Pathophysiology
The study suggests that balance issues in athletes with concussion history might stem from sensorimotor processing deficits or delayed neural responses affecting motor activation [PMID:40053116].
In adult rats, BDNF partially recreates the spontaneous reinnervation seen in developing brains, suggesting a mechanism by which therapeutic interventions might enhance recovery from cerebellar laceration and concussion [PMID:18299295].
Epidemiology
Concussions in NCAA WAG occur at a rate of 6.68 per 10,000 athlete exposures, highlighting the sport's risk profile [PMID:40135348].
This study reveals that among US adults who self-reported a concussion, nearly half may not receive medical evaluation, indicating significant gaps in healthcare access and utilization post-concussion [PMID:35125431].
This study highlights that while sports-related concussions are prevalent, non-sports mechanisms such as falls, being struck by or against objects, assaults, and motor vehicle crashes also contribute significantly to youth concussions, especially as children age [PMID:29627189].
Recent trends indicate an increase in medically attended concussions among youth, possibly attributed to greater involvement in sports, enhanced concussion awareness, and legislative changes [PMID:29627189].
The study found that falls are most common in children up to 4 years old, whereas older children experience more concussions from contact sports and external factors like motor vehicle crashes [PMID:29627189].
The study analyzed NEISS data from 2013-2022 and found that the number of concussions has grown, especially in males, with Karate and other forms of martial arts contributing significantly to this trend [PMID:40187105].
Falls and being punched, hit, or struck were the most common mechanisms, accounting for 23% and 20% of cases respectively. Females experienced more concussions during competitions in Judo and Taekwondo, while males had more incidents during practice in Judo and Karate [PMID:40187105].
Female service academy members who were NCAA athletes (HR [95% CI]: 1.58 [1.32, 1.90]), immediately reported their injury (HR [95% CI]: 1.40 [1.18, 1.67]), or had a sport-related concussion (SRC) (HR [95% CI]: 1.29 [1.08, 1.54]) were significantly more likely to initiate and complete RTA protocols sooner post-concussion compared to their counterparts [PMID:39658275].
Clinical Presentation
Exacerbation of concussion symptoms, including headache, nausea, and light sensitivity, can occur if gymnasts are exposed to acute or cumulative loads prematurely [PMID:40135348].
Disturbances in oculomotor function, such as accommodative insufficiency (AI) affecting near vision focus and impaired saccadic eye movements, are pivotal indicators post-SRCs and are crucial for sideline evaluations [PMID:38479117].
Adapted athletes with a history of concussion reported greater VOMS provocation on horizontal saccades (P = .008) compared to those without a history [PMID:38477127].
The research indicated weak associations between clinical reaction time and reactive balance measures (e.g., time to stability from I-mP&R) compared to other balance and cognitive tests, suggesting these could identify different aspects of concussion [PMID:36583958].
While most children recover within 2 weeks, about 30% face prolonged symptoms, emphasizing the need for prognostic tools like the BCTT to identify those at risk for delayed recovery [PMID:36881442].
Variables such as a motor vehicle accident as the mechanism of injury, a history of migraines, increased headaches during concentration, and abnormalities in horizontal vestibular ocular reflex were significantly associated with referral for vestibular therapy [PMID:36094515].
The study found that age, migraine history, and motion sickness history were significant predictors of false-positive results on the VOMS, with adjusted odds ratios indicating increased risk [PMID:35696602].
Initial visit symptom severity and initial degree of exercise intolerance were identified as significant predictors of how long recovery would take [PMID:35482774].
The research identifies that demographic characteristics and prior concussion history significantly affect whether individuals seek medical evaluation following a concussion event [PMID:35125431].
Vestibular and oculomotor related symptoms including poor balance, dizziness, and headache during head and eye movements are frequently reported following concussion in children [PMID:33656474].
Inertial sensors revealed that individuals with sport-related concussion (SRC) exhibit slower head velocities and smaller angular displacements during horizontal head turns while walking or sitting compared to healthy controls, suggesting these sensors offer a more sensitive method to identify motor impairments [PMID:30045224].
