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"Athletic Injuries - diagnosis"
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A combination of initial and follow-up physiotherapist examination predicts physician-determined time to return to play after hamstring injury, with no added value of MRI
BackgroundPrevious studies investigating prediction of return to play after acute hamstring injury were limited by examining a single postinjury clinical and MRI evaluation. We evaluated the added value of including follow-up clinical evaluation when predicting return to play.MethodsA range of clinical and MRI parameters were prospectively investigated for an association with the time to return to play in 90 athletes with MRI positive hamstring injuries undergoing a criteria-based rehabilitation programme. Clinical evaluation was performed within 5 days of injury and 7 days after this initial assessment (follow-up clinical evaluation). The association between possible prognostic parameters and the time to return to play was assessed with a multiple linear regression model.ResultsData of 90 athletes were available for analysis. At the first physiotherapy appointment, a combination of three demographic and six clinical variables explained 50% of the variance (±19 days) in the time to return to play. At follow-up assessment (7 days), a combination of 10 clinical and demographic variables explained 97.0% of the variance (±5 days) in time to return to play. In order of importance, the variables were: change in strength during the first week for the ‘mid-range’ test, peak isokinetic knee flexion torque of the uninjured leg, maximum pain at the time of injury, number of days to walk pain free, playing the sport of football, strength performing the ‘inner range’ hamstring test at day 1, presence of pain on a single leg bridge at day 7 or its absence during a single leg bridge, delay in starting treatment and percentage of strength in the ‘outer range’ test compared to the healthy leg. No MRI variables were retained in any of these analyses. MRI variables alone explained 8.6% of the variance—which is unhelpful to players and coaches.SummaryThe combination of initial and 7-day follow-up clinical evaluation is clinically helpful in predicting time to return to play (±5 days) following acute hamstring injury. MRI offered no useful clinical information regarding return to play duration in this cohort.Trial registration numberNCT01812564.
Journal Article
Predicting Sport-related mTBI Symptom Resolution Trajectory Using Initial Clinical Assessment Findings: A Retrospective Cohort Study
Objectives
To identify which aspects of initial clinical assessment for sport-related mild traumatic brain injury (SR-mTBI) predict whether an athlete achieves symptom resolution within 14 days of the injury.
Research Design
Retrospective cohort study using prospectively collected data.
Methods
Clinical assessment data were collected from 568 patients diagnosed with SR-mTBI at a single medical clinic between February 2017 and December 2018. Demographic data, medical history, SCAT-5 testing, and physician notes were included in the data set. Data were processed and analysed to identify a shortlist of predictor variables to develop a logistic regression model to discriminate between SR-mTBI symptom resolution that occurred in ≤ 14-days or > 14-days. The data were randomly divided into model development and validation subsamples. The top 15 models were analysed to determine the predictor variables to be included in the final logistic regression model. The final model was then applied to the validation subsample.
Results
Half of the athlete participants in this study experienced > 14-day symptom resolution. The final logistic regression model included sex, symptom reporting at initial assessment and presentation with a physiological predominant symptom cluster. The model accounted for 0.90 and 0.85 of the area under the curve and predicted recovery trajectory with 81% and 76% accuracy for the training and validation subsamples, respectively.
Conclusions
Being female, reporting a higher Positive Symptom Total at initial assessment, and being less likely to have a physiological predominant symptom cluster at initial assessment predicted > 14 versus ≤ 14-day SR-mTBI symptom resolution with a high level of accuracy.
Journal Article
Randomized Controlled Trial of a Novel Peer Concussion-Education Program for Collegiate Athletes
The National Collegiate Athletic Association and US Department of Defense have called for educational programs to change the culture of concussion reporting, increase reporting behavior, and enhance the safety of players and service members.
To evaluate the effects of a novel peer concussion-education program (PCEP) in changing knowledge, attitudes, and norms about concussion reporting among collegiate student-athletes and assess program implementation.
Randomized controlled trial and qualitative analysis of interviews.
National Collegiate Athletic Association athletic teams from randomly selected colleges or universities.
A total of 1614 male and female student-athletes from 60 teams at 10 colleges and universities and 8 athletic trainers.
The PCEP intervention trains 2 peer concussion educators to provide 2 education modules to their teammates. Knowledge, attitudes (oneself and teammates), and concussion occurrence or reporting were assessed at baseline, postintervention, and 1 month later. Eight athletic trainers were interviewed about program implementation.
