Epidemiology of Sport-Related Concussion

Sports Related Concussion

Sports-related concussions (SRC) have been a topic of interest for decades and are a prevalent risk of sports participation. The definition of SRC continues to evolve but includes a plausible mechanism and associated symptoms of injury. Rates of concussion vary among sports, and many sports have adopted rule changes to limit this risk for its athletes. There has been a considerable effort to prevent the occurrence of SRC, as well as a focus on safe return to learn and sport alike. There is growing concern about the ramifications of concussions, which will continue to warrant further investigation.

Healthy childhood development through outdoor risky play: Navigating the balance with injury prevention

Free play is essential for children's development and for their physical, mental, and social health. Opportunities to engage in outdoor free play-and risky play in particular-have declined significantly in recent years, in part because safety measures have sought to prevent all play-related injuries rather than focusing on serious and fatal injuries. Risky play is defined by thrilling and exciting forms of free play that involve uncertainty of outcome and a possibility of physical injury. Proponents of risky play differentiate "risk" from "hazard" and seek to reframe perceived risk as an opportunity for situational evaluation and personal development. This statement weighs the burden of play-related injuries alongside the evidence in favour of risky play, including its benefits, risks, and nuances, which can vary depending on a child's developmental stage, ability, and social and medical context. Approaches are offered to promote open, constructive discussions with families and organizations. Paediatricians are encouraged to think of outdoor risky play as one way to help prevent and manage common health problems such as obesity, anxiety, and behavioural issues.

Le développement sain de l'enfant par le jeu risqué extérieur : un équilibre à trouver avec la prévention des blessures

Le jeu libre est essentiel pour le développement de l'enfant, de même que pour sa santé physique, mentale et sociale. Les occasions de se livrer au jeu libre extérieur, et au jeu risqué en particulier, ont considérablement diminué ces dernières années, en partie parce que les mesures de sécurité ont visé à prévenir toutes les blessures liées aux jeux plutôt que seulement les blessures graves et fatales. Le jeu risqué désigne des formes passionnantes et stimulantes de jeu libre dont l'issue est incertaine et qui comportent une possibilité de blessure physique. Les promoteurs du jeu risqué distinguent le « risque » du « danger » et aspirent à recadrer la perception du risque pour qu'il devienne une occasion d'évaluer une situation et de favoriser le développement personnel. Dans le présent document de principes, les auteures soupèsent le fardeau des blessures liées au jeu par rapport aux données probantes en appui au jeu risqué, notamment les avantages, les risques et les nuances, qui peuvent varier en fonction de l'étape de développement de l'enfant, de ses aptitudes et du contexte social et médical. Elles proposent des approches pour promouvoir des échanges ouverts et constructifs avec les familles et les organisations. Les pédiatres sont invités à percevoir le jeu risqué extérieur comme un moyen de contribuer à prévenir et à gérer des problèmes de santé courants tels que l'obésité, l'anxiété et les problèmes de comportement.

Quantitative Pupillometry Predicts Return to Play and Tracks the Clinical Evolution of Mild Traumatic Brain Injury in US Military Academy Cadets: A Military Traumatic Brain Injury Initiative Study

BACKGROUND AND OBJECTIVES

The objective of this study was to determine the utility of the pupillary light reflex use as a biomarker of mild traumatic brain injury (mTBI).

METHODS

This prospective cohort study was conducted at The US Military Academy at West Point. Cadets underwent a standard battery of tests including Balance Error Scoring System, Sports Concussion Assessment Tool Fifth Edition Symptom Survey, Standard Assessment of Concussion, and measure of pupillary responses. Cadets who sustained an mTBI during training events or sports were evaluated with the same battery of tests and pupillometry within 48 hours of the injury (T1), at the initiation of a graded return to activity protocol (T2), and at unrestricted return to activity (T3).

RESULTS

Pupillary light reflex metrics were obtained in 1300 cadets at baseline. During the study period, 68 cadets sustained mTBIs. At T1 (<48 hours), cadets manifested significant postconcussion symptoms (Sports Concussion Assessment Tool Fifth Edition P < .001), and they had decreased cognitive performance (Standardized Assessment of Concussion P < .001) and higher balance error scores (Balance Error Scoring System P < .001) in comparison with their baseline assessment (T0). The clinical parameters showed normalization at time points T2 and T3. The pupillary responses demonstrated a pattern of significant change that returned to normal for several measures, including the difference between the constricted and initial pupillary diameter (T1 P < .001, T2 P < .05), dilation velocity (T1 P < .01, T2 P < .001), and percent of pupillary constriction (T1 P < .05). In addition, a combination of dilation velocity and maximum constriction velocity demonstrates moderate prediction ability regarding who can return to duty before or after 21 days (area under the curve = 0.71, 95% CI [0.56-0.86]).

CONCLUSION

This study's findings indicate that quantitative pupillometry has the potential to assist with injury identification and prediction of symptom severity and duration.

Efficacy of restitutive interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Mild traumatic brain injury (mTBI) can cause persistent symptoms suggestive of oculomotor deficits. This research synthesized evidence on restitutive interventions for reducing oculomotor deficits in adults with mTBI to understand if these interventions have clinical utility for improving recovery.

METHODS

Medline, EMBASE, CINHAL, PsychInfo, and Scopus, databases were searched for experimental studies published in English. We rated risk of bias (RoB) using recommended tools, and the certainty of the evidence according to GRADE guidelines. We conducted meta-analyses for similar outcomes reported in at least two studies.

RESULTS

Out of 5,328 citations, 12 studies (seven case series and five crossover design), with a combined sample size of 354 participants; (43% males) met the inclusion criteria and were analyzed. The analysis revealed a trend toward improvement of oculomotor deficits and visual tasks in response to restitutive intervention. None of the studies addressed sex or gender effects. All studies had high RoB, suggesting low certainty in the reported results.

DISCUSSION

Restitutive interventions may be beneficial for adults with oculomotor deficits after mTBI, however overall certainty of the evidence remains low. Future efforts must include enhancing attention to study methodology and reporting, sex and gender analyses, and reaching a consensus on outcome measures.

PROSPERO REGISTRATION NUMBER

CRD42022352276.

Sex Differences in Recovery Trajectories of Assessments for Sport-Related Concussion Among NCAA Athletes: A CARE Consortium Study

OBJECTIVES

The purpose of this study was to determine sex differences in recovery trajectories of assessments for sport-related concussion using Concussion Assessment, Research and Education (CARE) Consortium data.

METHODS

National Collegiate Athletic Association athletes (N = 906; 61% female) from sex-comparable sports completed a pre-season baseline assessment and post-sport-related concussion assessments within 6 h of injury, 24-48 h, when they initiated their return to play progression, when they were cleared for unrestricted return to play, and 6 months post-injury. Assessments included the Standardized Assessment of Concussion, Balance Error Scoring System, Brief Symptom Inventory-18, Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Sport Concussion Assessment Tool-3 symptom evaluation, Clinical Reaction Time, King-Devick test, Vestibular Ocular Motor Screen, 12-item Short-Form Health Survey, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale.

RESULTS

Only the Vestibular Ocular Motor Screen Total Symptom Score at the 24-48 h timepoint (p = 0.005) was statistically significantly different between sexes. Specifically, female athletes (mean = 60.2, 95% confidence interval [CI] 51.5-70.4) had higher Vestibular Ocular Motor Screen Total Symptom Scores than male athletes (mean = 36.9, 95% CI 27.6-49.3), but this difference resolved by the time of return-to-play initiation (female athletes, mean = 1.8, 95% CI 1.1-2.9; male athletes, mean = 4.1, 95% CI 1.5-10.9).

CONCLUSIONS

Sport-related concussion recovery trajectories for most assessments were similar for female and male National Collegiate Athletic Association athletes except for Vestibular Ocular Motor Screen symptoms within 48 h of sport-related concussion, which was greater in female athletes. Female athletes had a greater symptom burden across all timepoints, suggesting that cross-sectional observations may indicate sex differences despite similar recovery trajectories.

Mechanisms of Injury Leading to Concussions in Collegiate Soccer Players: A CARE Consortium Study

BACKGROUND

Few previous studies have investigated how different injury mechanisms leading to sport-related concussion (SRC) in soccer may affect outcomes.

PURPOSE

To describe injury mechanisms and evaluate injury mechanisms as predictors of symptom severity, return to play (RTP) initiation, and unrestricted RTP (URTP) in a cohort of collegiate soccer players.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The Concussion Assessment, Research and Education (CARE) Consortium database was used. The mechanism of injury was categorized into head-to-ball, head-to-head, head-to-body, and head-to-ground/equipment. Baseline/acute injury characteristics-including Sports Concussion Assessment Tool-3 total symptom severity (TSS), loss of consciousness (LOC), and altered mental status (AMS); descriptive data; and recovery (RTP and URTP)-were compared. Multivariable regression and Weibull models were used to assess the predictive value of the mechanism of injury on TSS and RTP/URTP, respectively.

