1. Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Concussion Symptoms in American Football Athletes Kerr ZY, Zuckerman SL, Wasserman EB, Covassin T, Djoko A, Dompier TP. Concussion symptoms and return to play time in youth, high school, and college American football athletes. JAMA Pediatr. Published online May 2, 2016. doi:10.1001/jamapediatrics.2016.0073.

2. Copyright restrictions may apply Background –A 2013 report by the Institute of Medicine highlighted the need for more extensive concussion data in athletes aged 5 to 21 years, which encompasses youth, high school, and collegiate athletes. –Little research has examined concussion across the youth/adolescent spectrum and even less has examined concussion-related outcomes (ie, symptoms and return to play). Study Objective –To examine and compare sport-related concussion outcomes (symptoms and return to play) in youth, high school, and collegiate football athletes. Introduction

3. Copyright restrictions may apply Study Design –Descriptive, epidemiological study. Setting –Athletic trainers attended each practice and game during the 2012-2014 seasons and reported injuries. Data were collected from convenience samples of youth, high school, and collegiate football teams. Patients –The Youth Football Surveillance System included more than 3000 youth football athletes aged 5-14 years from 118 teams, providing 310 team seasons (ie, 1 team providing 1 season of data). –The National Athletic Treatment, Injury, and Outcomes Network Program included 96 secondary school football programs, providing 184 team seasons. –The National Collegiate Athletic Association Injury Surveillance Program included 34 college football programs, providing 71 team seasons. Methods

4. Copyright restrictions may apply Methods Outcomes –Mean number of symptoms. –Proportion of concussions with return-to-play time of <24 hours. –Proportion of concussions with return-to-play time of ≥30 days. Generalized linear models assessed differences among competition levels in the mean number of reported symptoms. Logistic regression models estimated odds of return to play <24 hours and ≥30 days. Clusters (league or team) were included in models. Limitations –Did not evaluate for varying organizational, policy, or individual factors that may differ at each competition level. –Number of athletic trainers vary by competition level; may contribute to observed variability. –Symptom prevalence measure is an aggregate of symptoms reported at any point during recovery.

5. Copyright restrictions may apply Results Overall, 1429 concussions were reported. Mean (SD) of 5.48 (3.06) symptoms reported per concussion. Compared with youth, a higher number of concussion symptoms were reported in high school (β = 1.39; 95% CI, 0.55-2.24). No difference was found between college and youth or between high school and college. Mean number of symptoms reported by athletes with concussions in youth, high school, and college football, 2012 to 2014 seasons.

6. Copyright restrictions may apply Results 15.5% of concussions required ≥30 days before return to play. Odds of return-to-play time of ≥30 days were greater in youth (odds ratio = 2.75; 95% CI, 1.10-6.85) and high school (odds ratio = 2.89; 95% CI, 1.61-5.19) athletes than in college athletes. No difference was found between high school and youth. Percentage of concussions in youth, high school, and college football requiring ≥30 days before return to play, 2012 to 2014 seasons.

7. Copyright restrictions may apply Results 3.1% of concussions resulted in return to play in <24 hours. Odds of return-to-play time <24 hours were greater in youth athletes than in high school athletes (odds ratio = 6.23; 95% CI, 1.02-37.98). No difference was found between youth and college or between high school and college. Percentage of concussions in youth, high school, and college football with return-to-play time <24 hours, 2012 to 2014 seasons

8. Copyright restrictions may apply Comment The mean reported number of concussion-related symptoms was lowest in youth football athletes. Caution should be used in interpretation of these findings, as the understanding of the symptoms may vary by the age of those reporting. –Interviews with athletic trainers evaluating youth football athletes cited unfamiliarity with the youth population as the greatest challenge in assessing concussion. They also noted that young children may lack understanding of concussion symptoms. –Such challenges may have led to youth athletes reporting symptoms differently from their older counterparts. –These issues may also explain the larger percentage of concussions with return-to-play time <24 hours if youth athletes are unable to describe concussion symptoms sufficiently. Additional exploration of child-friendly methods to detect and diagnose concussions is warranted.

9. Copyright restrictions may apply Possible reasons for observed age differences: –Variations in settings, particularly organizational and policy initiatives or the number of athletic trainers and sports medicine professionals present. –Younger athletes in youth and high school settings generally have less access to resources regularly available in college programs (eg, medical professionals, neurologists, tutors, time management advisors). –Biological factors, such as puberty and brain development. Future research needs to consider variations in these settings and determine which factors are most beneficial to a safe and timely recovery for athletes with concussions. Comment

10. Copyright restrictions may apply If you have questions, please contact the corresponding author: –Zachary Y. Kerr, PhD, MPH, Datalys Center for Sports Injury Research and Prevention Inc, 401 W Michigan St, Ste 500, Indianapolis, IN 46202 (zkerr@datalyscenter.org). Funding/Support This work was supported by USA Football; the National Athletic Trainers’ Association Research and Education Foundation; BioCrossroads in partnership with the Central Indiana Corporate Partnership Foundation; and the National Collegiate Athletic Association. Conflict of Interest Disclosures None reported. Contact Information