Sports career-related concussion and mental health symptoms in former elite athletes

Concussion history associated with adolescent psychological distress but not hazardous gambling: a cross-sectional study

BACKGROUND

Sustaining multiple concussions over one's lifetime may be associated with behavioral and mood changes beyond the acute phase of injury. The present cross-sectional study examined the relationship between concussion history, the incidence of current moderate-severe psychological distress, and lifetime adolescent hazardous gambling in high school students.

METHODS

Four-hundred fifty-nine high school students from southern Sweden (age: 16.81 ± 0.83, 58.2% male) completed a survey assessing concussion history (0,1,2…>8), psychological distress using the Kessler-6 scale, and lifetime hazardous gambling using the NODS-CLiP scale.

RESULTS

Participants who self-reported three or more concussions were more likely to endorse moderate-severe symptoms of psychological distress than those with no concussion history while controlling for covariates, OR = 2.71, 95% CI [1.19, 6.18]. In contrast, concussion history was not associated with hazardous gambling after controlling for confounding variables.

CONCLUSIONS

Self-reporting three or more concussions was associated with increased current psychological distress beyond the acute phase of injury among high school students. Adolescents who have sustained multiple concussions should undergo mental health evaluations beyond the acute phase of injury to identify and treat psychological distress, but probing for hazardous gambling may not be clinically relevant in this previously concussed adolescent population.

Associations between repetitive head impact exposure and midlife mental health wellbeing in former amateur athletes

Introduction

Repetitive head impacts (RHI) have been suggested to increase the risk of developing a neurodegenerative disease, and many of these individuals develop a preceding mental health diagnosis. Given the lack of studies among amateur athletes, this study aimed to examine mental health outcomes in middle-aged amateur athletes who have been exposed to RHI through contact sport participation.

Methods

This is a single site, cohort study involving former amateur athletes aged between 30 and 60 with at least 10 years of organized contact or non-contact sport participation. All participants completed demographic and mental health questionnaires. Mental health outcomes included symptoms related to depression, anxiety, post-traumatic stress disorder (PTSD), attention deficit hyperactive disorder (ADHD), and aggression. Self-reported data on mental health diagnoses and associated prescription were elicited and used to estimate odds ratios (OR).

Results

Data from 41 contact athletes and 22 age/sex-matched non-contact athletes were available for analysis. The contact group exhibited a 2.25-fold higher likelihood of being diagnosed with mental health disorders and 1.29-fold higher likelihood of using associated medications compared to the non-contact group. The contact group reported significantly higher PTSD-related symptoms [4.61 (0.03,9.2), p=0.05] compared to the non-contact control group. While not statistically significant, the contact group showed increased depressive [2.37 (0.05, 4.79), p=0.07] and ADHD symptoms [4.53 (0.51, 9.57), p=0.08] compared to controls. In a secondary analysis, a distinct trend emerged within the contact group, revealing pronounced elevations in mental health symptoms among individuals with lower socioeconomic status (<$50,000/year) compared to higher income subgroups, and these symptoms decreased as income levels rose [depression: -3.08 (-4.47, -1.7), p<0.001; anxiety: -1.95 (-3.15, -0.76), p=0.002; ADHD: -4.99 (-8.28, -1.69), p=0.004; PTSD: -4.42 (-7.28, -1.57), p=0.003; aggression: -6.19 (-11.02, -1.36), p=0.01]. This trend was absent in the non-contact control group.

Discussion

Our data suggest that even individuals at the amateur level of contact sports have an increased likelihood of being diagnosed with mental health disorders or experiencing mental health symptoms compared to non-contact athletes. Our findings indicate that socioeconomic status may have an interactive effect on individuals' mental health, particularly among those with a long history of RHI exposure.

