title: On-field testing environment and balance error scoring system performance during preseason screening of healthy collegiate baseball players. Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes Evaluation of the King–Devick test as a concussion screening tool in high school football players Concussions in amateur rugby union identified with the use of a rapid visual screening tool The King–Devick test was useful in management of concussion in amateur rugby union and rugby league in New Zealand Eye Tracking Detects Disconjugate Eye Movements Associated with Structural Traumatic Brain Injury and Concussion Sideline Performance of the Balance Error Scoring System during a Live Sporting Event Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion EFFECTS OF A SEASON OF SUBCONCUSSIVE CONTACT ON CHILD- SCAT3 SCORES IN 8-12 YEAR-OLD MALE ATHLETES. Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. Immediate Neurocognitive Effects of Concussion Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: A pilot study Predictors of delayed recovery following pediatric sports-related concussion: a case-control study. The assessment of orientation following concussion in athletes. A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates. Use of the King–Devick test for sideline concussion screening in junior rugby league The reliability and validity of video analysis for the assessment of the clinical signs of concussion in Australian football. Effect of acute exercise on clinically measured reaction time in collegiate athletes.
abstract: CONTEXT To determine if testing environment affects Balance Error Scoring System ( BESS ) scores in healthy collegiate baseball players . DESIGN Experimental , r and omized , repeated- measures design with a sample of convenience . SETTING Uncontrolled sideline and controlled locker room baseball environments . PATIENTS OR OTHER PARTICIPANTS A total of 21 healthy collegiate baseball players ( age = 20.1 + /- 1.4 years , height = 185.1 + /- 6.8 cm , mass = 86.3 + /- 9.5 kg ) with no history of head injury within the last 12 months , no lower extremity injuries reported within the past 2 months that caused them to miss 1 or more days of practice or game time , and no history of otitis media , Parkinson disease , or Meniere disease . MAIN OUTCOME MEASURE(S ) Participants performed the  BESS test  in 2 environments , controlled locker room and uncontrolled sideline , in 2 testing sessions 1 week apart during the baseball preseason . The BESS scores were evaluated for each of the 6 conditions and total score across the testing sessions . Separate , paired- sample s t tests with Bonferroni adjustment ( P < .008 ) were used to examine differences between testing environments for each BESS subcategory and total score . Cohen d tests were calculated to evaluate effect sizes and relative change . RESULTS Significant group mean differences were found between testing environments for single-leg foam stance ( P = .001 ) , with higher scores reported for the uncontrolled sideline environment ( 7.33 + /- 2.11 errors ) compared with the controlled clinical environment ( 5.19 + /- 2.16 errors ) . Medium to large effect sizes ( 0.53 to 1.03 ) were also found for single-leg foam , t and em foam , and total BESS scores , with relative increases ( worse scores ) of 30 % to 44 % in the sideline environment compared with the clinical environment . CONCLUSIONS The BESS performance was impaired when participants were tested in a sideline environment compared with a clinical environment . Baseline testing for postural control using the BESS should be conducted in the setting or environment in which testing after injury will most likely be conducted Background : Sports-related concussion commonly affects the visual pathways . Current sideline protocol s test cognition and balance but do not include assessment s of visual performance . We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels . Methods : Participants in this prospect i ve study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Isl and University . Athletes underwent preseason baseline assessment s using : 1 ) the King – Devick ( K-D ) test , a < 2-minute visual performance measure of rapid number naming , 2 ) the St and ardized Assessment of Concussion ( SAC ) , a test of cognition , and 3 ) a timed t and em gait test of balance .  The SAC and timed t and em gait are components of the currently used Sport Concussion Assessment Tool , 3rd Edition ( SCAT3 and Child-SCAT3 ) . In the event of a concussion during the athletic season , injured athletes were retested on the sideline/rink-side . Nonconcussed athletes were also assessed as control participants under the same testing conditions . Results : Among 243 youth ( mean age 11 ± 3 years , range 5–17 ) and 89 collegiate athletes ( age 20 ± 1 years , range 18–23 )  , baseline time scores for the K-D test were lower ( better ) with increasing participant age ( P < 0.001 , linear regression models ) . Among 12 athletes who sustained concussions during their athletic season , K-D scores worsened from baseline by an average of 5.2 seconds ; improvement by 6.4 seconds was noted for the nonconcussed controls ( n = 14 ) . The  vision-based K-D test  showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury ( receiver operating characteristic [ ROC ] curve areas from logistic regression models , accounting for age = 0.92 for K-D , 0.87 for timed t and em gait , and 0.68 for SAC ; P = 0.0004 for