Understanding of head injury assessment and return to play processes and associated factors in United States Major League Rugby players.

OBJECTIVES: Evaluate professional rugby players' self-reported perceived understanding of the head injury assessment (HIA) and return to play (RTP) processes and determine factors related to understanding and trust pertaining to these processes. METHODS: An electronic survey measured concepts of interest. A thematic analysis of player understanding was performed, and player statements were coded. RESULTS: 207 U.S. Major League Rugby (MLR) players participated (26.7 ± 3.4 years). HIA and RTP protocol understanding was not correlated with concussion history (p = 0.41). International rugby experience and trust regarding MLR support of the following protocols and opposing team medical staff practices varied in their relationship to HIA understanding. Trust that all MLR teams follow the same protocols was positively correlated with all HIA questions (ps < 0.03). No HIA questions were correlated with trust in their own team's medical staff. All trust questions were significantly correlated with RTP process understanding. Qualitative analysis identified four HIA- and RTP-related themes: education needs, staffing needs, HIA criticisms, and importance of player safety. CONCLUSION: International playing experience and greater trust in the MLR and league stakeholders were associated with greater player understanding of the HIA and RTP protocols. These results provide insight into the importance of educating players on league-specific concussion protocols.

Integrating Clinical Reasoning Skills in a Pre-professional Undergraduate Human Anatomy Course.

Clinically integrated curricula in health science education has been shown to promote the development of problem-solving schema and positively impact knowledge acquisition. Despite its' purported benefits, this type of curricula can impose a high cognitive load, which may negatively impact novice learners' knowledge acquisition and problem-solving schema development. Introducing explicit clinical reasoning instruction within pre-professional undergraduate basic science courses may limit factors that increase cognitive load, enhance knowledge acquisition, and foster developing clinical problem-solving skills. This study, conducted over the Fall and Spring semesters of the 2018-2019 school year, sought to evaluate whether the implementation of a clinical reasoning instructional intervention within a clinically integrated pre-professional undergraduate general human anatomy course influenced students' acquisition of anatomical knowledge and development of clinical problem-solving skills. Results of the study were mixed regarding the acquisition of anatomical knowledge. Both the intervention and comparison groups performed similarly on multiple choice examinations of anatomical knowledge. However, the clinical reasoning intervention positively impacted students' ability to apply clinical reasoning skills to anatomically based clinical case studies. Results from M\mixed between-within subjects analysis of variance comparing scores on Written Clinical Reasoning Assessments revealed a significant interaction between time and group affiliation, with the groups receiving the interventions outperforming the comparison groups: Fall, P < 0.001; Spring, P < 0.001. The results of this study may imply that explicit clinical reasoning instruction within a clinically integrated undergraduate Human Anatomy course could hold potential for fostering students' early clinical reasoning skills.

Association of lower extremity injuries and injury mechanism with previous concussion history in adolescent athletes.

OBJECTIVE: Determine the association between concussion and subsequent contact, non-contact, and overuse lower extremity (LE) injuries in a cohort of adolescent athletes. Secondarily, to identify this association between males and females. STUDY DESIGN: Cross-sectional. SETTING: Summer athletic events with participants ages 12-18. MAIN OUTCOME: Anonymous survey included sport-related injuries (injury month/year) and participants classified injuries as a contact, non-contact, overuse injury, or concussion. Multivariable logistic regression analyses were used to examine associations between a concussion event and a subsequent LE injury while controlling for age and any previous LE injury. RESULTS: A concussion was reported in 219 athletes (Female = 96, 44%) and were matched with 219 non-concussed athletes (438 total participants). Concussion was not association with a specific injury mechanism but was significant for any subsequent LE injury (OR = 1.58 95%CI = [1.03-2.41]; p < 0.05). Concussed females were more likely to report any subsequent LE injury compared to non-concussed female athletes (2.49[1.31, 4.74]; p < 0.01). This relationship was not observed between concussed and non-concussed males (1.11[0.62-1.99]; p > 0.5). CONCLUSION: A history of concussion was associated with any subsequent LE injury, but not associated with a specific mechanism of injury. The association with concussion and a subsequent LE injury was different between males and females.

