Publications by authors named "Kathryn J Schneider"

44 Publications

Concurrent Validity of a Stationary Cycling Test and Buffalo Concussion Treadmill Test in Adults with Concussion.

J Athl Train 2021 Apr 22. Epub 2021 Apr 22.

1Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.

Context: Following concussion, a multi-faceted assessment is recommended, including tests of physical exertion. The current gold standard for exercise testing following concussion is the Buffalo Concussion Treadmill Test (BCTT); however, there is a lack of validated tests that utilize alternative exercise modalities.

Objective: To assess the feasibility and concurrent validity of a novel cycling test of exertion compared to the BCTT.

Design: Crossover Study Setting: University Sport-Medicine Clinic Patients: Twenty adults (aged 18-60 years) diagnosed with a Sport-Related Concussion Intervention: Participants completed the BCTT and a cycling test of exertion in a random order, approximately 48 hours apart.

Main Outcome Measures: The primary outcome of interest was maximum heart rate [HRmax; beats per minute (bpm)]. Secondary outcomes of interest included whether the participant reached volitional fatigue (yes/no), symptom responsible for test cessation (Post Concussion Symptom Scale), and Symptom Severity on a Visual Scale (/10).

Results: Of the 20 participants, 19 (10 male, 9 female) 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; (IQR: 139-184bpm)] was not significantly different than the median HRmax for the Cycle [173 bpm; (IQR: 160-182)] (z=-0.63, p=0.53). For both tests, the three most frequently reported symptoms responsible for test cessation were Headache, Dizziness, and Pressure in the head. Of interest, the majority of participants (64%) reported a different symptom responsible for test cessation on each test.

Conclusion: The novel cycling test of exertion achieved similar HRmax and test duration and 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.
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http://dx.doi.org/10.4085/1062-6050-0003.21DOI Listing
April 2021

The Impact of COVID-19 on High School Student-Athlete Experiences with Physical Activity, Mental Health, and Social Connection.

Int J Environ Res Public Health 2021 03 29;18(7). Epub 2021 Mar 29.

Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB T2N 1N4, Canada.

COVID-19 restrictions led to reduced levels of physical activity, increased screen usage, and declines in mental health in youth; however, in-depth understandings of the experiences of high school student-athletes have yet to be explored. To describe the experiences of the COVID-19 pandemic on student-athletes' physical activity, social connection, and mental health, 20 high school student-athletes living in Calgary, Alberta participated in semi-structured interviews, designed using phenomenography. Participants reported variations in physical activity, social connections, and mental health which were influenced by stay-at-home restrictions and weather. Access to resources, changes to routines, online classes, and social support all influenced engagement in physical activity. School and sports provided opportunities for in-person social connections, impacted by the onset of the pandemic. Participants reported their mental health was influenced by social connections, online classes, and physical activity. Findings from this study will inform the development of resources for high school student-athletes amidst COVID-19.
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http://dx.doi.org/10.3390/ijerph18073515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8036482PMC
March 2021

The Association of Saliva Cytokines and Pediatric Sports-Related Concussion Outcomes.

J Head Trauma Rehabil 2020 Sep/Oct;35(5):354-362

Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation (Messrs Seeger, Tabor, and La, and Drs Forkert and Debert), Hotchkiss Brain Institute (Messrs Seeger, Tabor, and Talai, Mss Rajashekar and Mouches, and Drs Schneider, Forkert, and Debert), Department of Kinesiology (Mr Tabor, Ms Sick, and Drs Schneider, Emery, and Debert), Department of Microbiology, Immunology & Infectious Diseases (MIID) (Dr Jenne), Department of Critical Care Medicine (Dr Jenne), Department of Radiology (Mr Talai, Mss Rajashekar and Mouches, and Dr Forkert), and Alberta Children's Hospital Research Institute (Drs Schneider, Forkert, Emery, and Debert), University of Calgary, Calgary, Alberta, Canada.

Objectives: This study aimed to explore cytokine alterations following pediatric sports-related concussion (SRC) and whether a specific cytokine profile could predict symptom burden and time to return to sports (RTS).

Setting: Sports Medicine Clinic.

Participants: Youth ice hockey participants (aged 12-17 years) were recruited prior to the 2013-2016 hockey season.

Design: Prospective exploratory cohort study.

Main Measure: Following SRC, saliva samples were collected and a Sport Concussion Assessment Tool version 3 (SCAT3) was administered within 72 hours of injury and analyzed for cytokines. Additive regression of decision stumps was used to model symptom burden and length to RTS based on cytokine and clinical features. RRelieFF feature selection was used to determine the predictive value of each cytokine and clinical feature, as well as to identify the optimal cytokine profile for the symptom burden and RTS.

