Applying the NIMHD Research Framework to Social Determinants of Health in the Context of Sport-Related Concussion: A Clinical Commentary.

Sport-related concussion (SRC) is a prevalent injury. There are significant disparities in SRC outcomes across racial and ethnic groups. These disparities may be attributed to the unequal distribution of political power (or influence) and resource allocation in various communities shaping individuals' social determinants of health (SDoH). However, the influence of SDoH on SRC outcomes remains understudied. In this clinical commentary we use the National Institute of Minority Health and Health Disparities Research Framework and describe how it's application can help address gaps in our understanding of SDoH and SRC. This framework provides a comprehensive approach to investigating and addressing health disparities by considering SDoH along multiple levels and domains of influence. Using this framework, athletic trainers (ATs) can identify areas requiring intervention and better understand how SDoH influence SRC outcomes. This understanding can help ATs develop tailored interventions to promote equitable care for SRC.

Depression, anxiety and stress among female student-athletes: a systematic review and meta-analysis.

OBJECTIVE: To identify, quantify and analyse determinants of depression, anxiety and stress symptoms among female student-athletes. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Five online databases (PubMed, CINAHL, PsychInfo, SportDiscus and Web of Science) searched from inception through 14 September 2023. Hand-searches and contacting authors for eligible studies. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Articles were included if they were published in English, included female student-athletes competing at National Collegiate Athletic Association institutions, and measured symptom-level depression, anxiety and/or stress. RESULTS AND SUMMARY: We screened 2415 articles; 52 studies (N=13 849) were included in the systematic review with 13 studies qualifying for meta-analysis. Seventeen determinants were identified including injury (eg, concussions), health (eg, sleep hygiene) and social factors (eg, social support). As data specific to female student-athletes was delineated from studies that included other populations, we observed 16 studies (30.7%) reported that identifying as female was a meaningful determinant of depression, anxiety and stress in athletes. Results of the meta-analysis (k=13, N=5004) suggested a small but significant association (r=0.15, 95% CI 0.05 to 0.24, p=0.004) between other determinants and depression, anxiety, and stress among female student-athletes. CONCLUSION: Coaches, trainers and clinicians are key contributors in supporting female student-athlete mental health, with responsibilities for integrating mental skill training, sleep hygiene education and regular assessments. Comprehensive mental health and tailored education programmes considering determinants such as injury, health and social factors specific to female student-athletes are needed to enhance mental health equity in sport. PROSPERO REGISTRATION NUMBER: CRD42022362163.

Concussion-Related Decision-Making by Certified Athletic Trainers: Implications for Concussion Prevention and Care.

Concussions are a common sport-related injury that require appropriate initial care. Athletic trainers, often a primary source of healthcare for student-athletes, are key individuals involved in initial concussion diagnostic and management decisions. Challenges exist within the athletic environment that may hinder the consistency, efficacy, and/or effectiveness of concussion-related decision-making by athletic trainers, thereby impacting secondary concussion prevention and patient health. The purpose of this study was to identify factors that impact the intentions of athletic trainers to make appropriate concussion-related decisions under various circumstances. Overall, 1029 participants completed a survey examining educational precursors (quantity and quality of healthcare communication educational focus), demographic precursors (age, gender, educational degree, and employment setting), theory-based mediators (attitudes, perceived norms, and personal agency), and external mediators (knowledge, salience, and communication/collaboration practices) on appropriate concussion-related decision-making intentions. Data were analyzed using a two-step structural equation modeling approach. Quality of healthcare communication educational focus indirectly impacted appropriate concussion-related decision-making intentions via perceived behavioral control and communication/collaboration practices. Additionally, several factors impacted intentions to make appropriate concussion-related decisions directly including employment setting, self-efficacy, and general attitudes towards decision-making and concussions. Concussion prevention is aided by the initial and appropriate action taken by a healthcare professional to reduce immediate consequences; however, this action may be influenced by stakeholder relationships. These influential factors of decision-making may place athletes at further injury risk and negatively impact overall athlete health. As such, a sound theoretical framework incorporating the complexity of factors that may influence decision-making is needed.