Awareness of Concussion-Education Requirements, and -Management Plans and Concussion Knowledge in High School and Club Sport Coaches.

CONTEXT: A growing number of high-school-aged athletes participate on club sport teams. Some, but not all, state concussion laws apply to both interscholastic and private sport organizations. However, concussion education, management plans, and knowledge have not been examined in club coaches who coach high school-aged athletes. OBJECTIVE: To determine if differences in concussion education, management plans, and knowledge exist between high school coaches and coaches of club sport teams. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 769 coaches (497 high school coaches, 272 club coaches coaching high school-aged athletes; 266 women [34.6%], 503 men [65.4%]) completed an anonymous online questionnaire. MAIN OUTCOME MEASURE(S): The questionnaire consisted of demographic and team information, requirements for concussion-education and -management plans, and concussion knowledge. RESULTS: High school coaches were more likely than club coaches to report that their organizing bodies or leagues required them to receive concussion-education information (97.4% versus 80.4%; P < .001) and that their organizing bodies or leagues had a concussion-management plan (94.0% versus 70.2%; P < .001). High school coaches were more likely than club coaches to correctly agree that most concussions resolve in 7 to 10 days (48.6% versus 40.1%; P = .02) and disagree that loss of consciousness is required to diagnose a concussion (87.1% versus 80.9%; P = .02). CONCLUSIONS: Club coaches were less likely to be aware of requirements for concussion-education and -management plans from their parent organizations and scored lower on specific concussion-knowledge questions than high school coaches despite the same education requirements across groups under their state concussion laws. These results raise concerns regarding the proper management of concussions in club sports and suggest a need for greater oversight and enforcement of state laws in the club sport setting.

Top 10 Research Questions Related to Preventing Sudden Death in Sport and Physical Activity.

Participation in organized sport and recreational activities presents an innate risk for serious morbidity and mortality. Although death during sport or physical activity has many causes, advancements in sports medicine and evidence-based standards of care have allowed clinicians to prevent, recognize, and treat potentially fatal injuries more effectively. With the continual progress of research and technology, current standards of care are evolving to enhance patient outcomes. In this article, we provided 10 key questions related to the leading causes and treatment of sudden death in sport and physical activity, where future research will support safer participation for athletes and recreational enthusiasts. The current evidence indicates that most deaths can be avoided when proper strategies are in place to prevent occurrence or provide optimal care.

Clinical Practices in Collegiate Concussion Management.

BACKGROUND: In recent years, sports leagues and sports medicine experts have developed guidelines for concussion management. The extent to which current clinical practice is consistent with guideline recommendations is unclear. At the collegiate level, there have been few examinations of concussion management practices and the extent to which meaningful differences across divisions of competition exist. PURPOSE: The purposes of this study were to (1) examine current practices in concussion diagnosis and management at National Collegiate Athletic Association (NCAA) member colleges, (2) explore the extent to which current practices reflect current recommendations for concussion diagnosis and management, and (3) determine whether there are differences in management patterns across divisions of competition. DESIGN: Descriptive epidemiology study. METHODS: An electronic questionnaire was sent to sports medicine clinicians at all NCAA member colleges during September and October 2013. Clinicians were asked about baseline assessments, diagnosis and management practices, return-to-play protocols, the perceived prevalence of underdiagnosis, and basic demographic information. RESULTS: Approximately 30% (n = 866) of contacted clinicians, representing nearly 50% (n = 527) of NCAA member colleges, responded to the questionnaire. Preparticipation baseline examinations were administered at the majority of schools (95%), but most (87.5%) administered baseline assessments only to selected high-risk athletes. Computerized neurocognitive testing and balance assessments were most commonly used as preseason baseline and postinjury assessments. Multimodal examination in line with NCAA and other guidance was used only at a minority of institutions. Athletic trainers most commonly administered and interpreted the preseason baseline examination. Most clinicians reported that their institutions' practices were in line with NCAA guidelines during the first 24 hours of an athlete's concussion diagnosis, with exact percentages varying across measures. Differences across divisions of competition included shorter return-to-play time at Division I schools than Division III schools (9.13 vs 10.31 days, respectively) and more frequently referring concussed athletes to a physician within 24 hours of diagnosis at Division I schools. CONCLUSION: Concussion management at many colleges in the United States incorporates elements recommended by current guidelines; however, there is room to improve. Increasing the use of a multimodal baseline and postinjury examination will elevate the concussion care provided to college athletes and better align with best practice guidance.

