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Glendon K, Blenkinsop G, Belli A, Pain MTG. Does early exercise intolerance effect time to return to play, symptom burden, neurocognition, Vestibular-Ocular-Motor (VOM) function and academic ability in acutely concussed student-athletes? Brain Inj 2024:1-11. [PMID: 38910338 DOI: 10.1080/02699052.2024.2367477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 06/08/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Early Exercise Intolerance (EEI) is associated with delayed recovery and longer time to Return To Play (RTP), but this has not been established.Participants; (n = 52, male n = 30) UK university-aged rugby-union student-athletes. METHODS Student-athletes completed baseline screening (July-October 2021 and 2022). The test battery was repeated within 48 h, 4, 8 and 14 days after a Sports-Related Concussion (SRC) with the Buffalo Concussion Bike or Treadmill Test to set sub-symptom heart rate threshold. Student-athletes then completed a controlled early exercise protocol in-between reassessment (days 3, 5-7 and 9-13). Those with EEI were compared to those with early-exercise tolerance. OUTCOME MEASURES Post-Concussion Symptom Scale, Immediate Post-Concussion and Cognitive Test, Vestibular-Ocular Motor Screening Tool and the Revised Perceived Academic Impact Tool. RESULTS EEI was seen throughout the initial 14-days post-SRC (23.8%, 22.4%, 25.5%. 25.0%). EEI was associated with a slower reaction time within 48 h (-0.01 (-0.030-0.043) Vs 0.06 (0.033-0.24), p = 0.004) and greater VOMS scores within 48 h; (0.00 (0.00-4.00) Vs 5.50 (2.75-9.00), p = 0.016) and 4 days (0.00 (0.00-2.00) Vs 5.00 (0.00-6.00), p = 0.044). RTP was 12.5 days longer in those with EEI at 14-days post-SRC. CONCLUSION EEI is prevalent following an SRC in university-aged student-athletes and was associated with delayed recovery and RTP.
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Affiliation(s)
- K Glendon
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - G Blenkinsop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - A Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - M T G Pain
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Glendon K, Pain MTG, Hogervorst E, Belli A, Blenkinsop G. Musculoskeletal injury or Sports-Related Concussion (SRC) in a season of rugby union does not affect performance on concussion battery testing in university-aged student-athletes. Phys Ther Sport 2024; 65:137-144. [PMID: 38181564 DOI: 10.1016/j.ptsp.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/08/2023] [Accepted: 12/18/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Sub-concussive and concussive impacts sustained during contact sports such as rugby may affect neurocognitive performance, vestibular-ocular-motor function, symptom burden and academic ability. METHOD Student-athletes (n = 146) participating in rugby union British Universities or domestic competitions were assessed on the Immediate Post-Concussion and Cognitive Test, Post-Concussion Symptom Scale, vestibular-oculo-motor screening tool and revised perceived academic impact tool. Individual change from pre-season (July-September 2021) to 2-weeks following last exposure to contact (April-July 2022) was analysed. RESULTS Symptom burden significantly worsened (p=0.016) over the season. Significant improvements on verbal memory (p=0.016), visual memory (p=0.008) and motor processing speed (p=0.001) suggest a possible learning effect. Surprisingly, the number of days lost to concussion significantly and positively affected performance on verbal memory (p = 0.018) and reaction time (p = 0.027). Previous concussive events significantly predicted a worsening in symptom burden (p < 0.028), as did in-season concussive events, predicting improved verbal memory (p = 0.033) and symptom burden change (p = 0.047). Baseline performance significantly affected change on several neurocognitive tests, with low-scorers showing more improvement over the season. CONCLUSION Participation in rugby union was not associated with deleterious effects on brain function. Previous concussive events and in-season factors, possibly related to learning effects, may explain improvement in cognitive function across the season.
