Return to play after sports concussion in elite and non-elite athletes?

OBJECTIVE: To examine the published literature relating to the difference in concussion management strategies between elite and non-elite athletes. DESIGN: Systematic literature review of concussion management. INTERVENTION: Pubmed, Medline, Psych Info, Cochrane Library and Sport Discus databases were reviewed using the MeSH keywords brain concussion and mild traumatic brain injury, combined with athletic injuries. Each were then refined by adding the keyword "return to play" (RTP). English language and human studies only were assessed. RESULTS: For the Medline search, using "brain concussion" as a keyword, 4319 articles were found; this was decreased to 111 when RTP was used to refine the search. When "mild traumatic brain injury" was used, 2509 articles were found; this decreased to 39 when RTP was used to refine the search. Following initial review, these articles form the basis of the discussion below. CONCLUSIONS: The non-elite athlete may not have the same resources available as the elite athlete (such as the presence of trained medical staff during practice and competition, a concussion programme as part of sideline preparedness, the benefit of neuropsychological or postural testing, as well as consultants with expertise in concussion readily available) and as a result will generally be managed more conservatively. Younger athletes often have a greater incidence of concussion with longer recovery time frames; however, they are often managed with less expertise and with limited resources.

Effect of an acute bout of soccer heading on postural control and self-reported concussion symptoms.

Our purpose was to determine if an acute bout of heading soccer balls adversely affected postural control and self-reported symptoms of cerebral concussion. Thirty-one college-aged soccer players were randomly placed into either a kicking group or a heading group. Subjects either kicked or headed 18 soccer balls over the course of 40 minutes. Subjects had their postural control assessed while standing on a force plate and completed a concussion symptoms checklist on three separate occasions: prior to, immediately following, and 24 hours after kicking or heading. There were no significant differences between the heading and kicking groups on the postural control measures prior to, immediately following, and 24 hours after kicking/heading. The heading group did, however, report significantly more concussion symptoms than the kicking group immediately after heading, but not 24 hours after heading. The number of previous concussions sustained by subjects did not influence the effects of heading. An acute bout of soccer heading appears to cause an increase in self-reported symptoms of cerebral concussion lasting less than 24 hours but no quantifiable deficits in postural control. Further research is needed to investigate the cumulative effects of soccer heading on postural control and other objective measures of brain function.

Differential effects of exhaustive cycle ergometry on concentric and eccentric torque production.

The purpose of this study was to investigate the potential differences in peak isokinetic concentric end eccentric torque following low- and high-intensity cycle exercise fatigue protocols. Ten healthy, recreationally-active men were tested in a balanced, randomized testing sequence for peak eccentric and concentric isokinetic torque (60 degrees/sec) immediately before and after three experimental conditions each separated by 48 hours: 1) a bout of high intensity cycling consisting of a maximal 90-second sprint; 2) a bout of low-intensity cycling at 60 rpm equated for total work with the high-intensity protocol: and 3) no exercise (control bout). Blood was drawn from an antecubital vein and plasma lactate concentrations were determined immediately before and after each experimental bout. Post-exercise plasma lactate concentrations were 15.1 +/- 2.5 and 4.7 +/- 1.9 mmol l(-1), respectively, following the high- and low-intensity protocols. The high intensity exercise bout resulted in the only post-exercise decrease in concentric and eccentric isokinetic peak torque. The percent decline in maximal force production was significantly (P< 0.05) greater for concentric muscle actions compared to eccentric (29 vs 15%, respectively). In conclusion, a 90-second maximal cycling sprint results in a significant decline in maximal torque of both concentric and eccentric muscle actions with the greatest magnitude observed during concentric muscle actions.

Lymphocyte proliferation in response to acute heavy resistance exercise in women: influence of muscle strength and total work.

