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ObjectiveConcern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes.DesignSystematic review.Data sourcesSearch of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022.Eligibility criteriaStudies measuring future risk (cohort studies) or approximating that risk (case-control studies).ResultsTen studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias.ConclusionEvidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors.PROSPERO registration numberCRD42022159486.

Background Cervical spine muscle weakness is well demonstrated in individuals with chronic neck pain. There is a lack of literature evaluating clinically applicable means of assessing isometric cervical strength in chronic whiplash associated disorder (WAD). This study assessed the reliability of self-resisted isometric cervical strength testing using a handheld dynamometer. The relationship between strength and neck pain-related disability and kinesiophobia was also investigated. Methods Twenty subjects with chronic WAD performed maximum-effort isometric cervical flexion, extension, side flexion, and rotation against a hand held dynamometer. The dynamometer was held by the subject, who provided self-resistance. Subjects completed two sessions of testing on one day with two different examiners, and one session on a subsequent day with one of the original examiners. Subjects completed the Neck Disability Index (NDI) and Tampa Scale for Kinesiophobia (TSK) prior to the first testing session. Results Intraclass correlation coefficients (ICC) for directional strength measures were fair to high (0.71–0.88 for intra-rater and 0.79–0.91 for inter-rater). Total strength (sum of all directional strengths) ICCs were high for both intra-rater (ICC = 0.91) and inter-rater (ICC = 0.94) measures. All statistical tests for ICCs demonstrated significance (α < 0.05). Agreement was assessed using Bland Altman (BA) analysis with 95% limits of agreement. BA analysis demonstrated difference scores between the two testing sessions that ranged from 3.0—17.3% and 4.5—28.5% of the mean score for intra and inter-rater measures, respectively. Most measures did not meet the a priori standard for agreement. A moderate to good inverse relationship was demonstrated between kinesiophobia (TSK score) and six out of seven strength measures (α < .05). No significant correlation was found between neck disability (NDI) and cervical strength in any direction. Conclusion This study demonstrated fair to high reliability of self resisted isometric cervical strength testing in the chronic WAD population. All directional strength measures except flexion demonstrated a significant inverse relationship with kinesiophobia. No cervical strength measures were correlated with neck disability. These results support testing cervical strength in this manner to reliably assess change over time within individual patients. The value of such measurement requires further consideration given the lack of correlation between cervical strength and disability. Further research is required to establish normative values and enhance clinical utility.

ObjectivesTo systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3–30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6).Data sourcesMEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results.Eligibility criteria(1) Original research, cohort studies, case–control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification.ResultsOf 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening.ConclusionCurrent SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.PROSPERO registration numberCRD42020154787.

Measurement of systolic and diastolic blood pressure as well as heart rate in the supine position (after 2 min rest) followed by repeat measures after 1 min standing, accompanied by the recording of any symptoms (eg, lightheaded, dizzy) associated with postural change. Due to the potential for sleep disturbances associated with SRC, anxiety related to the injury, and the overlap of depression and anxiety symptoms with SRC, inclusion of optional validated sleep screening tool and mental health screening tools was recommended.7–10 How to use the SCOAT6 The SCOAT6 is a multimodal clinical management tool to be used in the serial evaluation of athletes postconcussion. While remaining true to the systematic process that led to the determination of which diagnostic tests are most appropriate to include in the SCOAT6, it also needs to be acknowledged that such a tool requires flexibility to deal with variations in clinical context, HCP skill sets and time constraints. [...]although the inclusion criteria of the systematic review specified clinical tests used 3–30 days postconcussion, it is expected that clinicians will continue to use a similar clinical evaluation beyond this period when needed to monitor athletes and guide management. The authors gratefully acknowledge the assistance of librarians Alix Hayden and Heather Ganshorn with the literature search for the systematic review, as well as the input of Dr John Leddy and his clinical research group into aspects of the development of the SCOAT6, Dr David Howell for valuable input on gait analysis and Dr David Maddocks for his medicolegal expertise.

