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Petersell TL, Quammen DL, Crofts R, Morris AJ, Fino NF, Jensen CB, Hollien A, Pelo R, Roemmich BJ, Dibble LE, Fino PC. Instrumented Static and Reactive Balance in Collegiate Athletes: Normative Values and Minimal Detectable Change. J Athl Train 2024; 59:608-616. [PMID: 38014789 PMCID: PMC11220770 DOI: 10.4085/1062-6050-0403.23] [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: 11/29/2023]
Abstract
CONTEXT Wearable sensors are increasingly popular in concussion research because of their objective quantification of subtle balance deficits. However, normative data and minimal detectable change (MDC) values are necessary to serve as references for diagnostic use and tracking longitudinal recovery. OBJECTIVE To identify normative and MDC values for instrumented static- and reactive-balance tests, an instrumented static mediolateral (ML) root mean square (RMS) sway standing balance assessment and the instrumented, modified push and release (I-mP&R), respectively. DESIGN Cross-sectional study. SETTING Clinical setting. PATIENTS OR OTHER PARTICIPANTS Normative static ML RMS sway and I-mP&R data were collected on 377 (n = 184 female) healthy National Collegiate Athletic Association Division I athletes at the beginning of their competitive seasons. Test-retest data were collected in 36 healthy control athletes based on standard recovery timelines after concussion. MAIN OUTCOME MEASURE(S) Descriptive statistics, intraclass correlation coefficients (ICCs), and MDC values were calculated for primary outcomes of ML RMS sway in a static double-limb stance on firm ground and a foam block, and time to stability and latency from the I-mP&R in single- and dual-task conditions. RESULTS Normative outcomes across static ML RMS sway and I-mP&R were sensitive to sex and type of footwear. Mediolateral RMS sway demonstrated moderate reliability in the firm condition (ICC = 0.73; MDC = 2.7 cm/s2) but poor reliability in the foam condition (ICC = 0.43; MDC = 11.1 cm/s2). Single- and dual-task times to stability from the I-mP&R exhibited good reliability (ICC = 0.84 and 0.80, respectively; MDC = 0.25 and 0.29 seconds, respectively). Latency from the I-mP&R had poor to moderate reliability (ICC = 0.38 and 0.55; MDC = 107 and 105 milliseconds). CONCLUSIONS Sex-matched references should be used for instrumented static- and reactive-balance assessments. Footwear may explain variability in static ML RMS sway and time to stability of the I-mP&R. Moderate-to-good reliability suggests time to stability from the I-mP&R and ML RMS static sway on firm ground can be used for longitudinal assessments.
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Affiliation(s)
| | | | | | - Amanda J. Morris
- Departments of Health & Kinesiology and
- Department of Kinesiology, California State University Sacramento
| | - Nora F. Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City
| | | | | | - Ryan Pelo
- Physical Therapy and Athletic Training and
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Buckley TA, Passalugo SW, Gallo CA, Bodt B, Evans KM, Munkasy BA. Collegiate student-athletes concussion knowledge and attitudes: what a difference a decade Makes. Brain Inj 2024; 38:288-294. [PMID: 38369869 PMCID: PMC10911450 DOI: 10.1080/02699052.2024.2314549] [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: 09/25/2023] [Accepted: 01/31/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE The purpose of this study was to assess changes in concussion knowledge and attitudes amongst incoming intercollegiate student-athletes over the course of a decade (2010-2012 vs 2021-2023). METHODS There were 592 student-athletes from 2 cohorts (2010-2012, 2021-2023) who completed the Rosenbaum Concussion Knowledge and Attitudes Survey (ROCKaS) questionnaire which is comprised of a concussion knowledge index (CKI, 0-24) and attitude index (CAI, 15-75) with higher scores reflecting better performance. A three factor ANOVA (Group, Sex, Concussion History) compared performance on the CKI and CAI. Individual questions were compared between groups with a Chi-Square analysis. RESULTS For the CKI, there was a significant main effect for Group (2010-2012: 18.5 ± 2.6, 2021-2023: 19.4 ± 2.5, p < 0.001, η 2 = 0.032 ) . For the CAI, there was also a significant main effect for group (2010-2012: 52.9 ± 6.0, 2021-2023: 62.2 ± 6.5, p < 0.001, η 2 = 0.359 ) . CONCLUSIONS The results of this study show a modest increase in concussion knowledge; however, large improvements in concussion attitudes were observed between groups. These results suggest a continued improvement in student-athlete concussion awareness and provide specific areas to continue addressing persistent misconceptions.
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Affiliation(s)
- 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
| | - Scott W Passalugo
- Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
| | - Caitlin A Gallo
- Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
| | - Barry Bodt
- College of Health Sciences, University of Delaware, Newark, Delaware, USA
| | - Kelsey M Evans
- Department of General Surgery, Orlando Health, Orlando, Florida, USA
| | - Barry A Munkasy
- School of Health Sciences and Kinesiology, Georgia Southern University, Statesboro, Georgia, USA
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Munce TA, Peplowski AD, Bowman TG, Kelshaw PM, Campbell TR, Ahonen SB, Valentine VD, Cifu DX, Resch JE. Concussion diagnosis and recovery in relation to collegiate athletic department classification: a LIMBIC MATARS consortium investigation. Brain Inj 2024:1-11. [PMID: 38334036 DOI: 10.1080/02699052.2024.2310800] [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: 03/02/2023] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE We investigated time to reach concussion diagnosis and recovery milestones in collegiate athletes relative to their schools' National Collegiate Athletic Association (NCAA) classification. METHODS We retrospectively examined 849 (43.1% female) concussion cases from 11 NCAA institutions (Division I Power 5 [n = 4], Division I Non-Power 5 [n = 4], and Division II/III [n = 3]) from the 2015-16 to 2019-20 athletic seasons. Our primary outcome measures were days to reach specific clinical milestones following concussion. RESULTS Median (IQR) time from injury to diagnosis was significantly longer at Division II/III institutions (1 [0-4] days) compared to Division I Power 5 (0 [0-1] days) and Division I Non-Power 5 (0 [0-1] days) institutions (p < 0.001). Likewise, Division II/III athletes (15 [11-22] days) took significantly longer to return to sport after concussion than Division I Power 5 (10 [7-16] days) and Division I Non-Power 5 (11 [7-18.5] days) athletes (p < 0.001). CONCLUSION Division II/III athletes had delayed concussion diagnoses and return to sport timelines compared to Division I athletes. Our results suggest that differences in sports medicine resources across NCAA divisions may influence injury recognition and recovery in collegiate athletes with concussion.
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Affiliation(s)
- Thayne A Munce
- Environmental Influences on Health & Disease Group, Sanford Research, Sioux Falls, South Dakota, USA
| | - Allison D Peplowski
- Environmental Influences on Health & Disease Group, Sanford Research, Sioux Falls, South Dakota, USA
- Department of Biology, University of South Dakota, Vermillion, South Dakota, USA
| | - Thomas G Bowman
- Department of Athletic Training, College of Health Sciences, University of Lynchburg, Lynchburg, Virginia, USA
| | - Patricia M Kelshaw
- Department of Kinesiology, Brain Research and Assessment Initiative of New Hampshire (BRAIN) Laboratory, University of New Hampshire, Durham, New Hampshire, USA
| | - Thomas R Campbell
- School of Rehabilitation Sciences, College of Health Sciences, Old Dominion University, Norfolk, Virginia, USA
| | - Sean B Ahonen
- Intercollegiate Athletics and Community Wellness, Virginia Union University, Richmond, Virginia, USA
| | - Verle D Valentine
- Sanford Orthopedics and Sports Medicine, Sanford Health, Sioux Falls, South Dakota, USA
| | - David X Cifu
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
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Resch JE, Beidler E, Bowman TJ, Kelshaw T, Larson MJ, Munce TA, Oldham J, Walton SR, Cifu DX. Placing the keystone: the LIMBIC Military and Tactical Athlete Research Study. Brain Inj 2024:1-8. [PMID: 38328943 DOI: 10.1080/02699052.2024.2304861] [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: 03/02/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The LIMBIC Military and Tactical Athletic Research Study (MATARS) framework was established to confirm and extend understanding of concussion with initial studies driven by clinical data collected between 2015 and 2020 in a collegiate sports setting. The LIMBIC MATARS framework will be leveraged to apply gold-standard and innovative research designs to advance the science of concussion. This manuscript provides the background, methodology, and initial demographic data associated with the LIMBIC MATARS. METHODS Consensus-based common data elements were used to conduct a retrospective chart review, specific to collegiate athletes diagnosed with concussions between 2015 and 2020 at 11 universities. RESULTS A final sample of 1,311 (47.8% female) concussions were diagnosed during the five-year study period from athletes participating in a variety of National Collegiate Athlete Association (NCAA) sports. The LIMBIC MATARS demographic data, align with the NCAA and other pioneering multi-site concussion-related studies in terms of biological sex, race and ethnicity, and sport participation. CONCLUSION This pragmatic, methodological approach was used to address several a priori hypotheses related to concussion, align with other multi-site studies of concussion, and establish a consortium for future investigations.
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Affiliation(s)
- J E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
| | - E Beidler
- Department of Athletic Training, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - T J Bowman
- Department of Athletic Training, College of Health Sciences, University of Lynchburg, Lynchburg, Virginia, USA
| | - T Kelshaw
- Department of Kinesiology, University of New Hampshire, Durham, New Hampshire, USA
| | - M J Larson
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, USA
| | - T A Munce
- Environmental Influences on Health and Disease Group, Sanford Research, Sioux Falls, South Dakota, USA
| | - J Oldham
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - S R Walton
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - D X Cifu
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Buckley TA, Bryk KN, Hunzinger KJ, Costantini K. National Collegiate Athletic Association athletic trainers' response to the Arrington settlement: management, compliance, and practice patterns. PHYSICIAN SPORTSMED 2023; 51:427-433. [PMID: 36026565 DOI: 10.1080/00913847.2022.2118001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/23/2022] [Indexed: 10/15/2022]
Abstract
The primary purpose of this study was to assess Athletic Trainers' (ATs) report of NCAA member institution compliance with the Arrington settlement, the concussion lawsuit vs. the NCAA, and to elucidate compliance predictors. A secondary purpose was to provide a contemporary concussion management clinical practice pattern description among NCAA collegiate athletic trainers. Head Athletic Trainers from NCAA Division I, II, and III completed an electronic questionnaire in August 2020 regarding their institution's response to the Arrington Settlement and their current concussion management clinical practice patterns. The 37-item questionnaire included AT and institution demographics, current concussion management policies, and response to the Arrington settlement with a specific focus on the five settlement requirements. An overall compliance score on the five requirements, compliance on the individual requirements, and concussion management practices are reported with descriptives. Regression was used to identify specific predictors of both overall and individual settlement requirements. An ANOVA compared compliance by NCAA division level. Being pressured to be non-compliant was assessed between sexes by a chi-square. There were 223 respondents (21.8%), and overall compliance was high (4.1 ± 0.7) with the five required Arrington Settlement components. Settlement requirement 1, pre-season baseline testing, and requirement 5, presence of trained personnel at all contact sport practices, had the lowest compliance rates at 44.8% and 73.3%, respectively. The number of sports the institution offered was the only significant predictor of each requirement. There was no difference in compliance between NCAA divisions. Although the overall rate of being non-compliant pressure was low (13.8%), females were 3.28x more likely report being pressured than males. NCAA institutions are generally compliant with the Arrington settlement; however, lack of clarity in the requirements, particularly requirement 1, raises potential concerns. Concussion management practices continue to incorporate multifaceted approaches and are largely consistent with current best practices.
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Affiliation(s)
- Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
- Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | | | - Katherine J Hunzinger
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Katelyn Costantini
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
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Lempke LB, Teel EF, Lynall RC, Hoffman NL, Buckley TA, Eckner JT, McCrea MA, McAllister TW, Broglio SP, Schmidt JD. Early Exercise is Associated with Faster Concussion Recovery Among Collegiate Athletes: Findings from the NCAA-DoD CARE Consortium. Sports Med 2023; 53:1987-1999. [PMID: 37209368 DOI: 10.1007/s40279-023-01861-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Growing evidence indicates early exercise may improve symptoms and reduce clinical recovery time after concussion, but research examining collegiate student-athletes is scarce. OBJECTIVE The aim of this study was to compare symptom recovery time, clinical recovery time, and persisting post-concussion symptom (i.e., symptoms ≥ 28 days) prevalence by the timing of light exercise initiation before the graded return to play (RTP) protocol among concussed participants. METHODS Collegiate student-athletes (n = 1228; age 18.4 ± 0.9 years; 56.5% male, 76.3% division I; 33.7% ≥ 1 prior concussion) across 30 institutions enrolled in the CARE Consortium completed post-concussion assessments and were monitored over time. Symptom recovery (days from injury to symptom resolution) and clinical recovery (days from injury to return to play protocol completion) was determined by the student-athletes' clinicians. Student-athletes were categorized by timing of light exercise initiation. Early (< 2 days post-concussion; n = 161), typical (3-7 days post-concussion; n = 281), and late exercise (≥ 8 days post-concussion; n = 169) groups were compared with the no-exercise group (n = 617; i.e., did not exercise prior to beginning the RTP protocol) for all analyses. Multivariable Cox regression models with hazard ratios (HR) and survival curves and a multivariable binomial regression model with prevalence ratios (PR) compared recovery outcomes between exercise groups while accounting for covariates. RESULTS Compared to the no-exercise group, the early exercise group was 92% more probable to experience symptom recovery (HR 1.92; 95% CI 1.57-2.36), 88% more probable to reach clinical recovery (HR 1.88; 95% CI 1.55-2.28) and took a median of 2.4 and 3.2 days less to recover, respectively. The late exercise group relative to the no-exercise group was 57% less probable to reach symptom recovery (HR 0.43; 95% CI 0.35-0.53), 46% less probable to achieve clinical recovery (HR 0.54; 95% CI 0.45-0.66) and took 5.3 days and 5.7 days more to recover, respectively. The typical exercise group did not differ in hazard for symptom or clinical recovery (p ≥ 0.329) compared with the no-exercise group. The prevalence of persisting post-concussion symptoms in the combined sample was 6.6%. Early exercise had 4% lower prevalence (PR 0.96, 95% CI 0.94-0.99) and typical exercise had 3% lower prevalence (PR 0.97, 95% CI 0.94-0.99) of persisting post-concussion symptoms, while the late exercise group had an elevated prevalence (PR 1.11, 95% CI 1.04-1.18) compared with the no-exercise group. CONCLUSION Exercise < 2 days post-concussion was associated with more probable and faster symptom and clinical recovery, and lower persisting post-concussion symptom prevalence. When considering our findings and existing literature, qualified clinicians may implement early exercise into their clinical practice to provide therapeutic treatment and improve student-athlete recovery.