Results: Thirty-six participants provided samples post-SRC (81% male; age 14.4 ± 1.3 years). Of these, 10 features, sex, number of previous concussions, and 8 cytokines, were identified to lead to the best prediction of symptom severity (r = 0.505, P = .002), while 12 cytokines, age, and history of previous concussions predicted the number of symptoms best (r = 0.637, P < .001). The prediction of RTS led to the worst results, requiring 21 cytokines, age, sex, and number of previous concussions as features (r = -0.320, P = .076).

Conclusions: In pediatric ice hockey participants following SRC, there is evidence of saliva cytokine profiles that are associated with increased symptom burden. However, further studies are needed.
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http://dx.doi.org/10.1097/HTR.0000000000000605DOI Listing
September 2020

Changes in exertion-related symptoms in adults and youth who have sustained a sport-related concussion.

J Sci Med Sport 2021 Jan 21;24(1):2-6. Epub 2020 Jun 21.

Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada. Electronic address:

Objectives: To identify the symptoms responsible for cessation of exercise testing and evaluate changes in post-concussion symptom scores on the Post-Concussion Symptom Scale (PCSS) from the Sport-Concussion Assessment Tool (SCAT5) immediately, 1-4h, and 6-12h following completion of the Buffalo Concussion Treadmill Test (BCTT) in youth and adults who have sustained a sport-related concussion.

Design: Prospective case-series.

Methods: Individuals who were diagnosed with a sport-related concussion and self-reported difficulties with exertion were referred to perform an exertional treadmill test. Individuals were recruited from a university sports medicine clinic. Change in PCSS symptom severity scores were operationally defined as a change ≥4 points.

Results: Forty-five individuals aged 13-57 years consented to participate. A total of 14/24 (58.3%) female and 13/21 (61.9%) male participants reported an increase in symptom severity scores immediately following the BCTT. At 1-4h, 5/10 (50.0%) males and 5/14 (35.7%) females who completed the PCSS had elevated symptom severity scores compared to pre-exertion. Only 24.2% (3/17 males and 5/16 females) of participants completing the PCSS at 6-12h reported increased symptom severity scores.

Conclusion: Exertional testing is an important component of a multifaceted assessment following concussion; however, previous research evaluating symptom responses to exertion is limited. This study provides evidence to suggest individuals who experience an exacerbation of concussion-associated symptoms after exertion are likely to return to pre-exertion levels within the same day. Future research monitoring symptoms following exertion and throughout recovery should be performed in tandem with physiological measures to better understand the source of symptoms.
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http://dx.doi.org/10.1016/j.jsams.2020.06.005DOI Listing
January 2021

Mouthguard use in youth ice hockey and the risk of concussion: nested case-control study of 315 cases.

Br J Sports Med 2020 Jul 14;54(14):866-870. Epub 2020 Jan 14.

Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada

Background: Concussion is the most common injury in youth ice hockey. Whether mouthguard use lowers the odds of concussion remains an unanswered question.

Objective: To determine the association between concussion and mouthguard use in youth ice hockey.

Methods: Nested case-control design. Cases and controls were identified from two prospective cohort studies using valid injury surveillance methods. Cases were players concussed during a game or practice; controls were players who sustained a non-concussion injury during a game or practice. The primary exposure was mouthguard use at time of injury; mouthguard type (dental custom fit or off the shelf) was a secondary exposure. Physician-diagnosed or therapist-suspected concussion was the primary outcome. Dental injury was a secondary outcome. Multilevel logistic regression with random effect at a team level was used to obtain ORs for the mouthguard effect, adjusted for level of play, age group, position, concussion history, mechanism of injury, cohort, session type and body checking policy.

Results: Among cases, 236/315 (75%) were wearing a mouthguard at time of injury, while 224/270 (83%) controls were wearing a mouthguard at time of injury. Any mouthguard use was associated with an adjusted OR for concussion of 0.36 (95% CI 0.17 to 0.73). Off-the-shelf mouthguards were associated with a 69% lower odds of concussion (adjusted OR: 0.31; 95% CI 0.14 to 0.65). Dental custom-fit mouthguards were associated with a non-significant 49% lower odds of concussion (adjusted OR: 0.51; 95% CI 0.22 to 1.10). No dental injuries were identified in either cohort.

Conclusion: Mouthguard use was associated with lower odds of concussion. Players should be required to wear mouthguards in youth ice hockey.
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http://dx.doi.org/10.1136/bjsports-2019-101011DOI Listing
July 2020

Baseline Performance of High School Rugby Players on the Sport Concussion Assessment Tool 5.

J Athl Train 2020 Feb 9;55(2):116-123. Epub 2020 Jan 9.

Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Canada.

Context: Version 5 of the Sport Concussion Assessment Tool (SCAT5) was released in 2017 with an additional 10-word list option in the memory section and additional instructions for completing the symptom scale.

