Helmet Technology, Head Impact Exposure, and Cortical Thinning Following a Season of High School Football.

The purpose of this study was to compare the effects of wearing older, lower-ranked football helmets (LRank) to wearing newer, higher-ranked football helmets (HRank) on pre- to post-season changes in cortical thickness in response to repetitive head impacts and assess whether changes in cortical thickness are associated with head impact exposure for either helmet type. 105 male high-school athletes (NHRank = 52, NLRank = 53) wore accelerometers affixed behind the left mastoid during all practices and games for one regular season of American football to monitor head impact exposure. Pre- and post-season magnetic resonance imaging (MRI) were completed to assess longitudinal changes in cortical thickness. Significant reductions in cortical thickness (i.e., cortical thinning) were observed pre- to post-season for each group, but these longitudinal alterations were not significantly different between the LRank and HRank groups. Further, significant group-by-head impact exposure interactions were observed when predicting changes in cortical thickness. Specifically, a greater frequency of high magnitude head impacts during the football season resulted in greater cortical thinning for the LRank group, but not for the HRank group. These data provide preliminary in vivo evidence that HRank helmets may provide a buffer between the specific effect of high magnitude head impacts on regional thinning by dissipating forces more evenly throughout the cortex. However, future research with larger sample sizes, increased longitudinal measures and additional helmet technologies is warranted to both expand upon and further validate the present study findings.

Visual-Spatial Attentional Performance Identifies Lower Extremity Injury Risk in Adolescent Athletes.

OBJECTIVE: Strategies to identify lower extremity musculoskeletal (LEMSK) injury risk have been informed by prospectively identified biomechanical and neuromuscular risk factors. Emergent evidence suggests that cognitive and oculomotor performance may also contribute to LEMSK injury. The purpose of this study was to determine whether prospective cognitive and oculomotor measures identify adolescent athletes who sustain an in-season LEMSK injury. DESIGN: Prospective longitudinal study. SETTINGS: Controlled laboratory and athletic event settings. PARTICIPANTS: Four hundred eighty-eight adolescent male football and female soccer athletes aged 13 to 18 years. ASSESSMENT OF RISK FACTORS: Preseason baseline cognitive and oculomotor performance: Attention Network Task (ANT), cued task switching, King-Devick test, and near point of convergence. MAIN OUTCOME MEASURE: Incidence of LEMSK sprains and strains during a single competitive season. RESULTS: Attention Network Task-orienting network reaction time (RT) was the only cognitive or oculomotor measure significantly associated with LEMSK injury [B = 1.015, 95% confidence interval (CI): 1.01-1.024, P < 0.01]. Every 10 milliseconds increase in orienting network RT was associated with a 15% increased risk for LEMSK injury. Athletes demonstrating an orienting network RT ≥ 32.8 milliseconds had a higher risk for LEMSK injury relative to athletes below the cut-point (relative risk, 2.62; 95% CI, 1.52-4.52; odds ratio, 3.00; 95% CI, 1.63-5.52). CONCLUSIONS: Deficits in visual-spatial components of attention were associated with 2.62 times greater risk for LEMSK injury in adolescent athletes. The present results add evidence to suggest that visual-spatial attentional processing contributes to LEMSK injury and may supplement previously established LEMSK injury risk assessments.

Sex Moderates the Relationship between Perceptual-Motor Function and Single-Leg Squatting Mechanics.

To examine the isolated and combined effects of sex and perceptual-motor function on single-leg squatting mechanics in males and females. We employed a cross-sectional design in a research laboratory. Fifty-eight females (22.2 ± 3.5 yrs, 1.60 ± .07 m, 64.1 ± 13.0 kg) and 35 males (23.5 ± 5.0 yrs, 1.80 ± .06m, 84.7 ± 15.3 kg) free from time-loss injury in the six months prior, vertigo, and vestibular conditions participated in this study. Independent variables were sex, perceptual-motor metrics (reaction time, efficiency index, conflict discrepancy), and interaction effects. Dependent variables were peak frontal plane angles of knee projection, ipsilateral trunk flexion, and contralateral pelvic drop during single-leg squatting. After accounting for the sex-specific variance and perceptual-motor function effects on frontal plane squatting kinematics, female sex amplified the associations of: higher reaction time, lower efficiency index, and higher conflict discrepancy with greater right ipsilateral peak trunk lean (R2 = .13; p = .05); higher reaction time, lower efficiency index, and higher conflict discrepancy with decreased right contralateral pelvic drop (R2 = .22; p < .001); higher reaction time and lower conflict discrepancy with greater right frontal plane knee projection angle (R2 = .12; p = .03); and higher reaction time with greater left frontal plane knee projection angle (R2 = .22; p < .001). Female sex amplified the relationship between perceptual-motor function and two-dimensional frontal plane squatting kinematics. Future work should determine the extent to which perceptual-motor improvements translate to safer movement strategies.

