Sport-Related Concussion: Evaluation, Treatment, and Future Directions

Influence of social determinants of health and adversity on computerized neurocognitive assessment

Introduction: Social determinants of health and adversity, including poverty, maltreatment, and neighborhood deprivation, are individual-level factors that may significantly affect baseline neurocognitive testing and management that have yet to be thoroughly explored within the computerized neurocognitive assessment.Objectives: Examine individual-level experiences of poverty, abuse, neighborhood deprivation, and social mobility on computerized cognitive testing.Methods: The sample included 3,845 student-athletes who completed a baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and were enrolled in the Child-Household Integrated Longitudinal Data database. Multivariable linear regressions were used to assess independent variables of Supplemental Nutrition Assistance Program enrollment, abuse or neglect cases, Area Deprivation Index scores, and other demographic factors on four baseline ImPACT composite scores: verbal and visual memory, visuomotor, and reaction time.Results: Individual-level factors of persistent poverty and neighborhood deprivation were associated with lower composite scores; however, upward social mobility was not significantly associated with cognitive performance. The effects of mother's race on computerized cognitive testing performance were attenuated when accounting for measures of adversity.Conclusion: Findings highlight the importance of social determinants of health in computerized neurocognitive testing to ensure more culturally sensitive and precise understanding of athletic baselines.

Parental Factors Associated With Recovery After Mild Traumatic Brain Injury: A Systematic Review

While parental factors have been shown to potentially influence recovery after mild traumatic brain injury (mTBI) in children, both the strength and direction of the relationships remain unclear. We performed a systematic review regarding the association between parental factors and recovery after mTBI. PubMed, CINHL, Embase, PsychINFO, Web of Science, ProQuest, Cochrane Central, and Cochrane databases were queried for articles published between September 1, 1970, and September 10, 2022, reporting any parental factor and its association with recovery after mTBI in children younger than 18 years old. The review included both quantitative and qualitative studies published in English. Regarding the directionality of the association, only studies that assessed the effects of parental factors on recovery after mTBI were included. Study quality was assessed using a five-domain scale created by the Cochrane Handbook and the Agency for Healthcare Research and Quality. The study was prospectively registered with PROSPERO (CRD42022361609). Of 2050 studies queried, 40 met inclusion criteria, and 38 of 40 studies used quantitative outcome measures. Across 38 studies, 24 unique parental factors and 20 different measures of recovery were identified. The most common parental factors studied were socioeconomic status/income (SES; n = 16 studies), parental stress/distress (n = 11), parental level of education (n = 9), pre-injury family functioning (n = 8), and parental anxiety (n = 6). Among all associations between parental factors and recovery reported, having a family history of a neurologic disease (i.e., migraine, epilepsy, neurodegenerative disease; 5/6 significant associations reported, 83%), parental stress/distress (9/11, 82%), parental anxiety (4/6, 67%), parental level of education (5/9, 56%), and SES/income (11/19, 57.9%) were shown to have the strongest evidence reporting significant associations with recovery, while a family history of psychiatric disease (3/6, 50%) and pre-injury family functioning (4/9, 44%) showed mixed results. Evidence regarding other parental factors including parental sex, race/ethnicity, insurance status, parental history of concussion, family litigation status, family adjustment levels, and family psychosocial adversity were limited, as studies investigating such factors were few. The current review highlights literature describing several parental factors that significantly influence recovery from mTBI. It will likely be useful for future studies to incorporate parental SES, education, stress/distress, anxiety, quality of parent-child relationships, and parenting style when examining modifying factors in recovery after mTBI. Future studies should also consider how parental factors may serve as potential interventions or policy levers to optimize sport concussion-related policy and return-to-play guidelines.

Multisystem recovery after sport-related concussion in adolescent rugby players: a prospective study protocol

INTRODUCTION

Sport-related concussion is one of the most common injuries in adolescent rugby players with evidence of prolonged recovery in some concussed athletes. Concussion is a complex pathophysiological process that can affect a variety of subsystems with multifactorial presentation. Most research on adolescents recovery after concussion focuses on neurocognitive functioning and symptom outcomes over the short term. There is a need to explore concussion recovery over time across multiple subsystems in adolescent rugby players.