Brain-Computer Interface Training after Stroke Affects Patterns of Brain-Behavior Relationships in Corticospinal Motor Fibers.

Background: Brain-computer interface (BCI) devices are being investigated for their application in stroke rehabilitation, but little is known about how structural changes in the motor system relate to behavioral measures with the use of these systems. Objective: This study examined relationships among diffusion tensor imaging (DTI)-derived metrics and with behavioral changes in stroke patients with and without BCI training. Methods: Stroke patients (n = 19) with upper extremity motor impairment were assessed using Stroke Impact Scale (SIS), Action Research Arm Test (ARAT), Nine-Hole Peg Test (9-HPT), and DTI scans. Ten subjects completed four assessments over a control period during which no training was administered. Seventeen subjects, including eight who completed the control period, completed four assessments over an experimental period during which subjects received interventional BCI training. Fractional anisotropy (FA) values were extracted from each corticospinal tract (CST) and transcallosal motor fibers for each scan. Results: No significant group by time interactions were identified at the group level in DTI or behavioral measures. During the control period, increases in contralesional CST FA and in asymmetric FA (aFA) correlated with poorer scores on SIS and 9-HPT. During the experimental period (with BCI training), increases in contralesional CST FA were correlated with improvements in 9-HPT while increases in aFA correlated with improvements in ARAT but with worsening 9-HPT performance; changes in transcallosal motor fibers positively correlated with those in the contralesional CST. All correlations p < 0.05 corrected. Conclusion: These findings suggest that the integrity of the contralesional CST may be used to track individual behavioral changes observed with BCI training after stroke.

Cavum Septi Pellucidi in Symptomatic Former Professional Football Players.

Post-mortem studies reveal a high rate of cavum septi pellucidi (CSP) in chronic traumatic encephalopathy (CTE). It remains, however, to be determined whether or not the presence of CSP may be a potential in vivo imaging marker in populations at high risk to develop CTE. The aim of this study was to evaluate CSP in former professional American football players presenting with cognitive and behavioral symptoms compared with noncontact sports athletes. Seventy-two symptomatic former professional football players (mean age 54.53 years, standard deviation [SD] 7.97) as well as 14 former professional noncontact sports athletes (mean age 57.14 years, SD 7.35) underwent high-resolution structural 3T magnetic resonance imaging. Two raters independently evaluated the CSP, and interrater reliability was calculated. Within National Football League players, an association of CSP measures with cognitive and behavioral functioning was evaluated using a multivariate mixed effects model. The measurements of the two raters were highly correlated (CSP length: rho = 0.98; Intraclass Correlation Coefficient [ICC] 0.99; p < 0.0001; septum length: rho = 0.93; ICC 0.96; p < 0.0001). For presence versus absence of CSP, there was high agreement (Cohen kappa = 0.83, p < 0.0001). A higher rate of CSP, a greater length of CSP, as well as a greater ratio of CSP length to septum length was found in symptomatic former professional football players compared with athlete controls. In addition, a greater length of CSP was associated with decreased performance on a list learning task (Neuropsychological Assessment Battery List A Immediate Recall, p = 0.04) and decreased test scores on a measure of estimate verbal intelligence (Wide Range Achievement Test Fourth Edition Reading Test, p = 0.02). Given the high prevalence of CSP in neuropathologically confirmed CTE in addition to the results of this study, CSP may serve as a potential early in vivo imaging marker to identify those at high risk for CTE. Future research is needed to investigate the pathomechanism underlying the development of CSP after repetitive head impacts, and its potential association with neuropathologically confirmed CTE.

Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion.

CONTEXT: Anecdotal and qualitative evidence has suggested that some clinicians face pressure from coaches and other personnel in the athletic environment to prematurely return athletes to participation after a concussion. This type of pressure potentially can result in compromised patient care. OBJECTIVE: To quantify the extent to which clinicians in the collegiate sports medicine environment experience pressure when caring for concussed athletes and whether this pressure varies by the supervisory structure of the institution's sports medicine department, the clinician's sex, and other factors. DESIGN: Cross-sectional study. SETTING: Web-based survey of National College Athletic Association member institutions. PATIENTS OR OTHER PARTICIPANTS: A total of 789 athletic trainers and 111 team physicians from 530 institutions. MAIN OUTCOME MEASURE(S): We asked participants whether they had experienced pressure from 3 stakeholder populations (other clinicians, coaches, athletes) to prematurely return athletes to participation after a concussion. Modifying variables that we assessed were the position (athletic trainer, physician) and sex of the clinicians, the supervisory structure of their institutions' sports medicine departments, and the division of competition in which their institutions participate. RESULTS: We observed that 64.4% (n = 580) of responding clinicians reported having experienced pressure from athletes to prematurely clear them to return to participation after a concussion, and 53.7% (n = 483) reported having experienced this pressure from coaches. Only 6.6% (n = 59) reported having experienced pressure from other clinicians to prematurely clear an athlete to return to participation after a concussion. Clinicians reported greater pressure from coaches when their departments were under the supervisory purview of the athletic department rather than a medical institution. Female clinicians reported greater pressure from coaches than male clinicians did. CONCLUSIONS: Most clinicians reported experiencing pressure to prematurely return athletes to participation after a concussion. Identifying factors that are associated with variability in pressure on clinicians during concussion recovery can inform potential future strategies to reduce these pressures.

Age of first exposure to football and later-life cognitive impairment in former NFL players.

OBJECTIVE: To determine the relationship between exposure to repeated head impacts through tackle football prior to age 12, during a key period of brain development, and later-life executive function, memory, and estimated verbal IQ. METHODS: Forty-two former National Football League (NFL) players ages 40-69 from the Diagnosing and Evaluating Traumatic Encephalopathy using Clinical Tests (DETECT) study were matched by age and divided into 2 groups based on their age of first exposure (AFE) to tackle football: AFE <12 and AFE ≥12. Participants completed the Wisconsin Card Sort Test (WCST), Neuropsychological Assessment Battery List Learning test (NAB-LL), and Wide Range Achievement Test, 4th edition (WRAT-4) Reading subtest as part of a larger neuropsychological testing battery. RESULTS: Former NFL players in the AFE <12 group performed significantly worse than the AFE ≥12 group on all measures of the WCST, NAB-LL, and WRAT-4 Reading tests after controlling for total number of years of football played and age at the time of evaluation, indicating executive dysfunction, memory impairment, and lower estimated verbal IQ. CONCLUSIONS: There is an association between participation in tackle football prior to age 12 and greater later-life cognitive impairment measured using objective neuropsychological tests. These findings suggest that incurring repeated head impacts during a critical neurodevelopmental period may increase the risk of later-life cognitive impairment. If replicated with larger samples and longitudinal designs, these findings may have implications for safety recommendations for youth sports.

Age at First Exposure to Football Is Associated with Altered Corpus Callosum White Matter Microstructure in Former Professional Football Players.