Objective: To provide reference scores for high school rugby union players on the SCAT5, including immediate memory using the 10-word list, and examine how age, sex, and concussion history affected performance.

Design: Cross-sectional study.

Setting: Calgary, Alberta high schools.

Patients Or Other Participants: High school rugby union players (ages 15-18 years) participating in a 2018 season cohort study (n = 380, males = 210, females = 170).

Main Outcome Measure(s): Sport Concussion Assessment Tool 5 scores, including total number of symptoms (of 20), symptom severity (of 132), 10-word immediate memory (of 30), delayed memory (of 10), modified Standardized Assessment of Concussion (of 50), and balance examination (of 30).

Results: The median number of symptoms reported at baseline ranged from 5 to 8 across sex and age stratifications. Median symptom severity was lowest in males with no concussion history (7; range, 0-28) and highest in females with a concussion history (13, range = 0-45). Median total scores on immediate memory were 2-3 (range = 0-4) for males and 21 (range = 9-29) for females. Median total scores were 3 (range = 0-4) on digits backward and 7 (range = 0-20) on delayed memory (all groups). Based on simultaneous quantile (q) regression at 0.50 and 0.75, adjusted for age and concussion history, being female was associated with a higher total symptoms score (q0.75 β = 2.85; 99% confidence interval [CI] = 0.33, 5.37), higher total symptom severity score (q0.75 β = 8.00; 99% CI = 2.83, 13.17), and lower number of errors on the balance examination (q0.75 β = -3.00; 99% CI = -4.85, -1.15). Age and concussion history were not associated with any summary measures.

Conclusions: The 10-word list option in the memory section reduced the likelihood of a ceiling effect. A player's sex may be an important consideration when interpreting the SCAT5 after concussion.
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http://dx.doi.org/10.4085/1062-6050-123-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7017900PMC
February 2020

Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment.

J Orthop Sports Phys Ther 2019 11 14;49(11):799-810. Epub 2019 Oct 14.

Synopsis: The risk factors of concussion may be categorized as intrinsic (internal factors specific to the individual) or extrinsic (external factors related to the environment or sport). Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. In most cases, the symptoms of concussion resolve in the initial few days following the injury, and a strategy involving a gradual return to sport and school is recommended. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. .
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http://dx.doi.org/10.2519/jospt.2019.8926DOI Listing
November 2019

Does disallowing body checking in non-elite 13- to 14-year-old ice hockey leagues reduce rates of injury and concussion? A cohort study in two Canadian provinces.

Br J Sports Med 2020 Apr 6;54(7):414-420. Epub 2019 Sep 6.

Department of Paediatrics, Cumming Scjhool of Medicine, University of Calgary, Calgary, Alberta, Canada.

Objective: To compare rates of injury and concussion among non-elite (lowest 60% by division of play) Bantam (ages 13-14 years) ice hockey leagues that disallow body checking to non-elite Bantam leagues that allow body checking.

Methods: In this 2-year cohort study, Bantam non-elite ice hockey players were recruited from leagues where policy allowed body checking in games (Calgary/Edmonton 2014-2015, Edmonton 2015-2016) and where policy disallowed body checking (Kelowna/Vancouver 2014-2015, Calgary 2015-2016). All ice hockey game-related injuries resulting in medical attention, inability to complete a session and/or time loss from hockey were identified using valid injury surveillance methodology. Any player suspected of having concussion was referred to a study physician for diagnosis and management.

Results: 49 body checking (608 players) and 33 non-body checking teams (396 players) participated. There were 129 injuries (incidence rate (IR)=7.98/1000 hours) and 54 concussions (IR=3.34/1000 hours) in the body checking teams in games. After policy change, there were 31 injuries (IR=3.66/1000 hours) and 17 concussions (IR=2.01/1000 hours) in games. Policy disallowing body checking was associated with a lower rate of all injury (adjusted incidence rate ratio (IRR)=0.44; 95% CI: 0.27 to 0.74). The point estimate showed a lower rate of concussion (adjusted IRR=0.6; 95% CI: 0.31 to 1.18), but this was not statistically significant.

Conclusion: Policy change disallowing body checking in non-elite Bantam ice hockey resulted in a 56% lower rate of injury. There is growing evidence that disallowing body checking in youth ice hockey is associated with fewer injuries.
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http://dx.doi.org/10.1136/bjsports-2019-101092DOI Listing
April 2020

The Association Between Moderate and Vigorous Physical Activity and Time to Medical Clearance to Return to Play Following Sport-Related Concussion in Youth Ice Hockey Players.

Front Neurol 2019 6;10:588. Epub 2019 Jun 6.

Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.

