Is neuropsychological testing useful in the management of sport-related concussion? Predicting and preventing postconcussive problems in paediatrics (5P) study: protocol for a prospective multicentre clinical prediction rule derivation study in children with concussion Recovery of cerebral blood flow following sports-related concussion. Prevalence of neurocognitive and balance deficits in collegiate aged football players without clinically diagnosed concussion. The reliability and validity of video analysis for the assessment of the clinical signs of concussion in Australian football. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. Predicting Slow Recovery From Sport-Related Concussion: The New Simple-Complex Distinction Effectiveness of education in evidence-based healthcare: the current state of outcome assessments and a framework for future evaluations. Predictors of delayed recovery following pediatric sports-related concussion: a case-control study. Epidemiology of sports-related concussion in seven US high school and collegiate sports Persistent motor system abnormalities in formerly concussed athletes. Identification of risk factors by systematic review and development of risk-adjusted models for surgical site infection. HISTORY OF MULTIPLE SELF‐REPORTED CONCUSSIONS IS NOT ASSOCIATED WITH REDUCED COGNITIVE ABILITIES Athletic Trainers' Concussion-Assessment and -Management Practices: An Update.
OBJECTIVE Neuropsychological ( NP ) testing has been used for several years as a way of detecting the effects of sport-related concussion in order to aid in return-to-play determinations . In addition to st and ard pencil- and -paper tests , computerized NP tests are being commercially marketed for this purpose to professional , collegiate , high school , and elementary school programs . However , a number of important questions regarding the clinical validity and utility of these tests remain unanswered , and these questions present serious challenges to the applicability of NP testing for the management of sport-related concussion . Our purpose is to outline the criteria that should be met in order to establish the utility of NP instruments as a tool in the management of sport-related concussion and to review the degree to which existing tests have met these criteria . DATA SOURCES A comprehensive literature review of MEDLINE and PsychLit from 1990 to 2004 , including all prospect i ve , controlled studies of NP testing in sport-related concussion . DATA SYNTHESIS The effects of concussion on NP test performance are so subtle even during the acute phase of injury ( 1 - 3 days postinjury ) that they often fail to reach statistical significance in group studies . Thus , this method may lack utility in individual decision making because of a lack of sensitivity . In addition , most of these tests fail to meet other psychometric criteria ( eg , adequate reliability ) necessary for this purpose . Finally , it is unclear that NP testing can detect impairment in players once concussion-related symptoms ( eg , headache ) have resolved . Because no current guideline for the management of sport-related concussion allows a symptomatic player to return to sport , the incremental utility of NP testing remains question able . CONCLUSIONS / RECOMMENDATIONS Despite the theoretic rationale for the use of NP testing in the management of sport-related concussion , no NP tests have met the necessary criteria to support a clinical application at this time . Additional research is necessary to establish the utility of these tests before they can be considered part of a routine st and ard of care , and concussion recovery should be monitored via the st and ard clinical examination and subjective symptom checklists until NP testing or other methods are proven effective for this purpose Introduction Persistent postconcussive symptoms ( PCSs ) is the persistence of somatic , cognitive , physical , psychological and /or behavioural changes lasting more than 1 month following concussion . Persistent concussion impacts the quality of life through impaired cognition , memory and attention affecting school performance , mood and social engagement . No large epidemiological studies have determined the true prevalence of persistent concussion symptoms . Vali date d , easy-to-use prognosticators do not exist for clinicians to identify children at highest risk . The goal of Predicting and Preventing Postconcussive Problems in Pediatrics study is to derive a clinical prediction rule for the development of persistent postconcussion symptoms in children and adolescents presenting to emergency department following acute head injury . Methods and analysis This study is a prospect i ve , multicentre cohort study across nine academic Canadian paediatric emergency departments . We will recruit the largest prospect i ve epidemiological cohort of children with concussion . Eligible children will be followed using  Post-Concussion Symptom Inventory , a vali date d tool in children as young as 5 years . Patients will follow-up at 1 , 2 , 4 , 8 and 12 weeks postinjury . The main outcome will be the presence/absence of PCSs defined as three or more persistent concussion symptoms 1 month following the injury .  