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Pinto SM, Wright B, Annaswamy S, Nwana O, Nguyen M, Wilmoth K, Moralez G. Heart rate variability (HRV) after traumatic brain injury (TBI): a scoping review. Brain Inj 2024; 38:585-606. [PMID: 38590161 DOI: 10.1080/02699052.2024.2328310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 03/05/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Heart rate variability (HRV), defined as the variability between successive heart beats, is a noninvasive measure of autonomic nervous system (ANS) function, which may be altered following traumatic brain injury (TBI). This scoping review summarizes the existing literature regarding changes in HRV after TBI as well as the association between measures of HRV and outcomes following TBI. METHODS A literature search for articles assessing 'heart rate variability' and 'brain injury' or 'concussion' was completed. Articles were included if HRV was measured in human subjects with TBI or concussion. Review articles, protocol papers, and studies including non-traumatic injuries were excluded. RESULTS Sixty-three articles were included in this review. Varied methods were used to measure HRV in the different studies. Forty articles included information about differences in HRV measures after TBI and/or longitudinal changes after TBI. Fifteen studies assessed HRV and symptoms following TBI, and 15 studies assessed HRV and either functional or cognitive outcomes after TBI. CONCLUSIONS HRV has been studied in the context of mortality, clinical symptoms, and medical, functional, or cognitive outcomes following TBI. Methods used to measure HRV have varied amongst the different studies, which may impact findings, standardized protocols are needed for future research.
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Affiliation(s)
- Shanti M Pinto
- Department of Physical Medicine and Rehabilitation, O'Donnell Brain Institute Clinical Neuroscience Scholar, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Brittany Wright
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shreyas Annaswamy
- National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Maryland, USA
| | - Ola Nwana
- Department of Neurology, Houston Methodist Neuroscience Center Team at Willowbrook, Houston, Texas, USA
| | - Michael Nguyen
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Brain Injury and Stroke Medicine, TIRR Memorial Hermann, Houston, Texas, USA
| | - Kristin Wilmoth
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gilbert Moralez
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Glendon K, Blenkinsop G, Belli A, Pain MTG. Does early exercise intolerance effect time to return to play, symptom burden, neurocognition, Vestibular-Ocular-Motor (VOM) function and academic ability in acutely concussed student-athletes? Brain Inj 2024:1-11. [PMID: 38910338 DOI: 10.1080/02699052.2024.2367477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 06/08/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Early Exercise Intolerance (EEI) is associated with delayed recovery and longer time to Return To Play (RTP), but this has not been established.Participants; (n = 52, male n = 30) UK university-aged rugby-union student-athletes. METHODS Student-athletes completed baseline screening (July-October 2021 and 2022). The test battery was repeated within 48 h, 4, 8 and 14 days after a Sports-Related Concussion (SRC) with the Buffalo Concussion Bike or Treadmill Test to set sub-symptom heart rate threshold. Student-athletes then completed a controlled early exercise protocol in-between reassessment (days 3, 5-7 and 9-13). Those with EEI were compared to those with early-exercise tolerance. OUTCOME MEASURES Post-Concussion Symptom Scale, Immediate Post-Concussion and Cognitive Test, Vestibular-Ocular Motor Screening Tool and the Revised Perceived Academic Impact Tool. RESULTS EEI was seen throughout the initial 14-days post-SRC (23.8%, 22.4%, 25.5%. 25.0%). EEI was associated with a slower reaction time within 48 h (-0.01 (-0.030-0.043) Vs 0.06 (0.033-0.24), p = 0.004) and greater VOMS scores within 48 h; (0.00 (0.00-4.00) Vs 5.50 (2.75-9.00), p = 0.016) and 4 days (0.00 (0.00-2.00) Vs 5.00 (0.00-6.00), p = 0.044). RTP was 12.5 days longer in those with EEI at 14-days post-SRC. CONCLUSION EEI is prevalent following an SRC in university-aged student-athletes and was associated with delayed recovery and RTP.
