
Patricios JS, Davis GA, Ahmed OH, Blauwet C, Schneider GM, Purcell LK, Echemendia RJ, Fremont P, Fuller GW, Herring SA, Harmon KG, Loosemore M, Makdissi M, O'Halloran P, Putukian M, Turner M, Webborn N, Yeates KO, van Ierssel J, Schneider KJ.
Introducing the Sport Concussion Office Assessment Tool 6 (SCOAT6).
Br J Sports Med. 2023 Jun;57(11):648-650. doi: 10.1136/bjsports-2023-106860.
Abstract/Text
Scorza KA, Cole W.
Current Concepts in Concussion: Initial Evaluation and Management.
Am Fam Physician. 2019 Apr 1;99(7):426-434.
Abstract/Text
Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established. Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.
Harmon KG, Clugston JR, Dec K, Hainline B, Herring S, Kane SF, Kontos AP, Leddy JJ, McCrea M, Poddar SK, Putukian M, Wilson JC, Roberts WO.
American Medical Society for Sports Medicine position statement on concussion in sport.
Br J Sports Med. 2019 Feb;53(4):213-225. doi: 10.1136/bjsports-2018-100338.
Abstract/Text
Sport-related concussion (SRC) is a common injury in recreational and organised sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment and management of SRC. In addition to a growing need for knowledgeable healthcare professionals to provide evidence-based care for athletes with SRC, media attention and legislation have created awareness and, in some cases, fear about many issues and unknowns surrounding SRC. The American Medical Society for Sports Medicine (AMSSM) formed a writing group to review the existing literature on SRC, update its previous position statement, and to address current evidence and knowledge gaps regarding SRC. The absence of definitive outcomes-based data is challenging and requires relying on the best available evidence integrated with clinical experience and patient values. This statement reviews the definition, pathophysiology and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short-term and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The AMSSM is committed to best clinical practices, evidence-based research and educational initiatives that positively impact the health and safety of athletes.
© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.
McRae B, Stay S.
Assessment and management of sport-related concussion in general practice.
Aust J Gen Pract. 2024 Mar;53(3):121-126. doi: 10.31128/AJGP-12-23-7067.
Abstract/Text
BACKGROUND: Sport-related concussion (SRC) is a traumatic brain injury that occurs during sport or exercise activity. SRC is a growing health concern in Australia, with increasing public awareness and presentations to general practitioners being increasingly common.
OBJECTIVE: This article will focus on the assessment and management of SRC in general practice, including guidance for returning patients to sport. Concussion prevention, potential long-term complications, and the decision-making process regarding retirement from sport are beyond the scope of this article.
DISCUSSION: Recognising concussion can be difficult, as clinical symptoms and signs of SRC can evolve over a period of hours to days. General practitioners should be aware of the range of clinical concussion presentations. The key principles of management include relative rest, followed by a graduated return to cognitive and physical activity. Involvement of a multidisciplinary team can improve symptoms for those patients whose concussion symptoms are prolonged.
Pfister T, Pfister K, Hagel B, Ghali WA, Ronksley PE.
The incidence of concussion in youth sports: a systematic review and meta-analysis.
Br J Sports Med. 2016 Mar;50(5):292-7. doi: 10.1136/bjsports-2015-094978. Epub 2015 Nov 30.
Abstract/Text
OBJECTIVE: To conduct a comprehensive systematic review and meta-analysis of studies assessing the incidence of concussion in youth athletes. Specifically, we estimate the overall risk of concussion in youth sports and compare sport-specific estimates of concussion risk.
DESIGN: Systemic review and meta-analysis.
DATA SOURCES: A search of Medline, Embase (1980 through September 2014), and SportDiscus (1985 through September 2014) supplemented by manual searches of bibliographies and conference proceedings.
INCLUSION CRITERIA: We included studies if they met the inclusion criteria of study design (prospective cohort study), relevant sports identified from the literature (eg, American football, rugby, hockey, lacrosse, soccer/football, basketball, baseball, softball, wrestling, field hockey, track, taekwondo, volleyball and cheerleading), population (males and females ≤18 years old), and outcome (concussion).