1792 patients provide adequate power to derive a clinical decision rule using multivariate analyses to find predictor variables sensitive for detecting cases of persistent postconcussion symptoms . Ethics and dissemination Results of this large prospect i ve study will enable clinicians to identify children at highest risk , optimise treatment and provide families with realistic and appropriate anticipatory guidance . Ethics has been obtained through the Children 's Hospital of Eastern Ontario Research Ethics Board . Results will be disseminated at international conferences and in four manuscripts to peer- review ed journals . Trial registration This study is registered at Clinical trials.gov through the US National Institute of Health/National Library of Medicine ( NCT01873287 ; http:// clinical trials.gov/ct2/show/NCT01873287 ) IMPORTANCE Animal models suggest that reduced cerebral blood flow ( CBF ) is one of the most enduring physiological deficits following concussion . Despite this , longitudinal studies documenting serial changes in regional CBF following human concussion have yet to be performed . OBJECTIVE To longitudinally assess the recovery of CBF in a carefully selected sample of collegiate athletes and compare time course of CBF recovery with that of cognitive and behavioral symptoms . DESIGN , SETTING , AND PARTICIPANTS A cohort of collegiate football athletes ( N = 44 ) participated in this mixed longitudinal and cross-sectional study at a private research institute specializing in neuroimaging between March 2012 and December 2013 .  Serial imaging occurred approximately 1 day , 1 week , and 1 month postconcussion for a subset of participants ( n = 17 ) . All athletes reported no premorbid mood disorders , anxiety disorders , substance abuse , or alcohol abuse . MAIN OUTCOMES AND MEASURES  Arterial spin labeling magnetic resonance imaging  was used to collect voxelwise relative CBF at each visit . Neuropsychiatric evaluations and a brief cognitive screen  were also performed at all 3 points . Clinicians trained in sports medicine provided an independent measure of real-world concussion outcome ( ie , number of days withheld from competition ) . RESULTS The results indicated both cognitive ( simple reaction time ) and neuropsychiatric symptoms at 1 day postinjury that resolved at either 1 week ( cognitive ; P < .005 ) or 1 month ( neuropsychiatric ; P < .005 ) postinjury . Imaging data suggested both cross-sectional ( ie , healthy vs concussed athletes ; P < .05 ) and longitudinal ( 1 day and 1 week vs 1 month postinjury ; P < .001 ) evidence of CBF recovery in the right insular and superior temporal cortex . Importantly , CBF in the dorsal midinsular cortex was both decreased at 1 month postconcussion in slower-to-recover athletes ( t11 = 3.45 ; P = .005 ) and was inversely related to the magnitude of initial psychiatric symptoms ( Hamilton Depression Scale : r = -0.64 , P = .02 ; Hamilton Anxiety Scale : r = -0.56 , P = .046 ) , suggesting a potential prognostic indication for CBF as a biomarker . CONCLUSIONS AND RELEVANCE To our knowledge , these results provide the first prospect i ve evidence of reduced CBF in human concussion and subsequent recovery . The resolution of CBF abnormalities closely mirrors previous reports from the animal literature and show real-world validity for predicting outcome following concussion STUDY DESIGN Prospect i ve cohort . OBJECTIVES To identify the prevalence of neurocognitive and balance deficits in collegiate football players 48 hours following competition . BACKGROUND Neurocognitive testing , balance assessment s , and subjective report of symptoms are a commonly used test battery in examining athletes when concussion is suspected . Previous literature suggests many concussions go unreported . Little research exists examining the prevalence of neurocognitive or balance deficits in athletes who do not report concussion-like symptoms to a health care provider . METHODS Forty-five Division IA collegiate football players participated in this study . Preseason baseline scores using the  Balance Error Scoring System , the Immediate Post-Concussion Assessment and Cognitive Testing , and the Postconcussion Symptom Scale  were compared to posttest results obtained 48 hours following a game . Prevalence of symptoms was analyzed and reported . RESULTS Thirty-two ( 71 % ) of the 45 athletes tested demonstrated at least 1 deficit in either the Postconcussion Symptom Scale , Balance Error Scoring System , or at least 1 composite score of the Immediate Post-Concussion Assessment and Cognitive