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Wilde EA, Hunter JV, Li X, Amador C, Hanten G, Newsome MR, Wu TC, McCauley SR, Vogt GS, Chu ZD, Biekman B, Levin HS. Chronic Effects of Boxing: Diffusion Tensor Imaging and Cognitive Findings. J Neurotrauma 2015; 33:672-80. [PMID: 26414735 DOI: 10.1089/neu.2015.4035] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We used magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) to evaluate the effects of boxing on brain structure and cognition in 10 boxers (8 retired, 2 active; mean age = 45.7 years; standard deviation [SD] = 9.71) and 9 participants (mean age = 43.44; SD = 9.11) in noncombative sports. Evans Index (maximum width of the anterior horns of the lateral ventricles/maximal width of the internal diameter of the skull) was significantly larger in the boxers (F = 4.52; p = 0.050; Cohen's f = 0.531). Word list recall was impaired in the boxers (F(1,14) = 10.70; p = 0.006; f = 0.84), whereas implicit memory measured by faster reaction time (RT) to a repeating sequence of numbers than to a random sequence was preserved (t = 2.52; p < 0.04). Fractional anisotropy (FA) and the apparent diffusion coefficient (ADC) measured by tractography did not significantly differ between groups. However, DTI metrics were significantly correlated with declarative memory (e.g., left ventral striatum ADC with delayed recall, r = -0.74; p = 0.02) and with RT to the repeating number sequence (r = 0.70; p = 0.04) in the boxers. Years of boxing had the most consistent, negative correlations with FA, ranging from -0.65 for the right ventral striatum to -0.92 for the right cerebral peduncle. Years of boxing was negatively related to the number of words consistently recalled over trials (r = -0.74; p = 0.02), delayed recall (r = -0.83; p = 0.003), and serial RT (r = 0.66; p = 0.05). We conclude that microstructural integrity of white matter tracts is related to declarative memory and response speed in boxers and to the extent of boxing exposure. Implications for chronic traumatic encephalopathy are discussed.
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Affiliation(s)
- Elisabeth A Wilde
- 1 Rehabilitation Research & Development, Michael E. DeBakey VA Medical Center , Houston, Texas.,2 Baylor College of Medicine , Houston, Texas
| | | | - Xiaoqi Li
- 2 Baylor College of Medicine , Houston, Texas
| | | | | | - Mary R Newsome
- 1 Rehabilitation Research & Development, Michael E. DeBakey VA Medical Center , Houston, Texas.,2 Baylor College of Medicine , Houston, Texas
| | - Trevor C Wu
- 4 Hauenstein Neurosciences , Mercy Health St. Mary's, Grand Rapids, Michigan
| | - Stephen R McCauley
- 1 Rehabilitation Research & Development, Michael E. DeBakey VA Medical Center , Houston, Texas.,2 Baylor College of Medicine , Houston, Texas
| | - Gregory S Vogt
- 1 Rehabilitation Research & Development, Michael E. DeBakey VA Medical Center , Houston, Texas
| | | | | | - Harvey S Levin
- 1 Rehabilitation Research & Development, Michael E. DeBakey VA Medical Center , Houston, Texas.,2 Baylor College of Medicine , Houston, Texas
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52
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Saigal R, Berger MS. The long-term effects of repetitive mild head injuries in sports. Neurosurgery 2015; 75 Suppl 4:S149-55. [PMID: 25232880 DOI: 10.1227/neu.0000000000000497] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
At least 300 000 sports-related concussions occur in the United States annually. With millions of American athletes, the long-term effects of repeated concussion or mild traumatic brain injury are an important topic. Unfortunately, there is a lack of strong data on the causality or prevalence of long-term effects among athletes. Chronic traumatic encephalopathy (CTE), a progressive neurodegenerative tauopathy, with associated clinical, behavioral, and neuropathological findings, is an important clinical entity in need of further study. Diffusion tensor imaging can elucidate trauma-induced white matter damage, but the diagnosis of CTE cannot be proven until postmortem neuropathology shows characteristic neurofibrillary and astrocytic tangles. Concern exists that athletes subject to repeated concussive and even subconcussive blows may be at risk of CTE, but no definitive data exist due to the difficulty in diagnosis. Animal models suggest that mild traumatic brain injuries lead to primarily a metabolic derangement with increased excitotoxic neurotransmitter release, extracellular potassium, and intracellular calcium. Further understanding of the underlying pathophysiology may eventually lead to better therapeutic and diagnostic options for the treating clinician.
