Preseason Measures of Cervical Spine Function, Vestibulo-Ocular Reflex, Dynamic Balance, and Divided Attention in Youth Ice Hockey Players

OBJECTIVES: Report typical scores and examine preseason cervical spine, vestibulo-ocular reflex, dynamic balance, and divided attention measures in competitive youth ice hockey players aged 10 to 18 years with and without a previous concussion history. DESIGN: Cross-sectional secondary analysis. METHODS: The exposure of interest was self-reported history of concussion. The main outcomes were cervical spine measures (Cervical Flexor Endurance [CFE; seconds], Cervical Flexion-Rotation Test [normal/abnormal], Anterolateral Cervical Spine Strength [kilograms], Head Perturbation Test (/8), and Joint Position Error [JPE; centimeters]), vestibulo-ocular reflex (Dynamic Visual Acuity [logMAR], Head Thrust Test [Positive/Negative]), dynamic balance (Functional Gait Assessment [/30]) and divided attention (Walking While Talking Test [seconds]). Multivariable linear or logistic regression, adjusted for age-group, sex, level of play, and clustered by team, were used to assess potential differences by concussion history. RESULTS: We included data from 2311 participants in this study (87.2% male, 12.8% female, 39.0% reported a previous concussion). No differences by concussion history were found across any of the measures (P values range: 0.17-0.99). Measures of cervical spine function and divided attention differed by age group (eg, Median Left Anterolateral Cervical Spine Strength [kilograms] for males: U13 = 7.46, U15 = 9.10, U18 = 9.67). CONCLUSION: Clinical outcomes scores in youth ice hockey players did not differ by concussion history. Performance on cervical spine strength, CFE, and JPE test outcomes may improve with age, highlighting the importance of developmental considerations when interpreting test scores. J Orthop Sports Phys Ther 2024;54(3):1-11. Epub 30 November 2023. doi:10.2519/jospt.2023.11958.

Consensus for a primary care clinical decision-making tool for assessing, diagnosing, and managing low back pain in Alberta, Canada

BACKGROUND

Low back pain (LBP) is a common condition causing disability and high healthcare costs. Alberta faces challenges with unnecessary referrals to specialists and long wait times. A province-wide standardized clinical care pathway based on evidence-based best practices can improve efficiency, reduce wait times, and enhance patient outcomes. Implementing such pathways has shown success in other areas of healthcare in Alberta. This study developed a clinical decision-making pathway to standardize care and minimize uncertainty in assessment, diagnosis, and management.

METHODS

A systematic rapid review identified existing tools and evidence that could support a comprehensive LBP clinical decision-making tool. Forty-seven healthcare professionals participated in four rounds of a modified Delphi approach to reach consensus on the assessment, diagnosis, and management of patients presenting to primary care with LBP in Alberta, Canada. This project was a collaborative effort between Alberta Health Services' Bone and Joint Health Strategic Clinical Network (BJHSCN) and the Alberta Bone and Joint Health Institute (ABJHI).

RESULTS

A province-wide expert panel consisting of professionals from different health disciplines and regions collaborated to develop an LBP clinical decision-making tool. This tool presents clinical care pathways for acute, subacute, and chronic LBP. It also provides guidance for history-taking, physical examination, patient education, and management.

CONCLUSIONS

This clinical decision-making tool will help to standardize care, provide guidance on the diagnosis and management of LBP, and assist in clinical decision-making for primary care providers in both public and private sectors.

Amsterdam 2022 process: A summary of the methodology for the Amsterdam International Consensus on Concussion in Sport

The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27-30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.

Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children

OBJECTIVES

To systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3-30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6).

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results.

ELIGIBILITY CRITERIA

(1) Original research, cohort studies, case-control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification.

RESULTS

Of 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening.

CONCLUSION

Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Examining later-in-life health risks associated with sport-related concussion and repetitive head impacts: a systematic review of case-control and cohort studies

OBJECTIVE

Concern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes.

DESIGN

Systematic review.

DATA SOURCES

Search of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022.

ELIGIBILITY CRITERIA

Studies measuring future risk (cohort studies) or approximating that risk (case-control studies).

