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      Concussion in adolescent rugby union players: comprehensive acute assessment protocol and development of the SSC concussion passport to monitor long-term health

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          Abstract

          Introduction

          Sports-related concussion (SRC) can be challenging to diagnose, assess and manage. Much of the SRC research is conducted on adults. The assessment of SRC should aim to identify deficits using a detailed multimodal assessment; however, most studies investigating the effects of SRC use diagnostic tools in isolation. It is likely that a combination of diagnostic tests will improve diagnostic accuracy. In this study, we aim to investigate how concussion affects adolescent rugby players and how a variety of diagnostic tools interact with each other as participants recover from their injury. The study will also determine the logistics of recording an individual’s concussion history on a virtual ‘Concussion Passport’ that would remain with the individual throughout their sporting career to allow monitoring of long-term health.

          Methods and analysis

          All rugby players (n=211) from the Senior Cup Teams of five schools in Dublin, Ireland will be invited to participate in the study. Baseline testing will be performed at the Sports Surgery Clinic, Dublin (SSC) before the rugby season commences. Participants will be followed up over the course of the rugby season. At baseline and at each postconcussion visit, participants will complete the following: Questionnaire, Sports Concussion Assessment Tool 3, Balance Error Scoring System, Computerised Neurocognitive Testing, Vestibulo-ocular assessment, King Devick test, Graded exercise test, Blood tests, Neck strength, FitBit.

          Ethics and dissemination

          Ethical approval was obtained from the Sports Surgery Clinic Research Ethics Committee (Approval number: SSC 0020). On completion of the study, further papers will be written and published to present the results of the various tests.

          Trial registration number

          NCT03624634.

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          Most cited references42

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          The video head impulse test: diagnostic accuracy in peripheral vestibulopathy.

          H G MacDougall, K P Weber, L A McGarvie … (2009)
          The head impulse test (HIT) is a useful bedside test to identify peripheral vestibular deficits. However, such a deficit of the vestibulo-ocular reflex (VOR) may not be diagnosed because corrective saccades cannot always be detected by simple observation. The scleral search coil technique is the gold standard for HIT measurements, but it is not practical for routine testing or for acute patients, because they are required to wear an uncomfortable contact lens. To develop an easy-to-use video HIT system (vHIT) as a clinical tool for identifying peripheral vestibular deficits. To validate the diagnostic accuracy of vHIT by simultaneous measures with video and search coil recordings across healthy subjects and patients with a wide range of previously identified peripheral vestibular deficits. Horizontal HIT was recorded simultaneously with vHIT (250 Hz) and search coils (1,000 Hz) in 8 normal subjects, 6 patients with vestibular neuritis, 1 patient after unilateral intratympanic gentamicin, and 1 patient with bilateral gentamicin vestibulotoxicity. Simultaneous video and search coil recordings of eye movements were closely comparable (average concordance correlation coefficient r(c) = 0.930). Mean VOR gains measured with search coils and video were not significantly different in normal (p = 0.107) and patients (p = 0.073). With these groups, the sensitivity and specificity of both the reference and index test were 1.0 (95% confidence interval 0.69-1.0). vHIT measures detected both overt and covert saccades as accurately as coils. The video head impulse test is equivalent to search coils in identifying peripheral vestibular deficits but easier to use in clinics, even in patients with acute vestibular neuritis.
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            The Video Head Impulse Test (vHIT) of Semicircular Canal Function – Age-Dependent Normative Values of VOR Gain in Healthy Subjects