RESULTS

Among 391 soccer SRCs, 32.7% were attributed to a head-to-ball mechanism, 27.9% to a head-to-body mechanism, 21.7% to a head-to-head mechanism, and 17.6% to a head-to-ground/equipment mechanism. Event type was significantly associated with injury mechanism [χ2(3) = 63; P < .001), such that more head-to-ball concussions occurred in practice sessions (n = 92 [51.1%] vs n = 36 [17.1%]) and more head-to-head (n = 65 [30.8%] vs n = 20 [11.1]) and head-to-body (n = 76 [36%] vs n = 33 [18.3%]) concussions occurred in competition. The primary position was significantly associated with injury mechanism [χ2(3) = 24; P < .004], with goalkeepers having no SRCs from the head-to-head mechanism (n = 0 [0%]) and forward players having the least head-to-body mechanism (n = 15 [19.2%]). LOC was also associated with injury mechanism (P = .034), with LOC being most prevalent in head-to-ground/equipment. Finally, AMS was most prevalent in head-to-ball (n = 54 [34.2%]) and head-to-body (n = 48 [30.4%]) mechanisms [χ2(3) = 9; P = .029]. In our multivariable models, the mechanism was not a predictor of TSS or RTP; however, it was associated with URTP (P = .044), with head-to-equipment/ground injuries resulting in the shortest mean number of days (14 ± 9.1 days) to URTP and the head-to-ball mechanism the longest (18.6 ± 21.6 days).

CONCLUSION

The mechanism of injury differed by event type and primary position, and LOC and AMS were different across mechanisms. Even though the mechanism of injury was not a significant predictor of acute symptom burden or time until RTP initiation, those with head-to-equipment/ground injuries spent the shortest time until URTP, and those with head-to-ball injuries had the longest time until URTP.

Postconcussion Moderate to Vigorous Physical Activity Predicts Anxiety Severity among Adolescent Athletes

PURPOSE

This study aimed to examine how moderate-to-vigorous physical activity (MVPA) during concussion recovery influences self-reported anxiety symptoms at follow-up assessment. We hypothesized that more MVPA after concussion would be associated with lower anxiety rating at follow-up.

METHODS

We performed a prospective study of participants aged 13-18 yr initially assessed within 14 d of diagnosed concussion. Participants rated concussion symptoms using the Post-Concussion Symptom Inventory and were provided a wrist-worn actigraphy device to track activity for 1 wk after assessment. At follow-up assessment, participants rated anxiety symptoms using the four-question Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety subscale. Each question ranged from 1 (never) to 5 (almost always), with an overall score range of 4-20. For univariable analysis, we calculated correlation coefficients between MVPA and PROMIS anxiety subscale scores. We then created a multiple linear regression model with follow-up PROMIS anxiety subscale score as the outcome and MVPA, sex, initial symptom severity, and preconcussion anxiety as predictors.

RESULTS

We enrolled and initially tested 55 participants, and 48 were included in the final analysis (age, 14.6±2.7 yr; 56% female; initial assessment, 7.3± 3.1 d; follow-up assessment, 42.0±29.7 d). We observed an inverse and low correlation between MVPA and follow-up PROMIS anxiety subscale T-scores ( r = -0.30, P = 0.04). Multivariable regression results indicated that MVPA ( β = -5.30; 95% confidence interval (CI), -10.58 to -0.01), initial Post-Concussion Symptom Inventory score ( β = 0.11; 95% CI, 0.03 to 0.19), and preconcussion anxiety ( β = 5.56; 95% CI, 0.12 to 11.0), but not sex ( β = -2.60; 95% CI, -7.14, to 1.94), were associated with follow-up PROMIS anxiety subscale T-scores.

CONCLUSIONS

After adjusting for covariates, more MVPA early after concussion predicted lower PROMIS anxiety subscale scores at follow-up. Although initial concussion symptom severity and preconcussion anxiety were also associated with follow-up PROMIS anxiety subscale score, MVPA represents a modifiable factor that may contribute to lower anxiety symptoms.

The Postconcussion Syndrome and Posttraumatic Headaches in Civilians, Soldiers, and Athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After a mild traumatic brain, an estimated 11% to 82% of people develop a postconcussion syndrome, which has been controversial for more than 160 years. Headache is estimated as present in 30% to 90% of patients after a mild head injury. Most headaches are tension-type-like or migraine-like. Headaches in civilians, soldiers, athletes, and postcraniotomy are reviewed. The treatments are the same as for the primary headaches. Persistent posttraumatic headaches can continue for many years.

Sport-related concussion knowledge and attitudes of staff working in English elite women's football: a survey-based study

BACKGROUND

Sport-related concussion (SRC) remains an injury of concern in sport, including football(soccer). There has been little investigation into SRC knowledge and attitudes of support staff working in the professional setting.

METHODS

An amended version of the Rosenbaum Concussion Knowledge and Attitudes Survey(RoCKAS) was distributed online to coaching staff, and medical and performance staff, working at clubs in the English Football Association Women's SuperLeague (WSL) and Championship. Completion of the survey generated two scores: concussion knowledge index (CKI) and concussion attitudes index (CAI).

RESULTS

Sixty-three completed surveys were returned. Eighteen respondents were coaching staff, and 45 were medical and performance staff. The median CKI in medical and performance staff was significantly greater than in coaching staff. There was no significant difference in CAIbetween coaching staff and medical and performance staff. There was no correlation between CKI and CAI across all staff.

CONCLUSION

Medical and performance staff working in elite women's football have greater knowledge of SRC than coaching staff. However, this does not always translate into safe behaviours on the field. Education should continue to be mandated across the professional game amongst support staff in order to maximise player welfare and enhance injury outcomes, whilst also reinforcing present SRC guidance.

Systematic Review Examining the Reporting of Race and Ethnicity in Sport-Related Concussion Studies

OBJECTIVE

Sport-related concussion (SRC) is an evolving public health concern among youth athletes. Despite emerging evidence that race and ethnicity are important factors in determining concussion outcomes, studies examining race and ethnicity are limited. We conducted a systematic review to (1) determine the prevalence of SRC studies in which participants' race or ethnicity is reported, (2) describe how race and ethnicity are used within each study, and (3) assess predictive factors for the reporting of race and ethnicity.

DATA SOURCES

PubMed, Embase, PsycINFO, and CINAHL databases.

STUDY SELECTION

Study inclusion criteria were (1) primary and peer-reviewed research; (2) related to the diagnosis, treatment, or recovery of SRC; (3) involving school-aged athletes (ages 5 to 25); and (4) with 25 or more participants. The search was performed in March 2021 and included only studies published after March 2013.

DATA EXTRACTION

For each article, we looked at whether race and ethnicity were reported, and if so, which races or ethnicities were mentioned. For each race or ethnicity mentioned, we extracted the corresponding sample size and how they were used as variables in the study.

DATA SYNTHESIS

Of 4583 studies screened, 854 articles met inclusion criteria. Of the included articles, 132 (15.5%) reported race, and 65 (7.6%) reported ethnicity, whereas 721 (84.4%) reported neither. When examining the demographic characteristics of the 132 studies that reported race, 69.8% of athletes were White. Additionally, 79.5% of these studies used race solely as a demographic descriptor as opposed to a main exposure or covariate of interest. Studies published more recently were more likely to report race. Further, studies in specific study or journal topics and specific geographic locations of the authors were more likely to report race.

CONCLUSIONS

Reporting of race and ethnicity is limited in current SRC literature. Future authors should improve the reporting of race and ethnicity, diversify study samples by focusing on enrolling athletes from underrepresented groups, and consider the potential effect of race and ethnicity as social determinants of health on risk factors, recovery, and long-term sequelae after SRC.

Analysis of Player Performance and Financial Costs Associated With Implementation of an Updated National Hockey League Concussion Protocol: A Retrospective Comparative Study

Background

An updated National Hockey League (NHL) concussion protocol (NHLCP) was established in the 2016-2017 season to mitigate the negative outcomes of sport-related concussions. However, few studies on the effects of implementing the NHLCP have been performed.

Purpose

To define concussion incidence and investigate differences in NHL player performance after a concussion during periods before and after NHLCP implementation and assess the financial impact on NHL teams associated with NHLCP implementation.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective review of NHL players who sustained a concussion before (2000-2001 to 2015-2016 seasons) and after (2016-2017 to 2020-2021 seasons) implementing the NHLCP (pre-NHLCP and post-NHLCP groups). For each group, multiple performance metrics-including 30 days, 1 season, and 3 seasons before and after concussion-were compared for both groups. Return to play, total concussion cost, and association of return to play with cost were investigated using regression analysis.

Results

A total of 452 players (423 skaters, 29 goalies) sustained concussions during the study period, including 331 players (315 skaters, 16 goalies) in the pre-NHLCP group and 121 players (108 skaters, 13 goalies) in the post-NHLCP group. For both groups, no significant differences in standard performance were observed during the 30-day and 1-season periods before and after concussion. The mean return to play was significantly higher in the pre-NHLCP group than in the post-NHLCP group (20.1 vs 15.7 days; P = .022). The mean adjusted player salary was not different between groups; nonetheless, the mean adjusted replacement player salary was significantly higher in the post-NHLCP group ($744,505 vs $896,942; P = .032). The mean cost of time missed did not differ between groups. The mean return to play time significantly decreased over the entire study period (R2 = 0.33; P = .005), and the mean return to play time was positively associated with cost R2 = 0.215; P = .030).

