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      The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one

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          Abstract

          Context

          A battery of clinical measures of neurocognition, balance and symptoms has been recommended for the management of sport concussion (SC) but is based on variable evidence.

          Objective

          To examine the sensitivity and specificity of a battery of tests to assess SC in college athletes.

          Design

          Cross-sectional.

          Setting

          Research laboratory.

          Patients or other participants

          Division 1 athletes diagnosed with a SC (n=40) who were 20.2±1.60 years of age and 180.5±11.12 cm tall and healthy athletes (n=40) who were 19.0±0.93 years of age and 179.1±11.39 cm tall were enrolled.

          Intervention(s)

          Participants were administered Immediate Postconcussion Assessment and Cognitive Test (ImPACT), the Sensory Organization Test (SOT) and the Revised Head Injury Scale (HIS-r) prior to and up to 24 h following injury between the 2004 and 2014 sport seasons. Sensitivity and specificity were calculated using predictive discriminant analyses (PDA) and clinical interpretation guidelines.

          Main outcome measures

          Outcome measures included baseline and postinjury ImPACT, SOT and HIS-r composite scores.

          Results

          Using PDA, each clinical measure's sensitivity ranged from 55.0% to 77.5% and specificity ranged from 52.5% to 100%. The test battery possessed a sensitivity and specificity of 80.0% and 100%, respectively. Using clinical interpretation guidelines, sensitivity ranged from 55% to 97.5% individually, and 100% when combined.

          Conclusions

          Our results support a multidimensional approach to assess SC in college athletes which correctly identified 80–100% of concussed participants as injured. When each test was evaluated separately, up to 47.5% of our sample was misclassified. Caution is warranted when using singular measures to manage SC.

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          Most cited references37

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          National Athletic Trainers' Association position statement: management of sport concussion.

          To provide athletic trainers, physicians, and other health care professionals with best-practice guidelines for the management of sport-related concussions.
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            Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes.

            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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              The role of age and sex in symptoms, neurocognitive performance, and postural stability in athletes after concussion.

              Researchers have begun to focus on age and sex differences in concussion outcomes. Results suggest that younger athletes and female athletes may take longer to recover from a concussion. However, little is known about the interactive effects of age and sex on symptoms, neurocognitive testing (NCT), and postural stability. The purpose of the study was to examine sex and age differences in symptoms, NCT, and postural stability following concussion. We hypothesized that high school and female athletes would have worse symptoms, NCT, and postural stability than college and male athletes, respectively. Cohort study; Level of evidence, 2. A total of 296 concussed athletes from a multistate, 2-year study were enrolled in this study. Participants completed the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) and Post-Concussion Symptom Scale (PCSS) at baseline and again at 2, 7, and 14 days after concussion. Participants completed the Balance Error Scoring System (BESS) at 1, 2, and 3 days after concussion. Female athletes performed worse than male athletes on visual memory (mean, 65.1% and 70.1%, respectively; P = .049) and reported more symptoms (mean, 14.4 and 10.1, respectively) after concussion (P = .035). High school athletes performed worse than college athletes on verbal (mean, 78.8% and 82.7%, respectively; P = .001) and visual (mean, 65.8% and 69.4%, respectively; P = .01) memory. High school athletes were still impaired on verbal memory 7 days after concussion compared with collegiate athletes (P = .001). High school male athletes scored worse on the BESS than college male athletes (mean, 18.8 and 13.0, respectively; P = .001). College female athletes scored worse on the BESS than high school female athletes (mean, 21.1 and 16.9, respectively; P = .001). The results of the current study supported age differences in memory and sex differences in memory and symptoms and an interaction between age and sex on postural stability after concussion that warrant consideration from clinicians and researchers when interpreting symptoms, specific components of NCT, and postural stability tests. Future research should develop and assess interventions tailored to age and sex differences and include younger (<14 years) participants.
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                Author and article information

                Journal
                BMJ Open Sport Exerc Med
                BMJ Open Sport Exerc Med
                bmjosem
                bmjosem
                BMJ Open Sport — Exercise Medicine
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2055-7647
                2016
                19 January 2016
                : 2
                : 1
                : e000012
                Affiliations
                [1 ]Exercise and Sport Injury LaboratoryDepartment of Kinesiology The University of Virginia , Charlottesville, VA
                [2 ]St. Mary's Athletic Training Research Laboratory, Department of Kinesiology, University of Georgia , Athens, Georgia, USA
                [3 ]Atlanta Neuropsychology LLC Marble Hill , Georgia, USA
                [4 ]Orthopedic Specialty Associates , Fort Worth, Texas, USA
                [5 ]The University of Texas Southwestern Medical Center , Dallas, Texas, USA
                [6 ]The University of New Hampshire , Durham, New Hampshire, UK
                Author notes
                [Correspondence to ] Dr Jacob E Resch; jer6x@ 123456virginia.edu
                Article
                bmjsem-2015-000012
                10.1136/bmjsem-2015-000012
                5117030
                27900145
                ae864a85-4a1e-40bf-be5c-99c5a2d7faf7
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                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 and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 25 October 2015
                Categories
                Research
                1506

                sensitivity,specificity,concussion assessment,mild traumatic brain injury,neurocognitive

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