comparison of ROC curve areas ) . Conclusions : Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment . This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision OBJECTIVE Concussion is the most common type of traumatic brain injury , and results from impact or impulsive forces to the head , neck or face . Due to the variability and subtlety of symptoms , concussions may go unrecognized or be ignored , especially with the pressure placed on athletes to return to competition . The King-Devick ( KD ) test , an oculomotor test originally design ed for reading evaluation , was recently vali date d as a concussion screening tool in collegiate athletes . A prospect i ve study was performed using high school football players in an attempt to study the KD as a concussion screening tool in this younger population . METHODS 343 athletes from four local high school football teams were recruited to participate . These athletes were given baseline KD tests prior to competition . Individual demographic information was collected on the subjects . St and ard team protocol was employed to determine if a concussion had occurred during competition . Immediately after diagnosis , the KD test was re-administered to the concussed athlete for comparison to baseline . Post-season testing was also performed in non-concussed individuals . RESULTS Of the 343 athletes , nine were diagnosed with concussions . In all concussed players , cumulative read times for the KD test were significantly increased ( p<0.001 ) . Post-season testing of non-concussed athletes revealed minimal change in read times relative to baseline . Univariate analysis revealed that history of concussion was the only demographic factor predictive of concussion in this cohort . CONCLUSION The KD test is an accurate and easily administered sideline screening tool for concussion in adolescent football players AIM To use the King-Devick ( KD ) test and Sports Concussion Assessment Tool 2 ( SCAT2 ) in amateur rugby union players to identify witnessed and unrecognised episodes of concussion that occurred from match participation . METHODS A prospect i ve observational cohort study was conducted on a premier club level amateur rugby union team during the 2012 competition in New Zeal and . Every player completed a pre-competition question naire on concussion history , a baseline PCSS and two trials of the KD before they participated in any match activities . RESULTS For players reporting a concussion in the previous three years there was an average of 4.0±2.8 concussions per player . There were 22 concussive incidents recorded over the duration of the competition ( 46 per 1000 match hours ) . Five concussive incidents were witnessed ( 11 per 1000 match hours ) and 17 unrecognised concussive incidents were identified with the KD ( 37 per 1000 match hours ) . Witnessed concussions recorded , on average , a longer KD on the day of injury ( 5.5±2.4s ) than unrecognised concussions ( 4.4±0.9s ) when compared with their baseline KD . DISCUSSION The KD was able to identify players that had not shown , or reported , any signs or symptoms of a concussion but who had meaningful head injury . The current rate of concussion reported was a ten-fold increase in previously reported concussion injury rates . This makes the KD suitable for rapid assessment in a limited time frame on the sideline such as a five-minute window to assess and review suspected concussed players in rugby union AIM To use the King-Devick ( K-D ) test in senior amateur rugby union and rugby league players over a domestic competition season to see if it could identify witnessed and unwitnessed episodes of concussion that occurred from participation in competition matches over three years . METHODS A prospect i ve observational cohort study was conducted on a club level senior amateur rugby union team ( n=36 players in 2012 and 35 players in 2013 ) and a rugby league team ( n=33 players in 2014 ) during competition seasons in New Zeal and . All 104 players completed two trials 10min apart of the K-D at the beginning of their competition season . Concussions ( witnessed or unwitnessed ) were only recorded if they were formally diagnosed by a health practitioner . RESULTS A total of 52 ( 8 witnessed ; 44 unwitnessed ) concussive events were identified over the duration of the study result ing in a concussion injury incidence of 44 ( 95 % CI : 32 to 56 ) per 1000 match participation hours . There was a six-fold difference between witnessed and unwitnessed concussions recorded . There were observable learning effects observed between the first and the second K-D test baseline testing ( 50 vs. 45s ; z=-8.81 ; p<0.001 ) . For every 1 point reduction in each of the post-injury SAC components there was a corresponding increase ( worsening ) of  K-D test times post-match for changes in orientation ( 2.9s ) , immediate memory ( 1.8s ) concentration ( 2.8s ) , delayed recall ( 2.0s ) and SAC total score ( 1.7s ) . DISCUSSION The rate of undetected concussion was higher than detected concussions by using the K-D test routinely following matches . Worsening of the K-D test post-match was associated with reduction in components of the SAC . The appeal of the K-D test is in the rapid , easy manner of its administration and the reliable , objective results it provides to the administrator . The K-D test helped identify cognitive impairment in players without clinical ly observable symptoms Abstract Disconjugate eye movements have been associated with traumatic brain injury since ancient times . Ocular motility dysfunction may be present in up to 90 % of patients with concussion or blast injury . We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 sec and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen . We prospect ively eye tracked 64 normal healthy noninjured control subjects and compared findings to 75 trauma subjects with either a positive head computed tomography ( CT ) scan ( n=13 ) , negative head CT ( n=39 ) , or nonhead injury ( n=23 ) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion . Tracking metrics were then correlated to the clinical concussion measure Sport Concussion Assessment Tool 3 ( SCAT3 ) in trauma patients . Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to noninjured control subjects . Only one of five vertical disconjugacy measures was significantly increased in brain-injured patients relative to controls . Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total St and ardized Assessment of Concussion score . Abnormal eye-tracking metrics improved over time toward baseline in brain-injured subjects observed in follow-up . Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury Objective : The purpose was to examine the influence of a live sporting sideline environment on balance error scoring system ( BESS ) performance . Design : Prospect i ve longitudinal cohort study . Setting : The BESS was performed by all participants at 3 locations : ( 1 ) quiet laboratory , ( 2 ) football stadium sidelines , and ( 3 ) basketball arena sidelines . Participants : The experimental group had 38 participants ( age : 20.1 ± 1.1 years ; height : 170.0 ± 7.7 cm ; mass : 66.7 ± 9.5 kg ) who were female intercollegiate student-athletes ( SA ) . The control group consisted of 38 recreationally active female college students ( age : 20.8 ± 1.1 years ; height : 162.6 ± 6.0 cm ; mass : 63.7 ± 10.6 kg ) . Interventions : The 2 groups performed the tests at the same locations , the SA group during live sporting events and the control group when no event was occurring . Main Outcome Measures : The dependent variable was the total BESS score . Separate 2 × 3 mixed methods analyses of variance investigated the influence of the environment and practice effect . Results : There was a significant interaction for group by environment ( P = 0.004 ) , and the SA group committed more errors at both the football and the basketball setting s than the control group . The SA group also committed more errors at football ( P = 0.028 ) than baseline . The control group demonstrated a likely practice effect with fewer errors during each administration . Conclusions : The BESS score deteriorated when performed on the sidelines of a live sporting event potentially challenging the clinical utility of the BESS . Clinicians need to consider the role of the local environment when performing the BESS test and should perform postinjury tests in the same environment as the baseline test . Clinical Relevance : When performing balance testing of patients with suspected concussions , clinicians need to consider the environment in which the test is performed and attempt to match the preseason testing environment Background Concussion is one of the most commonly occurring injuries in sport today . The Sport Concussion Assessment Tool ( SCAT ) is a commonly used paper neurocognitive tool . To date , little is known about SCAT baseline normative values in youth athletes . Objective The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players . Methods This is a secondary data analysis of pooled data from three prospect i ve cohort studies examining the risk of injury in paediatric ice hockey players aged 9–17 years . A preseason baseline demographic and injury history question naire was completed by each player . Results A total of 4193 players completed SCATs at baseline and were included in the analysis . 781 players ( 18.6 % ) reported a previous history of concussion . Fatigue and low energy followed by headache were the most commonly reported symptoms in all players . The majority of youth players could recite all five words immediately but only three words when delayed . A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age . The median number of digits recited in reverse order was 4 . Conclusions Youth ratings varied between age groups , gender and from previously reported ratings of varsity athletes , possibly reflecting developmental and gender differences . An underst and ing of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion BACKGROUND Each year , over 173,000 children and adolescents visit emergency departments due to sports and recreation related concussions , an increase of 60 % over the last decade due to the rise in the number of children participating in sport . While numerous authors have sought to address the epidemiology of concussions across multiple age groups who participate in contact sports , a recent review of literature did not reveal a substantial amount of published articles that addressed the issue of subconcussive contact . Multiple tools have been developed to assess acute episodes of concussion . Among the assessment protocol s many include an assessment of balance , short and long term memory recall , and balance . The Child-SCAT3 was design ed specifically to evaluate concussions in children 5 - 12 years of age . OBJECTIVE The purpose of this study was to determine the effect of a season of subconcussive contact on  Child-SCAT3  scores in 8 - 12 year old males compared to their age matched peers who participated in non-contact sports .  