Acute Subdural Hematoma in High School Rugby Players in Japan: The Importance of Playing Experience for Injury Prevention.

OBJECTIVES: Acute subdural hematoma (ASDH) is known to be devasting sport-related head injury but it is relatively rare in rugby compared with other contact sports. Certain cases of ASDH have happened in high school rugby players in Japan. To prevent them from the injury we report a background of the players. METHODS: Data of high school rugby players who suffered ASDH were extracted from injury reports in the Japan Rugby Football Union between April 2004 and March 2020. The number of injured players, diagnosis on the report, school year, phase of play where the injury occurred, and playing career were analyzed. RESULTS: There were 30 cases of ASDH including 16 cases in the first year, 9 in the second year, and 5 in the third year of playing. Phase of play was mainly being tackled in 11 (37%), and tackling in 13 (43%). Novice players, defined as a player having less playing experience of rugby during junior high school, accounted for 77% of phase of tackling, 82% of being tackled. First year novice players accounted for 100% of phase of being tackled. Outcome within 6 months after injury was recovery in 14, morbidity in 6, mortality in 2, and unknown in 8. CONCLUSIONS: Playing experience in high school rugby players should be considered as an important factor for prevention of ASDH-in particular, phase of being tackled is riskier than that of tackling for first year novice players.

Trends in match injury risk in professional male rugby union: a 16-season review of 10 851 match injuries in the English Premiership (2002-2019): the Professional Rugby Injury Surveillance Project.

OBJECTIVES: The Professional Rugby Injury Surveillance Project is the largest and longest running rugby union injury surveillance project globally and focuses on the highest level of rugby in England. METHODS: We examined match injuries in professional men's rugby over the period 2002/2003 to 2018/2019 and described trends in injuries over this time. RESULTS: Over the period 2002/2003-2018/2019, 10 851 injuries occurred in 1 24 952 hours of match play, equating to a mean of 57 injuries per club per season and one injury per team per match. The mean incidence, severity (days absence) and burden (days absence/1000 hours) of injury were 87/1000 hours (95% CI 82 to 92), 25 days (95% CI 22 to 28) and 2178 days/1000 hours (95% CI 1872 to 2484), respectively. The tackle accounted for 43% injuries with running the second most common activity during injury (12%). The most common injury location was the head/face with an incidence of 11.3/1000 hours, while the location with the highest overall burden was the knee (11.1 days/1000 hours). Long-term trends demonstrated stable injury incidence and proportion of injured players, but an increase in the mean and median severity of injuries. Concussion incidence, severity and burden increased from the 2009/2010 season onwards and from 2011 to 2019 concussion was the most common injury. CONCLUSION: The rise in overall injury severity and concussion incidence are the most significant findings from this work and demonstrate the need for continued efforts to reduce concussion risk as well as a greater understanding of changes in injury severity over time.

Age of First Exposure to Football Is Not Associated with Midlife Brain Health Problems.

The purpose of this study was to determine if earlier age of first exposure (AFE) to football is associated with worse brain health in middle-aged men who played high school football. We assessed 123 men 35-55 years of age, who played high school football, using (1) a survey of demographic information as well as medical, sport participation, and concussion history; (2) the Patient Health Questionnaire-8 (PHQ-8); and (3) the British Columbia Post-Concussion Symptom Inventory (BC-PSI). Sixty-two (50.4%) men reported football participation starting before the age of 12 (i.e., AFE <12 years) and 61 (49.6%) reported football participation at or after the age of 12 (AFE > 12 years). Compared with those with AFE >12 years, a similar proportion of former high school football players who began playing tackle football before age 12 reported that they had been prescribed medications for mental health problems or that they had recently experienced symptoms of anxiety, depression, memory loss, chronic pain, or headaches. Moreover, there was no significant difference in their lifetime history of treatment by a mental health professional. The groups did not differ significantly on PHQ-8 (U = 1839.0, p = 0.791) or BC-PSI total scores (U = 1828.5, p = 0.751). These findings suggest that earlier AFE to football is not associated with worse brain health in middle-aged men in this sample who played high school football.

Functional Connectivity Changes in Retired Rugby League Players: A Data-Driven Functional Magnetic Resonance Imaging Study.