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Affiliation(s)
- Rajiv Saigal
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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53
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Chronic Traumatic Encephalopathy and Traumatic Brain Injury: Bridging Pathology, Function, and Prognosis. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0089-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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54
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Koerte IK, Lin AP, Willems A, Muehlmann M, Hufschmidt J, Coleman MJ, Green I, Liao H, Tate DF, Wilde EA, Pasternak O, Bouix S, Rathi Y, Bigler ED, Stern RA, Shenton ME. A review of neuroimaging findings in repetitive brain trauma. Brain Pathol 2015; 25:318-49. [PMID: 25904047 PMCID: PMC5699448 DOI: 10.1111/bpa.12249] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 12/14/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease confirmed at postmortem. Those at highest risk are professional athletes who participate in contact sports and military personnel who are exposed to repetitive blast events. All neuropathologically confirmed CTE cases, to date, have had a history of repetitive head impacts. This suggests that repetitive head impacts may be necessary for the initiation of the pathogenetic cascade that, in some cases, leads to CTE. Importantly, while all CTE appears to result from repetitive brain trauma, not all repetitive brain trauma results in CTE. Magnetic resonance imaging has great potential for understanding better the underlying mechanisms of repetitive brain trauma. In this review, we provide an overview of advanced imaging techniques currently used to investigate brain anomalies. We also provide an overview of neuroimaging findings in those exposed to repetitive head impacts in the acute/subacute and chronic phase of injury and in more neurodegenerative phases of injury, as well as in military personnel exposed to repetitive head impacts. Finally, we discuss future directions for research that will likely lead to a better understanding of the underlying mechanisms separating those who recover from repetitive brain trauma vs. those who go on to develop CTE.
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Affiliation(s)
- Inga K. Koerte
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- Department of Child and Adolescent PsychiatryPsychosomatic and PsychotherapyDr. von Hauner Children's HospitalLudwig‐Maximilian UniversityMunichGermany
| | - Alexander P. Lin
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- Center for Clinical SpectroscopyDepartment of RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Anna Willems
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- Department of Child and Adolescent PsychiatryPsychosomatic and PsychotherapyDr. von Hauner Children's HospitalLudwig‐Maximilian UniversityMunichGermany
| | - Marc Muehlmann
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- Department of Child and Adolescent PsychiatryPsychosomatic and PsychotherapyDr. von Hauner Children's HospitalLudwig‐Maximilian UniversityMunichGermany
| | - Jakob Hufschmidt
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- Department of Pediatric NeurologyDr. von Hauner Children's HospitalLudwig‐Maximilian UniversityMunichGermany
| | - Michael J. Coleman
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Isobel Green
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Huijun Liao
- Center for Clinical SpectroscopyDepartment of RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - David F. Tate
- General Dynamic Information Technologies ContractorDefense and Veterans Brain Injury CentersSan Antonio Military Medical CenterSan AntonioTX
| | - Elisabeth A. Wilde
- Departments of Physical Medicine and RehabilitationNeurology and RadiologyBaylor College of MedicineSan AntonioTX
- Michael E. DeBakey VA Medical CenterSan AntonioTX
| | - Ofer Pasternak
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Sylvain Bouix
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Yogesh Rathi
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Erin D. Bigler
- Neuroscience Center and Department of PsychologyBrigham Young UniversityProvoUT
| | - Robert A. Stern
- Departments of Neurology, Neurosurgery, and Anatomy and Neurobiology, Boston University Alzheimer's Disease CenterBoston University School of MedicineBostonMA
| | - Martha E. Shenton
- Psychiatry Neuroimaging LaboratoryDepartments of Psychiatry and RadiologyBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- VA Boston Healthcare SystemBostonMA
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Montenigro PH, Bernick C, Cantu RC. Clinical features of repetitive traumatic brain injury and chronic traumatic encephalopathy. Brain Pathol 2015; 25:304-17. [PMID: 25904046 PMCID: PMC8029369 DOI: 10.1111/bpa.12250] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 12/14/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease characterized by a distinct pattern of hyperphosphorylated tau (p-tau). Thought to be caused by repetitive concussive and subconcussive injuries, CTE is considered largely preventable. The majority of neuropathologically confirmed cases have occurred in professional contact sport athletes (eg, boxing, football). A recent post-mortem case series has magnified concerns for the public's health following its identification in six high school level athletes. CTE is diagnosed with certainty only following a post-mortem autopsy. Efforts to define the etiology and clinical progression during life are ongoing. The goal of this article is to characterize the clinical concepts associated with short- and long-term effects of repetitive traumatic brain injury, with a special emphasis on new clinical diagnostic criteria for CTE. Utilizing these new diagnostic criteria, two cases of neuropathologically confirmed CTE, one in a professional football player and one in a professional boxer, are reported. Differences in cerebellar pathology in CTE confirmed cases in boxing and football are discussed.
