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Gurau TV, Gurau G, Musat CL, Voinescu DC, Anghel L, Onose G, Munteanu C, Onu I, Iordan DA. Epidemiology of Injuries in Professional and Amateur Football Men (Part II). J Clin Med 2023; 12:6293. [PMID: 37834937 PMCID: PMC10573283 DOI: 10.3390/jcm12196293] [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: 08/02/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Background (1): Men's football is a physically demanding contact sport that involves intermittent bouts of sprinting, jogging, walking, jumping and changes of direction. The physical demands of the game vary by level of play (amateur club, sub-elite and open club or international), but injury rates at all levels of the men's football game remain the highest of all sports. Objective: The aim of this study is to conduct a systematic review of data from the epidemiological literature regarding the profile, severity and mechanisms of injuries and the frequency of recurrent injuries in professional and amateur football players. Methods (2): A systematic review, according to PRISMA guidelines, was performed up to June 2023 in the databases of PubMed, Web of Science, Google academic, Google scholar and the Diva portal. Twenty-seven studies that reported data on the type, severity, recurrence and mechanisms of injury in professional and amateur men's football were selected and analyzed. Two reviewers independently audited data and assessed the study quality using the additional and adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and the Newcastle Ottawa Scale (NOS) to assess risk of bias for the quality of external validity. Results (3): In professional male football players, the mean prevalence of muscle/tendon injuries was 39.78%, followed by joint and ligament injuries-21.13%, contusions-17.86%, and fractures-3.27%, and for amateur football players, the prevalence's were 44.56% (muscle/tendon injuries), 27.62% (joint and ligament injuries), 15.0% (contusions) and 3.05% (fracture), respectively. The frequency of traumatic injuries was higher in amateur football players (76.88%) compared to professional football players (64.16%), the situation being reversed in the case of overuse injuries: 27.62% in professional football players and 21.13% in amateur football players. Most contact injuries were found in professional footballers (50.70%), with non-contact injuries predominating in amateur footballers (54.04%). The analysis of the severity of injuries showed that moderate injuries dominated in the two categories of footballers; the severe injuries in amateur footballers exceeded the severe injuries recorded in professional footballers by 9.60%. Recurrence proportions showed an inverse relationship with the level of play, being higher in amateur footballers (16.66%) compared to professional footballers (15.25%). Conclusions (4): Football-related injuries have a significant impact on professional and amateur football players and their short- and long-term health status. Knowing the frequency of severe diagnoses, such as strains, tears and cramps of the thigh muscles, ankle ligament sprains and hip/groin muscle strain requires the establishment of adequate programs to prevent them, especially in amateur football players, who are more prone to serious injuries.
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Affiliation(s)
- Tudor Vladimir Gurau
- Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800008 Galati, Romania;
| | - Gabriela Gurau
- Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University, 800008 Galati, Romania;
| | - Carmina Liana Musat
- Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University, 800008 Galati, Romania;
- ‘Sf. Apostol Andrei’ Clinical Emergency County Hospital, 800578 Galati, Romania; (D.C.V.); (L.A.)
| | - Doina Carina Voinescu
- ‘Sf. Apostol Andrei’ Clinical Emergency County Hospital, 800578 Galati, Romania; (D.C.V.); (L.A.)
- Clinical Medical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800008 Galati, Romania
| | - Lucretia Anghel
- ‘Sf. Apostol Andrei’ Clinical Emergency County Hospital, 800578 Galati, Romania; (D.C.V.); (L.A.)