There is considerable interest in the long-term brain health of retired contact and collision sport athletes; however, little is known about possible underlying changes in functional brain connectivity in this group. We evaluated whole-brain functional connectivity patterns using multi-voxel pattern analysis (MVPA) to determine whether alterations in functional connectivity distinguish retired professional athletes from a matched group of healthy community control subjects. Thirty-two retired athletes with a history of multiple self-reported sport-related concussions and 36 healthy community control subjects who were similar in age and education, completed functional magnetic resonance imaging. We identified brain regions with abnormal functional connectivity patterns using whole-brain MVPA as implemented in the Conn toolbox. First-level MVPA was performed using 64 principal component analysis (PCA) components. Second-level F test was performed using the first three MVPA components for retired athletes > controls group contrast. Post hoc seed-to-voxel analyses using the MVPA cluster results as seeds were performed to characterize functional connectivity abnormalities from brain regions identified by MVPA. MVPA revealed one cluster of abnormal functional connectivity located in cerebellar lobule V. This region of lobule V corresponded to the ventral attention network. Post hoc seed-to-voxel analysis using the cerebellar MVPA cluster as a seed revealed multiple areas of cerebral cortical hyper-connectivity and hypo-connectivity in retired athletes when compared with controls. This initial report suggests that cerebellar dysfunction might be present and clinically important in some retired athletes.

Incidence of seizure exacerbation and injury related to football participation in people with epilepsy.

INTRODUCTION: There is scant evidence to quantify the risk of contact sports such as football to patients with epilepsy. This retrospective review was performed to evaluate the incidence of injuries or seizure exacerbation related to football participation in patients with epilepsy. METHODS: Between the years 1994 and 2004, 157,709 consecutive clinic notes were searched for mention of "football" and "epilepsy" or "seizure". Resulting notes were reviewed to quantify the number of seizure exacerbations and the number of injuries in this cohort. RESULTS: Seven of 44 subjects with epilepsy (15.9%) experienced injury while playing football. Four of 32 (12.5%) patients experienced seizure exacerbation during a time when they were concurrently participating in football though 3 of these patients stopped taking or were weaned off of their antiepileptic drugs (AEDs). One in 32 patients with epilepsy (3.1%) had an exacerbation of seizures while playing football and consistently taking AEDs. CONCLUSION: The risk of injury and seizure exacerbation due to participation in football for patients with epilepsy is low. Clinicians should use their best judgment in deciding whether contact sports increase risks for a particular patient based on individual seizure frequency, concurrent neurological and medical issues, and medication adverse effects.

Epidemiology of Cervical Injuries in NCAA Football Players.

STUDY DESIGN: Descriptive epidemiology study. OBJECTIVE: The purpose of this study was to describe the epidemiology of cervical spine injuries in collegiate football players. SUMMARY OF BACKGROUND DATA: The incidence and etiology of cervical spine injuries in National Collegiate Athletic Association (NCAA) football players has not been well defined in recent years. METHODS: The incidence and characteristics of cervical spine injuries were identified utilizing the NCAA-ISP database. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in one NCAA-sanctioned practice or competition. RESULTS: An estimated 7496 cervical spine injuries were identified. Of these, 85.6% were categorized as new injuries. These occurred at a rate of 2.91 per 10000 AEs. Stingers were most common (1.87 per 10000 AEs) followed by cervical strains (0.80 per 10000 AEs). Injuries were nine times more likely to occur during competition when compared with practice settings. When compared with the regular season, the relative risks of sustaining a cervical spine injury during the preseason and postseason were 0.69 (95% CI 0.52-0.90) and 0.39 (95% CI 0.16-0.94), respectively. The rate of cervical spine injuries was highest in Division I athletes. Direct contact-related injuries were most common, representing 90.8% of all injuries sustained. Injuries were most common in linebackers (20.3%) followed secondarily by defensive linemen (18.2%). Most players returned to play within 24 hours of the initial injury (64.4%), while only 2.8% remained out of play for > 21 days. CONCLUSION: Fortunately, the rate of significant and disabling cervical spine injuries appears to be low in the NCAA football athlete. The promotion of safer tackling techniques, appropriate modification of protective gear, and preventive rehabilitation in these aforementioned settings is of continued value. LEVEL OF EVIDENCE: 4.

Microstructural alterations of cortical and deep gray matter over a season of high school football revealed by diffusion kurtosis imaging.

