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Ly MT, Tuz-Zahra F, Tripodis Y, Adler CH, Balcer LJ, Bernick C, Zetterberg H, Blennow K, Peskind ER, Au R, Banks SJ, Barr WB, Wethe JV, Bondi MW, Delano-Wood LM, Cantu RC, Coleman MJ, Dodick DW, McClean MD, Mez JB, Palmisano J, Martin B, Hartlage K, Lin AP, Koerte IK, Cummings JL, Reiman EM, Shenton ME, Stern RA, Bouix S, Alosco ML. Association of Vascular Risk Factors and CSF and Imaging Biomarkers With White Matter Hyperintensities in Former American Football Players. Neurology 2024; 102:e208030. [PMID: 38165330 PMCID: PMC10870736 DOI: 10.1212/wnl.0000000000208030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Recent data link exposure to repetitive head impacts (RHIs) from American football with increased white matter hyperintensity (WMH) burden. WMH might have unique characteristics in the context of RHI beyond vascular risk and normal aging processes. We evaluated biological correlates of WMH in former American football players, including markers of amyloid, tau, inflammation, axonal injury, neurodegeneration, and vascular health. METHODS Participants underwent clinical interviews, MRI, and lumbar puncture as part of the Diagnostics, Imaging, and Genetics Network for the Objective Study and Evaluation of Chronic Traumatic Encephalopathy Research Project. Structural equation modeling tested direct and indirect effects between log-transformed total fluid-attenuated inversion recovery (FLAIR) lesion volumes (TLV) and the revised Framingham stroke risk profile (rFSRP), MRI-derived global metrics of cortical thickness and fractional anisotropy (FA), and CSF levels of amyloid β1-42, p-tau181, soluble triggering receptor expressed on myeloid cells 2 (sTREM2), and neurofilament light. Covariates included age, race, education, body mass index, APOE ε4 carrier status, and evaluation site. Models were performed separately for former football players and a control group of asymptomatic men unexposed to RHI. RESULTS In 180 former football players (mean age = 57.2, 36% Black), higher log(TLV) had direct associations with the following: higher rFSRP score (B = 0.26, 95% CI 0.07-0.40), higher p-tau181 (B = 0.17, 95% CI 0.01-0.43), lower FA (B = -0.28, 95% CI -0.42 to -0.13), and reduced cortical thickness (B = -0.25, 95% CI -0.45 to -0.08). In 60 asymptomatic unexposed men (mean age = 59.3, 40% Black), there were no direct effects on log(TLV) (rFSRP: B = -0.03, 95% CI -0.48 to 0.57; p-tau181: B = -0.30, 95% CI -1.14 to 0.37; FA: B = -0.07, 95% CI -0.48 to 0.42; or cortical thickness: B = -0.28, 95% CI -0.64 to 0.10). The former football players showed stronger associations between log(TLV) and rFSRP (1,069% difference in estimates), p-tau181 (158%), and FA (287%) than the unexposed men. DISCUSSION Risk factors and biological correlates of WMH differed between former American football players and asymptomatic unexposed men. In addition to vascular health, p-tau181 and diffusion tensor imaging indices of white matter integrity showed stronger associations with WMH in the former football players. FLAIR WMH may have specific risk factors and pathologic underpinnings in RHI-exposed individuals.
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Affiliation(s)
- Monica T Ly
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Fatima Tuz-Zahra
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Yorghos Tripodis
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Charles H Adler
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Laura J Balcer
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Charles Bernick
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Henrik Zetterberg
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Kaj Blennow
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Elaine R Peskind
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Rhoda Au
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Sarah J Banks
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - William B Barr
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Jennifer V Wethe
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Mark W Bondi
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Lisa M Delano-Wood
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Robert C Cantu
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Michael J Coleman
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - David W Dodick
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Michael D McClean
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Jesse B Mez
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Joseph Palmisano
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Brett Martin
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Kaitlin Hartlage
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Alexander P Lin
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Inga K Koerte
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Jeffrey L Cummings
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Eric M Reiman
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Martha E Shenton
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Robert A Stern
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Sylvain Bouix
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
| | - Michael L Alosco
- From the VA San Diego Healthcare System (M.T.L., M.W.B., L.M.D.-W.), CA; Department of Psychiatry (M.T.L., S.J.B., M.W.B., L.M.D.-W.), University of California San Diego Health, La Jolla; Departments of Biostatistics (F.T.-Z., Y.T.), Epidemiology (R.A.), Environmental Health (M.D.M.), Biostatistics and Epidemiology Data Analytics Center (J.P., B.M., K.H.), Boston University School of Public Health, MA; Boston University Alzheimer's Disease Research Center (Y.T., J.B.M., M.L.A., R.A., R.C.C., R.A.S.), Boston University CTE Center; Department of Neurology, Boston University Chobanian & Avedisian School of Medicine; Departments of Neurology (C.H.A., D.W.D.) and Psychiatry and Psychology (J.V.W.), Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale; Departments of Neurology (L.J.B.), Population Health and Ophthalmology, (L.J.B.), and Neurology (W.B.B.), NYU Grossman School of Medicine; Cleveland Clinic Lou Ruvo Center for Brain Health (C.B.), Las Vegas, NV; Department of Neurology (C.B.), University of Washington, Seattle; Department of Neurodegenerative Disease (H.Z.), and UK Dementia Research Institute (H.Z.), University College London Institute of Neurology, UK; Hong Kong Center for Neurodegenerative Diseases (H.Z.), China; Wisconsin Alzheimer's Disease Research Center (H.Z.), University of Wisconsin-Madison; Clinical Neurochemistry Laboratory (H.Z., K.B.), Sahlgrenska University Hospital, Gothenburg; Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden; VA Northwest Mental Illness Research, Education, and Clinical Center (E.R.P.), Seattle, WA; Department of Psychiatry and Behavioral Sciences (E.R.P.), University of Washington School of Medicine, Seattle; Framingham Heart Study (R.A., J.B.M.); Slone Epidemiology Center (R.A.), Boston University, MA; Department of Neurosciences (S.J.B.), University of California San Diego; Psychiatry Neuroimaging Laboratory (M.J.C., A.P.L., I.K.K., M.E.S., S.B.), Departments of Psychiatry Radiology (M.E.S.), and Center for Clinical Spectroscopy (A.P.L.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; cBRAIN (I.K.K.), Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany; Chambers-Grundy Center for Transformative Neuroscience (J.L.C.), Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas; Banner Alzheimer's Institute (E.M.R.), Phoenix; Department of Psychiatry (E.M.R.), University of Arizona, Phoenix; Arizona State University (E.M.R.), Phoenix; Translational Genomics Research Institute (E.M.R.), Phoenix; Arizona Alzheimer's Consortium (E.M.R.), Phoenix; and Department of Software Engineering and Information Technology (S.B.), École de technologie supérieure, Université du Québec, Montréal, Canada
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Hageman G, Hageman I, Nihom J. Chronic Traumatic Encephalopathy in Soccer Players: Review of 14 Cases. Clin J Sport Med 2024; 34:69-80. [PMID: 37403989 DOI: 10.1097/jsm.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 05/22/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Exposure to repetitive sports-related concussions or (sub)concussive head trauma may lead to chronic traumatic encephalopathy (CTE). Which impact (heading or concussion) poses the greatest risk of CTE development in soccer players? DESIGN Narrative review. SETTING Teaching hospital and University of Applied sciences. PATIENTS A literature search (PubMed) was conducted for neuropathologic studies in the period 2005-December 2022, investigating soccer players with dementia and a CTE diagnosis, limited to English language publications. 210 papers were selected for final inclusion, of which 7 papers described 14 soccer players. ASSESSMENT Magnetic resonance imaging studies in soccer players show that lifetime estimates of heading numbers are inversely correlated with cortical thickness, grey matter volume, and density of the anterior temporal cortex. Using diffusion tensor imaging-magnetic resonance imaging, higher frequency of headings-particularly with rotational accelerations-are associated with impaired white matter integrity. Serum neurofilament light protein is elevated after heading. MAIN OUTCOME MEASURES Chronic traumatic encephalopathy pathology, history of concussion, heading frequency. RESULTS In 10 of 14 soccer players, CTE was the primary diagnosis. In 4 cases, other dementia types formed the primary diagnosis and CTE pathology was a concomitant finding. Remarkably, 6 of the 14 cases had no history of concussion, suggesting that frequent heading may be a risk for CTE in patients without symptomatic concussion. Rule changes in heading duels, management of concussion during the game, and limiting the number of high force headers during training are discussed. CONCLUSIONS Data suggest that heading frequency and concussions are associated with higher risk of developing CTE in (retired) soccer players. However based on this review of only 14 players, questions persist as to whether or not heading is a risk factor for CTE or long-term cognitive decline.
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Affiliation(s)
- Gerard Hageman
- Department of Neurology, Medisch Spectrum Twente, Hospital Enschede, Enschede, the Netherlands; and
| | - Ivar Hageman
- Saxion University of Applied Sciences, Enschede, the Netherlands
| | - Jik Nihom
- Department of Neurology, Medisch Spectrum Twente, Hospital Enschede, Enschede, the Netherlands; and
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Amadon GK, Goeckner BD, Brett BL, Meier TB. Comparison of Various Metrics of Repetitive Head Impact Exposure And Their Associations With Neurocognition in Collegiate-Aged Athletes. Arch Clin Neuropsychol 2023; 38:714-723. [PMID: 36617242 PMCID: PMC10369361 DOI: 10.1093/arclin/acac107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Characterize the levels of various metrics of repetitive head impacts (RHI) in contact (CS) and non-contact (NCS) sport athletes and determine the extent to which they are associated with fluid cognition. METHODS Collegiate-aged athletes (n = 176) completed semi-structured interviews about participation in contact sport. RHI was operationalized based on current sport (CS/NCS), the cumulative number of years of participation, age at first exposure (AFE), and based on recently proposed traumatic encephalopathy syndrome (TES) categories. The NIH Toolbox Cognition Battery assessed fluid cognition. General linear models compared RHI metrics between CS and NCS athletes and tested associations of RHI measures with fluid cognition. RESULTS CS athletes had more years of RHI exposure, higher rates of "extensive" exposure based on TES criteria, and were more likely to have AFE before age 12 relative to NCS (ps < .001). A subset of NCS athletes, however, reported prior RHI at levels categorized as being "extensive" based on TES criteria (5%), while a larger minority had AFE before 12 (34%). No adverse associations of RHI and fluid cognition were observed (ps > .05). Across all RHI metrics, more or earlier RHI was associated with better episodic memory (ps ≤ .05). Secondary analyses showed this effect was driven by women. CONCLUSIONS Current results find no evidence that RHI in collegiate-aged athletes is associated with worse neurocognition. Although there was extensive overlap among RHI measures, results demonstrate that categorizing athletes based on their current sport undercounts the lifetime RHI exposure in many NCS athletes.
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Affiliation(s)
- Grace K Amadon
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bryna D Goeckner
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
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Iverson GL, Castellani RJ, Cassidy JD, Schneider GM, Schneider KJ, Echemendia RJ, Bailes JE, Hayden KA, Koerte IK, Manley GT, McNamee M, Patricios JS, Tator CH, Cantu RC, Dvorak J. Examining later-in-life health risks associated with sport-related concussion and repetitive head impacts: a systematic review of case-control and cohort studies. Br J Sports Med 2023; 57:810-821. [PMID: 37316187 DOI: 10.1136/bjsports-2023-106890] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Concern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes. DESIGN Systematic review. DATA SOURCES Search of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022. ELIGIBILITY CRITERIA Studies measuring future risk (cohort studies) or approximating that risk (case-control studies). RESULTS Ten studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias. CONCLUSION Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors. PROSPERO REGISTRATION NUMBER CRD42022159486.
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Affiliation(s)
- Grant L Iverson
- Sports Concussion Program, MassGeneral Hospital for Children, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, Massachusetts, USA
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Rudolph J Castellani
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - J David Cassidy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Geoff M Schneider
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Ruben J Echemendia
- Department of Psychology, University of Missouri-Kansas City, Kansas City, Missouri, USA
- University Orthopedic Centre, Concussion Care Clinic, State College, Pennsylvania, USA
| | - Julian E Bailes
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - K Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Inga K Koerte
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Mass General Brigham, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Michael McNamee
- Department of Movement Sciences, KU Leuven, Leuven, Belgium
- School of Sport and Exercise Sciences, Swansea University, Swansea, UK
| | - Jon S Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles H Tator
- Department of Surgery and Division of Neurosurgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Canadian Concussion Centre, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Robert C Cantu
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
- Robert C. Cantu Concussion Center, Emerson Hospital, Concord, Massachusetts, USA
| | - Jiri Dvorak
- Schulthess Clinic Zurich, Zurich, Switzerland
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Schaffert J, Didehbani N, LoBue C, Hart J, Wilmoth K, Cullum CM. No association between age beginning tackle football, or years played and neurocognitive performance later-in-life among older National Football League retirees. Arch Clin Neuropsychol 2023; 38:644-649. [PMID: 36533487 PMCID: PMC10202547 DOI: 10.1093/arclin/acac101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE In a retrospective cohort, we evaluated whether age beginning tackle football (ABTF) and more total years of playing football (TYPF) were associated with worse later-in-life neuropsychological change among older retired National Football League (NFL) players. METHOD Participants were 19 older NFL retirees aged 54-79, including 12 who returned for follow-up evaluation 15-51 months later. Mixed-linear models evaluated the association between ABTF/TYFP and baseline neuropsychological composite scores (executive functioning/attention/speed, language, memory), and neuropsychological composites over time. RESULTS ABTF and TYPF were not significantly associated with neuropsychological composites at baseline or over time (all p's > .05). There were no significant differences in neuropsychological performance between those ABTF <12 and ≥ 12 years old (all p's ≥ .475) or between those with TYPF <19 or ≥ 19 years played (median split; all p's ≥ .208). CONCLUSIONS Preliminary findings suggest that ABTF and TYPF does not worsen neurocognitive decline later-in-life among older NFL retirees.
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Affiliation(s)
- Jeff Schaffert
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nyaz Didehbani
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christian LoBue
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Hart
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Callier Center, School of Behavioral and Brain Sciences, UT Dallas, Dallas, TX, USA
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristin Wilmoth
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C Munro Cullum
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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6
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Alosco ML, Tripodis Y, Baucom ZH, Adler CH, Balcer LJ, Bernick C, Mariani ML, Au R, Banks SJ, Barr WB, Wethe JV, Cantu RC, Coleman MJ, Dodick DW, McClean MD, McKee AC, Mez J, Palmisano JN, Martin B, Hartlage K, Lin AP, Koerte IK, Cummings JL, Reiman EM, Stern RA, Shenton ME, Bouix S. White matter hyperintensities in former American football players. Alzheimers Dement 2023; 19:1260-1273. [PMID: 35996231 PMCID: PMC10351916 DOI: 10.1002/alz.12779] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 06/24/2022] [Accepted: 07/27/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The presentation, risk factors, and etiologies of white matter hyperintensities (WMH) in people exposed to repetitive head impacts are unknown. We examined the burden and distribution of WMH, and their association with years of play, age of first exposure, and clinical function in former American football players. METHODS A total of 149 former football players and 53 asymptomatic unexposed participants (all men, 45-74 years) completed fluid-attenuated inversion recovery magnetic resonance imaging, neuropsychological testing, and self-report neuropsychiatric measures. Lesion Segmentation Toolbox estimated WMH. Analyses were performed in the total sample and stratified by age 60. RESULTS In older but not younger participants, former football players had greater total, frontal, temporal, and parietal log-WMH compared to asymptomatic unexposed men. In older but not younger former football players, greater log-WMH was associated with younger age of first exposure to football and worse executive function. DISCUSSION In older former football players, WMH may have unique presentations, risk factors, and etiologies. HIGHLIGHTS Older but not younger former football players had greater total, frontal, temporal, and parietal lobe white matter hyperintensities (WMH) compared to same-age asymptomatic unexposed men. Younger age of first exposure to football was associated with greater WMH in older but not younger former American football players. In former football players, greater WMH was associated with worse executive function and verbal memory.
