Objectives The objective of this study was to investigate the time to recovery after an SRC comparing riboflavin 400mg daily to placebo in a group of elite level athletes from multiple sports. Methods The study was a double-blind randomized placebo-controlled trial with intention to treat conducted from 2016–2020 at two different academic institutions. The study enrolled varsity student-athletes (SA) at each institution. The investigators and participants were blinded to treatment allocation. The treatment group received 14 capsules of either riboflavin 400mg or placebo to take daily until completed. The team physician made the diagnosis of an SRC within 24 h of the injury. Results A total of sixty participants enrolled in the study. Fifty-two participants completed the study. Subjects in the riboflavin group had a statistically significant lower number of average days to recovery of 9.92 days (CI ± 2.8) compared to placebo of 22.2 days (CI ± 11.5) (P < 0.05). Subjects matched for age, gender, history of SRCs, attention deficit hyperactivity disorder and Periodic Health Questionnaire-9 scores. Conclusions This is one of the first studies that documents an effective treatment option for an SRC at the time of injury. Riboflavin is safe, inexpensive, and readily available making it an ideal treatment.

Objective To complete a systematic review of the literature examining neuroimaging findings unique to co-occurring syndromal depression in the setting of TBI. Methods A PRISMA compliant literature search was conducted in PubMed (MEDLINE), PsychINFO, EMBASE, and Scopus databases for articles published prior to April of 2022. The database query yielded 4447 unique articles. These articles were narrowed based on specific inclusion criteria (e.g., clear TBI definition, clear depression construct commenting on the syndrome of major depressive disorder, conducted empirical analyses comparing neuroimaging correlates in TBI subjects with depression versus TBI subjects without depression, controlled for the time interval between TBI occurrence and acquisition of neuroimaging). Results A final cohort of 10 articles resulted, comprising the findings from 423 civilians with brain injury, 129 of which developed post-TBI depression. Four articles studied mild TBI, three mild/moderate, one moderate/severe, and two all-comers, with nine articles focusing on single TBI and one including both single and recurrent injuries. Spatially convergent structural abnormalities in individuals with TBI and co-occurring syndromal depression were identified primarily in bilateral frontal regions, particularly in those with damage to the left frontal lobe and prefrontal cortices, as well as temporal regions including bilateral temporal lobes, the left superior temporal gyrus, and bilateral hippocampi. Various parietal regions and the nucleus accumbens were also implicated. EEG studies showed supporting evidence of functional changes in frontal regions. Conclusion Additional inquiry with attention to TBI without depression control groups, consistent TBI definitions, previous TBI, clinically diagnosed syndromal depression, imaging timing post-injury, acute prospective design, functional neuroimaging, and well-defined neuroanatomical regions of interest is crucial to extrapolating finer discrepancies between primary and TBI-related depression.

Objective Citation analyses identify the most-cited publications in a given field, which aids in understanding areas of the literature that are well-developed and those where additional research is required. Our objective was to perform a citation analysis in concussion to understand the state of the science from a bibliometric perspective. Design We performed a keyword search for articles related to concussion in Harzing's Publish or Perish, which scrapes Google Scholar for citation metrics. This approach was used to identify the 50 articles with the most lifetime citations as well as the 50 articles with the highest citation rate. Main outcome measures Citations and citation rates. Results Per our citation analysis, we found that concussion guidelines are among the most cited publications (comprising ≥20% of each citation cohort), yet there is a dearth of widely cited clinical trials to inform them; only one randomized trial (studying the effects of rest following concussion) was included in our citation analysis. The majority of study designs (≥40% of each citation cohort) were cross-sectional. Concussion recovery and secondary complications of concussion were common study topics, with ≥20% of publications in each citation cohort focused on these issues. The publications included in our analysis were authored by 596 authors from only 12 countries, suggesting a lack of global representation in concussion research. Conclusions Existing reviews and consensus statements have called for additional, high-quality research in concussion; our citation analysis quantifies this need. Further, although concussion is a global problem with its incidence and burden increasing in the developing world, our citation analysis demonstrates that the most-cited and discussed articles in concussion are published by authors from only 12 countries. Going forward, to address the global problem that is concussion, a more global research perspective is called for.