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Affiliation(s)
- K Glendon
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
| | - M T G Pain
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - E Hogervorst
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - A Belli
- Institute of Inflammation and Ageing, University of Birmingham, UK
| | - G Blenkinsop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
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Barnhart M, McLeod TV, Bay RC. The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients After Concussion: A Systematic Review of the Literature. J Athl Train 2024; 59:49-65. [PMID: 36913634 PMCID: PMC10783467 DOI: 10.4085/1062-6050-0429.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
OBJECTIVE The objective of this systematic review was to investigate if a positive vestibular or oculomotor screening is predictive of recovery in patients after concussion. DATA SOURCES Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search through PubMed, Ovid MEDLINE, SPORTDiscus, and the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searches of included articles. STUDY SELECTION Two authors evaluated all articles for inclusion and assessed their quality using the Mixed Methods Assessment Tool. DATA EXTRACTION After quality assessment was completed, the authors extracted recovery time, vestibular or ocular assessment results, study population demographics, number of participants, inclusion and exclusion criteria, symptom scores, and any other outcomes of assessments reported in the included studies. DATA SYNTHESIS Data were critically analyzed by 2 of the authors and categorized into tables regarding the ability of researchers of each article to answer the research question. Many patients who have vision, vestibular, or oculomotor dysfunction appear to have longer recovery times than patients who do not. CONCLUSIONS Researchers routinely reported that vestibular and oculomotor screenings are prognostic of time to recovery. Specifically, a positive Vestibular Ocular Motor Screening test appears to consistently predict longer recovery.
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Affiliation(s)
- Mitchell Barnhart
- Athletic Training Programs, A.T. Still University, Mesa, AZ; Phoenix Country Day School, Paradise Valley, AZ
| | - Tamara Valovich McLeod
- Department of Athletic Training, Athletic Training Programs and School of Osteopathic Medicine, A.T. Still University, Mesa, AZ
| | - R. Curtis Bay
- Department of Interdisciplinary Health Sciences, A.T. Still University, Mesa, AZ
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Pei Y, Kemp AM, O'Brien KH. Investigating the Student in Returning to Learn After Concussion: A Systematic Review and Meta-Analysis. THE JOURNAL OF SCHOOL HEALTH 2023; 93:594-620. [PMID: 36852558 DOI: 10.1111/josh.13307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/14/2022] [Accepted: 02/05/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE Examine concussion effects on academic outcomes, including student perspectives. METHODS This study included a systematic review and meta-analysis examining post-concussion school attendance, academic performance, perceptions of academic difficulty, and accommodations for students in elementary through college settings. The analysis considered pre- and post-injury factors, along with injury factors that contribute to post-concussion academic outcomes. RESULTS The systematic review showed that students with concussion miss more school days and perceive higher levels of academic difficulty, but results about academic performance varied. Meta-analysis yielded small concussion effects on school absence and academic performance and moderate effects on perceptions of academic difficulty. Female sex, older age, history of migraine, prior concussions, severe or persistent symptoms, vestibular-ocular motor, and cognitive disruptions are risk factors, but these moderators were not identified in the meta-analysis due to lack of effect sizes. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY This study confirmed negative concussion effects on academic absences, performance, and perceptions of academic difficulty. Identified contributing factors will guide future practices to support students returning to learn after concussion. CONCLUSIONS Negative impacts to academics from concussion may be amplified by complicating factors. Future investigations are needed to confirm risk factors and mitigating effects of early identification and post-injury supports.
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Affiliation(s)
- Yalian Pei
- Communication Sciences and Special Education, University of Georgia, 110 Carlton Street, Athens, GA, 30602
| | - Amy M Kemp
- Communication Sciences and Special Education, University of Georgia, 110 Carlton Street, Athens, GA, 30602
| | - Katy H O'Brien
- Communication Sciences and Special Education, University of Georgia, 110 Carlton Street, Athens, GA 30602; Courage Kenny Rehabilitation Institute Allina Health, 800 E 28th St, Minneapolis, MN, 55407
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Putukian M, Purcell L, Schneider KJ, Black AM, Burma JS, Chandran A, Boltz A, Master CL, Register-Mihalik JK, Anderson V, Davis GA, Fremont P, Leddy JJ, Maddocks D, Premji Z, Ronksley PE, Herring S, Broglio S. Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis. Br J Sports Med 2023; 57:798-809. [PMID: 37316183 DOI: 10.1136/bjsports-2022-106682] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC). DESIGN Systematic review and meta-analysis. DATA SOURCES 8 databases searched through 22 March 2022. ELIGIBILITY CRITERIA Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool. RESULTS 278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I2=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I2=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I2=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns. CONCLUSION Most athletes have full RTL by 10 days but take twice as long for an RTS. PROSPERO REGISTRATION NUMBER CRD42020159928.