- Clinical Medical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University of Galati, 800008 Galati, Romania
| | - Gelu Onose
- Neuromuscular Rehabilitation Clinic Division, Teaching Emergency Hospital “Bagdasar-Ar-seni”, 041915 Bucharest, Romania;
- Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020022 Bucharest, Romania
| | - Constantin Munteanu
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa” Iasi, 700454 Iasi, Romania;
| | - Ilie Onu
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa” Iasi, 700454 Iasi, Romania;
| | - Daniel Andrei Iordan
- Department of Individual Sports and Kinetotherapy, Faculty of Physical Education and Sport, ‘Dunarea de Jos’ University of Galati, 800008 Galati, Romania;
- Center of Physical Therapy and Rehabilitation, ‘Dunărea de Jos’ University of Galati, 800008 Galati, Romania
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Walker J, Marigi EM, Dancy M, Okoroha KR, Kharrazi FD, Mehran N. Concussions in the Women's National Basketball Association: Analysis of Incidence, Return-to-Play Timing, and Player Performance From 1997 to 2020. Orthop J Sports Med 2022; 10:23259671221105257. [PMID: 35898206 PMCID: PMC9310240 DOI: 10.1177/23259671221105257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The extent to which concussions affect Women’s National Basketball Association (WNBA) athletes has not been thoroughly examined. Purpose: To evaluate the incidence and impact of concussion injuries occurring in the WNBA. Study Design: Descriptive epidemiology study. Methods: Publicly available records were searched to identify all documented basketball-related concussions from WNBA seasons 1997 to 2020. Player demographics, injury details, and basketball career information were collected. Concussion incidence and return-to-play (RTP) timing were evaluated before and after the institution of the WNBA concussion protocol in 2012. Minutes per game and game score per minute were compared 5 games before and 5 games after the concussion was sustained. Player game availability and RTP performance were also compared with an age-, body mass index–, position-, and experience-matched control group of players who did not sustain any injuries during the index season. Results: A total of 70 concussions among 55 players were reported in the WNBA from 1997 to 2020, with a mean incidence of 2.9 ± 2.3 concussions per season. After the implementation of the WNBA concussion protocol, the incidence significantly increased from 1.7 to 5.0 concussions per season (P < .001). All players returned after a first-time concussion, missing a mean of 3.8 ± 4.7 games and 17.9 ± 20.7 days. After the adoption of the concussion protocol, the time to RTP significantly increased with games missed (P = .006) and days missed (P = .006). Minutes per game and game score per minute were not significantly affected by sustaining a concussion (P = .451 and P = .826, respectively). Conclusion: Since the adoption of the WNBA concussion protocol in the 2012 season, the incidence of concussions increased significantly. Athletes retained a high rate of RTP after missing a median of 4 games, and the time to RTP increased after the institution of the concussion protocol. Player game availability and performance within the same season were not significantly affected by concussion injuries after a successful RTP.
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Affiliation(s)
- Jasmine Walker
- Howard University College of Medicine, Washington, District of Columbia, USA
| | - Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Malik Dancy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nima Mehran
- Department of Orthopedic Surgery, Kaiser Permanente, Los Angeles, California, USA
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Lian J, Sewani F, Dayan I, Voleti PB, Gonzalez D, Levy IM, Musahl V, Allen A. Systematic Review of Injuries in the Men's and Women's National Basketball Association. Am J Sports Med 2022; 50:1416-1429. [PMID: 34213367 DOI: 10.1177/03635465211014506] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Numerous studies have reported the incidence and outcomes of injuries in the men's and women's National Basketball Association (NBA and WNBA, respectively). PURPOSE To synthesize published data regarding the incidence and outcomes of all injuries in the NBA and WNBA in a comprehensive review. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched 3 electronic databases (PubMed, MEDLINE, Embase) for studies of all levels of evidence since 1990 pertaining to injuries sustained by active players in the NBA and WNBA. Studies were excluded if the cohort of interest included ≤3 active players. RESULTS The initial search of the 3 databases yielded 1253 unique studies, of which 49 met final inclusion criteria for this review. Only 4 studies included athletes in the WNBA. Based on the mean annual incidence, the 5 most common orthopaedic sports injuries sustained in the NBA were concussions (9.5-14.9 per year), fractures of the hand (3.5-5.5 per year), lower extremity stress fractures (4.8 per year), meniscal tears (2.3-3.3 per year), and anterior cruciate ligament tears (1.5-2.6 per year). Cartilage defects treated using microfracture, Achilles tendon ruptures, and anterior cruciate ligament injuries were 3 injuries that led to significant reductions in performance measurements after injury. CONCLUSION With advances in sports technology and statistical analysis, there is rapidly growing interest in injuries among professional basketball athletes. High-quality prospective studies are needed to understand the prevalence and effect of injuries on player performance and career length. This information can inform preventative and treatment measures taken by health care providers to protect players and guide safe return to play at a high level.
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Affiliation(s)
- Jayson Lian
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Faraz Sewani
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Isaac Dayan
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Pramod B Voleti
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - David Gonzalez
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - I Martin Levy
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Answorth Allen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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DeFroda SF, Patel DD, Milner JD, Yang DS, Owens BD. Performance After Concussion in National Basketball Association Players. Orthop J Sports Med 2022; 10:23259671221083661. [PMID: 35309236 PMCID: PMC8928399 DOI: 10.1177/23259671221083661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Concussions have received national attention in collision sports such as football, soccer, and hockey, but less focus has been placed on basketball. Purpose: To determine return-to-play (RTP) and player performance in the first and second season after concussion in National Basketball Association (NBA) players. Study Design: Descriptive epidemiology study. Methods: An online database of publicly available NBA athlete injuries was queried for instances of “concussion” between 2010 and 2018. The age at injury, team, position, height, weight, body mass index, NBA experience, date of concussion, date of return, and seasons played postconcussion was recorded for each player. Regular-season statistics (games started, games played, minutes played, and player efficiency rating [PER]) were compiled for the season before, and 2 seasons immediately after, injury. Kaplan-Meier survivorship plots were computed for athlete RTP and retirement endpoints. Results: A total of 81 injuries were identified from 2010 to 2018, with a rate of 2.0 concussions per 100 player-years. Overall RTP was 100% after concussion, with nearly all (88%) returning in the season of injury; 12% of players experienced a season-ending concussion. RTP averaged 37.3 days after injury, varying widely (range, 2-291 days). Compared with preinjury season (78.0%), athletes played in significantly fewer overall games in the season of injury (36.6%; P < .0001), as well as 1 (69.5%; P = .0229) and 2 seasons postinjury (73.2%; P = .3192). PER scores were not significantly different across the study period. Each point increase in a player’s preinjury PER score was associated with a 2.4% decrease in PER from the preinjury season to season of injury (P = .0016) and a 3.1% decrease from preinjury to season after injury (P = .0053). Each increasing year of age or year of experience was associated with 5% decline in PER score at 1 season after injury. Conclusion: NBA players had a high RTP after concussion, with most returning in the same season as the injury. Players sustaining concussions played significantly fewer games for at least 2 seasons after injury. Performance via PER did not change across the entire cohort; however, players with higher preinjury PER, and older players were more likely to sustain a greater decline in performance after injury.