Background There is a need for objective biomarkers of sports-related concussion that are unaffected by physical and cognitive exertion. Electroencephalography-based biomarkers such as steady-state visually evoked potentials (SSVEPs) have been proposed as one such biomarker. The aim of this study was to investigate the effects of cognitive and physical exertion on SSVEP signal-to-noise ratio (SNR). Methods This study involved two experiments. The first experiment was performed in a controlled laboratory environment and involved a treadmill run designed to induce physical fatigue and a Stroop task designed to induce mental fatigue, completed in a randomized order on two separate visits. SSVEPs were evoked using a 15-Hz strobe using a Nurochek headset before and after each task. Changes in the 15-Hz SSVEP SNR and self-reported fatigue (visual analog scales) were assessed. In the second experiment, SSVEP SNR was measured before and after real-world boxing matches. Paired t-tests compared pre- and post-task SSVEP SNR and fatigue scores. Results Eighteen participants were recruited for experiment 1. Following the treadmill run, participants reported higher physical fatigue, mental fatigue, and overall fatigue ( p ≤ 0.005; d ≥ 0.90). Following the Stroop task, participants reported higher mental fatigue and overall fatigue ( p < 0.001; d ≥ 1.16), but not physical fatigue. SSVEP SNR scores were unchanged following either the Stroop task ( p = 0.059) or the treadmill task ( p = 0.590). Seven participants were recruited for experiment 2. SSVEP SNR scores were unchanged following the boxing matches ( p = 0.967). Conclusions The results of both experiments demonstrate that SSVEP SNR scores were not different following the treadmill run, Stroop task or amateur boxing match. These findings provide preliminary evidence that SSVEP fidelity may not be significantly affected by physical and cognitive exertion paradigms.

Background Clinical practice guidelines are systematically developed statements that assist clinicians in making evidence informed decisions regarding patient care. Within pediatric concussion, the Ontario Neurotrauma Foundation released the Guidelines for Diagnosing and Managing Pediatric Concussion in 2014. The purpose of this study was to evaluate the 2014 guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) evaluation tool, in addition to a brief knowledge translation survey, and to utilize the collected feedback from end users to inform improvements to support an updated version. An integrated knowledge translation approach was employed using clinical experts as guideline appraisers. Methods A purposive sample of researchers, physicians, allied health professionals, policy makers, educators and knowledge translation experts involved in updating the guidelines (N = 31) completed the AGREE II Likert scale survey regarding the 2014 guideline, and provided written justifications for their ratings. Domain and item AGREE II scaled scores were reported stratified by demographic factors, and written justifications were synthesized using content analysis to determine areas of improvement for the 2014 guideline. Results Appraisers scored the editorial independence (88.9%) and scope and purpose (80.8%) domains the highest, indicating high quality. The guidelines scored the lowest in the applicability domain (69.3%). Participants with less than 10 years of experience in their respective disciplines, as well as physicians and allied health professionals consistently provided higher ratings across domains compared to other professions. Conclusions The process of evaluating the 2014 guideline resulted in these important outcomes: (1) identified areas of the guideline that may have affected the lack of previous clinical uptake while abiding by a clinical practice guideline development framework; (2) shared and informed decision making regarding content and format of the revised clinical practice guideline; and (3) targeted content, clinical questions and dissemination strategies, which are key to clinical uptake.

Context Sport-related concussions (SRC) are common in student athletes. However, current literature suggests that many athletes do not accurately report their symptoms. The under-reporting of concussion symptoms can result in an increased risk of further injury and an underestimation of concussion prevalence. Objective This study aims to identify perspectives on concussion reporting behaviors in student athletes across levels of contact and by sex. Design Cross-sectional study. Setting Elementary and high school, college. Patients or other participants: 1126 female (52%) and male (48%) athletes, mean age 16.6 years. Main outcome measure(s): Standardized questionnaire on concussion reporting during a series of hypothetical scenarios. Results Student athletes participating in sports with higher levels of contact had more education about concussions, yet professed they were less likely to report a concussion. The most common reasons athletes chose not to report were ‘not wanting to miss the game’ and ‘not wanting to let the coach down.’ Minimal differences were found between sexes, with females being just as unlikely, or sometimes more unlikely, to report a concussion than males. Lastly, females playing contact and non-contact sports appear to be more concerned about not wanting to let their coach down than males. Conclusions Although perspective on concussion reporting behavior varied across sports of different levels of contact, we did not find any conclusive evidence of differences in willingness to report a concussion between sexes when compared within the same level of contact.

