Assessment of Blood Biomarker Profile After Acute Concussion During Combative Training Among US Military Cadets: A Prospective Study From the NCAA and US Department of Defense CARE Consortium.

Importance: Validation of protein biomarkers for concussion diagnosis and management in military combative training is important, as these injuries occur outside of traditional health care settings and are generally difficult to diagnose. Objective: To investigate acute blood protein levels in military cadets after combative training-associated concussions. Design, Setting, and Participants: This multicenter prospective case-control study was part of a larger cohort study conducted by the National Collegiate Athletic Association and the US Department of Defense Concussion Assessment Research and Education (CARE) Consortium from February 20, 2015, to May 31, 2018. The study was performed among cadets from 2 CARE Consortium Advanced Research Core sites: the US Military Academy at West Point and the US Air Force Academy. Cadets who incurred concussions during combative training (concussion group) were compared with cadets who participated in the same combative training exercises but did not incur concussions (contact-control group). Clinical measures and blood sample collection occurred at baseline, the acute postinjury point (<6 hours), the 24- to 48-hour postinjury point, the asymptomatic postinjury point (defined as the point at which the cadet reported being asymptomatic and began the return-to-activity protocol), and 7 days after return to activity. Biomarker levels and estimated mean differences in biomarker levels were natural log (ln) transformed to decrease the skewness of their distributions. Data were collected from August 1, 2016, to May 31, 2018, and analyses were conducted from March 1, 2019, to January 14, 2020. Exposure: Concussion incurred during combative training. Main Outcomes and Measures: Proteins examined included glial fibrillary acidic protein, ubiquitin C-terminal hydrolase-L1, neurofilament light chain, and tau. Quantification was conducted using a multiplex assay (Simoa; Quanterix Corp). Clinical measures included the Sport Concussion Assessment Tool-Third Edition symptom severity evaluation, the Standardized Assessment of Concussion, the Balance Error Scoring System, and the 18-item Brief Symptom Inventory. Results: Among 103 military service academy cadets, 67 cadets incurred concussions during combative training, and 36 matched cadets who engaged in the same training exercises did not incur concussions. The mean (SD) age of cadets in the concussion group was 18.6 (1.3) years, and 40 cadets (59.7%) were male. The mean (SD) age of matched cadets in the contact-control group was 19.5 (1.3) years, and 25 cadets (69.4%) were male. Compared with cadets in the contact-control group, those in the concussion group had significant increases in glial fibrillary acidic protein (mean difference in ln values, 0.34; 95% CI, 0.18-0.50; P < .001) and ubiquitin C-terminal hydrolase-L1 (mean difference in ln values, 0.97; 95% CI, 0.44-1.50; P < .001) levels at the acute postinjury point. The glial fibrillary acidic protein level remained high in the concussion group compared with the contact-control group at the 24- to 48-hour postinjury point (mean difference in ln values, 0.22; 95% CI, 0.06-0.38; P = .007) and the asymptomatic postinjury point (mean difference in ln values, 0.21; 95% CI, 0.05-0.36; P = .01). The area under the curve for all biomarkers combined, which was used to differentiate cadets in the concussion and contact-control groups, was 0.80 (95% CI, 0.68-0.93; P < .001) at the acute postinjury point. Conclusions and Relevance: This study's findings indicate that blood biomarkers have potential for use as research tools to better understand the pathobiological changes associated with concussion and to assist with injury identification and recovery from combative training-associated concussions among military service academy cadets. These results extend the previous findings of studies of collegiate athletes with sport-associated concussions.

Early Single Sport Specialization in a High-Achieving US Athlete Population: Comparing National Collegiate Athletic Association Student-Athletes and Undergraduate Students.