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Affiliation(s)
- Steven F. DeFroda
- Department of Orthopaedics, Missouri Orthopaedic Institute, Columbia, Missouri, USA
| | - Devan D. Patel
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - John D. Milner
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Daniel S. Yang
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Brett D. Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
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Heads Up Play: Acute Assessment and Management of Basketball-Related Craniofacial Injuries by On-Court Personnel. J Craniofac Surg 2021; 32:1580-1584. [PMID: 33654038 DOI: 10.1097/scs.0000000000007588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION With a following of over 825 million people, basketball currently ranks amongst the world's most popular sports. Despite a number of concussion awareness and player safety protocols that have been implemented at the professional level of organized play, a standardized, layperson-friendly algorithm for the acute management of basketball-related craniofacial injuries does not appear to presently exist. METHODS This 10-year retrospective cohort study was conducted using the National Electronic Injury Surveillance System database to examine basketball-related craniofacial injuries from 2010 to 2019. Within the National Electronic Injury Surveillance System dataset, factors including patient age, gender, diagnosis, injury type, and injury location were included in our analysis. RESULTS Overall, 22,529 basketball-related craniofacial injuries occurred between 2010 and 2019 in players ages 5 to 49 years old. Adolescent (12-18-year-old) and young adult (19-34-year-old) age groups had the highest incidence of craniofacial injuries. The adolescent cohort experienced a significantly greater proportion of concussions and lower proportion of both facial lacerations and fractures compared with the within group null hypothesis of equal proportions (P < 0.05). The young adult cohort experienced a significantly greater proportion of facial lacerations and fractures and lower proportion of concussions, contusions/abrasions, hematomas, and internal injuries compared to this cohort's null hypothesis (P < 0.05). Males experienced a significantly greater proportion of fractures, lacerations, and dental injuries and lower proportion of concussions, contusions/abrasions, and internal injuries compared to the hypothesized equality of proportions (P < 0.05). Females experienced a significantly greater proportion of concussions, contusions/abrasions, and internal injuries and lower proportion of fractures, lacerations, and dental injuries compared to the hypothesized equality of proportions (P < 0.05). CONCLUSIONS Although several steps have already been taken at the professional level to try to promote player safety, particularly with concussion protocols and prevention of lower extremity injuries, there remains a paucity of resources to guide management of other types of acute craniofacial injury. The role of layperson-friendly educational interventions remains intriguing as a potential means of improving outcomes regardless of socioeconomic status or health literacy. Additional studies still need to be completed to determine efficacy and best future direction.
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Mack CD, Solomon G, Covassin T, Theodore N, Cárdenas J, Sills A. Epidemiology of Concussion in the National Football League, 2015-2019. Sports Health 2021; 13:423-430. [PMID: 33872087 DOI: 10.1177/19417381211011446] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Concussion in American football, and specifically the National Football League (NFL) is a major area of interest and key focus for injury prevention. Complete and accurate characterization of when, how, and to whom these injuries occur can facilitate injury reduction efforts. Existing studies of concussion in the NFL use publicly available data, potentially limiting data quality and the inferences that can be made. HYPOTHESIS Concussion incidence in the NFL decreased across the 2015-2019 seasons. STUDY DESIGN Descriptive epidemiology study. LEVEL OF EVIDENCE Level 4. METHODS Concussion incidence, including counts, one-season risk, and rates per game and player-plays, among active NFL players from 2015 to 2019 is described by year, season, play type, and roster position. RESULTS A total 1302 concussions were identified from 2015 to 2019 among 1004 players. Of these, 80% occurred in NFL games. The average annual incidence of in-season game concussions changed over the study period, from 230.7 per season (2015-2017) to 177.0 per season (2018-2019); this represented a 23% decrease in game settings (P < 0.01). Practice concussions fluctuated across the years of the study from 38 to 67 per season (average = 50.8/season). There were 70.6 concussions per 100 preseason games, which was slightly higher than the regular season rate per game of 61.7. Overall, there were 790 regular season game concussions across 4,657,243 player-plays and 114,428 player-games during the 5-year study. In regular season games, the majority of concussions were sustained on running and passing plays (n = 119/season), and the highest average rate per play occurred on kickoffs (0.69/100 plays). Defensive secondary (cornerbacks, safeties, and generic defensive backs) and offensive line incurred the most concussions, and the highest rates of concussion were among tight ends and wide receivers. CONCLUSION AND RELEVANCE Concussions in the NFL are a key focus for player safety. Concussion reduction strategies were implemented before 2018, after which there was a sustained 2-year decrease in concussion incidence, providing a new benchmark from which to work toward further injury reduction.