Prospective cohort study. The recommendations regarding the optimal amount and type of rest for promoting recovery following concussion are based on expert opinion rather than evidence-based guidelines due to current a lack of high-level studies. There is an evident need for more research into the parameters of rest and activity and its effects on recovery from concussion. To evaluate the association between the amount of moderate and vigorous physical activity (MVPA) during the first 3 days following concussion diagnosis and time to medical clearance (days) to return to play in youth ice hockey players. Thirty youth ice hockey players (12-17 years) that were diagnosed with a concussion sustained during ice hockey were recruited to participate. The exposure was the cumulative amount of MVPA (minutes), measured using a waist-worn Actigraph accelerometer. Participants were dichotomized into high (≥148.5) and low (<148.5) activity groups based on the median of cumulative time spent in MVPA over the first 3 days following injury diagnosis. Participants in both the low and high activity group reported to the clinic at a median time of 4 days post-injury (low activity IQR: 3-5 days; high activity IQR: 3-7 days). The low activity group completed a median time of 110.7 min (IQR: 76.2-131.0 min) in MVPA, whereas the high activity had a median of 217.2 min (IQR 184.2-265.2 min) in MVPA. Kaplan Meier survival curves with Log-rank tests of hypothesis revealed the high activity group took significantly more time to be medically cleared to return to play ( = 0.041) compared to the low activity group. The results from this study suggest that more time in MVPA early in the recovery period may result in a greater time to medical clearance to return to full participation in ice hockey. Future research, using valid measures of activity, are required to better understand the relationship between early activity and recovery following concussion in youth.
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http://dx.doi.org/10.3389/fneur.2019.00588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563761PMC
June 2019

Concussion - Part I: The need for a multifaceted assessment.

Musculoskelet Sci Pract 2019 07 21;42:140-150. Epub 2019 May 21.

Sport Injury Prevention Research Centre, Faculty of Kinesiology, Hotchkiss Brain Institute, Alberta Children's Hospital Research Institute, University of Calgary, KNB3300D 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada. Electronic address:

Introduction: Concussion is among the most commonly occurring sport and recreation injuries in today's society. An understanding of the heterogenous nature of concussion will assist in directing a multifaceted and comprehensive interdisciplinary assessment following injury.

Purpose: The purpose of this masterclass article is to summarize the current state of the evidence in the area of concussion, describe typical symptom presentations and assessment techniques that may assist in directing appropriate management following concussion.

Implications: A comprehensive assessment including a thoughtful differential diagnosis will assist the clinician to direct care appropriately and efficiently in individuals who have suffered a concussion.
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http://dx.doi.org/10.1016/j.msksp.2019.05.007DOI Listing
July 2019

Concussion part II: Rehabilitation - The need for a multifaceted approach.

Musculoskelet Sci Pract 2019 07 25;42:151-161. Epub 2019 Jan 25.

Sport Injury Prevention Research Centre, Faculty of Kinesiology, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, KNB3300D 2500 University Drive NW, University of Calgary, Calgary, Alberta, T2N 1N4, Canada. Electronic address:

Introduction: While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit.

Purpose: The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion.

Implications: Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.
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http://dx.doi.org/10.1016/j.msksp.2019.01.006DOI Listing
July 2019

Concussion Burden, Recovery, and Risk Factors in Elite Youth Ice Hockey Players.

Clin J Sport Med 2021 Jan;31(1):70-77

Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada.

Objective: To examine rates of concussion and more severe concussion (time loss of greater than 10 days) in elite 13- to 17-year-old ice hockey players.

Methods: This is a prospective cohort study (Alberta, Canada). Bantam (13-14 years) and Midget (15-17 years) male and female elite (top 20% by division of play) youth ice hockey players participated in this study. Players completed a demographic and medical history questionnaire and clinical test battery at the beginning of the season. A previously validated injury surveillance system was used to document exposure hours and injury during one season of play (8 months). Players with a suspected ice hockey-related concussion were referred to the study sport medicine physicians for assessment. Time loss from hockey participation was documented on an injury report form.

Results: Overall, 778 elite youth ice hockey players (659 males and 119 females; aged 13-17 years) participated in this study. In total, 143 concussions were reported. The concussion incidence rate (IR) was 17.60 concussions/100 players (95% CI, 15.09-20.44). The concussion IR was 1.31 concussions/1000 player-hours (95% CI, 1.09-1.57). Time loss of greater than 10 days was reported in 74% of cases (106/143), and 20% (n = 28) had time loss of greater than 30 days.

Conclusions: Concussion is a common injury in elite youth ice hockey players. In this study population, a large proportion of concussions (74%) resulted in a time loss of greater than 10 days, possibly reflecting more conservative management or longer recovery in youth athletes.
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http://dx.doi.org/10.1097/JSM.0000000000000673DOI Listing
January 2021

Changes in Measures of Cervical Spine Function, Vestibulo-ocular Reflex, Dynamic Balance, and Divided Attention Following Sport-Related Concussion in Elite Youth Ice Hockey Players.