RESULTS: Of the 698 studies reviewed for eligibility, 23 articles were accepted for systematic review and 13 of which were included in a meta-analysis. Random effects models were used to pool overall and sport-specific concussion incidence rates per 1000 athlete exposures (AEs). The overall risk of concussion was estimated at 0.23 (95% CI 0.19 to 0.28). The three sports with the highest incidence rates were rugby, hockey and American football at 4.18, 1.20 and 0.53, respectively. Lowest incidence rates per 1000 AEs occurred in volleyball, baseball and cheerleading at 0.03, 0.06 and 0.07, respectively. Quality of the included studies varied, with the majority of studies not reporting age and gender-specific incidence rates or an operational definition for concussion.
CONCLUSIONS: There are striking differences in the rates of incident youth concussion across 12 sports. This systematic review and meta-analysis can serve as the current sport-specific baseline risk of concussion among youth athletes.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Zuckerman SL, Kerr ZY, Yengo-Kahn A, Wasserman E, Covassin T, Solomon GS.
Epidemiology of Sports-Related Concussion in NCAA Athletes From 2009-2010 to 2013-2014: Incidence, Recurrence, and Mechanisms.
Am J Sports Med. 2015 Nov;43(11):2654-62. doi: 10.1177/0363546515599634. Epub 2015 Sep 1.
Abstract/Text
BACKGROUND: The epidemiology of sports-related concussion (SRC) among student-athletes has been extensively researched. However, recent data at the collegiate level are limited.
PURPOSE: To describe the epidemiology of SRC in 25 National Collegiate Athletic Association (NCAA) sports.
STUDY DESIGN: Descriptive epidemiology study.
METHODS: SRC data from the NCAA Injury Surveillance Program during the 2009-2010 to 2013-2014 academic years were analyzed. Concussion injury rates, rate ratios (RRs), and injury proportion ratios were reported with 95% CIs. National estimates were also calculated to examine linear trends across time.
RESULTS: During the study period, 1670 SRCs were reported, representing a national estimate of 10,560 SRCs reported annually. Among the 25 sports, the overall concussion rate was 4.47 per 10,000 athlete-exposures (AEs) (95% CI, 4.25-4.68). Overall, more SRCs occurred in competitions (53.2%). The competition rate (12.81 per 10,000 AEs) was larger than the practice rate (2.57 per 10,000 AEs) (competition vs practice, RR = 4.99; 95% CI, 4.53-5.49). Of all SRCs, 9.0% were recurrent. Most SRCs occurred from player contact (68.0%). The largest concussion rates were in men's wrestling (10.92 per 10,000 AEs; 95% CI, 8.62-13.23), men's ice hockey (7.91 per 10,000 AEs; 95% CI, 6.87-8.95), women's ice hockey (7.50 per 10,000 AEs; 95% CI, 5.91-9.10), and men's football (6.71 per 10,000 AEs; 95% CI, 6.17-7.24). However, men's football had the largest annual estimate of reported SRCs (n = 3417), followed by women's soccer (n = 1113) and women's basketball (n = 998). Among all SRCs, a linear trend did not exist in national estimates across time (P = .17). However, increases were found within specific sports, such as men's football, women's ice hockey, and men's lacrosse.
CONCLUSION: The estimated number of nationally reported SRCs has increased within specific sports. However, it is unknown whether these increases are attributable to increased reporting or frequency of concussions. Many sports report more SRCs in practice than in competition, although competition rates are higher. Men's wrestling and men's and women's ice hockey have the highest reported concussion rates. Men's football had the highest annual national estimate of reported SRCs, although the annual participation count was also the highest. Future research should continue to longitudinally examine SRC incidence while considering differences by sex, division, and level of competition.
© 2015 The Author(s).
頭部外傷治療・管理のガイドライン作成委員会編. 頭部外傷治療・管理のガイドライン 第4版. 日本脳神経外科学会／日本脳神経外傷学会監, 医学書院, 2019.
Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F; Seattle Sports Concussion Research Collaborative.
Sports- and Recreation-Related Concussions in US Youth.
