Risk of Concussion During Sports Versus Physical Education Among New Mexico Middle and High School Students.

OBJECTIVES: To measure the risk of concussion among New Mexico middle and high school students during both sports and physical education. METHODS: Athletic directors or athletic trainers in 147 schools were asked to report the number of concussions occurring during sports and physical education in the 2013 to 2014 school year. We calculated 1-year cumulative incidence rates. RESULTS: Of the 147 schools, 99 responded (67%). During the school year, 598 students were removed from athletics because of a concussion, a 1-year cumulative incidence of 3.5 per 100. The concussion rate during sports was 3.0: 3.5 for boys and 2.4 for girls (relative risk [RR] = 1.5; 95% confidence interval [CI] = 1.2, 1.7). An additional 335 students experienced concussions during physical education. Concussion rates during physical education were 60% higher than during sports (RR = 1.6; 95% CI = 1.4, 1.8). CONCLUSIONS: In our data, the risk of concussion was higher in physical education than in sports. This suggests that concussions should be tracked for a wide range of youth athletic activities, not just for sports. Monitoring cumulative incidence, in addition to other measures, may allow comparisons across schools and regions. More prevention efforts are needed.

The effect of days since last concussion and number of concussions on cognitive functioning in Division I athletes.

OBJECTIVE: Cognitive recovery from sports concussion may be incomplete after resolution of other symptoms. It was hypothesized that independent effects of the number of days since last concussion (Days) and total number of concussions (Number) would predict poorer cognitive functioning. METHODS AND PROCEDURES: Cognition was assessed in an NCAA Division I student-athlete population (n = 87) using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery. In a MANOVA, the five ImPACT Composite scores were dependent variables, with Group (Concussion, Unaffected) as the independent variable and prior number of concussions (Number) and days since last concussion (Days; 68-2495 days) entered as covariates. OUTCOMES AND RESULTS: The hypothesis that Days and Number would each independently affect cognitive functioning (as assessed by ImPACT Composite scores) was only partly supported. A significant, multivariate, main effect of Days (p = 0.01) indicated that more Days predicted better cognitive functioning overall (p = 0.01). Univariate effects emerged such that more Days specifically predicted better visual memory (p = 0.004) and faster reaction times (p = 0.02). A trend toward a Group*Days*Number three-way interaction for reaction time emerged (p = 0.06), such that smaller Number and more Days each predicted slower reaction time. CONCLUSIONS: Cognitive recovery following sports concussion may take far longer than was previously thought, the aetiology of cognitive reductions may be very complex and the ImPACT appears to be sensitive to subtle changes in cognition across time.

A critical review of neuroimaging applications in sports concussion.

While abnormalities related to concussion are typically not identified on traditional clinical neuroimaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]), more sophisticated neuroimaging techniques have the potential to reveal the complex neurometabolic processes related to concussion and its recovery. Clinically, these techniques may one day provide useful information to guide clinicians in the management and treatment of sports concussion. This article critically reviews the current state of the literature regarding neuroimaging and sports concussion, identifies challenges in the application of these techniques, and identifies areas for future research.

Cyclophosphamide and the taste system: Effects of dose fractionation and amifostine on taste cell renewal.

Chemotherapy often causes side effects that include disturbances in taste functions. Cyclophosphamide (CYP) is a chemotherapy drug that, after a single dose, elevates murine taste thresholds at times related to drug-induced losses of taste sensory cells and disruptions of proliferating cells that renew taste sensory cells. Pretreatment with amifostine can protect the taste system from many of these effects. This study compared the effects of a single dose (75 mg/kg) of CYP with effects generated by fractionated dosing of CYP (5 doses of 15 mg/kg), a dosing approach often used during chemotherapy, on the taste system of mice using immunohistochemistry. Dose fractionation prolonged the suppressive effects of CYP on cell proliferation responsible for renewal of taste sensory cells. Fractionation also reduced the total number of cells and the proportion of Type II cells within taste buds. The post-injection time of these losses coincided with the life span of Type I and II taste cells combined with lack of replacement cells. Fractionated dosing also decreased Type III cells more than a single dose, but loss of these cells may be due to factors related to the general health and/or cell renewal of taste buds rather than the life span of Type III cells. In general, pretreatment with amifostine appeared to protect taste cell renewal and the population of cells within taste buds from the cytotoxic effects of CYP with few observable adverse effects due to repeated administration. These findings may have important implications for patients undergoing chemotherapy.

Convergent and discriminant validity of the ImPACT with traditional neuropsychological measures.

Neuropsychological assessment of cognitive sequelae secondary to sports concussion is limited by lengthy administration times and lack of readily available neuropsychologists. Brief computerized test batteries are now under development to address this, but the validity of these measures is not yet established. The validity of one such computerized test battery, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), was administered to 93 healthy NCAA Division I athletes, aged 18-24, along with a battery of traditional, well-described neuropsychological tests. Convergent and discriminant validity between the ImPACT and traditional measures was investigated using multitrait-multimethod matrix (MTMM) analysis. As an example, the ImPACT Visual Motor Speed composite demonstrated reasonably good convergent validity secondary to moderate correlations with traditional measures of processing speed, but it demonstrated relatively poor discriminant validity as it significantly correlated with the Reaction Time composite score. MTMM results were variable across ImPACT composites and data for each are presented. The ImPACT composite's validity was further investigated using exploratory factor analysis (EFA). Six principal components were termed processing speed, visual memory, verbal memory, attention & working memory, and verbal fluency, based upon traditional test loadings, and a sixth loaded only on the ImPACT Reaction Time composite. EFA indicated content validity of moderate strength for the Visual Motor Speed and Visual Memory composites, but revealed problems with specificity for the other composites. Based upon the present findings, validity problems render the interpretability of the ImPACT composites somewhat questionable, and more research is necessary prior to using the ImPACT for assessment of clinical populations.