METHODS AND ANALYSIS

This prospective study will use sensorimotor and oculomotor outcomes in adolescent male and female rugby players aged 16-18 years. Players will be recruited from school or club rugby teams across the province of Ulster. Baseline assessment will be undertaken at the start of the playing season and will include questionnaires, Quantified Y Balance Test and Pupillary Light Reflex. Players who sustain a concussive event will be reassessed on all outcomes at 3 days, 7 days, 14 days, 23 days, 90 days, 180 days and 365 days postconcussion. For serial outcome data, we will examine response curves for each participant and make comparisons between known groups. We will use logistic regression to explore any association between demographic variables and recovery. The strength of the predictive model will be determined using R2, p values and ORs, with 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been granted for this study from Ulster University Research Ethics Committee (REC/14/0060). This study will be published in an open-access research journal on completion.

TRIAL REGISTRATION NUMBER

ACTRN12622000931774p.

Neurotrauma Prevention Review: Improving Helmet Design and Implementation

Neurotrauma continues to contribute to significant mortality and disability. The need for better protective equipment is apparent. This review focuses on improved helmet design and the necessity for continued research. We start by highlighting current innovations in helmet design for sport and subsequent utilization in the lay community for construction. The current standards by sport and organization are summarized. We then address current standards within the military environment. The pathophysiology is discussed with emphasis on how helmets provide protection. As innovative designs emerge, protection against secondary injury becomes apparent. Much research is needed, but this focused paper is intended to serve as a catalyst for improvement in helmet design and implementation to provide more efficient and reliable neuroprotection across broad arenas.

Refined Analysis of Chronic White Matter Changes after Traumatic Brain Injury and Repeated Sports-Related Concussions: Of Use in Targeted Rehabilitative Approaches?

Traumatic brain injury (TBI) or repeated sport-related concussions (rSRC) may lead to long-term memory impairment. Diffusion tensor imaging (DTI) is helpful to reveal global white matter damage but may underestimate focal abnormalities. We investigated the distribution of post-injury regional white matter changes after TBI and rSRC. Six patients with moderate/severe TBI, and 12 athletes with rSRC were included ≥6 months post-injury, and 10 (age-matched) healthy controls (HC) were analyzed. The Repeatable Battery for the Assessment of Neuropsychological Status was performed at the time of DTI. Major white matter pathways were tracked using q-space diffeomorphic reconstruction and analyzed for global and regional changes with a controlled false discovery rate. TBI patients displayed multiple classic white matter injuries compared with HC (p < 0.01). At the regional white matter analysis, the left frontal aslant tract, anterior thalamic radiation, and the genu of the corpus callosum displayed focal changes in both groups compared with HC but with different trends. Both TBI and rSRC displayed worse memory performance compared with HC (p < 0.05). While global analysis of DTI-based parameters did not reveal common abnormalities in TBI and rSRC, abnormalities to the fronto-thalamic network were observed in both groups using regional analysis of the white matter pathways. These results may be valuable to tailor individualized rehabilitative approaches for post-injury cognitive impairment in both TBI and rSRC patients.

A Genome-wide Association Study for Concussion Risk

PURPOSE

This study aimed to screen the entire genome for genetic markers associated with risk for concussion.

METHODS

A genome-wide association analyses was performed using data from the Kaiser Permanente Research Bank and the UK Biobank. Concussion cases were identified based on electronic health records from the Kaiser Permanente Research Bank and the UK Biobank from individuals of European ancestry. Genome-wide association analyses from both cohorts were tested for concussion using a logistic regression model adjusting for sex, height, weight, and race/ethnicity using allele counts for single nucleotide polymorphisms. Previously identified genes within the literature were also tested for association with concussion.

RESULTS

There were a total of 4064 cases of concussion and 291,472 controls within the databases, with two single nucleotide polymorphisms demonstrating a genome-wide significant association with concussion. The first polymorphism, rs144663795 (P = 9.7 × 10-11; OR = 2.91 per allele copy), is located within the intron of SPATA5. Strong, deleterious mutations in SPATA5 cause intellectual disability, hearing loss, and vision loss. The second polymorphism, rs117985931 (P = 3.97 × 10-9; OR = 3.59 per allele copy), is located within PLXNA4. PLXNA4 plays a key role is axon outgrowth during neural development, and DNA variants in PLXNA4 are associated with risk for Alzheimer's disease. Previous investigations have identified five candidate genes that may be associated with concussion, but none showed a significant association in the current model (P < 0.05).

CONCLUSION

Two genetic markers were identified as potential risk factors for concussion and deserve further validation and investigation of molecular mechanisms.