Pediatrics. 2016 Jul;138(1). doi: 10.1542/peds.2015-4635. Epub 2016 Jun 20.
Abstract/Text
OBJECTIVE: The incidence of sports- and recreation-related concussions (SRRCs) in the United States is unknown. More than 44 million youth participate in sports annually, thus understanding the frequency of SRRCs in children is important on a population level. Our objective was to determine the number of SRRCs occurring annually among US youth ≤18 years old.
METHODS: We identified SRRCs using 3 national databases: MarketScan, National Electronic Injury Surveillance System, and National High School Sports Related Injury Surveillance System, Reporting Injury Online. We determined the number of SRRCs seen in health care settings (outpatient, inpatient, and emergency department) and SRRCs reported to certified high school athletic trainers (ATCs). We used these data and findings in recently published literature to generate a national estimate of SRRCs.
RESULTS: We estimate that between 1.1 and 1.9 million SRRCs occur annually in US children aged ≤18 years. Most children with SRRCs, 511 590 to 1 240 972, were not seen in health care settings. Of children with SRRCs seen in health care settings, most were seen as outpatients with 377 978 visits, compared with between 115 479 and 166 929 ED visits, and between 2886 and 4936 hospitalizations.
CONCLUSIONS: This study provides the most accurate and precise estimate to date of the number of concussions among US children annually. SRRCs are a common injury in children. Providers in all health care settings need to be trained in concussion care. There is a need for better surveillance to enhance our understanding of the epidemiology of concussions in youth.
Copyright © 2016 by the American Academy of Pediatrics.
公益財団法人スポーツ安全協会、公益財団法人日本体育協会. スポーツ外傷・障害予防ガイドブック [Internet]. Available from: https://www.sportsanzen.org/content/images/other/inj_guide_all.pdf
McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA, Ellenbogen R, Emery C, Engebretsen L, Feddermann-Demont N, Giza CC, Guskiewicz KM, Herring S, Iverson GL, Johnston KM, Kissick J, Kutcher J, Leddy JJ, Maddocks D, Makdissi M, Manley GT, McCrea M, Meehan WP, Nagahiro S, Patricios J, Putukian M, Schneider KJ, Sills A, Tator CH, Turner M, Vos PE.
Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016.
Br J Sports Med. 2017 Jun;51(11):838-847. doi: 10.1136/bjsports-2017-097699. Epub 2017 Apr 26.
Abstract/Text
谷諭. 脳振盪 スポーツに関わるスタッフに知ってもらいたい事. 日本臨床スポーツ医学会誌.2012; 20(2): 215-9.
Lumba-Brown A, Teramoto M, Bloom OJ, Brody D, Chesnutt J, Clugston JR, Collins M, Gioia G, Kontos A, Lal A, Sills A, Ghajar J.
Concussion Guidelines Step 2: Evidence for Subtype Classification.
Neurosurgery. 2020 Jan 1;86(1):2-13. doi: 10.1093/neuros/nyz332.
Abstract/Text
BACKGROUND: Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments.
OBJECTIVE: To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury.
METHODS: A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD).
RESULTS: The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI = 0.37, 0.67) and cognitive (0.40; 95% CI = 0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI = 0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P < .05). Children and adults with concussion showed significantly more cognitive symptoms than their respective controls (SMD = 0.66 and 0.24; P < .001). Furthermore, ocular-motor in adult patients (SMD = 0.72; P < .001) and vestibular symptoms in both pediatric and adult patients (SMD = 0.18 and 0.36; P < .05) were significantly worse in concussion patients than in controls.
CONCLUSION: Five concussion subtypes with varying prevalence within 3 d following injury are commonly seen clinically and identifiable upon systematic literature review. Sleep disturbance, a concussion-associated condition, is also common. There was insufficient information available for analysis of cervical strain. A comprehensive acute concussion assessment defines and characterizes the injury and, therefore, should incorporate evaluations of all 5 subtypes and associated conditions.
© Congress of Neurological Surgeons 2019.
日本外傷学会外傷初期診療ガイドライン改訂第5版編集委員会. 改訂第5版外傷初期診療ガイドラインJATEC. へるす出版, 東京; 2016.