Influence of Cognitive Performance on Musculoskeletal Injury Risk: A Systematic Review.

BACKGROUND: While a large number of studies have investigated the anatomic, hormonal, and biomechanical risk factors related to musculoskeletal (MSK) injury risk, there is growing evidence to suggest that cognition is an important injury contributor in the athletic population. A systematic review of the available evidence regarding the influence of cognitive performance on MSK injury risk has yet to be published in the sports medicine literature. PURPOSE/HYPOTHESIS: The purpose was to determine the effects of cognition on (1) MSK biomechanics during sports-specific tasks and (2) MSK injury occurrence in the athletic population. It was hypothesized that athletes with lower cognitive performance would demonstrate biomechanical patterns suggestive of MSK injury risk and that injured athletes would perform worse on baseline measures of cognition as compared with their noninjured counterparts. STUDY DESIGN: Systematic review. METHODS: PubMed and SPORTDiscus were searched from January 2000 to January 2020. Manual searches were performed on the reference lists of the included studies. A search of the literature was performed for studies published in English that reported MSK biomechanics as a function of cognitive performance and MSK injury occurrence after baseline measures of cognition. Two independent reviewers extracted pertinent study data in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 guidelines and assessed study quality using the Quality Assessment Tool for Observational Cohort and Cross-sectional Studies from the National Institutes of Health. A meta-analysis was not performed, owing to the heterogeneous nature of the study designs. RESULTS: Ten studies met inclusion criteria: 4 cognition-MSK biomechanics studies and 6 cognition-MSK injury studies. All 4 cognition-MSK biomechanics studies demonstrated that worse performance on measures of cognition was associated with lower extremity MSK biomechanical patterns suggestive of greater risk for MSK injury. The majority of the cognition-MSK injury studies demonstrated that injured athletes significantly differed on baseline cognition measures versus matched controls or that cognitive performance was a significant predictor for subsequent MSK injury. CONCLUSION: Although the literature exploring cognitive contributions to MSK injury risk is still in its infancy, it is suggested that sports medicine personnel conduct baseline assessments of cognition-in particular, reaction time and working memory-to identify which athletes may be at elevated risk for future MSK injury.

Effect of Subconcussive Head Impact Exposure and Jugular Vein Compression on Behavioral and Cognitive Outcomes after a Single Season of High-School Football: A Prospective Longitudinal Trial.

This prospective longitudinal trial aimed to (1) determine the role of head impact exposure on behavioral/cognitive outcomes, and (2) assess the protective effect(s) of a jugular vein compression (JVC) collar on behavioral/cognitive outcomes after one season of high-school football. Participants included 284 male high-school football players aged 13-18 years enrolled from seven Midwestern high-schools. Schools were allocated to the JVC collar intervention (four teams, 140 players) or no collar/no intervention control (three teams, 144 players) condition. Head impact exposure was measured throughout the season using CSx accelerometers. Outcome measures included post-season parent and adolescent report on Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Scale (SWAN) and Post-Concussion Symptom Inventory (PCSI), as well as adolescent performance on Attention Network Task (ANT), digital Trail Making Task (dTMT), and Cued Switching task. No significant effect of head impact exposure or JVC collar use on post-season SWAN or PCSI scores or performance on dTMT and Cued Switching task were noted. There was no effect of head impact exposure on ANT performance; however, the JVC collar group had greater post-season Alerting network scores than the no collar group (p = 0.026, d = 0.22). Findings provide preliminary evidence that the JVC collar may provide some protection to the alerting attention system. These findings should be interpreted cautiously as a greater understanding of the long-term sequelae of head impact exposure and the role of cumulative head impact exposure behavioral/cognitive outcomes is required.

Relationship Between Cognitive Performance and Lower Extremity Biomechanics: Implications for Sports-Related Concussion.