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Affiliation(s)
- Philip H. Montenigro
- Chronic Traumatic Encephalopathy CenterBoston University School of MedicineBostonMA
- Department of Anatomy and NeurobiologyBoston University School of MedicineBostonMA
| | | | - Robert C. Cantu
- Chronic Traumatic Encephalopathy CenterBoston University School of MedicineBostonMA
- Department of Neurology and NeurosurgeryBoston University School of MedicineBostonMA
- Department of NeurosurgeryEmerson HospitalConcordMA
- Sports Legacy InstituteWalthamMA
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56
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Montenigro PH, Corp DT, Stein TD, Cantu RC, Stern RA. Chronic traumatic encephalopathy: historical origins and current perspective. Annu Rev Clin Psychol 2015; 11:309-30. [PMID: 25581233 DOI: 10.1146/annurev-clinpsy-032814-112814] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is most often identified in postmortem autopsies of individuals exposed to repetitive head impacts, such as boxers and football players. The neuropathology of CTE is characterized by the accumulation of hyperphosphorylated tau protein in a pattern that is unique from that of other neurodegenerative diseases, including Alzheimer's disease. The clinical features of CTE are often progressive, leading to dramatic changes in mood, behavior, and cognition, frequently resulting in debilitating dementia. In some cases, motor features, including parkinsonism, can also be present. In this review, the historical origins of CTE are revealed and an overview of the current state of knowledge of CTE is provided, including the neuropathology, clinical features, proposed clinical and pathological diagnostic criteria, potential in vivo biomarkers, known risk factors, and treatment options.
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Affiliation(s)
- Philip H Montenigro
- Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, Massachusetts 02118; , ,
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57
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Murugavel M, Cubon V, Putukian M, Echemendia R, Cabrera J, Osherson D, Dettwiler A. A longitudinal diffusion tensor imaging study assessing white matter fiber tracts after sports-related concussion. J Neurotrauma 2014; 31:1860-71. [PMID: 24786666 PMCID: PMC4224056 DOI: 10.1089/neu.2014.3368] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The extent of structural injury in sports-related concussion (SRC) is central to the course of recovery, long-term effects, and the decision to return to play. In the present longitudinal study, we used diffusion tensor imaging (DTI) to assess white matter (WM) fiber tract integrity within 2 days, 2 weeks, and 2 months of concussive injury. Participants were right-handed male varsity contact-sport athletes (20.2±1.0 years of age) with a medically diagnosed SRC (no loss of consciousness). They were compared to right-handed male varsity non-contact-sport athletes serving as controls (19.9±1.7 years). We found significantly increased radial diffusivity (RD) in concussed athletes (n=12; paired t-test, tract-based spatial statistics; p<0.025) at 2 days, when compared to the 2-week postinjury time point. The increase was found in a cluster of right hemisphere voxels, spanning the posterior limb of the internal capsule (IC), the retrolenticular part of the IC, the inferior longitudinal fasciculus, the inferior fronto-occipital fasciculus (sagittal stratum), and the anterior thalamic radiation. Post-hoc, univariate, between-group (controls vs. concussed), mixed-effects analysis of the cluster showed significantly higher RD at 2 days (p=0.002), as compared to the controls, with a trend in the same direction at 2 months (p=0.11). Results for fractional anisotropy (FA) in the same cluster showed a similar, but inverted, pattern; FA was decreased at 2 days and at 2 months postinjury, when compared to healthy controls. At 2 weeks postinjury, no statistical differences between concussed and control athletes were found with regard to either RD or FA. These results support the hypothesis of increased RD and reduced FA within 72 h postinjury, followed by recovery that may extend beyond 2 weeks. RD appears to be a sensitive measure of concussive injury.