J Orthop Sports Phys Ther 2018 12 27;48(12):974-981. Epub 2018 Jul 27.

Background: Concussion is a commonly occurring injury. The extent to which the cervical spine, vestibulo-ocular reflex (VOR), dynamic balance, and divided attention are affected following concussion is not well understood.

Objectives: To evaluate acute changes in measures of (1) cervical spine function, (2) VOR function, (3) dynamic balance, and (4) tasks of divided attention in elite youth ice hockey players following a sport-related concussion.

Methods: In this prospective cohort study, elite 13- to 17-year-old ice hockey players completed cervical spine measures (cervical flexor endurance test, head perturbation test, anterolateral strength, cervical flexion rotation test, joint position error), VOR function tests (head thrust test, dynamic visual acuity [clinical and computerized]), dynamic balance tests (Functional Gait Assessment), and divided-attention tasks (walking-while-talking test) both in the preseason and following concussion.

Results: At least 1 test was completed by 69 of 97 (71%) players (a maximum of 55 for any 1 test) at both preseason and immediately following concussion (median, 4 days post concussion). After Bonferroni corrections (α = .00625), using Wilcoxon signed-rank tests, cervical spine measures were significantly worse following concussion compared to baseline (cervical flexor endurance test: z = -5.20, P<.001; anterolateral neck strength: z = -5.36, P<.001 and z = -5.45, P<.001; and head perturbation test: z = -4.36, P<.001). Time taken to complete a complex task of divided attention relative to normal walking speed was faster (improved) compared to the preseason (z = -2.59, P<.01). There was no change in VOR or dynamic balance following concussion.

Conclusion: Measures of cervical spine function and divided attention were altered following concussion. However, tests of VOR and dynamic balance were not significantly different from baseline. Future research to evaluate the mechanism underlying these changes is warranted. J Orthop Sports Phys Ther 2018;48(12):974-981. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8258.
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http://dx.doi.org/10.2519/jospt.2018.8258DOI Listing
December 2018

Cervicovestibular rehabilitation following sport-related concussion.

Br J Sports Med 2018 Jan 10;52(2):100-101. Epub 2017 Nov 10.

Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, Alberta, Canada.

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http://dx.doi.org/10.1136/bjsports-2017-098667DOI Listing
January 2018

What domains of clinical function should be assessed after sport-related concussion? A systematic review.

Br J Sports Med 2017 Jun;51(11):903-918

Department of Neurology, University Hospital Zurich, Zurich, Switzerland.

Background: Sport-related concussion (SRC) is a clinical diagnosis made after a sport-related head trauma. Inconsistency exists regarding appropriate methods for assessing SRC, which focus largely on symptom-scores, neurocognitive functioning and postural stability.

Design: Systematic literature review.

Data Sources: MEDLINE, EMBASE, PsycINFO, Cochrane-DSR, Cochrane CRCT, CINAHL, SPORTDiscus (accessed July 9, 2016).

Eligibility Criteria For Selecting Studies: Original (prospective) studies reporting on postinjury assessment in a clinical setting and evaluation of diagnostic tools within 2 weeks after an SRC.

Results: Forty-six studies covering 3284 athletes were included out of 2170 articles. Only the prospective studies were considered for final analysis (n=33; 2416 athletes). Concussion diagnosis was typically made on the sideline by an (certified) athletic trainer (55.0%), mainly on the basis of results from a symptom-based questionnaire. Clinical domains affected included cognitive, vestibular and headache/migraine. Headache, fatigue, difficulty concentrating and dizziness were the symptoms most frequently reported. Neurocognitive testing was used in 30/33 studies (90.9%), whereas balance was assessed in 9/33 studies (27.3%).

Summary/conclusions: The overall quality of the studies was considered low. The absence of an objective, gold standard criterion makes the accurate diagnosis of SRC challenging. Current approaches tend to emphasise cognition, symptom assessment and postural stability with less of a focus on other domains of functioning. We propose that the clinical assessment of SRC should be symptom based and interdisciplinary. Whenever possible, the SRC assessment should incorporate neurological, vestibular, ocular motor, visual, neurocognitive, psychological and cervical aspects.
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http://dx.doi.org/10.1136/bjsports-2016-097403DOI Listing
June 2017

What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? A systematic review.

Br J Sports Med 2017 Jun;51(11):895-901

The Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia.

Objectives: Several iterations of the Sport Concussion Assessment Tool (SCAT) have been published over the past 16 years. Our goal was to systematically review the literature related to the SCAT and provide recommendations for improving the tool. To achieve this goal, five separate but related searches were conducted and presented herein.

Design: Systematic literature review.

Data Sources: Medline, Embase, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, SPORTDiscus and PubMed.

Eligibility Criteria: Original, empirical, peer-reviewed findings published in English and included sports-related concussion (SRC). Review papers, case studies, editorials and conference proceedings/abstracts were excluded. The age range for the ChildSCAT was 5-12 years and for the Adult SCAT was 13 years and above.