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Affiliation(s)
| | - Laura Purcell
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amanda Marie Black
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Joel S Burma
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Avinash Chandran
- Datalys Center for Sports Injury Research and Prevention, Indianapolis, Indiana, USA
| | - Adrian Boltz
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Christina L Master
- Childrens Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Johna K Register-Mihalik
- Matthew Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vicki Anderson
- Clinical Sciences Research, Murdoch Children's Research Institute & Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gavin A Davis
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - John J Leddy
- UBMD Orthopaedics and Sports Medicine, SUNY Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - David Maddocks
- Perry Maddocks Trollope Lawyers, Melbourne, Victoria, Australia
| | - Zahra Premji
- Libraries and Cultural Resources, University of Victoria, Victoria, British Columbia, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Herring
- Departments of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Steven Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
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Babula G, Warunek E, Cure K, Nikolski G, Fritz H, Barker S. Vestibular Rehabilitation as an Early Intervention in Athletes Who are Post-concussion: A Systematic Review. Int J Sports Phys Ther 2023; V18:577-586. [PMID: 37425112 PMCID: PMC10324323 DOI: 10.26603/001c.75369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/11/2023] [Indexed: 07/11/2023] Open
Abstract
Background Sports-related concussions (SRC) are a common injury sustained by many athletes of all different age groups and sports. The current standard treatment is rest followed by aerobic activity. Minimal research has been done on the effects of vestibular rehabilitation for concussion treatment, especially in physical therapy practice. Objective The purpose of this study was to examine the effects of early intervention of vestibular rehabilitation (VRT) on an athlete's time to return to play compared to rest alone. Study Design Systematic Review. Methods Two searches were conducted (August 2021 and January 2022) using databases: CINAHL complete, MEDLINE, PubMed, and Wiley online database. One hand search was performed to find relevant articles. Search terms included "vestibular rehabilitation" or "vestibular therapy" and "concussion" or "mild traumatic brain injury" or "mTBI" and "athletes" or "sports" or "athletics" or "performance", and "early interventions" or "therapy" or "treatment". Inclusion criteria were athletes with a SRC, incorporation of vestibular rehabilitation in athletes' recovery, and early vestibular intervention tools. Tools used to assess quality and risk of bias were the PEDro scale and the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. The PRISMA method for determining inclusion and exclusion criteria. Results Eleven articles were included, six randomized control trials and five retrospective cohort studies. Various balance interventions, visual interventions utilizing vestibulo-ocular reflex (VOR), and cervical manual therapy were used during VRT for athletes' post-concussion. Incorporating visual interventions and cervical manual therapy into early rehabilitation significantly reduced symptoms and time to return to sport. However, balance interventions did not have a significant effect on reducing time to return to sport when used as a sole intervention. Conclusion Addressing VRT deficits in the acute stages of a concussion may contribute to a quicker resolution of symptoms and a quicker return to sport. More research needs to be performed to determine the effectiveness of early intervention of VRT in concussion recovery. Level of Evidence 1.
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Makdissi M, Critchley ML, Cantu RC, Caron JG, Davis GA, Echemendia RJ, Fremont P, Hayden KA, Herring SA, Hinds SR, Jordan B, Kemp S, McNamee M, Maddocks D, Nagahiro S, Patricios J, Putukian M, Turner M, Sick S, Schneider KJ. When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review. Br J Sports Med 2023; 57:822-830. [PMID: 37316181 DOI: 10.1136/bjsports-2023-106815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC. DATA SOURCES Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically. STUDY ELIGIBILITY CRITERIA Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery. RESULTS Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC. CONCLUSION No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC. PROSPERO REGISTRATION NUMBER CRD42022155121.