Conclusion

Concussion incidence did not change after implementation of the updated NHLCP; nonetheless, players had significantly less missed time from injury after protocol implementation. Changes in player performance 30 days and 1 year before and after concussion injury were not different before and after NHLCP implementation. No differences were found in the financial cost of concussions between the pre- and post-NHLCP groups, and missed time was significantly correlated with mean cost from missed time.

The Effect of Social Determinants of Health on Clinical Recovery Following Concussion: A Systematic Review

CONTEXT

Concussion evaluations include a multifaceted approach; however, individual differences can influence test score interpretations and validity. Social determinants of health (SDoH) differentially affect disease risk and outcomes based upon social and environmental characteristics. Efforts to better define, diagnose, manage, and treat concussion have increased, but minimal efforts have focused on examining SDoH that may affect concussion recovery.

OBJECTIVE

This review examined previous research that examined the effect of SDoH on concussion recovery of athletes.

EVIDENCE ACQUISITION

CINAHL, MEDLINE, PsycInfo, and SPORTDiscus databases were used to search the terms "concussion" AND "recovery," "youth, adolescent, teen and/or adult," and "social determinants of health" and variations of these terms. The evidence level for each study was evaluated using the 2011 Oxford Center for Evidence-Based Medicine Guide.

EVIDENCE SYNTHESIS

Seven thousand nine hundred and twenty-one articles were identified and screened for inclusion. Five studies met the inclusion criteria and were included in this systematic review. Using the Downs and Black Quality Index, the studies included in this review were deemed high quality.

CONCLUSION

Though limited literature exists, there is preliminary evidence to suggest that SDoH (specifically, economic stability, education access and quality, and social and community context) may have an impact on the clinical recovery from concussion. The dimensions evaluated varied between studies and the results were inconsistent. No single factor consistently affected clinical recovery; however, private insurance and race appear to have an association with the speed of recovery. Unfortunately, the potential intersection of these variables and other preinjury factors limits the ability to make clear recommendations. While most of the studies in this review are retrospective in nature, future efforts should focus on training clinicians to prospectively evaluate the effect of SDoH on concussion recovery and injury outcomes. Funding and registration for this systematic review were not obtained nor required.

Youth handball concussion prevention strategies: a workshop-based study with experts and end users

Sport-related concussion (SRC) is a serious injury in youth team sports, including handball. While research on the prevention of SRC has made progress over the past 5 years, prevention strategies are lacking in handball. The aim was to explore and develop strategies focusing on information, rules and training that may prevent concussion in youth handball by incorporating knowledge from experts and end users. Using a participatory methodology, experts (physiotherapy, biomechanics: n=3) and end users (players, coaches, referees, coach educators: n=7) contributed their experience and knowledge in a 2-hour online workshop. Participants were given three videos illustrating typical high-risk concussion scenarios from handball games and a youth player's accompanying fictional written scenario. In group discussions inspired by the brainwriting method, participants were asked to provide ideas for possible SRC prevention strategies related to information, rules and/or training. Data were collected on a digital whiteboard and analysed using reflexive thematic analysis. Three themes were derived: (1) 'Coaches' responsibility: raise awareness of the risk of injury and act to promote safe environments'; (2) 'Players' responsibility: safe defence and attack'; and (3) 'Improvement of personal skills'. Experts and end users found information about high-risk situations and SRC symptoms, stricter rules and safe playing strategy training for goalkeepers, attacking and defending players, respectively, may effectively reduce SRC in handball. Information and stricter rules could be delivered through education and dissemination activities, whereas safe playing strategies should be trained at regular handball practice.

Knowledge and Attitudes of Concussion Reporting Behavior Intentions in Parents of Youth Recreational Football Players

Purpose: This study: (1) Described the knowledge, attitudes, and reported behavior intentions of young recreational football players' parents toward concussion. (2) Investigated associations of the previous variables with parent demographics. Materials and Methods: A cross-sectional design utilized an online platform to survey parents of children (8-14 yrs.) in three youth football leagues in the southern United States. Demographics collected included items such as sex or concussion history. Knowledge was assessed via true/false items, with higher scores (0-20) representing greater concussion understanding. 4-point Likert scales were used to describe parents attitudes (1 = not at all, 4 = very much), confidence in intended recognition/reporting (1 = not-confident, 4 = extremely confident), and agreement with intended reporting behaviors (1 = strong- disagreement, 4 = strong-agreement). Descriptive statistics were calculated for demographics. Mann-Whitney U test or Kruskal-Wallis Tests examined survey responses across demographics. Results: Respondents (n = 101) were primarily female (64.4%), white (81.2%), and participated in contact sport (83.2%). Parents averaged 15.9 ± 1.4 on concussion knowledge, with only 34.7% (n = 35) of parents scoring > 17/20. Statements that received the lowest average agreement (3.29/4) regarding reporting intent were related to emotional symptoms. Some parents (n = 42, 41.6%) reported low confidence in recognizing symptoms of a concussion in their child. Parent demographics did not have clinically significant associations with survey responses, with 6/7 demographic variables resulting in no statistical significance (p > .05). Conclusions: Although one-third of parents attained high knowledge scores, several reported low confidence in recognizing concussion symptoms in their children. Parents scored lower in agreement with removing their child from play when concussion symptoms were subjective. Youth sports organizations providing concussion education to parents should consider these results when revising their materials.

Concussion-Related Disruptions to Hub Connectivity in the Default Mode Network Are Related to Symptoms and Cognition

Concussions present with a myriad of symptomatic and cognitive concerns; however, the relationship between these functional disruptions and the underlying changes in the brain are not yet well understood. Hubs, or brain regions that are connected to many different functional networks, may be specifically disrupted after concussion. Given the implications in concussion research, we quantified hub disruption within the default mode network (DMN) and between the DMN and other brain networks. We collected resting-state functional magnetic resonance imaging data from collegiate student-athletes (n = 44) at three time points: baseline (before beginning their athletic season), acute post-injury (approximately 48h after a diagnosed concussion), and recovery (after starting return-to-play progression, but before returning to contact). We used self-reported symptoms and computerized cognitive assessments collected across similar time points to link these functional connectivity changes to clinical outcomes. Concussion resulted in increased connectivity between regions within the DMN compared with baseline and recovery, and this post-injury connectivity was more positively related to symptoms and more negatively related to visual memory performance compared with baseline and recovery. Further, concussion led to decreased connectivity between DMN hubs and visual network non-hubs relative to baseline and recovery, and this post-injury connectivity was more negatively related to somatic symptoms and more positively related to visual memory performance compared with baseline and recovery. Relationships between functional connectivity, symptoms, and cognition were not significantly different at baseline versus recovery. These results highlight a unique relationship between self-reported symptoms, visual memory performance, and acute functional connectivity changes involving DMN hubs after concussion in athletes. This may provide evidence for a disrupted balance of within- and between-network communication highlighting possible network inefficiencies after concussion. These results aid in our understanding of the pathophysiological disruptions after concussion and inform our understanding of the associations between disruptions in brain connectivity and specific clinical presentations acutely post-injury.

Concussion Rates in Youth Lacrosse Players and Comparison With Youth American Football

Background

There has been little focus on concussions in youth lacrosse players in the United States.

Purpose

To provide a descriptive analysis of the epidemiology and incidence of concussions in youth lacrosse and compare the results with well-documented analyses of concussions in youth American football.

Study Design

Descriptive epidemiology study.

Methods

Data on concussions in pediatric patients playing lacrosse from 2006 to 2019 were collected using the National Electronic Injury Surveillance System (NEISS). Weighted calculations and combined participation data obtained from membership in USA Lacrosse were used to estimate injury incidence. A comparison dataset was created using the NEISS data on youth football-related concussions. The cause of concussion was categorized into player-to-player, player-to-stick, player-to-ball, or player-to-ground contact.

Results

A total of 37,974 concussion injuries related to lacrosse were identified in players with a mean age of 14.5 ± 3.5 years; 70% of concussions occurred in boys. National participation in lacrosse increased from 2006 to 2011 by a mean of 10.3% annually, followed by a lower annual growth rate of 2.5% from 2012 to 2019. The overall incidence of concussion injuries increased over the study period (r = 0.314), with the incidence rate in boys being greater than that of girls from 2009 to 2013. The most common cause of concussion was player-to-ground contact for boys and player-to-ball or player-to-stick contact for girls. The mean annual concussion incidences in youth lacrosse and youth football were 443 and 355 per 100,000 participants, respectively.

Conclusion

Over the study period, 16% of lacrosse injuries were diagnosed as concussions, a higher mean annual incidence per 100,000 participants than that of youth football (443 vs 355). The cause of concussion was different based on sex, with higher rates of player-to-ball or player-to-stick contact in female players versus player-to-ground contact in male players.