Prospective cohort study of long-term neurological outcomes in retired elite athletes: the Advanced BiomaRker, Advanced Imaging and Neurocognitive (BRAIN) Health Study protocol

INTRODUCTION

Although limited, recent research suggests that contact sport participation might have an adverse long-term effect on brain health. Further work is required to determine whether this includes an increased risk of neurodegenerative disease and/or subsequent changes in cognition and behaviour. The Advanced BiomaRker, Advanced Imaging and Neurocognitive Health Study will prospectively examine the neurological, psychiatric, psychological and general health of retired elite-level rugby union and association football/soccer players.

METHODS AND ANALYSIS

400 retired athletes will be recruited (200 rugby union and 200 association football players, male and female). Athletes will undergo a detailed clinical assessment, advanced neuroimaging, blood testing for a range of brain health outcomes and neuropsychological assessment longitudinally. Follow-up assessments will be completed at 2 and 4 years after baseline visit. 60 healthy volunteers will be recruited and undergo an aligned assessment protocol including advanced neuroimaging, blood testing and neuropsychological assessment. We will describe the previous exposure to head injuries across the cohort and investigate relationships between biomarkers of brain injury and clinical outcomes including cognitive performance, clinical diagnoses and psychiatric symptom burden.

ETHICS AND DISSEMINATION

Relevant ethical approvals have been granted by the Camberwell St Giles Research Ethics Committee (Ref: 17/LO/2066). The study findings will be disseminated through manuscripts in clinical/academic journals, presentations at professional conferences and through participant and stakeholder communications.

Stunt performers' reluctance to self-report head trauma: a qualitative study

BACKGROUND

Mild traumatic brain injuries receive voluminous attention in the research literature, but this is confined almost entirely to sports and military contexts. As an occupation, performing stunts in film, television, and entertainment places the head at high risk of repetitive impact and whiplash, but stunt performers do not enjoy the same level of healthcare supervision and access as that provided to sports participants. Therefore, the aim of this study was to evaluate stunt performers' qualitative perceptions of reporting and management of head trauma in their industry.

METHODS

After giving their informed consent, 87 motion picture and television stunt performers responded to a query about their views of ways to improve how stunt performers' occupational head trauma-specifically head impacts and head whips that could cause a concussion-are reported and managed. We analyzed their responses via content and thematic analyses. Two researchers independently marked and categorized key words, phrases, and texts to identify codes that described participants' comments. They then revised, discussed, and resolved coding discrepancies through consensus to establish inter-coder reliability. Next, we identified thematic patterns that described participants' understanding of the stunt performer industry and what must change to facilitate reporting of head trauma. We derived themes from data that occurred multiple times, both within and across short answer responses.

RESULTS

We identified three primary themes cited by the stunt performers as needs in their industry: (1) Need to Reduce the Stigma of Reporting a Stunt-Related Injury, (2) Need to Eliminate the "Cowboy Culture," and (3) Need to Improve the Quality of the Work Environment.

CONCLUSIONS

Stunt performers are crucial members of a global entertainment industry valued at approximately US$100 billion annually. A large segment of the world's population consumes their work in motion pictures, television, and live entertainment. When they are given an anonymous opportunity to speak, stunt performers offer insight into and recommendations for industry changes-primarily cultural and educational in nature-that could improve their physical and mental health, career longevity, and employability when they are confronted with head trauma.

Depressive Disorders in Athletes

Depressive disorders in athletes are thought to be at least as common as the general population. However, athletes have a unique set of risk factors that can affect the likelihood of developing depression. Screening tools have been developed specifically for athletes such as the Sport Mental Health Assessment Tool (SMHAT). The management of the depressed athlete should involve an individualized approach, with methods such as counseling, interpersonal therapy, or cognitive behavioral therapy being used. Some may require antidepressant medication. Depressive disorders are also linked to sucidality in athletes, and the team physician and sporting organisation should have a crisis management plan in place for mental health emergencies. Tackling the stigma that remains in sport is a key part to improving mental wellbeing for all athletes.