The Longitudinal Relationship Between Concussion History, Years of American Football Participation, and Alcohol Use Among Former National Football League Players: an NFL-LONG Study.

OBJECTIVE: Investigate the relationships between concussion history and years of football participation (repetitive head impact proxy) with alcohol use across multiple decades in former professional football players. METHODS: Participants (n = 348; mean age = 49.0 ± 9.4) completed health questionnaires in 2001 and 2019, which included self-reported concussion history and years of participation. Alcohol use frequency and amount per occasion were reported for three timepoints: during professional career, 2001, and 2019. Ordinal logistic regression models were fit to test associations of concussion history and years of participation with alcohol use at each timepoint. RESULTS: There were no significant associations between either concussion history or years of football participation with alcohol use (frequency and amount per occasion) at any timepoint. Effect estimates for concussion history and years of football participation with alcohol use were generally comparable across timepoints. CONCLUSIONS: Later life alcohol use by former American football players is not associated with concussion history or years of exposure to football.

Joint Injury, Osteoarthritis, and Cardiovascular Disease Risk Factors in Former National Football League Athletes: An NFL-LONG Study.

CONTEXT: Individuals with lower extremity osteoarthritis (OA) have a 25% greater risk of cardiovascular disease (CVD) than those without OA. The prevalence of traumatic joint injuries among National Football League (NFL) players exposes these athletes to an elevated risk for OA and potentially a greater risk of cardiovascular risk factors (CRFs) and CVD. OBJECTIVES: To examine the associations between a history of lower extremity joint injury, lower extremity OA, and the prevalence of CRFs and CVD among former NFL athletes. DESIGN: Cross-sectional study. PATIENTS OR OTHER PARTICIPANTS: Former NFL players completed a comprehensive health questionnaire that was used in an ongoing study, the Neurologic Function Across the Lifespan: A Prospective, Longitudinal, and Translational Study for Former NFL Players (NFL-LONG). A subsample of 1738 former players reported lifetime medical diagnoses including CVD or CRFs. MAIN OUTCOME MEASURE(S): Crude and adjusted prevalence ratios (PRsadj) characterized the associations between CVD or CRFs and injury, OA diagnosis, or both among athletes who reported (1) no history of lower extremity joint injury or surgery and no diagnosed OA, (2) a history of lower extremity joint injury or surgery and no diagnosed OA, and (3) a history of lower extremity joint injury or surgery and diagnosed OA. RESULTS: Neither a history of lower extremity joint injury (PRadj = 1.34; 95% CI = 0.86, 2.07) nor a history of lower extremity joint injury and diagnosed OA (PRadj = 1.41; 95% CI = 0.89, 2.25) was significantly associated with CVD. However, CRFs were 30% and 53% more prevalent in former players with lower extremity joint injury and no diagnosed OA (PRadj = 1.30; 95% CI = 1.12, 1.50) and those with lower extremity joint injury and diagnosed OA (PRadj = 1.53; 95% CI = 1.31, 1.78), respectively, versus athletes with no history of either condition. CONCLUSIONS: The prevalence of CRFs was highest among former NFL athletes with a history of lower extremity joint injury and diagnosed OA. These findings provide insight regarding the potential pathways to chronic diseases that may be initiated by joint injury early in life.

Call It an "Evolution": Promoting Student-Athlete Well-Being During the Transition From Collegiate Sport.

After highly publicized stories of student-athletes' struggles with mental health, the spotlight on mental health and well-being in this special issue coincides with a broader growing concern for the long-term impact of competitive sport participation on student-athlete health and wellness. The end of a competitive sport career represents a potentially vulnerable life transition. As demonstrated in the literature, the unique aspects of elite sport culture shape student-athletes' perceptions of their identity, health, and health behaviors, which have implications for how student-athletes navigate their health and well-being as they transition away from the embedded health care structure inherent to elite sport. Given evidence indicating that student-athletes may face mental and physical health concerns after retirement from sports, targeted transitional strategies are needed to provide patient-centered care in this population. In this article, we briefly summarize current understanding of sport transition and highlight some key findings from studies conducted by the contributing authors' research groups exploring the impact of sport career transitions on student-athlete well-being. We also reflect on limitations of the existing research and transition models and, in turn, propose potential directions for adopting a nuanced and multidimensional framework to explore interconnected transition domains. We conclude by offering recommendations for sports medicine professionals to consider in future research, programming, and policies to promote student-athletes' holistic well-being through this critical transition.