Testing . Nineteen of the 32 subjects demonstrated a change in 2 or more categories of neurocognitive and balance function . CONCLUSION In a cohort of football players tested 48 hours following their last game of the season , who did not seek medical attention related to a concussion , a significant number demonstrated limitations in neurocognitive and balance performance , suggesting that further research may need to be performed to improve recognition of an athlete 's deficits and to improve the ability to assess concussion . LEVEL OF EVIDENCE Differential diagnosis/symptom prevalence , level 3b OBJECTIVES The objective of this study was to determine the reliability and validity of identifying clinical signs of concussion using  video analysis in Australian football . DESIGN Prospect i ve cohort study . METHODS All impacts and collisions potentially result ing in a concussion were identified during 2012 and 2013 Australian Football League seasons . Consensus definitions were developed for clinical signs associated with concussion . For intra- and inter-rater reliability analysis , two experienced clinicians independently assessed 102 r and omly selected videos  on two occasions . Sensitivity , specificity , positive and negative predictive values were calculated based on the diagnosis provided by team medical staff . RESULTS 212 incidents result ing in possible concussion were identified in 414 Australian Football League games . The intra-rater reliability of the  video-based identification of signs associated with concussion was good to excellent . Inter-rater reliability was good to excellent for impact seizure , slow to get up , motor incoordination , ragdoll appearance ( 2 of 4 analyses ) , clutching at head and facial injury . Inter-rater reliability for loss of responsiveness and blank and vacant look was only fair and did not reach statistical significance . The feature with the highest sensitivity was slow to get up ( 87 % ) , but this sign had a low specificity ( 19 % ) . Other video signs had a high specificity but low sensitivity . Blank and vacant look ( 100 % ) and motor incoordination ( 81 % ) had the highest positive predictive value . CONCLUSIONS Video analysis may be a useful adjunct to the side-line assessment of a possible concussion . Video analysis however should not replace the need for a thorough multimodal clinical assessment CONTEXT Lack of empirical data on recovery time following sport-related concussion hampers clinical decision making about return to play after injury . OBJECTIVE To prospect ively measure immediate effects and natural recovery course relating to symptoms , cognitive functioning , and postural stability following sport-related concussion . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study of 1631 football players from 15 US colleges . All players underwent preseason baseline testing on concussion assessment measures in 1999 , 2000 , and 2001 . Ninety-four players with concussion ( based on American Academy of Neurology criteria ) and 56 noninjured controls underwent assessment of symptoms  , cognitive functioning  , and postural stability immediately , 3 hours , and 1 , 2 , 3 , 5 , 7 , and 90 days after injury . MAIN OUTCOME MEASURES Scores on the Grade d Symptom Checklist ( GSC ) , St and ardized Assessment of Concussion ( SAC ) , Balance Error Scoring System ( BESS ) , and a neuropsychological test battery . RESULTS No player with concussion was excluded from participation ; 79 players with concussion ( 84 % ) completed the protocol through day 90 . Players with concussion exhibited more severe symptoms ( mean GSC score 20.93 [ 95 % confidence interval [ CI ] , 15.65 - 26.21 ] points higher than that of controls ) , cognitive impairment ( mean SAC score 2.94 [ 95 % CI , 1.50 - 4.38 ] points lower than that of controls ) , and balance problems ( mean BESS score 5.81 [ 95 % CI , -0.67 to 12.30 ] points higher than that of controls ) immediately after concussion . On average , symptoms gradually resolved by day 7 ( GSC mean difference , 0.33 ; 95 % CI , -1.41 to 2.06 ) , cognitive functioning improved to baseline levels within 5 to 7 days ( day 7 SAC mean difference , -0.03 ; 95 % CI , -1.33 to 1.26 ) , and balance deficits dissipated within 3 to 5 days after injury ( day 5 BESS mean difference , -0.31 ; 95 % CI , -3.02 to 2.40 ) . Mild impairments in cognitive processing and verbal memory evident on neuropsychological testing 2 days after concussion resolved by day 7 . There were no significant differences in symptoms or functional impairments in the concussion and control groups 90 days after concussion . CONCLUSIONS Collegiate football players may require several days for recovery of symptoms , cognitive dysfunction , and postural instability after concussion . Further research is required to determine factors that predict variability in recovery time after concussion . St and ardized measurement