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Affiliation(s)
- Landon B Lempke
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA.
| | - Elizabeth F Teel
- Department of Health, Kinesiology & Applied Physiology, Concordia University, Montreal, QC, Canada
| | - Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - Nicole L Hoffman
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - James T Eckner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Michael A McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Julianne D Schmidt
- Department of Health, Kinesiology & Applied Physiology, Concordia University, Montreal, QC, Canada
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Memmini AK, Mosesso KM, Perkins SM, Brett BL, Pasquina PF, McAllister TW, McCrea MA, Broglio SP. Premorbid Risk Factors and Acute Injury Characteristics of Sport-Related Concussion Across the National Collegiate Athletic Association: Findings from the Concussion Assessment, Research, and Education (CARE) Consortium. Sports Med 2023; 53:1457-1470. [PMID: 36929588 DOI: 10.1007/s40279-023-01830-3] [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] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Previous sport-related concussion research highlights post-injury characteristics that influence recovery trajectories; however, there is limited information regarding premorbid factors that affect sport-related concussion risk. OBJECTIVE We aimed to (a) compare premorbid demographic factors among a large cohort of collegiate student athletes who did or did not sustain a sport-related concussion and (b) assess differences in acute injury characteristics based on biological sex and contact level. METHODS We conducted a cohort study of university student athletes from 22 sports enrolled in the Concussion Assessment, Research, and Education (CARE) Consortium study from 2014 to 2021 (n = 1804 student athletes with sport-related concussions; n = 21,702 student athletes without sport-related concussions). RESULTS Statistical analyses indicated student athletes who self-identified as Black (odds ratio [OR] = 1.61; 95% confidence interval [CI] = 1.42, 1.81) or multiracial (OR = 1.32; 95% CI 1.10, 1.59) demonstrated greater odds of experiencing sport-related concussions than White-identifying student athletes. Additional findings suggest male athletes (OR = 1.47; 95% CI 1.20, 1.81) and contact sport student athletes (OR = 1.40; 95% CI 1.16, 1.70) may be at increased odds for sport-related concussions if they were previously diagnosed with attention deficit hyperactive disorder. Notable post-injury characteristics across sexes included differences in the incident loss of consciousness (male: 5.9%, female: 2.6%; p < 0.001), post-traumatic amnesia (male: 13.6%, female: 5.1%; p < 0.001), and retrograde amnesia (male: 6.8%, female: 2.8%; p < 0.001). A greater proportion of contact-sport student athletes experienced an altered mental status (52.7%) than limited contact (36.2%) and non-contact (48.6%) [p < 0.001]. Last, student athletes participating at lower contact levels were more likely to have a longer delay in removal from activity following injury (contact: 73.6 ± 322.2 min; limited contact: 139.1 ± 560.0 min; non-contact: 461.4 ± 1870.8 min; p = 0.005). CONCLUSIONS The present study provides contemporary pre- and post-sport-related concussion injury characteristics using a considerably sized cohort of collegiate student athletes. These findings support previous work suggesting sport-related concussion results in complex individualized clinical presentations, which may influence management strategies.
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Affiliation(s)
- Allyssa K Memmini
- Department of Health, Exercise and Sports Sciences, University of New Mexico, Albuquerque, NM, 87131-0001, USA.
- Concussion Center, University of Michigan, Ann Arbor, MI, USA.
| | - Kelly M Mosesso
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Susan M Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul F Pasquina
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
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Lempke LB, Bergeron G, O'Connor S, Lynall RC, Resch JE, Walton SR. Concussion Assessment and Management Practices Among Irish and Canadian Athletic Therapists: An International Perspective. J Athl Train 2023; 58:293-304. [PMID: 35724361 PMCID: PMC11215646 DOI: 10.4085/1062-6050-0097.22] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Certified athletic therapists in Ireland and Canada serve essential concussion assessment and management roles, but their health care practices and concussion knowledge have not been established. OBJECTIVE To examine Irish and Canadian athletic therapist cohorts' (1) concussion knowledge, (2) current concussion assessment and management techniques across all job settings, and (3) the association of concussion assessment and management practices with years of clinical experience and highest degree attained. DESIGN Cross-sectional cohort study. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS Licensed Irish (49.7%, n = 91/183) and Canadian (10.1%, n = 211/2090) athletic therapists. MAIN OUTCOME MEASURE(S) Athletic therapists completed an online survey assessing their demographics, concussion knowledge (symptom recognition, patient-clinician scenarios), frequency of concussions assessed annually, and assessment and return-to-play (RTP) measures using a modified, previously validated survey. Symptom recognition consisted of 20 (8 true, 12 false) items on recognition of signs and symptoms that were scored as total correct. Descriptive statistics and odds ratios were used to examine survey responses where appropriate. RESULTS Irish (86.8%, n = 46/53) and Canadian (93.4%, n = 155/166) athletic therapists indicated RTP guidelines were the most common method for determining RTP. Symptom recognition scores were 72.8% ± 17.0% among Irish and 76.6% ± 17.0% among Canadian athletic therapists. Irish (91.2%, n = 52/57) and Canadian (90.4%, n = 161/178) athletic therapists reported standardized sideline assessments as the most used concussion assessment method. Irish and Canadian athletic therapists' use of 2-domain (Irish: 38.6% [n = 22/57]; Canadian: 73.6% [n = 131/178]) and 3-domain (Irish: 3.5% [n = 2/57]; Canadian: 19.7% [n = 35/178]) minimum assessments (ie, symptoms, balance, or neurocognitive) was not associated with education or clinical experience (P ≥ .07), except for Canadian athletic therapists with master's degrees having greater odds of completing 2-domain assessments at initial evaluation than those with bachelor's degrees (odds ratio = 1.80; 95% CI = 1.41, 1.95). CONCLUSIONS Irish and Canadian athletic therapists demonstrated similar concussion knowledge; however, most did not fully adhere to international consensus guidelines for concussion assessment as evidenced by low 2- and 3-domain assessment use. Athletic therapists should aim to implement multidimensional concussion assessments to ensure optimal health care practices and patient safety.
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Affiliation(s)
- Landon B. Lempke
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens
- School of Kinesiology, Michigan Concussion Center, University of Michigan, Ann Arbor
| | - Glen Bergeron
- Department of Kinesiology and Applied Health, The University of Winnipeg, Manitoba, Canada
| | - Siobhán O'Connor
- Centre for Injury Prevention and Performance, Athletic Therapy and Training, School of Health and Human Performance, Dublin City University, Ireland
| | - Robert C. Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens
| | - Jacob E. Resch
- Exercise and Sport Injury Laboratory, Department of Kinesiology, University of Virginia, Charlottesville
| | - Samuel R. Walton
- Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond
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Buckley TA, Chandran A, Mauntel TC, Kerr ZY, Brown DW, Boltz AJ, Herman DC, Hall EE, Lynall RC. Lower Extremity Musculoskeletal Injuries After Concussion in Collegiate Student-Athletes. Am J Sports Med 2023; 51:511-519. [PMID: 36255302 DOI: 10.1177/03635465221125155] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An association has been identified between concussion and lower extremity musculoskeletal injury (LEMSKI) after return to sports participation. However, the collegiate student-athlete studies have relied on relatively small single-institution studies, which limits generalizability. PURPOSE To assess odds of, and time to, LEMSKI after concussion in US collegiate athletes, using the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP). STUDY DESIGN Descriptive epidemiology study. METHODS Data from the NCAA ISP during the 2010-2011 through 2019-2020 athletic seasons were considered for analysis. Frequency distributions were examined for details related to the initial and subsequent injuries (injuries to bone, bursa, joint, ligament, muscle, or tendon). Multivariable logistic regression models and random-effects Poisson regression models examined odds of time loss (TL) and non-time loss (NTL) LEMSKI after concussion, as well as the time interval between initial concussion and subsequent LEMSKI in a single athletic season, or initial musculoskeletal injury (MSKI) and subsequent LEMSKI in a single athletic season. Analyses were performed separately for football and other sports. RESULTS A total of 31,556 initial injuries were recorded (football: 11,900; other sports: 19,656), which were followed by 0 or 1 injury in the same season. Overall, first injury type was not a significant predictor of subsequent LEMSKI, although certain contrasts yielded significant estimates. In football, the odds of NTL LEMSKI were higher after concussion than after upper extremity MSKI (UEMSKI; adjusted odds ratio [ORAdj], 1.56; 95% CI, 1.06-2.31). In football, the odds of TL LEMSKI were lower after concussion than after UEMSKI (ORAdj, 0.71; 95% CI, 0.51-0.99). No other significant effect estimates were observed for football or other sports. CONCLUSION First injury type, either concussion or upper extremity, was not associated with an elevated risk of LEMSKI. Specifically, the results of this study did not identify an elevated odds of LEMSKI after a concussion. However, the authors observed greater odds of NTL LEMSKI and lower odds of TL LEMSKI in football.
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Affiliation(s)
- Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA.,Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, Delaware, USA
| | - Avinash Chandran
- Datalys Center for Sports Injury Research and Prevention Inc, Indianapolis, Indiana, USA
| | - Timothy C Mauntel
- DoD-VA Extremity Trauma & Amputation Center of Excellence, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Zachary Yukio Kerr
- Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Derek W Brown
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Adrian J Boltz
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel C Herman
- Department of Physical Medicine and Rehabilitation, University of California, Davis, Davis, California, USA
| | - Eric E Hall
- Department of Exercise Science, Elon University, Elon, North Carolina, USA
| | - Robert C Lynall
- Department of Kinesiology, University of Georgia, Athens, Georgia, USA
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Stephenson K, Womble MN, Eagle S, Collins MW, Kontos AP, Elbin RJ. Symptom Provocation Following Post-concussion Computerized Neurocognitive Testing and Its Relationship to Other Clinical Measures of Concussion. ARCHIVES OF CLINICAL NEUROPSYCHOLOGY : THE OFFICIAL JOURNAL OF THE NATIONAL ACADEMY OF NEUROPSYCHOLOGISTS 2022; 38:548-556. [PMID: 36566500 DOI: 10.1093/arclin/acac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The objective of this study was to document the prevalence of post-computerized neurocognitive test (post-CNT) increases in symptoms in athletes with sport-related concussion, and to examine the effect of post-CNT symptom increases on concussion neurocognitive and vestibular/ocular motor clinical outcomes. METHODS This was a retrospective analysis of medical records from a concussion specialty clinic. Two hundred and three athletes (M = 16.48 ± 1.97 years; 44% [90/203] female) completed a clinical visit for concussion within 30 days of injury (M = 7.73 ± 5.54 days). Computerized neurocognitive testing (the Immediate Post-concussion Assessment and Cognitive Testing: ImPACT), the Post-Concussion Symptom Scale (PCSS), and the Vestibular Ocular Motor Screening (VOMS) were the main outcome measures for the current study. RESULTS Sixty-nine percent (141/203) of the sample did not report significant increases in PCSS scores following post-concussion CNT and were classified into a No Provocation (NO PROV) group. Thirty-one percent (62/203) of participants did report a significant increase in symptoms following post-concussion CNT and were classified into a Provocation (PROV) group. Neurocognitive performance was similar between groups. However, the PROV group reported significantly higher scores on the VOMS symptom items than the NO PROV group. CONCLUSIONS The majority of adolescent athletes can complete a post-concussion CNT without experiencing significant increases in concussion symptoms. Individuals that report symptom increases from completing a post-concussion CNT are more likely to exhibit increased vestibular/ocular motor symptoms. These findings underscore the relationship between the clinical findings from both CNT and vestibular/ocular motor measures following concussion.
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Affiliation(s)
- Katie Stephenson
- Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville, AR 72703, USA
| | - Melissa N Womble
- Inova Sports Medicine Concussion Program, Inova Hospital, Fairfax, VA 22031, USA
| | - Shawn Eagle
- UPMC Sports Medicine Concussion Program - Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15203, USA
| | - Michael W Collins
- UPMC Sports Medicine Concussion Program - Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15203, USA
| | - Anthony P Kontos
- UPMC Sports Medicine Concussion Program - Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15203, USA
| | - R J Elbin
- Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville, AR 72703, USA
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Erdman NK, Kelshaw PM, Hacherl SL, Caswell SV. The Clinical Utility of the Child SCAT5 for Acute Concussion Assessment. SPORTS MEDICINE - OPEN 2022; 8:104. [PMID: 35962887 PMCID: PMC9375738 DOI: 10.1186/s40798-022-00499-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 07/31/2022] [Indexed: 11/11/2022]
Abstract
Background The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5 and 12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion. Methods Our participants included 34 concussed (21 boys, 13 girls; age = 12.8 ± 0.86 years) and 44 non-concussed (31 boys, 13 girls; age = 12.4 ± 0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes (\documentclass[12pt]{minimal}
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Results Concussed children endorsed more symptoms (p < 0.001, \documentclass[12pt]{minimal}
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\begin{document}$$r$$\end{document}r=0.23), single leg (p = 0.035, \documentclass[12pt]{minimal}
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\begin{document}$$r$$\end{document}r=0.24), and total scores (p = 0.022, \documentclass[12pt]{minimal}
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\begin{document}$$r$$\end{document}r=0.26) for the mBESS than the non-concussed children. No significant differences were observed for the SAC-C scores (p’s ≥ 0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC = 0.76–0.77), negative predictive values (NPV = 0.84–0.88), and negative likelihood ratios (-LR = 0.22–0.31) of the Child SCAT5 scores. Conclusions Clinicians should prioritize interpretation of the symptom evaluation form of the Child SCAT5 as it was the most effective component for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion.