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Affiliation(s)
- Michael L. Alosco
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Yorghos Tripodis
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Boston University School of Medicine, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Zachary H. Baucom
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Charles H. Adler
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Laura J. Balcer
- Departments of Neurology, Population Health and Ophthalmology, NYU Grossman School of Medicine, New York, NY
| | - Charles Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV
- Department of Neurology, University of Washington, Seattle, WA
| | - Megan L. Mariani
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Boston University School of Medicine, Boston, MA
| | - Rhoda Au
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- Framingham Heart Study, Framingham, MA
- Slone Epidemiology Center, Boston University, Boston, MA
- Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Sarah J. Banks
- Departments of Neuroscience and Psychiatry, University of California, San Diego, CA
| | - William B. Barr
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
| | - Jennifer V. Wethe
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Robert C. Cantu
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Michael J. Coleman
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
| | - David W. Dodick
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Michael D. McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Ann C. McKee
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- VA Boston Healthcare System, Boston, MA
| | - Jesse Mez
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- Framingham Heart Study, Framingham, MA
| | - Joseph N. Palmisano
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Kaitlin Hartlage
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Alexander P. Lin
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Inga K. Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany
| | - Jeffrey L. Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas, Las Vegas, NV
| | - Eric M. Reiman
- Banner Alzheimer’s Institute, University of Arizona, Arizona State University, Translational Genomics Research Institute, and Arizona Alzheimer’s Consortium, Phoenix, AZ
| | - Robert A. Stern
- Boston University Alzheimer’s Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA
- Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA
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7
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Alosco ML, Ly M, Mosaheb S, Saltiel N, Uretsky M, Tripodis Y, Martin B, Palmisano J, Delano-Wood L, Bondi MW, Meng G, Xia W, Daley S, Goldstein LE, Katz DI, Dwyer B, Daneshvar DH, Nowinski C, Cantu RC, Kowall NW, Stern RA, Alvarez VE, Mez J, Huber BR, McKee AC, Stein TD. Decreased myelin proteins in brain donors exposed to football-related repetitive head impacts. Brain Commun 2023; 5:fcad019. [PMID: 36895961 PMCID: PMC9990992 DOI: 10.1093/braincomms/fcad019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/02/2022] [Accepted: 01/30/2023] [Indexed: 03/09/2023] Open
Abstract
American football players and other individuals exposed to repetitive head impacts can exhibit a constellation of later-life cognitive and neuropsychiatric symptoms. While tau-based diseases such as chronic traumatic encephalopathy can underpin certain symptoms, contributions from non-tau pathologies from repetitive head impacts are increasingly recognized. We examined cross-sectional associations between myelin integrity using immunoassays for myelin-associated glycoprotein and proteolipid protein 1 with risk factors and clinical outcomes in brain donors exposed to repetitive head impacts from American football. Immunoassays for myelin-associated glycoprotein and proteolipid protein 1 were conducted on dorsolateral frontal white matter tissue samples of 205 male brain donors. Proxies of exposure to repetitive head impacts included years of exposure and age of first exposure to American football play. Informants completed the Functional Activities Questionnaire, Behavior Rating Inventory of Executive Function-Adult Version (Behavioral Regulation Index), and Barratt Impulsiveness Scale-11. Associations between myelin-associated glycoprotein and proteolipid protein 1 with exposure proxies and clinical scales were tested. Of the 205 male brain donors who played amateur and professional football, the mean age was 67.17 (SD = 16.78), and 75.9% (n = 126) were reported by informants to be functionally impaired prior to death. Myelin-associated glycoprotein and proteolipid protein 1 correlated with the ischaemic injury scale score, a global indicator of cerebrovascular disease (r = -0.23 and -0.20, respectively, Ps < 0.01). Chronic traumatic encephalopathy was the most common neurodegenerative disease (n = 151, 73.7%). Myelin-associated glycoprotein and proteolipid protein 1 were not associated with chronic traumatic encephalopathy status, but lower proteolipid protein 1 was associated with more severe chronic traumatic encephalopathy (P = 0.03). Myelin-associated glycoprotein and proteolipid protein 1 were not associated with other neurodegenerative disease pathologies. More years of football play was associated with lower proteolipid protein 1 [beta = -2.45, 95% confidence interval (CI) [-4.52, -0.38]] and compared with those who played <11 years of football (n = 78), those who played 11 or more years (n = 128) had lower myelin-associated glycoprotein (mean difference = 46.00, 95% CI [5.32, 86.69]) and proteolipid protein 1 (mean difference = 24.72, 95% CI [2.40, 47.05]). Younger age of first exposure corresponded to lower proteolipid protein 1 (beta = 4.35, 95% CI [0.25, 8.45]). Among brain donors who were aged 50 or older (n = 144), lower proteolipid protein 1 (beta = -0.02, 95% CI [-0.047, -0.001]) and myelin-associated glycoprotein (beta = -0.01, 95% CI [-0.03, -0.002]) were associated with higher Functional Activities Questionnaire scores. Lower myelin-associated glycoprotein correlated with higher Barratt Impulsiveness Scale-11 scores (beta = -0.02, 95% CI [-0.04, -0.0003]). Results suggest that decreased myelin may represent a late effect of repetitive head impacts that contributes to the manifestation of cognitive symptoms and impulsivity. Clinical-pathological correlation studies with prospective objective clinical assessments are needed to confirm our findings.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Monica Ly
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, La Jolla, CA, USA
| | - Sydney Mosaheb
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Nicole Saltiel
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Madeline Uretsky
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Brett Martin
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph Palmisano
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Lisa Delano-Wood
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, La Jolla, CA, USA
| | - Mark W Bondi
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, La Jolla, CA, USA
| | | | - Weiming Xia
- VA Bedford Healthcare System, Bedford, MA, USA
- Department of Pharmacology and Experimental Therapeutics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sarah Daley
- VA Bedford Healthcare System, Bedford, MA, USA
- Department of Pharmacology and Experimental Therapeutics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Lee E Goldstein
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Biomedical, Electrical & Computer Engineering, Boston University College of Engineering, Boston, MA, USA
| | - Douglas I Katz
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Brigid Dwyer
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Daniel H Daneshvar
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | - Robert C Cantu
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Emerson Hospital, Concord, MA, USA
| | - Neil W Kowall
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Neurosurgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Victor E Alvarez
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- National Center for PTSD, VA Boston Healthcare, Jamaica Plain, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Bertrand Russell Huber
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- National Center for PTSD, VA Boston Healthcare, Jamaica Plain, Boston, MA, USA
| | - Ann C McKee
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- National Center for PTSD, VA Boston Healthcare, Jamaica Plain, Boston, MA, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Thor D Stein
- Boston University Alzheimer’s Disease Research Center and CTE Center, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
- Departments of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Jamaica Plain, Boston, MA, USA
- Framingham Heart Study, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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8
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Charney MF, Ye KQ, Fleysher R, DeMessie B, Stewart WF, Zimmerman ME, Kim M, Lipton RB, Lipton ML. Age of first exposure to soccer heading: Associations with cognitive, clinical, and imaging outcomes in the Einstein Soccer Study. Front Neurol 2023; 14:1042707. [PMID: 36846112 PMCID: PMC9947556 DOI: 10.3389/fneur.2023.1042707] [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: 09/12/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction The objective of this study is to assess the role of age at first exposure (AFE) to soccer heading as a predictor of known adverse associations of recent and longer-term heading with brain microstructure, cognitive, and behavioral features among adult amateur soccer players. Methods The sample included 276 active amateur soccer players (196 male and 81 female) aged 18-53 years old. AFE to soccer heading was treated as a binary variable, dichotomized at ≤ 10 years vs. >10 years old, based on a recently promulgated US Soccer policy, which bans heading for athletes ages 10 and under. Results We found that soccer players who began heading at age 10 or younger performed better on tests of working memory (p = 0.03) and verbal learning (p = 0.02), while accounting for duration of heading exposure, education, sex, and verbal intelligence. No difference in brain microstructure or behavioral measures was observed between the two exposure groups. Discussion The findings indicate that, among adult amateur soccer players, AFE to heading before age 10 compared to later start of heading, is not associated with adverse outcomes, and may be associated with better cognitive performance in young adulthood. Cumulative heading exposure across the lifespan, rather than early life exposure, may drive risk for adverse effects and should be the focus of future longitudinal studies to inform approaches to enhance player safety.
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Affiliation(s)
- Molly F. Charney
- Gruss Magnetic Resonance Imaging Center, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States,Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States,*Correspondence: Molly F. Charney ✉
| | - Kenny Q. Ye
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States,Department of Systems and Computational Biology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Roman Fleysher
- Gruss Magnetic Resonance Imaging Center, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States,Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Bluyé DeMessie
- Gruss Magnetic Resonance Imaging Center, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States,Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | | | | | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Richard B. Lipton
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States,Saul B. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, United States,Department of Neurology, Montefiore Medical Center, Bronx, NY, United States
| | - Michael L. Lipton
- Gruss Magnetic Resonance Imaging Center, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States,Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States,Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
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9
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Liang B, Alosco ML, Armañanzas R, Martin BM, Tripodis Y, Stern RA, Prichep LS. Long-Term Changes in Brain Connectivity Reflected in Quantitative Electrophysiology of Symptomatic Former National Football League Players. J Neurotrauma 2023; 40:309-317. [PMID: 36324216 PMCID: PMC9902050 DOI: 10.1089/neu.2022.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Exposure to repetitive head impacts (RHI) has been associated with long-term disturbances in cognition, mood, and neurobehavioral dysregulation, and reflected in neuroimaging. Distinct patterns of changes in quantitative features of the brain electrical activity (quantitative electroencephalogram [qEEG]) have been demonstrated to be sensitive to brain changes seen in neurodegenerative disorders and in traumatic brain injuries (TBI). While these qEEG biomarkers are highly sensitive at time of injury, the long-term effects of exposure to RHI on brain electrical activity are relatively unexplored. Ten minutes of eyes closed resting EEG data were collected from a frontal and frontotemporal electrode montage (BrainScope Food and Drug Administration-cleared EEG acquisition device), as well as assessments of neuropsychiatric function and age of first exposure (AFE) to American football. A machine learning methodology was used to derive a qEEG-based algorithm to discriminate former National Football League (NFL) players (n = 87, 55.40 ± 7.98 years old) from same-age men without history of RHI (n = 68, 54.94 ± 7.63 years old), and a second algorithm to discriminate former players with AFE <12 years (n = 33) from AFE ≥12 years (n = 54). The algorithm separating NFL retirees from controls had a specificity = 80%, a sensitivity = 60%, and an area under curve (AUC) = 0.75. Within the NFL population, the algorithm separating AFE <12 from AFE ≥12 resulted in a sensitivity = 76%, a specificity = 52%, and an AUC = 0.72. The presence of a profile of EEG abnormalities in the NFL retirees and in those with younger AFE includes features associated with neurodegeneration and the disruption of neuronal transmission between regions. These results support the long-term consequences of RHI and the potential of EEG as a biomarker of persistent changes in brain function.
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Affiliation(s)
- Bo Liang
- BrainScope Company, Chevy Chase, Maryland, USA
| | - Michael L. Alosco
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
- Department of Neurology, Boston University, Boston, Massachusetts, USA
| | - Ruben Armañanzas
- BrainScope Company, Chevy Chase, Maryland, USA
- Institute for Data Science and Artificial Intelligence, Universidad de Navarra, Pamplona, Spain
- Tecnun School of Engineering, Universidad de Navarra, Donostia-San Sebastian, Spain
| | - Brett M. Martin
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
| | - Yorghos Tripodis
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University, Boston, Massachusetts, USA
| | - Robert A. Stern
- Boston University CTE Center, Boston University, Boston, Massachusetts, USA
- Department of Neurology, Boston University, Boston, Massachusetts, USA
- Departments of Neurosurgery and Anatomy & Neurobiology, Boston University, Boston, Massachusetts, USA
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10
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Marks ME, Holcomb TD, Pritchard NS, Miller LE, Espeland MA, Miles CM, Moore JB, Foley KL, Stitzel JD, Urban JE. Characterizing Exposure to Head Acceleration Events in Youth Football Using an Instrumented Mouthpiece. Ann Biomed Eng 2022; 50:1620-1632. [PMID: 36274103 PMCID: PMC9815159 DOI: 10.1007/s10439-022-03097-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/03/2022] [Indexed: 01/11/2023]
Abstract
Understanding characteristics of head acceleration events (HAEs) in youth football is vital in developing strategies to improve athlete safety. This study aimed to characterize HAEs in youth football using an instrumented mouthpiece. Youth football athletes (ages 11-13) participating on two teams were enrolled in this study for one season. Each athlete was instrumented with a mouthpiece-based sensor throughout the season. HAEs were verified on film to ensure that mouthpiece-based sensors triggered during contact. The number of HAEs, peak resultant linear and rotational accelerations, and peak resultant rotational velocity were quantified. Mixed effects models were used to evaluate differences in mean kinematic metrics among all HAEs for session type, athlete position, and contact surface. A total of 5,292 HAEs were collected and evaluated from 30 athletes. The median (95th percentile) peak resultant linear acceleration, rotational acceleration, and rotational velocity was 9.5 g (27.0 g), 666.4 rad s-2 (1863.3 rad s-2), and 8.5 rad s-1 (17.4 rad s-1), respectively. Athletes experienced six (22) HAEs per athlete per session (i.e., practice, game). Competition had a significantly higher mean number of HAEs per athlete per session and mean peak rotational acceleration. Peak resultant rotational kinematics varied significantly among athlete positions. Direct head impacts had higher mean kinematics compared to indirect HAEs, from body collisions. The results of this study demonstrate that session type, athlete position, and contact surface (i.e., direct, indirect) may influence HAE exposure in youth football.
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Affiliation(s)
- Madison E Marks
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575 Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, NC, USA
| | - Ty D Holcomb
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575 Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, NC, USA
| | - N Stewart Pritchard
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575 Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, NC, USA
| | - Logan E Miller
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575 Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, NC, USA
| | - Mark A Espeland
- Department of Biostatistics and Data Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Christopher M Miles
- Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Justin B Moore
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Epidemiology & Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575 Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, NC, USA
| | - Jillian E Urban
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575 Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA.
- Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, NC, USA.
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11
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van Amerongen S, Caton DK, Ossenkoppele R, Barkhof F, Pouwels PJW, Teunissen CE, Rozemuller AJM, Hoozemans JJM, Pijnenburg YAL, Scheltens P, Vijverberg EGB. Rationale and design of the “NEurodegeneration: Traumatic brain injury as Origin of the Neuropathology (NEwTON)” study: a prospective cohort study of individuals at risk for chronic traumatic encephalopathy. Alzheimers Res Ther 2022; 14:119. [PMID: 36050790 PMCID: PMC9438060 DOI: 10.1186/s13195-022-01059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022]
Abstract
Background Repetitive head injury in contact sports is associated with cognitive, neurobehavioral, and motor impairments and linked to a unique neurodegenerative disorder: chronic traumatic encephalopathy (CTE). As the clinical presentation is variable, risk factors are heterogeneous, and diagnostic biomarkers are not yet established, the diagnostic process of CTE remains a challenge. The general objective of the NEwTON study is to establish a prospective cohort of individuals with high risk for CTE, to phenotype the study population, to identify potential fluid and neuroimaging biomarkers, and to measure clinical progression of the disease. The present paper explains the protocol and design of this case-finding study. Methods NEwTON is a prospective study that aims to recruit participants at risk for CTE, with features of the traumatic encephalopathy syndrome (exposed participants), and healthy unexposed control individuals. Subjects are invited to participate after diagnostic screening at our memory clinic or recruited by advertisement. Exposed participants receive a comprehensive baseline screening, including neurological examination, neuropsychological tests, questionnaires and brain MRI for anatomical imaging, diffusion tensor imaging (DTI), resting-state functional MRI (rsfMRI), and quantitative susceptibility mapping (QSM). Questionnaires include topics on life-time head injury, subjective cognitive change, and neuropsychiatric symptoms. Optionally, blood and cerebrospinal fluid are obtained for storage in the NEwTON biobank. Patients are informed about our brain donation program in collaboration with the Netherlands Brain Brank. Follow-up takes place annually and includes neuropsychological assessment, questionnaires, and optional blood draw. Testing of control subjects is limited to baseline neuropsychological tests, MRI scan, and also noncompulsory blood draw. Results To date, 27 exposed participants have finished their baseline assessments. First baseline results are expected in 2023. Conclusions The NEwTON study will assemble a unique cohort with prospective observational data of male and female individuals with high risk for CTE. This study is expected to be a primary explorative base and designed to share data with international CTE-related cohorts. Sub-studies may be added in the future with this cohort as backbone.