BACKGROUND: Collegiate athletes with prior sports-related concussion (SRC) are at increased risk for lower extremity (LE) injuries; however, the biomechanical and cognitive mechanisms underlying the SRC-LE injury relationship are not well understood. PURPOSE: To examine the association between cognitive performance and LE land-and-cut biomechanics among collegiate athletes with and without a history of SRC and to determine the association among multiple cognitive testing batteries in the same athlete cohort. STUDY DESIGN: Controlled laboratory study. METHODS: A cohort of 20 collegiate athletes with prior SRC (9 men, 11 women; mean ± standard deviation [SD] age, 20.5 ± 1.3 years; mean ± SD time since last SRC, 461 ± 263 days) and 20 matched controls (9 men, 11 women; mean ± SD age, 19.8 ± 1.3 years) completed land-and-cut tasks using the dominant and nondominant limbs. LE biomechanical variables and a functional visuomotor reaction time (FVMRT) were collected during each trial. Athletes also completed the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) and Senaptec Sensory Station assessments. RESULTS: In the SRC cohort, Pearson correlation coefficients indicated slower FVMRT was moderately correlated with decreased dominant limb (r = -0.512) and nondominant limb (r = -0.500) knee flexion, while increased dominant limb knee abduction moment was moderately correlated with decreased ImPACT Visual Memory score (r = -0.539) and slower ImPACT Reaction Time (r = 0.515). Most computerized cognitive measures were not associated with FVMRT in either cohort (P > .05). CONCLUSION: Decreased reaction time and working memory performance were moderately correlated with decreased sagittal plane knee motion and increased frontal plane knee loading in collegiate athletes with a history of SRC. The present findings suggest a potential unique relationship between cognitive performance and LE neuromuscular control in athletes with a history of SRC injury. Last, we determined that computerized measures of cognitive performance often utilized for SRC management are dissimilar to sport-specific cognitive processes. CLINICAL RELEVANCE: Understanding the relationship between cognitive performance and LE biomechanics in athletes with prior SRC may inform future clinical management strategies. Future research should prospectively assess cognitive and biomechanical measures, along with LE injury incidence, to identify mechanisms underlying the SRC-LE injury relationship.

Loss of Motor Stability After Sports-Related Concussion: Opportunities for Motor Learning Strategies to Reduce Musculoskeletal Injury Risk.

Current best practices to direct recovery after sports-related concussion (SRC) typically require asymptomatic presentation at both rest and during a graduated exercise progression, and cognitive performance resolution. However, this standard of care results in a significantly elevated risk for musculoskeletal (MSK) injury after return-to-sport (RTS). The elevated risk is likely secondary to, in part, residual neurophysiological and dual-task motor stability deficits that remain despite RTS. These deficits present as a loss of autonomous control of gait and posture and an increased need for cognition for motor stability. Thus, the incorporation of strategies that can enhance motor stability and restore autonomous control of gait and posture during SRC recovery and RTS progression may facilitate a reduction of the elevated risk of secondary MSK injury. We provide a theoretical framework for the application of motor learning principles to restore autonomous gait and postural stability after SRC via incorporation, or targeted manipulation, of external focus, enhanced expectations, autonomy support, practice schedule variability, and dual-task strategies during rehabilitation and RTS training.

Skilled Throwing Performance: A Test of the OPTIMAL Theory.

The OPTIMAL theory of motor learning postulates that autonomy support (AS), enhanced expectancies (EE), and an external focus of attention (EF) facilitate improved motor learning and performance. However, its applicability to elite-level throwing athletes has not been investigated by previous literature. The primary purpose of this study was to investigate the successive implementation of AS, EE, and EF factors on overhand throwing performance in elite collegiate softball athletes (14.44 ± 2.75 years of softball experience). The secondary purpose was to determine whether self-efficacy beliefs would be augmented by factor manipulation. Twenty-four participants threw softballs at a bullseye target during five blocks. The Baseline test (Block 1) was used to subsequently assign participants to either the OPTIMAL or control group. Three middle blocks (Block 2 to 4) followed with successive factor implementation for the OPTIMAL group and without instruction for the control group. The final block (Block 5) served as the Transfer test, at which time throwing distance was increased. During Blocks 2 to 4, the OPTIMAL group was given the choice between softballs (AS), a liberal definition of successful throwing performance (EE), and instructed to focus on the bullseye (EF). Self-efficacy beliefs were assessed after applying the factors and before all blocks. There were no significant differences between the groups in throwing accuracy or self-efficacy scores across all blocks. The results suggest that the OPTIMAL theory does not augment skilled throwing performance or alter self-efficacy in elite softball throwing, potentially attributed to a natural adoption of EF and previously high self-efficacy.

The effect of landing type on kinematics and kinetics during single-leg landings.