RESULTS

Ten studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias.

CONCLUSION

Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors.

PROSPERO REGISTRATION NUMBER

CRD42022159486.

Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion

BACKGROUND

Concussion is one of the most commonly occurring injuries in sport today. The Sport Concussion Assessment Tool (SCAT) is a commonly used paper neurocognitive tool. To date, little is known about SCAT baseline normative values in youth athletes.

OBJECTIVE

The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players.

METHODS

This is a secondary data analysis of pooled data from three prospective cohort studies examining the risk of injury in paediatric ice hockey players aged 9-17 years. A preseason baseline demographic and injury history questionnaire was completed by each player.

RESULTS

A total of 4193 players completed SCATs at baseline and were included in the analysis. 781 players (18.6%) reported a previous history of concussion. Fatigue and low energy followed by headache were the most commonly reported symptoms in all players. The majority of youth players could recite all five words immediately but only three words when delayed. A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age. The median number of digits recited in reverse order was 4.

CONCLUSIONS

Youth ratings varied between age groups, gender and from previously reported ratings of varsity athletes, possibly reflecting developmental and gender differences. An understanding of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion.

Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: an exploratory study in chronic whiplash patients

Background

The cervical zygapophyseal joints may be a primary source of pain in up to 60% of individuals with chronic whiplash associated disorders (WAD) and may be a contributing factor for peripheral and centrally mediated pain (sensory hypersensitivity). Sensory hypersensitivity has been associated with a poor prognosis. The purpose of the study was to determine if there is a change in measures indicative of sensory hypersensitivity in patients with chronic WAD grade II following a medial branch block (MBB) procedure in the cervical spine.

Methods

Measures of sensory hypersensitivity were taken via quantitative sensory testing (QST) consisting of pressure pain thresholds (PPT's) and cold pain thresholds (CPT's). In patients with chronic WAD (n = 18), the measures were taken at three sites bilaterally, pre- and post- MBB. Reduced pain thresholds at remote sites have been considered an indicator of central hypersensitivity. A healthy age and gender matched comparison group (n = 18) was measured at baseline. An independent t-test was applied to determine if there were any significant differences between the WAD and normative comparison groups at baseline with respect to cold pain and pressure pain thresholds. A dependent t-test was used to determine whether there were any significant differences between the pre and post intervention cold pain and pressure pain thresholds in the patients with chronic WAD.

Results

At baseline, PPT's were decreased at all three sites in the WAD group (p < 0.001). Cold pain thresholds were increased in the cervical spine in the WAD group (p < 0.001). Post-MBB, the WAD group showed significant increases in PPT's at all sites (p < 0.05), and significant decreases in CPT's at the cervical spine (p < 0.001).

Conclusions

The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. The WAD group revealed decreased sensory hypersensitivity following a decrease in their primary source of pain stemming from the cervical zygapophyseal joints.

Cardiovascular haemodynamic response to repeated mental stress in normotensive subjects at genetic risk of hypertension: evidence of enhanced reactivity, blunted adaptation, and delayed recovery