Reflex sympathetic dystrophy treated by electroconvulsive therapy: intractable pain, depression, and bilateral electrode ECT.

An adult female patient without previous history of pain or psychiatric disorder developed reflex sympathetic dystrophy (RSD) in her left hand and arm after 2 separate injuries, and subsequent arthroscopy and arthroscopic surgery. Traditional management with systemic medications, nerve blocks, and behavioral pain management were unsuccessful. With subsequent development of depression and suicide attempt, electroconvulsive therapy (ECT) was administered using bilateral lead placement. Total resolution of her pain occurred for several hours after the first treatment. Over the course of the full ECT series the pain, vasculature changes of RSD, and depression resolved completely. Prominent psychiatric disturbances were complications arising after ECT and the resolution of the RSD, and during long-term follow-up. A review of the literature from the 1940s revealed numerous cases of chronic, intractable pain treated successfully by ECT, although none of the case series were controlled studies. More recent literature questions if 'modified' ECT, using unilateral lead placement, is less effective than bilateral lead placement, in treating pain syndromes. Resolution of the vascular changes of RSD after ECT raises questions of possible cerebral contributions to the pathophysiology of RSD.

Documenting the prominence of forensic neuropsychology at national meetings and in relevant professional journals from 1990 to 2000.

Numerous authors have opined that forensic activities have become more prominent within clinical neuropsychology. To investigate the merits of these claims, the entire contents of Archives of Clinical Neuropsychology (ACN), Journal of Clinical and Experimental Neuropsychology (JCEN), and The Clinical Neuropsychologist (TCN) from 1990 through 2000 were reviewed and cataloged. These three journals were selected because they are the highest-ranking clinical subscription journals according to surveys of neuropsychology practitioners. Prior to rating journal content, various categories of interest were delineated and practice ratings were obtained until the two raters reached 92% agreement. Each of the raters read the journal contents and recorded content ratings for half of the journal issues under review. Results of the 8323 ratings demonstrated increases across time in the absolute numbers of articles related to forensic neuropsychology, although variable and different for each journal. Published articles that were partially or substantially forensic in nature in the three journals combined increased from 4% in 1990 to 14% in 2000. An annual peak in absolute number (n=32;16%) of forensic journal articles occurred in 1997. The most common topic of 139 articles published in ACN, JCEN, and TCN from 1990 to 2000 was malingering, which appeared in 86% of the general forensic articles. Forensic presentations at annual NAN meetings ranged from 3.9 to 11.3% (M=8%) of the convention programs, whereas within Division 40's programs at the American Psychological Association meeting, the average percentage ranged from 2.3 to 11.7% (M=6%). Results pertaining to each journal and to specific forensic topics are presented and implications of these and other results are discussed.

Validity indicators within the Wisconsin Card Sorting Test: application of new and previously researched multivariate procedures in multiple traumatic brain injury samples.

The Wisconsin Card Sorting Test (WCST) is a popular neuropsychological measure of executive dysfunction that has been researched with regard to invalid performances, a subset of which in a forensic context could be associated with malingering. In the first of three studies, WCST multivariate approaches identified in prior research (Bernard, McGrath, & Houston, 1996; Suhr & Boyer, 1999), as well as newly created variables, were used to differentiate 33 chronic traumatic brain injury (TBI) patients with good effort and 27 patients with probable insufficient effort (IE). Newly created variables that were derived logically based upon hypotheses regarding strategies that might be employed by malingerers were not effective in differentiating TBI and IE groups. Application of previously researched validity indicators based upon commonly used WCST variables, individually, and within new logistic regression findings were reasonably effective in differentiating TBI and IE groups. In order to determine whether results would vary in different TBI samples, these validity indicators were examined in Study 2 with 75 moderate and severe, acute TBI rehabilitation patients whose posttraumatic amnesia had just resolved. Statistically significant differences were present between the IE group of Study 1 and the rehabilitation patient group of Study 2 on failures to maintain set, number of trials to achieve first correct category, and number of categories completed. All these measures were performed more poorly by the IE group. However, previously used multivariate approaches and the logistic regression analysis developed in Study 1 ranged widely in the degree to which Study 2's more acute rehabilitation patients were correctly classified. Specifically, the discriminant function of Bernard and colleagues correctly classified 73% and the Suhr and Boyer logistic regression correctly classified 75% of the Study 2 participants. The Study 1 logistic regression classified 97% of the Study 2 participants correctly. In Study 3, 130 mild to severe TBI patients in the VA system were studied. The Study 1 IE group performed significantly worse than the more acute and more severe VA TBI group on all 10 common WCST variables of interest. Application of the three multivariate procedures resulted in good to excellent classification rates: Suhr and Boyer logistic regression 85%, Bernard et al. discriminant function 85%, and Study 1 logistic regression 99%. The aggregate discussion of the three studies focuses on apparent differences in samples associated with varying degrees of success in identifying TBI patients. Application of these validity indicators in forensic situations should consider that some of these multivariate approaches possess possible classification limitations associated with chronicity and severity of the reported TBI. Only the Study 1 logistic regression demonstrated improved classification rates with the more acute and severe patients of Study 2 and Study 3. As with all validity indicators, use of any WCST IE criteria in isolation would not be appropriate.