中山晴雄. スポーツ頭部外傷の診断と対応. Neurological Surgery. 2019; 47(2): 231-40.
May T, Foris LA, Donnally III CJ.
StatPearls
Abstract/Text
Second impact syndrome (SIS) is a condition in which an individual experiences a second head injury before completely recovering from a prior head injury. Second impact syndrome has recently gained increased attention as many cite athletes sustaining a concussion and returning to the sport early as being particularly at risk. Though it is a relatively rare condition, physicians should be aware of SIS and educate patients who have experienced or are at risk of experiencing a head injury, as the syndrome is often deadly. The term second impact syndrome entered the medical lexicon in 1984 when Saunders and Harbaugh wrote an article describing a case report of a football player who died four days after suffering a head injury after he returned to play on the day of his death. He collapsed and died after a presumed second head injury.
Putukian M, Purcell L, Schneider KJ, Black AM, Burma JS, Chandran A, Boltz A, Master CL, Register-Mihalik JK, Anderson V, Davis GA, Fremont P, Leddy JJ, Maddocks D, Premji Z, Ronksley PE, Herring S, Broglio S.
Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis.
Br J Sports Med. 2023 Jun;57(12):798-809. doi: 10.1136/bjsports-2022-106682.
Abstract/Text
OBJECTIVE: To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC).
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: 8 databases searched through 22 March 2022.
ELIGIBILITY CRITERIA: Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool.
RESULTS: 278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I2=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I2=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I2=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns.
CONCLUSION: Most athletes have full RTL by 10 days but take twice as long for an RTS.
PROSPERO REGISTRATION NUMBER: CRD42020159928.
© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.
Broglio SP, McAllister T, Katz BP, LaPradd M, Zhou W, McCrea MA; CARE Consortium Investigators.
The Natural History of Sport-Related Concussion in Collegiate Athletes: Findings from the NCAA-DoD CARE Consortium.
Sports Med. 2022 Feb;52(2):403-415. doi: 10.1007/s40279-021-01541-7. Epub 2021 Aug 24.
Abstract/Text
BACKGROUND: Sport-related concussion is recognized as a significant injury with variable recovery rates.
OBJECTIVE: This study defined the acute natural history of sport concussion in male and female collegiate athletes participating in a broad array of sports.
METHODS: We conducted a prospective, longitudinal investigation among collegiate student athletes (n = 34,709) from 30 academic institutions. Primary outcomes included the time (days) from injury until initiation of a return to participation (RTP) protocol and time from injury until medical clearance for unrestricted RTP.
RESULTS: Concussed athletes (n = 1751, 19.2 years, 63.2% male) participating in 22 different sports began the RTP protocol in a median 6.4 (IQR 3.7-11.8) days. Time to initiate the RTP protocol was lengthened by less frequent post-injury assessments, greater initial post-injury symptom severity, limited contact sports participation, practice/training injuries, and three or more prior concussions. The median total RTP duration was 12.8 (IQR 8.7-20.1) days. Total RTP duration was shorter with ADHD medication usage, males, and greater assessment frequency; while greater initial post-injury symptom severity, practice-/training-related injuries, and three or more prior concussions had longer recoveries.
CONCLUSION: Although median recovery times are consistent with previous guidelines, it was not until 1 month post-injury that a preponderance of collegiate athletes were cleared to begin the RTP protocol (92%) or cleared for unrestricted sport participation (85%). Intrinsic and extrinsic factors had a small effect, altering recovery trajectories by up to 2 days, suggesting a largely unified approach to post-injury monitoring and management across all athletes. These data represent a shift from previous classification parameters of normal clinical recovery.
© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.
Iverson GL, Gardner AJ, Terry DP, Ponsford JL, Sills AK, Broshek DK, Solomon GS.
Predictors of clinical recovery from concussion: a systematic review.
Br J Sports Med. 2017 Jun;51(12):941-948. doi: 10.1136/bjsports-2017-097729.
Abstract/Text
OBJECTIVE: A systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion. Clinical recovery was defined functionally as a return to normal activities, including school and sports, following injury.