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12
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Relationship between Aggressiveness, Self-Confidence, and Perceived Coach Support and Head Impact Exposure in Youth Football. Sports (Basel) 2022; 10:sports10080115. [PMID: 36006081 PMCID: PMC9412463 DOI: 10.3390/sports10080115] [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: 06/11/2022] [Revised: 07/06/2022] [Accepted: 07/23/2022] [Indexed: 11/17/2022] Open
Abstract
This study evaluated head impact exposure (HIE) metrics in relation to individual-level determinants of HIE. Youth (n = 13) and high school (n = 21) football players were instrumented with the Head Impact Telemetry (HIT) system during one season. Players completed the Trait-Robustness of Self-Confidence Inventory (TROSCI), Sports Climate Questionnaire (SCQ), and Competitive Aggressiveness and Anger Scale (CAAS), measuring self-confidence, perceived coach support, and competitive aggressiveness, respectively. Relationships between HIE metrics (number of impacts, median and 95th percentile accelerations, and risk-weighted exposure (RWE)) and survey scores were evaluated using linear regression analysis. For middle school athletes, TROSCI scores were significantly negatively associated with the number of competition impacts and the mean number of impacts per player per competition. SCQ scores were significantly positively associated with median linear acceleration during practice. CAAS scores were not significantly associated with biomechanical metrics at either level of play. Perceived coach support and self-confidence might influence HIE among middle school football players. Football athletes' competitive aggressiveness may have less influence their HIE than other factors.
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13
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Oldham JR, Lanois CJ, Caccese JB, Crenshaw JR, Knight CA, Berkstresser B, Wang F, Howell DR, Meehan WP, Buckley TA. Association Between Collision Sport Career Duration and Gait Performance in Male Collegiate Student-Athletes. Am J Sports Med 2022; 50:2526-2533. [PMID: 35736366 DOI: 10.1177/03635465221104685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Investigations of estimated age of first exposure to repetitive head impacts from collision and contact sports have shown no associations with neurocognitive or neurobehavioral function at the collegiate level, but the effect of career duration may be a more comprehensive factor. Understanding whether longer career duration influences gait performance would provide insights into potential neurological impairment. PURPOSE To examine the relationship between career duration of collision sports and single/dual-task gait performance in collegiate student-athletes. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We recruited 168 male student-athletes from collision sports: football, lacrosse, ice hockey, and wrestling (mean ± SD age, 19.2 ± 1.3 years; height, 184.5 ± 7.2 cm; mass, 94.3 ± 15.9 kg; estimated age of first exposure, 8.6 ± 3.1 years; career duration, 10.6 ± 3.0 years). All participants completed a baseline single- and dual-task gait assessment before the start of their athletic season. Inertial measurement units were used to measure gait speed and stride length. During the dual task, participants were asked to perform working memory cognitive tasks while walking. The dependent variables were single/dual-task gait speed and stride length, cognitive accuracy, and dual-task cost. The relationship between career duration, analyzed as a continuous variable, and the dependent variables was analyzed using a linear regression. RESULTS There were no significant associations between career duration and single-task gait speed (1.16 ± 0.16 m/s; β = -0.004; P = .35; 95% CI = -0.012 to 0.004; η2 = 0.005) or dual-task gait speed (1.02 ± 0.17 m/s; β = -0.003; P = .57; 95% CI = -0.011 to 0.006; η2 = 0.002). There were also no significant associations between career duration and single/dual-task stride length, cognitive accuracy, or dual-task cost. CONCLUSION Career duration among collegiate collision sport athletes was not associated with single- or dual-task gait performance, suggesting that a greater exposure to repetitive head impacts is not detrimental to dynamic postural control at the college level. However, the effects of diminished gait performance over the lifetime remain to be elucidated.
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Affiliation(s)
- Jessie R Oldham
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Corey J Lanois
- Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jeremy R Crenshaw
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA.,Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
| | - Christopher A Knight
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA.,Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
| | | | - Francis Wang
- Harvard University Health Service, Cambridge, Massachusetts, USA
| | - David R Howell
- Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA.,Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
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14
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Miller LE, Urban JE, Espeland MA, Walkup MP, Holcomb JM, Davenport EM, Powers AK, Whitlow CT, Maldjian JA, Stitzel JD. Cumulative strain-based metrics for predicting subconcussive head impact exposure-related imaging changes in a cohort of American youth football players. J Neurosurg Pediatr 2022; 29:387-396. [PMID: 35061991 PMCID: PMC9404368 DOI: 10.3171/2021.10.peds21355] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/27/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Youth football athletes are exposed to repetitive subconcussive head impacts during normal participation in the sport, and there is increasing concern about the long-term effects of these impacts. The objective of the current study was to determine if strain-based cumulative exposure measures are superior to kinematic-based exposure measures for predicting imaging changes in the brain. METHODS This prospective, longitudinal cohort study was conducted from 2012 to 2017 and assessed youth, male football athletes. Kinematic data were collected at all practices and games from enrolled athletes participating in local youth football organizations in Winston-Salem, North Carolina, and were used to calculate multiple risk-weighted cumulative exposure (RWE) kinematic metrics and 36 strain-based exposure metrics. Pre- and postseason imaging was performed at Wake Forest School of Medicine, and diffusion tensor imaging (DTI) measures, including fractional anisotropy (FA), and its components (CL, CP, and CS), and mean diffusivity (MD), were investigated. Included participants were youth football players ranging in age from 9 to 13 years. Exclusion criteria included any history of previous neurological illness, psychiatric illness, brain tumor, concussion within the past 6 months, and/or contraindication to MRI. RESULTS A total of 95 male athletes (mean age 11.9 years [SD 1.0 years]) participated between 2012 and 2017, with some participating for multiple seasons, resulting in 116 unique athlete-seasons. Regression analysis revealed statistically significant linear relationships between the FA, linear coefficient (CL), and spherical coefficient (CS) and all strain exposure measures, and well as the planar coefficient (CP) and 8 strain measures. For the kinematic exposure measures, there were statistically significant relationships between FA and RWE linear (RWEL) and RWE combined probability (RWECP) as well as CS and RWEL. According to area under the receiver operating characteristic (ROC) curve (AUC) analysis, the best-performing metrics were all strain measures, and included metrics based on tensile, compressive, and shear strain. CONCLUSIONS Using ROC curves and AUC analysis, all exposure metrics were ranked in order of performance, and the results demonstrated that all the strain-based metrics performed better than any of the kinematic metrics, indicating that strain-based metrics are better discriminators of imaging changes than kinematic-based measures. Studies relating the biomechanics of head impacts with brain imaging and cognitive function may allow equipment designers, care providers, and organizations to prevent, identify, and treat injuries in order to make football a safer activity.
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Affiliation(s)
- Logan E. Miller
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem,School of Biomedical Engineering and Sciences, Virginia Tech–Wake Forest University, Winston-Salem
| | - Jillian E. Urban
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem,School of Biomedical Engineering and Sciences, Virginia Tech–Wake Forest University, Winston-Salem
| | - Mark A. Espeland
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem
| | - Michael P. Walkup
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem
| | - James M. Holcomb
- Department of Radiology, University of Texas Southwestern Medical School, Dallas, Texas
| | | | - Alexander K. Powers
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem,Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem
| | - Christopher T. Whitlow
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem,Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joseph A. Maldjian
- Department of Radiology, University of Texas Southwestern Medical School, Dallas, Texas
| | - Joel D. Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem,School of Biomedical Engineering and Sciences, Virginia Tech–Wake Forest University, Winston-Salem
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15
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Robles DJ, Dharani A, Rostowsky KA, Chaudhari NN, Ngo V, Zhang F, O'Donnell LJ, Green L, Sheikh-Bahaei N, Chui HC, Irimia A. Older age, male sex, and cerebral microbleeds predict white matter loss after traumatic brain injury. GeroScience 2022; 44:83-102. [PMID: 34704219 PMCID: PMC8811069 DOI: 10.1007/s11357-021-00459-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/11/2021] [Indexed: 10/20/2022] Open
Abstract
Little is known on how mild traumatic brain injury affects white matter based on age at injury, sex, cerebral microbleeds, and time since injury. Here, we study the fractional anisotropy of white matter to study these effects in 109 participants aged 18-77 (46 females, age μ ± σ = 40 ± 17 years) imaged within [Formula: see text] 1 week and [Formula: see text] 6 months post-injury. Age is found to be linearly associated with white matter degradation, likely due not only to injury but also to cumulative effects of other pathologies and to their interactions with injury. Age is associated with mean anisotropy decreases in the corpus callosum, middle longitudinal fasciculi, inferior longitudinal and occipitofrontal fasciculi, and superficial frontal and temporal fasciculi. Over [Formula: see text] 6 months, the mean anisotropies of the corpus callosum, left superficial frontal fasciculi, and left corticospinal tract decrease significantly. Independently of other predictors, age and cerebral microbleeds contribute to anisotropy decrease in the callosal genu. Chronically, the white matter of commissural tracts, left superficial frontal fasciculi, and left corticospinal tract degrade appreciably, independently of other predictors. Our findings suggest that large commissural and intra-hemispheric structures are at high risk for post-traumatic degradation. This study identifies detailed neuroanatomic substrates consistent with brain injury patients' age-dependent deficits in information processing speed, interhemispheric communication, motor coordination, visual acuity, sensory integration, reading speed/comprehension, executive function, personality, and memory. We also identify neuroanatomic features underlying white matter degradation whose severity is associated with the male sex. Future studies should compare our findings to functional measures and other neurodegenerative processes.
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Affiliation(s)
- David J Robles
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, 90089, USA
| | - Ammar Dharani
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, 90089, USA
| | - Kenneth A Rostowsky
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, 90089, USA
| | - Nikhil N Chaudhari
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, 90089, USA
| | - Van Ngo
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, 90089, USA
| | - Fan Zhang
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Lauren J O'Donnell
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Lauren Green
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Nasim Sheikh-Bahaei
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
- Department of Radiology, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Los Angeles, CA, 90033, USA
| | - Helena C Chui
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Andrei Irimia
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, 90089, USA.
- Corwin D. Denney Research Center, Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, 90089, USA.
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16
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Career Head Impact Exposure Profile of Canadian University Football Players. J Appl Biomech 2022; 38:47-57. [PMID: 35045388 DOI: 10.1123/jab.2020-0228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/03/2021] [Accepted: 12/08/2021] [Indexed: 11/18/2022]
Abstract
This study quantified head impact exposures for Canadian university football players over their varsity career. Participants included 63 players from one team that participated in a minimum of 3 seasons between 2013 and 2018. A total of 127,192 head impacts were recorded from 258 practices and 65 games. The mean (SD) number of career impacts across all positions was 2023.1 (1296.4), with an average of 37.1 (20.3) impacts per game and 7.4 (4.4) impacts per practice. The number of head impacts that players experienced during their careers increased proportionally to the number of athletic exposures (P < .001, r = .57). Linebackers and defensive and offensive linemen experienced significantly more head impacts than defensive backs, quarterbacks, and wide receivers (P ≤ .014). Seniority did not significantly affect the number of head impacts a player experienced. Mean linear acceleration increased with years of seniority within defensive backs and offensive linemen (P ≤ .01). Rotational velocity increased with years of seniority within defensive backs, defensive and offensive linemen, running backs, and wide receivers (P < .05). These data characterize career metrics of head impact exposure for Canadian university football players and provide insights to reduce head impacts through rule modifications and contact regulations.
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17
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Forodighasemabadi A, Baucher G, Soustelle L, Troalen T, Girard OM, Guye M, Grisoli JB, Ranjeva JP, Duhamel G, Callot V. Spinal cord and brain tissue impairments as long-term effects of rugby practice? An exploratory study based on T1 and ihMTsat measures. NEUROIMAGE: CLINICAL 2022; 35:103124. [PMID: 35905667 PMCID: PMC9421542 DOI: 10.1016/j.nicl.2022.103124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 12/03/2022] Open
Abstract
Diffuse degeneration of spinal cord (higher T1) is observed in retired rugby players. Demyelination of brain WM tracts (higher T1 / lower ihMTsat values) is present in rugby players. Early aging in both brain and spinal cord tissues may be linked to the rugby practice. The aforementioned effects may suggest cumulative effects of long-term impacts on the tissues.
Rugby players are subject to multiple impacts to their head and neck that could have adverse neurological effects and put them at increased risk of neurodegeneration. Previous studies demonstrated altered default mode network and diffusion metrics on brain, as well as more foraminal stenosis, disc protrusion and neck pain among players of contact sports as compared to healthy controls. However, the long-term effects of practice and repetitive impacts on brain and cervical spinal cord (cSC) of the rugby players have never been systematically investigated. In this study, 15 retired professional and amateur rugby players (R) and 15 age-matched healthy controls (HC) (all males; mean age R: 46.8 ± 7.6; and HC: 48.6 ± 9.5) were recruited both to investigate cord impairments and further characterize brain structure damage. Medical questionnaires including modified Japanese Orthopedic Association scale (mJOA) and Neck Disability Index (NDI) were filled by all participants. A 3 T multi-parametric MR protocol including conventional qualitative techniques such as T1-, T2-, and T2*-weighted sequences, as well as state-of-the art quantitative techniques including MP2RAGE T1 mapping and 3D ihMTRAGE, was used on both brain and cSC. Normalized brain WM and GM volumes, spine Overall Stenosis Score, cord cross-sectional area and regional T1 and ihMT metrics were derived from these acquisitions. Rugby players showed significantly higher NDI scores, as well as a faster decline of normalized brain GM volume with age as compared to HC. Moreover, higher T1 values on cSC suggestive of structural degeneration, together with higher T1 and lower ihMTsat on brain WM suggestive of demyelination, were observed in retired rugby players as compared to age-matched controls, which may suggest cumulative effects of long-term impacts on the tissues. Metrics also suggest early aging and different aging processes on brain tissue in the players. These preliminary observations provide new insights in the domain, which should now be further investigated on larger cohorts and multicentric longitudinal studies, and further correlated to the likelihood of neurodegenerative diseases and risk factors.