Landing research attempts to simulate sport activities; however, movements performed pre- or post-landing may alter landing mechanics and injury risk. Therefore, this study compared lower extremity biomechanics of single-leg drop landings, drop jump (DJ) and countermovement jump (CMJ) landings as well as sex-related differences. A total of 25 recreational athletes (11 females) performed landings from 80% maximum jump height with impact forces, kinematics and joint moments measured during each landing. Altered kinematic and kinetic variables were revealed when a jump was performed pre- or post-landing. CMJ landings were generally performed with a more extended lower extremity at ground contact, less hip and knee motion in the frontal and transverse planes and larger joint moments compared to other landings (p < 0.01). The DJ landings demonstrated greater joint flexion and large frontal and transverse plane motion, paired with decreased impact forces and joint moments (p < 0.05). Across all landings, males displayed larger impact forces and joint moments (p < 0.01), and females demonstrated frontal plane kinematics associated with increased injury risk (p < 0.05). These findings suggest that activities surrounding the landing directly impact landing mechanics and overall risk. Therefore, matching landing type to sport-specific activities increases the efficacy of assessing injury risk during training or rehabilitation programmes.

The Influence of Sport-Related Concussion on Lower Extremity Injury Risk: A Review of Current Return-to-Play Practices and Clinical Implications.

Sport-related concussions (SRCs) are now classified as a major health concern affecting athletes across all sporting levels, with recent evidence suggesting upwards of 3.8 million SRCs occur each year. Multiple injury surveillance datasets have recently determined that athletes post-SRC, compared to non-concussed counterparts, are at greater risk for lower extremity (LE) injury beyond the resolution of traditional SRC assessment batteries. However, it is presently uncertain if common clinical practices (symptom reporting, neuropsychological (NP) examination, and static postural control analysis) can determine athletes at risk for LE injury following an SRC. A comprehensive review of the literature determined that these tools may not reveal subtle cognitive and neuromuscular deficits that lead to subsequent LE injury during dynamic sporting tasks. Current return-to-play (RTP) protocols should consider clarifying the addition of specific objective locomotor analysis, such as gait tasks and sport-specific maneuvers, to determine the risk of LE injury after an athlete has sustained an SRC.

Landing Biomechanics in Adolescent Athletes With and Without a History of Sports-Related Concussion.

Recent evidence suggests previously concussed athletes are at greater risk for lower-extremity (LE) injuries than are controls. However, little is known regarding the influence of sports-related concussion (SRC) on landing biomechanics that may provide a mechanistic rationale for LE injury risk. The purpose of this investigation was to examine LE drop-landing biomechanics in adolescent athletes with and without a previous SRC history. Participants included 10 adolescent athletes with an SRC history and 11 controls from multiple sports. Three-dimensional kinematic and kinetic data associated with LE injury risk were analyzed across 5 trials for 30- and 60-cm landing heights. Multivariate analyses indicated group differences in landing patterns from the 30- (P = .041) and 60-cm (P = .015) landing heights. Follow-up analyses indicated that concussed adolescent athletes demonstrated significantly less ankle dorsiflexion and knee flexion versus controls when performing drop landings. Our findings suggest that previously concussed adolescent athletes complete drop-landing maneuvers with ankle and knee joint kinematic patterns that suggest greater risk for LE injury. While limitations such as sport variety and explicit LE injury history are present, the results of this study provide a possible biomechanical rationale for the association between SRC and LE injury risk.

Pre- and Post-Activity Stretching Practices of Collegiate Soccer Coaches in the United State.

Current pre- and post-activity stretching guidelines are designed to optimize performance and reduce injury risk. However, it is unclear whether soccer coaches adhere to these recommendations. The purpose of this study was to determine if collegiate soccer coaches' perceptions and practices align with current scientific recommendations. A total of 781 questionnaires were electronically distributed to soccer coaches from NCAA Division I and III universities. The questionnaire obtained demographic, professional, and educational information, as well as stretching practices. Statistical analysis consisted of computing frequency counts and means where applicable. Pearson's Chi-square tests were performed to assess the potential differences in stretching perceptions and practices among the cohort of soccer coaches. Results suggest that soccer coaches are choosing some forms of stretching more frequently than other coaches (χ2 = 342.7, p < 0.001). Further analysis failed to determine significant associations between stretching type and coaching certification, level, sex, years of experience, and age. Of the 209 respondents, 84.9% believed pre-activity stretching to be of greater than average importance on a seven-point Likert scale. Dynamic stretching (68.7%) or a combination of static and ballistic stretching (18.0%) prior to athletic events was the most typical stretching prescribed. Current post-activity practices demonstrate that most coaches (95.4%) are using some form of a general cool-down following practice or competition. This study is an important assessment of the extent to which collegiate coaches administer appropriate stretching techniques. Most coaches adhere to current recommendations; however, they should continue to evaluate their practices against ongoing research and the practices of their peers.