CONTEXT: Early single-sport specialization and the relative age effect are often cited as improving the chances of sport success. Both concepts suggest that genetics and the environment have little influence on sport success. OBJECTIVE: To compare National Collegiate Athletic Association Division I student-athletes (SAs) with their undergraduate nonathlete peers (NAs) in terms of birth month, age of sport initiation, and age of single-sport specialization. A family history of sport participation was examined as a potential marker for genetic and social influences. DESIGN: Cross-sectional survey. SETTING: Large urban university. PATIENTS OR OTHER PARTICIPANTS: A total of 273 Division I SAs (138 women, 135 men) and 155 NAs (78 women, 77 men) participated. The NAs had been involved in competitive youth sports before entering the university. MAIN OUTCOME MEASURE(S): Participants were asked to complete a questionnaire that addressed the age of sport initiation, birth month, age of single-sport specialization, and parental and sibling sport achievement. MAIN RESULTS: Neither birth month nor the age of sport initiation differed between groups (age of sport initiation = 7.16 ± 2.6 years for the SAs versus 7.71 ± 3.5 for the NAs; P = .176). A larger proportion of SAs began participating before 10 years of age (80% versus 63%; P = .02). The parents of SAs were more likely to have participated in collegiate (32.4% versus 8.4%; P < .0001) and professional (10.9% versus 1.3%; P = .0005) sports. The SAs specialized in a single sport at an older age (15.38 ± 2.7 years versus 14.30 ± 2.6 years; P = .002). Both groups participated in multiple sports in childhood (SAs = 3.9 ± 1.8 sports, NAs = 3.2 ± 1.8 sports; P = .366). CONCLUSIONS: The Division I SAs did not specialize in a single sport at a younger age than the NAs. No evidence of a relative age effect was present. Importantly, higher levels of sport achievement among the parents and siblings of SAs suggest that genetic endowment and family or other environmental dynamics play a large role in athletic performance. Overall, the results are not consistent with deliberate practice theory and point toward an alternative model that includes not only sport-specific skill development but also genetic and social factors as key elements of long-term sport achievement.

Influences of Mental Illness, Current Psychological State, and Concussion History on Baseline Concussion Assessment Performance.

BACKGROUND: A student-athlete's mental state, including history of trait anxiety and depression, or current psychological state may affect baseline concussion assessment performance. PURPOSE: (1) To determine if mental illness (anxiety, depression, anxiety with depression) influences baseline scores, (2) to determine if psychological state correlates with baseline performance, and (3) to determine if history of concussion affects Brief Symptom Inventory-18 (BSI-18) subscores of state anxiety, depression, and somatization. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A sample of 8652 collegiate student-athletes (54.5% males, 45.5% females) participated in the Concussion Assessment, Research and Education (CARE) Consortium. Baseline assessments included a demographic form, a symptom evaluation, Standardized Assessment of Concussion, Balance Error Scoring System, a psychological state assessment (BSI-18), and Immediate Post-concussion Assessment and Cognitive Test. Baseline scores were compared between individuals with a history of anxiety (n = 59), depression (n = 283), and anxiety with depression (n = 68) and individuals without a history of those conditions (n = 8242). Spearman's rho correlations were conducted to assess the relationship between baseline and psychological state subscores (anxiety, depression, somatization) (α = .05). Psychological state subscores were compared between individuals with a self-reported history of concussions (0, 1, 2, 3, 4+) using Kruskal-Wallis tests (α = .05). RESULTS: Student-athletes with anxiety, depression, and anxiety with depression demonstrated higher scores in number of symptoms reported (anxiety, 4.3 ± 4.2; depression, 5.2 ± 4.8; anxiety with depression, 5.4 ± 3.9; no anxiety/depression, 2.5 ± 3.4), symptom severity (anxiety, 8.1 ± 9.8; depression, 10.4 ± 12.4; anxiety with depression, 12.4 ± 10.7; no anxiety/depression, 4.1 ± 6.9), and psychological distress in state anxiety (anxiety, 3.7 ± 4.7; depression, 2.5 ± 3.6; anxiety with depression, 3.8 ± 4.2; no anxiety/depression, 0.8 ± 1.8), depression (anxiety, 2.4 ± 4.0; depression, 3.2 ± 4.5; anxiety with depression, 3.8 ± 4.8; no anxiety/depression, 0.8 ± 1.8), and somatization (anxiety, 2.3 ± 2.9; depression, 1.8 ± 2.8; anxiety with depression, 2.2 ± 2.4; no anxiety/depression, 0.9 ± 1.7). A moderate positive relationship existed between all BSI-18 subscores and total symptom number (n = 8377; anxiety: rs = 0.43, P < .001; depression: rs = 0.42, P < .001; somatization: rs = 0.45, P < .001), as well as total symptom severity (anxiety: rs = 0.43, P < .001; depression: rs = 0.41, P < .001; somatization: rs = 0.45, P < .001). Anxiety, depression, and somatization subscores were greater among student-athletes that self-reported more concussions. CONCLUSION: Clinicians should be cognizant that student-athletes with a history of trait anxiety, depression, and anxiety with depression may report higher symptom score and severity at baseline. Individuals with extensive concussion history may experience greater state anxiety, depression, and somatization.