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Affiliation(s)
- K Glendon
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - G Blenkinsop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - A Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - M T G Pain
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Tan CO, Grashow R, Thorpe R, Miller KK, Nathan DM, Izzy S, Radmanesh F, Kim JH, Weisskopf MG, Taylor HA, Zafonte RD, Baggish AL. Concussion burden and later-life cardiovascular risk factors in former professional American-style football players. Ann Clin Transl Neurol 2024; 11:1604-1614. [PMID: 38808967 PMCID: PMC11187967 DOI: 10.1002/acn3.52045] [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: 01/16/2024] [Revised: 02/18/2024] [Accepted: 03/04/2024] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVE Mid-life cardiovascular risk factors are associated with later cognitive decline. Whether repetitive head injury among professional athletes impacts cardiovascular risk is unknown. We investigated associations between concussion burden and postcareer hypertension, high cholesterol, and diabetes among former professional American-style football (ASF) players. METHODS In a cross-sectional study of 4080 professional ASF players conducted between January 2015 and March 2022, we used an mulitsymptom concussion symptom score (CSS) and the number of loss-of-consciousness (LOC) episodes as a single severe symptom to quantify football-related concussion exposure. Primary outcomes were hypertension, dyslipidemia, and diabetes, defined by current or recommended prescription medication use. RESULTS The prevalence of hypertension, high cholesterol, and diabetes among former players (52 ± 14 years of age) was 37%, 34%, and 9%. Concussion burden was significantly associated with hypertension (lowest vs. highest CSS quartile, odds ratio (OR) = 1.99; 95%CI: 1.33-2.98; p < 0.01) and high cholesterol (lowest vs. moderate CSS, OR = 1.46, 95%CI, 1.11-1.91; p < 0.01), but not diabetes. In fully adjusted models, the prevalence of multiple CVD was associated with CSS. These results were driven by younger former players (≤ 40 year of age) in which the odds of hypertension were over three times higher in those in the highest CSS quartile (OR = 3.29, 95%CI: 1.39-7.61; p = 0.01). Results were similar for LOC analyses. INTERPRETATION Prior concussion burden is associated with postcareer atherogenic cardiovascular risk profiles among former professional American football players.
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Affiliation(s)
- Can Ozan Tan
- RAM Group, Department of Electrical Engineering, Mathematics, and Computer ScienceUniversity of Twentethe Netherlands
| | - Rachel Grashow
- Football Players Health Study at Harvard UniversityHarvard Medical SchoolBostonMassachusettsUSA
- Department of Environmental HealthHarvard T. H. Chan School of Public HealthBostonMassachusettsUSA
| | - Roland Thorpe
- Program of Research on Men's Health, Hopkins Center for Health Disparities SolutionsJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of Health Behavior and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Johns Hopkins Alzheimer's Disease Resource Center for Minority Aging ResearchBaltimoreMarylandUSA
| | - Karen K. Miller
- Football Players Health Study at Harvard UniversityHarvard Medical SchoolBostonMassachusettsUSA
- Neuroendocrine UnitMassachusetts General Hospital and Harvard Medical SchoolBoston02114MassachusettsUSA
| | - David M. Nathan
- Football Players Health Study at Harvard UniversityHarvard Medical SchoolBostonMassachusettsUSA
- Diabetes Research CenterMassachusetts General Hospital and Harvard Medical SchoolBoston02114MassachusettsUSA
| | - Saef Izzy
- Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care NeurologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Farid Radmanesh
- Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care NeurologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Division of Neurocritical Care, Department of NeurologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Jonathan H. Kim
- Emory Clinical Cardiovascular Research InstituteEmory University School of MedicineAtlantaGeorgiaUSA
| | - Marc G. Weisskopf
- Football Players Health Study at Harvard UniversityHarvard Medical SchoolBostonMassachusettsUSA
- Department of Environmental HealthHarvard T. H. Chan School of Public HealthBostonMassachusettsUSA
| | - Herman A. Taylor
- Football Players Health Study at Harvard UniversityHarvard Medical SchoolBostonMassachusettsUSA
- Cardiovascular Research InstituteMorehouse School of MedicineAtlantaGeorgiaUSA
| | - Ross D. Zafonte
- Football Players Health Study at Harvard UniversityHarvard Medical SchoolBostonMassachusettsUSA
- Department of Physical Medicine and RehabilitationSpaulding Rehabilitation HospitalCharlestownMassachusettsUSA
- Cardiovascular Performance ProgramMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Aaron L. Baggish
- Football Players Health Study at Harvard UniversityHarvard Medical SchoolBostonMassachusettsUSA
- Cardiovascular Performance ProgramMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of CardiologyUniversity of LausanneLausanneSwitzerland
- Department of Sports ScienceUniversity of LausanneLausanneSwitzerland
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Wesolowski E, Ahmed Z, Di Pietro V. History of concussion and lowered heart rate variability at rest beyond symptom recovery: a systematic review and meta-analysis. Front Neurol 2024; 14:1285937. [PMID: 38318235 PMCID: PMC10838961 DOI: 10.3389/fneur.2023.1285937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/26/2023] [Indexed: 02/07/2024] Open