OBJECTIVES: To probe microstructural changes that are associated with subconcussive head impact exposure in deep and cortical gray matter of high school football players over a single season. METHODS: Players underwent diffusion kurtosis imaging (DKI) and quantitative susceptibility mapping (QSM) scans. Head impact data was recorded. Association between parametric changes and frequency of frontal head impact was assessed. RESULTS: In deep gray matter, significant decreases in mean kurtosis (MK) and increases in mean diffusivity (MD) over the season were observed in the thalamus and putamen. Correlations between changes in DKI metrics and frequency of frontal impacts were observed in the putamen and caudate. In cortical gray matter, decreases in MK were observed in regions including the pars triangularis and inferior parietal. In addition, increases in MD were observed in the rostral middle frontal cortices. Negative correlations between MK and frequency of frontal impacts were observed in the posterior part of the brain including the pericalcarine, lingual and middle temporal cortices. Magnetic susceptibility values exhibited no significant difference or correlation, suggesting these diffusion changes common within the group may not be associated with iron-related mechanisms. CONCLUSION: Microstructural alterations over the season and correlations with head impacts were captured by DKI metrics, which suggested that DKI imaging of gray matter may yield valuable biomarkers for evaluating brain injuries associated with subconcussive head impact. Findings of associations between frontal impacts and changes in posterior cortical gray matter also indicated that contrecoup injury rather than coup injury might be the dominant mechanism underlying the observed microstructural alterations. ADVANCES IN KNOWLEDGE: Significant microstructural changes, as reflected by DKI metrics, in cortical gray matter such as the rostral middle frontal cortices, and in deep gray matter such as the thalamus were observed in high school football players over the course of a single season without clinically diagnosed concussion. QSM showed no evidence of iron-related changes in the observed subconcussive brain injuries. The detected microstructural changes in cortical and deep gray matter correlated with frequency of subconcussive head impacts. IMPLICATIONS FOR PATIENT CARE: DKI may yield valuable biomarkers for evaluating the severity of brain injuries associated with subconcussive head impacts in contact sport athletes.

Evolution of game-play in the Australian Football League from 2001 to 2015.

This study investigated the evolution of game-play manifested via team performance indicator characteristics in the Australian Football League (AFL) from the 2001 to 2015 seasons. The mean values for 18 performance indicators were collated for every AFL team over 15-seasons. A multivariate analysis was used to uncover temporal trends in the dataset. Compared to the 2004 season, the 2005 to 2010 seasons were characterised by large growth in the counts of handballs (d = 0.83; 90% CI = 0.22-1.43), disposals (d = 1.24; 90% CI = 0.59-1.87), uncontested possessions (d = 1.37; 90% CI = 0.71-2.01), clangers (d = 2.14; 90% CI = 1.39-2.86) and marks (d = 1.43; 90% CI = 0.76-2.07). Contrastingly, the effective disposal percentage declined rapidly during the same period. The number of inside 50 m counts remained stable throughout the 15-season period. The ordination plot of league-wide performance indicator characteristics illustrated a distinct cluster from the 2001 to 2004 seasons, an abrupt shift from the 2005 to 2009 seasons, and an emergent (re)stabilisation from the 2010 to 2015 seasons. The results demonstrate the synchronous league-wide evolution of game-play in the AFL from the 2001 to 2015 seasons. Amongst other constituents, this evolution likely reflects the introduction of modernised coaching strategies, rule changes and changing perceptions of rule interpretations.

Emergency department surveillance of injuries and head injuries associated with baseball, football, soccer and ice hockey, children and youth, ages 5 to 18 years, 2004 to 2014.

TITRE: Surveillance aux services d'urgence des blessures à la tête et de l'ensemble des blessures provoquées par le baseball, le football, le soccer ou le hockey sur glace chez les enfants et les jeunes de 5 à 18 ans, 2004 à 2014.

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

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

Ultrasound-guided musculoskeletal interventions in American football: 18 years of experience.

OBJECTIVE: Myotendinous strains, contusions, and hematomas are common injuries in American football. Along with ligament sprains and inflammatory disorders, musculoskeletal injuries often result in lost participation time. This article summarizes 18 years of experience with 128 ultrasound-guided drainages and injections in 69 football players with 88 injuries. CONCLUSION: When performed by an operator with sufficient expertise in diagnostic and procedural skills, ultrasound-guided musculoskeletal interventions are minimally invasive, are safe, and can play an integral role in injury management.

Accelerating progress on the road to safer sports: based on remarks of NFL Commissioner Roger Goodell in the Neurosurgical Society of America (NSA) medal lecture.

Roger Goodell was invited by the Neurosurgical Society of America (NSA) to give the keynote speech as the NSA Medalist 2013. As President of the NSA, and Co-Chairs of the National Football league's Head Neck and Spine Committee, we provided the introduction for Goodell. He was cited for his tireless advocacy on behalf of professional and student athletes. We noted that the National Football League has been a world leader in funding traumatic brain injury research and a catalyst for safety in youth and professional sports. Mr Goodell's national leadership in thinking and acting boldly on the subject of traumatic brain injury prevention and treatment was the primary motivation for awarding him the NSA medal. What follows is a transcript of his NSA Medal Lecture to the Neurosurgical Society of America.

Secular trend: morphology and performance.