To identify unique cardiovascular responses to stressors in a population at genetic risk of hypertension, we studied haemodynamic responses in initial reactivity to, subsequent adaptation to, and final recovery from repeated active mental stress in young, normotensive individuals stratified by hypertension parental history (PH). Two groups (n=21/group) of normotensive white males underwent stress testing. One group (N+PH) had a hypertensive parent, while the other group (N-PH) did not. Cardiovascular response was measured before, during, and after repeated serial-subtraction math. Initial reactivity was measured as the difference between baseline and initial stress response, subsequent adaptation as the difference in response to repeated trials, and final recovery was assessed by the difference between baseline and postbaseline levels. The influence of PH on reactivity, adaptation, and recovery was assessed by repeated measures ANOVA for stroke volume, cardiac output, pre-ejection period, total peripheral resistance, mean successive heartbeat time difference, blood pressure, and heart rate. Multivariate analysis of variance (MANOVA) determined the effect of PH on overall reactivity, adaptation, and recovery. As compared to the N-PH group, initial reactivity was higher in the N+PH group for cardiac index (P<0.05) and pre-ejection period (P<0.05). Subsequent adaptation in the N+PH group was significantly slower for pre-ejection period (P=0.03). Finally, the N+PH group showed delayed recovery in heart rate (P=0.03), diastolic blood pressure (P<0.05), and pre-ejection period (P=0.007). In conclusion, the heightened reactivity, lack of adaptation, and delayed recovery occur in the sympathetic system of normotensive subjects at genetic risk of hypertension, specifically in beta-adrenergic responses (pre-ejection period). The parasympathetic response (mean successive heartbeat time difference) was not different. Increased cardiac output reactivity in the N+PH group (P<0.05) thus precedes any difference in blood pressure reactivity (P<0.99). Delayed recovery of diastolic blood pressure is also found in the N+PH group (P<0.05), which suggests lower baroreceptor sensitivity. Since delayed recovery in heart rate (P=0.03), and diastolic blood pressure (P<0.05) occur in N+PH subjects even before the corresponding changes in reactivity (P>0.10) or adaptation (P>0.07) are seen, these recovery impairments may be among the earliest precursors to the development of essential hypertension in this population. Finally, PH group haemodynamic differences suggest that these traits (reactivity, adaptation, and recovery) may constitute early 'intermediate' phenotypes in the pathogenesis of hypertension.

Injuries and injury risk factors among men and women in U.S. Army Combat Medic Advanced individual training

No previous reports have evaluated injuries or injury risk factors during the advanced individual training (AIT) that follows the Army's initial or basic combat training (BCT). This study examined injuries and injury risk factors among 439 men and 287 women participating in combat medic AIT. A questionnaire addressing demographic and lifestyle characteristics (age, race, tobacco and alcohol use, physical activity, etc.) was administered to all subjects. Stature and body mass were obtained from battalion records. Injuries occurring during both BCT and AIT were transcribed from subject medical records. Results indicated that cumulative injury incidence (subjects with one or more injuries) in BCT was 26% for men and 52% for women (p < 0.01), in consonance with previous investigations. In AIT, injury incidence was 24% for men and 30% for women (p = 0.08). In both BCT and AIT, overuse injuries and lower body injuries accounted for the largest proportions of injuries by diagnosis and anatomical location. Logistic regression revealed that older age (> 25 years), split option (a break in service between BCT and AIT), and higher body mass were independent risk factors for AIT injuries among women. None of the examined variables were independent risk factors for AIT injuries among men.

Involvement of central mu- but not delta- or kappa-opioid receptors in immunomodulation

Studies completed in both humans and animals have shown that opioids have significant effects on the immune system via pharmacological interactions with the opioid receptor. However, the type of opioid receptor at which morphine binding produces changes in immune status has not been well characterized. To determine the type of opioid receptor involved in opioid-induced immune alterations, the present study assessed the effects of agonists selective for the mu-, delta-, and kappa-opioid receptors. The site of action (i.e., peripheral vs central) at which opioids produce immune changes was investigated by injecting the agonists directly into the left lateral ventricle of the brain. Specifically, Lewis rats received an intracerebroventricular administration of [d-Ala(2),N-Me-Phe(4), Gly-ol(5)]enkephalin (DAMGO), a mu-receptor selective agonist, [D-Pen(2,5)]enkephalin (DPDPE), a delta-opioid receptor agonist, or U69,593, a kappa-receptor agonist. Immune assessments completed 1 h following drug administration showed that the mu-receptor selective agonist DAMGO produced a dose-dependent decrease in natural killer cell activity and T-lymphocyte proliferation to the mitogen concanavalin A (Con A); no immunological changes were found following DPDPE or U69,593 treatment. Calculation of the number of white blood cells per sample showed no differences between rats treated with saline and rats treated with any of the selective agonists. Administration of the opioid antagonist N-methylnaltrexone prior to DAMGO treatment attenuated the DAMGO-induced changes in immune status. Results from the present study indicate that the immunomodulatory effects of opioids can be attributed to interactions with the mu-opioid receptor.