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Ferris LM, Kontos AP, Eagle SR, Elbin RJ, Clugston JR, Ortega J, Port NL. Optimizing VOMS for identifying acute concussion in collegiate athletes: Findings from the NCAA-DoD CARE consortium. Vision Res 2022; 200:108081. [PMID: 35926346 DOI: 10.1016/j.visres.2022.108081] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 03/07/2022] [Accepted: 06/07/2022] [Indexed: 01/25/2023]
Abstract
The Vestibular/Ocular-Motor Screening (VOMS), an important component in acute (<72 h) sport-related concussion (SRC) assessment, is increasingly used alongside the Sport Concussion Assessment Tool (SCAT) and as part of the Military Acute Concussion Evaluation 2 (MACE2). VOMS demonstrates clinically useful diagnostic accuracy for acute SRC and improves the overall utility when added to the SCAT3. However, potential overlap among VOMS's vestibular and oculomotor items suggests the possibility of a more efficient version. VOMS and SCAT3 scores were analyzed for 3,958 preseason (47.8% female) and 496 acute-SRC (37.5% female) NCAA-DoD Concussion Assessment, Research, and Education (CARE) consortium collegiate athlete evaluations. Analyses revealed very large effect sizes (d = 2.39-2.45) and high correlations (rho = 0.95-0.99) among all VOMS items except near point of convergence distance (d = 0.79, rho ≤ 0.341). Receiver operating characteristic (ROC) curve analyses showed clinically useful discriminative utility for VOMS Total (AUC = 0.85) and the VOMS Total change score, where pretest symptoms were incorporated (AUC = 0.81). A modified VOMS (mVOMS) consisting of four items (smooth pursuits, horizontal saccades, horizontal vestibulo-ocular reflex, visual motion sensitivity) yielded identical AUCs to VOMS Total. Integer cutoff analyses suggest a score of ≥4 for VOMS Total and ≥4 for mVOMS Total optimizes concussion identification. Incorporating VOMS or mVOMS into SCAT3 (AUC = 0.79) significantly improved the combined tool's acute utility for acute concussion identification by a maximum of 4% (SCAT3+VOMS AUC = 0.84, SCAT3+mVOMS AUC = 0.83). Future versions of SCAT or MACE may want to consider incorporating a more parsimonious VOMS for the purpose of identifying acute concussion.
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Affiliation(s)
| | | | | | - R J Elbin
- University of Arkansas, United States
| | | | - Justus Ortega
- Humboldt State University Kinesiology and Recreation Administration, United States
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Ferris LM, Kontos AP, Eagle SR, Elbin RJ, Collins MW, Mucha A, McAllister TW, Broglio SP, McCrea M, Pasquina PF, Port NL. Utility of VOMS, SCAT3, and ImPACT Baseline Evaluations for Acute Concussion Identification in Collegiate Athletes: Findings From the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium. Am J Sports Med 2022; 50:1106-1119. [PMID: 35179972 DOI: 10.1177/03635465211072261] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Vestibular/Ocular-Motor Screening (VOMS) is a valuable component of acute (<72 hours) sports-related concussion (SRC) assessments and is increasingly used with the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) instrument and the third edition of the Sport Concussion Assessment Tool (SCAT3). Research has suggested that VOMS acute postinjury scores are useful in identifying acute concussion. However, the utility of preseason baseline measurements to improve diagnostic accuracy remains ambiguous. To this end, there is a need to determine how reliable VOMS baseline assessments are across years and whether incorporating individuals' baseline performance improves diagnostic yield for acute concussions. PURPOSE To analyze VOMS, SCAT3, and ImPACT to evaluate the test-retest reliability of consecutive-year preseason baseline assessments to directly compare the diagnostic utility of these tools when incorporating baseline assessments versus using postinjury data alone to identify acute SRC. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS Preseason and postinjury VOMS, SCAT3, ImPACT Post-Concussion Symptom Scale (PCSS), and ImPACT composite scores were analyzed for 3958 preseason (47.7% female) and 496 acute (≤48 hours) SRC (37.5% female) collegiate athlete evaluations in the National Collegiate Athletic Association-Department of Defense Concussion Assessment Research and Education Consortium. Descriptive statistics, Kolmogorov-Smirnov significance, and Cohen d effect size were calculated. Consecutive-year baseline reliability was evaluated for a subset of 447 athlete encounters using Pearson r, Cohen κ, Cohen d, and 2-way mixed intraclass correlation coefficients (ICCs). Wilcoxon signed rank tests were used to determine the statistical significance between population performances, and the 90% reliable change index (RCI) was calculated from the test-retest results. Preseason to postinjury change scores were then calculated from each tool's RCI. Finally, receiver operating characteristic (ROC) curve analyses were conducted, and DeLong method was used to compare the area under the curve (AUC) of raw postinjury scores versus change scores from preseason baseline assessments. Potential effects of sex, medical history (learning disorders or attention-deficit/hyperactivity disorder), and outlier data were also explored. RESULTS Effect sizes were large, and overall predictive utilities were clinically useful for postinjury VOMS Total (d = 2.44; AUC = 0.85), the SCAT3 Symptom Evaluation total severity score (d = 1.74; AUC = 0.82), and the ImPACT PCSS total severity score (d = 1.67; AUC = 0.80). Comparatively, effect sizes were small and predictive utilities were poor for Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (mBESS), and all ImPACT composites (d = 0.11-0.46; AUC = 0.48-0.59). Preseason baseline test-retest reliability was poor to moderate (r = 0.23-0.52; κ = 0.32-0.36; ICC = 0.36-0.68) for all assessments except ImPACT Visual Motion Sensitivity (r = 0.73; ICC = 0.85). Incorporating baseline scores for VOMS Total, SCAT3 (Symptom Evaluation, SAC, mBESS), ImPACT PCSS, or ImPACT composites did not significantly improve AUCs. CONCLUSION VOMS Total and symptom severity (SCAT3, PCSS) total scores had large effect sizes and clinically useful AUCs for identifying acute concussion. However, all tools demonstrated high within-patient test-retest variability, resulting in poor reliability. The findings in this sample of collegiate athletes suggest that incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion.
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Affiliation(s)
- Lyndsey M Ferris
- Indiana University School of Optometry, Bloomington, Indiana, USA
| | | | - Shawn R Eagle
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - R J Elbin
- University of Arkansas, Fayetteville, Arkansas, USA
| | | | - Anne Mucha
- UPMC Centers for Rehab Services, Pittsburg, Pennsylvania, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael McCrea
- Neurosurgery, Medical College of Wisconsin, Millwauke, Wisconsin, USA
| | - Paul F Pasquina
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Nicholas L Port
- Indiana University School of Optometry, Bloomington, Indiana, USA
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Buckley TA, Munkasy BA, Evans KM, Clouse B. Acute Physical and Mental Activity Influence on Concussion Recovery. Med Sci Sports Exerc 2022; 54:307-312. [PMID: 34559729 PMCID: PMC8760145 DOI: 10.1249/mss.0000000000002787] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Physical activity (PA) and mental activity (MA) postconcussion has received renewed attention to improve concussion management; however, most protocols start after several days and do not assess the acute window. Therefore, the purpose of this study was to assess PA and MA in the first 48 h postconcussion on the time to symptom-free status and return to play. METHODS We recruited 78 NCAA Division I athletes (male, 51.3%; age, 19.6 ± 1.4 yr; height, 173.7 ± 11.5 cm; weight, 80.1 ± 23.2 kg) who were diagnosed with a sports-related concussion. Participants completed a 0-5 PA and MA scale daily until fully cleared for return to participation (mean, 15.1 ± 6.9 d). A quadratic model regression assessed PA and MA over the first 2 d (acute) postconcussion on to time to symptom-free status and return to play. RESULTS The overall model was significant for both time to symptom free (r2 = 0.27, P = 0.004) and return to play (r2 = 0.23, P = 0.019). Reported PA was the only significant predictor for time to symptom-free (P = 0.002) and return-to-participation (P = 0.006) day. Reported MA was not associated either outcome. CONCLUSIONS The primary finding of this study was that mild to moderate PA acutely postconcussion was associated with reduced time to symptom free and return to participation as opposed to either lower or higher levels of PA. Conversely, acute MA was not associated with recovery outcomes. These results further elucidate the role of postconcussion PA.
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Affiliation(s)
- Thomas A. Buckley
- Department of Kinesiology and Applied Physiology, Interdisciplinary program in Biomechanics and Movement Science University of Delaware, Newark, DE
| | - Barry A. Munkasy
- School of Health and Kinesiology, Georgia Southern University, Statesboro, GA
| | | | - Brandy Clouse
- Department of Intercollegiate Athletics, Georgia Southern University, Statesboro, GA
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Holoyda KA, Donato DP, Magno-Padron DA, Simpson AM, Agarwal JP. Hand and wrist injuries among collegiate athletes vary with athlete division. Inj Epidemiol 2021; 8:69. [PMID: 34906242 PMCID: PMC8670021 DOI: 10.1186/s40621-021-00363-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rates, severity and consequences of hand and wrist injuries sustained by National Collegiate Athletic Association athletes are not well characterized. This study describes the epidemiology of hand and wrist injuries among collegiate athletes competing in different divisions. METHODS The National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) was accessed from 2004 to 2015 for the following sports: baseball, basketball, football, ice hockey, lacrosse, soccer, wrestling, field hockey, gymnastics, softball and volleyball. The data were used to identify all hand and wrist injuries, the specific injury diagnosis, mean time loss of activity following injury, and need for surgery following injury. These were then stratified by gender. Descriptive statistics were performed to examine the association between sports, event type and division. Student's t test was used to calculate p-values for independent variables. Chi-Square test was used to calculate odds ratio. P < 0.05 was considered significant. RESULTS 103,098 hand and wrist injuries were reported in in the studied NCAA sports from 2004 to 2015. Male athletes sustained 72,423 injuries (6.01/10,000 athlete exposure) and female athletes sustained 30,675 injuries (4.13/10,000 athlete exposure). Division I athletes sustained significantly more injuries compared to divisions II and III. Overall, 3.78% of hand and wrist injuries required surgical intervention. A significantly higher percentage of division I athletes (both male and female) underwent surgical intervention compared to divisions II and III. The mean time lost due to hand and wrist injury was 7.14 days for all athletes. Division I athletes missed the fewest days due to injury at 6.29 days though this was not significant. CONCLUSIONS Hand and wrist injuries are common among collegiate athletes. Division I athletes sustain higher rates of injuries and higher surgical intervention rates, while tending to miss fewer days due to injury. Improved characterization of divisional differences in hand and wrist injuries can assist injury management and prevention.
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Affiliation(s)
- Kathleen A Holoyda
- Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT, 84132, USA
| | - Daniel P Donato
- Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT, 84132, USA
| | - David A Magno-Padron
- Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT, 84132, USA
| | - Andrew M Simpson
- Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT, 84132, USA
| | - Jayant P Agarwal
- Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT, 84132, USA.
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Oldham JR, Howell DR, Knight CA, Crenshaw JR, Buckley TA. Single-Task and Dual-Task Tandem Gait Performance Across Clinical Concussion Milestones in Collegiate Student-Athletes. Clin J Sport Med 2021; 31:e392-e397. [PMID: 32852299 PMCID: PMC7887129 DOI: 10.1097/jsm.0000000000000836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/19/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the length of time after concussion that impaired tandem gait performance is observed. DESIGN Clinical measurement, prospective longitudinal. SETTING NCAA collegiate athletic facility. PARTICIPANTS Eighty-eight concussed NCAA Division I student-athletes and 30 healthy controls. INDEPENDENT VARIABLES Group (concussion/control) and time (Baseline, Acute, Asymptomatic, and RTP). MAIN OUTCOME MEASURES Participants completed 4 single-task and dual-task tandem gait trials. The concussion group completed tests at the following time points: preseason (Baseline), within 48 hours after concussion (Acute), on the day symptoms were no longer reported (Asymptomatic), and when cleared to return to sports (RTP). Controls completed the same protocol at similar intervals. The dual-task trials involved minimental style cognitive questions answered simultaneously during tandem gait. We analyzed the best time of the 4 trials, comparing groups with a linear mixed model. RESULTS Acutely after concussion, the concussion group performed single-task tandem gait slower (worse) than controls (concussion: 11.36 ± 2.43 seconds, controls: 9.07 ± 1.78 seconds, P < 0.001). The concussion group remained significantly slower than controls (9.95 ± 2.21 vs 8.89 ± 1.65 seconds, P = 0.03) at Asymptomatic day but not RTP. There were significant group (P < 0.001) and time (P < 0.001) effects for dual-task tandem gait. The groups were not significantly different at baseline for single-task (P = 0.95) or dual-task (P = 0.22) tandem gait. CONCLUSIONS Our results indicate that tandem gait performance is significantly impaired acutely after concussion, compared with both preseason measures and controls. Postural control impairments were not present when the student-athletes were cleared for RTP. This information can assist clinicians when assessing postural control and determining recovery after a concussive injury.
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Affiliation(s)
- Jessie R. Oldham
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
- Division of Sports Medicine, Department of Orthopedics, Boston Children’s Hospital, Boston, MA, USA
| | - David R. Howell
- Sports Medicine Center, Children’s Hospital Colorado, Aurora, CO, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher A. Knight
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
- Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | - Jeremy R. Crenshaw
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
- Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | - Thomas A. Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
- Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
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Anderson MN, Lempke LB, Johnson RS, Lynall RC, Schmidt JD. Concussion Characteristics and Early Postinjury Outcomes Between College Students and Intercollegiate Athletes. Arch Phys Med Rehabil 2021; 103:323-330. [PMID: 34673035 DOI: 10.1016/j.apmr.2021.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe concussion characteristics among general college students and compare postinjury outcomes to intercollegiate student athletes. DESIGN Retrospective cohort. SETTING Large university in the Southeast region of the United States. PARTICIPANTS A total of 179 (N=179) college students' (female=120; 67.0%; 23.9±3.9 years) and 49 athletes' (female=28, 57.1%;19.3±1.3 years) medical records were examined. Participants self-reported injury mechanism, health history information, and completed clinical assessments acutely (<7 days postinjury). MAIN OUTCOME MEASURES Descriptive statistics were calculated for each group. Concussion outcomes between students with and without certain health history diagnoses were assessed using separate t tests. We conducted univariate regression analyses to determine if sex, age, and time from concussion to first clinical assessment were significant predictors of clinical outcomes. Statistically significant variables were included as covariates in a series of 1-way analyses of covariance to identify differences in balance, symptom severity, total symptom presence, and neurocognitive domain performance between students and athletes. Fisher exact tests were used to compare health history information between groups (α<0.05). RESULTS Among students, 24% reported sustaining a concussion while participating in recreational sports, and 27% of impacts occurred to the back of the head. Students had higher proportions of headache, migraine, anxiety, and depression (P<.05). Students reported greater total symptom presence (P=.006) and performed worse on the computerized neurocognitive test domain score for complex attention (P=.015) relative to athletes. CONCLUSIONS These findings highlight the need for better access to medical care for non- National Collegiate Athletic Association sanctioned athletes because of a large proportion of concussions in the student sample being sustained during sports participation. Identifying common injury mechanisms can provide clinicians with powerful information to improve evaluation and treatment models.