Diagnosis
The King-Devick Test (KDT) assesses saccadic performance and reading difficulties post-SRC, while peripheral awareness tests like the Useful Field of View (UFOV) can help diagnose concussions, though results may vary due to concurrent physical demands [PMID:38479117].
Higher functional classifications (2.0-4.5) showed greater provocation on various VOMS components compared to lower classifications (1.0-1.5), highlighting the importance of baseline assessments [PMID:38477127].
The study found weak correlations between current clinical assessments, suggesting minimal redundancy and highlighting that reactive balance represents a distinct functional domain that could enhance concussion diagnostic comprehensiveness [PMID:36583958].
Participants with a history of migraines and those experiencing heightened headaches during cognitive tasks were more likely to be referred for vestibular therapy, indicating that detailed clinical history and symptom assessment are crucial [PMID:36094515].
In a study of US Army Special Operations Command personnel, a history of motion sickness was identified as a significant predictor of false-positive findings on the mBESS (aOR = 2.34; 95% CI = 1.34, 4.05; P = .002) [PMID:35696602].
Participants underwent weekly reassessment of exercise tolerance using the Buffalo Concussion Treadmill Test (BCTT), which guided adjustments to their training target heart rate [PMID:35482774].
Examining evaluation patterns helps in identifying subgroups of the population who are less likely to be captured in national surveillance data, suggesting areas for enhancing diagnostic practices [PMID:35125431].
While the Vestibular Ocular Motor Screening Tool (VOMS) is commonly used to assess severity of symptoms, more objective tools such as eye-tracking videography and force-plate posturography offer a clearer picture of vestibular and ocular function [PMID:33656474].
The study hypothesizes and provides evidence that head motion during horizontal head turns, quantified with inertial sensors, can differentiate concussion patients from healthy controls, potentially improving diagnostic accuracy [PMID:30045224].
Law et al. [PMID:40329636] recommend considering the SCAT6 for visually impaired athletes, as it may offer adjustments that better accommodate their requirements, particularly in visual tracking sections [PMID:40329636].
While three subtypes were proposed based on physical examination findings, the study concluded that these subtypes lacked both statistical support and clinical relevance without incorporating symptom assessment, mood evaluation, cognitive problems, and graded exertion testing [PMID:38329287].
Increases in heart rate, rate of perceived exertion (RPE), and symptom presentation were similar between the MOVE protocol and the BCTT in children with subacute concussion, suggesting comparable diagnostic utility [PMID:37212272].
The study found that adding VOMS to SCAT3 boosted overall diagnostic ability by 4.4%, achieving an area under the curve of 0.848, and improved test sensitivity by 9% compared to SCAT3 alone [PMID:33600216].
ConcHx athletes showed significantly higher symptom scores on several VOMS items, including saccades and vestibular-ocular reflex, suggesting these tools may help in diagnosing lingering effects of concussion [PMID:30829684].
Differential Diagnosis
The study suggests that exercise intolerance on the BCTT can serve as a clinical marker to differentiate recovery trajectories in pediatric concussion patients [PMID:36881442].
The mBESS showed a notably higher false-positive rate of 36.5%, primarily associated with a history of motion sickness, highlighting the need for careful interpretation in differential diagnosis [PMID:35696602].
Benign paroxysmal positional vertigo (BPPV) has been proposed as a possible cause of persistent vestibular symptoms in children following concussion [PMID:33656474].
While the study focuses on musculoskeletal injuries, the potential for traumatic brain injuries, including concussions and cerebellar lacerations, should be considered given the high-impact nature of wakeboarding [PMID:14754740].
Management
Proposed protocols recommend starting with complete rest and progressing through stages such as light aerobic activity, vertical work, and gradually reintroducing tumbling and advanced skills [PMID:40135348].
Gymnasts should cautiously increase training volume and skill complexity, using intermediary drills to rebuild confidence and prevent symptom exacerbation [PMID:40135348].
Conducting visual function tests during sporting events is essential for sideline evaluations but must account for physiological changes due to exercise that can impact visual system performance [PMID:38479117].