of postconcussive symptoms , cognitive functioning , and postural stability may enhance clinical management of athletes recovering from concussion Objective : Following the Second International Conference on Concussion in Sport in 2005 , a summary agreement statement was published that introduced new terminology for sport-related concussions . This new classification system is binary ( ie , “ simple ” versus “ complex ” concussions ) . Athletes who are slow to recover ( ie , > 10 days ) are classified as having complex concussions . The purpose of this study was to determine if high school football players , retrospectively classified as having a simple or a complex concussion , could be differentiated in the first 48 after injury on the basis of symptom reporting or neuropsychological testing . Design : Case-control study . Setting : Pennsylvania high school football programs . Participants : The total sample consisted of 114 concussed high school football players who were identified through a 3 year prospect i ve cohort study . Interventions : All completed a computerized neuropsychological screening evaluation within 72 hours of injury . They were followed clinical ly until they recovered and were cleared to return to play . They were classified retrospectively as having a simple ( n = 55 ) or complex ( n = 59 ) concussion based on their recovery times . Main Outcome Measurements : Neurocognitive test performance and symptom ratings . Results : Within 72 hours after injury , athletes with complex concussions performed more poorly on neuropsychological testing and reported more symptoms than those with simple concussions . Athletes with complex concussions who were slow to recover were 18 times more likely to have 3 unusually low neuropsychological test scores than those with simple concussions ( 95 % CI = 2.3 - 144.9 ) . Athletes with previous concussions did not recover more slowly . Conclusions : This study provides evidence that supports and refutes the clinical usefulness of the new simple-complex concussion classification system Background A discipline which critically looks at the evidence for practice should itself be critically examined . Credible evidence for the effectiveness of training in evidence -based healthcare ( EBHC ) is essential . We attempted to summarise the current knowledge on evaluating the effectiveness of training in EBHC while identifying the gaps . Methods A working group of EBHC teachers developed a conceptual framework of key areas of EBHC teaching and practice in need of evidence mapped to appropriate methods and outcomes . A literature search was conducted to review the current state of research in these key areas . Studies of training interventions that evaluated effectiveness by considering learner , patient or health system outcomes in terms of knowledge , skills , attitude , judgement , competence , decision-making , patient satisfaction , quality of life , clinical indicators or cost were included . There was no language restriction . Results Of 55 articles review ed , 15 met the inclusion criteria : six systematic review s , three r and omised controlled trials and six before-after studies . We found weak indications that undergraduate training in EBHC improves knowledge but not skills , and that clinical ly integrated postgraduate teaching improves both knowledge and skills . Two r and omised controlled trials reported no impact on attitudes or behaviour . One before-after study found a positive impact on decision-making , while another suggested change in learners ' behaviour and improved patient outcome . We found no studies assessing the impact of EBHC training on patient satisfaction , health-related quality of life , cost or population -level indicators of health . Conclusions Literature evaluating the effectiveness of training in EBHC has focused on short-term acquisition of knowledge and skills . Evaluation design s were method ologically weak , controlled trials appeared inadequately powered and systematic review s could not provide conclusive evidence owing to weakness of study design OBJECT Pediatric sports-related concussions are a growing public health concern . The factors that determine injury severity and time to recovery following these concussions are poorly understood . Previous studies suggest that initial symptom severity and diagnosis of attention deficit hyperactivity disorder ( ADHD ) are predictors of prolonged recovery ( > 28 days ) after pediatric sports-related concussions . Further analysis of baseline patient characteristics may allow for a more accurate prediction of which patients are at risk for delayed recovery after a sports-related concussion . METHODS The authors performed a single-center retrospective case-control study involving patients cared for at the multidisciplinary Concussion Clinic at Children 's of Alabama between August 2011 and January 2013 . Patient