Getting psyched up: Developing the field of Sport and Exercise Psychiatry in South Africa

Elite athletes and their entourage are exposed to intense stressors and commonly experience mental health symptoms and disorders. While there is limited literature on prevalence rates in a South African setting, initial data show that both current and retired athletes may experience these symptoms, but with low treatment rates. There is a need to improve mental health literacy and mental health care in athletes. Athletes may benefit from systematic mental health surveillance and additional screening during high-risk periods, such as injury or retirement. This commentary brings athlete mental health into focus and advocates for the inclusion of sport and exercise psychiatry into the athlete entourage and broader mental health team, in order to close the treatment gap. We provide seven recommendations for the initial way forward for sport and exercise psychiatry in South Africa.

No Association Between Processing Speed and Risk of Sport-Related Concussion in Youth Soccer

OBJECTIVE

To determine whether slow processing speed is associated with risk of sport-related concussion.

DESIGN

We conducted a retrospective cohort study using computerized neurocognitive assessments (Immediate Post-concussion Assessment and Cognitive Testing [ImPACT]) from the Massachusetts Concussion Management Coalition. Slow processing speed was defined as 2 SD below the sample mean (n = 131) and fast processing speed as 2 SD above the sample mean (n = 259). We used a binary logistic regression model to determine the odds of sustaining a concussion with our main predictor being processing speed (high or low) adjusted for the effects of age, sex, and prior number of concussions.

SETTING

Massachusetts Concussion Management Coalition, Institutional care.

PARTICIPANTS

Three hundred ninety junior high soccer players ages 10 to 15 with a baseline score for ImPACT.

INDEPENDENT VARIABLES

Processing Speed.

MAIN OUTCOME MEASURES

Risk of sustaining a concussion.

RESULTS

Those with slow processing speed had a visual motor composite score of ≤19.92, those with fast-processing speed had a score of ≥46.20. Athletes with slow processing speed were younger (13 vs 14 years; P < 0.001) and more likely to be male (57% vs 49%; P = 0.014). After adjusting for the effects of age, sex, and prior concussions, there was no significant difference in the odds of sustaining a concussion between groups (aOR 1.01; 95% CI, 0.99-1.04).

CONCLUSIONS

Despite previous research showing that slow processing speed is a risk factor for musculoskeletal injuries during sports, our study suggests that processing speed is not associated with the risk of sustaining a concussion among junior high school soccer players.

Gender and Workplace Stress Affect the Association Between Concussion History and Depression Symptoms in Professional Jockeys

Objective

Professional jockeys experience high rates of concussion, workplace stress, and poor mental health. The present cross-sectional study, for the first time, concurrently assessed the potential interplay between concussion history and workplace stress with current depression symptoms.

Method

Seventy-two professional flat-track jockeys (male = 49, female = 23) were grouped based on self-reported concussion history (CG; n = 56) and those who did not report a concussion history (NCG; total n = 16). Analyses featured both between (CG vs NCG) and within group (CG only) assessment on self-reported measures of workplace stress and depression symptoms (affect, daily functioning).

Results

Jockeys in the CG had more symptoms of negative affect than the NCG. This association, however, was nonsignificant after covarying for age, gender, and workplace stress. Higher workplace stress (p = .005) and gender (p = .001) were associated with poorer daily functioning after controlling for concussion history (CG vs. NCG) and age. Gender moderated the association between concussion group and poorer daily functioning (β = −18.739, t (71) = −2.924, p = .005), with the difference between CG and NCG significant for females, but not males (β = 33.648, t (71) = 3.420, p = .001).

Conclusions

The findings provide preliminary evidence that previously concussed females may be more likely to report poorer daily functioning than males with a history of concussion, and that workplace stress may reduce the association between a history of concussion and depression symptoms. Prospective studies are required to validate and extend these findings.