DESIGN: Systematic review.
DATA SOURCES: PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus and Web of Science.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies published by June of 2016 that addressed clinical recovery from concussion.
RESULTS: A total of 7617 articles were identified using the search strategy, and 101 articles were included. There are major methodological differences across the studies. Many different clinical outcomes were measured, such as symptoms, cognition, balance, return to school and return to sports, although symptom outcomes were the most frequently measured. The most consistent predictor of slower recovery from concussion is the severity of a person's acute and subacute symptoms. The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. Those with a preinjury history of mental health problems appear to be at greater risk for having persistent symptoms. Those with attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk. There is some evidence that the teenage years, particularly high school, might be the most vulnerable time period for having persistent symptoms-with greater risk for girls than boys.
CONCLUSION: The literature on clinical recovery from sport-related concussion has grown dramatically, is mostly mixed, but some factors have emerged as being related to outcome.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Davis GA, Echemendia RJ, Ahmed OH, Anderson V, Blauwet C, Brett BL, Broglio S, Bruce JM, Burma JS, Gioia G, Giza CC, Guskiewicz KM, Harmon KG, Herring SA, Makdissi M, Master CL, McCrea M, Meehan WP 3rd, Naidu D, Patricios JS, Purcell LK, Putukian M, Schneider KJ, Valovich McLeod TC, Walton SR, Yeates KO, Zemek R.
Child SCAT6.
Br J Sports Med. 2023 Jun;57(11):636-647. doi: 10.1136/bjsports-2023-106982.
Abstract/Text
Davis GA, Patricios JS, Purcell LK, Anderson V, Gioia G, Giza CC, Yeates KO, Ahmed OH, Blauwet C, Corwin D, Master CL, Schneider G, van Ierssel J, Echemendia RJ, Fremont P, Fuller GW, Harmon KG, Herring SA, Holte K, Loosemore M, Makdissi M, McCrea M, Meehan WP 3rd, O'Halloran P, Premji Z, Putukian M, Shill IJ, Turner M, Vaandering K, Webborn N, Schneider KJ.
Child SCOAT6.
Br J Sports Med. 2023 Jun;57(11):672-688. doi: 10.1136/bjsports-2023-106984.
Abstract/Text
大橋洋輝. スポーツに関連する頭部外傷（脳震盪）への対応. 総合診療, 2015; 25(7): 649-52.
Lishman WA.
Physiogenesis and psychogenesis in the 'post-concussional syndrome'.
Br J Psychiatry. 1988 Oct;153:460-9. doi: 10.1192/bjp.153.4.460.
Abstract/Text
The aetiological factors relevant to the development of post-concussional symptoms are reviewed. From the numerous studies carried out to date, it would appear that both physiogenic and psychogenic influences are important in their genesis. However, where mild-to-moderate injuries are concerned, organic factors are chiefly relevant in the earlier stages, whereas long-continued symptoms are perpetuated by secondary neurotic developments, often of a complex nature.
和田孝次郎, 豊岡輝繁, 大塚陽平ほか. 実は怖いスポーツ脳振盪と頭痛. 防衛医科大学校雑誌, 2020; 45(4): 134-42.
森達郎, 川又達朗. セカンドインパクト症候群. 臨床スポーツ医学, 2014; 31(3): 276-9.
McCrory PR, Berkovic SF.
Second impact syndrome.
Neurology. 1998 Mar;50(3):677-83. doi: 10.1212/wnl.50.3.677.
Abstract/Text
Diffuse cerebral swelling with delayed catastrophic deterioration, a known complication of brain trauma, has been postulated to occur after repeated concussive brain injury in sports--the "second impact syndrome" (SIS). Certain current concussion management guidelines are contingent upon this assumption. We established criteria for definite, probable, and possible SIS and analyzed all published cases. A total of 17 cases were identified in which the reports described the cases as being consistent with SIS. Of these, only five probable cases of SIS were found based on our diagnostic criteria. We also studied the accuracy of recalled episodes of minor concussion in football players by their teammates because the diagnosis of SIS is usually based on such accounts. We found overreporting of recalled episodes of concussion in teammates when compared with self reports and videotape analysis. Based on case reports, the claim that SIS is a risk factor for diffuse cerebral swelling is not established. Prevention strategies for sports-related cerebral swelling are difficult to implement in the absence of established risk factors.