demographic data , medical history , sport concussion assessment tool 2 ( SCAT2 ) and symptom severity scores , injury characteristics , and patient balance assessment s were analyzed for each outcome group . The control group consisted of patients whose symptoms resolved within 28 days . The case group included patients whose symptoms persisted for more than 28 days . The presence or absence of the SCAT2 assessment had a modifying effect on the risk for delayed recovery ; therefore , stratum-specific analyses were conducted for patients with recorded SCAT2 scores and for patients without SCAT2 scores . Unadjusted ORs and adjusted ORs ( aORs ) for an association of delayed recovery outcome with specific risk factors were calculated with logistic regression analysis . RESULTS A total of 294 patients met the inclusion criteria of the study . The case and control groups did not statistically significantly differ in age ( p = 0.7 ) . For the patients who had received SCAT2 assessment s , a previous history of concussion ( aOR 3.67 , 95 % CI 1.51 - 8.95 ) , presenting SCAT2 score < 80 ( aOR 5.58 , 95 % CI 2.61 - 11.93 ) , and female sex ( aOR 3.48 , 95 % CI 1.43 - 8.49 ) were all associated with a higher risk for postconcussive symptoms lasting more than 28 days . For patients without SCAT2 scores , female sex and reporting a history of ADHD significantly increased the odds of prolonged recovery ( aOR 4.41 , 95 % CI 1.93 - 10.07 and aOR 3.87 , 95 % CI 1.13 - 13.24 , respectively ) . Concussions result ing from playing a nonhelmet sport were also associated with a higher risk for prolonged symptoms in patients with and without SCAT2 scores ( OR 2.59 , 95 % CI 1.28 - 5.26 and OR 2.17 , 95 % CI 0.99 - 7.73 , respectively ) . Amnesia , balance abnormalities , and a history of migraines were not associated with symptoms lasting longer than 28 days . CONCLUSIONS This case-control study suggests c and i date risk factors for predicting prolonged recovery following sports-related concussion . Large prospect i ve cohort studies of youth athletes examined and treated with st and ardized protocol s will be needed to definitively establish these associations and confirm which children are at highest risk for delayed recovery Background The epidemiology of sports-related concussion is not well-described in the literature . This paper presents a descriptive epidemiology of concussion in seven high school and collegiate sports . Methods We used the data from Concussion Prevention Initiative ( CPI ) , which enrolled 8905 athletes at 210 high schools and 26 colleges in a prospect i ve cohort study of 7 sports ( football , men ’s and women ’s soccer , men ’s and women ’s lacrosse , and men ’s and women ’s ice hockey ) between 1999 and 2001 . Injury risks and injury rates were used to characterize the incidence of concussion , and changes in symptoms over time were described . Results A total of 375 concussions were observed . The incidence of concussion was highest in football , followed by women ’s lacrosse , men ’s lacrosse , men ’s soccer , and women ’s soccer ( only 10 ice hockey teams were included , too few to quantify incidence ) . The rate of incident concussion was strongly associated with history of concussion in the previous 24 months ( rate ratio = 5.5 ; 95 % CI : 3.9 , 7.8 , for 2 or more concussions relative to no previous concussion ) . The most common symptoms at time of injury were headache ( 87 % ) , balance problems/dizziness ( 77 % ) , and feeling “ in a fog ” ( 62 % ) . Loss of consciousness and amnesia were present in relatively few cases ( 9 and 30 % ) . The most common mechanism of injury was collision with another player . Conclusions Sports-related concussions present with a diverse range of symptoms and are associated with previous concussion history CONTEXT The known detrimental effects of sport concussions on motor system function include balance problems , slowed motor execution , and abnormal motor cortex excitability . OBJECTIVE To assess whether these concussion-related alterations of motor system function are still evident in collegiate football players who sustained concussions but returned to competition more than 9 months before testing . DESIGN Case-control study . SETTING University laboratory . PATIENTS OR OTHER PARTICIPANTS A group of 21 active , university-level football players who had experienced concussions was compared with 15 university football players who had not sustained concussions . INTERVENTION(S ) A force platform was used to assess center-of-pressure ( COP ) displacement and COP oscillation regularity ( approximate entropy ) as measures of postural stability in the upright position . A rapid alternating-movement task was also used to assess motor execution speed . Transcranial magnetic stimulation over the motor cortex was used to measure long-interval intracortical inhibition and the cortical silent period , presumably