Concussion Knowledge and Self-Reported Behaviors in Youth Rugby Players and Their Coaches: A Population-Wide Cross-Sectional Survey

OBJECTIVE

To investigate concussion knowledge and self-reported behaviors in Italian youth rugby players and their coaches. To investigate predictors of lower concussion knowledge and association between athletes' self-reported knowledge and behavior.

DESIGN

Cross-sectional, population-wide, survey study.

SETTING

All rugby clubs (n = 52) of the Veneto region (Italy).

PARTICIPANTS

Players and coaches of all under 15, 17 and 19 teams. Overall, 1719 athlete surveys (92.2% male; response rate, 71.1%) and 235 coach surveys (93.6% male; response rate, 93.2%) were eligible for analysis.

INTERVENTION

Surveys circulated from September 20 to December 13, 2021.

MAIN OUTCOME MEASURES

Knowledge scores were reported as a percentage of correct answers. Descriptive statistics were reported for all answers. The primary outcomes were concussion knowledge and self-reported behaviors. The secondary outcomes were the association between knowledge and participant individual factors and self-reported behaviors.

RESULTS

Median knowledge score for athletes was 55% (IQR: 44-67) and for coaches was 60% (IQR: 52.5-69). Only 33.3% of athletes and 40% of coaches were aware of an increased risk of a second concussion after sustaining one. Athletes who had never heard of the word concussion (effect: -9.31; SE: 1.35, 95% CI: -12.0 to -6.7; P < 0.0001) and coaches with longer coaching experience (effect: -4.35; SE: 2.0, 95% CI: -8.29 to -0.41; P < 0.03) reported lower knowledge scores. There was no statistical association between knowledge scores and athlete self-reported behavior.

CONCLUSION

Athletes and coaches had a similar level of concussion knowledge. Knowledge score of athletes did not predict self-reported behaviors. Although enhanced concussion education should be undertaken, interventions to ensure appropriate concussion reporting behaviors are also required.

Can exercise test intensity and modality affect the prevalence of arrhythmic events in young athletes?

Pre-participation screening is performed to identify underlying cardiac conditions that may also lead to sudden cardiac death. Our aim is to compare submaximal Harvard Step Test (HST) with incremental Maximal Exercise Test (MET) on treadmill to induce and detect arrhythmias in younger athletes. A total of 1000 athletes (mean age 14.6 ± 4.7 years) were evaluated, 500 with MET and 500 with HST, all with continuous ECG monitoring until three minutes of recovery. Pre-test evaluation includes medical history, clinical evaluation and resting electrocardiogram. Ventricular and/or supraventricular arrhythmias were observed in 2.6% of athletes performing HST and in 8.4% during MET (p < 0.001). Incidence of arrhythmias remained higher for MET also considering separately exercise phase (0.8% vs. 5.2%; p < 0.001) and recovery phase (2.0% vs. 6.0%; p < 0.01). No gender differences were observed. Results suggest that MET induces more arrhythmias than submaximal HST, regardless of test phase. Higher test intensity and longer exercise duration might influence test outcomes, making MET more arrhythmogenic.

Early repolarization in adolescent athletes: A gender comparison of ECG and echocardiographic characteristics

BACKGROUND

The early repolarization pattern (ERp) is an electrocardiographic finding previously associated with arrhythmic risk in adults. The purpose of this study is to evaluate the prevalence and characteristics of ERp in a group of adolescent athletes according to gender. Furthermore, potential associations with clinical, electrocardiographic, and echocardiographic parameters are explored.

METHODS

In this cross-sectional study young athletes (age < 18 years) were consecutively enrolled during the annual pre-participation evaluation, undergoing also transthoracic echocardiography assessment from January 2015 to March 2020.

RESULTS

The prevalence of ERp was 27% in the whole population. Athletes with ERp were more frequently men practicing endurance sports. Women with ERp showed lower heart rate at rest, greater posterior, and relative ventricular wall thickness than those without ERp. Men with ERp presented higher systolic blood pressure at peak exercise, greater septal wall thickness, and indexed left ventricular mass than those without ERp. Both genders with ERp showed increased QRS voltage and narrower QRS duration. The ERp phenotype in men was more frequently notched with higher amplitude and ascending ST segment. Women's ERp presented more frequently a slurred morphology, especially in the inferior leads, and horizontal ST slope. No differences emerged in the occurrence of arrhythmias at rest and during maximal exercise test between groups, even considering higher risk phenotypes.