Abstract
Introduction Concussion is a growing concern in worldwide sporting culture. Heart rate variability (HRV) is closely tied with autonomic nervous system (ANS) deficits that arise from a concussion. The objective of this review was to determine if a history of concussion (HOC) can impact HRV values in the time-domain in individuals at rest. This review works to add to the literature surrounding HRV testing and if it can be used to check for brain vulnerabilities beyond the recovery of concussion symptoms. Materials and methods The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) method. A computer based systematic review scanned articles dating from 1996 to June 2023 through PubMed, Cochrane Library, Google Scholar, and EMBASE databases. A risk of bias assessment was conducted using the ROBINS-E tool. The average difference in time between heartbeats (MeanNN), the standard deviation of the differences (SDNN), and the root mean squared of the successive intervals (RMSSD) were measured. Results Six total studies were found that fit the inclusion criteria including a total of 242 participants (133 without HOC, 109 with HOC). The average age of the control group was 23.3 ± 8.2, while the average age of the history of TBI group was 25.4 ± 9.7, with no significant difference between the groups (p = 0.202). Four of the studies reported no significant difference in any of the three measures, while two of the studies reported significant difference for all three measures. The meta-analysis was conducted and found that MeanNN (p = 0.03) and RMSSD (p = 0.04) reached statistical significance, while SDNN did not (p = 0.11). Conclusion The results of this meta-analysis showed significant difference in two of the three HRV time-domain parameters evaluated. It demonstrates that there can be lowered HRV values that expand beyond the recovery of symptoms, reflecting an extensive period of ANS susceptibility after a concussion. This may be an important variable in determining an athlete's return to play (RTP). Lack of homogenous study populations and testing methods introduces potential for bias and confounding factors, such as gender or age. Future studies should focus on baseline tests to compare individuals to themselves rather than matched controls.
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Affiliation(s)
- Eric Wesolowski
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, United Kingdom
| | - Valentina Di Pietro
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, United Kingdom
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Izzy S, Grashow R, Radmanesh F, Chen P, Taylor H, Formisano R, Wilson F, Wasfy M, Baggish A, Zafonte R. Long-term risk of cardiovascular disease after traumatic brain injury: screening and prevention. Lancet Neurol 2023; 22:959-970. [PMID: 37739576 PMCID: PMC10863697 DOI: 10.1016/s1474-4422(23)00241-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 09/24/2023]
Abstract
Traumatic brain injury (TBI) is highly prevalent among individuals participating in contact sports, military personnel, and in the general population. Although it is well known that brain injury can cause neurological and psychiatric complications, evidence from studies on individuals exposed to a single or repetitive brain injuries suggests an understudied association between TBI and the risk of developing chronic cardiovascular diseases and risk factors for cardiovascular disease. Several studies have shown that people without pre-existing comorbidities who sustain a TBI have a significantly higher risk of developing chronic cardiovascular disease, than people without TBI. Similar observations made in military and professional American-style football cohorts suggest causal pathways through which modifiable cardiovascular risk factors might mediate the relationship between brain injury and chronic neurological diseases. A better understanding of cardiovascular disease risk after TBI combined with a proactive, targeted screening programme might mitigate long-term morbidity and mortality in individuals with TBI, and improve their quality of life.
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Affiliation(s)
- Saef Izzy
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Football Players Health Study at Harvard University, Boston, MA, USA
| | - Rachel Grashow
- Department of Environmental Health, T H Chan School of Public Health, Harvard University, Boston, MA, USA; Football Players Health Study at Harvard University, Boston, MA, USA
| | - Farid Radmanesh
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurology, Division of Neurocritical Care, University of New Mexico, Albuquerque, NM, USA
| | - Patrick Chen
- Department of Neurology, University of California Irvine, Orange, CA, USA
| | - Herman Taylor
- Football Players Health Study at Harvard University, Boston, MA, USA; Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Fiona Wilson
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Meagan Wasfy
- Harvard Medical School, Boston, MA, USA; Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Aaron Baggish
- Football Players Health Study at Harvard University, Boston, MA, USA; Institute for Sport Science and Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ross Zafonte
- Harvard Medical School, Boston, MA, USA; Football Players Health Study at Harvard University, Boston, MA, USA; Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, MA, USA.