Sport-related concussion in soccer -a scoping review of available guidelines and a call for action to FIFA & soccer governing bodies

Introduction

Sport-related concussions (SRC) have been a concern in all sports, including soccer. The long-term effects of soccer-related head injuries are a public health concern. The Concussion in Sport Group (CISG) released a consensus statement in 2017 and several soccer governing associations have published their own SRC guidelines while referring to it but it is unclear whether this has been universally adopted.

Research question

We aimed to investigate whether guidelines published by soccer associations have any discrepancies; and the extent to which they follow the CISG recommendations.

Materials and methods

A scoping review of available soccer-specific SRC guidelines was performed via databases PubMed, Google Scholar, and official soccer association websites via web browser Google. The inclusion criteria were soccer-specific SRC guidelines. Comparisons between guidelines were made concerning the following index items: initial (on-site) assessment, removal from play, re-evaluation with neuroimaging, return-to-sport protocol, special populations, and education.

Results

Nine soccer associations with available guidelines were included in this review. Guidelines obtained were from official associations in the United Kingdom, United States of America, Canada, Australia, and New Zealand. When compared to each other and the CISG recommendations, discrepancies were found within guidelines regarding the index items. Additionally, major soccer associations in some countries famous for soccer were found to have not published any publicly available guidelines.

Discussion and conclusion

SRC guidelines from different soccer associations contain discrepancies which may be detrimental to athletes, both short and long-term. We recommend that all major soccer governing associations publish guidelines that are standardised and accessible to all athletes.

Minimal Detectable Change for the ImPACT Subtests at Baseline

OBJECTIVE

To establish the minimal detectable change (MDC) of the subtests that comprise the composite scores from remotely administered Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) baselines.

METHOD

Remote ImPACT baseline data from 172 (male = 45, female = 127) National Collegiate Athletic Association Division I student-athletes from the 2020 and 2021 athletic preseasons were used to calculate the MDC at the 95%, 90%, and 80% confidence intervals (CIs) for all subtest scores used to generate the four core composite scores and the impulse control composite.

RESULTS

The MDCs for the verbal memory subtests at the 95% CI were 10.31 for word memory percent correct, 4.68 for symbol match total correct hidden, and 18.25 for three letters percentage correct. Visual memory subtest MDCs were 19.03 for design memory total percent correct and 4.90 for XO total correct memory. Visual motor speed subtest MDCs were 18.89 for XO total correct interference and 5.40 for three letters average counted correctly. Reaction time (RT) MDCs were 0.12 for XO average correct, 0.95 for symbol match average correct RT, and 0.28 for color match average correct. Impulse control MDCs were 5.97 for XO total incorrect and 1.15 for color match total commissions. One-way repeated measures MANOVA, repeated measures ANOVAs, and Wilcoxon signed-ranks test all suggested no significant difference between any subtests across two remote ImPACT baselines.

CONCLUSIONS

The ImPACT subtest scores did not significantly change between athletic seasons. Our study suggests the subtests be evaluated in conjunction with the composite scores to provide additional metrics for clinical interpretation.

The knowledge and attitude concerning sport-related concussion among coaches: A survey study

Background

There are no studies investigating the level of knowledge about and attitude towards sports-related concussions (SRC) among sports coaches in Jordan.

Objectives

This study aimed to examine the knowledge about and attitude towards SRC among Jordanian sports coaches.

Method

Our study was based on a cross-sectional survey. An Arabic version of the questionnaire from the Centers for Disease Control and Prevention was used to collect data. The survey identified participants' demographics and knowledge about (0-10 points with higher scores indicating a higher knowledge) and attitude towards (8-40 with lower scores indicating favourable attitudes) SRC. Descriptive statistics and the Kruskal-Wallis test were used to examine knowledge and attitude differences by demographic factors. Spearman's correlation examined the correlation between the total knowledge and attitude scores.

Results

Participants included 193 coaches (62 basketball, 66 martial arts, 30 soccer, and 35 swimming). The median total knowledge and attitude scores were 4 and 30, respectively. The total knowledge score was the highest in martial arts coaches (median = 4) and those with graduate degrees (median = 5). The total attitude score was the lowest among basketball coaches (median = 28) and those who were 40-50 years old (median = 28). No significant correlation between knowledge and attitude scores was observed.

Conclusion

Jordanian coaches have a deficiency in knowledge about SRC and hold attitudes that are not consistent with current practice recommendations.

Clinical implications

Knowledge and attitude about SRC can be improved through education, access to healthcare providers, and adherence to SRC management guidelines.

Concussion-Related Decision-Making by Certified Athletic Trainers: Implications for Concussion Prevention and Care

Concussions are a common sport-related injury that require appropriate initial care. Athletic trainers, often a primary source of healthcare for student-athletes, are key individuals involved in initial concussion diagnostic and management decisions. Challenges exist within the athletic environment that may hinder the consistency, efficacy, and/or effectiveness of concussion-related decision-making by athletic trainers, thereby impacting secondary concussion prevention and patient health. The purpose of this study was to identify factors that impact the intentions of athletic trainers to make appropriate concussion-related decisions under various circumstances. Overall, 1029 participants completed a survey examining educational precursors (quantity and quality of healthcare communication educational focus), demographic precursors (age, gender, educational degree, and employment setting), theory-based mediators (attitudes, perceived norms, and personal agency), and external mediators (knowledge, salience, and communication/collaboration practices) on appropriate concussion-related decision-making intentions. Data were analyzed using a two-step structural equation modeling approach. Quality of healthcare communication educational focus indirectly impacted appropriate concussion-related decision-making intentions via perceived behavioral control and communication/collaboration practices. Additionally, several factors impacted intentions to make appropriate concussion-related decisions directly including employment setting, self-efficacy, and general attitudes towards decision-making and concussions. Concussion prevention is aided by the initial and appropriate action taken by a healthcare professional to reduce immediate consequences; however, this action may be influenced by stakeholder relationships. These influential factors of decision-making may place athletes at further injury risk and negatively impact overall athlete health. As such, a sound theoretical framework incorporating the complexity of factors that may influence decision-making is needed.

Most cited articles involving lacrosse since 1990 primarily focus on concussion and traumatic brain injury

OBJECTIVES

The purpose of this study was to identify the 50 most-cited publications relating to lacrosse since 1990 and conduct a bibliometric analysis of the identified studies.

METHODS

Clarivate Analytics Web of Science database was queried to identify all publication titles, abstracts, and keywords for the term 'lacrosse' on 9 June 2023. The resulting articles were sorted by total number of citations. Titles and abstracts were included based on their relevance to lacrosse. Once the 50 most cited articles were identified, each article was further analyzed to obtain author name, publication year, country of origin, journal name, article type, research topic, competition level, total number of citations, and the level of evidence. Citation density (total number of citations/years since publication) was calculated and recorded for each of the most-cited studies.

RESULTS

The 50 most-cited articles were cited 4237 of times with an average of 84 citations per article. The most cited article was cited 637 (15.0%) times. The articles came from 2 different countries, with the United States and Australia comprising 49 and 1 articles, respectively. All articles were published in English. The American Journal of Sports Medicine published the most articles (n = 21, 42.0%). The most studied topic was concussion/traumatic brain injury (n = 18) followed by studies assessing all injuries (n = 7). Collegiate-level lacrosse was the most studied level of competition (n = 22), while high school-level followed (n = 12).

CONCLUSIONS

The majority of the 50 most-cited articles related to lacrosse since 1990 focus on the prevalence, diagnosis and identification of concussion/traumatic brain injury in high school and collegiate-level athletes. These articles are predominantly epidemiological or cohort studies with Level III or IV evidence that almost unanimously originate from the United States.

Review of Media Representation of Sport Concussion and Implications for Youth Sports

Participation in sport can incur a risk of sport-related concussion (SRC). Media representation of SRC is frequently at odds with up-to-date scientific data. Our findings confirm a significant amount of false, confusing, or misleading terminology used in reporting on the topic, which is concerning as media is as a major source of SRC information. Individuals have a variable base of knowledge pertaining to this injury, and accurate understanding of SRC does not always correlate to appropriate action. Inaccurate portrayal of SRC media may contribute to the confusion surrounding it. Popular media presents an opportunity to convey evidence-based information on SRC.

Early intervention treatment in the first 2 weeks following concussion in adults: A systematic review of randomised controlled trials

OBJECTIVE

International guidelines support a repertoire of therapeutic interventions that may assist recovery following concussion. We aimed to systematically review the efficacy of early pharmacological and non-pharmacological interventions initiated within two weeks of injury on symptoms and functional recovery of adults with concussion.

METHODS

We conducted a Systematic Review (SR) of Randomised Controlled Trials (RCTs) without meta-analysis utilising the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed of four databases. Study inclusion criteria were adult participants diagnosed with concussion and commencing active intervention within 14 days of injury.