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18
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Kochsiek J, O’Donnell LJ, Zhang F, Bonke EM, Sollmann N, Tripodis Y, Wiegand TLT, Kaufmann D, Umminger L, Di Biase MA, Kaufmann E, Schultz V, Alosco ML, Martin BM, Lin AP, Coleman MJ, Rathi Y, Pasternak O, Bouix S, Stern RA, Shenton ME, Koerte IK. Exposure to Repetitive Head Impacts Is Associated With Corpus Callosum Microstructure and Plasma Total Tau in Former Professional American Football Players. J Magn Reson Imaging 2021; 54:1819-1829. [PMID: 34137112 PMCID: PMC8633029 DOI: 10.1002/jmri.27774] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Exposure to repetitive head impacts (RHI) is associated with an increased risk of later-life neurobehavioral dysregulation and neurodegenerative disease. The underlying pathomechanisms are largely unknown. PURPOSE To investigate whether RHI exposure is associated with later-life corpus callosum (CC) microstructure and whether CC microstructure is associated with plasma total tau and neuropsychological/neuropsychiatric functioning. STUDY TYPE Retrospective cohort study. POPULATION Seventy-five former professional American football players (age 55.2 ± 8.0 years) with cognitive, behavioral, and mood symptoms. FIELD STRENGTH/SEQUENCE Diffusion-weighted echo-planar MRI at 3 T. ASSESSMENT Subjects underwent diffusion MRI, venous puncture, neuropsychological testing, and completed self-report measures of neurobehavioral dysregulation. RHI exposure was assessed using the Cumulative Head Impact Index (CHII). Diffusion MRI measures of CC microstructure (i.e., free-water corrected fractional anisotropy (FA), trace, radial diffusivity (RD), and axial diffusivity (AD)) were extracted from seven segments of the CC (CC1-7), using a tractography clustering algorithm. Neuropsychological tests were selected: Trail Making Test Part A (TMT-A) and Part B (TMT-B), Controlled Oral Word Association Test (COWAT), Stroop Interference Test, and the Behavioral Regulation Index (BRI) from the Behavior Rating Inventory of Executive Function, Adult version (BRIEF-A). STATISTICAL TESTS Diffusion MRI metrics were tested for associations with RHI exposure, plasma total tau, neuropsychological performance, and neurobehavioral dysregulation using generalized linear models for repeated measures. RESULTS RHI exposure was associated with increased AD of CC1 (correlation coefficient (r) = 0.32, P < 0.05) and with increased plasma total tau (r = 0.34, P < 0.05). AD of the anterior CC1 was associated with increased plasma total tau (CC1: r = 0.30, P < 0.05; CC2: r = 0.29, P < 0.05). Higher trace, AD, and RD of CC1 were associated with better performance (P < 0.05) in TMT-A (trace, r = 0.33; AD, r = 0.31; and RD, r = 0.28) and TMT-B (trace, r = 0.31; RD, r = 0.34). Higher FA and AD of CC2 were associated with better performance (P < 0.05) in TMT-A (FA, r = 0.36; AD, r = 0.28), TMT-B (FA, r = 0.36; AD, r = 0.27), COWAT (FA, r = 0.36; AD, r = 0.32), and BRI (AD, r = 0.29). DATA CONCLUSION These results suggest an association among RHI exposure, CC microstructure, plasma total tau, and clinical functioning in former professional American football players. LEVEL OF EVIDENCE 3 Technical Efficacy Stage: 1.
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Affiliation(s)
- Janna Kochsiek
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Lauren J. O’Donnell
- Laboratory of Mathematics in Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Fan Zhang
- Laboratory of Mathematics in Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Elena M. Bonke
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität, Munich, Germany
| | - Nico Sollmann
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, MA, USA
| | - Tim L. T. Wiegand
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - David Kaufmann
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Radiology, Charité Universitätsmedizin, Berlin, Germany
- Department of Radiology, University Hospital Augsburg, University of Augsburg, Germany
| | - Lisa Umminger
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Maria A. Di Biase
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisabeth Kaufmann
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Neurology, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Vivian Schultz
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael L. Alosco
- Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, MA, USA
- Department of Neurology, Boszon University School of Medicine, Boston, MA, USA
| | - Brett M. Martin
- Data Coordinating Center, Boston University School of Public Health, Boston, MA, USA
| | - Alexander P. Lin
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J. Coleman
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Yogesh Rathi
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ofer Pasternak
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert A. Stern
- Alzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, MA, USA
- Department of Neurology, Boszon University School of Medicine, Boston, MA, USA
- Departments of Neurosugery and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Inga K. Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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19
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Morgan R, Prosapio J, Kara S, Sonty S, Youssef P, Nedd K. Preliminary clinical diagnostic criteria for chronic traumatic encephalopathy: A case report and literature review. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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20
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Narad ME, Epstein J, Peugh J, Barber Foss KD, Diekfuss JA, Bonnette S, Orban S, Yuan W, Dudley J, DiCesare CA, Reddington DL, Zhong W, Nissen KS, Shafer J, Avedesian JM, Slutsky-Ganesh AB, Lloyd RS, Howell D, Myer GD. The effect of subconcussive head impact exposure and jugular vein compression on behavioral and cognitive outcomes after a single season of high-school football: A prospective longitudinal trial. J Neurotrauma 2021; 39:49-57. [PMID: 34779241 DOI: 10.1089/neu.2021.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This prospective longitudinal trial aimed to 1) determine the role of head impact exposure on behavioral/cognitive outcomes, and 2) assess the protective effect(s) of a jugular vein compression (JVC) collar on behavioral/cognitive outcomes following one season of high-school football. Participants included 284 male high-school football players aged 13-18 years enrolled from seven midwestern high-schools. Schools were allocated to the JVC collar intervention(four teams, 140 players) or non-collar/no intervention control (three teams, 144 players) condition. Head impact exposure was measured throughout the season using CSx accelerometers. Outcome measures included post season parent and adolescent report on Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Scale (SWAN) and Post-Concussion Symptom Inventory (PCSI), as well as adolescent performance on Attention Network Task (ANT), digital Trail Making Task (dTMT), and Cued Switching task. No significant effect of head impact exposure or JVC collar use on post-season SWAN or PCSI scores or performance on dTMT and Cued Switching task were noted. There was no effect of head impact exposure on ANT performance; however, the JVC collar group had greater post-season Alerting network scores than the non-collar group (p=.026, d=.22). Findings provide preliminary evidence that the JVC collar may provide some protection to the alerting attention system. These findings should be interpreted cautiously as a greater understanding of the long-term sequalae of head impact exposure and the role of cumulative head impact exposure behavioral/cognitive outcomes is required.
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Affiliation(s)
- Megan E Narad
- Cincinnati Children's Hospital Medical Center, Division of Behavioral Medicine & Clinical Psychology, 3333 Burnet Ave, mlc 10006, Cincinnati, Ohio, United States, 45229;
| | - Jeffery Epstein
- Cincinnati Children's Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Ohio, United States;
| | - James Peugh
- Cincinnati Children's Hospital Medical Center, 2518, Behavioral Medicine & Clinical Psychology, Cincinnati, Ohio, United States;
| | - Kim D Barber Foss
- Emory University, 1371, Emory Sport Performance and Research Center, Atlanta, Georgia, United States;
| | - Jed A Diekfuss
- Emory University, 1371, Emory Sport Performance and Research Center, Atlanta, Georgia, United States;
| | - Scott Bonnette
- Cincinnati Children's Hospital Medical Center, 2518, The SPORT Center, Division of Sports Medicine, Cincinnati, Ohio, United States;
| | - Sarah Orban
- University of Tampa, Department of psychology, Tampa, FL, United States;
| | - Weihong Yuan
- Cincinnati Children's Hospital Medical Center, 2518, 3333 Burnew Ave, Cincinnati, Ohio, United States, 45229-3026;
| | - Jonathan Dudley
- Cincinnati Children's Hospital Medical Center, 2518, 3333 Burnet Ave, Cincinnati, Ohio, United States, 45229-3026;
| | - Christopher A DiCesare
- University of Michigan, 1259, Department of Mechanical engineering, Ann Arbor, Michigan, United States;
| | - Danielle L Reddington
- Cincinnati Children's Hospital Medical Center, 2518, Cincinnati, Ohio, United States;
| | - Wen Zhong
- Cincinnati Children's Hospital Medical Center, 2518, Cincinnati, Ohio, United States;
| | | | - Jessica Shafer
- Cincinnati Children's Hospital Medical Center, 2518, Cincinnati, Ohio, United States;
| | | | - Alexis B Slutsky-Ganesh
- The University of North Carolina at Greensboro, Department of Kinesiology, Greensboro, North Carolina, United States;
| | - Rhodri S Lloyd
- Cardiff Metropolitan University, 11352, Cardiff, Cardiff, United Kingdom of Great Britain and Northern Ireland.,AUT University, Auckland, New Zealand.,Waikato Institute of Technology, 3715, Hamilton, New Zealand;
| | - David Howell
- University of Colorado Denver School of Medicine, 12225, Department of Orthopedics , Aurora, Colorado, United States;
| | - Greg D Myer
- Emory University School of Medicine, 12239, Atlanta, Georgia, United States.,the Micheli Center for Sports Injury Prevention, Waltham, Ma, United States;
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21
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Walton SR, Kerr ZY, Mannix R, Brett BL, Chandran A, DeFreese JD, McCrea MA, Guskiewicz KM, Meehan WP, Echemendia RJ. Subjective Concerns Regarding the Effects of Sport-Related Concussion on Long-Term Brain Health among Former NFL Players: An NFL-LONG Study. Sports Med 2021; 52:1189-1203. [PMID: 34773581 DOI: 10.1007/s40279-021-01589-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Potential links between a history of sport-related concussions and later-life neurobiological and psychological brain health have been studied in former collision-sport athletes. However, empirical studies of how former athletes perceive the future of their brain health as a result of these injuries are missing. OBJECTIVES We aimed to (1) identify the extent to which former National Football League players currently have concerns about their long-term psychological and cognitive functioning as a result of concussions sustained while playing football; (2) examine whether current concerns are different than concerns they had while playing football; (3) examine the relationship between current brain health concerns and self-reported concussion history (SR-CHx); and (4) explore other important factors associated with these concerns. METHODS In this cross-sectional study, former National Football League players with a SR-CHx of one or more concussions (n = 1514; aged mean [standard deviation] = 52.3 [15.7] years) completed a general health questionnaire. Participants reported their lifetime concussion history, as well as both their current concerns and concerns while playing football (i.e., retrospective concerns) regarding the long-term effects of concussions on their memory, thinking skills, and risk of developing chronic traumatic encephalopathy. Current and retrospective concerns were self-reported on a five-point Likert scale. Four concussion history categories were created based on SR-CHx: 1-2 (n = 309); 3-5 (n = 413); 6-9 (n = 356); and 10 + (n = 436) lifetime concussions. Proportions of participants reporting each level of current and retrospective concerns were examined to identify whether concerns presently exist in these former players, and whether their current concerns are different than retrospective concerns. Next, we explored associations between current concerns and SR-CHx. RESULTS More than one-third of participants reported being currently "extremely concerned" about memory problems (36.9%), thinking skills (37.8%), and developing chronic traumatic encephalopathy (39.5%). In contrast, when asked about concerns while playing, most reported being "not at all concerned" regarding memory = 61.2%, thinking skills = 56.1%, and developing chronic traumatic encephalopathy = 71.2%. Of those who retrospectively endorsed being "not at all" or "slightly" concerned regarding memory (n = 1159/1514), thinking skills (n = 1080/1514), and developing chronic traumatic encephalopathy (n = 1219/1514), approximately half reported being currently "moderately" or "extremely" concerned about those same issues (n = 586/1159; n = 534/1080; n = 619/1219, respectively). Current concerns regarding memory (χ216 = 316.61; p < 0.001; V = 0.264), thinking skills (χ216 = 333.17; p < 0.001; V = 0.271), and developing chronic traumatic encephalopathy (χ216 = 280.85; p < 0.001; V = 0.249) were significantly related to SR-CHx, with more concussions being associated with greater current concerns. CONCLUSIONS Former National Football League players reported significant concerns regarding the potential effects of their prior concussions on long-term brain health, and these concerns are more prevalent now than when they were playing football. Cognitive and mental health concerns are readily identifiable targets for clinical intervention. Clinicians working with former players may wish to explore the extent to which individual players experience these concerns, the nature and depth of these concerns, and the impact of these concerns on the player's functioning and well-being.
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Affiliation(s)
- Samuel R Walton
- Center for the Study of Retired Athletes, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Zachary Y Kerr
- Center for the Study of Retired Athletes, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebekah Mannix
- Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Avinash Chandran
- Center for the Study of Retired Athletes, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Datalys Center for Sports Injury Research and Prevention, Indianapolis, IN, USA
| | - Jonathan D DeFreese
- Center for the Study of Retired Athletes, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kevin M Guskiewicz
- Center for the Study of Retired Athletes, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William P Meehan
- Micheli Center for Sports Injury Prevention and Boston Children's Hospital, Waltham, MA, USA
- Department of Pediatrics and Orthopedics, Harvard Medical School, Boston, MA, USA
| | - Ruben J Echemendia
- Department of Psychology, University of Missouri, Kansas City, Kansas City, MO, USA.
- University Orthopedics Center Concussion Clinic, 101 Regent Ct., State College, PA, 16801, USA.
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22
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Cournoyer J, Karton C, Koncan D, Gilchrist MD, Cantu RC, Hoshizaki TB. Brain trauma exposure for American tackle football players 5 to 9 and 9 to 14 years of age. J Biomech 2021; 127:110689. [PMID: 34416530 DOI: 10.1016/j.jbiomech.2021.110689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/28/2021] [Accepted: 08/09/2021] [Indexed: 01/13/2023]
Abstract
American football helmets used by youth players are currently designed and tested to the same standards as professionals. The National Operating Committee on Standard and Safety requested research aiming at understanding the differences in brain trauma in youth American football for players aged five to nine and nine to fourteen years old to inform a youth specific American football standard. Video analysis and laboratory reconstructions of head impacts were undertaken to measure differences in head impact frequency, event types, and magnitudes of maximum principal strain (MPS) for the two age groups. Overall frequencies and frequencies for five categories of MPS representing different magnitudes of risk were tabulated. The MPS categories were very low (<0.08), low (0.08-0.169), medium (0.17-0.259), high (0.26-0.349) and very high (>0.35). Both cohorts experienced a majority of head impacts (>56%) at very low magnitude of MPS. Youth American football players aged 9-14 yrs. sustained a greater frequency of head impacts at MPS between 0.08 and 0.169 % associated with changes in brain structure and function. There were no differences in overall frequency, or in frequency of head impacts in other categories of MPS. The proportion of impacts considered injurious (MPS > 0.08) was greater in the 5-9 group (44%), than the 9-14 group (39%), and impacts above 0.35 % were only reported for the younger age group. The larger helmet-to-shoulder ratio in the younger age groups may have contributed to this finding suggesting that youth American football players under the age of nine would benefit from a child-specific football helmet.
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Affiliation(s)
- J Cournoyer
- University of Ottawa, School of Human Kinetics, Ottawa, Canada.
| | - C Karton
- University of Ottawa, School of Human Kinetics, Ottawa, Canada
| | - D Koncan
- University of Ottawa, School of Human Kinetics, Ottawa, Canada
| | - M D Gilchrist
- University College Dublin, School of Mechanical and Materials Engineering
| | - R C Cantu
- Boston University Alzheimer's Disease and Chronic Encephalopathy Center, Boston University School of Medicine, Boston, MA, USA; Department of Neurology, Boston University School of Medicine, Boston, MA, USA; Department of neurosurgery, Boston University School of Medicine, Boston, MA, USA; Department of neurosurgery, Emerson Hospital, Concord, MA, USA; Concussion Legacy Foundation, Boston, MA, USA
| | - T B Hoshizaki
- University of Ottawa, School of Human Kinetics, Ottawa, Canada
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23
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Iverson GL, Büttner F, Caccese JB. Age of First Exposure to Contact and Collision Sports and Later in Life Brain Health: A Narrative Review. Front Neurol 2021; 12:727089. [PMID: 34659092 PMCID: PMC8511696 DOI: 10.3389/fneur.2021.727089] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/27/2021] [Indexed: 12/11/2022] Open
Abstract
A controversial theory proposes that playing tackle football before the age of 12 causes later in life brain health problems. This theory arose from a small study of 42 retired National Football League (NFL) players, which reported that those who started playing tackle football at a younger age performed worse on selected neuropsychological tests and a word reading test. The authors concluded that these differences were likely due to greater exposure to repetitive neurotrauma during a developmentally sensitive maturational period in their lives. Several subsequent studies of current high school and collegiate contact/collision sports athletes, and former high school, collegiate, and professional tackle football players have not replicated these findings. This narrative review aims to (i) discuss the fundamental concepts, issues, and controversies surrounding existing research on age of first exposure (AFE) to contact/collision sport, and (ii) provide a balanced interpretation, including risk of bias assessment findings, of this body of evidence. Among 21 studies, 11 studies examined former athletes, 8 studies examined current athletes, and 2 studies examined both former and current athletes. Although the literature on whether younger AFE to tackle football is associated with later in life cognitive, neurobehavioral, or mental health problems in former NFL players is mixed, the largest study of retired NFL players (N = 3,506) suggested there was not a significant association between earlier AFE to organized tackle football and worse subjectively experienced cognitive functioning, depression, or anxiety. Furthermore, no published studies of current athletes show a significant association between playing tackle football (or other contact/collision sports) before the age of 12 and cognitive, neurobehavioral, or mental health problems. It is important to note that all studies were judged to be at high overall risk of bias, indicating that more methodologically rigorous research is needed to understand whether there is an association between AFE to contact/collision sports and later in life brain health. The accumulated research to date suggests that earlier AFE to contact/collision sports is not associated with worse cognitive functioning or mental health in (i) current high school athletes, (ii) current collegiate athletes, or (iii) middle-aged men who played high school football. The literature on former NFL players is mixed and does not, at present, clearly support the theory that exposure to tackle football before age 12 is associated with later in life cognitive impairment or mental health problems.