            Leigh A. McGarvie, Hamish G. MacDougall, G. Michael Halmagyi … (2015)
            Background/hypothesis The video Head Impulse Test (vHIT) is now widely used to test the function of each of the six semicircular canals individually by measuring the eye rotation response to an abrupt head rotation in the plane of the canal. The main measure of canal adequacy is the ratio of the eye movement response to the head movement stimulus, i.e., the gain of the vestibulo-ocular reflex (VOR). However, there is a need for normative data about how VOR gain is affected by age and also by head velocity, to allow the response of any particular patient to be compared to the responses of healthy subjects in their age range. In this study, we determined for all six semicircular canals, normative values of VOR gain, for each canal across a range of head velocities, for healthy subjects in each decade of life. Study design The VOR gain was measured for all canals across a range of head velocities for at least 10 healthy subjects in decade age bands: 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89. Methods The compensatory eye movement response to a small, unpredictable, abrupt head rotation (head impulse) was measured by the ICS impulse prototype system. The same operator delivered every impulse to every subject. Results Vestibulo-ocular reflex gain decreased at high head velocities, but was largely unaffected by age into the 80- to 89-year age group. There were some small but systematic differences between the two directions of head rotation, which appear to be largely due to the fact that in this study only the right eye was measured. The results are considered in relation to recent evidence about the effect of age on VOR performance. Conclusion These normative values allow the results of any particular patient to be compared to the values of healthy people in their age range and so allow, for example, detection of whether a patient has a bilateral vestibular loss. VOR gain, as measured directly by the eye movement response to head rotation, seems largely unaffected by aging.
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              Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes.

              Robin Lovell-Badge, Melvin Field, Joseph C. Maroon … (2003)
              To evaluate symptoms and neurocognitive recovery patterns after sports-related concussion in high school and college athletes. College athletes (n = 371) and high school athletes (n = 183) underwent baseline neuropsychological evaluation between 1997 and 2000. Individuals who received a concussion during athletic competition (n = 54) underwent serial neuropsychologic evaluation after injury and were compared with a noninjured within-sample control group (n = 38). Main outcome measures included structured interview, four memory measures, and Concussion Symptom Scale ratings. Baseline to postinjury change scores and multiple analyses of variance were used to compare recovery curves within and between groups. High school athletes with concussion had prolonged memory dysfunction compared with college athletes with concussion. High school athletes performed significantly worse than age-matched control subjects at 7 days after injury (F = 2.90; P <.005). College athletes, despite having more severe in-season concussions, displayed commensurate performance with matched control subjects by day 3 after concussion. Self-report of postconcussion symptoms by student athletes was not predictive of poor performance on neuropsychologic testing. Caution and systematic evaluation should be undertaken before returning athletes with concussion to competition. Sole reliance on the self-report of the athlete may be inadequate. Preliminary data may suggest a more protracted recovery from concussion in high school athletes.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open Sport Exerc Med
                Journal ID (iso-abbrev): BMJ Open Sport Exerc Med
                Journal ID (hwp): bmjosem
                Journal ID (publisher-id): bmjosem
                Title: BMJ Open Sport — Exercise Medicine
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2055-7647
                Publication date Collection: 2018
                Publication date (Electronic): 5 November 2018
                Volume: 4
                Issue: 1
                Electronic Location Identifier: e000455
                Affiliations
                [1 ] departmentSports Medicine Department , Sports Surgery Clinic , Dublin, Ireland
                [2 ] departmentCentre for Health Exercise and Sports Medicine , University of Melbourne , Melbourne, Australia
                [3 ] departmentDepartment of Medicine , University College Cork , Cork, Ireland
                [4 ] departmentEmergency Department , St. Vincent’s University Hospital , Dublin, Ireland
                [5 ] The Florey Institute of Neuroscience and Mental Health , Heidelberg, Victoria, Australia
                Author notes
                [Correspondence to ] Ciaran Cosgrave; ciarancosgrave@ 123456sportssurgeryclinic.com
                Author information
                http://orcid.org/0000-0002-5860-5569
                Article
                Publisher ID: bmjsem-2018-000455
                DOI: 10.1136/bmjsem-2018-000455
                PMC ID: 6241986
                SO-VID: e95ba342-0ad7-41c9-b01d-bf32e39b7e1f
                Copyright © © Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date accepted : 15 October 2018
                Categories
                Subject: Protocol
                Subject: 1506
                Custom metadata
                special-feature unlocked

                Keywords: concussion,rugby,adolescent,injury
                Data availability:
                Keywords: concussion, rugby, adolescent, injury

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