RESULTS AND CONCLUSIONS

Of 7531 studies identified, 11 were included in the final review. Six studies were rated as high-risk of bias, three with some concerns and two as low-risk of bias. We found no evidence to support specific pharmacotherapeutic management to hasten the natural recovery time-course. Two studies reported significant improvement in selected concussion symptoms following manual therapy (at 48-72 hours post-treatment) or telephone counselling interventions (at 6 months post-injury). No high quality RCTs demonstrate superior effects of early therapeutic interventions on concussion recovery in the first 2 weeks. We advocate future research to examine impacts of health-clinician contact points aligned with symptom-specific interventions.

Injury Incidence, Outcomes, and Return to Competition Times after Sports-Related Concussions during One Professional Ice Hockey Season: A Prospective Cohort Study

OBJECTIVE

The objective of this study was to analyze the incidence and characteristics of sports-related concussions (SRCs) for a professional ice hockey team during one regular season in the International Central European Hockey League.

BACKGROUND

Repeated concussions are a common cause of long periods of absence in team contact sports, with a wide range of potential short- and long-term consequences for the affected athlete. Questions mainly regarding early diagnosis and ideal follow-up treatment remain unanswered, especially regarding the timing of return to sports (RTS).

METHOD

A prospective data analysis for a professional ice hockey team during a regular season was conducted. Firstly, concussions per 1000 athlete exposure (AE) and average time loss due to SRC were calculated. Secondly, the data from ImPACT Applications were analyzed for those players who were diagnosed with an SRC.

RESULTS

Five SRCs were evaluated during the regular season, which resulted in 1.35 concussions/1000 AEs, a maximum of 17 missed games, and a median of three games per SRC. The average symptom count was 9.6, with the most common symptoms being headache, sensitivity to light, and dizziness.

CONCLUSIONS

SRCs sustained in professional ice hockey are a common in-competition injury, while practices play a subsidiary role. The duration of RTS is highly individual and can be associated with symptoms lasting days to months.

Epidemiology of pediatric sports-related concussions presenting to the emergency room over the last decade in the United States

BACKGROUND

There continues to be clinical significance of pediatric sports-related concussion (pSRC) for pediatric specialists. The overall trends of pSRC are not well understood. The aim of this study was to summarize the epidemiology of pSRC presenting to the emergency room (ER) in the United States (US) over the last decade.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was retrospectively interrogated to identify pediatric (≤ 18 years) presenting to ERs in the US between 2013 and 2022. Weighted estimates and 95 % confidence intervals (CI) were generated using survey data analyses, and trends evaluated using linear regression analyses.

RESULTS

In 2022, an estimated total of 96,135 [95 % CI 71,486-120,783] cases of pSRC presented to the ER, equivalent to 132 [97-165] cases per 100,000 pediatric population. There has been a significant downtrend in pSRC presentations over the last decade (P = 0.02), with 2020 having the lowest number of cases in the 2013-2022 time period. In terms of gender, the latest proportion of presentations were 65 % [63-67 %] male and 35 % [33-37 %] female, with there being a significantly higher proportion of females and lower proportion of males over the last decade (P < 0.01). Of all causes for pSRC, the most frequent by proportion were football in 23 % [20-26 %], soccer in 9.6 % [7.7-12 %], basketball in 8.6 % [7.0-10 %], bicycle in 5.0 % [4.0-6.3 %], and baseball 4.1 % [3.3-5.0 %], with both football and basketball rates decreasing over the last decade. In 2020, there was a noticeable, non-sustained, decrease in proportion of football and basketball presentations, and an increase in proportion of bicycle presentations. Finally, there were multiples differences between sports and gender with only four in common sports causes amongst the ten most common sports (football, basketball, soccer, bicycle), although they were differently ranked by gender.

CONCLUSIONS

In the last decade, the incidence of pSRC presenting to the ER in the US has decreased. This is likely driven by decrease in proportion of football and basketball related injuries, which in turn has led to an increase in proportion of female pSRC which more commonly result from other sports. The Covid-19 pandemic in 2020 resulted in a number of trend anomalies which have since largely resolved. This data implicates that future prevention and treatment protocols should be more individualized.

Sport-Specific Recovery Trajectories for NCAA Collegiate Athletes Following Concussion

The recovery trajectories of collegiate athletes with sport-related concussion (SRC) are well characterized in contact/collision sports but are less well understood in limited contact sports with lower risk, reducing the ability of clinicians to effectively manage the return-to-play (RTP) process. The current study investigated the time to asymptomatic and RTP across a broad range of male and female collegiate sports and sought to group sports by recovery intervals. Data from the Concussion Assessment, Research and Education (CARE) Consortium included 1049 collegiate athletes who sustained a SRC while participating in game or practice/training of their primary sport. Injury setting and subsequent clinical presentation data were obtained. Survival analysis using the Cox Proportional Hazard model estimated the median recovery times for each sport. Optimal univariate K-means clustering grouped sports into recovery categories. Across all sports, median time to asymptomatic following SRC ranged from 5.9 (female basketball) to 8.6 days (male wrestling). Median RTP protocol duration ranged from 4.9 days (female volleyball) to 6.3 days (male wrestling). Median total RTP days ranged from 11.2 days (female lacrosse) to 16.9 days (male wrestling). Sport clusters based on recovery differences in time to asymptomatic (3) and RTP protocol duration (2) were identified. The findings from this study of a large sample of more than 1000 NCAA collegiate athletes with SRC show there exists ranges in recovery trajectories. Clinicians can thus manage athletes with similar guidelines, with individualized treatment and recovery plans.

Baseline Evaluation of Concussion-Like Symptoms and Modifying Factors in Collegiate Club-Sport Athletes

CONTEXT

Collegiate club-sport athletes participate in a variety of competitive sports and have been understudied in the concussion literature. Baseline performance measures are warranted to better understand assessment and management.

OBJECTIVE

To quantify normative values and the effects of modifying factors sex, concussion history, diagnosed attention disabilities (attention-deficit/hyperactivity disorder [ADHD]), and sport type on baseline symptom evaluation among collegiate club-sport athletes.

DESIGN

Cross-sectional study.

SETTING

Retrospective chart review.

PATIENTS OR OTHER PARTICIPANTS

A total of 1034 collegiate club-sport athletes (N = 649 males, 62.7%) from 29 sports at a single institution.

MAIN OUTCOME MEASURE(S)

Chart reviews were conducted for club-sport athletes who completed athlete background and symptom information on the Sport Concussion Assessment Tool-5th edition as a baseline concussion assessment during a single academic year. Demographics (eg, age, sex, sport), background medical information (eg, concussion history, ADHD), and symptom evaluation, consisting of individual 22-item symptom reports, the total number of symptoms, symptom severity scores, and symptom factors (eg, physical, cognitive, insomnia, and emotional), were analyzed.

RESULTS

On baseline symptom reporting, 68% of club-sport athletes were asymptomatic, with mild symptoms described by 3% to 12% and moderate or severe symptoms by ≤4%. Modifier groups differed with a higher total number of symptoms and symptom severity in females (P < .001), individuals reporting a history of concussion (P < .001), and those with ADHD (total number P = .04, symptom severity P = .02). Similar significant findings were noted for females and the history of concussion group on all 4 symptom factors; however, those in collision or contact sports also indicated greater cognitive (P = .03) and insomnia (P = .02) factors. Those with ADHD endorsed more cognitive (P < .001) factors.

CONCLUSIONS

Normative symptoms for a collegiate club-sport sample revealed approximately 70% were asymptomatic. Higher total number of symptoms and symptom severity were demonstrated by females and those with a history of concussion. Cognitive-specific symptoms were greater in those diagnosed with ADHD and those who participated in collision or contact sports.

ApoE Mimetic Peptides as Therapy for Traumatic Brain Injury

The lack of targeted therapies for traumatic brain injury (TBI) remains a compelling clinical unmet need. Although knowledge of the pathophysiologic cascades involved in TBI has expanded rapidly, the development of novel pharmacological therapies has remained largely stagnant. Difficulties in creating animal models that recapitulate the different facets of clinical TBI pathology and flaws in the design of clinical trials have contributed to the ongoing failures in neuroprotective drug development. Furthermore, multiple pathophysiological mechanisms initiated early after TBI that progress in the subacute and chronic setting may limit the potential of traditional approaches that target a specific cellular pathway for acute therapeutic intervention. We describe a reverse translational approach that focuses on translating endogenous mechanisms known to influence outcomes after TBI to develop druggable targets. In particular, numerous clinical observations have demonstrated an association between apolipoprotein E (apoE) polymorphism and functional recovery after brain injury. ApoE has been shown to mitigate the response to acute brain injury by exerting immunomodulatory properties that reduce secondary tissue injury as well as protecting neurons from excitotoxicity. CN-105 represents an apoE mimetic peptide that can effectively penetrate the CNS compartment and retains the neuroprotective properties of the intact protein.

Increased Risk of Fracture, Dislocation, and Hospitalization Are Associated With Collision in Contact Sports

Purpose

To quantitatively determine whether there is an added risk of orthopaedic injury attributable to the collision forces that athletes participating in collision-contact (CC) sports regularly encounter.