Youth football players may incur hundreds of repetitive head impacts (RHI) in one season. Our recent research suggests that exposure to RHI during a critical neurodevelopmental period prior to age 12 may lead to greater later-life mood, behavioral, and cognitive impairments. Here, we examine the relationship between age of first exposure (AFE) to RHI through tackle football and later-life corpus callosum (CC) microstructure using magnetic resonance diffusion tensor imaging (DTI). Forty retired National Football League (NFL) players, ages 40-65, were matched by age and divided into two groups based on their AFE to tackle football: before age 12 or at age 12 or older. Participants underwent DTI on a 3 Tesla Siemens (TIM-Verio) magnet. The whole CC and five subregions were defined and seeded using deterministic tractography. Dependent measures were fractional anisotropy (FA), trace, axial diffusivity, and radial diffusivity. Results showed that former NFL players in the AFE <12 group had significantly lower FA in anterior three CC regions and higher radial diffusivity in the most anterior CC region than those in the AFE ≥12 group. This is the first study to find a relationship between AFE to RHI and later-life CC microstructure. These results suggest that incurring RHI during critical periods of CC development may disrupt neurodevelopmental processes, including myelination, resulting in altered CC microstructure.

Profile of self-reported problems with executive functioning in college and professional football players.

Repetitive mild traumatic brain injury (mTBI), such as that experienced by contact-sport athletes, has been associated with the development of chronic traumatic encephalopathy (CTE). Executive dysfunction is believed to be among the earliest symptoms of CTE, with these symptoms presenting in the fourth or fifth decade of life. The present study used a well-validated self-report measure to study executive functioning in football players, compared to healthy adults. Sixty-four college and professional football players were administered the Behavior Rating Inventory of Executive Function, adult version (BRIEF-A) to evaluate nine areas of executive functioning. Scores on the BRIEF-A were compared to published age-corrected normative scores for healthy adults Relative to healthy adults, the football players indicated significantly more problems overall and on seven of the nine clinical scales, including Inhibit, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, and Task Monitor. These symptoms were greater in athletes 40 and older, relative to younger players. In sum, football players reported more-frequent problems with executive functioning and these symptoms may develop or worsen in the fifth decade of life. The findings are in accord with a growing body of evidence that participation in football is associated with the development of cognitive changes and dementia as observed in CTE.

Clinical presentation of chronic traumatic encephalopathy.

OBJECTIVE: The goal of this study was to examine the clinical presentation of chronic traumatic encephalopathy (CTE) in neuropathologically confirmed cases. METHODS: Thirty-six adult male subjects were selected from all cases of neuropathologically confirmed CTE at the Boston University Center for the Study of Traumatic Encephalopathy brain bank. Subjects were all athletes, had no comorbid neurodegenerative or motor neuron disease, and had next-of-kin informants to provide retrospective reports of the subjects' histories and clinical presentations. These interviews were conducted blind to the subjects' neuropathologic findings. RESULTS: A triad of cognitive, behavioral, and mood impairments was common overall, with cognitive deficits reported for almost all subjects. Three subjects were asymptomatic at the time of death. Consistent with earlier case reports of boxers, 2 relatively distinct clinical presentations emerged, with one group whose initial features developed at a younger age and involved behavioral and/or mood disturbance (n = 22), and another group whose initial presentation developed at an older age and involved cognitive impairment (n = 11). CONCLUSIONS: This suggests there are 2 major clinical presentations of CTE, one a behavior/mood variant and the other a cognitive variant.

Chronic traumatic encephalopathy: neurodegeneration following repetitive concussive and subconcussive brain trauma.

Chronic Traumatic Encephalopathy (CTE) is a neurodegenerative disease thought to be caused, at least in part, by repetitive brain trauma, including concussive and subconcussive injuries. It is thought to result in executive dysfunction, memory impairment, depression and suicidality, apathy, poor impulse control, and eventually dementia. Beyond repetitive brain trauma, the risk factors for CTE remain unknown. CTE is neuropathologically characterized by aggregation and accumulation of hyperphosphorylated tau and TDP-43. Recent postmortem findings indicate that CTE may affect a broader population than was initially conceptualized, particularly contact sport athletes and those with a history of military combat. Given the large population that could potentially be affected, CTE may represent an important issue in public health. Although there has been greater public awareness brought to the condition in recent years, there are still many research questions that remain. Thus far, CTE can only be diagnosed post-mortem. Current research efforts are focused on the creation of clinical diagnostic criteria, finding objective biomarkers for CTE, and understanding the additional risk factors and underlying mechanism that causes the disease. This review examines research to date and suggests future directions worthy of exploration.