The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27–30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.

Correspondence to Professor Gavin A Davis, Neurosurgery, Cabrini Health, Malvern, VIC 3144, Australia; gavin.davis@me.com Background and rationale The Concussion in Sport Group (CISG) introduced tools for assessment and management of concussion in 2004.1 Age-appropriate, child-specific tools were introduced in 2012.2 The most recent iteration, the Child Sport Concussion Assessment Tool 5 (Child SCAT5) was introduced in 2016,3 and has been determined to be most effective in the acute stage following sport-related concussion (SRC), and up to day 7 post-injury.4 Based on feedback from clinicians, the CISG scientific committee determined that a tool for assessment and management of SRC in the subacute period (beyond 72 hours post-injury) would be useful, and established the process for development of the Sport Concussion Office Assessment Tool 6 (SCOAT6).5 Consistent with the approach for the SCAT and Child SCAT, the requirement for an age-appropriate version of the SCOAT6 for children aged 8–12 years led to the development of the Child SCOAT6. Importantly, no validated or normative data are available to support use in this age group, and caution is required in its use in younger children. During the Amsterdam meeting, considerations related to the para athlete were emphasised, and the paucity of data on the paediatric para athlete suggests that significant work is required to develop age-appropriate tools for the para athlete in school, community and elite sport settings. Grants/Research Support: Hit-IQ (2022-2023); NIH NINDS (R01 NS110757 2019-2024); NINDS (U54 NS121688 2021-2026); UCLA Brain Injury Research Center, UCLA Steve Tisch Brain SPORTprogram, Easton Clinic for Brain Health Clinical Consultant (provide clinical care to athletes): NBA, NFL-Neurological Care Program, NHL/NHLPA, Los Angeles Lakers Advisory Board (Non compensated): Major League Soccer, National Basketball Association, US Soccer Federation.

Background Concussion is one of the most commonly occurring injuries in sport today. The Sport Concussion Assessment Tool (SCAT) is a commonly used paper neurocognitive tool. To date, little is known about SCAT baseline normative values in youth athletes. Objective The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players. Methods This is a secondary data analysis of pooled data from three prospective cohort studies examining the risk of injury in paediatric ice hockey players aged 9–17 years. A preseason baseline demographic and injury history questionnaire was completed by each player. Results A total of 4193 players completed SCATs at baseline and were included in the analysis. 781 players (18.6%) reported a previous history of concussion. Fatigue and low energy followed by headache were the most commonly reported symptoms in all players. The majority of youth players could recite all five words immediately but only three words when delayed. A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age. The median number of digits recited in reverse order was 4. Conclusions Youth ratings varied between age groups, gender and from previously reported ratings of varsity athletes, possibly reflecting developmental and gender differences. An understanding of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion.

Background The cervical zygapophyseal joints may be a primary source of pain in up to 60% of individuals with chronic whiplash associated disorders (WAD) and may be a contributing factor for peripheral and centrally mediated pain (sensory hypersensitivity). Sensory hypersensitivity has been associated with a poor prognosis. The purpose of the study was to determine if there is a change in measures indicative of sensory hypersensitivity in patients with chronic WAD grade II following a medial branch block (MBB) procedure in the cervical spine. Methods Measures of sensory hypersensitivity were taken via quantitative sensory testing (QST) consisting of pressure pain thresholds (PPT's) and cold pain thresholds (CPT's). In patients with chronic WAD (n = 18), the measures were taken at three sites bilaterally, pre- and post- MBB. Reduced pain thresholds at remote sites have been considered an indicator of central hypersensitivity. A healthy age and gender matched comparison group (n = 18) was measured at baseline. An independent t-test was applied to determine if there were any significant differences between the WAD and normative comparison groups at baseline with respect to cold pain and pressure pain thresholds. A dependent t-test was used to determine whether there were any significant differences between the pre and post intervention cold pain and pressure pain thresholds in the patients with chronic WAD. Results At baseline, PPT's were decreased at all three sites in the WAD group (p < 0.001). Cold pain thresholds were increased in the cervical spine in the WAD group (p < 0.001). Post-MBB, the WAD group showed significant increases in PPT's at all sites (p < 0.05), and significant decreases in CPT's at the cervical spine (p < 0.001). Conclusions The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. The WAD group revealed decreased sensory hypersensitivity following a decrease in their primary source of pain stemming from the cervical zygapophyseal joints.