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Affiliation(s)
| | - Gary Solomon
- Department of Neurological Surgery and Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee.,National Football League Player Health and Safety Department, New York, New York
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, Michigan
| | - Nicholas Theodore
- Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Javier Cárdenas
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
| | - Allen Sills
- Department of Neurological Surgery and Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee.,National Football League Player Health and Safety Department, New York, New York
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Allahabadi S, Su F, Lansdown DA. Systematic Review of Orthopaedic and Sports Medicine Injuries and Treatment Outcomes in Women's National Basketball Association and National Basketball Association Players. Orthop J Sports Med 2021; 9:2325967120982076. [PMID: 33623799 PMCID: PMC7878958 DOI: 10.1177/2325967120982076] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/31/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Athletes in the Women’s National Basketball Association (WNBA) and National Basketball Association (NBA) are subject to high injury rates given the physical demands of the sport. Comprehensive data regarding injury patterns and rates in these athletes are limited. Purpose: To summarize available data on orthopaedic and sports medicine–related injuries through 2020 in professional female and male basketball players. Study Design: Systematic review; Level of evidence, 4. Methods: A search was conducted using PubMed and Embase through April 5, 2020, to identify injury studies regarding WNBA and NBA players. Studies were included if the injury or surgery was considered a direct consequence of game play including musculoskeletal/orthopaedic, concussion, ophthalmologic, and craniomaxillofacial injuries. Systematic reviews, screening studies, or studies without sufficient WNBA or NBA player subgroup analysis were excluded. Results: A total of 49 studies met inclusion criteria, 43 (87.8%) of which detailed musculoskeletal injuries. The lower extremity represented 63.3% of studies. A majority (59.2%) of studies were level 4 evidence. The source of data was primarily comprehensive online search (n = 33; 67.3%), followed by official databases (n = 11; 22.4%). Only 3 studies concerned WNBA athletes compared with 47 that concerned NBA athletes. The lowest return-to-play rates were cited for Achilles tendon repairs (61.0%-79.5%). Variability in return-to-play rates existed among studies even with similar seasons studied. Conclusion: The majority of literature available on orthopaedic and sports medicine–related injuries of NBA and WNBA athletes is on the lower extremity. The injuries that had the greatest effect on return to play and performance were Achilles tendon ruptures and knee cartilage injuries treated using microfracture. The reported outcomes are limited by heterogeneity and overlapping injury studies. There are limited available data on WNBA injuries specifically.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Favian Su
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Drew A Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
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8
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Concussion Is Associated With Increased Odds of Acute Lower-Extremity Musculoskeletal Injury Among National Basketball Association Players. Arthrosc Sports Med Rehabil 2020; 3:e219-e225. [PMID: 33615268 PMCID: PMC7879202 DOI: 10.1016/j.asmr.2020.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 09/13/2020] [Indexed: 01/20/2023] Open
Abstract
Purpose To determine the odds of sustaining an acute lower-extremity (LE) musculoskeletal injury during the 90-day period after return-to-play (RTP) from concussion in National Basketball Association (NBA) athletes. Methods Concussion data for NBA players were collected from the 1999-2000 to 2017-2018 seasons, from publicly available sources. Age, position, injury, time to RTP, and demographic factors were collected. The 90-day period after each case of concussion was reviewed for acute noncontact LE musculoskeletal injury. Control athletes without a documented history of concussion were matched to concussed athletes by age, body mass index, position, and experience. Conditional logistic regression with a calculated odds ratio and a 95% confidence interval were used to assess the association between concussion and subsequent risk of LE injury. Results In total, 189 concussions were documented in 153 athletes. Of these, 140 cases were the first recorded instance of concussion in players with publicly available data. Thirty-six (25.7%) athletes sustained a LE injury within 90 days of concussion; 26 (20.2%) were non–season-ending and included in RTP analysis. The odds of sustaining an acute LE musculoskeletal injury within the 90-day period after concussion was 4.69 times greater in concussed players compared with controls (95% confidence interval 1.96-11.23, P < .001). There was no significant difference in games (4.2 ± 5.0 vs 4.7 ± 4.7 games, P = .566) or days (18.5 ± 39.1 days vs 10.9 ± 10.6 days, P = .912) missed between concussed players with LE injury and nonconcussed controls. The most common LE injuries in concussed athletes were ligament sprains/tears (65%). Conclusions Concussed NBA athletes have increased odds for sustaining an acute LE musculoskeletal injury within 90 days of RTP compared with nonconcussed controls. The most common injuries were ligament strains or tears. Changes in neuromotor control and proprioception following a concussion should be evaluated in high-level basketball players returning to sport. Level of Evidence Level III, Case-Control Study.