Compared with the control group, the intervention group showed greater increases occurred postintervention and at 1 month in concussion knowledge (
= 51.3,
< .0001), intention to report (oneself,
= 82.3,
< .0001; teammates,
= 53.9,
< .0001), return-to-play protocol knowledge, (
= 28.4,
< .0001), direct subjective norms (oneself,
= 51.7,
< .0001; teammates,
= 40.6,
< .0001), direct perceived behavioral control (oneself,
= 53.7,
< .0001; teammates,
= 68.2,
< .0001), and indirect attitudes (oneself,
= 47.1,
< .001; teammates,
= 40.9,
< .0001). Peer concussion-education program participants discussed concussion more often with a teammate (
= 13.96,
< .0001) or athletic staff (
= 6.62,
< .001). Qualitative program analysis revealed both positive aspects of the PCEP and areas for improvement.
The PCEP showed promise in increasing concussion knowledge, intention to report concussion, reporting a teammate's concussion, and facilitating attitudinal changes that support reporting among student-athletes.
Journal Article
Cognitions That Support Concussion Reporting in Collegiate Athletes: An Analysis of a Worksheet Activity
Background
Sports related concussions continue to be a public health concern and improving reporting behavior a focus of educational programs. While educational programs have addressed changes in knowledge of concussion symptoms, it has been challenging to design educational programs which have lasting effects on reporting behavior.
Aims
The current analysis describes an intervention in which thoughts about reporting behavior are actively written down in a worksheet exercise to “pre-arm” athletes with cognitions designed to enhance reporting behavior prior to the injury event.
Method
A total of 503 male and female college athletes participating in collision (football, field hockey, ice hockey, lacrosse, and soccer) and contact sports (baseball, basketball, and softball) from 7 colleges/universities competing across all three NCAA divisions provided data collected during a randomized trial of a peer concussion education program.
Results
Qualitative analysis revealed 10 themes that would improve reporting including short-term benefits, faster recover, safe and healthy return to play, reporting helps the team, reporting protects the brain, risk aversion, long-term benefits, coach will be supportive, teammates will be supportive and understanding, and academic performance will be affected.
Discussion
Athletes had awareness of key risks involved in concussions and understood both short- and long-term consequences.
Conclusion
These findings have important implications for understanding how to change athletes’ thoughts about reporting concussions.
Journal Article
Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial
Background
Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition.
Methods/design
This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline.
Discussion
The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated.
Trial registration
ClinicalTrials.gov,
NCT03034720
. Registered on January 27, 2017.
Journal Article
Concurrent Validity of a Stationary Cycling Test and the Buffalo Concussion Treadmill Test in Adults With Concussion
After concussion, a multifaceted assessment is recommended, including tests of physical exertion. The current criterion standard for exercise testing after concussion is the Buffalo Concussion Treadmill Test (BCTT); however, validated tests that use alternative exercise modalities are lacking.
To evaluate the feasibility and concurrent validity of a universal cycling test of exertion compared with the BCTT in adults who sustained a sport-related concussion.
Crossover study.
University sports medicine clinic.
Twenty adults (age = 18-60 years) diagnosed with a sport-related concussion.
Participants completed the BCTT and a cycling test of exertion in random order, approximately 48 hours apart.
The primary outcome of interest was maximum heart rate (HRmax; beats per minute [bpm]). Secondary outcomes of interest were the total number of symptoms endorsed on the Post-Concussion Symptom Scale, whether the participant reached volitional fatigue (yes or no), the symptom responsible for test cessation (Post-Concussion Symptom Scale), maximum rating of perceived exertion, symptom severity on a visual scale (0-10), and the time to test cessation.
Of the 20 participants, 19 (10 males, 9 females) completed both tests. One participant did not return for the second test and was excluded from the analysis. No adverse events were reported. The median HRmax for the BCTT (171 bpm; interquartile range = 139-184 bpm) was not different from the median HRmax for the cycle (173 bpm; interquartile range = 160-182 bpm; z = -0.63; P = .53). For both tests, the 3 most frequently reported symptoms responsible for test cessation were headache, dizziness, and pressure in the head. Of interest, most participants (64%) reported a different symptom responsible for cessation of each test.
On the novel cycling test of exertion, participants achieved similar HRmax and test durations and, therefore, this test may be a suitable alternative to the BCTT. Future research to understand the physiological reason for the heterogeneity in symptoms responsible for test cessation is warranted.