The study emphasizes the need for tailored vestibular and oculomotor assessments in managing adapted athletes, particularly those with a history of concussion and higher functional classifications [PMID:38477127].
Given the unique information provided by reactive balance assessments, integrating these into clinical management protocols could offer a more comprehensive approach to concussion diagnosis and monitoring [PMID:36583958].
This study highlights the importance of assessing exercise tolerance via BCTT outside the acute phase (10 to 21 days post-injury) to guide management strategies and predict recovery duration in children with concussion [PMID:36881442].
A multidomain assessment, including symptom scales, clinical profiles, and vestibular screenings, can predict the need for vestibular therapy, highlighting the importance of comprehensive evaluations in concussion management [PMID:36094515].
Participants who adhered to their aerobic exercise prescriptions recovered faster than those who did not, highlighting the importance of adherence to prescribed exercise programs for quicker recovery from sport-related concussion [PMID:35482774].
Participants completed daily symptom assessments using the ReCoUPS mobile application, capturing symptom progression and aiding in the monitoring of recovery [PMID:35482774].
Developmental stages in children can affect the completion and interpretation of vestibular and oculomotor tasks, with ongoing debate about when balance function reaches adult-like maturity [PMID:33656474].
Inertial sensors offer a more sensitive tool compared to traditional observational methods for assessing motor function, which could be valuable in tracking recovery and guiding rehabilitation efforts in patients with concussion [PMID:30045224].
Differentiating between sports-related and non-sports-related mechanisms of concussion can help tailor prevention efforts and return-to-play policies more effectively [PMID:29627189].
The findings suggest that clinicians managing concussion in visually impaired athletes should tailor the assessment process, potentially removing or modifying sections like the read-aloud component and adjusting visual tracking tasks as indicated by Law et al. [PMID:40329636].
Ninety-six point four percent of concussion cases were treated and released from the ED, while only 3.1% required hospitalization, indicating that outpatient management is predominant [PMID:40187105].
Given that attentional demands significantly impact balance control in these athletes, rehabilitation efforts should focus on enhancing balance stability during multitasking situations [PMID:40053116].
The study suggests that easy access to medical personnel, such as athletic trainers, and higher awareness among coaches and athletes may facilitate quicker initiation and completion of return-to-activity protocols, particularly in NCAA athletes [PMID:39658275].
The identification of visio-vestibular, cervicogenic, and autonomic/balance subtypes suggests that tailored management strategies could be more effective by addressing specific impairments observed in pediatric athletes [PMID:38329287].
The MOVE protocol, a no-equipment, virtually administered GXT, demonstrated safety and feasibility in both healthy children and those with subacute concussion, showing similar physiological responses and symptom presentations compared to the Buffalo Concussion Treadmill Test (BCTT) [PMID:37212272].
The study highlights that the MOVE protocol can be effectively conducted virtually using telehealth platforms, with all feasibility criteria met and no adverse events reported among participants with subacute concussion [PMID:37212272].
Thirteen gymnasts returned to the clinic for subsequent injuries after their initial concussion, indicating potential challenges in recovery and reinjury prevention [PMID:37204184].
Complications
Those with a history of disordered eating experienced significantly more time-loss injuries (78% vs 65%; p = 0.004), a higher incidence of osteoporosis (4% vs 0%; p = 0.003), and worse current physical function (12.2 vs 11.0; p = 0.01) compared to those without such a history [PMID:33186080].
Prognosis & Follow-up
Identifying baseline modifiers such as history of concussion and functional classification through VOMS can inform prognosis and follow-up strategies for these athletes [PMID:38477127].
In a cohort study of 855 children with sports-related concussion, reduced exercise tolerance measured by the BCTT during the subacute phase (10 to 21 days post-injury) was linked to longer recovery times [PMID:36881442].
Participants taking longer than 4 weeks to recover are considered to have Persistent Post-Concussive Symptoms (PPCS), which is linked to adverse educational, social, and developmental outcomes [PMID:35482774].
Studies suggest that while vestibular reflexes may remain intact, central mechanisms affecting balance and perception of verticality could be impaired post-concussion, impacting recovery [PMID:33656474].