A secondary purpose was to evaluate how scores of the sub- components of the Child-SCAT3 compare between contact and non-contact athletes . DESIGN A prospect i ve cohort study was performed of 71 male athletes ( 58 football , 13 baseball ) ages 8 - 12 ( contact mean age 10.30 years , SD 1.20 ; non-contact mean age 10.03 years , SD 1.26 ) over the course of a season . METHODS Portions of The Child-SCAT3 were administered and scored in pre-adolescent athletes prior to and following a season of participation in football ( contact sport group ) and baseball ( non-contact sport group ) . The outcome measures of interest included the portions related to Cognitive ability , Balance , and Coordination . RESULTS No statistically significant differences were found in group , time or time and group interaction for any of the utilized portions of the Child-SCAT3 . Statistically significant differences were found between groups for preseason cognitive orientation and postseason immediate memory . Cognitive orientation and coordination were also found to be statistically significantly improved across both groups over the course of the season . LIMITATIONS This study was potentially limited by the number of control subjects tested . CONCLUSIONS A season of subconcussive contact in football was not detrimental to cognitive and balance scores on the Child-SCAT3 . LEVEL OF EVIDENCE 3 Objective : To examine the influence of age , sex , attention-deficit hyperactivity disorder ( ADHD ) status , previous history of concussion , and days since injury on postconcussion postural control assessment in adolescents who have suffered a concussion . Design : Prospect i ve cohort study . Setting : Hospital-based outpatient clinic . Participants : Seventy-one participants ( 42 males ; 29 females ) with mean age 14.14 ± 2.44 . Independent Variables : Age , sex , previous concussion history , ADHD status , total and severity of postconcussion symptoms , and days since injury . Main Outcome Measures : Total Balance Error Scoring System score , path length , center-of-pressure ( COP ) area , sample entropy , and Romberg quotient . Results : Pearson product – moment correlation coefficients were calculated to test for potential associations between the continuous participant characteristics and the postural control variables . Spearman correlation was used to test the association between symptom severity and the postural control variables . St and ard multiple regression was used to model the extent to which participant characteristics accounted for the variance in the postural sway variables . Age was significantly associated with all of the postural sway variables except COP area for the eyes open condition and sample entropy in the anterior – posterior direction for the eyes closed condition . Sex , ADHD status , and previous concussion history did not significantly predict postural control scores . Conclusions : Age significantly influences scores on common postconcussion postural control assessment s. Clinical Relevance : This study demonstrates that age is a critical factor that needs to be accounted for to improve the clinical appropriateness and utility of current postconcussion postural control assessment OBJECT The authors investigated return-to-play duration for initial and recurrent concussion in the same season in 2 teams of junior ( 16 - 21-year-old ) ice hockey players during a regular season . METHODS The authors conducted a prospect i ve cohort study during 1 junior regular season ( 2009 - 2010 ) of 67 male fourth-tier ice hockey players ( mean age 18.2 ± 1.2 years [ SD ] , range 16 - 21 years ) from 2 teams . Prior to the start of the season , every player underwent baseline assessment s that were determined using the  Sideline Concussion Assessment Tool 2 ( SCAT2 ) and the Immediate Post-Concussion Assessment and Cognitive Test ( ImPACT ) . The study protocol also required players who entered the study during the season to complete a baseline SCAT2 and ImPACT . If the protocol was not followed , the postinjury test results of a player without true baseline test results were compared with previously established age- and sex-matched group normative levels . Each game was directly observed by a physician and at least 1 neutral nonphysician observer . Players suspected of suffering a concussion were evaluated by the physician during the game . If a concussion was diagnosed , the player underwent clinical evaluation at the physician 's office within 24 hours . The return-to-play decision was based on clinical evaluation guided by the Zurich return-to-play protocol ( contained in the consensus statement of international expert opinion at the 3rd International Conference on Concussion in Sport held in Zurich , November 2008 ) . This clinical evaluation and return-to-play protocol was augmented by the 2 tests ( SCAT2 and ImPACT ) also recommended by the Zurich consensus statement , for which baseline values had been obtained . RESULTS Seventeen players sustained a physician-observed or self-reported , physician-diagnosed concussion during a physician-observed ice hockey game . The mean clinical return-to-play duration ( in 15 cases ) was 12.8 ± 7.02 days ( median 10 days , range 7 - 29 days ) ; the mean number of physician office visits by players who suffered a concussion ( 15 cases ) was 2.1 ± 1.29 ( median 1.5 visits ) . Five of the 17 players who sustained a concussion also suffered a recurrent or second concussion . One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician , and as a result this single case was not included in the total of 21 concussions . This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated . The mean interval between the first and second concussions in these 5 players was 78.6 ± 39.8 days ( median 82 days ) , and the mean time between the return-to-play date of the first and second concussions was 61.8 ± 39.7 days ( median 60 days ) . CONCLUSIONS The mean rates of return to play for single and recurrent concussions were higher than rates cited in recent studies involving sport concussions . The time interval between the first and second concussions was also greater than previously cited . This difference may be the result of the methodology of direct independent physician observation , diagnosis , and adherence to the Zurich return-to-play protocol OBJECTIVE To prospect ively measure the immediate neurocognitive effects and early course of recovery from concussion and to examine the effects of loss of consciousness ( LOC ) and posttraumatic amnesia ( PTA ) on the severity of neurocognitive impairment immediately after concussion . METHODS A sports-related concussion research model was used to allow prospect i ve immediate evaluation of concussion . A total of 2385 high school and college football players were studied . Ninety-one players ( 3.8 % ) sustained concussions during the study . A brief neurocognitive and neurological screening measure , the St and ardized Assessment of Concussion  , was used to assess cognitive functioning before the football season , immediately after injury , and 15 minutes , 48 hours , and 90 days after injury . RESULTS St and ardized Assessment of Concussion scores immediately after concussion were significantly lower than the preseason baseline score and the noninjured population baseline mean , even for injured subjects without LOC or PTA . Subjects with LOC were most severely impaired immediately after injury , whereas those without LOC or PTA were least impaired . Significant impairment was also detected 15 minutes after injury , but all three groups returned to baseline levels of cognitive functioning within 48 hours . CONCLUSION These findings are the first to demonstrate not only that a gradient of increasing concussion severity is represented by PTA and LOC but also that measurable neurocognitive abnormalities are evident immediately after injury without PTA or LOC 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 AIM This study undertook to use the K-D sideline test with the SCAT2 to see if concussions could be identified in amateur rugby league players over a representative competition period . METHOD A prospect i ve cohort study was conducted on two teams participating in an amateur rugby league . All players were tested for signs of concussion utilising the K-D test and players with longer times than their baseline scores undertook a further concussion assessment with the SCAT2 . RESULTS Five athletes with suspected concussion were evaluated by K-D testing .  Three concussions were associated with witnessed events during the matches and two athletes were identified by the team medic as having longer K-D time scores incidentally post-match compared to baseline . Post-match K-D scores for all concussed athletes were worse than baseline for those with reported or witnessed concussion events ( 7s ; 5.0 - 7.1 ; p=0.025 ) and for those identified incidentally ( > 5s ; 8.9 - 9.1s ) . Both groups also reported more symptoms on the PCSS ( a part of the SCAT2 ) post-match . DISCUSSION In this rugby cohort , the K-D test was not only useful in identifying changes in players with witnessed head trauma , but in identifying changes in players with an un-witnessed suspected concussion 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 The purpose of this study was to investigate the sensitivity of  orientation and recent memory questions  in the diagnosis of concussion . In a prospect i ve study over 7 consecutive years ( 1985 - 1991 ) , all players at a professional Australian Rules Football club who sustained a concussive injury ( n = 28 ) were administered a set of questions evaluating orientation and recent memory .  Concussion was diagnosed independently on the basis of loss or disturbance of consciousness and clinical symptoms . A control group of age-matched nonconcussed players was administered the same set of questions . The results showed that items evaluating recently acquired information were more sensitive in the assessment of concussion than st and ard orientation items . The relative sensitivity of orientation questions must be considered when they are used in the clinical diagnosis of concussion in sport OBJECT The objective of this study was to measure the incidence of concussion ( scaled relative to number of athlete exposures ) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players ( 16 - 21 years old ) during 1 regular season . METHODS A prospect i ve cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season ( 2009 - 2010 ) involving 67 male fourth-tier ice hockey players ( mean age 18.2 ± 1.2 years , range 16 - 21 years ) from 2 teams . Prior to the start of the season , every player underwent baseline assessment s using the Sideline Concussion Assessment Tool 2 ( SCAT2 ) and the Immediate Post-Concussion Assessment and Cognitive Test ( ImPACT ) . The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing . If the protocol was not followed , the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels . Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer . Players who suffered a suspected concussion were evaluated at the game . If a concussion diagnosis was made , the player was subsequently examined in the physician 's office for a full clinical evaluation and the SCAT2 and ImPACT were repeated . Based on these evaluations , players were counseled on the decision of when to return to play . Athlete exposure was defined as 1 game played by 1 athlete . RESULTS Twenty-one concussions occurred during the 52 physician-observed games ( incidence 21.5 concussions per 1000 athlete exposures ) . Five players experienced repeat concussions . No concussions were reported during practice sessions . A concussion was diagnosed by the physician in 19 ( 36.5 % ) of the 52 observed games . One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician , and as a result this single case was not included in the total of 21 total concussions . This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated . CONCLUSIONS The incidence of game-related concussions ( per 100 [ corrected ] athlete exposures ) in these fourth-tier junior [ corrected ] ice hockey players was 7 [ corrected ] times higher than [ corrected ] previously reported in the literature . This difference may be the result of the use of st and ardized direct physician observation , diagnosis , and subsequent treatment . The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings . These follow-up studies should involve other contact sports ( for example football and rugby ) and also include the full spectrum of gender , age , and skill levels AIM To determine whether the King-Devick ( K-D ) test used as a sideline test in junior rugby league players over 12 matches in a domestic competition season could identify witnessed and incidentally identified episodes of concussion . METHODS A prospect i ve observational cohort study of a club level junior rugby league team ( n=19 ) during the 2014 New Zeal and competition season involved every player completing two pre-competition season baseline trials of the K-D test .  Players removed from match participation , or who reported any signs or symptoms of concussion were assessed on the sideline with the K-D test and referred for further medical assessment . Players with a pre- to post-match K-D test difference > 3s were referred for physician evaluation . RESULTS The baseline test-retest reliability of the K-D test was high ( rs=0.86 ; p<0.0001 ) . Seven concussions were medically identified in six players who recorded pre- to post-match K-D test times greater than 3s ( mean change of 7.4s ) . Post-season testing of players demonstrated improvement of K-D time scores consistent with learning effects of using the K-D test ( 67.7s vs. 62.2s ) . DISCUSSION Although no witnessed concussions occurred during rugby play , six players recorded pre- to post-match changes with a mean delay of 4s result ing in seven concussions being subsequently confirmed post-match by health practitioners . All players were medically managed for a return to sports participation . CONCLUSION The K-D test was quickly and easily administered making it a practical sideline tool as part of the continuum of concussion assessment tools for junior rugby league players 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 PURPOSE We have developed a reliable and valid clinical test of reaction time ( RTclin ) that is sensitive to the acute effects of concussion . If RTclin is to be used as a sideline concussion assessment tool then the acute effects of exercise on RTclin may need to be controlled for . The purpose of this study was therefore to determine the effect of exercise on RTclin . METHODS A gender-balanced group of 42 collegiate athletes were assigned to an  exercise ( n = 28 ) and a  control ( n = 14 ) group using 2:1 block r and omization . The exercise group completed a grade d four-stage exercise protocol on a stationary bicycle ( 100 W × 5 min ; 150 W × 5 min ; 200 W × 5 min ; sprint × 2 min ) , whereas the control group was tested at identical periods without exercising .  Mean RTclin was calculated for eight trials as the fall time of a vertically suspended rigid shaft after its release by the examiner before being caught by the athlete . RTclin was measured at baseline and after each of the four stages . RESULTS As both HR and RPE significantly increased for the four stages in the exercise group ( P < 0.001 ) , mean RTclin showed a significant overall decline during repeated test administration ( P < 0.008 ) . However , there were no significant group ( exercise vs control , P = 0.822 ) or group-by-stage interaction ( P = 0.169 ) effects on RTclin as assessed by repeated- measures analysis of variance . CONCLUSIONS Exercise did not appear to affect RTclin performance in this study . This suggests that RTclin measured during a sideline concussion assessment does not need to be adjusted to account for the acute effects of exercise
target: 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
background: Objectives Several iterations of the Sport Concussion Assessment Tool ( SCAT ) have been published over the past 16 years .
  Our goal was to systematic ally review the literature related to the SCAT and provide recommendations for improving the tool .