Forced-air warming decreases vasodilator requirement after coronary artery bypass surgery

Postoperative hypothermia is common and associated with adverse hemodynamic consequences, including adrenergically mediated systemic vasoconstriction and hypertension. Hypothermia is also a known predictor of dysrhythmias and myocardial ischemia in high-risk patients. We describe a prospective, randomized trial designed to test the hypothesis that forced-air warming (FAW) provides improved hemodynamic variables after coronary artery bypass graft. After institutional review board approval and written informed consent, 149 patients undergoing coronary artery bypass graft were randomized to receive postoperative warming with either FAW (n = 81) or a circulating water mattress (n = 68). Core temperature was measured at the tympanic membrane. A weighted mean skin temperature was calculated. Heart rate, mean arterial blood pressure, central venous pressure, cardiac output, and systemic vascular resistance were monitored for 22 h postoperatively. Mean arterial blood pressure was maintained by protocol between 70 and 80 mm Hg by titration of nitroglycerin and sodium nitroprusside. The two groups had similar demographic characteristics. Tympanic and mean skin temperatures were similar between groups on intensive care unit admission. During postoperative rewarming, tympanic temperature was similar between groups, but mean skin temperature was significantly greater in the FAW group (P < 0.05). Heart rate, mean arterial pressure, central venous pressure, cardiac output, and systemic vascular resistance were similar for the two groups. The percent of patients requiring nitroprusside to achieve the hemodynamic goals was less (P < 0.05) in the FAW group. In conclusion, aggressive cutaneous warming with FAW results in a higher mean skin temperature and a decreased requirement for vasodilator therapy in hypothermic patients after cardiac surgery. This most likely reflects attenuation of the adrenergic response or opening of cutaneous vascular beds as a result of surface warming. IMPLICATIONS Forced-air warming after cardiac surgery decreases the requirement for vasodilator drugs and may be beneficial in maintaining hemodynamic variables within predefined limits.

Role of central mu-opioid receptors in the modulation of nitric oxide production by splenocytes

Previous studies have shown that administration of morphine results in alterations of splenic macrophage nitric oxide production. The present studies were conducted to determine the subtype of opioid receptor involved in the modulation of macrophage nitric oxide production. Moreover, the present work was directed at determining whether nitric oxide production is regulated through opioid receptors in the central nervous system (CNS) or via opioid receptors found directly on splenocytes. The study shows that intracerebroventricular (i.c.v.) administration of the mu-selective opioid agonist, DAMGO, to rats dose-dependently increases the production of nitric oxide by splenocytes stimulated with toxic shock syndrome toxin (TSST-1). The effect of DAMGO is blocked by prior i.c.v. administration of N-methylnaltrexone. In contrast, i.c.v. administration of the kappa-selective agonist, U69,593, and the delta-selective agonist, DPDPE, have no significant effect on the production of nitric oxide. Furthermore, the in vitro administration of DAMGO, DPDPE, or U69,593 to splenocytes cultures does not significantly alter the production of nitric oxide by splenocytes. In addition, the present work shows that elevation of nitric oxide production by i.c.v. administration of DAMGO produces functional changes in splenic lymphocytes. Collectively, these results indicate that mu-opioid receptors within the CNS are involved in the regulation of splenic nitric oxide production.

Effectiveness of methods used to teach breast self-examination

The efficacy of breast self-examination (BSE) is limited by the extent to which women can be taught to perform a frequent and proficient examination. We randomized 783 women from a health maintenance organization into group instruction, individual instruction, individual instruction with a reminder system, or minimal intervention designed to simulate an office encounter where BSE was encouraged but not taught. The percentage of lumps 1 cm and smaller detected in silicone breast models, the number of false-positive detections, the search technique, and the self-reported BSE frequency were measured before and four months after intervention. Multiple tests for comparisons of interventions showed that the interventions containing BSE instruction were comparable in increasing true- and false-positive detection of lumps and in improving search technique, but the minimal intervention resulted in lower scores for all three outcomes (P less than .0001). Women in all four intervention groups increased their BSE frequency over the four-month follow-up period, but the greatest improvement in frequency was reported among women receiving reminders.