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Moore RD, Kay JJM, Gunn B, Harrison AT, Torres-McGehee T, Pontifex MB. Increased anxiety and depression among collegiate athletes with comorbid ADHD and history of concussion. PSYCHOLOGY OF SPORT AND EXERCISE 2023; 68:102418. [PMID: 37665895 DOI: 10.1016/j.psychsport.2023.102418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 01/28/2023] [Accepted: 03/07/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Attention Deficit Hyperactivity Disorder (ADHD) is prevalent among student-athletes when compared to the general population. Mental health disruptions (i.e., depression or anxiety) are common among student-athletes, and risk of experiencing depressive and anxious symptoms may be even greater among student-athletes that have incurred concussion. OBJECTIVE To examine the influence of pre-existing ADHD and history of concussion on mental health in collegiate student-athletes. DESIGN Retrospective cross-sectional study. SETTING National Collegiate Athletic Association Division-I (NCAA) athletics. PATIENTS Between 2010 and 2017, student-athletes at a Southeastern NCAA Division-I institution were surveyed as part of a Performance, Health, and Wellness Program. Analyses were conducted using a sample of 324 student athletes (212 female) with either a prior diagnosis of ADHD, a prior history of a sport-related concussion, both prior diagnosis of ADHD and a history of sport-related concussion, or neither (controls). MAIN OUTCOME MEASURE(S) Symptomatology associated with ADHD was characterized using the Behavior Assessment System for Children Self-Report of Personality College Version. The State-Trait Anxiety Inventory and the Center of Epidemiological Studies-Depression Scale examined anxious and depressive symptomatology. RESULTS Student-athletes with ADHD and a history of concussion had 16.4 times greater odds of exhibiting clinically significant symptoms of state anxiety and 7.9 times greater odds of exhibiting clinically significant symptoms of depression, relative to control student-athletes. Every participant with both a diagnosis of ADHD and a history of concussion exhibited clinically significant attentional problems. CONCLUSIONS Having both ADHD and a history of concussion may have a synergistic effect on mental health beyond that of ADHD and/or concussion alone. Additional longitudinal research is necessary to verify current findings. However, athletic trainers and other health care professionals are encouraged to be mindful of student-athletes with ADHD, as they may be more vulnerable to experiencing symptoms of depression and state anxiety with elevated inattentive behaviors following a concussion.
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Affiliation(s)
- Robert Davis Moore
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA; Institute of Mind & Brain, University of South Carolina, Columbia, SC, USA.
| | - Jacob J M Kay
- PRISMA Health Concussion Clinic, PRISMA Health Children's Hospital, Columbia, SC, USA
| | - Brett Gunn
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Adam T Harrison
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Toni Torres-McGehee
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Matthew B Pontifex
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
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Pelo R, Suttman E, Fino PC, McFarland MM, Dibble LE, Cortez MM. Autonomic dysfunction and exercise intolerance in concussion: a scoping review. Clin Auton Res 2023; 33:149-163. [PMID: 37038012 PMCID: PMC10812884 DOI: 10.1007/s10286-023-00937-x] [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: 02/01/2023] [Accepted: 03/23/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE Concussion commonly results in exercise intolerance, often limiting return to activities. Improved understanding of the underlying mechanisms of post-concussive exercise intolerance could help guide mechanism-directed rehabilitation approaches. Signs of altered cardiovascular autonomic regulation-a potential contributor to exercise intolerance-have been reported following concussion, although it is not clear how these findings inform underlying mechanisms of post-concussive symptoms. Systematic summarization and synthesis of prior work is needed to best understand current evidence, allowing identification of common themes and gaps requiring further study. The purpose of this review was to (1) summarize published data linking exercise intolerance to autonomic dysfunction, and (2) summarize key findings, highlighting opportunities for future investigation. METHODS The protocol was developed a priori, and conducted in five stages; results were collated, summarized, and reported according to PRISMA guidelines. Studies including injuries classified as mild traumatic brain injury (mTBI)/concussion, regardless of mechanism of injury, were included. Studies were required to include both autonomic and exercise intolerance testing. Exclusion criteria included confounding central or peripheral nervous system dysfunction beyond those stemming from the concussion, animal model studies, and case reports. RESULTS A total of 3116 publications were screened; 17 were included in the final review. CONCLUSION There was wide variability in approach to autonomic/exercise tolerance testing, as well as inclusion criteria/testing timelines, which limited comparisons across studies. The reviewed studies support current clinical suspicion of autonomic dysfunction as an important component of exercise intolerance. However, the specific mechanisms of impairment and relationship to symptoms and recovery require additional investigation.
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Affiliation(s)
- Ryan Pelo
- Department of Physical Therapy and Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Erin Suttman
- Department of Physical Therapy and Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Peter C Fino
- Department of Health and Kinesiology, University of Utah, Salt Lake City, UT, USA
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT, USA
| | - Leland E Dibble
- Department of Physical Therapy and Athletic Training, University of Utah, 520 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Melissa M Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
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