Incorporation of concussion history as part of the LIfestyle for BRAin Health (LIBRA) modifiable factors risk score and associations with cognition in older former National Football League players.

OBJECTIVE: Investigate associations between the LIfestyle for BRAin Health (LIBRA) risk score with odds of mild cognitive impairment (MCI) diagnosis and cognitive function, incorporating concussion history. METHODS: Former National Football League (NFL) players (N = 1050; mean age = 64.8 ± 9.0-years) completed initial testing for integration of concussion history into LIBRA scores (i.e., modified-LIBRA) and completed the Brief Test of Adult Cognition by Telephone (BTACT). Modified-LIBRA score (including concussion history) associations with odds of MCI and cognitive dysfunction were assessed via logistic and linear regression. RESULTS: The highest quartile LIBRA scores were six times more likely to have a diagnosis of MCI compared to the lowest quartile (OR = 6.27[3.61, 10.91], p < 0.001). Modified-LIBRA scores significantly improved model fit for odds of MCI above original LIBRA scores (χ2 (1) = 7.76, p = 0.005) and accounted for a greater fraction of variance in executive function (ΔR2  = 0.02, p = 0.003) and episodic memory (ΔR2  = 0.02, p = 0.002). CONCLUSIONS: Modified-LIBRA score, incorporating concussion history, may help monitoring risk status in former contact sport athletes, by targeting modifiable, lifestyle-related risk factors.

Relating American Football Age of First Exposure to Patient-Reported Outcomes and Medical Diagnoses Among Former National Football League Players: An NFL-LONG study.

BACKGROUND: The age of first exposure (AFE) to American football participation is a growing concern for late-life function. Mixed evidence exists surrounding AFE and may be attributed to varied methods employed across studies. OBJECTIVE: To examine the associations between AFE to American football participation with measures of cognitive, behavioral, and physical function and brain-related medical diagnoses across age categories among former National Football League players. METHODS: We conducted a cross-sectional survey of 1784 former players (age: 52.3 ± 16.3 years, AFE: 11.3 ± 2.9 years, years of football: 17.5 ± 4.5 years, 86.9% ≥ one lifetime concussion). Players completed a general health questionnaire recording demographics, football playing history (including AFE), and diagnoses (anxiety, depression, any form of dementia, mild cognitive impairment). Players completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures assessing domains of cognitive and physical function, anxiety, depression, sleep disturbance, pain interference, and emotional-behavioral dyscontrol. Multivariable linear and binomial regression models were used to examine the associations of AFE and age with PROMIS outcomes and diagnoses, respectively. RESULTS: No significant AFE by age interactions were detected for PROMIS outcomes (p ≥ 0.066) or diagnoses (p ≥ 0.147). Younger AFE associated with higher PROMIS scores of anxiety (B = - 0.22, p = 0.016), depression (B = - 0.22, p = 0.010), sleep disturbances (B = - 0.16, p = 0.007), pain interference (B = - 0.19, p = 0.014), and emotional-behavioral dyscontrol (B = - 0.22, p = 0.019). Age was associated with all PROMIS outcomes (p ≤ 0.042). AFE was not associated with the prevalence of anxiety, depression, dementia, or mild cognitive impairment (p ≥ 0.449), while age was (p ≤ 0.013). CONCLUSIONS: AFE was significantly associated with PROMIS outcomes, albeit low-strength associations (i.e., effect sizes), but not with diagnoses. Our findings indicate AFE is a significant but minor contributing factor for health-related quality of life in this cohort. Future work should incorporate additional characterizations of cumulative head impacts and related factors when examining long-term outcomes associated with football participation.