reflecting y-aminobutyric acid subtype B receptor-mediated intracortical inhibition . MAIN OUTCOME MEASURE(S ) COP displacement and oscillation regularity , motor execution speed , long-interval intracortical inhibition , cortical silent period . RESULTS Relative to controls , previously concussed athletes showed persistently lower COP oscillation r and omness , normal performance on a rapid alternating-movement task , and more M1 intracortical inhibition that was related to the number of previous concussions . CONCLUSIONS Sport concussions were associated with pervasive changes in postural control and more M1 intracortical inhibition , providing neurophysiologic and behavioral evidence of lasting , sub clinical changes in motor system integrity in concussed athletes BACKGROUND  Surgical site infections ( SSIs ) are complications of surgery that cause significant postoperative morbidity . SSI has been proposed as a potential indicator of the quality of care in the context of clinical governance and monitoring of the performance of NHS organisations against targets . OBJECTIVES We aim ed to address a number of objectives . Firstly , identify risk factors for SSI , criteria for stratifying surgical procedures and evidence about the importance of postdischarge surveillance ( PDS ) . Secondly , test the importance of risk factors for SSI in surveillance data bases and investigate interactions between risk factors . Thirdly , investigate and vali date different definitions of SSI . Lastly , develop models for making risk-adjusted comparisons between hospitals . DATA SOURCES A single hospital surveillance data base was used to address objectives 2 and 3 and the UK Surgical Site Infection Surveillance Service data base to address objective 4 . STUDY DESIGN There were four elements to the research : ( 1 ) systematic review s of risk factors for SSI ( two review ers assessed titles and abstract s of studies identified by the search strategy and the quality of studies was assessed using the Newcastle Ottawa Scale ) ; ( 2 ) assessment of agreement between four SSI definitions ; ( 3 ) validation of definitions of SSI , quantifying their ability to predict clinical outcomes ; and ( 4 ) development of operation-specific risk models for SSI , with hospitals fitted as r and om effects . RESULTS Review s of SSI risk factors other than established SSI risk indices identified other risk ; some were operation specific , but others applied to multiple operations . The factor most commonly identified was duration of preoperative hospital stay . The review of PDS for SSI confirmed the need for PDS if SSIs are to be compared meaningfully over time within an institution . There was wide variation in SSI rate ( SSI% ) using different definitions . Over twice as many wounds were classified as infected by one definition only as were classified as infected by both . Different SSI definitions also classified different wounds as being infected . The two most established SSI definitions had broadly similar ability to predict the chosen clinical outcomes . This finding is paradoxical given the poor agreement between definitions . Elements of each definition not common to both may be important in predicting clinical outcomes or outcomes may depend on only a subset of elements which are common to both . Risk factors fitted in multivariable models and their effects , including age and gender , varied by surgical procedure . Operative duration was an important risk factor for all operations , except for hip replacement . Wound class was included least often because some wound classes were not applicable to all operations or were combined because of small numbers . The American Association of Anesthesiologists class was a consistent risk factor for most operations . CONCLUSIONS The research literature does not allow surgery-specific or generic risk factors to be defined . SSI definitions varied between surveillance programmes and potentially between hospitals . Different definitions do not have good agreement , but the definitions have similar ability to predict outcomes influenced by SSI . Associations between components of the National Nosocomial Infections Surveillance risk index and odds of SSI varied for different surgical procedures . There was no evidence for effect modification by hospital . Estimates of SSI% should be disseminated within institutions to inform infection control . Estimates of SSI% across institutions or countries should be interpreted cautiously and should not be assumed to reflect quality of medical care . Future research should focus on developing an SSI definition that has satisfactory psychometric properties , that can be applied in everyday clinical setting s , includes PDS and is formulated to detect SSIs that are important to patients or health services . FUNDING The National Institute for Health Research Technology Assessment programme OBJECTIVE The