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Heintz EC, Breaux L, Lewis A, Foreman JJ. Determinants of Missed Games Following Concussions in the National Football League. Front Sports Act Living 2020; 2:595445. [PMID: 33345173 PMCID: PMC7739784 DOI: 10.3389/fspor.2020.595445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/12/2020] [Indexed: 11/13/2022] Open
Abstract
Concussions in the National Football League (NFL) are a rising topic of concern and debate. With the implementation of new protocols, NFL players are required to be removed from play and must follow specific processes before full return to play after sustaining a concussion. While concussion severity is the primary determinant of time-off, it is possible that other factors associated with player value influence time-off as well. The purpose of this study is to examine determinants of NFL games missed after a concussion. NFL concussion data from 2012 to 2015 were used in conjunction with player salary, position, previous concussions, average plays per game, and season during which the concussion occurred. Results indicate that quarterbacks and players who sustained multiple concussions missed more games, while players involved in more plays per game miss less games, providing evidence that player health and value are determinants of time-off after a concussion. Additionally, the number of games missed has increased each year, which could be the result of NFL efforts to increase safety and increased media attention.
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Affiliation(s)
- Elizabeth C Heintz
- School of Kinesiology, University of Louisiana at Lafayette, Lafayette, LA, United States
| | - Lindsey Breaux
- School of Kinesiology, University of Louisiana at Lafayette, Lafayette, LA, United States
| | - Abilgail Lewis
- School of Kinesiology, University of Louisiana at Lafayette, Lafayette, LA, United States
| | - Jeremy J Foreman
- School of Kinesiology, University of Louisiana at Lafayette, Lafayette, LA, United States
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Patel BH, Okoroha KR, Jildeh TR, Lu Y, Baker JD, Nwachukwu BU, Foster MG, Allen AA, Forsythe B. Adductor injuries in the National Basketball Association: an analysis of return to play and player performance from 2010 to 2019. PHYSICIAN SPORTSMED 2020; 48:450-457. [PMID: 32202444 DOI: 10.1080/00913847.2020.1746978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives: 1) To evaluate return to play (RTP) timing in National Basketball Association (NBA) athletes following adductor injuries, and 2) to evaluate the effect of adductor injuries on player performance, game availability, and career longevity following RTP. Methods: Adductor injuries in NBA athletes from the 2009-2010 to 2018-2019 seasons were identified utilizing publicly available records via previously validated methodology. RTP time was calculated, and player performance and game availability were compared pre- vs. post-injury. Additionally, an injury-free control group matched for age, BMI, position, and experience was assembled to allow for comparisons in performance, availability, and career length. Results: In total, 79 adductor injuries across 65 NBA athletes were identified. The average injured player was 28.3 ± 4.0 years of age, and had 6.5 ± 4.2 seasons of NBA experience. Guards were injured more frequently than forwards or centers (49% vs 25% vs 25%, respectively). All players were able to RTP following first-time adductor injury after missing an average of 7.7 ± 9.8 games (median [IQR]: 4 [1-9]) and 16.9 ± 20.4 days (median [IQR]: 9 [3.5-20]). Twelve players (18.5%) suffered an adductor re-injury at a mean latency of 509.5 ± 503.9 days. Adductor injuries did not result in significant changes in any major statistical category (points, assists, rebounds, steals, blocks, turnovers, field goal percentage), player efficiency rating (PER), minutes/game, games/season, or a number of all-star selections (all P > 0.05) following RTP. Additionally, when compared to matched controls, no difference was found in pre- to post-injury change of PER, games/season, or minutes/game (all P > 0.05). Career longevity was not significantly different between groups (P = 0.44). Conclusion: Following adductor injury, NBA players returned to gameplay after missing an average of 16 to 17 days, or 7 to 8 games. Adductor injury did not affect player performance, nor game availability or career longevity.