Measurement implications on the association between self-reported concussion history and depression: An NFL-LONG study.

ObjectiveThis study examined how associations of self-reported concussion history and depression vary based on different variable characterizations. Methods Former NFL players (n = 1,697) completed a General Health Survey, indicating the number of concussions they sustained during their football career and whether a physician had diagnosed them with depression, and the PROMIS 4-item Depression scale. Self-reported concussion history was characterized as: a 3-category variable (0, 1-2, 3+) with (1) indicator variables and (2) as an ordinal variable; a 5-category variable (0, 1-2, 3-5, 6-9, 10+) with (3) indicator variables and (4) as an ordinal variable; and (5) the original interval scale (0, 1, 2,…, 10, 10+). Depression was characterized as: (1) physician diagnosis (yes/no); and the PROMIS 4-item Depression scale treated as: (2) the original T-score variable and (3) using a cut-off of a T-score >60 versus ≤60. Regression models with various combinations of the characterizations, while adjusting for age, race/ethnicity, education, pain interference, and stress level, estimated prevalence ratios and mean differences for binary and continuous outcomes, respectively. Concussion history-related effect estimates were compared across all models. Results Self-reported concussion history emerged as a significant predictor of each depression measure. With a higher number of concussions reported, be it via the categories or the interval scale, stronger associations between self-reported concussion history and depression were observed. Conclusions The various approaches to characterize self-reported concussion history and depression provided evidence of significant associations between the two variables, with the degree of association varying based on characterization of each construct.

A dominance analysis of subjective cognitive complaint comorbidities in former professional football players with and without mild cognitive impairment.

OBJECTIVES: Subjective cognitive difficulties (SCDs) are associated with factors commonly reported in older adults and former contact sport athletes, regardless of objective cognitive decline. We investigated the relative contribution of these factors to SCD in former National Football League (NFL)-players with and without a diagnosis of mild cognitive impairment (MCI). METHODS: Former NFL players (n = 907) aged ≥ 50 years (mean = 64.7 ± 8.9), with (n = 165) and without (n = 742) a diagnosis of MCI completed health questionnaires. Multivariable regression and dominance analyses determined the relative importance of SCD factors on SCD: 1) depression, 2) anxiety, 3) sleep disturbance, 4) pain interference, 5) ability to participate in social roles and activities, 6) stress-related events, 7) fatigue, 8) concussion history, and 9) education. SCD outcomes included Neuro-QoL Emotional-Behavioral Dyscontrol and the PROMIS Cognitive Function. Fisher's z-transformation compared comorbid contributing factors to SCD across MCI and non-MCI groups. RESULTS: Complete dominance of anxiety was established over most comorbid factors across the MCI and non-MCI groups. Fatigue also exhibited complete dominance over most comorbid factors, though its influence in the MCI group was less robust (general dominance). Average contributions to variance accounted for by comorbid factors to ratings of SCD across MCI and non-MCI groups did not statistically differ (Z-statistics <1.96, ps>.05). CONCLUSIONS: Anxiety and fatigue are the most robust factors associated with SCD in former professional football players across various combinations of clinical presentations (different combinations of comorbid factors), regardless of documented cognitive impairment. Self-reported deficits may be less reliable in detecting objective impairment in the presence of these factors, with multidimensional assessment being ideal.

Active Warfighter Mental Health Lower in Mid-Career.

PURPOSE: The present study investigated Special Operations Forces (SOF) combat Servicemember mental health at different SOF career stages in association with resilience. METHODS: Fifty-eight SOF combat Service Members either entering SOF (career start; n=38) or multiple years with their SOF organization (mid-career; n=20) self-reported mild traumatic brain injury (TBI) history, resilience, subjective well-being, depression, anxiety, and posttraumatic stress. Poisson regression analyses were employed to test SOF career stage differences in each mental health symptom using resilience, while accounting for other pertinent military factors. RESULTS: There were significant interaction effects of SOF career stage and resilience on mental health symptoms. SOF career start combat Servicemembers endorsed lower depression and posttraumatic stress and higher subjective well-being with higher resilience, but these associations between resilience and mental health symptoms were not seen in SOF mid-career Servicemembers. CONCLUSIONS: Although preliminary, the adaptive association between resilience and mental health seemed to be blunted in combat Servicemembers having served multiple years in SOF. This information informs research to provide evaluation tools to support prophylactic performance and long-term health preservation in military populations.