Head Injury Assessment in the Elite Level Rugby Union in Japan: Review of 3 Seasons

Head Injury Assessment (HIA) is the screening tool for head injury during a rugby game. The purpose of this study was to investigate the epidemiology of HIA in the Japan Rugby Top League (JRTL). The incidences of HIA, defined concussion (per 1,000 player-hours) and repeated concussions were evaluated in three seasons (2016-17, 2017-18, 2018-19; total 360 games). The HIA incidence rates were 12.7 (95% confidence interval 9.5-15.9), 20.8 (16.8-24.9), and 25.0 (20.5-29.5) in each season. HIA-1 criteria 2, which is applied for suspected concussion cases, was performed for 46 cases in the 2016-17 season, 81 cases in the 2017-18 season, and 88 cases in the 2018-19 season. The concussion incidence rates were significantly greater in the 2017-18 season (9.6/1000 player-hours, 95% confidence interval 6.8-12.4) and the 2018-19 season (14.4, 11-17.8) compared to the 2016-17 season (4.8, 2.8-6.8). The number of repeated concussion cases in the same season was 1 in the 2016-17 season and 4 in both the 2017-18 and 2018-19 seasons. This study confirmed significantly higher HIA and concussion incidence rates over time. Although the HIA system might have been established in the three seasons in JRTL, comprehensive management needs to be improved to prevent repeated concussions.

Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review

Objective:

Concussion is a common yet heterogenous injury. Approximately 15–30% of cases present with persistent post-concussion symptoms (PPCS), continuing 4 weeks or more post-injury in children, youth, and adolescents, and 3 months or more in adults. There are known bidirectional links between PPCS and mental health outcomes. The focus of this scoping review is to explore the literature on mental health outcomes in individuals experiencing PPCS. Research objectives were to explore: (1) the mental health outcomes of individuals with PPCS and types of assessments used to identify mental health outcomes this group, and (2) how mental health outcomes compare in terms of similarities and differences among pediatric and adult populations with PPCS.

Method

Ovid MEDLINE; EMBASE; CINAHL, and PsycInfo databases were searched. After title and abstract screening of 11,920 studies, 481 articles were reviewed. Twenty-five papers met inclusion criteria. Results were organized by mental health outcomes of pediatric and adult populations, separately.

Results

There was a significantly higher number of studies devoted to adult populations. Of the 25 studies, 19 (76%) focused on adults, while six (24%) focused on adolescents. In adult populations, studies focused on symptoms of: anxiety (n = 2), depression (n = 8), and anxiety and depression (n = 9). Two studies assessed other emotional outcomes (10.5%). Within pediatric populations, an equal number of studies explored symptoms of: anxiety (n = 2), depression (n = 2), and anxiety and depression (n = 2). No studies focused on other emotional outcomes. Studies ranged greatly in methods, design, and control group. Most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.

Discussion

This review contributes to the understanding of mental health outcomes in those experiencing PPCS. Mental health and PPCS requires greater attention in pediatric populations, and consider strategies for those experiencing PPCS and mental health impacts. Future studies should consider including a wider range of emotional outcomes in their design, not limited to anxiety and depression. Study results may lead to improvements and research in the identification, assessment, and management of PPCS and mental health.

Role of club doctors in the mental health management of Australian rules football players: a Delphi study

Professional team athletes experience a range of mental health problems, both sports and non-sports related. However, there is limited information available for those charged with responsibility for managing these mental health conditions, particularly within the context of professional sporting clubs. This paper reports on consensus findings from a study of club doctors, who are primary care providers for professional team athletes within a specific code, the Australian Football League (AFL). Drawing on findings from a systematic literature search, a two-round Delphi procedure was used to develop a consensus on best practice for managing mental health conditions for club doctors as primary care providers for professional team athletes. Participants in this study were current and former club doctors employed in professional AFL clubs across Australia, with 28 doctors participating across two survey rounds. Overall, 77 statements were presented, with 50 endorsed as essential or important by ≥ 80% of the participants across the two rounds. Primary themes across nine domains include: (1) Prevention and Mental Health Promotion Activities; (2) Screening; (3) Engaging External Specialists; (4) Duty of Care; (5) Treatment: Assessment, Treatment and Case Coordination; (6) Communication; (7) Confidentiality; (8) Sleep Management and (9) Substance Use Management. This study is the first to offer club doctors working in professional team settings consensus guidelines for the management of mental health conditions, and the opportunity for greater clarification and consistency in role delivery.