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Affiliation(s)
- Michael Makdissi
- Australian Football League, Melbourne, Victoria, Australia
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
| | - Meghan L Critchley
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Robert C Cantu
- Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jeffrey G Caron
- School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Québec, Canada
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Ruben J Echemendia
- Psychology, University of Missouri-Kansas City, Kansas City, MO, USA
- Orthopedics Center Concussion Care Clinic, State College, Pennsylvania, Pennsylvania, USA
| | - Pierre Fremont
- Rehabilitation, Laval University, Quebec, Quebec, Canada
| | - K Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Stanley A Herring
- Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Barry Jordan
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Simon Kemp
- Sports Medicine, Rugby Football Union, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Michael McNamee
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
- School of Sport and Exercise Sciences, Swansea University, Swansea, UK
| | - David Maddocks
- Perry Maddocks Trollope Lawyers, Melbourne, Victoria, Australia
| | - Shinji Nagahiro
- Department of Neurosurgery, Yoshinogawa Hospital, Tokushima, Japan
| | - Jon Patricios
- Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Margot Putukian
- Major League Soccer, Princeton University, Princeton, New Jersey, USA
| | - Michael Turner
- International Concussion and Head Injury Research Foundation, London, UK
- University College London, London, UK
| | - Stacy Sick
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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Wait TJ, Eck AG, Loose T, Drumm A, Kolaczko JG, Stevanovic O, Boublik M. Median Time to Return to Sports After Concussion Is Within 21 Days in 80% of Published Studies. Arthroscopy 2023; 39:887-901. [PMID: 36574536 DOI: 10.1016/j.arthro.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To perform a systematic review of the literature and evaluate the return to play (RTP) time frame after a concussion diagnosis. Our secondary purpose was to analyze and compare different prognostic variables affecting concussions, time to return to school, time to symptom resolution of concussive symptoms, and time each patient spent in the RTP protocol. METHODS A PubMed, Scopus, Medline, Embase, and Cochrane Library database literature review was performed in August 2022. The studies needed to report, in days, the length of time a patient/athlete was removed from play due to concussion management. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for risk of bias for each study, and Methodological Index for Non-Randomized Studies criteria were used for quality assessment. RESULTS There were 65 studies included in the systematic review and a total of 21,966 patients evaluated. The RTP time intervals ranged from 1 to 1,820 days, with 80.7% of the median RTP time frames for each study within 21 days. Preconcussion risk factors for prolonged RTP included female sex, younger age, presence of psychiatric disorders, and history of previous concussion. Postconcussion risk factors included severe symptom scores at initial clinic visit, loss of consciousness, nonelite athletes, and delayed removal from competition. The most common sports resulting in concussion were contact sports, most commonly football and soccer. Median time to return to school was 3 to 23 days. Median time to symptom resolution ranged from 2 to 11 days. Median time in RTP protocol was 1 to 6 days. CONCLUSIONS Median time to return to sports after concussion is within 21 days in 80% of published studies. LEVEL OF EVIDENCE IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Trevor J Wait
- University of Colorado - Steadman Hawkins Clinic of Denver, Englewood, Colorado, U.S.A..
| | - Andrew G Eck
- Department of Orthopaedics, UT Health San Antonio, San Antonio, Texas, U.S.A
| | - Tyler Loose
- University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Amelia Drumm
- University of Colorado School of Medicine, Englewood, Colorado, U.S.A
| | - Jensen G Kolaczko
- University of Colorado - Steadman Hawkins Clinic of Denver, Englewood, Colorado, U.S.A
| | - Ognjen Stevanovic
- University of Colorado - Steadman Hawkins Clinic of Denver, Englewood, Colorado, U.S.A
| | - Martin Boublik
- University of Colorado - Steadman Hawkins Clinic of Denver, Englewood, Colorado, U.S.A
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