The stability of self-reported professional football concussion history among former players: A longitudinal NFL-LONG study.

OBJECTIVES: To examine the stability of former National Football League (NFL) players' recall of professional football concussion. METHODS: Two-hundred-and-nine former NFL players (ceasing football participation before/in 2001) completed surveys in 2001, 2010, and 2019 and reported the number of concussions sustained during their professional careers (0, 1 … 10, >10). Participants were categorized into four 'recall stability' groups, based upon concussion recall [e.g., 'Same' (same number recalled), 'Increased' (more recalled than in prior time point)]. In 2019, participants completed measures of functioning (e.g., PROMIS Cognitive Function, Anxiety, Depression). Fleiss Kappa and generalized linear mixed models (GLMM)-based ordinal measures Kappa assessed stability across time points. 'Recall stability group' functioning scores were compared. RESULTS: Overall, 45.9% recalled more concussions over time; 14.8% reported the same number. Fleiss Kappa and GLMM-based ordinal measures Kappa suggested fair (0.22, 95% CI: 0.26, 0.38) and moderate stability (0.41, 95% CI: 0.35, 0.46), respectively. Higher cognitive functioning (P = 0.002), lower anxiety (P = 0.003), and lower depression (P = 0.007) were observed in the 'Same' vs 'Increased' groups. CONCLUSIONS: Despite subtle time-based variations in reporting, professional football concussion history recall was relatively stable. Better cognitive and psychological functioning was associated with greater stability in concussion recall.

Warfighter Resilience.

PURPOSE: Our aim in this study was to psychometrically test resilience assessments (Ego Resiliency Scale [ER89], Connor-Davidson Resilience Scale [CD-RISC 25], Responses to Stressful Experiences Scale [RSES short-form]) and describe resilience levels in a Special Operations Forces (SOF) combat sample. METHODS: Fifty-eight SOF combat Servicemembers either entering SOF (career start; n = 38) or having served multiple years with their SOF organization (mid-career; n = 20) self-reported resilience, mild traumatic brain injury (mTBI) history, and total military service. RESULTS: All resilience metrics demonstrated acceptable internal consistency, but ceiling effects were found for CD-RISC and RSES scores. ER89 scores were moderate on average. ER89 scores were higher in SOF career start than mid-career Servicemembers (ηρ2 = 0.07) when accounting for the interaction between SOF career stage and total military service (ηρ2 = 0.07). DISCUSSION: SOF mid-career Servicemembers had similar ER89 resilience scores with more total military service. The SOF career start combat Servicemembers had higher ER89 measured resilience with less total military service only, potentially showing a protective effect of greater service before entering SOF. CONCLUSION: The ER89 may be a more optimal military resilience metric than the other metrics studied; longitudinal research on SOF combat Servicemember resilience is warranted.

Transition-Related Psychosocial Factors and Mental Health Outcomes in Former National Football League Players: An NFL-LONG Study.

Transition from professional sport to nonsport endeavors has implications for postcareer health and well-being of athletes. The purpose of the current study was to examine associations among transition-related psychosocial factors and current mental health outcomes in former National Football League (NFL) players. Participants were former NFL players (n = 1,784; mean age = 52.3 ± 16.3 years) who responded to a questionnaire assessing the nature of their discontinuation from professional football (i.e., any degree of voluntary choice vs. forced discontinuation), prediscontinuation transition planning (yes vs. no), and current symptoms of depression and anxiety. After adjusting for relevant covariates, having an involuntary discontinuation and no transition plan prior to discontinuation were associated with greater depressive and anxiety symptom severity. Autonomy in discontinuation and pretransition planning are important to former NFL football players' mental health. Increasing autonomy in the discontinuation decision and pretransition planning represent psychoeducational intervention targets for this population.