CONCLUSIONS

ERp is an ECG finding compatible with normal cardiac adaptations to training in young athletes. ERp demonstrated gender differences regarding phenotypes previously associated with increased cardiovascular risk, not showing any differences in arrhythmias during maximal exercise test.

Do Androgenic Pattern, Insulin State and Growth Hormone Affect Cardiorespiratory Fitness and Strength in Young Women with PCOS?

In this study, cardiorespiratory fitness (CRF) and strength level were assessed in women with and without polycystic ovary syndrome (PCOS), matched for age, body composition, androgenic pattern and insulinemic pattern. Patients with and without PCOS were evaluated at the Endocrinology Unit and Sport Medicine Division to assess endocrinological (insulinemic, androgenic pattern and growth hormone), anthropometric (with DEXA) and functional parameters (with cardiopulmonary exercise test and handgrip test), as well as physical activity level (with the Global Physical Activity Questionnaire). A total of 31 patients with PCOS and 13 controls were included. No statistically significant differences were found between groups in terms of age, body mass index, body composition, androgenic pattern, insulin state, growth hormone and physical activity level. The PCOS group demonstrated significantly better cardiorespiratory fitness (VO₂max per kg (30.9 ± 7.6 vs. 24.8 ± 4.1 mL/kg/min; p = 0.010), VO₂max per kg of fat-free mass (52.4 ± 8.9 vs. 45.3 ± 6.2 mL/kg/min; p = 0.018)), strength levels (handgrip per kg (0.36 ± 0.09 vs. 0.30 ± 0.08; p = 0.009), handgrip per kg of fat-free mass (13.03 ± 2.32 vs. 11.50 ± 1.91; p = 0.001)) and exercise capacity (METs at test (14.4 ± 2.72 vs. 12.5 ± 1.72 METs; p = 0.019)). In this study, women with PCOS showed a better cardiorespiratory fitness and strength than the control group. The only determinant that could explain the differences observed seems to be the presence of the syndrome itself. These results suggest that PCOS per se does not limit exercise capacity and does not exclude good functional capacity.

Prevalence of exercise-induced arrhythmias in young athletes with fragmented QRS pattern in lead V1

Funding Acknowledgements

Type of funding sources: None.

Background

Resting 12-lead electrocardiogram (ECG) in apparently health athletes has specific pattern, typically associate to heart remodelling in response to regular exercise. (1,2) Moreover, these adaptations were correlated to typical ventricular arrhythmias, not associated with underlying cardiac abnormalities.(3) Recently, also fragmented QRS complex in lead V1 (fQRSV1), representing right ventricular (RV) activation, seems related to training-induced RV remodelling in athletes, where its prevalence is greater.(4)

Purpose

Evaluate presence of fQRSV1pattern at resting ECG in a population of young athletes and its relationship with training-associated structural heart adaptations and exercise-induced ventricular arrhythmias.

Methods

This study retrospectively enrolled subjects who consecutively undergo to annual pre-participation screening and also to transthoracic echocardiography assessment, from January 2015 to September 2020. For each participant, medical history, physical examination, resting ECG, maximal standardized exercise test and echocardiographic evaluation were collected. All ECG were reviewed by two independent physicians to evaluate fQRSV1 pattern.

Results

684 young athletes (mean age 14.87±1.96 years, 36% female) were included and the overall prevalence of fQRSV1was 27%. Figure 1 shows an example of fQRSV1 pattern. Principal subject characteristics and evaluations data are shown in Table 1. fQRSV1 subjects presented a significantly wider QRS interval (p=0.004) and lower heart rate at rest (p=0.001). Exercise workload expressed in METs and exercise duration were higher in subjects with fQRSV1 (p=0.002 and p=0.023, respectively). Echocardiographic data showed that subjects with fQRSV1differ in morphological and functional right ventricular (RV) characteristics, especially had a higher indexed RV end diastolic diameter (p=0.019) and higher TAPSE (p=0.013). Patients with fQRSV1did not show an increased occurrence of supraventricular or ventricular arrhythmias, regardless of morphology, neither for isolated nor for repetitive events.