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Affiliation(s)
- Bhavik H Patel
- Midwest Orthopaedics at RUSH, Rush University Medical Center , Chicago, IL, USA
| | - Kelechi R Okoroha
- Department of Orthopaedic Surgery, Henry Ford Health System , Detroit, MI, USA
| | - Toufic R Jildeh
- Department of Orthopaedic Surgery, Henry Ford Health System , Detroit, MI, USA
| | - Yining Lu
- Midwest Orthopaedics at RUSH, Rush University Medical Center , Chicago, IL, USA
| | - James D Baker
- Midwest Orthopaedics at RUSH, Rush University Medical Center , Chicago, IL, USA
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery , New York, NY, USA
| | - Mitchell G Foster
- School of Medicine, University of California, San Diego , La Jolla, CA, USA
| | - Answorth A Allen
- Department of Orthopaedic Surgery, Hospital for Special Surgery , New York, NY, USA
| | - Brian Forsythe
- Midwest Orthopaedics at RUSH, Rush University Medical Center , Chicago, IL, USA
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Salehi PP, Heiser A, Torabi SJ, Azizzadeh B, Lee J, Lee YH. Facial Fractures and the National Basketball Association: Epidemiology and Outcomes. Laryngoscope 2020; 130:E824-E832. [DOI: 10.1002/lary.28690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/09/2020] [Accepted: 03/25/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Parsa P. Salehi
- Department of Surgery, Otolaryngology–Head and Neck Surgery Yale University School of Medicine New Haven Connecticut U.S.A
| | - Alyssa Heiser
- Department of Otolaryngology–Head and Neck Surgery The University of Vermont Medical Center Burlington Vermont U.S.A
| | - Sina J. Torabi
- Department of Surgery, Otolaryngology–Head and Neck Surgery Yale University School of Medicine New Haven Connecticut U.S.A
| | - Babak Azizzadeh
- Center for Advanced Facial Plastic Surgery Beverly Hills California U.S.A
- Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery David Geffen School of Medicine at the University of California Los Angeles California Los Angeles U.S.A
| | - Jonathan Lee
- Department of Surgery, Division of Plastic Surgery Baystate Medical Center Springfield Massachusetts U.S.A
| | - Yan H. Lee
- Department of Surgery, Otolaryngology–Head and Neck Surgery Yale University School of Medicine New Haven Connecticut U.S.A
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Ramkumar PN, Navarro SM, Haeberle HS, Luu BC, Jang A, Frangiamore SJ, Farrow LD, Schickendantz MS, Williams RJ. Concussion in American Versus European Professional Soccer: A Decade-Long Comparative Analysis of Incidence, Return to Play, Performance, and Longevity. Am J Sports Med 2019; 47:2287-2293. [PMID: 31303010 DOI: 10.1177/0363546519859542] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence and effect of sports-related concussions (SRCs) within the global sport of professional soccer is poorly described. PURPOSE To comparatively examine the effects of SRC on athletes in Major League Soccer (MLS) and the English Premier League (EPL) in terms of incidence, return to play (RTP), performance, and career longevity. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Contracts, transactions, injury reports, and performance statistics from 2008 to 2017 were obtained and cross-referenced across 6 publicly available websites detailing MLS and EPL data, including official league publications. For each league, players who sustained a concussion were compared with the 2008-2017 uninjured player pool. RTP and games missed were analyzed and compared. Career length was analyzed with Kaplan-Meier survival curves. Player performance changes were evaluated before and after concussion. RESULTS Of the 1784 eligible MLS and 2001 eligible EPL players evaluated over the 10-year period, the incidence of publicly reported concussions per 1000 athlete-exposures was 20.22 and 18.68, respectively (P = .53). The incidence of reported concussions steadily increased in both leagues. MLS players missed a mean 7.3 games after concussion (37.0 days missed); EPL players missed a mean 0.6 games after concussion (10.9 days missed) (P < .0001, P < .0001). Statistical performance in terms of games started, assists, shots on goal, and total shots after concussion was significantly reduced at all nongoalie positions for players in the EPL; however, MLS nongoalie positions with concussion had no significant decreases in these categories. Goalies in both leagues had no significant change in performance or games started. The probability of playing a full season after concussion was not significantly decreased when compared with the uninjured pool in both leagues. CONCLUSION This study established the SRC incidence among elite soccer players in 2 international professional leagues and identified major RTP and performance differences between EPL and MLS players. While career longevity was unaffected, the approach to managing concussion as in MLS may better promote player safety and preserve on-field performance.