Results: Out of 2961 articles screened, a total of 96 articles were included across the five searches. Searches were not mutually exclusive. The final number of articles included in the qualitative synthesis for each search was 21 on Adult SCAT, 32 on ChildSCAT, 21 on sideline, 8 on video/observation and 14 on oculomotor.

Summary/conclusions: The SCAT is the most widely accepted and deployable sport concussion assessment and screening tool currently available. There is some degree of support for using the SCAT2/SCAT3 and ChildSCAT3 in the evaluation of SRC, with and without baseline data. The addition of an oculomotor examination seems indicated, although the most valid method for assessing oculomotor function is not clear. Video-observable signs of concussion show promise, but there is insufficient evidence to warrant widespread use at this time.
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http://dx.doi.org/10.1136/bjsports-2016-097466DOI Listing
June 2017

Advancing Concussion Assessment in Pediatrics (A-CAP): a prospective, concurrent cohort, longitudinal study of mild traumatic brain injury in children: protocol study.

BMJ Open 2017 Jul 13;7(7):e017012. Epub 2017 Jul 13.

Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.

Introduction: Paediatric mild traumatic brain injury (mTBI) is a public health burden. Clinicians urgently need evidence-based guidance to manage mTBI, but gold standards for diagnosing and predicting the outcomes of mTBI are lacking. The objective of the Advancing Concussion Assessment in Pediatrics (A-CAP) study is to assess a broad pool of neurobiological and psychosocial markers to examine associations with postinjury outcomes in a large sample of children with either mTBI or orthopaedic injury (OI), with the goal of improving the diagnosis and prognostication of outcomes of paediatric mTBI.

Methods And Analysis: A-CAP is a prospective, longitudinal cohort study of children aged 8.00-16.99 years with either mTBI or OI, recruited during acute emergency department (ED) visits at five sites from the Pediatric Emergency Research Canada network. Injury information is collected in the ED; follow-up assessments at 10 days and 3 and 6 months postinjury measure a variety of neurobiological and psychosocial markers, covariates/confounders and outcomes. Weekly postconcussive symptom ratings are obtained electronically. Recruitment began in September 2016 and will occur for approximately 24 months. Analyses will test the major hypotheses that neurobiological and psychosocial markers can: (1) differentiate mTBI from OI and (2) predict outcomes of mTBI. Models initially will focus within domains (eg, genes, imaging biomarkers, psychosocial markers), followed by multivariable modelling across domains. The planned sample size (700 mTBI, 300 OI) provides adequate statistical power and allows for internal cross-validation of some analyses.

Ethics And Dissemination: The ethics boards at all participating institutions have approved the study and all participants and their parents will provide informed consent or assent. Dissemination will follow an integrated knowledge translation plan, with study findings presented at scientific conferences and in multiple manuscripts in peer-reviewed journals.
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http://dx.doi.org/10.1136/bmjopen-2017-017012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724225PMC
July 2017

Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review.

Br J Sports Med 2017 Jun 8;51(12):958-968. Epub 2017 May 8.

Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.

Objective: To conduct a systematic review of the literature regarding assessment and treatment modalities in patients with persistent symptoms following sport-related concussion (SRC).

Data Sources: We searched Medline, Embase, SPORTSDiscus, PsycINFO, CINAHL, Cochrane library and ProQuest Dissertation & Theses Global electronic databases.

Study Eligibility Criteria: Studies were included if they were original research, reported on SRC as the primary source of injury, included patients with persistent postconcussive symptoms (>10 days) and investigated the role of assessment or treatment modalities.

Results: Of 3225 articles identified in the preliminary search, 25 articles met the inclusion criteria. 11 articles were concerned with assessment and 14 articles with treatment of persistent symptoms following SRC. There were three randomised control trials and one quasi-experimental study. The remainder consisting of cross-sectional studies, historical cohorts and case series.

Summary: 'Persistent symptoms' following SRC can be defined as clinical recovery that falls outside expected time frames (ie, >10-14 days in adults and >4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding pathologies. A detailed multimodal clinical assessment is required to identify specific primary and secondary processes, and treatment should target specific pathologies identified. There is preliminary evidence supporting the use of symptom-limited aerobic exercise, targeted physical therapy and a collaborative approach that includes cognitive behavioural therapy. Management of patients with persistent symptoms is challenging and should occur in a multidisciplinary collaborative setting, with healthcare providers with experience in SRC.
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http://dx.doi.org/10.1136/bjsports-2016-097470DOI Listing
June 2017

Role of advanced neuroimaging, fluid biomarkers and genetic testing in the assessment of sport-related concussion: a systematic review.

Br J Sports Med 2017 Jun 28;51(12):919-929. Epub 2017 Apr 28.

Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Objective: To conduct a systematic review of published literature on advanced neuroimaging, fluid biomarkers and genetic testing in the assessment of sport-related concussion (SRC).

Data Sources: Computerised searches of Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus and Cochrane Library from 1 January 2000 to 31 December 2016 were done. There were 3222 articles identified.

Study Selection: In addition to medical subject heading terms, a study was included if (1) published in English, (2) represented original research, (3) involved human research, (4) pertained to SRC and (5) involved data from neuroimaging, fluid biomarkers or genetic testing collected within 6 months of injury. Ninety-eight studies qualified for review (76 neuroimaging, 16 biomarkers and 6 genetic testing).

Data Extraction: Separate reviews were conducted for neuroimaging, biomarkers and genetic testing. A standardised data extraction tool was used to document study design, population, tests employed and key findings. Reviewers used a modified quality assessment of studies of diagnostic accuracy studies (QUADAS-2) tool to rate the risk of bias, and a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to rate the overall level of evidence for each search.

Data Synthesis: Results from the three respective reviews are compiled in separate tables and an interpretive summary of the findings is provided.

Conclusions: Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools, but require further validation to determine their ultimate clinical utility in the evaluation of SRC. Future research efforts should address current gaps that limit clinical translation. Ultimately, research on neurobiological and genetic aspects of SRC is predicted to have major translational significance to evidence-based approaches to clinical management of SRC, much like applied clinical research has had over the past 20 years.
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http://dx.doi.org/10.1136/bjsports-2016-097447DOI Listing
June 2017

What is the physiological time to recovery after concussion? A systematic review.

Br J Sports Med 2017 Jun 28;51(12):935-940. Epub 2017 Apr 28.

Department of Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA.

Aim Or Objective: The aim of this study is to consolidate studies of physiological measures following sport-related concussion (SRC) to determine if a time course of postinjury altered neurobiology can be outlined. This biological time course was considered with respect to clinically relevant outcomes such as vulnerability to repeat injury and safe timing of return to physical contact risk.

Design: Systematic review.

Data Sources: PubMed, CINAHL, Cochrane Central, PsychINFO.

Eligibility Criteria For Selecting Studies: Studies were included if they reported original research on physiological or neurobiological changes after SRC. Excluded were cases series <5 subjects, reviews, meta-analyses, editorials, animal research and research not pertaining to SRC.

Results: A total of 5834 articles were identified, of which 80 were included for full-text data extraction and review. Relatively few longitudinal studies exist that follow both physiological dysfunction and clinical measures to recovery.

Summary/conclusions: Modalities of measuring physiological change after SRC were categorised into the following: functional MRI, diffusion tensor imaging, magnetic resonance spectroscopy, cerebral blood flow, electrophysiology, heart rate, exercise, fluid biomarkers and transcranial magnetic stimulation. Due to differences in modalities, time course, study design and outcomes, it is not possible to define a single 'physiological time window' for SRC recovery. Multiple studies suggest physiological dysfunction may outlast current clinical measures of recovery, supporting a buffer zone of gradually increasing activity before full contact risk. Future studies need to use generalisable populations, longitudinal designs following to physiological and clinical recovery and careful correlation of neurobiological modalities with clinical measures.
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http://dx.doi.org/10.1136/bjsports-2016-097464DOI Listing
June 2017

A systematic review of potential long-term effects of sport-related concussion.

Br J Sports Med 2017 Jun 28;51(12):969-977. Epub 2017 Apr 28.

Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital; MassGeneral Hospital for Children Sports Concussion Program; & Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston, USA.

Objective: Systematic review of possible long-term effects of sports-related concussion in retired athletes.

Data Sources: Ten electronic databases.

Study Selection: Original research; incidence, risk factors or causation related to long-term mental health or neurological problems; individuals who have suffered a concussion; retired athletes as the subjects and possible long-term sequelae defined as 10 years after the injury.

Data Extraction: Study population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, neuroimaging findings and neuropathology results. Risk of bias and level of evidence were evaluated by two authors.

Results: Following review of 3819 studies, 47 met inclusion criteria. Some former athletes have depression and cognitive deficits later in life, and there is an association between these deficits and multiple prior concussions. Former athletes are not at increased risk for death by suicide (two studies). Former high school American football players do not appear to be at increased risk for later life neurodegenerative diseases (two studies). Some retired professional American football players may be at increased risk for diminishment in cognitive functioning or mild cognitive impairment (several studies), and neurodegenerative diseases (one study). Neuroimaging studies show modest evidence of macrostructural, microstructural, functional and neurochemical changes in some athletes.

Conclusion: Multiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals. More research is needed to better understand the prevalence of chronic traumatic encephalopathy and other neurological conditions and diseases, and the extent to which they are related to concussions and/or repetitive neurotrauma sustained in sports.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466926PMC
June 2017

What is the difference in concussion management in children as compared with adults? A systematic review.