Predictors and Correlates of Depression in Retired Elite Level Rugby League Players

Background: There is considerable interest in determining whether later-in-life depression is associated with lifetime history of concussions or the duration of a career in professional contact and collision sports. Rugby league is a high-intensity collision sport involving a large number of tackles per game and a high rate of concussions. We examined predictors and correlates of depression in retired elite level rugby league players in Australia.

Methods: Retired elite level rugby league players (N = 141, age: M = 52.6, SD = 13.8; Range = 30–89 years) completed the Depression, Anxiety, and Stress Scale (DASS), Brief Pain Inventory, Connor-Davidson Resilience Scale (CD-RISC), and Epworth Sleepiness Scale; they also reported on lifetime history of concussions. The DASS depression score was regressed on age, total number of self-reported concussions, years played professionally, CD-RISC score, BPI pain interference score, and ESS score.

Results: The retired players reported a median of 15 total lifetime concussions [interquartile range (IQR) = 6–30], and a median of 8 years playing professional sports (IQR = 3.5–11). The proportion of the sample endorsing at least mild current depression was 29%. The DASS depression score was positively correlated with the DASS anxiety (r = 0.54) and DASS stress scores (r = 0.58). The CD-RISC score was negatively correlated with the depression score (r = −0.53). Depression scores were not significantly correlated with pain severity (r = 0.14), and were weakly correlated with life interference due to pain (r = 0.20) and years playing professional sports (r = −0.17). Depression scores were not significantly correlated with lifetime history of concussions (r = 0.14). A multiple regression model, with age, total number of self-reported concussions, years played professionally, the CD-RISC, Brief Pain Inventory-pain interference score, and Epworth Sleepiness Scale score as predictors was significant, with 35% of the variance in DASS depression accounted for. The two significant independent predictors of depression were lower resilience and greater life interference due to pain.

Conclusions: This is the first large study of depression in retired rugby league players. Depression in these retired players was not meaningfully associated with lifetime history of concussions or number of years playing elite level collision sport. Depression was associated with current anxiety, stress, resilience, and life interference due to chronic pain.

The clinical utility of the cervical vestibular-evoked myogenic potential (cVEMP) in university-level athletes with concussion

INTRODUCTION

Concussion is defined as a mild traumatic brain injury that can occur in all sport activities. Cervical vestibular-evoked myogenic potentials (cVEMPs) are accepted to demonstrate the vestibulocollic reflex. MAIN: To evaluate subclinical cervical abnormalities in the vestibulospinal pathway in subjects with concussion history with and without related symptoms via evoked vestibular potential.

METHODS

Monaurally air conduction cVEMP (500 Hz tone bursts) at intensity of 100 dBnHL and 200 sweeps. All responses were replicated.

RESULTS

One hundred fifty-four participants were initially tested; however, three (03) participants did not produce usable data (no response) and were eliminated for the dataset cutoff values analysis, being considered just as abnormal response. One hundred fifty-one responses consisted of 45 non-athlete individuals without any history of a concussion or concussion symptoms (normative group), 45 athletes without any history of a concussion or concussion symptoms (control group), 33 athletes with a history of at least one concussion but no concussion symptoms related (history group), and 28 athletes with a history of at least one concussion and concussion symptoms (symptoms group). The history and symptoms groups had statistically higher latency scores than the control and the normative groups. The Index Ratio data and Threshold data did not produce a significant effect for four groups. But, a pattern of abnormal cVEMP was found when comparing those without a history of concussion (0% abnormal response) versus the history group (24%) and symptoms group (32.3%).

CONCLUSION

The study provides data which supports the positive impact of cVEMP when evaluating athletes and identifying concussion processes.