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Affiliation(s)
- Murali Murugavel
- Princeton Neuroscience Institute, Princeton University, Princeton New Jersey
| | - Valerie Cubon
- Department of Chemistry, Kent State University, Warren, Ohio
| | - Margot Putukian
- University Health Services, Princeton University, Princeton, New Jersey
| | - Ruben Echemendia
- Psychological and Neurobehavioral Associates, Inc., State College, Pennsylvania
| | - Javier Cabrera
- Department of Statistics, Rutgers University, Piscataway, New Jersey
| | - Daniel Osherson
- Department of Psychology, Princeton University, Princeton, New Jersey
| | - Annegret Dettwiler
- Princeton Neuroscience Institute, Princeton University, Princeton New Jersey
- University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey
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59
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Abstract
BACKGROUND Mixed martial arts (MMA) is a full combative sport with a recent global increase in popularity despite significant scrutiny from medical associations. To date, the empirical research of the risk of head injuries associated with this sport is limited. Youth and amateur participation is growing, warranting investigation into the burden and mechanism of injuries associated with this sport. PURPOSE (1) To determine the incidence, risk factors, and characteristics of knockouts (KOs) and technical knockouts (TKOs) from repetitive strikes in professional MMA; and (2) to identify the mechanisms of head trauma and the situational factors that lead to KOs and TKOs secondary to repetitive strikes through video analysis. STUDY DESIGN Descriptive epidemiology study. METHODS Competition data and video records for all KOs and TKOs from numbered Ultimate Fighting Championship MMA events (n = 844) between 2006 to 2012. Analyses included (1) multivariate logistic regression to investigate factors associated with an increased risk of sustaining a KO or TKO secondary to repetitive strikes and (2) video analysis of all KOs and TKOs secondary to repetitive strikes with descriptive statistics. RESULTS During the study period, the KO rate was 6.4 per 100 athlete-exposures (AEs) (12.7% of matches), and the rate of TKOs secondary to repetitive strikes was 9.5 per 100 AEs (19.1% of matches), for a combined incidence of match-ending head trauma of 15.9 per 100 AEs (31.9% of matches). Logistic regression identified that weight class, earlier time in a round, earlier round in a match, and older age were risk factors for both KOs and TKOs secondary to repetitive strikes. Match significance and previously sustained KOs or TKOs were also risk factors for KOs. Video analysis identified that all KOs were the result of direct impact to the head, most frequently a strike to the mandibular region (53.9%). The average time between the KO-strike and match stoppage was 3.5 seconds (range, 0-20 seconds), with losers sustaining an average of 2.6 additional strikes (range, 0-20 strikes) to the head. For TKOs secondary to strikes, in the 30-second interval immediately preceding match stoppage, losers sustained, on average, 18.5 strikes (range, 5-46 strikes), with 92.3% of these being strikes to the head. CONCLUSION Rates of KOs and TKOs in MMA are higher than previously reported rates in other combative and contact sports. Public health authorities and physicians should be cognizant of the rates and mechanisms of head trauma. Preventive measures to lessen the risks of head trauma for those who elect to participate in MMA are described.
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Affiliation(s)
- Michael G Hutchison
- David L. MacIntosh Sport Medicine Clinic, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - David W Lawrence
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Cusimano
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Division of Neurosurgery, Injury Prevention Research Office, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tom A Schweizer
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Keenan Research Centre for Biomedical Science of St Michael's Hospital, Toronto, Ontario, Canada
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60
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Bernick C, Banks S. What boxing tells us about repetitive head trauma and the brain. ALZHEIMERS RESEARCH & THERAPY 2013; 5:23. [PMID: 23731821 PMCID: PMC3706825 DOI: 10.1186/alzrt177] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Boxing and other combat sports may serve as a human model to study the effects of repetitive head trauma on brain structure and function. The initial description of what is now known as chronic traumatic encephalopathy (CTE) was reported in boxers in 1928. In the ensuing years, studies examining boxers have described the clinical features of CTE, its relationship to degree of exposure to fighting, and an array of radiologic findings. The field has been hampered by issues related to study design, lack of longitudinal follow-up, and absence of agreed-upon clinical criteria for CTE. A recently launched prospective cohort study of professional fighters, the Professional Fighters Brain Health Study, attempts to overcome some of the problems in studying fighters. Here, we review the cross-sectional results from the first year of the project.
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Affiliation(s)
- Charles Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W. Bonneville Avenue, Las Vegas, NV 89106, USA
| | - Sarah Banks
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W. Bonneville Avenue, Las Vegas, NV 89106, USA
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