Mild Cognitive Impairment and Dementia Reported by Former Professional Football Players over 50 yr of Age: An NFL-LONG Study.

PURPOSE: This study aimed to estimate prevalence of mild cognitive impairment (MCI) and dementia diagnoses in former National Football League (NFL) players ≥50 yr old and examine the relationships among these diagnoses and an array of predictors of long-term brain health. METHODS: A cross section of former NFL players (n = 922; mean ± SD age, 64.8 ± 8.9 yr) completed a questionnaire. Prevalence of self-reported medical diagnoses of MCI and dementia was reported alongside U.S. population estimates across 5-yr age intervals (e.g., 60-64 yr). Prevalence ratios (PR) were calculated for multiple predictors of long-term brain health. RESULTS: Overall, MCI prevalence and dementia prevalence were n = 219(23.8%) and n = 82(8.9%), respectively. Each diagnosis was more prevalent in former NFL players across age-groups than U.S. norms, with greater disparities at relatively younger ages (e.g., 65-69 yr) compared with older ages. Greater prevalence of MCI and dementia was associated with self-reported concussion history (10+ vs 0; PRadjusted [95% CI] = 1.66 [1.02-2.71] and 2.61 [1.01-6.71], respectively); recent pain intensity (PRadjusted [95% CI] = 1.13 [1.07-1.20] and 1.15 [1.03-1.28]); and diagnoses of depression (PRadjusted [95% CI] = 2.70 [1.92-3.81] and 3.22 [1.69-6.14]), anxiety (PRadjusted [95% CI] = 1.96 [1.26-3.07] and 3.14 [1.47-6.74]), or both (PRadjusted [95% CI] = 3.11 [2.38-4.08] and 4.43 [2.71-7.25]). Higher MCI prevalence was related to sleep apnea (PRadjusted [95% CI] = 1.30 [1.06-1.60]); higher dementia prevalence was associated with age (5-yr interval, PRadjusted [95% CI] = 1.42 [1.26-1.60]) and race (non-White vs White, PRadjusted [95% CI] = 1.64 [1.07-2.53]). CONCLUSIONS: Self-reported MCI prevalence and dementia prevalence were higher in former NFL players than national estimates and were associated with numerous personal factors, including mood-related disorders and a high number of self-reported concussions. Predictors of higher MCI and dementia prevalence may be modifiable and warrant consideration by clinicians and researchers as potential targets to mitigate the onset of these conditions.

Disparate Associations of Years of Football Participation and a Metric of Head Impact Exposure with Neurobehavioral Outcomes in Former Collegiate Football Players.

OBJECTIVES: Years of sport participation (YoP) is conventionally used to estimate cumulative repetitive head impacts (RHI) experienced by contact sport athletes. The relationship of this measure to other estimates of head impact exposure and the potential associations of these measures with neurobehavioral functioning are unknown. We investigated the association between YoP and the Head Impact Exposure Estimate (HIEE), and whether associations between the two estimates of exposure and neurobehavioral functioning varied. METHODS: Former American football players (N = 58; age = 37.9 ± 1.5 years) completed in-person evaluations approximately 15 years following sport discontinuation. Assessments consisted of neuropsychological assessment and structured interviews of head impact history (i.e., HIEE). General linear models were fit to test the association between YoP and the HIEE, and their associations with neurobehavioral outcomes. RESULTS: YoP was weakly correlated with the HIEE, p = .005, R2 = .13. Higher YoP was associated with worse performance on the Symbol Digit Modalities Test, p = .004, R2 = .14, and Trail Making Test-B, p = .001, R2 = .18. The HIEE was associated with worse performance on the Delayed Recall trial of the Hopkins Verbal Learning Test-Revised, p = .020, R2 = .09, self-reported cognitive difficulties (Neuro-QoL Cognitive Function), p = .011, R2 = .10, psychological distress (Brief Symptom Inventory-18), p = .018, R2 = .10, and behavioral regulation (Behavior Rating Inventory of Executive Function for Adults), p = .017, R2 = .10. CONCLUSIONS: YoP was marginally associated with the HIEE, a comprehensive estimate of head impacts sustained over a career. Associations between each exposure estimate and neurobehavioral functioning outcomes differed. Findings have meaningful implications for efforts to accurately quantify the risk of adverse long-term neurobehavioral outcomes potentially associated with RHI.

