Longitudinal Assessment of Selective Motor Dysfunction in Service Members With Combat-Related Mild TBI.

INTRODUCTION: Evaluations of clinical outcomes in service members with mild traumatic brain injury (TBI) sustained in combat have largely focused on neurobehavioral and somatic symptoms, neurocognitive functioning, and psychological/psychiatric health. Questions remain regarding other domains, such as gross or fine motor abilities, that could be impacted and are mission-critical to functional warfighters. MATERIALS AND METHODS: The objective of the current study was to evaluate longitudinal motor function in U.S. Military personnel with and without mild TBI sustained in combat to assess the possible long-term impact. Data from the EValuation Of Longitudinal outcomes in mild TBI active duty military and VEterans (EVOLVE) study were leveraged for analysis. The EVOLVE study has evaluated and followed service members from combat and following medical evacuation with and without blast-related mild TBI, as well as blunt impact mild TBI, and noninjured combat-deployed service members, tracking 1-, 5-, and 10-year outcomes. Longitudinal demographic, neuropsychological, and motor data were leveraged. Cross-sectional differences in outcomes at each year among the 4 injury groups were assessed using rank regression, adjusting for age, education, sex, branch of service (Army vs. other), subsequent head injury exposure, and separation from service. To understand the possible performance impact of time on all the measures, mixed-effects rank regression was employed, assessing time with adjustments for group, age, education, subsequent head injury exposure, and service separation status, followed by Benjamini-Hochberg correction for multiple comparisons. RESULTS: Evaluation for cognitive performance across 19 primary measures of interest at 1, 5, and 10 years did not identify any significant differences; however, gross motor function was found to be significantly different across groups at all time points (adjusted P < .001 at 1 year, P = .004 at 5 years, and P < .001 at 10 years) with both TBI groups consistently performing slower on the 25-Foot Walk and Grooved Pegboard than the nonblast control groups. While there were no cross-sectional differences across groups, many cognitive and motor measures were found to have significant changes over time, though not always in the direction of worse performance. Selective motor impairment in both TBI groups was identified compared to nonblast controls, but all groups were also found to exhibit a level of motor slowing when comparing performance at 1- to 10-year follow-ups. CONCLUSIONS: Assessment of gross motor function reflected a consistent pattern of significantly slower performances for blast and nonblast TBI groups compared to controls, over all follow-up intervals. Fine motor function performance reflected a similar significant difference pattern at 1- and 5-year follow-up intervals, with a reduced difference from control groups at the 10-year follow-up. Maintenance of high-level motor functions, including overall motor speed, coordination, and reaction time, is a primary component for active warfighters, and any motor-related deficits could create an increased risk for the service member or unit. While the service members in this longitudinal study did not meet criteria for any specific clinical motor-related diagnoses or movement disorders, the finding of motor slowing may reflect a subclinical but significant change that could be a focus for intervention to return to preinjury levels.

Combat Deployed Service Members by Blast TBI and Service Separation Status 5-years Post-deployment: Comparison of Cognitive, Neurobehavioral, and Psychological Profiles of Those Who Left vs. Those Still Serving.