Objective To report the observed effect of erenumab in mild posttraumatic headache migraine phenotype with and without aura. Background There is no clinical algorithm of pharmacotherapy for migraine following posttraumatic headache. Most migraine preventatives that are typically used are either ineffective or not tolerated. Methods Seven patients who met the clinical criteria for migraine with or without aura following posttraumatic headache who failed or were intolerant of conventional migraine preventatives were treated with erenumab 140 mg subcutaneously. Most had no history of migraine. In those patients with a history of migraine, the posttraumatic headache migraine headaches were different than the past migraine experience. Descriptive headache intensity or disability using the Head Impact Test-6 and monthly headache days were recorded before and after treatment. All patients were debilitated on presentation and demonstrated no signs of spontaneous resolution. Results Patients responded with a 95% (SD 1.22, p < .001) reduction in headache days. All Head Impact Test-6 scores went from disabling to non-disabling without adverse effects. Most required only one dose of erenumab with no migraine recurrence. Onset of efficacy often became apparent within days to four weeks. Extended follow-up six months after treatment revealed no relapses. Conclusions Erenumab is effective in the treatment of posttraumatic headache with migraine phenotype in this small cohort. Large-scale studies are urgently required for this highly prevalent, disabling, condition which has no effective established treatment.

Background Between 1.6 and 3.8 million sports- and recreation-related concussions occur in the United States annually. Reports indicate that a significant number of athletes who have experienced symptoms of a potential sport-related concussion did not disclose their symptoms. Aims The purpose of this study was to investigate the impact of coach communication about concussion disclosure on student-athlete intentions to disclose symptoms of a concussion and encourage another student-athlete to disclose their concussion symptoms. Methods A total of 2881 student-athletes completed a web-based survey during Fall of 2016. Multiple linear regression was conducted to primarily investigate the relationship between coach communication and intentions to disclose concussion symptoms. Secondarily, biological sex, year in school, athletic division, and sport category was also assessed. Results Coach communication predicted greater intentions to disclose symptoms to their coach, athletic trainer/sports medicine sports medicine staff member and encourage another athlete to disclose their symptoms of a concussion. Biological sex and sport category also predicted intentions to disclose concussion symptoms. Discussion Findings from this study provide support for the important role coaches play in an athlete’s regarding concussion safety and introduces preliminary evidence suggesting the impact of coach communication on athlete intentions to disclose concussion symptoms to a coach or athletic trainer/sports medicine staff member. Conclusion Future studies and behavioral interventions ought to consider the inclusion of coach communication or other coach-related variables when exploring concussion disclosure among athletes.

Brain-derived neurotrophic factor (BDNF) helps restore neuronal function following mild traumatic brain injury. BDNF levels can be obtained in blood serum and more recently in saliva. However, the relationship between serum and salivary BDNF is poorly understood—especially in relation to alterations in BDNF levels following mild traumatic brain injury. In this study, serum and salivary BDNF were collected from a sample of 42 collegiate student athletes. Half of the participants were recently cleared by a physician and/or an athletic trainer to return-to-play after experiencing a sports-related concussion. The other half had not experienced a concussion within the past year and were matched by age, sex, sport, and time of sample. Results suggest that incidences of depression, anxiety, and stress were all elevated in the concussion group, relative to the control participants. When controlling for stress-related negative affect, serum BDNF was elevated in the concussion group. However, there was no difference in salivary BDNF. Serum and salivary BDNF were uncorrelated across the entire sample. Yet, these measures of BDNF were correlated in the concussion group, but not the control group. In sum, serum BDNF is elevated in concussion post return-to-play; however, further research is needed to explore the utility of salivary BDNF following concussion.