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Affiliation(s)
- Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- Spaulding Research Institute, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
- Sports Concussion Program, MassGeneral Hospital for Children, Boston, MA, United States
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States
| | - Fionn Büttner
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Jaclyn B. Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH, United States
- Chronic Brain Injury Program, The Ohio State University, Columbus, OH, United States
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24
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Hunzinger KJ, Caccese JB, Costantini KM, Swanik CB, Buckley TA. Age of First Exposure to Collision Sports Does Not Affect Patient Reported Outcomes in Women and Men Community Rugby Players. Med Sci Sports Exerc 2021; 53:1895-1902. [PMID: 33731652 DOI: 10.1249/mss.0000000000002657] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to determine the relationship between age of first exposure (AFE) to repetitive head impacts through contact/collision sports and patient-reported outcomes in community rugby players. METHODS We recruited community rugby players older than 18 yr with at least 1 yr of contact rugby participation to complete an online survey. Participants completed the Brief Symptom Inventory-18 (BSI-18), Short-Form Health Survey 12 (SF-12), and Satisfaction with Life Scale (SWLS) via Qualtrics. We used generalized linear models to examine the association between AFE (continuous) and patient-reported outcomes by sex, while controlling for cumulative years contact/collision sport history, age, and concussion history (yes/no). In addition, we used Mann-Whitney U tests to compare patient-reported outcomes between AFE <12 and AFE ≥12. RESULTS A total of 1037 rugby players (31.6 ± 11.3 yr (range, 18-74 yr), 59.1% men) participated in this study. Whether analyzed continuously or dichotomously at age 12 yr, younger AFE was not associated with worse patient-reported outcomes for either men or women. Positive concussion history was a significant predictor of worse BSI-18 subscores, SF-12 subscores, and SWLS in women and worse BSI-18 subscores in men. Cumulative contact/collision sport history was a significant predictor of better BSI-18 Depression and SF-12 (Mental Component Summary) subscores in men only. In men and women, older age was a significant predictor of better BSI-18 Depression, Anxiety, and GSI subscores; better SWLS (in men only); and better SF-12 Mental Component Summary, but worse SF-12 (Physical Component Summary). CONCLUSIONS Younger AFE to contact/collision sport is not associated with worse patient-reported outcomes in early adult rugby players. Concussion history was predictive of worse patient-reported outcomes.
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Affiliation(s)
| | - Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH
| | - Katelyn M Costantini
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
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Caccese J, Schmidt J, Moody J, Broglio S, McAllister T, McCrea M, Pasquina P, Buckley T, Investigators CC. Association between sports participation history and age of first exposure to high-risk sports with concussion history. Res Sports Med 2021; 31:260-272. [PMID: 34402703 DOI: 10.1080/15438627.2021.1966008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to examine the association between sports participation history, including estimated age of first exposure (eAFE) to high-risk sports, and concussion history in first year (i.e., freshmen) collegiate athletes. Athletes increased their odds of sustaining a pre-college concussion by 5% [odds ratio(OR) = 1.05 (95%CI:1.05-1.06)] for each additional year of contact sports participation - 24% of all student athletes reported one or more pre-college concussions. When eAFE was analysed dichotomously at age 12, a greater proportion of those who started playing football before age 12 reported a positive concussion history compared to those who started playing football at age 12 or later (Х2 = 4.483, p = 0.034, Phi = 0.049). When eAFE was analysed continuously, later eAFE to women's high-risk sports was associated with a lower likelihood of sustaining a pre-college concussion [OR = 0.93 (95%CI:0.88-0.98)]. Our findings suggest that there is a relationship between eAFE to football and to women's high-risk sports and concussion history.
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Affiliation(s)
- Jaclyn Caccese
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, United States
| | - Julianne Schmidt
- Department of Kinesiology, University of Georgia, Athens, United States
| | - Jena Moody
- Department of Psychology, The Ohio State University, Columbus, United States
| | - Steven Broglio
- School of Kinesiology, Michigan Concussion Center, University of Michigan, Ann Arbor, United States
| | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, United States
| | - Michael McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, United States
| | - Paul Pasquina
- Department of Physical Medicine and Rehabilitation, School of Medicine, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, United States
| | - Thomas Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, United States
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Alosco ML, Mariani ML, Adler CH, Balcer LJ, Bernick C, Au R, Banks SJ, Barr WB, Bouix S, Cantu RC, Coleman MJ, Dodick DW, Farrer LA, Geda YE, Katz DI, Koerte IK, Kowall NW, Lin AP, Marcus DS, Marek KL, McClean MD, McKee AC, Mez J, Palmisano JN, Peskind ER, Tripodis Y, Turner RW, Wethe JV, Cummings JL, Reiman EM, Shenton ME, Stern RA. Developing methods to detect and diagnose chronic traumatic encephalopathy during life: rationale, design, and methodology for the DIAGNOSE CTE Research Project. Alzheimers Res Ther 2021; 13:136. [PMID: 34384490 PMCID: PMC8357968 DOI: 10.1186/s13195-021-00872-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/29/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that has been neuropathologically diagnosed in brain donors exposed to repetitive head impacts, including boxers and American football, soccer, ice hockey, and rugby players. CTE cannot yet be diagnosed during life. In December 2015, the National Institute of Neurological Disorders and Stroke awarded a seven-year grant (U01NS093334) to fund the "Diagnostics, Imaging, and Genetics Network for the Objective Study and Evaluation of Chronic Traumatic Encephalopathy (DIAGNOSE CTE) Research Project." The objectives of this multicenter project are to: develop in vivo fluid and neuroimaging biomarkers for CTE; characterize its clinical presentation; refine and validate clinical research diagnostic criteria (i.e., traumatic encephalopathy syndrome [TES]); examine repetitive head impact exposure, genetic, and other risk factors; and provide shared resources of anonymized data and biological samples to the research community. In this paper, we provide a detailed overview of the rationale, design, and methods for the DIAGNOSE CTE Research Project. METHODS The targeted sample and sample size was 240 male participants, ages 45-74, including 120 former professional football players, 60 former collegiate football players, and 60 asymptomatic participants without a history of head trauma or participation in organized contact sports. Participants were evaluated at one of four U.S. sites and underwent the following baseline procedures: neurological and neuropsychological examinations; tau and amyloid positron emission tomography; magnetic resonance imaging and spectroscopy; lumbar puncture; blood and saliva collection; and standardized self-report measures of neuropsychiatric, cognitive, and daily functioning. Study partners completed similar informant-report measures. Follow-up evaluations were intended to be in-person and at 3 years post-baseline. Multidisciplinary diagnostic consensus conferences are held, and the reliability and validity of TES diagnostic criteria are examined. RESULTS Participant enrollment and all baseline evaluations were completed in February 2020. Three-year follow-up evaluations began in October 2019. However, in-person evaluation ceased with the COVID-19 pandemic, and resumed as remote, 4-year follow-up evaluations (including telephone-, online-, and videoconference-based cognitive, neuropsychiatric, and neurologic examinations, as well as in-home blood draw) in February 2021. CONCLUSIONS Findings from the DIAGNOSE CTE Research Project should facilitate detection and diagnosis of CTE during life, and thereby accelerate research on risk factors, mechanisms, epidemiology, treatment, and prevention of CTE. TRIAL REGISTRATION NCT02798185.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Megan L Mariani
- Boston University CTE Center, Boston University School of Medicine, Boston, MA, USA
| | - Charles H Adler
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Laura J Balcer
- Departments of Neurology, Population Health and Ophthalmology, NYU Grossman School of Medicine, New York, NY, USA
| | - Charles Bernick
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Rhoda Au
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Framingham Heart Study, and Slone Epidemiology Center, Boston, MA, USA
- Departments of Anatomy & Neurobiology and Neurology, Boston University School of Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sarah J Banks
- Departments of Neuroscience and Psychiatry, University of California, San Diego, CA, USA
| | - William B Barr
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C Cantu
- Boston University Alzheimer's Disease Research Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, Boston, MA, USA
| | - Michael J Coleman
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, MA, USA
| | - David W Dodick
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Lindsay A Farrer
- Departments of Medicine (Biomedical Genetics), Neurology, Ophthalmology, Epidemiology, and Biostatistics, BU Schools of Medicine and Public Health, Boston, MA, USA
| | - Yonas E Geda
- Alzheimer's Disease and Memory Disorders Program, Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- Encompass Health Braintree Rehabilitation Hospital, Braintree, MA, USA
| | - Inga K Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany
| | - Neil W Kowall
- Boston University Alzheimer's Disease Research Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Alexander P Lin
- Center for Clinical Spectroscopy, Department of Radiology, Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel S Marcus
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kenneth L Marek
- Institute for Neurodegenerative Disorders, Invicro, LLC, New Haven, CT, USA
| | - Michael D McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Framingham Heart Study, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Joseph N Palmisano
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Elaine R Peskind
- VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert W Turner
- Department of Clinical Research & Leadership, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Jennifer V Wethe
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Jeffrey L Cummings
- Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Eric M Reiman
- Banner Alzheimer's Institute, University of Arizona, Arizona State University, Translational Genomics Research Institute, and Arizona Alzheimer's Consortium, Phoenix, AZ, USA
| | - Martha E Shenton
- Psychiatry Neuroimaging Laboratory, Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA.
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Rose SC, Yeates KO, Nguyen JT, Ercole PM, Pizzimenti NM, McCarthy MT. Subconcussive Head Impacts and Neurocognitive Function Over 3 Seasons of Youth Football. J Child Neurol 2021; 36:768-775. [PMID: 33834862 DOI: 10.1177/08830738211004490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the association between repetitive subconcussive head impacts and neurobehavioral outcomes in youth tackle football players. METHODS Using helmet-based sensors, we measured head impacts for 3 consecutive seasons of play in 29 male players age 9-11. Cumulative impact g's were calculated. Players completed a battery of outcome measures before and after each season, including neuropsychological testing, vestibular-ocular sensitivity, and self- and parent-reported measures of symptoms and attention-deficit hyperactivity disorder (ADHD). RESULTS Average cumulative impact over 3 seasons was 13 900g. High-intensity hits predicted worse change for self-reported social adjustment (P = .001). Cumulative impact did not predict change in any of the outcome measures. History of ADHD, anxiety, and depression predicted worse change for self-reported symptoms and social adjustment, independent of head impacts. When players were stratified into 3 groups based on cumulative impact across all 3 seasons, differences in outcome measures existed prior to the start of the first season. These differences did not further increase over the course of the 3 seasons. CONCLUSION Over 3 consecutive seasons of youth tackle football, we found no association between cumulative head impacts and neurobehavioral outcomes. Larger sample sizes and longer follow-up times would further assist in characterizing this relationship.
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Affiliation(s)
- Sean C Rose
- Division of Child Neurology, 2647Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Keith Owen Yeates
- Department of Psychology, Alberta Children's Hospital Research Institute, and Hotchkiss Brain Institute, 2129University of Calgary, Calgary, Alberta, Canada
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28
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Iverson GL, Caccese JB, Merz ZC, Büttner F, Terry DP. Age of First Exposure to Football Is Not Associated With Later-in-Life Cognitive or Mental Health Problems. Front Neurol 2021; 12:647314. [PMID: 34025554 PMCID: PMC8131846 DOI: 10.3389/fneur.2021.647314] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/25/2021] [Indexed: 01/09/2023] Open
Abstract
Background: The purpose of this study was to determine if earlier age of first exposure to football is associated with worse brain health in middle-aged and older adult men who played high school football. Methods: Men from the United States, aged 35 and older, who reported playing high school football, completed a customized, online health survey via the Amazon Mechanical Turk (mTurk) platform. Survey items included physical, psychological, and cognitive symptoms over the past week and over the past year, sports participation history (including age of first exposure to football), medical history, and concussion history. Participants also completed the Patient Health Questionnaire-8 (PHQ-8) and the British Columbia Post-Concussion Symptom Inventory (BC-PSI). Results: There were 186 men (age M = 51.78, SD = 10.93) who participated in high school football, and 87 (46.8%) reported football participation starting before the age of 12 and 99 (53.2%) reported football participation at or after the age of 12. Those who started playing football at an earlier age reported a greater number of lifetime concussions (M = 1.95, SD = 1.79) compared to those who started playing at age 12 or later (M = 1.28, SD = 1.52; U = 3,257.5, p = 0.003). A similar proportion of men who played football before vs. after the age of 12 reported a lifetime history of being prescribed medications for depression, anxiety, chronic pain, headaches, or memory problems. When comparing men who played football before vs. after the age of 12, the groups did not differ significantly in their ratings of depression, anger, anxiety, headaches, migraines, neck or back pain, chronic pain, concentration problems, or memory problems over the past week or the past year. The two groups did not differ significantly in their ratings of current symptoms of depression (PHQ-8; U = 4,187.0, p = 0.74) or post-concussion-like symptoms (BC-PSI; U = 3,944.0, p = 0.53). Furthermore, there were no statistically significant correlations between the age of first exposure to football, as a continuous variable, and PHQ-8 or BC-PSI scores. Conclusion: This study adds to a rapidly growing body of literature suggesting that earlier age of first exposure to football is not associated with later-in-life brain health.
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Affiliation(s)
- Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Spaulding Research Institute, Spaulding Rehabilitation Hospital, Charlestown, MA, United States.,Sports Concussion Program, MassGeneral Hospital for Children, Boston, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States
| | - Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Zachary C Merz
- Department of Physical Medicine and Rehabilitation, University of North Carolina, UNC Memorial Hospital, Chapel Hill, NC, United States.,LeBauer Department of Neurology, Moses H. Cone Memorial Hospital, Greensboro, NC, United States
| | - Fionn Büttner
- Physiotherapy and Sports Science, School of Public Health, University College Dublin, Dublin, Ireland
| | - Douglas P Terry
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Sports Concussion Program, MassGeneral Hospital for Children, Boston, MA, United States.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, United States
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Tayebi M, Holdsworth SJ, Champagne AA, Cook DJ, Nielsen P, Lee TR, Wang A, Fernandez J, Shim V. The role of diffusion tensor imaging in characterizing injury patterns on athletes with concussion and subconcussive injury: a systematic review. Brain Inj 2021; 35:621-644. [PMID: 33843389 DOI: 10.1080/02699052.2021.1895313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Traumatic brain injury (TBI) is a major public health problem. The majority of TBIs are in the form of mild TBI (also known as concussion) with sports-related concussion (SRC) receiving public attention in recent years.Here we have performed a systematic review of the literature on the use of Diffusion Tensor Imaging (DTI) on sports-related concussion and subconcussive injuries. Our review found different patterns of change in DTI parameters between concussed and subconcussed groups. The Fractional Anisotropy (FA) was either unchanged or increased for the concussion group, while the subconcussed group generally experienced a decrease in FA. A reverse pattern was observed for Mean Diffusivity (MD) - where the concussed group experienced a decrease in MD while the subconcussed group showed an increase in MD. However, in general, discrepancies were observed in the results reported in the literature - likely due to the huge variations in DTI acquisition parameters, and image processing and analysis methods used in these studies. This calls for more comprehensive and well-controlled studies in this field, including those that combine the advanced brain imaging with biomechancial modeling and kinematic sensors - to shed light on the underlying mechanisms behind the structural changes observed from the imaging studies.