Conclusion

Overall prevalence of fQRSV1 pattern in young athletes is comparable with the one studied in other population of adult athletes in previous studies. Adolescent athletes with fQRSV1 present structural heart characteristic that differ from subjects without this ECG pattern, especially in RV feature. No differences in prevalence of any type of exercise-induced arrhythmias was shown, especially in common ventricular arrhythmias consistent with origin from the right ventricular outflow tract, previously described in healthy athletes.

Head Injury Assessment in Italian rugby union: a two-seasons prospective analysis

BACKGROUND

In Italy, to the best of our knowledge, there is no literature relating to injury and concussion epidemiology in rugby union. Therefore, the primary aim of this study is to describe the incidence of sport-related concussion in Italian rugby union and the associated management of Head Injury Assessment (HIA).

METHODS

This is an observational prospective study, analysing the Italian elite rugby championship (Top 12 and Coppa Italia) for two seasons (2018/2019 and 2019/2020). Twelve male teams of the Italian elite rugby championship were included. The diagnosis of traumatic brain injury was provided by a team doctor with HIA, while no match day doctor or video analysis was available. A concussion expert of Italian Rugby Federation reviewed all the HIAs. The outcome of interest were: incidence, playing situation and mechanism responsible for traumatic brain injury.

RESULTS

In the study period, 47 HIAs were performed during matches (45.3/1000 player-match-hours) and 7 concussions were diagnosed by team doctors (6.75/1000 player-match-hours). After the concussion expert HIAs' review, the thirty-three percent of 16 diagnoses were made later, during follow-up, or based on clinical suspicion. Most symptoms complained about by players were neck pain and headache, in 14.6% and 13.4% of HIA, respectively. Concussions were predominately the result of tackling (46.5%) for the tackler (90.9%).

CONCLUSIONS

The incidence of concussion in Italian Rugby appears to be low compared to that of rugby outside Italy, which is likely due to the learning curve of HIA and the absence of video analysis and match day doctors during competitions. The implementation of educational projects may be fundamental to promoting HIA process.

Ventilatory Response at Rest and During Maximal Exercise Testing in Patients with Severe Obesity Before and After Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) has become a widespread treatment option in patients affected by severe obesity. However, studies investigating the impact of the subsequent weight loss on the ventilatory response at rest and during physical exercise are lacking.

METHODS

This is an observational study on 46 patients with severe obesity (76% females), comparing parameters of ventilatory function 1 month before and 6 months after SG. Patients were first evaluated by resting spirometry and subsequently with an incremental, maximal cardiopulmonary exercise test (CPET) on treadmill.

RESULTS

The important weight loss of 26.35 ± 6.17% of body weight (BMI from 43.59 ± 5.30 to 32.27 ± 4.84 kg/m2) after SG was associated with a significant improvement in lung volumes and flows during forced expiration at rest, while resting ventilation and tidal volume were reduced (all p ≤ 0.001). CPET revealed decreased ventilation during incremental exercise (p < 0.001), with a less shallow ventilatory pattern shown by a lower increase of breathing frequency (∆BFrest to AT p = 0.028) and a larger response of tidal volume (∆TVAT to Peak p < 0.001). Furthermore, a concomitant improvement of the calculated dead space ventilation, VE/VCO2 slope and peripheral oxygen saturation was shown (all p ≤ 0.002). Additionally, the increased breathing reserve at peak exercise was associated with a lower absolute oxygen consumption but improved exercise capacity and tolerance (all p < 0.001).

CONCLUSION

The weight loss induced by SG led to less burdensome restrictive limitations of the respiratory system and to a reduction of ventilation at rest and during exercise, possibly explained by an increased ventilatory efficiency and a decrease in oxygen demands.

Ankle Brachial Index in Different Types of Popliteal Artery Entrapment Syndrome: A Systematic Review of Case Reports

Similar to other peripheral artery diseases, vessel narrowing in popliteal artery entrapment syndrome (PAES) reduces the ankle brachial index (ABI). Since the PAES is related to several anatomical or functional variations, we sought to determine if the ABI was correlated with the type of syndrome. Through a systematic review of literature, we identified case reports and series in which the diagnosis of PAES was accompanied by ABI measurement. Twenty-seven studies included in the qualitative synthesis described 87 limbs. The most common types of the syndrome were those caused by an abnormal medial head of the gastrocnemius (type II, n = 35, 40.23%) and aberrant course of the popliteal artery (type I, n = 20, 22.99%). The variation of plantaris muscle (n = 7, 8.05%) is currently not included in the classification system. The median value of ABI was 0.87 (interquartile range (IQR) = 0.6–1.0). There were no differences among types of syndrome (F = 0.13, p = 0.72). In conclusion, despite clinical recommendations, the ABI remains underused in PAES diagnosis. No correlation was detected between the index score and type of syndrome. The cases of PAES involving structures other than the gastrocnemius or popliteus muscle suggest the need to revisit the current clinical classification system.