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Affiliation(s)
- Melissa N Anderson
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia.
| | - Landon B Lempke
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia; Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts; Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
| | - Rachel S Johnson
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia
| | - Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia
| | - Julianne D Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, Mary Frances Early College of Education, University of Georgia, Athens, Georgia
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McGowan AL, Bretzin AC, Anderson M, Pontifex MB, Covassin T. Paired cognitive flexibility task with symptom factors improves detection of sports-related concussion in high school and collegiate athletes. J Neurol Sci 2021; 428:117575. [PMID: 34304023 DOI: 10.1016/j.jns.2021.117575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/24/2021] [Accepted: 07/08/2021] [Indexed: 11/18/2022]
Abstract
Determining the sensitivity and specificity of short neurocognitive assessments to objectively detect concussion will help clinicians more confidently integrate such tools in clinical management decisions. This study quantified the sensitivity and specificity of a computerized cognitive flexibility task isolating shifts of visuospatial attention in combination with clinical symptoms acutely (< 72 h) following concussion. A total of 100 athletes (53 concussed; 47 non-injured control; 42% female) completed computerized neurocognitive testing and clinical symptom reports (Sport Concussion Assessment Tool 3rd edition: SCAT3). Separate discriminant function analyses were performed for individual, combination, and stepwise inclusion of neurocognitive and clinical symptomology assessments. Findings revealed the combination of neurocognitive outcomes (i.e., mean reaction time, response accuracy, and response accuracy cost) with clinical symptom factor scores exhibited the greatest sensitivity (95.7%) and specificity (88.7%) as well as the highest positive predictive value (95.9%) and negative predictive value (88%) relative to other approaches. Further, a stepwise approach predicting concussion status using the discriminant functions improved detection of concussion (98.2% sensitivity, 95.7% specificity, 96.4% positive predictive value, and 97.8% negative predictive value) when clinical symptom factors failed to indicate the presence of a concussion. Incorporating a cognitive flexibility task involving shifts of visuospatial attention combined with clinical symptom factor scores may improve clinical decision-making as this approach exceeds the sensitivity and specificity of widely popular neurocognitive test batteries and takes less than 10 min to administer.
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Affiliation(s)
- Amanda L McGowan
- Addiction, Health, and Adolescence Lab, Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Abigail C Bretzin
- Penn Injury Science Center, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Morgan Anderson
- Department of Kinesiology, Michigan State University, East Lansing, MI, United States of America
| | - Matthew B Pontifex
- Department of Kinesiology, Michigan State University, East Lansing, MI, United States of America
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, MI, United States of America
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Bratsman A, Wassef A, Wassef CR, Jayaram P, Mosely JB, Shybut TB. Epidemiology of NCAA Bone Stress Injuries: A Comparison of Athletes in Divisions I, II, and III. Orthop J Sports Med 2021; 9:23259671211014496. [PMID: 34291114 PMCID: PMC8274115 DOI: 10.1177/23259671211014496] [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: 11/17/2020] [Accepted: 01/03/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Bone stress injuries (BSIs) are a major source of functional impairment in athletes of all sports, with many risk factors, including athlete characteristics and type of sport. In National Collegiate Athletic Association (NCAA) athletics, the stratification of programs into divisions with different characteristics and makeup has been identified as increasing the risk for certain kinds of injuries, but there have been no studies on the difference of BSI rates and characteristics between athletes in Division I (DI) and those in Divisions II and III (DII and DIII). Purpose/Hypothesis: To characterize the BSI rates in each division and compare the incidence and characteristics of BSIs within divisions. Our hypothesis was that BSI rates would be higher in DII and DIII athletes as compared with DI athletes. Study Design: Descriptive epidemiology study. Methods: Five years of recorded BSI data in collegiate athletes via the NCAA Injury Surveillance Program were examined for the academic years 2009-2010 to 2013-2014. BSI rates per 100,000 athlete-exposures (AEs) were compared for DI versus DII and DIII athletes using risk ratios and 95% CIs. Time lost to injury, time of season of injury, and class composition of injured athletes were also compared between divisions. Results: Over the 5 years studied, DII and DIII programs reported 252 BSIs more than 1,793,777 AEs (14.05 per 100,000 AEs), and DI programs reported 235 BSIs over 2,022,592 AEs (11.62 per 100,000 AEs). The risk ratio was significant for D1 versus DII and DIII (1.21; 95% CI, 1.01-1.44). There was a significant difference in time lost to injury in DI versus DII and DIII, χ2(5, n = 449) = 16.54; P = .006. When data were stratified by individual sport, there were no significant divisional differences in high-risk sports. Conclusion: In the current study, NCAA DII and DIII athletes had higher rates of BSI than their DI counterparts. As compared with DII and DIII athletes, the DI athletes had a significantly greater proportion of BSIs that did not result in absence from participation in sport.
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Affiliation(s)
- Andrew Bratsman
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Audrey Wassef
- Department of Orthopedic Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christina R Wassef
- Department of Orthopedic Surgery, John Peter Smith Health Network, Fort Worth, Texas, USA
| | - Prathap Jayaram
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - J Bruce Mosely
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Theodore B Shybut
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
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Oldham JR, Master CL, Walker GA, Meehan WP, Howell DR. The Association between Baseline Eye Tracking Performance and Concussion Assessments in High School Football Players. Optom Vis Sci 2021; 98:826-832. [PMID: 34328459 PMCID: PMC9254265 DOI: 10.1097/opx.0000000000001737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SIGNIFICANCE Concussions are complex injuries that require a multifaceted testing battery. Vision impairments are common after concussion, but it is unknown exactly how eye tracking may be affected after injury and how it is associated with other clinical concussion assessments. PURPOSE This study aimed to (1) examine the relationship between eye tracking performance (BOX score) and other common concussion evaluations, (2) identify if eye tracking adds novel information that augments baseline concussion evaluations, and (3) examine the effect of age, concussion history, and attention-deficit/hyperactivity disorder on eye tracking and other ophthalmological measures. METHODS A total of 102 male high school football athletes (age, 16.0 years; 95% confidence interval, 15.8 to 16.2 years) completed a series of visual and neurocognitive tests during their pre-season baseline assessment. The main outcome measures were BOX score, near point of convergence (NPC) distance, binocular accommodative amplitude (BAA) distance, Standardized Assessment of Concussion score, and Immediate Post-Concussion Assessment and Cognitive Testing composite scores. RESULTS BOX score was not significantly associated with symptoms, Standardized Assessment of Concussion score, NPC distance, BAA distance, or any Immediate Post-Concussion Assessment and Cognitive Testing composite scores. Age, concussion history, attention-deficit/hyperactivity disorder, and number of prior years playing football were not significantly associated with BOX score or NPC distance, but there was a significant association between concussion history and greater BAA distance (β = 1.60; 95% confidence interval = 0.19 to 3.01; P < .03). The BOX score cutoff of 10 resulted in a 12% false-positive rate. CONCLUSIONS Eye tracking was not significantly associated with the commonly used clinical concussion assessments. These results suggest that an objective eye tracking variable may be a valuable addition to the current concussion battery.
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Affiliation(s)
- Jessie R. Oldham
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
- Division of Sports Medicine, Department of Orthopedics, Boston Children’s Hospital, Boston, MA, USA
| | - Christina L. Master
- Sports Medicine and Performance Center, Division of Orthopedics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory A. Walker
- Sports Medicine Center, Children’s Hospital Colorado, Aurora, CO, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - William P. Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
- Division of Sports Medicine, Department of Orthopedics, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics and Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - David R. Howell
- Sports Medicine Center, Children’s Hospital Colorado, Aurora, CO, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
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21
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Abstract
Recent research has yielded multivariate base rates (MBRs) of low scores in healthy populations using a widely adopted concussion screening measure, Immediate Postconcussion and Cognitive Testing (ImPACT). However, the extent to which individuals with concussion obtain reliable changes at divergent frequencies relative to healthy individuals is largely unknown. The present study examined whether MBRs of reliable change accurately discriminated between those with and without concussion. This archival review consisted of 129 healthy individuals and 81 individuals with concussion. MBRs of reliable change scores were examined at varying cutoffs and frequencies between those with and without concussion. Composites showed small to medium effect sizes in differentiating between those with and without concussion. MBRs of reliable change scores on ImPACT provided limited discriminative utility in isolation. Computations of posttest probabilities using Bayes' Theorem yielded evidence for incremental gains when utilizing MBRs of reliable change under certain constraints.
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Affiliation(s)
- Charles E Gaudet
- Brown University, Providence, Rhode Island, USA.,University of Rhode Island, Kingston, Rhode Island, USA
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22
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Gaudet CE, Konin J, Faust D. Immediate Post-concussion and Cognitive Testing: Ceiling Effects, Reliability, and Implications for Interpretation. Arch Clin Neuropsychol 2021; 36:561-569. [PMID: 32978632 DOI: 10.1093/arclin/acaa074] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 06/22/2020] [Accepted: 08/24/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The most commonly used computerized neurocognitive test in concussion assessment and management, Immediate Post-concussion and Cognitive Testing (ImPACT), has demonstrated varying and sometimes concerning levels of test-retest reliability. This study aimed to further examine ImPACT's psychometric qualities and whether ceiling effects may suppress its reliability. METHOD A total of 300 consecutively selected ImPACT score reports for students attending a secondary school between 2010 and 2015 were reviewed. Test-retest reliabilities for composite scores and subscales were computed using Pearson product moment correlations (r) and intraclass correlation coefficients. To examine the potential influence of ceiling effects, we conducted frequency analyses of scores falling at, or near, the maximum possible score. RESULTS A total of 92 score reports met inclusion criteria. Test-retest reliabilities ranged from 0.42 to 0.69 for composite scores and 0.19 to 0.71 for subscales. Subscales comprising the Verbal and Visual Memory composites evidenced the most prominent ceiling effects. CONCLUSIONS Obtained test-retest reliabilities were consistent with a large segment of the literature and add to concerns about ImPACT's reliability. Furthermore, at least in a select sample, this study identified sizeable ceiling effects that likely diminish the reliability of some composite scores. To mitigate the risk of false-negative errors on post-injury testing, ImPACT users should be cognizant of such ceiling effects. Supplemental, or alternative, approaches to protect against underestimating baseline functioning also warrant consideration.
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Affiliation(s)
- Charles E Gaudet
- Department of Psychology, University of Rhode Island, Kingston, RI, USA
| | - Jeff Konin
- Department of Athletic Training, Florida International University, Miami, FL, USA
| | - David Faust
- Department of Psychology, University of Rhode Island, Kingston, RI, USA
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23
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Certified Athletic Trainers' Use of Cervical Clinical Testing in the Diagnosis and Management of Sports-Related Concussion. J Sport Rehabil 2021; 30:926-934. [PMID: 33771946 DOI: 10.1123/jsr.2020-0394] [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: 08/31/2020] [Revised: 12/22/2020] [Accepted: 12/30/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Despite evidence implicating cervicogenic symptoms in the development of persistent postconcussion symptoms, factors that influence utilization of cervical clinical tests to identify cervicogenic symptoms following concussion are poorly understood. OBJECTIVE Explore barriers to the utilization of cervical clinical testing in multifaceted concussion evaluation. DESIGN Cross-sectional. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS A total of 122 athletic trainers (AT) (age = 42.6 [6.4] y; female = 51.6%; 52% >10 y of clinical practice; 68% master's degree or greater; 35% treated a minimum of 15 concussions/y). MAIN OUTCOME MEASURE(S) Perceived importance, clinical experience, number of concussions treated, utilization of cervical clinical tests following nonspecific cervical pathology and following concussion, comfort with cervical treatment modalities following a concussion, and recommendation for cervical-specific therapy to treat persistent postconcussion symptoms. RESULTS Ordinal logistic regression revealed perceived importance had the strongest positive impact on AT's likelihood of high utilization of cervical clinical testing following concussion (95% CI, .17 to .99; P = .005), while clinical experience (95% CI, -.43 to .29; P = .71) and number of concussions treated/y (95% CI, -.21 to .31; P = .71) had no bearing. Moreover, low comfort with cervical treatments following a concussion (95% CI, -2.86 to -.26; P = .018) and low utilization of cervical clinical testing following nonspecific cervical pathology (95% CI, -7.01 to -3.39; P ≤ .001) had a strong positive impact on high utilization of cervical clinical testing following concussion. Two logistic regression models demonstrated how recommendations for cervical-specific therapy in persistent post-concussion symptom patients could be predicted based on (1) cervical test utilization and (2) perceptions and clinical experience with 79% and 78%, respectively. CONCLUSIONS Perceived importance played a major role in utilization of cervical clinical test following concussion. ATs who utilized common cervical treatments when dealing with non-concussive injuries were more likely to utilize those same treatments to treat comorbid cervical pathology following a concussion.
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24
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Ferris LM, Kontos AP, Eagle SR, Elbin RJ, Collins MW, Mucha A, Clugston JR, Port NL. Predictive Accuracy of the Sport Concussion Assessment Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In Combination: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Consortium Analysis. Am J Sports Med 2021; 49:1040-1048. [PMID: 33600216 DOI: 10.1177/0363546520988098] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vestibular and ocular symptoms in sport-related concussions are common. The Vestibular/Ocular-Motor Screening (VOMS) tool is a rapid, free, pen-and-paper tool that directly assesses these symptoms and shows consistent utility in concussion identification, prognosis, and management. However, a VOMS validation study in the acute concussion period of a large sample is lacking. PURPOSE To examine VOMS validity among collegiate student-athletes, concussed and nonconcussed, from the multisite National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. A secondary aim was to utilize multidimensional machine learning pattern classifiers to deduce the additive power of the VOMS in relation to components of the Sport Concussion Assessment Tool 3 (SCAT3). STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS Preseason and acute concussion assessments were analyzed for 419 student-athletes. Variables in the analysis included the VOMS, Balance Error Scoring System, Standardized Assessment of Concussion, and SCAT3 symptom evaluation score. Descriptive statistics were calculated for all tools, including Kolmogorov-Smirnov significance and Cohen d effect size. Correlations between tools were analyzed with Spearman r, and predictive accuracy was evaluated through an Ada Boosted Tree machine learning model's generated receiver operating characteristic curves. RESULTS Total VOMS scores and SCAT3 symptom scores demonstrated significant increases in the acute concussion time frame (Cohen d = 1.23 and 1.06; P < .0001), whereas the Balance Error Scoring System lacked clinical significance (Cohen d = 0.17). Incorporation of VOMS into the full SCAT3 significantly boosted overall diagnostic ability by 4.4% to an area under the curve of 0.848 (P < .0001) and produced a 9% improvement in test sensitivity over the existing SCAT3 battery. CONCLUSION The results from this study highlight the relevance of the vestibular and oculomotor systems to concussion and the utility of the VOMS tool. Given the 3.8 million sports-related and 45,121 military-related concussions per year, the addition of VOMS to the SCAT3 is poised to identify up to an additional 304,000 athletes and 3610 servicemembers annually who are concussed, thereby improving concussion assessment and diagnostic rates. Health care providers should consider the addition of VOMS to their concussion assessment toolkits, as its use can positively affect assessment and management of concussions, which may ultimately improve outcomes for this complex and common injury.