long-term impact of sports-related concussion is uncertain . Several studies using traditional neuropsychological measures have found a relationship between a previous history of concussion and reduced cognitive abilities . In contrast , studies using computerized neuropsychological measures have typically found no relationship between concussion history and cognition . In the present study , we examined the association between a self-reported concussion history and cognition using traditional and computer-based neuropsychological tests . METHODS A computerized neuropsychological battery was administered to a sample of 858 collegiate male athletes . Of this sample , 298 athletes reported a history of concussion . A traditional neuropsychological battery was administered to a separate sample of 479 male collegiate athletes , 187 of whom reported a history of concussion . Finally , both a computerized and a traditional neuropsychological battery were administered to a third distinct sample of 175 male collegiate athletes , 57 of whom reported a history of concussion . Concussion history was assessed via self-report . None of the athletes had been concussed in the 6 months before testing . RESULTS No significant association was found between self-reported concussion history and performance on either  computerized or traditional neuropsychological tests .  CONCLUSION Findings suggest that athletes who report a distant history of concussion have minimal enduring neurocognitive deficits . Given conflicting findings in the literature , prospect i ve studies that attempt to identify moderating factors are necessary to help determine who is at risk for long-term cognitive difficulties after concussion CONTEXT Athletic trainers ( ATs ) are often the first health care providers to conduct concussion assessment s and carry out postinjury management . Best practice s for concussion evaluation and management have changed rapidly in recent years , outdating previous reports of ATs ' concussion practice s. OBJECTIVE To examine ATs ' current concussion- assessment and -management techniques . DESIGN Cross-sectional study . SETTING Web-based survey . PATIENTS OR OTHER PARTICIPANTS A r and om convenience sample of 8777 ATs ( response rate = 15.0 % [ n = 1307 ] ; years certified = 15.0 ± 10.6 ) from the National Athletic Trainers ' Association membership . MAIN OUTCOME MEASURE(S ) Survey Web links were e-mailed to prospect i ve participants , with 2 follow-up e-mails sent by the National Athletic Trainers ' Association . The survey collected demographic information , the number of concussions assessed , the concussion-recovery patterns , and the assessment and return-to-participation ( RTP ) decision-making methods used . RESULTS The ATs reported assessing a median of 12.0 ( range = 0 - 218 ) concussions per year . A total of 95.3 % ( 953/1000 ) ATs cited clinical examination as the most frequently used concussion- assessment tool , followed by symptom assessment ( 86.7 % ; 867/1000 ) . A total of 52.7 % ( 527/1000 ) ATs described a 3-domain minimum multidimensional concussion- assessment battery . Published RTP guidelines were the most common RTP decision-making tool ( 91.0 % ; 864/949 ) , followed by clinical examination ( 88.2 % ; 837/949 ) . The ATs with master 's degrees were 1.36 times ( 95 % confidence interval [ CI ] = 1.02 , 1.81 ) more likely to use a 3-domain concussion- assessment battery than ATs with only bachelor 's degrees ( χ2 = 4.44 , P = .05 ) . Collegiate ATs were 2.12 ( 95 % CI = 1.59 , 2.84 ) and 1.63 ( 95 % CI = 1.03 , 2.59 ) times more likely to use a 3-domain concussion- assessment battery than high school and clinic-based ATs , respectively ( χ2 = 26.29 , P < .001 ) . CONCLUSIONS Athletic trainers were using the clinical examination , st and ardized assessment tools , and a 3-domain concussion- assessment -battery approach more frequently in clinical practice than previously reported . However , despite practice improvements , nearly half of ATs were not using a 3-domain minimum concussion- assessment battery . Clinicians should strive to implement multidimensional concussion assessment s in their practice s to ensure optimal diagnosis and management
: The results of this systematic review identify the consistent and prevalent indicators of concussion and their associations , derived from the strongest evidence in the published literature .
BACKGROUND : Currently , there is no evidence -based definition for concussion that is being uniformly applied in clinical and research setting s. OBJECTIVE : To conduct a systematic review of the highest- quality literature about concussion and to assemble evidence about the prevalence and associations of key indicators of concussion .
The goal was to establish an evidence -based foundation from which to derive , in future work , a definition , diagnostic criteria , and prognostic indicators for concussion .