BackgroundEvaluation of multiple sensory and motor domains at time of return to play (RTP) may inform risk of recurrent concussion and injury following concussion.ObjectiveTo evaluate if measures of (1) cervical spine function, (2) vestibulo-ocular reflex (VOR) function, (3) dynamic balance and (4) tasks of divided attention have returned to preinjury levels at medical clearance to RTP in elite youth ice hockey players.DesignCase series nested in a prospective cohort study (n=559).SettingCanadian youth ice hockey.ParticipantsYouth ice hockey players [13–17 years; n=45 (8 female, 37 male)].InterventionsPlayers who were diagnosed with an ice hockey-related concussion completed preseason and RTP measures.Main Outcome MeasurementsCervical spine measures (cervical flexor endurance test, head perturbation test, anterolateral strength, cervical flexion rotation test, joint position error), VOR tests [head thrust test, dynamic visual acuity (clinical and computerized)], dynamic balance tests (functional gait) and divided attention tasks (walking-while-talking-test WWTT) were included. Non-parametric (Wicoxon signed-rank, Stuart-Maxwell) analyses compared preseason to RTP scores.ResultsSymptoms of dizziness, neck pain, and headache were reported by 29%, 18% and 20% fewer players at RTP than preseason respectively. Anterolateral cervical muscle strength (z=-5.16, p<0.0001) and joint position error (left) (z=2.91, p=0.0036) were poorer at RTP compared to preseason. The WWTT time (z=-2.66, p=0.0079) and FGA scores were improved at RTP (z=-2.55, p=0.011).ConclusionsAnterolateral cervical spine strength and joint position error (left) did not return to preseason values at RTP and may suggest incomplete recovery not indicated by symptoms at RTP. WWTT and dynamic balance were improved at RTP. Further evaluation of clinical outcomes on risk of subsequent injury following concussion is warranted.

ObjectiveTo evaluate Patient Specific Functional Scale (PSFS) scores in youth diagnosed with sport-related concussion (SRC).DesignCross-sectional.SettingCommunity sport medicine and rehabilitation clinic.ParticipantsTwenty-four youth participating in a randomized controlled trial (RCT) age 10–18 years [15 (62.5%) females; median age 14 (range 11–16), median time since injury 25.5 days (range 10–107)] diagnosed with a SRC as per the 4thor 5th International Consensus Conference and with persisting symptoms >10 days of dizziness, neck pain and/or headaches.Interventions (or Assessment of Risk Factors)N/AOutcome MeasuresThe PSFS is a self-reported measure designed to assess functional change. Patients are asked to report their specific functional challenges (up to 5) and rate them on a scale of 0–10 (0=unable to perform to 10=no functional limitation). Self-reported functional challenges (written text) and scores (0–10) were recorded on the PSFS at time of enrollment into an RCT.Main ResultsThree activity limitations were listed by 21 participants and two by 3 participants. The most frequently reported activity limitations were related to sport/physical activity in 18 (75.0%) participants, reading/school in 5 (20.8%), and concentration in 1 (4.2%), with a median rating of 3/10 (range: 0–9). A total of 66 activities (39 by females:27 by males) were listed by participants and related to functioning in sport (57.6%)(female:male 22:16); school (27.3%)(11:7); daily activities around the house (7.6%)(5:0), social environments (1.5%)(0:1), sleep (3.0%)(1:1), playing a musical instrument (1.5%)(0:1), and video games (1.5%)(0:1).ConclusionsSport/physical activity and reading/school functional limitations are commonly reported by adolescents following concussion and should be considered when planning rehabilitation programs.