INTRODUCTION: Longitudinal research regarding the pre- and post-separation experience has been relatively limited, despite its potential as a major life transition. Separating from the military and re-integration to civilian life is noted to be a period of increased risk of significant adjustment challenges, which impacts a service member in a multitude of areas. Active duty service members with combat-related physical or mental health or pre-existing adjustment conditions may be more likely to separate from service and more at risk for post-military service adjustment problems. MATERIALS AND METHODS: This is a secondary data analysis from a prospective, observational, longitudinal, multicohort study involving deployed service members originally enrolled between 2008 and 2013 in combat or following medical evacuation to Landstuhl, Germany. Two combat-deployed cohorts were examined: non-head-injured control without blast exposure (n = 109) and combat-related concussion arising from blast (n = 165). Comprehensive clinical evaluations performed at 1 year and 5 year follow-up included identical assessment batteries for neurobehavioral, psychiatric, and cognitive outcomes. In addition to demographics collected at each study visit, the current analysis leveraged the Glasgow Outcome Scale Extended (GOS-E), a measure of overall global disability. For neurobehavioral impairment, the Neurobehavioral Rating Scale-Revised (NRS) was used as well as the Headache Impact Test (HIT-6) to assess headache burden. To compare psychiatric symptom burden between those separated to those still serving, the Clinician-Administered PTSD Scale for DSM-IV (CAPS) and Montgomery-Asberg Depression Rating Scale (MADRS) for depression were used as well as the Michigan Alcohol Screening Test (MAST) to be able to compare alcohol misuse across groups. Overall cognitive function/performance was defined for each service member by aggregating the 19 neuropsychological measures. RESULTS: Overall comparisons following adjustment by linear regression and correction for multiple comparisons by separation status subgroup for non-blast control or blast traumatic brain injury (TBI) identified significant differences at 5 years post-enrollment in measures of global disability, neurobehavioral impairment, and psychiatric symptom burden. Those who separated had worse global disability, worse neurobehavioral symptoms, worse Post-Traumatic Stress Disorder symptoms, and worse depression symptoms than active duty service members. While service members who sustain a mild blast TBI during combat are more likely to separate from service within 5 years, there is a proportion of those non-injured who also leave during this time frame. Clinical profiles of both groups suggest service members who separated have elevated psychiatric and neurobehavioral symptoms but not cognitive dysfunction. Interestingly, the symptom load in these same domains is lower for those without blast TBI who separated during this time frame. CONCLUSIONS: These results appear to support previous research depicting that, for some service members, transitioning out of the military and re-integrating into civilian life can be a challenging adjustment. Many factors, including personal and social circumstances, prior mental or emotional difficulties, availability of social or community support or resources, can influence the adjustment outcomes of veterans. Service members with prior adjustment difficulties and/or those with blast TBI history (and ongoing neurobehavioral symptoms) may find the transition from military to civilian life even more challenging, given the potential substantial changes in lifestyle, structure, identity, and support.

Virtual Interviews in Neurosurgery Resident Selection: A Follow-up Report.

BACKGROUND: The 2021 U.S. neurosurgery residency match interviews were conducted virtually; we surveyed applicants and interviewers to determine satisfaction with that virtual interview process. Subsequently, we conducted a follow-up survey to determine satisfaction with the virtual interview process after the residency match for faculty interviewers and 2022 interns. METHODS: A 22-question online faculty survey was sent to 116 U.S. neurosurgery training programs. A 26-question survey was sent to these programs for distribution to their intern classes. Data were analyzed quantitatively, including mean Likert score. Open-ended questionnaire responses were reviewed to identify themes. RESULTS: Overall, 32 interns representing 20 programs and 73 faculty representing 62 programs responded. Most respondents agreed that virtual interviews were more convenient (86% faculty, 90% interns) and cost-effective (100% interns) than in-person interviews. Faculty respondents agreed or strongly agreed that virtual interviews were effective to evaluate applicants' competence as residents (44%); fewer faculty agreed or strongly agreed that virtual interviews were an effective way to evaluate candidates' fit in the program (27%). For interns, 44% agreed or strongly agreed that virtual interviews gave them a good sense of the program faculty; 75% agreed or strongly agreed they were satisfied with the process related to where they matched. CONCLUSIONS: Virtual interviews offer an advantage in terms of time and cost but potentially at the expense of adequate faculty assessment of candidates' "fit" within a program's culture. Despite this, interns undergoing an all-virtual interview process report high satisfaction with the results of the residency match.

Effect of RISE Bundle implementation on school adoption of a student-centered return-to-learn program in Washington state.

BACKGROUND: Appropriate concussion care in school is vital for full recovery, but school return-to-learn (RTL) programs are lacking and vary in quality. Establishing student-centered RTL programs may reduce disparities in RTL care. OBJECTIVE: To examine the effect of RISE Bundle (Return to Learn Implementation Bundle for Schools) implementation on high school adoption of a student-centered RTL program. METHODS: A convenience sample of fourteen (4 rural and 10 urban) small and large Washington (WA) State public high schools were enrolled in a stepped-wedge study with baseline, end of study, and monthly measures over the 2021-2022 academic year. Schools identified an RTL champion who led RISE Bundle implementation in 6-week steps. Concussion knowledge and impact of RTL program on concussion care were examined. RESULTS: Ten schools (71.4%) successfully completed RISE Bundle implementation and established a functional RTL program. Self-reported concussion knowledge from RTL Champions increased post intervention. Establishing RTL programs facilitated provision of tailored accommodations, and perceived variation and inequities in RTL care were reduced. CONCLUSION: RISE Bundle implementation proved feasible, supported the establishment of a functional RTL program, and perceived to reduce disparities in concussion care in rural and urban WA State public high schools of varying sizes.