Unsafe workout: a weak and painful shoulder in a professional volleyball player

A 29-year-old professional volleyball player started complaining of a dull ache in the right lateral base of the neck. This pain arose during a preseasonal athletic training intense session. After 3 days, he presented deficiency of right scapula adduction, limitation of scapula elevation, right shoulder weakness and local mild pain. He had asymmetrical neckline with drooping of the affected shoulder, lateral displacement and minimal winging of the right scapula. After 1 week, hypothrophy of superior trapezius appeared. An electromyography of right upper limb showed a denervation in the upper, middle and lower components of the right trapezius muscle, due to axonotmesis of spinal accessory nerve (SAN). A subsequent MRI was consistent with muscular suffering caused by early denervation. This case shows idiopathic SAN palsy, likely secondary to an inappropriate use of a weight-lifting machine, where the athlete recovered after an adequate rest and rehabilitation period.

Exercise stress test in apparently healthy individuals - where to place the finish line? The Ferrari corporate wellness programme experience

AIMS

The aim of our study was to assess the clinical significance of the exercise stress testing endpoints, namely 85% of maximal theoretical heart rate (MTHR), metabolic equivalent of task, and rating of perceived exertion (RPE), and their relation to electrocardiographic (ECG) changes in a healthy adult population.

METHODS

A cross-sectional study was conducted on 408 males and 52 females (mean age 39.4 ± 8.6 years) who performed the maximal cycle ergometer exercise stress test until volitional exhaustion, reporting the RPE score at 85% of MTHR and at peak exercise. Metabolic equivalents of task were indirectly calculated from the maximum workload and compared with the predicted values. Sitting torso-lead ECG and blood pressure were recorded at rest, during exercise and during recovery.

RESULTS

Of 460 participants, 73% exceeded 85% of MTHR. The RPE score represented the overall most significant endpoint of exercise stress testing, with the median value of 17 at peak exercise. ECG events were detected in 23/124 (18.5%) who reached ≤ 85% of MTHR and in 61/336 (18.2%) who achieved >85% of MTHR ( p = 0.92). In the latter group, 54% of ECG changes occurred at < 85% of MTHR and 46% at > 85% of MTHR ( p = 0.51). If the exercise stress testing had been interrupted at ≤ 85% of MTHR, almost half of the ECG events would have remained undetected and 35% of the cardiovascular abnormalities observed at the diagnostic follow-up would have remained undiagnosed.

CONCLUSION

Terminating exercise stress testing before volitional exhaustion and an RPE score of 17 limits the test accuracy and reduces the possibility to detect cardiovascular abnormalities in apparently healthy adult populations.

Prevalence of musculocutaneous nerve variations: Systematic review and meta-analysis

We aimed to establish the prevalence of the musculocutaneous nerve (MCN) variations and the probability of the variation being pure or mixed in the same plexus. We applied the principles of evidence-based anatomy to find, appraise, and synthesize data through a meta-analysis of anatomical studies. The variations were grouped based on the presence and location of the communicating branch with the median nerve and the origin of branches to anterior arm muscles. Forty-three cadaveric studies met the inclusion criteria, providing data from 4124 plexuses. The overall pooled prevalence of plexuses with MCN variations was 20%. Based on the classification applied in our study, the pooled prevalence of variations was 17% in region 1A, 20% in region 1B, 36% in region 2 and 49% in region 3. Importantly, 64.58% of variations in region 1A and 74.14% of variations in region 1B were mixed, that is, associated with a variation in another region. The odds of finding another variation in the presence of a variation in region 2 or 3 were equal 0.37 and 0.52, respectively, demonstrating a significantly lower probability of finding mixed variations involving these regions, when compared with region 1A. Variations of the MCN are most common in the part distal to the exit from within or beneath the coracobrachialis muscle. Proximal variations are more often associated with another variation located along the nerve. These findings can assist health care professionals in the treatment of brachial plexus lesions. Clin. Anat. 32:183-195, 2019. © 2018 Wiley Periodicals, Inc.