Cumulative Concussion and Odds of Stroke in Former National Football League Players.

BACKGROUND AND PURPOSE: Postmortem and experimental studies indicate a potential association between repeated concussions and stroke risk in older contact sport athletes. We examined the relationship between concussion and stroke history in former National Football League players aged ≥50 years. METHODS: Former professional football players aged ≥50 years who played ≥1 year in the National Football League were enrolled in the cross-sectional study. Indirect standardization was used to calculate overall and decade-specific standardized prevalence ratios. Logistic regression using Firth's bias reduction method examined the association between lifetime concussion history 0 (n=119; 12.2%), 1 to 2 (n=152; 15.5%), 3 to 5 (n=242; 24.7%), 6 to 9 (201; 20.5%), and 10+(n=265; 27.1%) and stroke. Adjusted odds ratios for stroke were calculated for concussion history groups, age, and coronary artery disease and/or myocardial infarction. RESULTS: The 979 participants who met inclusion criteria had a mean age of 65.0±9.0 years (range, 50-99). The prevalence of stroke was 3.4% (n=33), significantly lower than expected based on rates of stroke in US men aged 50 and over (standardized prevalence ratio=0.56, Z= -4.56, P<0.001). Greater odds of stroke history were associated with concussion history (10+ versus 0, adjusted odds ratio [95% CI]=5.51 [1.61-28.95]), cardiovascular disease (adjusted odds ratio [95% CI]=2.24 [1.01-4.77]), and age (1-year-increase adjusted odds ratio [95% CI]=1.07 [1.02-1.11]). CONCLUSIONS: The prevalence of stroke among former National Football League players aged ≥50 years was lower than the general population, with significantly increased risk among those with 10 or more prior concussions. Findings add to the evidence suggesting that traumatic brain injuries are associated with increased risk of stroke. Clinically, management of cardio- and cerebrovascular health may be pertinent to those with a history of multiple prior concussions.

Factorial Validity and Invariance of an Adolescent Depression Symptom Screening Tool.

CONTEXT: Depression is among the most common mental health disorders in youth, results in significant impairment, and is associated with a higher risk of suicide. Screening is essential, but assessment tools may not account for the complex interrelatedness of various demographic factors, such as sex, socioeconomic status, and race. OBJECTIVES: To determine the (1) the factor structure of the Patient Health Questionnaire-Adolescent (PHQ-A) for measuring depression in a group of adolescent athletes and (2) measurement invariance between Black and White patients on the PHQ-A. DESIGN: Retrospective cohort design. SETTING: Data were obtained from a secure database collected at a free, comprehensive, mass preparticipation physical examination event hosted by a large health care system. PATIENTS OR OTHER PARTICIPANTS: Participants were 683 high school athletes (Black = 416, White = 267). The independent variables were somatic and affective factors contributing to the construct of depression measured by the PHQ-A and participant race (Black or White). MAIN OUTCOME MEASURE(S): (1) Factors upon which the construct of depression is measured and (2) measurement invariance between Black and White participants. RESULTS: A 2-factor model, involving affective and somatic components, was specified and exhibited adequate fit to the data (comparative fit index >0.90). All items exhibited moderate to high squared multiple correlation values (R2 = 0.10-0.65), suggesting that these items resonated relatively well with participants. The 2-factor model demonstrated noninvariance between Black and White participants (root mean square error of approximation = 0.06-0.08). CONCLUSIONS: Overall, the structure of the PHQ-A was supported by a 2-factor model in adolescent athletes, measuring both affective and somatic symptoms of depression. However, a 2-factor PHQ-A structure was not fully invariant for the adolescents sampled across participant groups, indicating that the model functioned differently between the Black and White participants sampled.