Stability of MRI metrics in the advanced research core of the NCAA-DoD concussion assessment, research and education (CARE) consortium.

The NCAA-DoD Concussion Assessment, Research, and Education (CARE) consortium is performing a large-scale, comprehensive study of sport related concussions in college student-athletes and military service academy cadets. The CARE "Advanced Research Core" (ARC), is focused on executing a cutting-edge investigative protocol on a subset of the overall CARE athlete population. Here, we present the details of the CARE ARC MRI acquisition and processing protocol along with preliminary analyzes of within-subject, between-site, and between-subject stability across a variety of MRI biomarkers. Two experimental datasets were utilized for this analysis. First, two "human phantom" subjects were imaged multiple times at each of the four CARE ARC imaging sites, which utilize equipment from two imaging vendors. Additionally, a control cohort of healthy athletes participating in non-contact sports were enrolled in the study at each CARE ARC site and imaged at four time points. Multiple morphological image contrasts were acquired in each MRI exam; along with quantitative diffusion, functional, perfusion, and relaxometry imaging metrics. As expected, the imaging markers were found to have varying levels of stability throughout the brain. Importantly, between-subject variance was generally found to be greater than within-subject and between-site variance. These results lend support to the expectation that cross-site and cross-vendor advanced quantitative MRI metrics can be utilized to improve analytic power in assessing sensitive neurological variations; such as those effects hypothesized to occur in sports-related-concussion. This stability analysis provides a crucial foundation for further work utilizing this expansive dataset, which will ultimately be freely available through the Federal Interagency Traumatic Brain Injury Research Informatics System.

American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships.

The American Medical Society for Sports Medicine (AMSSM) developed a musculoskeletal ultrasound curriculum for sports medicine fellowships in 2010. As the use of diagnostic and interventional ultrasound in sports medicine has evolved, it became clear that the curriculum needed to be updated. Furthermore, the name 'musculoskeletal ultrasound' was changed to 'sports ultrasound' (SPORTS US) to reflect the broad range of diagnostic and interventional applications of ultrasound in sports medicine. This document was created to outline the core competencies of SPORTS US and to provide sports medicine fellowship directors and others interested in SPORTS US education with a guide to create a SPORTS US curriculum. By completing this SPORTS US curriculum, sports medicine fellows and physicians can attain proficiency in the core competencies of SPORTS US required for the practice of sports medicine.

American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships.

The following sports ultrasound (SPORTS US) curriculum is a revision of the curriculum developed by the American Medical Society for Sports Medicine (AMSSM) in 2010. Several changes have been made to the curriculum with the primary aim of providing a pathway by which a sports medicine fellow can obtain sufficient SPORTS US training to become proficient in the core competencies of SPORTS US. The core competencies of SPORTS US are outlined in the learning objectives section of this document. The term "SPORTS US" was purposefully chosen rather than "musculoskeletal ultrasound" (MSK US) because it was recognized by the panel that the evolving field of SPORTS US encompasses non-MSK applications of ultrasound such as the FAST examination (focused assessment with sonography for trauma). Although the SPORTS US core competencies in this curriculum are all MSK in nature, they represent the minimum SPORTS US knowledge a sports medicine fellow should acquire during fellowship. However, additional training in more advanced MSK and non-MSK applications of ultrasound can be provided at the fellowship director's discretion. Completion of this SPORTS US curriculum fulfills the American Institute of Ultrasound in Medicine's (AIUM) requirements to perform an MSK US examination and the prerequisites for the American Registry for Diagnostic Medical Sonography's (ARDMS) MSK sonography certification examination.