Journal Article
A Social-Marketing Intervention and Concussion-Reporting Beliefs
Concussion-symptom education remains the primary approach used by athletic trainers to address underreporting of possible sport-related concussions. Social marketing represents an untapped approach to promote concussion reporting by communicating the benefits or consequences of reporting or not reporting, respectively.
To apply expectancy value theory and identify how marketing the possible consequences of concealing concussion symptoms influenced young adults' concussion-reporting beliefs to increase the likelihood of reporting.
Randomized controlled clinical trial.
Laboratory.
A total of 468 competitive collegiate club sport athletes at a large US university who engaged in 1 of 46 sports with various levels of concussion risk.
Participants were randomly assigned by team to 1 of 3 conditions. The treatment condition was a social-marketing program focused on the possible consequences of the reporting decision. The control condition was traditional concussion-symptom education based on the National Collegiate Athletic Association's publication, \"Concussion: A Fact Sheet for Student-Athletes.\" An additional condition mirrored the traditional symptom education but included a less clinical delivery.
Positive and negative beliefs regarding concussion reporting were assessed. We applied expectancy value theory, which posits that changing beliefs in the short term will produce greater reporting intentions in the long term.
Club sport athletes exposed to consequence-based social marketing showed higher levels of positive reporting beliefs and lower levels of negative reporting beliefs than athletes exposed to traditional or revised symptom education. We observed no differences between the traditional and revised symptom-education programs. Exposure to consequence-based marketing decreased negative beliefs about reporting (B = -0.165, P = .01) and increased positive beliefs about reporting (B = 0.165, P = .01).
Social marketing offers athletic trainers another strategic tool for motivating athletes to report concussion symptoms by translating scientific findings into marketable statements and then communicating the benefits of reporting or the negative consequences of concealing concussion symptoms.
Journal Article
FUNCTIONAL BRAIN ABNORMALITIES ARE RELATED TO CLINICAL RECOVERY AND TIME TO RETURN-TO-PLAY IN ATHLETES
Abstract
OBJECTIVE
The relationship between athlete reports of symptoms, neurophysiological activation, and neuropsychological functioning is investigated in a sample of high school athletes.
METHODS
All athletes were evaluated using functional magnetic resonance imaging (fMRI), a computer-based battery of neurocognitive tests, and a subjective symptom scale. Athletes were evaluated within approximately 1 week of injury and again after clinical recovery using all assessment modalities.
RESULTS
This study found that abnormal fMRI results during the first week of recovery predicted clinical recovery. As a group, athletes who demonstrated hyperactivation on fMRI scans at the time of their first fMRI scan demonstrated a more prolonged clinical recovery than athletes who did not demonstrate hyperactivation at the time of their first fMRI scan.
CONCLUSION
These results demonstrate the relationship between neurophysiological, neuropsychological, and subjective symptom data in a relatively large sample composed primarily of concussed high school athletes. fMRI represents an important evolving technology for the understanding of brain recovery after concussion and may help shape return-to-play guidelines in the future.
Journal Article
Pilot Randomized Evaluation of Publically Available Concussion Education Materials: Evidence of a Possible Negative Effect
Many states and sports leagues are instituting concussion policies aimed at reducing risk of morbidity and mortality; many include mandates about the provision of concussion education to youth athletes. However, there is limited evidence if educational materials provided under these typically vague mandates are in fact effective in changing concussion risk-related behavior or any cognition predictive of risk-related behavior. The purpose of this pilot randomized controlled study was to conduct a theory-driven evaluation of three publically available concussion education materials: two videos and one informational handout. Participants were 256 late adolescent males from 12 teams in a single league of ice hockey competition in the United States. Randomization of educational condition occurred at the team level. Written surveys assessing postimpact symptom reporting behavior, concussion knowledge, and concussion reporting cognitions were completed by participants immediately before receiving their educational intervention, I day after, and I month after. Results indicated no change in any measure over any time interval, with the exception of perceived underreporting norms. In one of the video conditions, perceived underreporting norms increased significantly I day after viewing the video. Possible content and viewing environmentrelated reasons for this increase are discussed. Across all conditions, perceived underreporting norms increased I month after intervention receipt, raising the possibility that late in the competitive season underreporting may be perceived as normative. The need for the development of theory-driven concussion education materials, drawing on best practices from health behavior scholars, is discussed.
Journal Article