中山晴雄，平元侑，岩渕聡東. 慢性外傷性脳症（CTE）. 診断と治療. 2018;12；106(12):1489–1493.
宮内崇, 藤田基, 末廣栄一ほか. 軽症頭部外傷に関連する病態と対応. 日救急医会誌, 2014; 25(5): 191-200.
Katz DI, Bernick C, Dodick DW, Mez J, Mariani ML, Adler CH, Alosco ML, Balcer LJ, Banks SJ, Barr WB, Brody DL, Cantu RC, Dams-O'Connor K, Geda YE, Jordan BD, McAllister TW, Peskind ER, Petersen RC, Wethe JV, Zafonte RD, Foley ÉM, Babcock DJ, Koroshetz WJ, Tripodis Y, McKee AC, Shenton ME, Cummings JL, Reiman EM, Stern RA.
National Institute of Neurological Disorders and Stroke Consensus Diagnostic Criteria for Traumatic Encephalopathy Syndrome.
Neurology. 2021 May 4;96(18):848-863. doi: 10.1212/WNL.0000000000011850. Epub 2021 Mar 15.
Abstract/Text
OBJECTIVE: To develop evidence-informed, expert consensus research diagnostic criteria for traumatic encephalopathy syndrome (TES), the clinical disorder associated with neuropathologically diagnosed chronic traumatic encephalopathy (CTE).
METHODS: A panel of 20 expert clinician-scientists in neurology, neuropsychology, psychiatry, neurosurgery, and physical medicine and rehabilitation, from 11 academic institutions, participated in a modified Delphi procedure to achieve consensus, initiated at the First National Institute of Neurological Disorders and Stroke Consensus Workshop to Define the Diagnostic Criteria for TES, April, 2019. Before consensus, panelists reviewed evidence from all published cases of CTE with neuropathologic confirmation, and they examined the predictive validity data on clinical features in relation to CTE pathology from a large clinicopathologic study (n = 298).
RESULTS: Consensus was achieved in 4 rounds of the Delphi procedure. Diagnosis of TES requires (1) substantial exposure to repetitive head impacts (RHIs) from contact sports, military service, or other causes; (2) core clinical features of cognitive impairment (in episodic memory and/or executive functioning) and/or neurobehavioral dysregulation; (3) a progressive course; and (4) that the clinical features are not fully accounted for by any other neurologic, psychiatric, or medical conditions. For those meeting criteria for TES, functional dependence is graded on 5 levels, ranging from independent to severe dementia. A provisional level of certainty for CTE pathology is determined based on specific RHI exposure thresholds, core clinical features, functional status, and additional supportive features, including delayed onset, motor signs, and psychiatric features.
CONCLUSIONS: New consensus diagnostic criteria for TES were developed with a primary goal of facilitating future CTE research. These criteria will be revised as updated clinical and pathologic information and in vivo biomarkers become available.
© 2021 American Academy of Neurology.
永廣信治, 溝渕佳史. スポーツ頭部外傷を可視化する. 脳神経外科ジャーナル. 2014; 23(12): 957-64.
Eliason PH, Galarneau JM, Kolstad AT, Pankow MP, West SW, Bailey S, Miutz L, Black AM, Broglio SP, Davis GA, Hagel BE, Smirl JD, Stokes KA, Takagi M, Tucker R, Webborn N, Zemek R, Hayden A, Schneider KJ, Emery CA.
Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis.
Br J Sports Med. 2023 Jun;57(12):749-761. doi: 10.1136/bjsports-2022-106656.
Abstract/Text
OBJECTIVES: To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and/or head impact risk.
DESIGN: This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
DATA SOURCES: Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review.
ELIGIBILITY CRITERIA: Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English.
RESULTS: In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies.
CONCLUSIONS: Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC.
PROSPERO REGISTRATION NUMBER: CRD42019152982.
© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.
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