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Affiliation(s)
- Maryam Tayebi
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Samantha J Holdsworth
- Department of Anatomy and Medical Imaging & Centre for Brain Research, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Mātai Medical Research Insitute, Gisborne, New Zealand
| | - Allen A Champagne
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Douglas J Cook
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Poul Nielsen
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Tae-Rin Lee
- Advanced Institute of Convergence Technology, Seoul National University, Seoul, Republic of Korea
| | - Alan Wang
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.,Department of Anatomy and Medical Imaging & Centre for Brain Research, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Justin Fernandez
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.,Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - Vickie Shim
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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30
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DiFabio MS, Buckley TA. Effectiveness of a Computerized Cognitive Training Program for Reducing Head Impact Kinematics in Youth Ice Hockey Players. INTERNATIONAL JOURNAL OF EXERCISE SCIENCE 2021; 14:149-161. [PMID: 34055136 PMCID: PMC8136557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Cognitive training (CT) is an effective technique to improve neurological performance, but has not been investigated as a head impact primary prevention strategy. The purpose of this study was to investigate the CT's effectiveness in reducing head impact kinematics in youth ice hockey players. Twenty youth were divided into two groups: a CT and Control group. The CT group performed two 30-minute sessions of IntelliGym CT weekly for 20 weeks and the control group performed two 30-minute sessions weekly evaluating hockey videos. The dependent variables, number of head impacts, cumulative linear acceleration (CLA) and rotational acceleration (CRA) and mean linear and rotation peak acceleration, were compared with repeated measures ANOVAs, with post-hoc for main effect of time for each group, between the first and second half of the season. There were significant interactions for number of head impacts (p = 0.014) and CLA (p = 0.043) and post-hoc testing identified reductions in the second half of the season for the CT, but not control, group. There were no interactions for CRA, mean peak linear acceleration, and mean peak rotational acceleration. These preliminary results suggest CT may be an effective primary prevention strategy to reduce head impacts and cumulative linear acceleration in youth ice hockey players.
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Affiliation(s)
- Melissa S DiFabio
- Department of Biomedical Engineering, University of Delaware, Newark, DE, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, DE, USA
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31
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Alosco ML, Culhane J, Mez J. Neuroimaging Biomarkers of Chronic Traumatic Encephalopathy: Targets for the Academic Memory Disorders Clinic. Neurotherapeutics 2021; 18:772-791. [PMID: 33847906 PMCID: PMC8423967 DOI: 10.1007/s13311-021-01028-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to repetitive head impacts, such as those from contact sports. The pathognomonic lesion for CTE is the perivascular accumulation of hyper-phosphorylated tau in neurons and other cell process at the depths of sulci. CTE cannot be diagnosed during life at this time, limiting research on risk factors, mechanisms, epidemiology, and treatment. There is an urgent need for in vivo biomarkers that can accurately detect CTE and differentiate it from other neurological disorders. Neuroimaging is an integral component of the clinical evaluation of neurodegenerative diseases and will likely aid in diagnosing CTE during life. In this qualitative review, we present the current evidence on neuroimaging biomarkers for CTE with a focus on molecular, structural, and functional modalities routinely used as part of a dementia evaluation. Supporting imaging-pathological correlation studies are also presented. We targeted neuroimaging studies of living participants at high risk for CTE (e.g., aging former elite American football players, fighters). We conclude that an optimal tau PET radiotracer with high affinity for the 3R/4R neurofibrillary tangles in CTE has not yet been identified. Amyloid PET scans have tended to be negative. Converging structural and functional imaging evidence together with neuropathological evidence show frontotemporal and medial temporal lobe neurodegeneration, and increased likelihood for a cavum septum pellucidum. The literature offers promising neuroimaging biomarker targets of CTE, but it is limited by cross-sectional studies of small samples where the presence of underlying CTE is unknown. Imaging-pathological correlation studies will be important for the development and validation of neuroimaging biomarkers of CTE.
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Affiliation(s)
- Michael L Alosco
- Department of Neurology, Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Boston University School of Medicine, 72 E Concord St, Suite B7800, MA, 02118, Boston, USA.
| | - Julia Culhane
- Department of Neurology, Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Boston University School of Medicine, 72 E Concord St, Suite B7800, MA, 02118, Boston, USA
| | - Jesse Mez
- Department of Neurology, Boston University Alzheimer's Disease Research Center, Boston University CTE Center, Boston University School of Medicine, 72 E Concord St, Suite B7800, MA, 02118, Boston, USA
- Framingham Heart Study, Boston University School of Medicine, MA, Boston, USA
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32
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Preseason Cerebrovascular Function in Adolescent Athletes. Ann Biomed Eng 2021; 49:2734-2746. [PMID: 33754253 DOI: 10.1007/s10439-021-02764-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to investigate the effects of sport participation, concussion history, and age of first exposure to football on preseason cerebrovascular function in adolescent athletes. Athletes (n = 53, age = 15.8 ± 1.2 years) were examined based on three exposure groupings: (1) sport participation (football vs. non-collision), (2) concussion history (none vs. ≥ 1), and (3) age of first exposure (football participants only). Transcranial Doppler assessed cerebrovascular reactivity (CVR) and neurovascular coupling (NVC), and separate independent samples t-tests evaluated group differences in CVR and NVC outcomes. Separate univariate linear regressions determined how age of first exposure related to CVR and NVC outcomes. Linear mixed effects models assessed group differences in CVR and NVC relative response curves. Differential response to NVC visual task response was significantly greater in non-collision sport athletes (F1,2946 = 38.69, p < 0.0001) and athletes without a concussion history (F1,2946 = 25.23, p < 0.0001). Older age of first exposure significantly predicted reduced breath-holding CVR response (F1,1560 = 2.92, p = 0.03). Healthy adolescent athletes have similar pre-season cerebrovascular function despite different sport participation and concussion history. However, age of first exposure may predict CVR in adolescent football athletes. Developmental literature identifies cerebrovascular function as dynamically changing throughout adolescence. Our study provides fundamental data informing the clinical meaningfulness of short- and long-term physiological function changes.
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33
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DeSimone JC, Davenport EM, Urban J, Xi Y, Holcomb JM, Kelley ME, Whitlow CT, Powers AK, Stitzel JD, Maldjian JA. Mapping default mode connectivity alterations following a single season of subconcussive impact exposure in youth football. Hum Brain Mapp 2021; 42:2529-2545. [PMID: 33734521 PMCID: PMC8090779 DOI: 10.1002/hbm.25384] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/14/2022] Open
Abstract
Repetitive head impact (RHI) exposure in collision sports may contribute to adverse neurological outcomes in former players. In contrast to a concussion, or mild traumatic brain injury, “subconcussive” RHIs represent a more frequent and asymptomatic form of exposure. The neural network‐level signatures characterizing subconcussive RHIs in youth collision‐sport cohorts such as American Football are not known. Here, we used resting‐state functional MRI to examine default mode network (DMN) functional connectivity (FC) following a single football season in youth players (n = 50, ages 8–14) without concussion. Football players demonstrated reduced FC across widespread DMN regions compared with non‐collision sport controls at postseason but not preseason. In a subsample from the original cohort (n = 17), players revealed a negative change in FC between preseason and postseason and a positive and compensatory change in FC during the offseason across the majority of DMN regions. Lastly, significant FC changes, including between preseason and postseason and between in‐ and off‐season, were specific to players at the upper end of the head impact frequency distribution. These findings represent initial evidence of network‐level FC abnormalities following repetitive, non‐concussive RHIs in youth football. Furthermore, the number of subconcussive RHIs proved to be a key factor influencing DMN FC.
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Affiliation(s)
- Jesse C. DeSimone
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Elizabeth M. Davenport
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Jillian Urban
- Department of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Yin Xi
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - James M. Holcomb
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Mireille E. Kelley
- Department of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Christopher T. Whitlow
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Department of Radiology – NeuroradiologyWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Clinical and Translational Sciences InstituteWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Alexander K. Powers
- Department of NeurosurgeryWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Joel D. Stitzel
- Department of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Clinical and Translational Sciences InstituteWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Childress Institute for Pediatric TraumaWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Joseph A. Maldjian
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
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Kaufmann D, Sollmann N, Kaufmann E, Veggeberg R, Tripodis Y, Wrobel PP, Kochsiek J, Martin BM, Lin AP, Coleman MJ, Alosco ML, Pasternak O, Bouix S, Stern RA, Shenton ME, Koerte IK. Age at First Exposure to Tackle Football is Associated with Cortical Thickness in Former Professional American Football Players. Cereb Cortex 2021; 31:3426-3434. [PMID: 33676369 DOI: 10.1093/cercor/bhab021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/29/2020] [Accepted: 01/20/2021] [Indexed: 11/13/2022] Open
Abstract
Younger age at first exposure (AFE) to repetitive head impacts while playing American football increases the risk for later-life neuropsychological symptoms and brain alterations. However, it is not known whether AFE is associated with cortical thickness in American football players. Sixty-three former professional National Football League players (55.5 ± 7.7 years) with cognitive, behavioral, and mood symptoms underwent neuroimaging and neuropsychological testing. First, the association between cortical thickness and AFE was tested. Second, the relationship between clusters of decreased cortical thickness and verbal and visual memory, and composite measures of mood/behavior and attention/psychomotor speed was assessed. AFE was positively correlated with cortical thickness in the right superior frontal cortex (cluster-wise P value [CWP] = 0.0006), the left parietal cortex (CWP = 0.0003), and the occipital cortices (right: CWP = 0.0023; left: CWP = 0.0008). A positive correlation was found between cortical thickness of the right superior frontal cortex and verbal memory (R = 0.333, P = 0.019), and the right occipital cortex and visual memory (R = 0.360, P = 0.012). In conclusion, our results suggest an association between younger AFE and decreased cortical thickness, which in turn is associated with worse neuropsychological performance. Furthermore, an association between younger AFE and signs of neurodegeneration later in life in symptomatic former American football players seems likely.
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Affiliation(s)
- David Kaufmann
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-Universität, 80337 Munich, Germany.,Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.,Department of Radiology, Charité Universitätsmedizin, 10117 Berlin, Germany
| | - Nico Sollmann
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-Universität, 80337 Munich, Germany.,Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.,Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Elisabeth Kaufmann
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-Universität, 80337 Munich, Germany.,Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.,Department of Neurology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Rosanna Veggeberg
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118, USA.,Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA 02118, USA
| | - Pawel P Wrobel
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-Universität, 80337 Munich, Germany.,Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Janna Kochsiek
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-Universität, 80337 Munich, Germany.,Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Brett M Martin
- Data Coordinating Center, Boston University School of Public Health, Boston, MA 02118, USA
| | - Alexander P Lin
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Michael J Coleman
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA 02118, USA.,Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA
| | - Ofer Pasternak
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, MA 02118, USA.,Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA.,Department of Neurosurgery, Boston University School of Medicine, Boston, MA 02118, USA.,Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA 02118, USA
| | - Martha E Shenton
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,VA Boston Healthcare System, Brockton Division, Brockton, MA 02301, USA
| | - Inga K Koerte
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-Universität, 80337 Munich, Germany.,Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA.,Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.,Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität, 82152 Munich, Germany
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Miller LE, Urban JE, Davenport EM, Powers AK, Whitlow CT, Maldjian JA, Stitzel JD. Brain Strain: Computational Model-Based Metrics for Head Impact Exposure and Injury Correlation. Ann Biomed Eng 2021; 49:1083-1096. [PMID: 33258089 PMCID: PMC10032321 DOI: 10.1007/s10439-020-02685-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/20/2020] [Indexed: 12/20/2022]
Abstract
Athletes participating in contact sports are exposed to repetitive subconcussive head impacts that may have long-term neurological consequences. To better understand these impacts and their effects, head impacts are often measured during football to characterize head impact exposure and estimate injury risk. Despite widespread use of kinematic-based metrics, it remains unclear whether any single metric derived from head kinematics is well-correlated with measurable changes in the brain. This shortcoming has motivated the increasing use of finite element (FE)-based metrics, which quantify local brain deformations. Additionally, quantifying cumulative exposure is of increased interest to examine the relationship to brain changes over time. The current study uses the atlas-based brain model (ABM) to predict the strain response to impacts sustained by 116 youth football athletes and proposes 36 new, or derivative, cumulative strain-based metrics that quantify the combined burden of head impacts over the course of a season. The strain-based metrics developed and evaluated for FE modeling and presented in the current study present potential for improved analytics over existing kinematically-based and cumulative metrics. Additionally, the findings highlight the importance of accounting for directional dependence and expand the techniques to explore spatial distribution of the strain response throughout the brain.
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Affiliation(s)
- Logan E Miller
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA.
- School of Biomedical Engineering and Sciences, Virginia Tech - Wake Forest University, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA.
| | - Jillian E Urban
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- School of Biomedical Engineering and Sciences, Virginia Tech - Wake Forest University, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
| | - Elizabeth M Davenport
- Department of Radiology, Southwestern Medical School, University of Texas, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Alexander K Powers
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- Department of Neurosurgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Christopher T Whitlow
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- Department of Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Joseph A Maldjian
- Department of Radiology, Southwestern Medical School, University of Texas, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
- School of Biomedical Engineering and Sciences, Virginia Tech - Wake Forest University, 575 N. Patterson Avenue, Suite 530, Winston-Salem, NC, 27101, USA
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36
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Caccese JB, Bodt BA, Iverson GL, Kaminski TW, Bryk K, Oldham J, Broglio SP, McCrea M, McAllister T, Buckley TA. Estimated Age of First Exposure to Contact Sports and Neurocognitive, Psychological, and Physical Outcomes in Healthy NCAA Collegiate Athletes: A Cohort Study. Sports Med 2021; 50:1377-1392. [PMID: 32002824 DOI: 10.1007/s40279-020-01261-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Collegiate football players who started playing tackle football before age 12 years did not show worse neuropsychological test performance than those who started playing tackle football after age 12 years. It is unknown if beginning other contact sports, such as lacrosse, at a younger age is associated with worse neurocognitive performance, greater psychological distress, or worse postural stability in collegiate student athletes. OBJECTIVE The purpose of this study was to examine the association between estimated age of first exposure (eAFE) to repetitive head impacts (RHI) and these outcome measures in collegiate student athletes. METHODS 1891 female and 4448 male collision/contact (i.e., football, ice hockey, lacrosse, wrestling, soccer) and non-contact (i.e., golf, rifle, rowing/crew, swimming, tennis) sport athletes completed baseline testing, including the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Brief Symptom Inventory 18 (BSI-18), and Balance Error Scoring System (BESS). RESULTS For women, the eAFE-by-sport interaction was associated with ImPACT Verbal Memory and Visual Memory, whereby earlier eAFE to contact sports was associated with higher composite scores (B = - 0.397, B = - 0.485, respectively). For men, the eAFE-by-sport interaction was associated with BSI-18 Depression and Global Severity Index and symptom severity scores, whereby earlier eAFE to football was associated with lower psychological distress and symptom severity [Depression, Exp(B) = 1.057; Global Severity Index, Exp(B) = 1.047; Symptom Severity, Exp(B) = 1.046]. Parameter estimates were small suggesting these results may have minimal practical relevance. CONCLUSION Findings suggest that RHI during early adolescence is unrelated to brain health as measured by these specific outcome measures in collegiate student athletes.