Longitudinal Clinical and Neuroimaging Evaluation of Symptomatic Concussion in 10- to 14-year-old Youth Athletes.

This study longitudinally assessed 10- to 14-year-old patients with sports and recreational concussion (n = 22) who remained symptomatic 3 to 4weeks post-injury compared with typically developing controls (n = 24). Examination by multi-modal magnetic resonance imaging (MRI) and multi-domain clinical outcome measures was completed at 1-month and 6-months post-injury. Concussion patients showed evidence of improvement by 6-month follow-up in domains of cognitive function, whereas measures of psychological health were less resolved with patients exhibiting sustained symptoms of depression, behavior impairment, and concussion symptoms. Quantitative neuroimaging measures identified measures indicative of chronic injury with regional reductions observed by both volumetric segmentation and white matter fractional anisotropy (FA) from diffusion tensor imaging (DTI). Volumetric reductions (p < 0.01) were observed in the middle anterior and posterior portions of the corpus callosum, and right caudal anterior cingulate cortex of patients, although none held after strict correction. Examination of the FA data identified significant reductions in the left middle frontal gyrus white matter (p = 0.0003). Linear regression analysis on the 6-month depression outcome variable using the initial clinical, demographic, and imaging measures identified the top predictive models to include concussion diagnosis, and initial symptoms of depression, concussion symptoms, and sleep impairment with additional contribution from other measures of mental health, behavior impairment, and quality of life depending on the model (adjusted r-squared = 0.69 indicating strong predictive ability). This study supports further inclusion of mental health rehabilitation and imaging supplementing traditional cognitive rehabilitation strategies employed in these young athletes.

Quantitative Volumetric Imaging and Clinical Outcome Characterization of Symptomatic Concussion in 10- to 14-Year-Old Adolescent Athletes.

OBJECTIVE: Prior work suggests that younger athletes may be more vulnerable to postconcussive syndrome. We investigated measures of clinical outcome and quantitative volumetric imaging in 10- to 14-year-old adolescent athletes to better understand the impact of concussion on this younger population. SETTING: Outpatient clinics. PARTICIPANTS: Ten- to 14-year-old symptomatic pediatric sports concussion patients and typically developing active controls. DESIGN: Prospective, observational multiclinic study. MAIN MEASURES: Demographics, magnetic resonance imaging, clinical assessments (neurocognitive function, postconcussive symptoms, mental health symptoms, quality of life). RESULTS: Neuropsychological performance was comparable between groups while symptoms of mental health were discriminating and comprised the top regression model describing factors related to overall health behavior impairment. Concussion patients had smaller total brain volume as well as total intracranial volume in comparison with controls even though there was no difference on measures of natural development (age, height, weight, education, gender, and handedness). CONCLUSIONS: Findings indicate that 10- to 14-year-old concussion patients symptomatic at 1 month more likely exhibit mental health symptoms impairing health behavior than cognitive dysfunction. There may be a vulnerability for those with smaller brain volumes at the time of the exposure. The study provides new data to support further investigation into risk factors for prolonged symptoms in this younger athlete population.

GABA alterations in pediatric sport concussion.

OBJECTIVE: To evaluate whether frontal-lobe magnetic resonance spectroscopy measures of γ-aminobutyric acid (GABA) would be altered in a sample of adolescents scanned after sport concussion because mild traumatic brain injury is often associated with working memory problems. METHODS: Eleven adolescents (age 14-17 years) who had sustained a first-time sport concussion were studied with MRI/magnetic resonance spectroscopy within 23 to 44 days after injury (mean 30.4 ± 6.1 days). Age- and sex-matched healthy controls, being seen for sports-related injuries not involving the head and with no history of concussion, were also examined. GABA/creatine + phosphocreatine (Cre) was measured in left-sided frontal lobe and central posterior cingulate regions. The frontal voxel was positioned to overlap with patient-specific activation on a 1-back working memory task. RESULTS: Increased GABA/Cre was shown in the frontal lobe for the concussed group. A decreased relationship was observed in the parietal region. High correlations between GABA/Cre and task activation were observed for the control group in the frontal lobe, a relationship not shown in the concussed participants. CONCLUSIONS: GABA/Cre appears increased in a region colocalized with working memory task activation after sport concussion. Further work extending these results in larger samples and at time points across the injury episode will aid in refining the clinical significance of these observations.