Longitudinal trajectory of depression symptom severity and the influence of concussion history and physical function over a 19-year period among former National Football League (NFL) players: an NFL-LONG Study.

OBJECTIVE: This study investigated the longitudinal course of depressive symptom severity over 19 years in former American football players and the influence of concussion history, contact sport participation and physical function on observed trajectories. METHODS: Former American football players completed a general health questionnaire involving demographic information, medical/psychiatric history, concussion/football history and validated measures of depression and physical function at three time points (2001, 2010 and 2019). Parallel process latent growth curve modelling tested associations between concussion history, years of football participation, and overall and change in physical function on the overall level and trajectory of depressive symptoms. RESULTS: Among the 333 participants (mean(SD) age, 48.95 (9.37) at enrolment), there was a statistically significant, but small increase in depressive symptom severity from 2001 (48.34 (7.75)) to 2019 (49.77 (9.52)), slope=0.079 (SE=0.11), p=0.007. Those with greater concussion history endorsed greater overall depressive symptom severity, B=1.38 (SE=0.33), p<0.001. Concussion history, B<0.001 (SE=0.02), p=0.997 and years of participation, B<0.001 (SE=0.01), p=0.980, were not associated with rate of change (slope factor) over 19 years. Greater decline in physical function, B=-0.71 (SE=0.16), p<0.001, was predictive of a faster growth rate (ie, steeper increase) of depression symptom endorsement over time. CONCLUSIONS: Concussion history, not years of participation, was associated with greater depressive symptom severity. Neither factor was predictive of changes over a 19-year period. Decline in physical function was a significant predictor of a steeper trajectory of increased depressive symptoms, independent of concussion effects. This represents one viable target for preventative intervention to mitigate long-term neuropsychiatric difficulties associated with concussion across subsequent decades of life.

Distinct latent profiles based on neurobehavioural, physical and psychosocial functioning of former National Football League (NFL) players: an NFL-LONG Study.

OBJECTIVE: To identify subgroups of former National Football League (NFL) players using latent profile analysis (LPA) and examine their associations with total years of participation (TYP) and self-reported lifetime sport-related concussion history (SR-CHx). METHODS: Former NFL players (N=686) aged 50-70 years, with an average 18.0 TYP (±4.5) completed a questionnaire. SR-CHx distributions included: low (0-3; n=221); intermediate (4-8; n=209) and high (9+; n=256). LPA measures included: Quality of Life in Neurological Disorders Emotional-Behavioral Dyscontrol, Patient Reported Outcomes Measurement Information System Cognitive Function, Emotional Support, Self-Efficacy, Meaning and Purpose, Physical Function, Pain Interference, Participation in Social Roles and Activities, Anxiety, Depression, Fatigue, and Sleep Disturbance. Demographic, medical/psychiatric history, current psychosocial stressors, TYP and SR-CHx were compared across latent profiles (LPs). RESULTS: A five profile solution emerged: (LP1) global higher functioning (GHF; 26.5%); (LP2) average functioning (10.2%); (LP3) mild somatic (pain and physical functioning) concerns (22.0%); (LP4) somatic and cognitive difficulties with mild anxiety (SCA; 27.5%); LP5) global impaired functioning (GIF; 13.8%). The GIF and SCA groups reported the largest number ofe- medical/psychiatric conditions and higher psychosocial stressor levels. SR-CHx was associated with profile group (χ2(8)=100.38, p<0.001); with a higher proportion of GIF (72.6%) and SCA (43.1%) groups reporting being in the high SR-CHx category, compared with GHF (23.1%), average (31.4%) and somatic (27.8%) groups. TYP was not significantly associated with group (p=0.06), with greater TYP reported by the GHF group. CONCLUSIONS: Five distinct profiles of self-reported functioning were identified among former NFL players. Several comorbid factors (ie, medical/psychiatric diagnoses and psychosocial stressors) and SR-CHx were associated with greater neurobehavioural and psychosocial dysfunction.