The persistent deficits in balance control observed suggest the need for ongoing assessment to evaluate the long-term functional consequences of multiple concussions [PMID:40053116].
The recurrence of injuries in 13 gymnasts highlights the importance of ongoing monitoring and follow-up care for these athletes post-concussion [PMID:37204184].
The study found that high school freshmen/sophomores required 9.5 ± 14.9 days to return to learning activities, whereas juniors/seniors took 7.6 ± 12.6 days, indicating a shorter RTL duration for older students [PMID:37148225].
The PPCS incidence was notably lower at 21% for those with >3 signs who underwent aerobic exercise, compared to 38% in the stretching group [PMID:36884297].
Adults who sought care sooner at specialty concussion clinics reported fewer serious persisting symptoms at three months compared to those evaluated later [PMID:36083237].
The study suggests that targeted upper-extremity training can lead to meaningful improvements in whole-body reactive agility, indicating potential long-term benefits in recovery and performance for athletes with a history of concussion [PMID:33418536].
Special Populations
No significant sex differences were observed, but history of concussion and functional classification significantly influenced VOMS outcomes, underscoring the need for individualized assessment approaches [PMID:38477127].
The research underscores the importance of considering age and sociodemographic factors when addressing concussion management, as these variables influence the types of activities leading to injury [PMID:29627189].
Female athletes in Judo and Taekwondo had a higher incidence of concussions during competitions, suggesting a need for tailored safety measures in these contexts [PMID:40187105].
The study involved young male athletes, highlighting that this demographic with recurrent concussions faces specific challenges in maintaining balance and performing dual tasks effectively [PMID:40053116].
Female service academy members, particularly NCAA athletes, exhibit unique characteristics affecting their concussion recovery, including differences in reporting behaviors and recovery speeds compared to non-NCAA members [PMID:39658275].
The study found no significant association between disability level and injury risk, indicating that safety measures should be uniformly applied across different disability categories [PMID:36083334].
The research highlights that female collegiate gymnasts face significant long-term health risks associated with early specialization, concussion history, and disordered eating, emphasizing the need for tailored medical and psychological support [PMID:33186080].
The study involved young adult athletes (average age 21.8 years), showing that this demographic may experience prolonged effects on motor perception and coordination post-concussion, warranting specific attention [PMID:30829684].
Key Recommendations
General return to sport strategies may not fully address the gymnastics environment, emphasizing the need for gymnastics-specific protocols like those proposed by May et al. and the FIG [PMID:40135348]. (Evidence: Expert opinion)
Given the prognostic value of BCTT results in the subacute phase, clinicians are advised to incorporate this assessment to tailor recovery plans and predict recovery timelines [PMID:36881442]. (Evidence: Expert opinion)
Future initiatives should focus on improving access to medical care across various injury settings and educating female service academy members on the importance of early concussion reporting to optimize recovery outcomes [PMID:39658275]. (Evidence: Expert opinion)
The exploratory analysis suggests a need for larger, confirmatory studies to validate the benefits of early aerobic exercise for adolescents with more severe concussion presentations [PMID:36884297]. (Evidence: Expert opinion)
The study suggests that enhancing public awareness and encouraging prompt medical evaluation after a concussion can help reduce persistent symptoms [PMID:36083237]. (Evidence: Expert opinion)
The study recommends incorporating graded exercise testing in the subacute phase to safely transition patients to return-to-activity protocols, thereby optimizing clinical management and resource allocation [PMID:30439726]. (Evidence: Expert opinion)
Early comprehensive assessments including neurocognitive and vestibular evaluations, as highlighted in [PMID:28192036], can provide valuable insights into recovery trajectories, guiding clinicians in formulating more precise recommendations for patients with sport-related concussions. (Evidence: Moderate)
Given that no observed differences exceeded clinically reliable change indices, clinicians should interpret rebaseline assessments cautiously, recognizing that improvements may reflect normal variability rather than meaningful recovery gains [PMID:26580474]. (Evidence: Expert opinion)
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