Concussion evaluation methods among Washington State high school football coaches and athletic trainers.

OBJECTIVE: To evaluate awareness of concussion assessment methods and to determine whether there are differences among Washington State high school football coaches and athletic trainers in urban versus rural school districts. DESIGN: A Catalyst WebQ survey link was randomly sent by e-mail to varsity head football coaches, athletic trainers, and athletic directors in Washington State school districts. PARTICIPANTS: Survey participants were high school varsity head football coaches and athletic trainers from a total of 106 Washington State high schools. METHODS: A 12-item questionnaire on Catalyst WebQ was distributed via e-mail. The survey inquired about use of the methods of concussion assessment, both on the field and for follow-up; participants' concussion education training; and familiarity with Washington State's Zackery Lystedt Law. MAIN OUTCOME MEASUREMENTS: The survey examined differences in concussion management practices between rural and urban school districts and also between coaches and athletic trainers in Washington State, specifically regarding the use of the Standardized Concussion Assessment Tool 2 (SCAT2) and neurocognitive testing (NCT). RESULTS: Twenty-seven of 48 respondents (56%) used the SCAT2 for on-the-field assessment; urban respondents were significantly more likely to use SCAT2 (P < .05). The difference between coaches and athletic trainers with respect to SCAT2 use was not significant (P = .08). NCT was used by 18 of 58 respondents (31%). This was more commonly used by those in urban districts (P < .01) and by athletic trainers (P < .01). Eleven of these 18 individuals (61%) reported that a neuropsychologist interpreted the results; the rest used other providers not specifically trained in neuropsychology. There was no statistically significant correlation between years of experience and use of the SCAT2, but those with more than 10 years of experience were less likely to use NCT (P < .01). All respondents reported being familiar with Washington State's Zackery Lystedt Law, but only 44.1% reported that the law changed their concussion management. CONCLUSIONS: There were statistically significant differences between SCAT2 and NCT use for respondents from urban and rural districts, and also between coaches and athletic trainers, as well as NCT use among respondents with varying years of experience. Further understanding and identification of barriers that limit identification and management of concussions in high school athletes are crucial to prevent serious permanent injury. Additional education is necessary to ensure that athletic trainers and coaches are aware of current recommendations within the medical literature for the evaluation and management of concussions.

Use of neuropsychological evaluations.

Neuropsychological or neurocognitive tests provide information regarding the cognitive and emotional status of the concussed athlete. The development and availability of computerized testing platforms has allowed the application of baseline and follow-up testing models, and provide a more precise measurement of reaction time and processing speed. A combination of computerized assessment and a more expanded battery of tests may be a better approach to understanding the nature of the cognitive impact of sports concussion in youth athletes. This approach may be especially important for athletes with general risk factors and other potential modifiers or influencers on the cognitive performance data.

Attention deficit hyperactivity disorder and the athlete: an American Medical Society for Sports Medicine position statement.

Attention deficit hyperactivity disorder (ADHD) is an important issue for the physician taking care of athletes since ADHD is common in the athletic population, and comorbid issues affect athletes of all ages. The health care provider taking care of athletes should be familiar with making the diagnosis of ADHD, the management of ADHD, and how treatment medications impact exercise and performance. In this statement, the term "Team Physician" is used in reference to all healthcare providers that take care of athletes. These providers should understand the side effects of medications, regulatory issues regarding stimulant medications, and indications for additional testing. This position statement is not intended to be a comprehensive review of ADHD, but rather a directed review of the core issues related to the athlete with ADHD.

Neurocognitive correlates of positive and negative perfectionism.

The present study examined the neurocognitive correlates of positive and negative perfectionism. A clinical sample of 160 patients undergoing standard neuropsychological testing was administered the Positive and Negative Perfectionism Scale (PANPS), a 40-item questionnaire measure of positive and negative perfectionism. The main question addressed in the study was how individual differences in positive and negative perfectionism relate to differences in neurocognitive performance. The general hypotheses to be tested were that positive perfectionism would be associated primarily with tests that relied on mental and physical "effort," while negative perfectionism would be associated with tests involving both "speed and accuracy." The results of the study provided general support for these hypotheses. Implications for the perfectionism literature and sports psychology are briefly discussed.