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Affiliation(s)
- Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, 453 W 10th Ave, Columbus, OH, 43210, USA
| | - Barry A Bodt
- College of Health Sciences, University of Delaware, 540 S. College Ave, Newark, DE, 19713, USA
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Spaulding Research Institute, MassGeneral Hospital for Children Sports Concussion Program and Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, USA.,Center for Health and Rehabilitation Research, 79/96 Thirteenth Street, Charlestown, MA, 20129, USA
| | - Thomas W Kaminski
- Interdisciplinary Biomechanics and Movement Science Program, Department of Kinesiology and Applied Physiology, University of Delaware, 541 S. College Ave, Newark, DE, 19716, USA
| | - Kelsey Bryk
- Interdisciplinary Biomechanics and Movement Science Program, Department of Kinesiology and Applied Physiology, University of Delaware, 100 Discovery Blvd, Newark, DE, 19713, USA
| | - Jessie Oldham
- The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, 9 Hope Ave, Waltham, MA, 02453, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, 401 Washtenaw Ave, Ann Arbor, MI, 48104, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Thomas McAllister
- Indiana University School of Medicine, Goodman Hall, 355 W. 16th St., Suite 4800, Indianapolis, IN, 46202, USA
| | - Thomas A Buckley
- Interdisciplinary Biomechanics and Movement Science Program, Department of Kinesiology and Applied Physiology, University of Delaware, 100 Discovery Blvd, Newark, DE, 19713, USA.
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Arciniega H, Shires J, Furlong S, Kilgore-Gomez A, Cerreta A, Murray NG, Berryhill ME. Impaired visual working memory and reduced connectivity in undergraduates with a history of mild traumatic brain injury. Sci Rep 2021; 11:2789. [PMID: 33531546 PMCID: PMC7854733 DOI: 10.1038/s41598-021-80995-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/01/2021] [Indexed: 12/30/2022] Open
Abstract
Mild traumatic brain injury (mTBI), or concussion, accounts for 85% of all TBIs. Yet survivors anticipate full cognitive recovery within several months of injury, if not sooner, dependent upon the specific outcome/measure. Recovery is variable and deficits in executive function, e.g., working memory (WM) can persist years post-mTBI. We tested whether cognitive deficits persist in otherwise healthy undergraduates, as a conservative indicator for mTBI survivors at large. We collected WM performance (change detection, n-back tasks) using various stimuli (shapes, locations, letters; aurally presented numbers and letters), and wide-ranging cognitive assessments (e.g., RBANS). We replicated the observation of a general visual WM deficit, with preserved auditory WM. Surprisingly, visual WM deficits were equivalent in participants with a history of mTBI (mean 4.3 years post-injury) and in undergraduates with recent sports-related mTBI (mean 17 days post-injury). In seeking the underlying mechanism of these behavioral deficits, we collected resting state fMRI (rsfMRI) and EEG (rsEEG). RsfMRI revealed significantly reduced connectivity within WM-relevant networks (default mode, central executive, dorsal attention, salience), whereas rsEEG identified no differences (modularity, global efficiency, local efficiency). In summary, otherwise healthy current undergraduates with a history of mTBI present behavioral deficits with evidence of persistent disconnection long after full recovery is expected.
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Affiliation(s)
- Hector Arciniega
- Department of Psychology, Programs in Cognitive and Brain Sciences, and Integrative Neuroscience, University of Nevada, 1664 N. Virginia St., MS 296, Reno, NV, 89557, USA.
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02215, USA.
| | - Jorja Shires
- Department of Psychology, Programs in Cognitive and Brain Sciences, and Integrative Neuroscience, University of Nevada, 1664 N. Virginia St., MS 296, Reno, NV, 89557, USA
| | - Sarah Furlong
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Alexandrea Kilgore-Gomez
- Department of Psychology, Programs in Cognitive and Brain Sciences, and Integrative Neuroscience, University of Nevada, 1664 N. Virginia St., MS 296, Reno, NV, 89557, USA
| | - Adelle Cerreta
- Department of Psychology, Programs in Cognitive and Brain Sciences, and Integrative Neuroscience, University of Nevada, 1664 N. Virginia St., MS 296, Reno, NV, 89557, USA
| | - Nicholas G Murray
- Department of Psychology, Programs in Cognitive and Brain Sciences, and Integrative Neuroscience, University of Nevada, 1664 N. Virginia St., MS 296, Reno, NV, 89557, USA
- School of Community Health Sciences, University of Nevada, Reno, 89557, USA
| | - Marian E Berryhill
- Department of Psychology, Programs in Cognitive and Brain Sciences, and Integrative Neuroscience, University of Nevada, 1664 N. Virginia St., MS 296, Reno, NV, 89557, USA
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38
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Montanino A, Li X, Zhou Z, Zeineh M, Camarillo D, Kleiven S. Subject-specific multiscale analysis of concussion: from macroscopic loads to molecular-level damage. BRAIN MULTIPHYSICS 2021. [DOI: 10.1016/j.brain.2021.100027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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39
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Castellanos J, Phoo CP, Eckner JT, Franco L, Broglio SP, McCrea M, McAllister T, Wiens J. Predicting Risk of Sport-Related Concussion in Collegiate Athletes and Military Cadets: A Machine Learning Approach Using Baseline Data from the CARE Consortium Study. Sports Med 2020; 51:567-579. [PMID: 33368027 DOI: 10.1007/s40279-020-01390-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To develop a predictive model for sport-related concussion in collegiate athletes and military service academy cadets using baseline data collecting during the pre-participation examination. METHODS Baseline assessments were performed in 15,682 participants from 21 US academic institutions and military service academies participating in the CARE Consortium Study during the 2015-2016 academic year. Participants were monitored for sport-related concussion during the subsequent season. 176 baseline covariates mapped to 957 binary features were used as input into a support vector machine model with the goal of learning to stratify participants according to their risk for sport-related concussion. Performance was evaluated in terms of area under the receiver operating characteristic curve (AUROC) on a held-out test set. Model inputs significantly associated with either increased or decreased risk were identified. RESULTS 595 participants (3.79%) sustained a concussion during the study period. The predictive model achieved an AUROC of 0.73 (95% confidence interval 0.70-0.76), with variable performance across sports. Features with significant positive and negative associations with subsequent sport-related concussion were identified. CONCLUSION(S) This predictive model using only baseline data identified athletes and cadets who would go on to sustain sport-related concussion with comparable accuracy to many existing concussion assessment tools for identifying concussion. Furthermore, this study provides insight into potential concussion risk and protective factors.
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Affiliation(s)
- Joel Castellanos
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, 325 E. Eisenhower Parkway, Ann Arbor, MI, 48108, USA.,Anestheshiology, School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Cheng Perng Phoo
- Computer Science and Engineering, University of Michigan, Ann Arbor, MI, USA.,Computer Science, Cornell University, New York, USA
| | - James T Eckner
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, 325 E. Eisenhower Parkway, Ann Arbor, MI, 48108, USA.
| | - Lea Franco
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, 325 E. Eisenhower Parkway, Ann Arbor, MI, 48108, USA
| | | | - Mike McCrea
- Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Jenna Wiens
- Computer Science and Engineering, University of Michigan, Ann Arbor, MI, USA
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40
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Iverson GL, Terry DP, Caccese JB, Büttner F, Merz ZC. Age of First Exposure to Football Is Not Associated with Midlife Brain Health Problems. J Neurotrauma 2020; 38:538-545. [PMID: 33126834 DOI: 10.1089/neu.2020.7041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The purpose of this study was to determine if earlier age of first exposure (AFE) to football is associated with worse brain health in middle-aged men who played high school football. We assessed 123 men 35-55 years of age, who played high school football, using (1) a survey of demographic information as well as medical, sport participation, and concussion history; (2) the Patient Health Questionnaire-8 (PHQ-8); and (3) the British Columbia Post-Concussion Symptom Inventory (BC-PSI). Sixty-two (50.4%) men reported football participation starting before the age of 12 (i.e., AFE <12 years) and 61 (49.6%) reported football participation at or after the age of 12 (AFE > 12 years). Compared with those with AFE >12 years, a similar proportion of former high school football players who began playing tackle football before age 12 reported that they had been prescribed medications for mental health problems or that they had recently experienced symptoms of anxiety, depression, memory loss, chronic pain, or headaches. Moreover, there was no significant difference in their lifetime history of treatment by a mental health professional. The groups did not differ significantly on PHQ-8 (U = 1839.0, p = 0.791) or BC-PSI total scores (U = 1828.5, p = 0.751). These findings suggest that earlier AFE to football is not associated with worse brain health in middle-aged men in this sample who played high school football.
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Affiliation(s)
- Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA.,Spaulding Research Institute, Charlestown, Massachusetts, USA.,MassGeneral Hospital for Children Sports Concussion Program, Boston, Massachusetts, USA.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, Massachusetts, USA.,Center for Health and Rehabilitation Research, Charlestown, Massachusetts, USA
| | - Douglas P Terry
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA.,Spaulding Research Institute, Charlestown, Massachusetts, USA.,MassGeneral Hospital for Children Sports Concussion Program, Boston, Massachusetts, USA.,Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, Massachusetts, USA.,Center for Health and Rehabilitation Research, Charlestown, Massachusetts, USA
| | - Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Fionn Büttner
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Zachary C Merz
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, UNC Memorial Hospital, Chapel Hill, North Carolina
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Abstract
As awareness on the short-term and long-term consequences of sports-related concussions and repetitive head impacts continues to grow, so too does the necessity to establish biomechanical measures of risk that inform public policy and risk mitigation strategies. A more precise exposure metric is central to establishing relationships among the traumatic experience, risk, and ultimately clinical outcomes. Accurate exposure metrics provide a means to support evidence-informed decisions accelerating public policy mandating brain trauma management through sport modification and safer play.
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Affiliation(s)
- Clara Karton
- Neurotrauma Impact Science Laboratory, University of Ottawa, A106-200 Lees Avenue, Ottawa, ON K1N 6N5, Canada.
| | - Thomas Blaine Hoshizaki
- Neurotrauma Impact Science Laboratory, University of Ottawa, A106-200 Lees Avenue, Ottawa, ON K1N 6N5, Canada
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42
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Alosco ML, Tripodis Y, Rowland B, Chua AS, Liao H, Martin B, Jarnagin J, Chaisson CE, Pasternak O, Karmacharya S, Koerte IK, Cantu RC, Kowall NW, McKee AC, Shenton ME, Greenwald R, McClean M, Stern RA, Lin A. A magnetic resonance spectroscopy investigation in symptomatic former NFL players. Brain Imaging Behav 2020; 14:1419-1429. [PMID: 30848432 PMCID: PMC6994233 DOI: 10.1007/s11682-019-00060-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The long-term neurologic consequences of exposure to repetitive head impacts (RHI) are not well understood. This study used magnetic resonance spectroscopy (MRS) to examine later-life neurochemistry and its association with RHI and clinical function in former National Football League (NFL) players. The sample included 77 symptomatic former NFL players and 23 asymptomatic individuals without a head trauma history. Participants completed cognitive, behavior, and mood measures. N-acetyl aspartate, glutamate/glutamine, choline, myo-inositol, creatine, and glutathione were measured in the posterior (PCG) and anterior (ACG) cingulate gyrus, and parietal white matter (PWM). A cumulative head impact index (CHII) estimated RHI. In former NFL players, a higher CHII correlated with lower PWM creatine (r = -0.23, p = 0.02). Multivariate mixed-effect models examined neurochemical differences between the former NFL players and asymptomatic individuals without a history of head trauma. PWM N-acetyl aspartate was lower among the former NFL players (mean diff. = 1.02, p = 0.03). Between-group analyses are preliminary as groups were recruited based on symptomatic status. The ACG was the only region associated with clinical function, including positive correlations between glutamate (r = 0.32, p = 0.004), glutathione (r = 0.29, p = 0.02), and myo-inositol (r = 0.26, p = 0.01) with behavioral/mood symptoms. Other positive correlations between ACG neurochemistry and clinical function emerged (i.e., behavioral/mood symptoms, cognition), but the positive directionality was unexpected. All analyses controlled for age, body mass index, and education (for analyses examining clinical function). In this sample of symptomatic former NFL players, there was a direct effect between RHI and reduced cellular energy metabolism (i.e., lower creatine). MRS neurochemicals associated with neuroinflammation also correlated with behavioral/mood symptoms.
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Affiliation(s)
- Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Benjamin Rowland
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 4 Blackfan Street HIM-820, Boston, MA, 02115, USA
| | - Alicia S Chua
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Huijun Liao
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 4 Blackfan Street HIM-820, Boston, MA, 02115, USA
| | - Brett Martin
- Boston University Alzheimer's Disease and CTE Center, Boston University School of Medicine, Boston, MA, USA
- Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Johnny Jarnagin
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Christine E Chaisson
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Biostatistics & Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Ofer Pasternak
- Departments of Psychiatry and Radiology, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarina Karmacharya
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Inga K Koerte
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Child and Adolescent Psychiatry, Psychosomatic, and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Robert C Cantu
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology and Neurosurgery, Boston University School of Medicine, Boston, MA, USA
- Concussion Legacy Foundation, Boston, MA, USA
| | - Neil W Kowall
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology, and Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
- Neurology Service, VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
| | - Ann C McKee
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology, and Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Department of Veterans Affairs Medical Center, Bedford, MA, USA
| | - Martha E Shenton
- Departments of Psychiatry and Radiology, Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
| | - Richard Greenwald
- Simbex, Lebanon, NH, USA
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Michael McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Center, Departments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Alexander Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 4 Blackfan Street HIM-820, Boston, MA, 02115, USA.
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Yao ZF, Sligte IG, Moreau D, Hsieh S, Yang CT, Ridderinkhof KR, Muggleton NG, Wang CH. The brains of elite soccer players are subject to experience-dependent alterations in white matter connectivity. Cortex 2020; 132:79-91. [PMID: 32956909 DOI: 10.1016/j.cortex.2020.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/26/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023]
Abstract
Soccer is the only major sport with voluntary unprotected head-to-ball contact. It is crucial to determine if head impact through long-term soccer training is manifested in brain structure and connectivity, and whether such alterations are due to sustained training per se. Using diffusion tensor imaging, we documented a comprehensive view of soccer players' brains in a sample of twenty-five right-handed male elite soccer players aged from 18 to 22 years and twenty-five non-athletic controls aged 19-24 years. Importantly, none had recalled a history of concussion. We performed a whole-brain tract-based spatial statistical analysis, and a tract-specific probabilistic tractography method to measure the differences of white matter properties between groups. Whole-brain integrity analysis showed stronger microstructural integrity within the corpus callosum tract in soccer players compared to controls. Further, tract-specific probabilistic tractography revealed that the anterior part of corpus callosum may be the brain structure most relevant to training experience, which may put into perspective prior evidence showing corpus callosum alteration in retired or concussed athletes practicing contact sports. Intriguingly, experience-related alterations showed left hemispheric lateralization of potential early signs of concussion-like effects. In sum, we concluded that the observed gains and losses may be due to a consequence of engagement in protracted soccer training that incurs prognostic hallmarks associated with minor injury-induced neural inflammation.
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Affiliation(s)
- Zai-Fu Yao
- Brain and Cognition, Department of Psychology, University of Amsterdam, the Netherlands
| | - Ilja G Sligte
- Brain and Cognition, Department of Psychology, University of Amsterdam, the Netherlands; Amsterdam Brain and Cognition, University of Amsterdam, the Netherlands
| | - David Moreau
- Centre for Brain Research, School of Psychology, The University of Auckland, New Zealand
| | - Shulan Hsieh
- Cognitive Electrophysiology Laboratory: Control, Aging, Sleep, and Emotion (CASE), Department of Psychology, National Cheng Kung University, Taiwan; Institute of Allied Health Sciences, National Cheng Kung University, Taiwan; Department and Institute of Public Health, National Cheng Kung University, Taiwan; Department of Psychology, National Cheng Kung University, Taiwan
| | - Cheng-Ta Yang
- Institute of Allied Health Sciences, National Cheng Kung University, Taiwan; Department of Psychology, National Cheng Kung University, Taiwan
| | - K Richard Ridderinkhof
- Brain and Cognition, Department of Psychology, University of Amsterdam, the Netherlands; Amsterdam Brain and Cognition, University of Amsterdam, the Netherlands
| | - Neil G Muggleton
- Institute of Cognitive Neuroscience, National Central University, Taoyuan City, Taiwan; Institute of Cognitive Neuroscience, University College London, London, United Kingdom; Department of Psychology, Goldsmiths, University of London, London, United Kingdom
| | - Chun-Hao Wang
- Institute of Physical Education, Health & Leisure Studies, National Cheng Kung University, Taiwan.