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Affiliation(s)
- Lyndsey M Ferris
- Indiana University School of Optometry, Bloomington, Indiana, USA
| | | | - Shawn R Eagle
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - R J Elbin
- University of Arkansas, Fayatteville, Arkansas, USA
| | | | - Anne Mucha
- UPMC Centers for Rehab Services, Pittsburgh, Pennsylvania, USA
| | | | - Nicholas L Port
- Indiana University School of Optometry, Bloomington, Indiana, USA
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25
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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: 20] [Impact Index Per Article: 6.7] [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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26
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Caccese JB, Eckner JT, Franco-MacKendrick L, Hazzard JB, Ni M, Broglio SP, McAllister TW, McCrea M, Buckley TA. Clinical Reaction-Time Performance Factors in Healthy Collegiate Athletes. J Athl Train 2020; 55:601-607. [PMID: 32320283 DOI: 10.4085/1062-6050-164-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT In the absence of baseline testing, normative data may be used to interpret postconcussion scores on the clinical reaction-time test (RTclin). However, to provide normative data, we must understand the performance factors associated with baseline testing. OBJECTIVE To explore performance factors associated with baseline RTclin from among candidate variables representing demographics, medical and concussion history, self-reported symptoms, sleep, and sport-related features. DESIGN Cross-sectional study. SETTING Clinical setting (eg, athletic training room). PATIENTS OR OTHER PARTICIPANTS A total of 2584 National Collegiate Athletic Association student-athletes (n = 1206 females [47%], 1377 males [53%], and 1 unreported (<0.1%); mass = 76.7 ± 18.7 kg; height = 176.7 ± 11.3 cm; age = 19.0 ± 1.3 years) from 3 institutions participated in this study as part of the Concussion Assessment, Research and Education Consortium. MAIN OUTCOME MEASURE(S) Potential performance factors were sex; race; ethnicity; dominant hand; sport type; number of prior concussions; presence of anxiety, learning disability, attention-deficit disorder or attention-deficit/hyperactivity disorder, depression, or migraine headache; self-reported sleep the night before the test; mass; height; age; total number of symptoms; and total symptom burden at baseline. The primary study outcome measure was mean baseline RTclin. RESULTS The overall RTclin was 202.0 ± 25.0 milliseconds. Female sex (parameter estimate [B] = 8.6 milliseconds, P < .001, Cohen d = 0.54 relative to male sex), black or African American race (B = 5.3 milliseconds, P = .001, Cohen d = 0.08 relative to white race), and limited-contact (B = 4.2 milliseconds, P < .001, Cohen d = 0.30 relative to contact) or noncontact (B = 5.9 milliseconds, P < .001, Cohen d = 0.38 relative to contact) sport participation were associated with slower RTclin. Being taller was associated with a faster RTclin, although this association was weak (B = -0.7 milliseconds, P < .001). No other predictors were significant. When adjustments are made for sex and sport type, the following normative data may be considered (mean ± standard deviation): female, noncontact (211.5 ± 25.8 milliseconds), limited contact (212.1 ± 24.3 milliseconds), contact (203.7 ± 21.5 milliseconds); male, noncontact (199.4 ± 26.7 milliseconds), limited contact (196.3 ± 23.9 milliseconds), contact (195.0 ± 23.8 milliseconds). CONCLUSIONS Potentially clinically relevant differences existed in RTclin for sex and sport type. These results provide normative data adjusting for these performance factors.
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Affiliation(s)
- Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus
| | - James T Eckner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
| | | | | | - Meng Ni
- The Institute for Concussion Research & Services, Bloomsburg University, Pennsylvania
| | | | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology and Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark
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27
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Baugh CM, Kroshus E, Lanser BL, Lindley TR, Meehan WP. Sports Medicine Staffing Across National Collegiate Athletic Association Division I, II, and III Schools: Evidence for the Medical Model. J Athl Train 2020; 55:573-579. [PMID: 32364760 DOI: 10.4085/1062-6050-0463-19] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT The ratio of clinicians to patients has been associated with health outcomes in many medical contexts but has not been explored in collegiate sports medicine. The relationship between administrative and financial oversight models and staffing is also unknown. OBJECTIVE To (1) evaluate staffing patterns in National Collegiate Athletic Association sports medicine programs and (2) investigate whether staffing was associated with the division of competition, Power 5 conference status, administrative reporting structure (medical or athletic department), or financial structure (medical or athletic department). DESIGN Cross-sectional study. SETTING Collegiate sports medicine programs. PATIENTS OR OTHER PARTICIPANTS Representatives of 325 universities. MAIN OUTCOME MEASURE(S) A telephone survey was conducted during June and July 2015. Participants were asked questions regarding the presence and full-time equivalence of the health care providers on their sports medicine staff. The number of athletes per athletic trainer was determined. RESULTS Responding sports medicine programs had 0.5 to 20 full-time equivalent staff athletic trainers (median = 4). Staff athletic trainers at participating schools cared for 21 to 525 athletes per clinician (median = 100). Both administrative and financial oversight from a medical department versus the athletics department was associated with improved staffing across multiple metrics. Staffing levels were associated with the division of competition; athletic trainers at Division I schools cared for fewer athletes than athletic trainers at Division II or III schools, on average. The support of graduate assistant and certified intern athletic trainers varied across the sample as did the contributions of nonphysician, nonathletic trainer health care providers. CONCLUSIONS In many health care settings, clinician : patient ratios are associated with patient health outcomes. We found systematic variations in clinician : patient ratios across National Collegiate Athletic Association divisions of competition and across medical versus athletics organizational models, raising the possibility that athletes' health outcomes vary across these contexts. Future researchers should evaluate the relationships between clinician : patient ratios and athletes' access to care, care provision, health care costs, health outcomes, and clinician job satisfaction.
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Affiliation(s)
- Christine M Baugh
- Interfaculty Initiative in Health Policy, Harvard University, Boston, MA
| | - Emily Kroshus
- Department of Pediatrics, University of Washington, Seattle.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute
| | | | - Tory R Lindley
- Intercollegiate Sports Medicine, Northwestern University, Evanston, IL
| | - William P Meehan
- Division of Sports Medicine, Sports Concussion Clinic, Boston Children's Hospital, MA. Dr Baugh is now at the Center for Bioethics and Humanities, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora
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28
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Baugh CM, Meehan WP, McGuire TG, Hatfield LA. Staffing, Financial, and Administrative Oversight Models and Rates of Injury in Collegiate Athletes. J Athl Train 2020; 55:580-586. [PMID: 32348154 DOI: 10.4085/1062-6050-0517.19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Structural features of health care environments are associated with patient health outcomes, but these relationships are not well understood in sports medicine. OBJECTIVE To evaluate the association between athlete injury outcomes and structural measures of health care at universities: (1) clinicians per athlete, (2) financial model of the sports medicine department, and (3) administrative reporting structure of the sports medicine department. DESIGN Descriptive epidemiology study. SETTING Collegiate sports medicine programs. PATIENTS OR OTHER PARTICIPANTS Colleges that contribute data to the National Collegiate Athletic Association (NCAA) Injury Surveillance Program. MAIN OUTCOME MEASURE(S) We combined injury data from the NCAA Injury Surveillance Program, sports medicine staffing data from NCAA Research, athletic department characteristics from the United States Department of Education, and financial and administrative oversight model data from a previous survey. Rates of injury, reinjury, concussion, and time loss (days) in NCAA athletes. RESULTS Compared with schools that had an average number of clinicians per athlete, schools 1 standard deviation above average had a 9.5% lower injury incidence (103.6 versus 93.7 per 10000 athlete-exposures [AEs]; incidence rate ratio [IRR] = 0.905, P < .001), 2.7% lower incidence of reinjury (10.6 versus 10.3 per 10000 AEs; IRR = 0.973, P = .004), and 6.7% lower incidence of concussion (6.1 versus 5.7 per 10000 AEs; IRR = 0.933, P < .001). Compared with the average, schools that had 1 standard deviation more clinicians per athlete had 16% greater injury time loss (5.0 days versus 4.2 days; IRR = 1.16, P < .001). At schools with sports medicine departments financed by or reporting to the athletics department (or both), athletes had higher injury incidences (31% and 9%, respectively). CONCLUSIONS The financial and reporting structures of collegiate sports medicine departments as well as the number of clinicians per athlete were associated with injury risk. Increasing the number of sports medicine clinicians on staff and structuring sports medicine departments such that they are financed by and report to a medical institution may reduce athlete injury incidence.
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Affiliation(s)
- Christine M Baugh
- Interfaculty Initiative in Health Policy, Harvard University, Boston, MA
| | - William P Meehan
- Division of Sports Medicine, Sports Concussion Clinic, Boston Children's Hospital, MA
| | - Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School, Boston, MA. Dr Baugh is now at the Center for Bioethics and Humanities, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, MA. Dr Baugh is now at the Center for Bioethics and Humanities, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora
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29
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Buckley TA, Howard CM, Oldham JR, Lynall RC, Swanik CB, Getchell N. No Clinical Predictors of Postconcussion Musculoskeletal Injury in College Athletes. Med Sci Sports Exerc 2020; 52:1256-1262. [PMID: 31972629 DOI: 10.1249/mss.0000000000002269] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to identify clinical predictors of postconcussion subsequent musculoskeletal (MSK) injuries. METHODS We recruited 66 National Collegiate Athletic Association intercollegiate student-athletes with a diagnosed concussion as well as 36 National Collegiate Athletic Association student-athletes without a concussion. All participants completed a multifaceted concussion baseline consisting of 1) 22-item 0-6 self-reported symptom checklist with outcomes including both the number of symptoms endorsed (0-22) and 2) total symptom score (0-132), 3) Standard Assessment of Concussion, 4) Balance Error Scoring System, 5) Immediate Post-Concussion Assessment and Cognitive Testing, 6) clinical reaction time, and 7) the King-Devick as well as demographic and injury characteristics. The concussion participants completed the same examination acutely postconcussion, and binary logistic regression was used to identify predictors of subsequent MSK from the change scores (acute minus baseline). From the 66 concussed student-athletes, a subset 36, matched with the healthy athletes, compared the risk of subsequent MSK in the year before and year after their concussion. RESULTS The concussion participants were 1.78 times (95% confidence interval, 1.12-2.84; P = 0.015) more likely to suffer a lower extremity MSK in the year after their concussion than the control participants. The participant demographics and injury characteristics (P = 0.318) and concussion clinical outcomes (P = 0.461) did not predict subsequent MSK. CONCLUSION The concussion participants were 1.78 times more likely to sustain a subsequent MSK; however, no demographic, injury characteristic, or concussion assessments predicted the MSK. Thus, clinicians are not able to utilize common neurological measures or participant demographics to identify those at risk for subsequent lower extremity MSK. Injury prevention strategies should be considered for collegiate student-athletes upon premature return to participation after a concussion to reduce the subsequent MSK.
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Affiliation(s)
| | - Caroline M Howard
- Department of Intercollegiate Athletics, University of Delaware, Newark, DE
| | - Jessie R Oldham
- Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, MA
| | - Robert C Lynall
- Department of Kinesiology, University of Georgia, Athens, GA
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Walton SR, Broshek DK, Freeman JR, Hertel J, Meyer JP, Erdman NK, Resch JE. Institutionally Based ImPACT Test® Normative Values May Differ from Manufacturer-Provided Normative Values. Arch Clin Neuropsychol 2020; 35:275-282. [PMID: 31711107 DOI: 10.1093/arclin/acz068] [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: 07/30/2019] [Revised: 08/30/2019] [Accepted: 10/15/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The necessity for pre-injury baseline computerized neurocognitive assessments versus comparing post-concussion outcomes to manufacturer-provided normative data is unclear. Manufacturer-provided norms may not be equivalent to institution-specific norms, which poses risks for misclassifying the presence of impairment when comparing individual post-concussion performance to manufacturer-provided norms. The objective of this cohort study was to compare institutionally derived normative data to manufacturer-provided normative values provided by ImPACT® Applications, Incorporated. METHOD National Collegiate Athletic Association Division 1 university student athletes (n = 952; aged 19.2 ± 1.4 years, 42.5% female) from one university participated in this study by completing pre-injury baseline Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) assessments. Participants were separated into 4 groups based on ImPACT's age and gender norms: males <18 years old (n = 186), females <18 years old (n = 165), males >19 years old (n = 361) or females >19 years old (n = 240). Comparisons were made between manufacturer-provided norms and institutionally derived normative data for each of ImPACT's clinical composite scores: Verbal (VEM) and Visual (VIM) Memory, Visual Motor Speed (VMS), and Reaction Time (RT). Outcome scores were compared for all groups using a Chi-squared goodness of fit analysis. RESULTS Institutionally derived normative data indicated above average performance for VEM, VIM, and VMS, and slightly below average performance for RT compared to the manufacturer-provided data (χ2 ≥ 20.867; p < 0.001). CONCLUSIONS Differences between manufacturer- and institution-based normative value distributions were observed. This has implications for an increased risk of misclassifying impairment following a concussion in lieu of comparison to baseline assessment and therefore supports the need to utilize baseline testing when feasible, or otherwise compare to institutionally derived norms rather than manufacturer-provided norms.