Methods

The National Electronic Injury Surveillance System was used to collect data on patients presenting to an emergency department with a contact sports-related injury between 2014 and 2020. Select contact sports were classified as either belonging to a CC or noncollision-contact (NCC) sports group based on involvement of frequent and intentional player-to-player collisions.

Results

From 2014 to 2020, 25,784 patients with team-based sports related injuries presented to an emergency department, of whom 7,591 sustained an injury during a CC sport and 18,193 during a NCC sport. The CC group was associated with significantly increased odds of sustaining at least 1 fracture (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.35-1.52) (P < .001), dislocation (OR 1.2, 95 % CI 1.06-1.33) (P < .001), and being admitted into the hospital (OR 1.6, 95% CI 1.34-1.86) (P < .001), compared with the NCC group.

Conclusions

We found that frequent and intentional high-energy collisions associated with CC sports significantly increase the risk of sustaining fractures and dislocations. Furthermore, we found that that the injuries sustained by players engaging in CC sports required hospitalization at a significantly greater rate than those sustained in contact sports that do not involve frequent and intentional player-to-player collisions.

Level of Evidence

Level III, prognostic (retrospective cohort study).

Making the case for prophylactic use of betaine to promote brain health in young (15-24 year old) athletes at risk for concussion

Betaine supplementation in the context of human nutrition, athletic performance, and clinical therapy demonstrate that the osmolyte and methyl donor, betaine, is cytoprotective and beneficial to human health. These studies also demonstrate that betaine supplementation in healthy humans is straight-forward with no reported adverse effects. Here, we explore betaine uptake in the central nervous system (CNS) and contribute to evidence that betaine may be uniquely protective to the brain. We specifically describe the therapeutic potential of betaine and explore the potential implications of betaine on inhibition mediated by GABA and glycine neurotransmission. The influence of betaine on neurophysiology complement betaine's role as an osmolyte and metabolite and is consistent with clinical evidence of betaine-mediated improvements to cognitive function (reported in elderly populations) and its anti-convulsant properties. Betaine's therapeutic potential in neurological disorders including epilepsy and neurodegenerative diseases combined with benefits of betaine supplementation on athletic performance support the unique application of betaine as a prophylaxis to concussion. As an example, we identify young athletes (15-24 years old), especially females, for prophylactic betaine supplementation to promote brain health and resilience in a cohort at high risk for concussion and for developing Alzheimer's disease.

Sleep/Wake Disorders After Sports Concussion: Risks, Revelations, and Interventions

SUMMARY

Sleep-wake disturbances (SWDs) are among the most prevalent, persistent, and often disregarded sequelae of traumatic brain injury. Identification and treatment of SWDs in patients with traumatic brain injury is important and can complement other efforts to promote maximum functional recovery. SWDs can accentuate other consequences of traumatic brain injury, negatively affect mood, exacerbate pain, heighten irritability, and diminish cognitive abilities and the potential for recovery. The risk for sports injuries increases when athletes are sleep deprived. Sleep deprivation increases risk-taking behaviors, predisposing to injuries. SWDs are an independent risk factor for prolonged recovery after sports-related concussion. SWDs following sports-related concussion have been shown to impede recovery, rehabilitation, and return to preinjury activities.

Concussion Education for Athletes: Symptom Reporting and Safe Return to Sport

» Educational programs on concussion have been demonstrated to improve knowledge for athletes, families, athletic trainers, and coaches about concussion, with the goal of reducing concussion incidence, duration, severity, and complications.» Despite the widespread availability and often mandatory concussion education provided to high school and collegiate athletes, there has not been an adequate change in knowledge, attitudes, and self-reporting behavior in this population.» Recently published studies suggest improving concussion education by emphasizing athletes' symptom reporting behavior, to contrast with current emphasis on knowledge-based outcomes.» Future educational programs about concussions for athletes, families, athletic trainers, and coaches should aim to emphasize cultural and behavioral changes that demonstrate outcome changes rather than solely evaluating knowledge improvements to determine effective programming.

Neck strength and force in reaction time task of adolescent athletes with and without concussion history: A pilot study

OBJECTIVES

Assess the impact of concussion by comparing reaction time, peak force recruitment, and rate of force development of adolescent athletes returning from concussion against age- and sex-matched controls in visual-elicited neck movement.

DESIGN

Athletes sat secured in a custom-built isometric device with their heads secured in a helmet and attached to a 6-axis load cell. They performed neck flexion, extension, and lateral flexion in response to a visual cue. Three trials in each direction were used for statistical analyses; peak force and rate of force development were normalized against athlete mass.

SETTING

Laboratory.

PARTICIPANTS

26 adolescent/young adult athletes (8F/18M), either recently concussed (and cleared for return to sport) or an age- and sex-matched healthy control.

MAIN OUTCOME MEASURES

Reaction time, angle, standard deviation of angle, deviation from target angle, peak force, and RFD over 50, 100, 150,and 200 ms of movement were measured for each trial.

RESULTS

Concussed athletes had decreased normalized peak force (P = 0.008) and rate of force development (P < 0.001-0.007). In neck extension, concussed athletes also had decreased movement precision (P = 0.012).

CONCLUSIONS

Concussion is associated with alterations of neck biomechanics that decrease overall neck strength.

An Attempt to Develop a Model of Brain Waves Using Quantitative Electroencephalography with Closed Eyes in K1 Kickboxing Athletes-Initial Concept

BACKGROUND

Brain injuries are a common problem in combat sports, especially in disciplines such as kickboxing. Kickboxing is a combat sport that has several variations of competition, with the most contact-oriented fights being carried out under the format of K-1 rules. While these sports require a high level of skill and physical endurance, frequent micro-traumas to the brain can have serious consequences for the health and well-being of athletes. According to studies, combat sports are one of the riskiest sports in terms of brain injuries. Among the sports disciplines with the highest number of brain injuries, boxing, mixed martial arts (MMA), and kickboxing are mentioned.

METHODS

The study was conducted on a group of 18 K-1 kickboxing athletes who demonstrate a high level of sports performance. The subjects were between the ages 18 and 28. QEEG (quantitative electroencephalogram) is a numeric spectral analysis of the EEG record, where the data is digitally coded and statistically analysed using the Fourier transform algorithm. Each examination of one person lasts about 10 min with closed eyes. The wave amplitude and power for specific frequencies (Delta, Theta, Alpha, Sensorimotor Rhythm (SMR), Beta 1, and Beta2) were analysed using 9 leads.

RESULTS

High values were shown in the Alpha frequency for central leads, SMR in the Frontal 4 (F4 lead), Beta 1 in leads F4 and Parietal 3 (P3), and Beta2 in all leads.

CONCLUSIONS

The high activity of brainwaves such as SMR, Beta and Alpha can have a negative effect on the athletic performance of kickboxing athletes by affecting focus, stress, anxiety, and concentration. Therefore, it is important for athletes to monitor their brainwave activity and use appropriate training strategies to achieve optimal results.

Incidence of injuries among lacrosse athletes: a systematic review and meta-analysis

OBJECTIVES

The purpose of this systematic review was to determine the incidence of injuries among lacrosse athletes and the differences in rates of injury by location and gender.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were implemented to conduct this systematic review.[1] The following variables were extracted from each of the included articles: location of injury, gender of patient, and incidence of injury among study population. The methodological quality of the included studies was assessed using mixed-methods appraisal tool (MMAT) version 2018.[2] Estimated rates were reported as pooled proportion with 95% CI. Rates of injury were calculated as a rate per 1000 athletic exposures (AEs), defined as an athlete participating in 1 practice or competition in which he or she was exposed to the possibility of athletic injury.

RESULTS

This study found that the highest injury rate among lacrosse athletes was to the lower leg/ankle/foot with a rate of 0.66 injuries per 1000 AEs (95% CI, 0.51, 0.82). This injury pattern was also found to be the highest among both male and female lacrosse athletes. No statistical significance was detected when comparing rates of injury across gender, regardless of location. The injury pattern with the lowest rates of injury for female athletes being to the shoulder/clavicle and the neck for male athletes.

CONCLUSION

The highest rate of injury among lacrosse athletes was to the lower leg/ankle/foot. As participation in lacrosse continues to rise, there is a greater need for understanding the rate of injury and injury characteristics for physicians and trainers to provide effective care to lacrosse athletes.

Multicenter Analysis of the Epidemiology of Injury Patterns and Return to Sport in Collegiate Gymnasts

Background

Gymnastics requires intense year-round upper and lower extremity strength training typically starting from an early age. As such, the injury patterns observed in these athletes may be unique.

Purpose

To characterize the types of injuries and provide return-to-sport data in male and female collegiate gymnasts.

Study Design

Descriptive epidemiology study.

Methods

A conference-specific injury database was utilized to perform a retrospective review of injuries for male and female National Collegiate Athletic Association (NCAA) Division I gymnasts within the Pacific Coast Conference between 2017 and 2020 (N = 673 gymnasts). Injuries were stratified by anatomic location, sex, time missed, and injury diagnoses. Relative risk (RR) was used to compare results between sexes.