Br J Sports Med 2017 Jun 28;51(12):949-957. Epub 2017 Apr 28.

Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada.

Aim: To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp).

Design: Systematic review.

Data Sources: MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID).

Eligibility Criteria For Selecting Studies: Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC.

Results: A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5-12 years.

Summary/conclusions: This systematic review recommends that in children: child and adolescent age-specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.

Systematic Review Registration: PROSPERO 2016:CRD42016039184.
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June 2017

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale.

Br J Sports Med 2017 Jun 26;51(11):859-861. Epub 2017 Apr 26.

The Sports Neurology Clinic at the CORE Institute, Michigan, USA.

This article presents the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). The Sport Concussion Assessment Tool was introduced in 2004, following the 2nd International Conference on Concussion in Sport in Prague, Czech Republic. Following the 4th International Consensus Conference, held in Zurich, Switzerland, in 2012, the SCAT 3rd edition (Child SCAT3) was developed for children aged between 5 and12 years. Research to date was reviewed and synthesised for the 5th International Consensus Conference on Concussion in Sport in Berlin, Germany, leading to the current revision of the test, the Child SCAT5. This article describes the development of the Child SCAT5.
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http://dx.doi.org/10.1136/bjsports-2017-097492DOI Listing
June 2017

The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport.

Br J Sports Med 2017 Jun 26;51(11):873-876. Epub 2017 Apr 26.

The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.

The purpose of this paper is to summarise the methodology for the 5th International Consensus Conference on Concussion in Sport. The 18 months of preparation included engagement of a scientific committee, an expert panel of 33 individuals in the field of concussion and a modified Delphi technique to determine the primary questions to be answered. The methodology also involved the writing of 12 systematic reviews to inform the consensus conference and submission and review of scientific abstracts. The meeting itself followed a 2-day open format, a 1-day closed expert panel meeting and two additional half day meetings to develop the Concussion Recognition Tool 5 (Pocket CRT5), Sport Concussion Assessment Tool 5 (SCAT5) and Child SCAT5.
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http://dx.doi.org/10.1136/bjsports-2017-097569DOI Listing
June 2017

Early return to physical activity post-concussion associated with reduced persistent symptoms.

J Pediatr 2017 05;184:235-238

University of CalgaryCalgary, Alberta, Canada.

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http://dx.doi.org/10.1016/j.jpeds.2017.02.049DOI Listing
May 2017

Rest and treatment/rehabilitation following sport-related concussion: a systematic review.

Br J Sports Med 2017 Jun 24;51(12):930-934. Epub 2017 Mar 24.

Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia.

Aim Or Objective: The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC).

Design: Systematic review.

Data Sources: MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically.

Eligibility Criteria For Selecting Studies: Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded.

Results: Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care.

Summary/conclusions: A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit.

Systematic Review Registration: PROSPERO 2016:CRD42016039570.
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http://dx.doi.org/10.1136/bjsports-2016-097475DOI Listing
June 2017

The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada's national body checking policy change.

Br J Sports Med 2017 Dec 9;51(24):1767-1772. Epub 2017 Mar 9.

Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.

Background: In 2013, Hockey Canada introduced an evidence-informed policy change delaying the earliest age of introduction to body checking in ice hockey until Bantam (ages 13-14) nationwide.

Objective: To determine if the risk of injury, including concussions, changes for Pee Wee (11-12 years) ice hockey players in the season following a national policy change disallowing body checking.

Methods: In a historical cohort study, Pee Wee players were recruited from teams in all divisions of play in 2011-2012 prior to the rule change and in 2013-2014 following the change. Baseline information, injury and exposure data for both cohorts were collected using validated injury surveillance.

Results: Pee Wee players were recruited from 59 teams in Calgary, Alberta (n=883) in 2011-2012 and from 73 teams in 2013-2014 (n=618). There were 163 game-related injuries (incidence rate (IR)=4.37/1000 game-hours) and 104 concussions (IR=2.79/1000 game-hours) in Alberta prior to the rule change, and 48 injuries (IR=2.16/1000 game-hours) and 25 concussions (IR=1.12/1000 game-hours) after the rule change. Based on multivariable Poisson regression with exposure hours as an offset, the adjusted incidence rate ratio associated with the national policy change disallowing body checking was 0.50 for all game-related injuries (95% CI 0.33 to 0.75) and 0.36 for concussion specifically (95% CI 0.22 to 0.58).

Conclusions: Introduction of the 2013 national body checking policy change disallowing body checking in Pee Wee resulted in a 50% relative reduction in injury rate and a 64% reduction in concussion rate in 11-year-old and 12-year-old hockey players in Alberta.
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http://dx.doi.org/10.1136/bjsports-2016-097392DOI Listing
December 2017