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Caccese JB, Houck Z, Kaminski TW, Clugston JR, Iverson GL, Bryk KN, Oldham JR, Pasquina PF, Broglio SP, McAllister TW, McCrea M, Hoy AMR, Hazzard JB, Kelly LA, Ortega JD, Port N, Putukian M, Langford TD, Giza CC, Goldman JT, Benjamin HJ, Schmidt JD, Feigenbaum LA, Eckner JT, Mihalik JP, Miles JD, Anderson S, Master CL, Collins MW, Kontos AP, Chrisman SPD, Brooks A, Jackson JC, McGinty G, Cameron KL, Susmarski A, O'Donnell PG, Duma S, Rowson S, Miles CM, Bullers CT, Dykhuizen BH, Lintner L, Buckley TA. Estimated age of first exposure to American football and outcome from concussion. Neurology 2020; 95:e2935-e2944. [PMID: 32907967 DOI: 10.1212/wnl.0000000000010672] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/30/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the association between estimated age at first exposure (eAFE) to American football and clinical measures throughout recovery following concussion. METHODS Participants were recruited across 30 colleges and universities as part of the National Collegiate Athletic Association (NCAA)-Department of Defense Concussion Assessment, Research and Education Consortium. There were 294 NCAA American football players (age 19 ± 1 years) evaluated 24-48 hours following concussion with valid baseline data and 327 (age 19 ± 1 years) evaluated at the time they were asymptomatic with valid baseline data. Participants sustained a medically diagnosed concussion between baseline testing and postconcussion assessments. Outcome measures included the number of days until asymptomatic, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) composite scores, Balance Error Scoring System (BESS) total score, and Brief Symptom Inventory 18 (BSI-18) subscores. The eAFE was defined as participant's age at the time of assessment minus self-reported number of years playing football. RESULTS In unadjusted regression models, younger eAFE was associated with lower (worse) ImPACT Visual Motor Speed (R 2 = 0.031, p = 0.012) at 24-48 hours following injury and lower (better) BSI-18 Somatization subscores (R 2 = 0.014, p = 0.038) when the athletes were asymptomatic. The effect sizes were very small. The eAFE was not associated with the number of days until asymptomatic, other ImPACT composite scores, BESS total score, or other BSI-18 subscores. CONCLUSION Earlier eAFE to American football was not associated with longer symptom recovery, worse balance, worse cognitive performance, or greater psychological distress following concussion. In these NCAA football players, longer duration of exposure to football during childhood and adolescence appears to be unrelated to clinical recovery following concussion.
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Affiliation(s)
- Jaclyn B Caccese
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Zac Houck
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Thomas W Kaminski
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - James R Clugston
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Grant L Iverson
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Kelsey N Bryk
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Jessie R Oldham
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Paul F Pasquina
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Steven P Broglio
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Thomas W McAllister
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Michael McCrea
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - April Marie Reed Hoy
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Joseph B Hazzard
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Louise A Kelly
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Justus D Ortega
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Nicholas Port
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Margot Putukian
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - T Dianne Langford
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Christopher C Giza
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Joshua T Goldman
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Holly J Benjamin
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Julianne D Schmidt
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Luis A Feigenbaum
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - James T Eckner
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Jason P Mihalik
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Jessica Dysart Miles
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Scott Anderson
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Christina L Master
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Micky W Collins
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Anthony P Kontos
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Sara P D Chrisman
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Alison Brooks
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Jonathan C Jackson
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Gerald McGinty
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Kenneth L Cameron
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Adam Susmarski
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Patrick G O'Donnell
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Stefan Duma
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Steve Rowson
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Christopher M Miles
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Christopher T Bullers
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Brian H Dykhuizen
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Laura Lintner
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC
| | - Thomas A Buckley
- From the Ohio State University College of Medicine (J.B.C.), Columbus; University of Florida (Z.H., J.R.C.), Gainesville; University of Delaware (T.W.K., K.N.B., T.A.B.), Newark; Harvard Medical School (G.L.I.), Boston; Spaulding Rehabilitation Hospital and Spaulding Research Institute (G.L.I.), Charlestown; MassGeneral Hospital for Children (G.L.I.), Boston; Home Base (G.L.I.), A Red Sox Foundation and Massachusetts General Hospital Program, Boston; The Micheli Center for Sports Injury Prevention (J.R.O.), Boston Children's Hospital, Waltham, MA; Uniformed Services University of the Health Sciences (P.F.P.), Bethesda; Walter Reed National Military Medical Center (P.F.P.), Bethesda, MD; University of Michigan (S.P.B.), Ann Arbor; Indiana University School of Medicine (T.W.M.), Indianapolis; Medical College of Wisconsin (M.M.), Milwaukee; Azusa Pacific University (A.M.H.), CA; Bloomsburg University (J.B.H.), PA; California Lutheran University (L.A.K.), Thousand Oaks; Humboldt State University (J.D.O.), Arcata, CA; Indiana University (N.P.), Bloomington; Princeton University (M.P.), NJ; Temple University (T.D.L.), Philadelphia, PA; University of California (C.C.G., J.T.G.), Los Angeles; University of Chicago (H.J.B.), IL; University of Georgia (J.D.S.), Athens; University of Miami (L.A.F.), FL; University of Michigan (J.T.E.), Ann Arbor; University of North Carolina at Chapel Hill (J.P.M.); University of North Georgia (J.D.M.), Dahlonega; University of Oklahoma (S.A.), Norman; University of Pennsylvania (C.L.M.), Philadelphia; University of Pittsburgh (M.W.C., A.P.K.), PA; University of Washington (S.P.D.C.), Seattle; University of Wisconsin-Madison (A.B.); United States Air Force Academy (J.C.J., G.M.), Colorado Springs, CO; United States Military Academy (K.L.C.), West Point, NY; United States Naval Academy (A.S.), Annapolis, MD; United States Coast Guard Academy (P.G.O.), New London, CT; Virginia Tech (S.D., S.R.), Blacksburg; Wake Forest University (C.M.M., C.T.B.), Winston-Salem, NC; Wilmington College (B.H.D.), OH; Winston-Salem University (L.L.), NC.
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Mariani M, Alosco ML, Mez J, Stern RA. Clinical Presentation of Chronic Traumatic Encephalopathy. Semin Neurol 2020; 40:370-383. [PMID: 32740900 DOI: 10.1055/s-0040-1713624] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repetitive head impacts (RHI), such as those received in contact/collision sports, blast injury in military veterans, and domestic violence. Currently, CTE can only be diagnosed following death. Although the clinical features of former boxers have been described for almost a century, and there is increasing evidence of long-term cognitive and neuropsychiatric impairments in living former American football players, the specific clinical presentation associated with underlying CTE neuropathology remains unclear. These features include diverse and nonspecific changes in cognition, mood, behavior, and motor functioning. Currently, there are no validated and widely accepted clinical diagnostic criteria. Proposed criteria are primarily based on retrospective telephonic interviews with the next of kin of individuals who were diagnosed with CTE postmortem. Prospective studies involving individuals presumably at high risk for CTE are underway; these will hopefully clarify the clinical features and course of CTE, allow the diagnostic criteria to be refined, and lead to the development and validation of in vivo biomarkers. This article reviews what is currently known about the clinical presentation of CTE and describes the evolution of this knowledge from early case reports of "punch drunk" boxers through larger case series of neuropathologically confirmed CTE. This article concludes with a discussion of gaps in research and future directions to address these areas.
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Affiliation(s)
- Megan Mariani
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts
| | - Michael L Alosco
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Robert A Stern
- Boston University Alzheimer's Disease Center and Boston University CTE Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurology, Neurosurgery, and Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
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Uretsky M, Nowinski CJ. Chronic Traumatic Encephalopathy: Advocacy and Communicating with the Public. Semin Neurol 2020; 40:461-468. [PMID: 32712947 DOI: 10.1055/s-0040-1713621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Over the past 40 years, advocacy groups have been instrumental in raising awareness for neurodegenerative diseases such as Alzheimer's disease. More recently, advocates have emerged to educate about sports concussions and chronic traumatic encephalopathy (CTE), including the Concussion Legacy Foundation (CLF). CTE is a neurodegenerative disease caused in part by repetitive head impacts (RHI). While the majority of CTE research has focused on studying former American football players, CTE has also been found in military personnel, victims of domestic violence, and contact sport athletes from high school to professional levels of play. Advocates' many goals include creating a culture of brain donation and modifying youth contact sports to decrease RHI. Here, we provide the first review of CTE advocacy, summarize the accomplishments of the CLF, and consider the connections between CTE advocacy, research, and legislation over the last decade.
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Affiliation(s)
- Madeline Uretsky
- Boston University Alzheimer's Disease and Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, MA.,Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Christopher J Nowinski
- Boston University Alzheimer's Disease and Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, MA.,Concussion Legacy Foundation, Boston, MA
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Phelps A, Mez J, Stern RA, Alosco ML. Risk Factors for Chronic Traumatic Encephalopathy: A Proposed Framework. Semin Neurol 2020; 40:439-449. [PMID: 32674182 DOI: 10.1055/s-0040-1713633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease that has been neuropathologically diagnosed in contact and collision sport athletes, military veterans, and others with a history of exposure to repetitive head impacts (RHI). Identifying methods to diagnose and prevent CTE during life is a high priority. Timely diagnosis and implementation of treatment and preventative strategies for neurodegenerative diseases, including CTE, partially hinge upon early and accurate risk characterization. Here, we propose a framework of risk factors that influence the neuropathological development of CTE. We provide an up-to-date review of the literature examining cumulative exposure to RHI as the environmental trigger for CTE. Because not all individuals exposed to RHI develop CTE, the direct and/or indirect influence of nonhead trauma exposure characteristics (e.g., age, sex, race, genetics) on the pathological development of CTE is reviewed. We conclude with recommendations for future directions, as well as opinions for preventative strategies that could mitigate risk.
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Affiliation(s)
- Alyssa Phelps
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse Mez
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Robert A Stern
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts.,Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, Massachusetts
| | - Michael L Alosco
- Boston University Alzheimer's Disease and CTE Centers, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
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Savino AK, Huang L, Yang J, Pizzimenti NM, McCarthy MT, Rose SC. Head Impact Burden Differs Between Seasons in Youth and High School US Football Players. Ann Biomed Eng 2020; 48:2763-2771. [DOI: 10.1007/s10439-020-02548-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 06/12/2020] [Indexed: 11/28/2022]
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49
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Manning KY, Brooks JS, Dickey JP, Harriss A, Fischer L, Jevremovic T, Blackney K, Barreira C, Brown A, Bartha R, Doherty T, Fraser D, Holmes J, Dekaban GA, Menon RS. Longitudinal changes of brain microstructure and function in nonconcussed female rugby players. Neurology 2020; 95:e402-e412. [PMID: 32554762 PMCID: PMC7455316 DOI: 10.1212/wnl.0000000000009821] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/05/2020] [Indexed: 12/17/2022] Open
Abstract
Objective To longitudinally assess brain microstructure and function in female varsity athletes participating in contact and noncontact sports. Methods Concussion-free female rugby players (n = 73) were compared to age-matched (ages 18–23) female swimmers and rowers (n = 31) during the in- and off-season. Diffusion and resting-state fMRI (rs-fMRI) measures were the primary outcomes. The Sports Concussion Assessment Tool and head impact accelerometers were used to monitor symptoms and impacts, respectively. Results We found cross-sectional (contact vs noncontact) and longitudinal (in- vs off-season) changes in white matter diffusion measures and rs-fMRI network connectivity in concussion-free contact athletes relative to noncontact athletes. In particular, mean, axial, and radial diffusivities were increased with decreased fractional anisotropy in multiple white matter tracts of contact athletes accompanied with default mode and visual network hyperconnectivity (p < 0.001). Longitudinal diffusion changes in the brainstem between the in- and off-season were observed for concussion-free contact athletes only, with progressive changes observed in a subset of athletes over multiple seasons. Axial diffusivity was significantly lower in the genu and splenium of the corpus callosum in those contact athletes with a history of concussion. Conclusions Together, these findings demonstrate longitudinal changes in the microstructure and function of the brain in otherwise healthy, asymptomatic athletes participating in contact sport. Further research to understand the long-term brain health and biological implications of these changes is required, in particular to what extent these changes reflect compensatory, reparative, or degenerative processes.
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Affiliation(s)
- Kathryn Y Manning
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Jeffrey S Brooks
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - James P Dickey
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Alexandra Harriss
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Lisa Fischer
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Tatiana Jevremovic
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Kevin Blackney
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Christy Barreira
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Arthur Brown
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Robert Bartha
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Tim Doherty
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Douglas Fraser
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Jeff Holmes
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Gregory A Dekaban
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
| | - Ravi S Menon
- From Medical Biophysics (K.Y.M., R.B., R.S.M.), School of Kinesiology (J.S.B., J.P.D.), Microbiology and Immunology (K.B.), Health and Rehabilitation Sciences (A.H.), Anatomy and Cell Biology (A.B.), Physical Medicine and Rehabilitation (T.D.), and School of Occupational Therapy (J.H.), Western University; Centre for Functional and Metabolic Mapping (K.Y.M., R.B., R.S.M.) and Molecular Medicine Research Laboratories (K.B., C.B., A.B., G.A.D.), Robarts Research Institute; Primary Care Sport Medicine (L.F., T.J.), Fowler Kennedy Sport Medicine; and Paediatrics Critical Care Medicine (D.F.), London Health Sciences Centre, Ontario, Canada
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50
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Caccese JB, Santos FV, Yamaguchi F, Jeka JJ. Age of First Exposure to Soccer Heading and Sensory Reweighting for Upright Stance. Int J Sports Med 2020; 41:616-627. [PMID: 32365387 DOI: 10.1055/a-1141-3553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
US Soccer eliminated soccer heading for youth players ages 10 years and younger and limited soccer heading for children ages 11-13 years. Limited empirical evidence associates soccer heading during early adolescence with medium-to-long-term behavioral deficits. The purpose of this study was to compare sensory reweighting for upright stance between college-aged soccer players who began soccer heading ages 10 years and younger (AFE ≤ 10) and those who began soccer heading after age 10 (AFE > 10). Thirty soccer players self-reported age of first exposure (AFE) to soccer heading. Sensory reweighting was compared between AFE ≤ 10 and AFE > 10. To evaluate sensory reweighting, we simultaneously perturbed upright stance with visual, vestibular, and proprioceptive stimulation. The visual stimulus was presented at two different amplitudes to measure the change in gain to vision, an intra-modal effect; and change in gain to galvanic vestibular stimulus (GVS) and vibration, both inter-modal effects. There were no differences in gain to vision (p=0.857, η2=0.001), GVS (p=0.971, η2=0.000), or vibration (p=0.974, η2=0.000) between groups. There were no differences in sensory reweighting for upright stance between AFE ≤ 10 and AFE > 10, suggesting that soccer heading during early adolescence is not associated with balance deficits in college-aged soccer players, notwithstanding potential deficits in other markers of neurological function.
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Affiliation(s)
- Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, Ohio State University College of Medicine, Columbus, United States
| | | | - Felipe Yamaguchi
- College of Health Sciences, Kinesiology and Applied Physiology, University of Delaware, Newark, United States
| | - John J Jeka
- College of Health Sciences, Kinesiology and Applied Physiology, University of Delaware, Newark, United States
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