Results

Of the 673 gymnasts, 183 (27.2%) experienced 1093 injuries during the study period. Injuries were sustained in 35 of 145 male athletes (24.1%) as compared with 148 of 528 female athletes (28.0%; RR, 0.86 [95% CI, 0.63-1.19]; P = .390). Approximately 66.1% (723/1093) of injuries occurred in a practice setting, compared with 84 of 1093 injuries (7.7%) occurring during competition. Overall, 417 of 1093 injuries (38.2%) resulted in no missed time. Shoulder injuries and elbow/arm injuries were significantly more common in male versus female athletes (RR, 1.99 [95% CI, 1.32-3.01], P = .001; and RR, 2.08 [95% CI, 1.05-4.13], P = .036, respectively). In total, 23 concussions affected 21 of 673 athletes (3.1%); 6 concussions (26.1%) resulted in the inability to return to sport during the same season.

Conclusion

For the majority of musculoskeletal injuries, the gymnasts were able to return to sport during the same season. Male athletes were more likely to experience shoulder and elbow/arm injuries, likely because of sex-specific events. Concussions occurred in 3.1% of the gymnasts, highlighting the need for vigilant monitoring. This analysis of the incidence and outcomes of injuries observed in NCAA Division I gymnasts may guide injury prevention protocols as well as provide important prognostic information.

Concussion and Psychological Effects: A Review of Recent Literature

ABSTRACT

The aim of this article is to provide an up-to-date review of psychological changes in association with postconcussive athletes. In particular, this article focused on the symptomatology, risk factors, and treatment of psychiatric diagnoses in patients who suffered a sports-related concussion (SRC). After an extensive review of prior and current literature, there is significant evidence that demonstrates an association of changes in mood and behavior, including new or worsening symptoms of anxiety, depression, and difficulty with attention and concentration in those who are recovering from a concussion. The goal of care in these patients is to identify and treat these psychological symptoms early to have more favorable long-term outcomes. Primary treatment should focus on psychotherapy; however, other considerations may be warranted in certain cases, such as selective serotonin reuptake inhibitors for depression and tricyclic antidepressants and gabapentin for short-term cognitive symptom improvement.

Molecular mechanisms of exercise contributing to tissue regeneration

Physical activity has been known as an essential element to promote human health for centuries. Thus, exercise intervention is encouraged to battle against sedentary lifestyle. Recent rapid advances in molecular biotechnology have demonstrated that both endurance and resistance exercise training, two traditional types of exercise, trigger a series of physiological responses, unraveling the mechanisms of exercise regulating on the human body. Therefore, exercise has been expected as a candidate approach of alleviating a wide range of diseases, such as metabolic diseases, neurodegenerative disorders, tumors, and cardiovascular diseases. In particular, the capacity of exercise to promote tissue regeneration has attracted the attention of many researchers in recent decades. Since most adult human organs have a weak regenerative capacity, it is currently a key challenge in regenerative medicine to improve the efficiency of tissue regeneration. As research progresses, exercise-induced tissue regeneration seems to provide a novel approach for fighting against injury or senescence, establishing strong theoretical basis for more and more "exercise mimetics." These drugs are acting as the pharmaceutical alternatives of those individuals who cannot experience the benefits of exercise. Here, we comprehensively provide a description of the benefits of exercise on tissue regeneration in diverse organs, mainly focusing on musculoskeletal system, cardiovascular system, and nervous system. We also discuss the underlying molecular mechanisms associated with the regenerative effects of exercise and emerging therapeutic exercise mimetics for regeneration, as well as the associated opportunities and challenges. We aim to describe an integrated perspective on the current advances of distinct physiological mechanisms associated with exercise-induced tissue regeneration on various organs and facilitate the development of drugs that mimics the benefits of exercise.

Optimizing Concussion Care Seeking: The Influence of Previous Concussion Diagnosis Status on Baseline Assessment Outcomes

BACKGROUND

The prevalence of unreported concussions is high, and undiagnosed concussions can lead to worse postconcussion outcomes. It is not clear how those with a history of undiagnosed concussion perform on subsequent standard concussion baseline assessments.

PURPOSE

To determine if previous concussion diagnosis status was associated with outcomes on the standard baseline concussion assessment battery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Concussion Assessment, Research, and Education (CARE) Consortium participants (N = 29,934) self-reported concussion history with diagnosis status and completed standard baseline concussion assessments, including assessments for symptoms, mental status, balance, and neurocognition. Multiple linear regression models were used to estimate mean differences and 95% CIs among concussion history groups (no concussion history [n = 23,037; 77.0%], all previous concussions diagnosed [n = 5315; 17.8%], ≥1 previous concussions undiagnosed [n = 1582; 5.3%]) at baseline for all outcomes except symptom severity and Brief Symptom Inventory-18 (BSI-18) score, in which negative binomial models were used to calculate incidence rate ratios (IRRs). All models were adjusted for sex, race, ethnicity, sport contact level, and concussion count. Mean differences with 95% CIs excluding 0.00 and at least a small effect size (≥0.20), and those IRRs with 95% CIs excluding 1.00 and at least a small association (IRR, ≥1.10) were considered significant.

RESULTS

The ≥1 previous concussions undiagnosed group reported significantly greater symptom severity scores (IRR, ≥1.38) and BSI-18 (IRR, ≥1.31) scores relative to the no concussion history and all previous concussions diagnosed groups. The ≥1 previous concussions undiagnosed group performed significantly worse on 6 neurocognitive assessments while performing better on only 2 compared with the no concussion history and all previous concussions diagnosed groups. There were no between-group differences on mental status or balance assessments.

CONCLUSION

An undiagnosed concussion history was associated with worse clinical indicators at future baseline assessments. Individuals reporting ≥1 previous undiagnosed concussions exhibited worse baseline clinical indicators. This may suggest that concussion-related harm may be exacerbated when injuries are not diagnosed.

Long-term postural control in elite athletes following mild traumatic brain injury

Background

Traumas to the head and neck are common in sports and often affects otherwise healthy young individuals. Sports-related concussions (SRC), defined as a mild traumatic brain injury (mTBI), may inflict persistent neck and shoulder pain, and headache, but also more complex symptoms, such as imbalance, dizziness, and visual disturbances. These more complex symptoms are difficult to identify with standard health care diagnostic procedures.

Objective

To investigate postural control in a group of former elite athletes with persistent post-concussive symptoms (PPCS) at least 6 months after the incident.

Method

Postural control was examined using posturography during quiet stance and randomized balance perturbations with eyes open and eyes closed. Randomized balance perturbations were used to examine motor learning through sensorimotor adaptation. Force platform recordings were converted to reflect the energy used to maintain balance and spectrally categorized into total energy used, energy used for smooth corrective changes of posture (i.e., <0.1 Hz), and energy used for fast corrective movements to maintain balance (i.e., >0.1 Hz).

Results

The mTBI group included 20 (13 males, mean age 26.6 years) elite athletes with PPCS and the control group included 12 athletes (9 males, mean age 26.4 years) with no history of SRC. The mTBI group used significantly more energy during balance perturbations than controls: +143% total energy, p = 0.004; +122% low frequency energy, p = 0.007; and +162% high frequency energy, p = 0.004. The mTBI subjects also adapted less to the balance perturbations than controls in total (18% mTBI vs. 37% controls, p = 0.042), low frequency (24% mTBI vs. 42% controls, p = 0.046), and high frequency (6% mTBI vs. 28% controls, p = 0.040). The mTBI subjects used significantly more energy during quiet stance than controls: +128% total energy, p = 0.034; +136% low-frequency energy, p = 0.048; and +109% high-frequency energy, p = 0.015.

Conclusion

Athletes with previous mTBI and PPCS used more energy to stand compared to controls during balance perturbations and quiet stance and had diminished sensorimotor adaptation. Sports-related concussions are able to affect postural control and motor learning.

Proteomic Profiling of Plasma Biomarkers Associated With Return to Sport Following Concussion: Findings From the NCAA and Department of Defense CARE Consortium

Objective

To investigate the plasma proteomic profiling in identifying biomarkers related to return to sport (RTS) following a sport-related concussion (SRC).

Methods

This multicenter, prospective, case-control study was part of a larger cohort study conducted by the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium, athletes (n = 140) with blood collected within 48 h of injury and reported day to asymptomatic were included in this study, divided into two groups: (1) recovery <14-days (n = 99) and (2) recovery ≥14-days (n = 41). We applied a highly multiplexed proteomic technique that uses DNA aptamers assay to target 1,305 proteins in plasma samples from concussed athletes with <14-days and ≥14-days.

Results

We identified 87 plasma proteins significantly dysregulated (32 upregulated and 55 downregulated) in concussed athletes with recovery ≥14-days relative to recovery <14-days groups. The significantly dysregulated proteins were uploaded to Ingenuity Pathway Analysis (IPA) software for analysis. Pathway analysis showed that significantly dysregulated proteins were associated with STAT3 pathway, regulation of the epithelial mesenchymal transition by growth factors pathway, and acute phase response signaling.