The biomechanical effect of warm-up stretching strategies on landing mechanics in female volleyball athletes.

Female volleyball athletes incorporate dynamic and static stretching into a warm-up, with evidence generally supporting dynamic stretching to improve performance. However, the effects of these stretching practices on injury risk during subsequent volleyball manoeuvres have yet to be fully elucidated in the warm-up literature. Three-dimensional kinematic data associated with non-contact, lower extremity injury were recorded on 12 female collegiate club volleyball athletes during unilateral landing tasks on the dominant and non-dominant limb. Participants performed landings as part of a volleyball-simulated manoeuvre prior to and post-dynamic (DWU) and combined dynamic-static (CDS) warm-ups. A significant reduction in non-dominant hip adduction angle was found at 15 min post CDS warm-up (p = 0.016; d = 0.38), however, no other warm-up differences were detected. The non-dominant limb demonstrated greater knee abduction (p = 0.006; d = 0.69) and internal rotation angle (p = 0.004; d = 0.88), suggesting that this limb demonstrates more risky landing patterns that are potentially due to altered trunk positioning upon landing. The results show that the majority of selected landing kinematics are unaffected by additional static stretching to a dynamic warm-up and that the non-dominant limb may be at a higher injury risk in female volleyball athletes.

Anticipatory effects on lower extremity kinetics during a land and cross step maneuver in female volleyball players.

BACKGROUND: Anticipation has been previously shown to affect lower extremity mechanics during both landing and cutting maneuvers. However, little research has been conducted looking at the effects of anticipation on lower body kinetics and kinematics during a land and cross step maneuver, which due to similar kinematics, may elicit injury. The purpose of this study was to investigate competitive female volleyball players and the effect of anticipation on lower extremity mechanics during a landing and subsequent cross stepping maneuver. METHODS: Twelve female, college-level volleyball players performed right and left cross step maneuvers following a landing under anticipated and unanticipated conditions. Kinetics were measured for the ankle, knee and hip of the dominant limb during the landing phase of the land and cross step anticipatory conditions. RESULTS: An interaction effect (anticipation x direction; P=0.001) was observed for vertical ground reaction force (VGRF), in which greater VGRF was found during unanticipated pivoting maneuvers. Additional interaction effects were determined for ankle (P=0.004) and hip (P=0.037) power absorption, in which greater absorption was found during anticipated, push off conditions. Frontal plant knee kinetics revealed a higher-order interaction, as a larger knee adduction moment was shown during anticipated, push off trials (P=0.001). CONCLUSIONS: High risk cross step maneuvers were found during unanticipated and anticipated conditions, as athletes demonstrated movement mechanics that may increase the risk of knee injury when performing movements away from the dominant limb. Consideration should be given to drills familiarizing volleyball players with unanticipated and anticipated changes of direction, as well as improving strength of the lower extremity muscles required to effectively decelerate the body, as both training modalities may minimize injury risk during cross step maneuvers.

Kinetic Analysis of Unilateral Landings in Female Volleyball Players After a Dynamic and Combined Dynamic-Static Warm-up.

Avedesian, JM, Judge, LW, Wang, H, and Dickin, DC. Kinetic analysis of unilateral landings in female volleyball players after a dynamic and combined dynamic-static warm-up. J Strength Cond Res 33(6): 1524-1533, 2019-A warm-up is an important period before training or competition to prepare an athlete for the physical demands of subsequent activity. Previous research has extensively focused on the effects of warm-up in relation to various jumping performance attributes; however, limited research has examined the biomechanical nature of landings after common warm-up practices. Twelve female, collegiate-level volleyball players performed unilateral landings on the dominant and nondominant limb before and after dynamic warm-ups and combined dynamic-static (CDS) warm-ups. Kinetic variables of interest were measured at the hip and knee during the landing phase of a volleyball-simulated jump-landing maneuver. A significant 3-way interaction (warm-up × limb × time) for peak internal knee adduction moment was observed, as this kinetic parameter significantly increased (p = 0.01; d = 0.79) in the nondominant limb at 1-minute post-CDS warm-up. No other warm-up differences were detected; however, significant main effects of limb were determined for dominant-limb internal hip abduction moment (p < 0.01; d = 1.32), dominant-knee internal rotation moment (p < 0.01; d = 1.88), and nondominant-knee external rotation moment (p < 0.01; d = 1.86), which may be due to altered hip and trunk mechanics during the jump landings. This information provides strength and conditioning professionals with biomechanical information to determine warm-up protocols that reduce the risk of injury in female volleyball athletes.