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Affiliation(s)
- Samuel R Walton
- Department of Kinesiology, University of Virginia, Charlottesville, VA 22903, USA.,Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Donna K Broshek
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Jason R Freeman
- Department of Athletics, Sports Psychology, University of Virginia, Charlottesville, VA 22903, USA
| | - Jay Hertel
- Department of Kinesiology, University of Virginia, Charlottesville, VA 22903, USA
| | - J Patrick Meyer
- Department of Leadership, Foundations and Policy, University of Virginia, Charlottesville, VA 22903, USA.,Northwest Evaluation Association, Portland, OR 97209, USA
| | - Nicholas K Erdman
- Department of Kinesiology, University of Virginia, Charlottesville, VA 22903, USA
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, VA 22903, USA
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Validity of Postural Sway Assessment on the Biodex BioSway™ Compared With the NeuroCom Smart Equitest. J Sport Rehabil 2020; 30:516-520. [PMID: 32882681 DOI: 10.1123/jsr.2020-0227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Current tools for sideline assessment of balance following a concussion may not be sufficiently sensitive to identify impairments, which may place athletes at risk for future injury. Quantitative field-expedient balance assessments are becoming increasingly accessible in sports medicine and may improve sensitivity to enable clinicians to more readily detect these subtle deficits. OBJECTIVE To determine the validity of the postural sway assessment on the Biodex BioSway™ compared with the gold standard NeuroCom Smart Equitest System. DESIGN Cross-sectional cohort study. SETTING Clinical research laboratory. PARTICIPANTS Forty-nine healthy adults (29 females: 24.34 [2.45] y, height 163.65 [7.57] cm, mass 63.64 [7.94] kg; 20 males: 26.00 [3.70] y, height 180.11 [7.16] cm, mass 82.97 [12.78] kg). INTERVENTION(S) The participants completed the modified clinical test of sensory interaction in balance on the Biodex BioSway™ with 2 additional conditions (head shake and firm surface; head shake and foam surface) and the Sensory Organization Test and Head Shake Sensory Organization Test on the NeuroCom Smart Equitest. MAIN OUTCOME MEASURES Interclass correlation coefficient and Bland-Altman limits of agreement for Sway Index, equilibrium ratio, and area of 95% confidence ellipse. RESULTS Fair-good reliability (interclass correlation coefficient = .48-.65) was demonstrated for the stance conditions with eyes open on a firm surface. The Head Shake Sensory Interaction and Balance Test condition on a firm surface resulted in fair reliability (interclass correlation coefficient = .50-.59). The authors observed large ranges for limits of agreement across outcome measures, indicating that the systems should not be used interchangeably. CONCLUSIONS The authors observed fair reliability between BioSway™ and NeuroCom, with better agreement between systems with the assessment of postural sway on firm/static surfaces. However, the agreement of these systems may improve by incorporating methods that mitigate the floor effect in an athletic population (eg, including a head shake condition). BioSway™ may provide a surrogate field-expedient measurement tool.
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Buckley T, Murray NG, Munkasy BA, Oldham JR, Evans KM, Clouse B. Impairments in Dynamic Postural Control across Concussion Clinical Milestones. J Neurotrauma 2020; 38:86-93. [PMID: 32674657 DOI: 10.1089/neu.2019.6910] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim of this study was to assess gait initiation (GI) performance longitudinally across clinical concussion recovery milestones through return to participation (RTP). We recruited 54 collegiate student-athletes, 27 with concussions and 27 matched controls (15 female and 12 male per group). Participants performed five trials of GI at baseline and again at five post-concussion clinical milestones: 1) Acute, the day clinical tests achieved baseline values on the 2) Balance Error Scoring System (BESS), 3) Immediate Post-Concussion Assessment and Cognitive Test ImPACT, 4) Asymptomatic, and 5) RTP Day. GI performance on six outcome measures (anterior/posterior and medial/lateral center of pressure displacements and velocities during the anticipatory postural adjustment [APA] phase and initial step length and velocity) with repeated-measures mixed model and pair-wise post hoc. A reliable change index (RCI) was calculated, and post-concussion participant's performance was compared to the RCI at milestones. There were significant interactions for APA posterior and lateral displacement, APA posterior velocity, step length, and step velocity. The post-hoc tests identified significant deficits across clinical milestones and at RTP for APA posterior and lateral displacement, step length, and step velocity. There were no post-hoc differences for any outcome measure in the control group. At RTP, 85.2-88.9% of concussion participants had at least one outcome measure which exceeded the 80% or 95% RCI. The primary finding of this study was persistent impairments in dynamic postural control, suggesting ongoing neurophysiological impairment despite clinical recovery. These results suggest that collegiate student-athletes may be RTP before neurophysiological recovery and potentially exposing themselves to elevated risk of recurrent concussion or subsequent musculoskeletal injury.
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Affiliation(s)
- Thomas Buckley
- Department of Kinesiology and Applied Physiology, Interdisciplinary program in Biomechanics and Movement Science University of Delaware, Newark, Delaware, USA
| | - Nicholas G Murray
- School of Community Health Sciences, University of Nevada, Reno, Nevada, USA
| | - Barry A Munkasy
- School of Health and Kinesiology, Georgia Southern University, Statesboro, Georgia, USA
| | - Jessie R Oldham
- Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, Massachusetts, USA
| | - Kelsey M Evans
- Department of Surgery, Orlando Health, Orlando, Florida, USA
| | - Brandy Clouse
- Department of Intercollegiate Athletics, Georgia Southern University, Statesboro, Georgia, USA
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Bliss RA, Carr WD. KNOWLEDGE OF VESTIBULAR OCULAR DYSFUNCTION AND UTILIZATION OF VESTIBULAR OCULAR MOTOR SCREENING (VOMS) TOOL COMPONENTS AMONG PROFESSIONAL SPORTS LEAGUE ATHLETIC TRAINERS. Int J Sports Phys Ther 2020; 15:603-610. [PMID: 33354393 PMCID: PMC7735692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The Vestibular Ocular Motor Screen (VOMS) is a relatively new measurement tool intended for the non-vestibular practitioner to identify vestibular ocular dysfunction (VOD) following sport related concussion (SRC). Specific knowledge of VOD and usage of the VOMS among athletic trainers in professional sports leagues is currently unknown. HYPOTHESIS/PURPOSE The purpose of this study was to examine knowledge of VOD following SRC and utilization of the VOMS tool and other vestibular ocular tests and measures among athletic trainers in professional sports. STUDY DESIGN Cross Sectional Study. METHODS A total of 117 athletic trainers from Major League Baseball, the National Basketball Association, the National Football League and Major League Soccer, with a mean of 17 ± 9 years in the athletic training profession were surveyed via Qualtrics™ with a response rate of 33%. The survey contained three primary sub-sections; demographics, knowledge of vestibular ocular deficits following SRC, and VOMS component utilization at baseline, acute and return-to-play phases of management. Total knowledge scores as well as percentage of utilization based on concussion management stages were calculated. RESULTS The average percentage correct on the knowledge items was 56% (range of 30% to 65%). There was no difference in knowledge score among athletic trainers with formal post-professional concussion training (p = 0.29) compared to those with no formal training. There was no relationship found between total years practicing and total knowledge score, r = -.128, (p = 0.17). Smooth pursuit testing was the most commonly utilized (70%) in clinical practice and Visual Motion Sensitivity (VMS) was the least utilized (17%). Balance assessment measures to examine vestibular functioning remained the highest utilized examination technique at all-time points in management of SRC. CONCLUSION The range of correct responses from 30% to 65% indicates that at the time of survey the participants had decreased knowledge of VOD following SRC. There was low overall utilization of all VOMS components despite recent evidence showing good sensitivity and low false positive rates in SRC. The results of this study identify an opportunity for future training specific to vestibular-ocular impairments and assessment following concussion injury. LEVEL OF EVIDENCE 2c.
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Affiliation(s)
- Rebecca A Bliss
- University of Missouri, Department of Physical Therapy, Columbia, MO, USA
| | - W. David Carr
- Missouri State University, Department of Public Health and Sports Medicine, Springfi ed, MO, USA
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College Athletic Trainers' Perceptions of Rest and Physical Activity When Managing Athletes With a Sport-Related Concussion. J Sport Rehabil 2020; 30:395-400. [PMID: 32736343 DOI: 10.1123/jsr.2019-0084] [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: 02/24/2019] [Revised: 04/09/2020] [Accepted: 05/08/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Cognitive and physical rest are commonly utilized when managing a sport-related concussion (SRC); however, emerging research now suggests that excessive rest may negatively impact recovery. Despite current research recommendations, athletic trainers (ATs) may be behind in implementing this emerging research into clinical practice. OBJECTIVE To assess college ATs' perceptions and implementation of an emerging SRC management approach (cognitive and physical rest and activity). DESIGN Cross-sectional study. SETTING Survey. PARTICIPANTS A total of 122 (11.8%) ATs (53.3% female; 10.8 [9.8] y experience; 8.7 [6.9] SRCs managed annually) responded to the survey, which was randomly distributed to 1000 members of the National Athletic Trainers' Association, as well as 31 additional ATs from varying universities. MAIN OUTCOME MEASURES A 5-point Likert scale assessed the ATs' perceptions and clinical practices as they relate to specific athlete behaviors (ie, texting, sleeping). The ATs were asked about their willingness to incorporate physical activity into clinical practice. RESULTS Playing video games (95.9%) and practicing (93.4%) were the activities most perceived to extend SRC recovery. However, sleeping more than usual (7.4%) and increased time in a dark environment (11.5%) were viewed as less likely to extend recovery. ATs restricted practicing (98.4%) and working out (91.8%) for athletes with SRC, while sleeping more than usual (6.6%) and increased time in a dark environment (13.1%) were less restricted. About 71% of the ATs would implement light physical activity for athletes with a symptom score of 1 to 5, 31% with scores of 6 to 10, and 15% with scores of 11 to 20. About 43%, 74%, and 97% believe that light, moderate, and vigorous physical activity, while symptomatic, will extend recovery, respectively. CONCLUSIONS The ATs were receptive to including light physical activity into their SRC management, although only in certain situations. However, most ATs' beliefs and clinical practices did not completely align with emerging research recommendations for the management of SRCs.
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Lempke LB, Schmidt JD, Lynall RC. Concussion Knowledge and Clinical Experience Among Athletic Trainers: Implications for Concussion Health Care Practices. J Athl Train 2020; 55:666-672. [PMID: 32556144 DOI: 10.4085/1062-6050-340-19] [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] [Indexed: 11/09/2022]
Abstract
CONTEXT Athletic trainers (ATs) are heavily involved in concussion assessment and return-to-play (RTP) decision making. Despite ATs' crucial role, few researchers have directly examined ATs' knowledge of concussions or whether concussion knowledge or clinical experience affects clinical concussion-management practices. OBJECTIVE To determine the overall concussion knowledge of ATs and whether concussion knowledge and clinical experience affect concussion-assessment and -management practices. DESIGN Cross-sectional study. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS Random convenience sample of 8725 (15.0% response rate [1307/8725]; certified, 14.8 ± 10.6 years) ATs surveyed from the National Athletic Trainers' Association membership. MAIN OUTCOME MEASURE(S) The survey collected demographics, concussion-assessment and -management tools used, and concussion knowledge (patient-clinician scenarios, signs and symptoms recognition). We used multiple logistic regression models to determine the odds ratios (ORs) for using assessment and management tools based on signs and symptoms recognition and years of clinical experience. RESULTS The ATs correctly identified 78.0% ± 15.1% of concussion signs and symptoms. Approximately 46% (357/770) of ATs indicated an athlete could RTP if the athlete stated he or she had a "bell rung." Every additional year of clinical experience decreased the odds of using standardized sideline-assessment tools by 3% (OR = 0.97, 95% Confidence Interval [CI] = 0.95, 0.99). The odds of using standardized sideline tools (OR = 0.98, 95% CI = 0.96, 0.99) and symptom checklists (OR = 0.98, 95% CI = 0.97, 0.99) for RTP assessment were significantly decreased for each additional year of clinical experience. No other tools used for RTP assessment were influenced by signs and symptoms recognition (P ≥ .136) or clinical experience (P ≥ .158). CONCLUSIONS The ATs with greater clinical experience had lower odds of using concussion-assessment and -management tools. Athletic trainers should frequently review and implement current consensus guidelines into clinical practice to improve concussion recognition and prevent improper management.
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Affiliation(s)
- Landon B Lempke
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens
| | - Julianne D Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens
| | - Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens
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Baugh CM, Kerr ZY, Kroshus E, Lanser BL, Lindley TR, Meehan WP. Sports Medicine Staffing Patterns and Incidence of Injury in Collegiate Men's Ice Hockey. J Athl Train 2020; 55:587-593. [PMID: 32383984 DOI: 10.4085/1062-6050-0464.19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT The relative availability of clinicians as well as the types and training of health care providers have been associated with morbidity and mortality in non-athletic health care settings. Whether staffing variations are associated with injury incidence in collegiate athletes is unknown. OBJECTIVE To evaluate whether the institutional ratio of athletes to athletic trainers (patient load) or the ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers or both is associated with the incidence of injuries sustained by male ice hockey athletes at the school. DESIGN Descriptive epidemiology study. SETTING National Collegiate Athletic Association (NCAA) men's ice hockey teams. PATIENTS OR OTHER PARTICIPANTS Collegiate men's ice hockey athletes. MAIN OUTCOME MEASURE(S) The NCAA Injury Surveillance Program collected data from collegiate men's ice hockey athletes. Staffing patterns were obtained through telephone interviews. Injury counts, injury rates per 1000 athlete-exposures, and injury rate ratios with 95% confidence intervals were calculated and compared between the following groups: (1) schools with high (versus low) patient load and (2) schools with high (versus low) ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers. RESULTS Both the patient load and relative number of staff athletic trainers were associated with variations in the incidences and types of diagnosed injuries in male ice hockey players. Specifically, fewer injuries were diagnosed by clinicians at institutions with high patient loads. The rates of injury overall and non-time-loss injuries were lower in the high patient-load group. Time-loss injury rates, severe injury rates, concussion rates, and overall rates of injury during competition were greater in the group with a higher proportion of staff athletic trainers, whereas non-time-loss injury rates were lower. CONCLUSIONS In this study of collegiate men's ice hockey players, athlete health outcomes were directly related to the number and types of clinicians available. Future researchers should evaluate whether this finding extends beyond men's ice hockey.