In a context of morphological expansion of the general population, how do athletes follow such a pattern of anthropometric growth? Is there any relation to performance? Biometric data including mass, height, body mass index (BMI) and age were collected for 50,376 American athletes representing 249,336 annual performers playing in professional baseball, football, ice hockey and basketball. Distributions by mass in National Football League (NFL) players are described by periods. Field goals have been studied in relation to players' height in the National Basketball Association (NBA). Between 1871 and 2011, athletes from the four sports have increased significantly in mass, height and BMI, following a multi-exponential function series. Consequently, biometric differences between athletes and the general population are increasing gradually. Changes in the mass distribution within the NFL show the emergence of a biometrical specificity in relation to the field position. At the professional level, performance remains structured around precise biometric values. In the NBA, a height-attractor at 201.3 ± 6.3 cm for the best scorers is invariant, regardless of the level of play. These results suggest that laws of growth and biometrics drive high-level sport and organise performance around the specific constraint of each field position. Discrepancies between some mass and height developments question the (disproportionate) large mass increase (relative to the height increase) during the 1980s and 1990s.

10-year changes in upper body strength and power in elite professional rugby league players--the effect of training age, stage, and content.

The purpose of this investigation was to observe changes in maximal upper body strength and power across a 10-year period in professional athletes who were experienced resistance trainers. Six professional rugby league players were observed with test data reported according to 2 important training stages in their professional careers. The first stage (1996-1998) monitored the changes as the subjects strived to establish themselves as elite professionals in their sport. The remaining test data are from the latter stage (2000-2006), which is characterized by a longer competition schedule and shorter periods devoted to improving physical preparation. The changes in upper body strength, assessed by the 1 repetition maximum bench press and mean maximum power during bench press throws with various barbell resistances of 40-80 kg, were assessed by effect size (ES) and smallest worthwhile change (SWC) statistics. Large increases in strength and power of approximately 22-23% were reported across the 10-year period, however, only small changes (as determined by ES) in strength or power occurred after year 2000 till 2006. This result of only small changes in strength or power despite 6 years of intense resistance training was attributed to 3 main factors. Key among them are the possible existence of a "strength ceiling" for experienced resistance trainers, the Long-term Athlete Development model, and possibly an inappropriate volume of strength-endurance training from 2004 to 2005. The fact that an SWC in strength and power occurred in the year after the cessation of strength-endurance training suggests that training program manipulation is still an influencing factor in continuing strength and power gains in experienced resistance trainers.

Positional demands of international rugby union: evaluation of player actions and movements.

UNLABELLED: In rugby union, published analyses of actions and movements of players during matches have been limited to small samples of games at regional or national level. OBJECTIVES: To analyse movements and activities of players in international rugby union matches with a sample size sufficient to clearly delineate positional roles. DESIGN: Observational study. METHODS: Actions of 763 players were coded from video recordings of 90 international matches played by the New Zealand national team (the All Blacks) from 2004 to 2010. Movements of players were coded for 27 of these matches via a semi-automated player-tracking system. Movements and activities of all players from both teams were coded. RESULTS: Cluster analysis of activities and time-motion variables produced five subgroups of forwards (props, hookers, locks, flankers, Number 8 forwards) and five subgroups of backs (scrum-half, fly-half, midfield backs, wings and fullbacks). Forwards sustained much higher contact loads per match than backs, via scrums, rucks, tackles and mauls. Mean distance covered per match ranged from 5400 to 6300m, with backs generally running further than forwards. There were marked differences between positional groups in the amount of distance covered at various speeds. The amount of play per match varies by position due to differences in rates at which players are substituted. CONCLUSIONS: The distance covered by players at relatively fast running speeds (in excess of 5ms(-1)) appears to be higher during international matches than when competing at lower levels of the professional game. The specific match demands for positional groups need to be considered when managing player workloads.

Changes in the athletic profile of elite college American football players.

The purpose of this study was to compare positional anthropometric and National Football League (NFL) Combine performance levels in elite college American football players over the 3-year period from 1999 to 2001 to the 3-year period from 2008 to 2010. The sample included 15 offensive and defensive positions, and only those players invited to the combine and subsequently drafted in the same year (n = 1,712) were included in the study. Data from 10 combine physical tests were examined, including weight; height; the 9.1-, 18.3-, and 36.6-m sprints; the vertical and horizontal jumps; the 18.3-m shuttle run; the 3-cone drill; and the 102.1-kg bench press for maximum repetitions. Independent samples t-tests detected differences for each of the 15 positions (p < 0.05). There were no discernible trends in height and weight over the period in question, whereas players in the more recent group significantly improved performance in straight sprinting, the 3-cone drill, and the horizontal jump. Findings suggest that these tests better reflect characteristics such as explosiveness and first-step quickness as compared with the 18.3-m shuttle and the vertical jump, and that such characteristics have become more highly sought after by NFL coaches and scouts. The results of the present research suggest that the position-specific profiles changed over a relatively short period of time. Coaches and practitioners will be able to use the findings of this research to better prepare athletes for entry into the NFL.