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Affiliation(s)
- Prem N Ramkumar
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Heather S Haeberle
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Bryan C Luu
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Albert Jang
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Lutul D Farrow
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Riley J Williams
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Patel BH, Okoroha KR, Jildeh TR, Lu Y, Idarraga AJ, Nwachukwu BU, Shen SA, Forsythe B. Concussions in the National Basketball Association: Analysis of Incidence, Return to Play, and Performance From 1999 to 2018. Orthop J Sports Med 2019; 7:2325967119854199. [PMID: 31276004 PMCID: PMC6598335 DOI: 10.1177/2325967119854199] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The effect of concussions on professional athletes has been investigated in many sports. However, few studies have evaluated concussions in National Basketball Association (NBA) players. HYPOTHESIS We hypothesized that concussion incidence has increased, yet the return-to-play (RTP) rate will remain high following the institution of the NBA concussion policy (NBACP). We also hypothesized that the incidence of repeat concussions will be similar to first occurrences and that player performance and game availability will not be significantly affected by sustaining a concussion. STUDY DESIGN Descriptive epidemiology study. METHODS Publicly available records were searched to identify all concussions from NBA seasons 1999-2000 to 2017-2018. Player demographics and information regarding career history were tabulated. Incidence of concussion and RTP timing were evaluated before and after institution of the NBACP (2011). Minutes per game and game score per minute were evaluated pre- versus postconcussion. Player availability and performance were also compared with an age-, body mass index-, position-, and experience-matched control group of players who did not sustain a concussion. RESULTS A total of 189 concussions were reported in the NBA from 1999 to 2018, with a mean ± SD incidence of 9.7 ± 7.3 concussions per season. Following implementation of the NBACP, incidence significantly increased from 5.7 ± 2.8 to 16.7 ± 7.5 concussions per season (P = .007). All players returned to play following first-time concussion after missing 7.7 ± 8.6 days and 3.5 ± 4.1 games. RTP time was not significantly different after implementation of the NBACP (games missed, P = .24; days missed, P = .27), and there was no difference in concussion-free time interval (P = .29). Game score per minute and minutes per game were not significantly affected by sustaining a concussion (both P > .05). CONCLUSION Concussion incidence in NBA players is approximately 17 instances per season since the 2011 institution of a league-wide concussion policy. The number of reported concussions significantly increased following the policy, in line with trends seen in other professional sports leagues. Players have retained a high rate of RTP after 3 to 4 missed games. Player performance and availability are not affected by sustaining a concussion following successful RTP.
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Affiliation(s)
- Bhavik H. Patel
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Kelechi R. Okoroha
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Toufic R. Jildeh
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Yining Lu
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander J. Idarraga
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Benedict U. Nwachukwu
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Sarek A. Shen
- School of Medicine, University of California, San Diego, San Diego, California USA
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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14
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Dai JB, Li AY, Haider SF, Tomaselli R, Gometz A, Sobotka S, Post AF, Adams R, Maniya AY, Lau GK, Kaye-Kauderer HP, Lovell MR, Choudhri TF. Effects of Game Characteristics and Player Positions on Concussion Incidence and Severity in Professional Football. Orthop J Sports Med 2018; 6:2325967118815448. [PMID: 30627588 PMCID: PMC6311573 DOI: 10.1177/2325967118815448] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Increasing efforts have been made to reduce the incidence and severity of concussion in high-contact sports. Despite these efforts, a relative lack of knowledge is available regarding modulating factors affecting concussion injury. Purpose: To analyze the potential influence of game characteristics and outcomes on concussion incidence and severity in professional football. Study Design: Descriptive epidemiology study. Methods: PBS Frontline Concussion Watch was used to collect concussion injury data from regular-season games of 32 National Football League (NFL) teams from 2012 to 2015. Game characteristic variables such as rushing and passing attempts, turnovers, and margin of victory were collected from ESPN. Analysis included descriptive statistics, analysis of variance, t tests, and correlation tests. Results: Away teams demonstrated a significantly greater concussion incidence per game than home teams. Losing teams had a significantly greater concussion incidence per game than winning teams. Being both the away team and the losing team appeared to have an additive effect. The home-versus-away and win-versus-loss effects were significant for offensive but not defensive positions. Within individual positions, significantly greater concussion incidence was associated with tight ends, running backs, wide receivers, and cornerbacks. When running versus passing positions were compared, passing positions (wide receiver, tight end, cornerback, safety) had significantly greater concussion incidence. A total of 626 games were missed as a result of reported concussions. Away teams had significantly more games missed due to concussion when they lost. Play time did not significantly differ before or after concussion injury. Other game characteristic variables did not significantly affect concussion frequency or intensity. Conclusion: Position, game location, and game outcome affect concussion incidence for professional football players. In a subset of analyses, the number of games missed aligned with concussion incidence, but this appeared to be an imperfect measure. These findings highlight new factors that may modulate concussion incidence and merit further study on how they may influence concussion evaluation.