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Affiliation(s)
- Christine M Baugh
- Interfaculty Initiative in Health Policy, Harvard University, Boston, MA.,Dr Baugh is now at the Center for Bioethics and Humanities, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora
| | - Zachary Y Kerr
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Emily Kroshus
- Department of Pediatrics, University of Washington, Seattle; Seattle Children's Research Institute, Center for Child Health, Behavior and Development
| | | | - Tory R Lindley
- Intercollegiate Sports Medicine, Northwestern University, Evanston, IL
| | - William P Meehan
- Division of Sports Medicine, Sports Concussion Clinic, Boston Children's Hospital, MA
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Buckley TA, Munkasy BA, Krazeise DA, Oldham JR, Evans KM, Clouse B. Differential Effects of Acute and Multiple Concussions on Gait Initiation Performance. Arch Phys Med Rehabil 2020; 101:1347-1354. [PMID: 32343972 DOI: 10.1016/j.apmr.2020.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/17/2020] [Accepted: 03/27/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To identify the effect of acute and multiple concussions on gait initiation performance. DESIGN Cohort study. SETTING University research center. PARTICIPANTS A population-based sample of participants (N=45) divided into 3 groups: No Prior Concussion, ≥3 Prior Concussions, and Acute Concussion. The Acute Concussion participants were assessed within 24 hours of their concussion. Participants were matched based on (1) sport, (2) position, and (3) anthropometric measures. INTERVENTIONS Participants were tested on a single occasion and performed 5 trials of gait initiation on 4 force plates. The No Prior Concussion and ≥3 Prior Concussions groups were tested out of their primary athletic season. MAIN OUTCOME MEASURES The dependent variables were the posterior and lateral displacement and velocity of the center of pressure (COP) during the anticipatory postural adjustment phase and initial step kinematics (step length and step velocity). Comparisons between groups used a 1-way analysis of variance with Tukey post hoc when significant effects were identified and effect sizes were calculated. RESULTS There were significant effects for group for all 6 outcome measures with large effect sizes. Post hoc tests identified differences between Acute Concussion and No Prior Concussion groups for all measures. The ≥3 Prior Concussions group and No Prior Concussion group were different for COP posterior displacement (4.91±1.09 and 4.91±1.09cm, respectively, P=.032, d=0.91) and velocity (0.18±0.06 and 0.27±0.08m/s, respectively, P=.002, d=1.27). CONCLUSION There was continuum of performance identified whereby the Acute Concussion participants performed worse and the No Prior Concussion participants performed the best. The ≥3 Prior Concussions generally fell between these 2 groups, but only statistical significance on COP posterior displacement and velocity. These results suggest there may be subtle neurophysiological deficits present in collegiate student-athletes with ≥3 Prior Concussions group, and further investigation over the lifespan is warranted.
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Affiliation(s)
- Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE; Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE.
| | - Barry A Munkasy
- School of Health and Kinesiology, Georgia Southern University, Statesboro, GA
| | | | - Jessie R Oldham
- Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, MA
| | - Kelsey M Evans
- Brody School of Medicine, Each Carolina University, Greenville, NC
| | - Brandy Clouse
- Department of Intercollegiate Athletics, Georgia Southern University, Statesboro, GA
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Caccese JB, DeWolf RM, Kaminski TW, Broglio SP, McAllister TW, McCrea M, Buckley TA. Estimated Age of First Exposure to American Football and Neurocognitive Performance Amongst NCAA Male Student-Athletes: A Cohort Study. Sports Med 2020; 49:477-487. [PMID: 30747378 DOI: 10.1007/s40279-019-01069-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Repetitive head impacts in young athletes are potentially detrimental to later life (e.g., age 50 + years) neurological function; however, it is unknown what the short-term effects (e.g., age 20 years) are in collegiate student-athletes. OBJECTIVE The purpose of this study was to determine the effect of the estimated age of first exposure to American tackle football participation on neurocognitive performance and symptom severity scores in collegiate student-athletes. METHODS We used a cohort study in which neurocognitive performance was assessed using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test in 4376 male athletes (age 19.3 ± 1.5 years, mass 96.3 ± 20.3 kg, height 185.0 ± 7.4 cm). Athletes were grouped by sport participation [American football (n = 3462) or non-contact (n = 914)] and estimated age of first exposure [< 12 years (n = 3022) or ≥ 12 years (n = 1354)]. The outcome measures were the four primary cognitive scores and the symptom severity score from ImPACT. We assessed primary outcomes across groups, controlling for age, learning accommodations, and concussion history. RESULTS Neurocognitive performance was not associated with the estimated age of first exposure-by-group interaction. CONCLUSION Our findings indicate that participation in American tackle football before age 12 years does not result in neurocognitive deficits in college. Therefore, we suggest the following: the consequences of early exposure to repetitive head impacts do not manifest by college, the ImPACT test was not sensitive enough to identify the effects of an earlier estimated age of first exposure, or there is no association between an earlier estimated age of first exposure and neurocognitive functioning. Future longitudinal studies are warranted.
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Affiliation(s)
- Jaclyn B Caccese
- Department of Kinesiology and Applied Physiology, University of Delaware, 349 Tower at STAR, 100 Discovery Blvd, Newark, DE, 19713, USA
| | - Ryan M DeWolf
- Massachusetts General Hospital, Institute of Health Professions, Boston, MA, USA
| | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, 349 Tower at STAR, 100 Discovery Blvd, Newark, DE, 19713, USA
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, DE, USA
| | - Steven P Broglio
- NeuroTrauma Research Laboratory, University of Michigan Injury Center, University of Michigan, Ann Arbor, MI, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael McCrea
- Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, 349 Tower at STAR, 100 Discovery Blvd, Newark, DE, 19713, USA.
- Biomechanics and Movement Science Interdisciplinary Program, University of Delaware, Newark, DE, USA.
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Runyon LM, Welch Bacon CE, Neil ER, Eberman LE. Understanding the Athletic Trainer's Role in the Return-to-Learn Process at National Collegiate Athletic Association Division II and III Institutions. J Athl Train 2020; 55:365-375. [PMID: 32053405 DOI: 10.4085/1062-6050-116-19] [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] [Indexed: 11/09/2022]
Abstract
CONTEXT Postconcussion, student-athletes should return to the classroom using a gradual, stepwise process to ensure that symptoms are not exacerbated by cognitive activities. The National Collegiate Athletic Association (NCAA) has mandated that its affiliated institutions develop return-to-learn (RTL) policies to support the return to the classroom. OBJECTIVE To investigate athletic trainers' (ATs') perceptions of their role in the RTL policy development and implementation at NCAA Division II and III institutions. DESIGN Qualitative study. SETTING Individual phone interviews. PATIENTS OR OTHER PARTICIPANTS Fifteen ATs (age = 40 ± 11 years, clinical practice experience = 16 ± 9 years, employment term = 9 ± 9 years) representing NCAA Division II (n = 6) or III (n = 9) institutions. DATA COLLECTION AND ANALYSIS Interviews were transcribed verbatim and checked for accuracy by the principal investigator. A 2-member data-analysis team independently coded a portion of the transcripts and then met to discuss the codebook. The codebook was applied to the remaining transcripts, confirmed, and externally reviewed. RESULTS Five themes emerged: (1) approach, (2) collaborative practice, (3) patient advocacy, (4) institutional autonomy, and (5) barriers. Policies must allow for an individualized, evidence-based approach through facilitated, active communication among members of the RTL team and the student-athlete. Collaborative practice was described as key to successful policy implementation and should include interprofessional collaboration beyond health care providers (eg, educating academicians about the purpose of RTL). The RTL process was triggered by a specific member of the RTL team, usually a medical doctor or the head AT. Participants noted that the purpose of the RTL policy was to advocate for the student-athlete's successful postconcussion outcomes. CONCLUSIONS For the development and implementation of a successful RTL policy, strong communication and interprofessional practice must extend beyond health care professionals. Members of the health care team must establish a network with academic partners to develop a policy that is appropriate for the institution's available resources and the needs of its student-athletes.
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Affiliation(s)
- Lacey M Runyon
- Department of Human Movement Sciences, Carroll University, Waukesha, WI.,Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory, Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute
| | - Cailee E Welch Bacon
- Department of Interdisciplinary Health Sciences, A.T. Still University, Mesa, AZ
| | - Elizabeth R Neil
- Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory, Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute
| | - Lindsey E Eberman
- Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory, Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute
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40
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Anderson MN, Lempke LB, Bell DH, Lynall RC, Schmidt JD. The ability of CNS vital signs to detect coached sandbagging performance during concussion baseline testing: a randomized control trial. Brain Inj 2020; 34:369-374. [DOI: 10.1080/02699052.2020.1724332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- M. N. Anderson
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - L. B. Lempke
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - D. H. Bell
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - R. C. Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - J. D. Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
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41
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Gunasekaran P, Hodge C, Pearce A, King D, Fraser C. A review of concussion diagnosis and management in Australian professional sporting codes. PHYSICIAN SPORTSMED 2020; 48:1-7. [PMID: 31132020 DOI: 10.1080/00913847.2019.1624656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: The recognition and management of concussion has become a major health concern across all sports. Despite recent attention, concussion assessment and return-to-play protocols appear to be highly variable between leading professional sporting bodies across Australia. Without readily available guidelines, players at all levels may be at risk of suboptimal management following in-game trauma. The purpose of this study was to explore the publicly available concussion guidelines of the major Australian sporting codes with an aim to identify potential opportunities to develop a national sporting consensus.Methods: Internet sites of the major sporting organizations within Australia were accessed between June 2018 to July 2018. Sites were reviewed for information pertaining to an available concussion protocol or guidelines including; concussion definition, player education documentation, requirement of baseline testing, standard concussion diagnostic measures, use of sideline testing and removal from play guidelines, return-to-play, minimum return-to-play intervals and the implementation of external evaluation of potential concussion cases.Results: Twelve sites were visited. There was consensus between many of the sporting organizations in terms of concussion definition, removal of play and sideline testing protocols. A step-wise return-to-play protocol was prevalent across most sports. A number of sporting sites however did not have readily available information.Conclusions: There is notable room for the development of concussion guidelines in Australian sport. Researchers and sporting organizations need to continuously amend current protocols to ensure this reflects best evidence-based practice.
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Affiliation(s)
- Premkumar Gunasekaran
- Discipline of Orthoptics, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Christopher Hodge
- Discipline of Orthoptics, Graduate School of Health, University of Technology Sydney, Sydney, Australia.,The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, Australia
| | - Alan Pearce
- School of Allied Health, La Trobe University, Melbourne, Australia
| | - Doug King
- School of Science and Technology, University of New England, Armidale, Australia
| | - Clare Fraser
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, Australia
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42
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Dec KL, Kelly KC, Gilman JB. Management of Adult Sports Concussion. Concussion 2020. [DOI: 10.1016/b978-0-323-65384-8.00011-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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43
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Breedlove KM, Ortega JD, Kaminski TW, Harmon KG, Schmidt JD, Kontos AP, Clugston JR, Chrisman SPD, McCrea MA, McAllister TW, Broglio SP, Buckley TA. King-Devick Test Reliability in National Collegiate Athletic Association Athletes: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Report. J Athl Train 2019; 54:1241-1246. [PMID: 31618072 DOI: 10.4085/1062-6050-219-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT The King-Devick (KD) test has received considerable attention in the literature as an emerging concussion assessment. However, important test psychometric properties remain to be addressed in large-scale independent studies. OBJECTIVE To assess (1) test-retest reliability between trials, (2) test-retest reliability between years 1 and 2, and (3) reliability of the 2 administration modes. DESIGN Cross-sectional study. SETTING Collegiate athletic training facilities. PATIENTS OR OTHER PARTICIPANTS A total of 3248 intercollegiate student-athletes participated in year 1 (male = 55.3%, age = 20.2 ± 2.3 years, height = 1.78 ± 0.11 m, weight = 80.7 ± 21.0 kg) and 833 participated in both years. MAIN OUTCOME MEASURE(S) Time, in seconds, to complete the KD error free. The KD test reliability was assessed between trials and between annual tests over 2 years and stratified by test modality (spiral-bound cards [n = 566] and tablet [n = 264]). RESULTS The KD test was reliable between trials (trial 1 = 43.2 ± 8.3 seconds, trial 2 = 40.8 ± 7.8 seconds; intraclass correlation coefficient [ICC] (2,1) = 0.888, P < .001), between years (year 1 = 40.8 ± 7.4 seconds, year 2 = 38.7 ± 7.7 seconds; ICC [2,1] = 0.827, P < .001), and for both spiral-bound cards (ICC [2,1] = 0.834, P < .001) and tablets (ICC [2,1] = 0.827, P < .001). The mean change between trials for a single test was -2.4 ± 3.8 seconds. Although most athletes improved from year 1 to year 2, 27.1% (226 of 883) of participants demonstrated worse (slower) KD times (3.2 ± 3.9 seconds) in year 2. CONCLUSIONS The KD test was reliable between trials and years and when stratified by modality. A small improvement of 2 seconds was identified with annual retesting, likely due to a practice effect; however, 27% of athletes displayed slowed performance from year 1 to year 2. These results suggest that the KD assessment was a reliable test with modest learning effects over time and that the assessment modality did not adversely affect baseline reliability.
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Affiliation(s)
- Katherine M Breedlove
- Center for Clinical Spectroscopy, Brigham and Women's Hospital and Department of Radiology, Harvard Medical School, Boston, MA
| | - Justus D Ortega
- Department of Kinesiology and Recreation Administration, Humboldt State University, Arcata, CA
| | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | | | | | | | - James R Clugston
- Department of Community Health and Family Medicine, Department of Neurology, and Division of Sports Health, University Athletic Association, University of Florida, Gainesville
| | - Sara P D Chrisman
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington, Seattle
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | | | | | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
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44
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Houck ZM, Asken BM, Bauer RM, Caccese JB, Buckley TA, McCrea MA, McAllister TW, Broglio SP, Clugston JR. Academic aptitude mediates the relationship between socioeconomic status and race in predicting ImPACT scores in college athletes. Clin Neuropsychol 2019; 34:561-579. [PMID: 31549576 DOI: 10.1080/13854046.2019.1666923] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To evaluate the influences of sociodemographic factors, estimated head impact exposure, and academic aptitude on ImPACT scores in college athletes.Methods: Data were reported on 18,886 participants (58% male) from the NCAA/DoD CARE Consortium. Race, SES, concussion history, estimated repetitive head impact exposure (eRHIE), and academic aptitude (SAT or ACT score) were our predictors of interest. Cognition was measured using ImPACT composite scores. We evaluated the mediating effects of academic aptitude on sociodemographic predictors and eRHIE on ImPACT scores. We then evaluated a football-only subsample and added age of first exposure to football (AFE) to the model. Males, females, and football players were analyzed separately using structural equation modeling.Results: Academic aptitude was associated with Black/African American race, SES, and each of the ImPACT composite scores. There were significant indirect effects of Black/African American race and SES on all ImPACT composite scores. Academic aptitude fully mediated SES effects and either fully or partially mediated race effects. Contrary to expectation, greater concussion history and eRHIE predicted better ImPACT scores.Conclusions: Academic aptitude, a stable indicator of premorbid cognitive function, consistently and most strongly predicted baseline ImPACT scores in collegiate student-athletes. Concussion and eRHIE history demonstrated a small positive, but non-significant, relationship with cognitive scores at the time of college athletic participation. This study suggests that attempts to characterize cognitive ability across the lifespan must consider premorbid functioning and sociodemographic variables.