Conclusion

Our data showed the feasibility of large-scale plasma proteomic profiling in concussed athletes with a <14-days and ≥ 14-days recovery. These findings provide a possible understanding of the pathophysiological mechanism in neurobiological recovery. Further study is required to determine whether these proteins can aid clinicians in RTS decisions.

Concussions in the Women's National Basketball Association: Analysis of Incidence, Return-to-Play Timing, and Player Performance From 1997 to 2020

Background:

The extent to which concussions affect Women’s National Basketball Association (WNBA) athletes has not been thoroughly examined.

Purpose:

To evaluate the incidence and impact of concussion injuries occurring in the WNBA.

Study Design:

Descriptive epidemiology study.

Methods:

Publicly available records were searched to identify all documented basketball-related concussions from WNBA seasons 1997 to 2020. Player demographics, injury details, and basketball career information were collected. Concussion incidence and return-to-play (RTP) timing were evaluated before and after the institution of the WNBA concussion protocol in 2012. Minutes per game and game score per minute were compared 5 games before and 5 games after the concussion was sustained. Player game availability and RTP performance were also compared with an age-, body mass index–, position-, and experience-matched control group of players who did not sustain any injuries during the index season.

Results:

A total of 70 concussions among 55 players were reported in the WNBA from 1997 to 2020, with a mean incidence of 2.9 ± 2.3 concussions per season. After the implementation of the WNBA concussion protocol, the incidence significantly increased from 1.7 to 5.0 concussions per season (P < .001). All players returned after a first-time concussion, missing a mean of 3.8 ± 4.7 games and 17.9 ± 20.7 days. After the adoption of the concussion protocol, the time to RTP significantly increased with games missed (P = .006) and days missed (P = .006). Minutes per game and game score per minute were not significantly affected by sustaining a concussion (P = .451 and P = .826, respectively).

Conclusion:

Since the adoption of the WNBA concussion protocol in the 2012 season, the incidence of concussions increased significantly. Athletes retained a high rate of RTP after missing a median of 4 games, and the time to RTP increased after the institution of the concussion protocol. Player game availability and performance within the same season were not significantly affected by concussion injuries after a successful RTP.

Post-Concussive Vestibular Dysfunction Is Related to Injury to the Inferior Vestibular Nerve

Symptoms of vestibular dysfunction such as dizziness and vertigo are common after sports-related concussions (SRC) and associated with a worse outcome and a prolonged recovery. Vestibular dysfunction after SRC can be because of an impairment of the peripheral or central neural parts of the vestibular system. The aim of the present study was to establish the cause of vestibular impairment in athletes with SRC who have persisting post-concussive symptoms (PPCS). We recruited 42 participants-21 athletes with previous SRCs and PPCS ≥6 months and 21 healthy athletic age- and sex-matched controls-who underwent symptom rating, a detailed test battery of vestibular function and 7T magnetic resonance imaging with diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI) of cerebellar white matter tracts, and T1-weighted imaging for cerebellar volumetrics. Vestibular dysfunction was observed in 13 SRC athletes and three controls (p = 0.001). Athletes with vestibular dysfunction reported more pronounced symptoms on the Dizziness Handicap Inventory (DHI; p < 0.001) and the Hospital Anxiety and Depression Scale (HADS; p < 0.001). No significant differences in DTI metrics were found, while in DKI two metrics were observed in the superior and/or inferior cerebellar tracts. Cerebellar gray and white matter volumes were similar in athletes with SRC and controls. Compared with controls, pathological video head impulse test results (vHIT; p < 0.001) and cervical vestibular evoked myogenic potentials (cVEMP; p = 0.002) were observed in athletes with SRC, indicating peripheral vestibular dysfunction and specifically suggesting injury to the inferior vestibular nerve. In athletes with persisting symptoms after SRC, vestibular dysfunction is associated with injury to the inferior vestibular nerve.

Balance and Cognition in Male Collegiate Lacrosse Players

Concussion screening among collegiate lacrosse athletes is a major safety priority. Although attention has been directed at concussion management following injury, less is known about the association between cognition and balance during preseason screening. The purpose of the study was to assess the relationship between balance and neurocognition among collegiate male lacrosse players and to examine predictive determinants of postural stability. Participants included a convenience sample of 49 male collegiate Division 3 lacrosse players who completed a demographic survey and performed the immediate postconcussion test (ImPACT) and instrumented Sensory Organization Test (SOT). There was a significant association between balance SOT performance and both verbal memory (r = .59, p < .01) and visual motor speed scores (r = .43, p < .05). Significant correlations between verbal memory and SOT Conditions 2, 5, and 6 were also noted (all p < .05). Verbal memory predicted 33% of the variance in the SOT composite balance score (p < .001). Our results indicate a significant relationship exists between postural stability and both verbal memory and visual processing speed among collegiate male lacrosse players and supports vestibulocortical associations. Findings warrant ongoing performance and executive function tracking and can serve as a conduit for integrated sensorimotor and dual-task training.

Nutritional Considerations for Injury Prevention and Recovery in Combat Sports

Sports participation is not without risk, and most athletes incur at least one injury throughout their careers. Combat sports are popular all around the world, and about one-third of their injuries result in more than 7 days of absence from competition or training. The most frequently injured body regions are the head and neck, followed by the upper and lower limbs, while the most common tissue types injured are superficial tissues and skin, followed by ligaments and joint capsules. Nutrition has significant implications for injury prevention and enhancement of the recovery process due to its effect on the overall physical and psychological well-being of the athlete and improving tissue healing. In particular, amino acid and protein intake, antioxidants, creatine, and omega-3 are given special attention due to their therapeutic roles in preventing muscle loss and anabolic resistance as well as promoting injury healing. The purpose of this review is to present the roles of various nutritional strategies in reducing the risk of injury and improving the treatment and rehabilitation process in combat sports. In this respect, nutritional considerations for muscle, joint, and bone injuries as well as sports-related concussions are presented. The injury risk associated with rapid weight loss is also discussed. Finally, preoperative nutrition and nutritional considerations for returning to a sport after rehabilitation are addressed.

More Physical Activity after Concussion Is Associated with Faster Return to Play among Adolescents

Concussion management has evolved to de-emphasize rest in favor of early introduction of post-injury physical activity. However, the optimal quantity, frequency and intensity of physical activity are unclear. Our objective was to examine the association between objective physical activity metrics and clinical recovery after concussion. We prospectively enrolled a cohort of 32 youth athletes with concussion, evaluated within 14 days of injury and after return-to-play (RTP) clearance. For two weeks after enrollment, we quantified steps/day and exercise frequency, duration, and intensity via wrist-worn actigraphy. We grouped participants by RTP clearance timing (<28 days vs. ≥28 days). Seventeen (53%) participants required ≥28 days post-concussion for RTP clearance. Groups were similar in age (14.9 ± 1.9 vs. 15.4 ± 1.5 years; p = 0.38), proportion of females (47% vs. 40%; p = 0.69), and concussion history (59% vs. 47%; p = 0.49). During the study period, the RTP ≥ 28 days group took fewer steps/day (8158 ± 651 vs. 11,147 ± 4013; p = 0.02), exercised fewer days/week (2.9 ± 2.4 vs. 5.0 ± 1.9 days/week; p = 0.01), and exercised fewer total minutes/week (117 ± 122 vs. 261 ± 219 min/week; p = 0.03). Furthermore, we observed ≥10,251 average steps/day, ≥4 exercise sessions/week, and exercising ≥134 total minutes/week were optimal cutpoints to distinguish between groups. These findings support the benefit of physical activity during concussion recovery.

Iron Metabolism Disorders for Cognitive Dysfunction After Mild Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the most harmful forms of acute brain injury and predicted to be one of the three major neurological diseases that cause neurological disabilities by 2030. A series of secondary injury cascades often cause cognitive dysfunction of TBI patients leading to poor prognosis. However, there are still no effective intervention measures, which drive us to explore new therapeutic targets. In this process, the most part of mild traumatic brain injury (mTBI) is ignored because its initial symptoms seemed not serious. Unfortunately, the ignored mTBI accounts for 80% of the total TBI, and a large part of the patients have long-term cognitive dysfunction. Iron deposition has been observed in mTBI patients and accompanies the whole pathological process. Iron accumulation may affect long-term cognitive dysfunction from three pathways: local injury, iron deposition induces tau phosphorylation, the formation of neurofibrillary tangles; neural cells death; and neural network damage, iron deposition leads to axonal injury by utilizing the iron sensibility of oligodendrocytes. Thus, iron overload and metabolism dysfunction was thought to play a pivotal role in mTBI pathophysiology. Cerebrospinal fluid-contacting neurons (CSF-cNs) located in the ependyma have bidirectional communication function between cerebral-spinal fluid and brain parenchyma, and may participate in the pathway of iron-induced cognitive dysfunction through projected nerve fibers and transmitted factor, such as 5-hydroxytryptamine, etc. The present review provides an overview of the metabolism and function of iron in mTBI, and to seek a potential new treatment target for mTBI with a novel perspective through combined iron and CSF-cNs.