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Affiliation(s)
- Jennifer B Dai
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam Y Li
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Syed F Haider
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Alex Gometz
- Concussion Management of New York, New York, New York, USA
| | - Stanislaw Sobotka
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander F Post
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ryan Adams
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Akbar Y Maniya
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - George K Lau
- Touro College of Osteopathic Medicine, New York, New York, USA
| | | | - Mark R Lovell
- ImPACT Applications Inc, Pittsburgh, Pennsylvania, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Navarro SM, Pettit RW, Haeberle HS, Frangiamore SJ, Rahman NM, Farrow LD, Schickendantz MS, Ramkumar PN. Short-Term Impact of Concussion in the NHL: An Analysis of Player Longevity, Performance, and Financial Loss. J Neurotrauma 2018; 35:2391-2399. [DOI: 10.1089/neu.2017.5611] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Sergio M. Navarro
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Rowland W. Pettit
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Heather S. Haeberle
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
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16
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Navarro SM, Sokunbi OF, Haeberle HS, Schickendantz MS, Mont MA, Figler RA, Ramkumar PN. Short-term Outcomes Following Concussion in the NFL: A Study of Player Longevity, Performance, and Financial Loss. Orthop J Sports Med 2017; 5:2325967117740847. [PMID: 29226164 PMCID: PMC5714087 DOI: 10.1177/2325967117740847] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A short-term protocol for evaluation of National Football League (NFL) athletes incurring concussion has yet to be fully defined and framed in the context of the short-term potential team and career longevity, financial risk, and performance. PURPOSE To compare the short-term career outcomes for NFL players with concussions by analyzing the effect of concussions on (1) franchise release rate, (2) career length, (3) salary, and (4) performance. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS NFL player transaction records and publicly available injury reports from August 2005 to January 2016 were analyzed. All players sustaining documented concussions were evaluated for a change to inactive or DNP ("did not participate") status. A case-control design compared franchise release rates and remaining NFL career span. Career length was analyzed via survival analysis. Salary and performance differences were analyzed with publicly available contract data and a performance-scoring algorithm based on position/player level. RESULTS Of the 5894 eligible NFL players over the 11-year period, 307 sustained publicly reported concussions resulting in the DNP injury protocol. Analysis of the probability of remaining in the league demonstrated a statistically significantly shorter career length for the concussion group at 3 and 5 years after concussion. The year-over-year change in contract value for the concussion group resulted in a mean overall salary reduction of $300,000 ± $1,300,000 per year (interquartile range, -$723,000 to $450,000 per year). The performance score reduction for all offensive scoring players sustaining concussions was statistically significant. CONCLUSION This retrospective study demonstrated that NFL players who sustain a concussion face a higher overall franchise release rate and shorter career span. Players who sustained concussions may incur significant salary reductions and perform worse after concussion. Short-term reductions in longevity, performance, and salary after concussion exist and deserve additional consideration.
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Affiliation(s)
- Sergio M. Navarro
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Olumide F. Sokunbi
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Heather S. Haeberle
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Michael A. Mont
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard A. Figler
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Prem N. Ramkumar
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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17
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Yengo-Kahn AM, Zuckerman SL, Stotts J, Zalneraitis BH, Gardner RM, Kerr ZY, Solomon GS. Performance following a first professional concussion among National Basketball Association players. PHYSICIAN SPORTSMED 2016; 44:297-303. [PMID: 27294806 DOI: 10.1080/00913847.2016.1200956] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Basketball is a physical game played on a hardwood floor among high-jumping athletes at risk for injury. It is currently unknown how sport-related concussion (SRC) affects player performance after injury among professional basketball players. The objective of this study was to explore the impact of SRC on basketball performance among National Basketball Association (NBA) players. METHODS A retrospective, archival cohort study was performed that compared NBA player performance following concussion to pre-concussive performance. A comprehensive NBA injury database, compiled from publically available sources, was queried for NBA players who suffered concussion from 2005-06 to 2014-15 (10 seasons). Intra-and inter-player analyses were performed against a matched control group of players who missed playing time for personal reasons. RESULTS Following application of inclusion/exclusion criteria and a matching process, 51 concussed players and 51 control players were included in analysis. There were no statistically significant decrements in baseline to post-concussion performance metrics in intra-player or player vs. controls after 5 return games. CONCLUSIONS Our findings suggest that at the NBA level, an athlete's performance in the initial 5 games following injury does not suffer from the after-effects of concussive injury. These results may be useful in counseling professional athletes following a concussion.
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Affiliation(s)
- Aaron M Yengo-Kahn
- a Vanderbilt Sports Concussion Center , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Scott L Zuckerman
- a Vanderbilt Sports Concussion Center , Vanderbilt University School of Medicine , Nashville , TN , USA.,b Department of Neurological Surgery , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Jeff Stotts
- c Department of Athletic Training , St. Vincent Health System , Little Rock , AR , USA
| | - Brian H Zalneraitis
- a Vanderbilt Sports Concussion Center , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Ryan M Gardner
- a Vanderbilt Sports Concussion Center , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Zachary Y Kerr
- d Datalys Center for Sports Injury Research and Prevention , Indianapolis , IN , USA
| | - Gary S Solomon
- a Vanderbilt Sports Concussion Center , Vanderbilt University School of Medicine , Nashville , TN , USA.,b Department of Neurological Surgery , Vanderbilt University School of Medicine , Nashville , TN , USA
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18
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Reider B. Like a Pro. Am J Sports Med 2016; 44:2199-201. [PMID: 27587843 DOI: 10.1177/0363546516665102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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