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Affiliation(s)
- Zachary M Houck
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Breton M Asken
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Russell M Bauer
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Jaclyn B Caccese
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Michael A McCrea
- Department of Neurology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - James R Clugston
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, USA
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45
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Abstract
OBJECTIVES To (1) examine the association between a commonly used concussion test, tandem gait, in single/dual-task conditions with single-task and dual-task average walking speed, (2) characterize the prevalence of tandem gait false positives, and (3) develop a normative reference range of dual-task tandem gait times. DESIGN Cross-sectional study. SETTING Two NCAA collegiate athletic facilities. INDEPENDENT VARIABLES Athletes completed the tandem gait test and a gait evaluation in single/dual-task conditions during a preseason examination. MAIN OUTCOME MEASURES Associations between tandem gait times and average walking speeds were evaluated using multiple linear regression models. Various tandem gait test time pass/fail cutoffs were calculated to examine false-positive rates. RESULTS Among the 171 participants (103 men, 19.8 ± 1.2 years of age), dual-task tandem gait completion times were independently associated with dual-task average walking speed [β = -4.018; 95% confidence interval (CI), -7.153 to -0.883], but single-task associations were not found. Male gender was associated with faster tandem gait times in both single-task (β = -0.880, 95% CI, -1.731 to -0.029) and dual-task conditions (β = -2.225, 95% CI, -3.691 to -0.759). A pass/fail cutoff threshold of 14 seconds resulted in a 2% false-positive rate for single-task tandem gait, while it resulted in a 29% false-positive rate during dual-task tandem gait. CONCLUSIONS Average walking speed and dual-task tandem gait represent objective measures that are useful in concussion management. While a single-task tandem gait cutoff of 14 seconds seems appropriate for males, adjustments may be necessary based on sex and alternate pass/fail criteria may be appropriate for dual-task tandem gait.
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46
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Oldham JR, Difabio MS, Kaminski TW, Dewolf RM, Howell DR, Buckley TA. Efficacy of Tandem Gait to Identify Impaired Postural Control after Concussion. Med Sci Sports Exerc 2019; 50:1162-1168. [PMID: 29315170 DOI: 10.1249/mss.0000000000001540] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose was to evaluate tandem gait (TG), Balance Error Scoring System (BESS), and modified Balance Error Scoring System (mBESS) performance acutely after concussion in collegiate student-athletes. In addition, we sought to evaluate the psychometric properties of TG, including minimal detectable change (MDC), sensitivity, and specificity. METHODS Seventy-six National Collegiate Athletic Association student-athletes performed TG and BESS tests: 38 acutely after concussion and 38 controls. Participants were tested at baseline (time 1) and again acutely after concussion, or the following year for controls (time 2). Ten controls, tested simultaneously by two researchers, established a TG interrater minimal detectable change. A 2 × 2 mixed-design ANOVA compared each outcome variable. An receiver operating characteristic curve analysis was used to evaluate sensitivity, specificity, and area under the curve (AUC). RESULT There was a significant interaction (F = 8.757, P = 0.004) for TG whereby the concussion group was slower after concussion (10.59 ± 1.53 vs 11.80 ± 2.67 s), whereas there was no difference for controls (10.13 ± 1.72 vs 9.93 ± 1.85 s). There was no significant interaction for BESS (F = 0.235, P = 0.630) or mBESS (F = 0.007, P = 0.935). TG had a sensitivity of 0.632, a specificity of 0.605, and an AUC of 0.704. BESS had a sensitivity of 0.447, a specificity of 0.500, and an AUC of 0.508. mBESS had a sensitivity of 0.474, a specificity of 0.632, and an AUC of 0.535. CONCLUSIONS Participants completed TG significantly slower after concussion, whereas no change across time was detected for controls. In contrast, BESS and mBESS performances were similar at both testing times in both groups. Our AUC analysis was acceptable for TG, but a failure for both BESS and mBESS; thus, TG may be a useful alternative for clinicians conducting postconcussion postural control assessments.
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Affiliation(s)
- Jessie R Oldham
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
| | - Melissa S Difabio
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE.,Biomechanics and Movement Science, University of Delaware, Newark, DE
| | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
| | - Ryan M Dewolf
- Sports Concussion Clinic, MassGeneral Hospital for Children, Boston, MA
| | - David R Howell
- Sports Medicine Center, Colorado Children's Hospital, Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE.,Biomechanics and Movement Science, University of Delaware, Newark, DE
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47
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Howell DR, Lynall RC, Buckley TA, Herman DC. Neuromuscular Control Deficits and the Risk of Subsequent Injury after a Concussion: A Scoping Review. Sports Med 2018; 48:1097-1115. [PMID: 29453743 DOI: 10.1007/s40279-018-0871-y] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
An emerging area of research has identified that an increased risk of musculoskeletal injury may exist upon returning to sports after a sport-related concussion. The mechanisms underlying this recently discovered phenomenon, however, remain unknown. One theorized reason for this increased injury risk includes residual neuromuscular control deficits that remain impaired despite clinical recovery. Thus, the objectives of this review were: (1) to summarize the literature examining the relationship between concussion and risk of subsequent injury and (2) to summarize the literature for one mechanism with a theorized association with this increased injury risk, i.e., neuromuscular control deficits observed during gait after concussion under dual-task conditions. Two separate reviews were conducted consistent with both specified objectives. Studies published before 9 December, 2016 were identified using PubMed, Web of Science, and Academic Search Premier (EBSCOhost). Inclusion for the objective 1 search included dependent variables of quantitative measurements of musculoskeletal injury after concussion. Inclusion criteria for the objective 2 search included dependent variables pertaining to gait, dynamic balance control, and dual-task function. A total of 32 studies were included in the two reviews (objective 1 n = 10, objective 2 n = 22). According to a variety of study designs, athletes appear to have an increased risk of sustaining a musculoskeletal injury following a concussion. Furthermore, dual-task neuromuscular control deficits may continue to exist after patients report resolution of concussion symptoms, or perform normally on other clinical concussion tests. Therefore, musculoskeletal injury risk appears to increase following a concussion and persistent motor system and attentional deficits also seem to exist after a concussion. While not yet experimentally tested, these motor system and attentional deficits may contribute to the risk of sustaining a musculoskeletal injury upon returning to full athletic participation.
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Affiliation(s)
- David R Howell
- Department of Orthopedics, Sports Medicine Center, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Avenue B060, Aurora, CO, 80045, USA. .,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA.
| | - Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA.,Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | - Daniel C Herman
- Divisions of Physical Medicine and Rehabilitation, Sports Medicine, and Research, Department of Orthopaedics and Rehabilitation, Orthopaedics and Sports Medicine Institute, University of Florida, Gainesville, FL, USA
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48
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Williamson CL, Norte GE, Broshek DK, Hart JM, Resch JE. Return to Learn After Sport-Related Concussion: A Survey of Secondary School and Collegiate Athletic Trainers. J Athl Train 2018; 53:990-1003. [PMID: 30398928 DOI: 10.4085/1062-6050-234-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
CONTEXT Recent recommendations have emphasized return-to-learn (RTL) protocols to aid athletes in recovery from sport-related concussion (SRC) but have been based primarily on anecdotal evidence. OBJECTIVE To investigate the RTL practices of certified athletic trainers (ATs) after an SRC. DESIGN Cross-sectional study. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS A total of 1083 individuals (27%) from a random sample of 4000 ATs in the National Athletic Trainers' Association membership database completed an electronic survey. Participants consisted of 729 self-identified secondary school ATs (SSATs; 67.3%; experience = 14.0 ± 9.7 years) and 354 self-identified collegiate ATs (CATs; 32.7%; experience = 13.4 ± 9.7 years). MAIN OUTCOME MEASURE(S) We used χ2 analyses to assess respondent differences related to current knowledge, current practices, and available resources. Independent t tests were used to compare SSATs and CATs on years of certification and annual number of SRCs evaluated. RESULTS Of our total respondents, 41.2% (n = 446) correctly indicated the absence of evidence-based RTL guidelines. Whereas most (73.9%, n = 800) respondents had an established RTL policy, only 38.1% (n = 413) used such guidelines in their clinical practice. Most (97.1%, n = 708) SSATs and 82.2% (n = 291) of CATs had access to (a) mental health professional(s); however, minorities of SSATs (21.4%, n = 156) and CATs (37.0%, n = 131) never accessed these resources to care for concussed student-athletes. CONCLUSIONS Our results suggested that, despite the absence of empirical evidence, most surveyed ATs incorporated some form of RTL protocol in their SRC management policy. The varying AT knowledge, clinical practices, and resources highlighted by our results should be considered when creating or refining an RTL protocol.
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Affiliation(s)
- Chelsea L Williamson
- Department of Kinesiology, Sports Medicine Program Area, University of Virginia, Charlottesville
| | - Grant E Norte
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville
| | - Donna K Broshek
- School of Exercise and Rehabilitation Sciences, Athletic Training Program, University of Toledo, OH
| | - Joseph M Hart
- Department of Kinesiology, Sports Medicine Program Area, University of Virginia, Charlottesville
| | - Jacob E Resch
- Department of Kinesiology, Sports Medicine Program Area, University of Virginia, Charlottesville
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49
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Savage JL, Covassin T. The Self-Efficacy of Certified Athletic Trainers in Assessing and Managing Sport-Related Concussions. J Athl Train 2018; 53:983-989. [PMID: 30311504 DOI: 10.4085/1062-6050-394-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT: Diagnostic and return-to-play assessments of athletes with sport-related concussions (SRCs) have changed dramatically over the past decade. Currently, SRC assessment and management has taken a multifaceted approach, with new SRC measures being developed yearly. However, to date, no researchers have examined certified athletic trainers' (ATs') self-efficacy in assessing and managing a patient with an SRC. OBJECTIVE: To examine the self-efficacy of ATs in assessing and managing athletes with SRCs, with a secondary purpose of examining job setting (high school and college). DESIGN: Cross-sectional study. SETTING: Web-based questionnaire. PATIENTS OR OTHER PARTICIPANTS: A total of 94 ATs (high school setting = 54.3%, n = 51; collegiate setting = 45.7%, n = 43) completed an online survey, for a response rate of 9.2%. MAIN OUTCOME MEASURE(S): The survey contained 3 primary subsections: demographics, self-efficacy in assessing SRCs, and self-efficacy in managing SRCs. Possible self-efficacy ratings for SRC assessment and management in the survey ranged from 0 to 100. Multivariate analyses of variance were performed to identify differences in the self-efficacy of high school and collegiate ATs in assessing and managing athletes with SRCs. RESULTS: The self-efficacy of all 94 participants in their assessment of SRCs was 60.34 ± 14.5 and in their management of SRCs was 55.30 ± 14.1. Collegiate ATs reported higher self-efficacy in the assessment of SRCs using balance ( P < .001) and the King-Devick test ( P = .04), and their responses approached significance for vestibular-ocular motor screening ( P = .05). Additionally, their self-efficacy in the management of SRCs was greater using balance ( P < .001) and vestibular-ocular therapy ( P = .01) compared with high school ATs. CONCLUSIONS: Athletic trainers had moderate self-efficacy regarding their assessment and management of SRCs. Collegiate ATs had higher self-efficacy in newer SRC assessment and management tools than high school ATs.
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Affiliation(s)
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing
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50
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Haider MN, Leddy JJ, Pavlesen S, Kluczynski M, Baker JG, Miecznikowski JC, Willer BS. A systematic review of criteria used to define recovery from sport-related concussion in youth athletes. Br J Sports Med 2018; 52:1179-1190. [PMID: 28735282 PMCID: PMC5818323 DOI: 10.1136/bjsports-2016-096551] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 05/26/2017] [Accepted: 05/29/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The Concussion in Sport Group guidelines recommend a multifaceted approach to help clinicians make return to sport decisions. The purpose of this study was to identify the most common multifaceted measures used to define clinical recovery from sport-related concussion in young athletes (high school and/or college level) and to summarise existing knowledge of criteria used to make return to sport decisions. DESIGN Systematic review. DATA SOURCES The PubMed (MEDLINE), SPORTDiscus and Embase electronic databases were searched from 1 January 2000 to 1 March 2017 by three independent reviewers. ELIGIBILITY CRITERIA Inclusion criteria: elementary, high school and college age groups, and a specific definition of clinical recovery that required two or more measures. EXCLUSION CRITERIA review articles, articles using the same sample population, case studies, non-English language and those that used one measure only or did not specify the recovery measures used. STUDY QUALITY Study quality was assessed using the Downs and Black Criteria. RESULTS Of 2023 publications, 43 met inclusion criteria. Included articles reported the following measures of recovery: somatic symptom resolution or return to baseline (100%), cognitive recovery or return to baseline (86%), no exacerbation of symptoms on physical exertion (49%), normalisation of balance (30%), normal special physical examination (12%), successful return to school (5%), no exacerbation of symptoms with cognitive exertion (2%) and normalisation of cerebral blood flow (2%). Follow-up to validate the return to sport decision was reported in eight (19%) articles. Most studies were case-control or cohort (level of evidence 4) and had significant risk of bias. CONCLUSION All studies of sport-related concussion use symptom reports to define recovery. A minority of studies used multiple measures of outcome or had clearly defined recovery criteria, the most common being a combination of a self-reported symptom checklist and a computerised neurocognitive test. Future studies ideally should define recovery a priori using objective physiological measures in addition to symptom reports.
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Affiliation(s)
- Mohammad N Haider
- SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Psychiatry
| | - John J Leddy
- SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, UBMB Department of Orthopaedics and Sports Medicine
| | - Sonja Pavlesen
- SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, UBMB Department of Orthopaedics and Sports Medicine
| | - Melissa Kluczynski
- SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, UBMB Department of Orthopaedics and Sports Medicine
| | - John G Baker
- SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, UBMB Department of Orthopaedics and Sports Medicine
- SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Nuclear Medicine
| | | | - Barry S Willer
- SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Psychiatry
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