Little is understood about the immune responses to heavy resistance exercise. The purpose of this investigation was to determine the influence of physical strength and the ability to do more total work on lymphocyte proliferation after an acute bout of heavy resistance exercise. A group of 50 healthy but nonstrength trained women were recruited for the study and tested for their one repetition maximum (i.e. 1 RM or maximal mass lifted once). From the normal distribution of strength the top and bottom 8 women [mean age 22.5 (SD 3.1) years] were asked to volunteer to define our two groups (i.e. high strength and low strength). The two groups were significantly different (P < 0.05) in 1 RM squat strength [low strength 39.9 (SD 4.6) kg, 0.65 (SD 0.08) kg.kg body mass-1 and high strength 72.2 (SD 10.7) kg, 1.1 (SD 0.12) kg.kg body mass-1] but were not significantly different in body mass, age, activity levels, and menstrual status (all in same phase). Each performed a resistance exercise protocol consisting of six sets of 10 RM squats with 2 min rest between the sets. The 10 RM loads and total work were significantly greater in the high strength group than in the low strength group. Blood samples were obtained pre-exercise and immediately post-exercise for test for lactate (significant increase with exercise) and cortisol (no changes) concentrations with no differences noted between groups. Immunological assays on the blood samples determined the incorporation of tritiated thymidine by lymphocytes in responses to concanavalin A (ConA), phytohemagglutinin (PHA), and pokeweed mitogen (PWM). Following the squat exercise, there was a significant decrease in lymphocyte responsiveness to PWM in the high strength but not in the low strength group for both total proliferation and proliferation adjusted per B or T cell. On the other hand, lymphocytes from the low strength group proliferated to a significantly greater extent (adjusted per T cell) in response to ConA and PHA. These data indicate that the heavy resistance exercise protocol reduced the lymphocyte proliferative responses only in the stronger group of subjects. This effect may have been due to the high absolute total work and the greater exercise stress created by the resistance exercise protocol in the high strength group. Therefore, individuals performing at the same relative exercise intensity (i.e. 10 RM) in a resistance exercise protocol may have different immune responses stemming from differences in absolute total work performance.

Influence of compression therapy on symptoms following soft tissue injury from maximal eccentric exercise.

STUDY DESIGN: A between groups design was used to compare recovery following eccentric muscle damage under 2 experimental conditions. OBJECTIVE: To determine if a compression sleeve donned immediately after maximal eccentric exercise would enhance recovery of physical function and decrease symptoms of soreness. BACKGROUND: Prior investigations using ice, intermittent compression, or exercise have not shown efficacy in relieving symptoms of delayed onset muscle soreness (DOMS). To date, no study has shown the effect of continuous compression on DOMS, yet this would offer a low cost intervention for patients suffering with the symptoms of DOMS. METHODS AND MEASURES: Twenty nonimpaired non-strength-trained women participated in the study. Subjects were matched for age, anthropometric data, and one repetition maximum concentric arm curl strength and then randomly placed into a control group (n = 10) or an experimental compression sleeve group (n = 10). Subjects were instructed to avoid pain-relieving modalities (eg, analgesic medications, ice) throughout the study. The experimental group wore a compressive sleeve garment for 5 days following eccentric exercise. Subjects performed 2 sets of 50 passive arm curls with the dominant arm on an isokinetic dynamometer with a maximal eccentric muscle action superimposed every fourth passive repetition. One repetition maximum elbow flexion, upper arm circumference, relaxed elbow angle, blood serum cortisol, creatine kinase, lactate dehydrogenase, and perception of soreness questionnaires were collected prior to the exercise bout and daily thereafter for 5 days. RESULTS: Creatine kinase was significantly elevated from the baseline value in both groups, although the experimental compression test group showed decreased magnitude of creatine kinase elevation following the eccentric exercise. Compression sleeve use prevented loss of elbow motion, decreased perceived soreness, reduced swelling, and promoted recovery of force production. CONCLUSIONS: Results from this study underline the importance of compression in soft tissue injury management.

Neuropsychological test performance prior to and following sports-related mild traumatic brain injury.

OBJECTIVE: To examine the utility of neuropsychological tests in assessing college athletes prior to and following a sports-related mild Traumatic Brain Injury (mTBI). DESIGN: A prospective study of college athletes who sustained mTBI while engaged in sport. Preinjury baseline neuropsychological test data were obtained for athletes at risk for mTBI. Following an mTBI, the athlete and his or her matched noninjured control were evaluated at 2 hours, 48 hours, 1 week, and I month postinjury. SETTING: Male and female athletes from a Division I college. PARTICIPANTS: Male and female athletes from the football, men's ice hockey, men's and women's soccer, and men's and women's basketball teams at Penn State University. A total of 29 injured and 20 noninjured athletes participated in the study. INTERVENTIONS: Neuropsychological test batteries were administered at baseline and serially following mTBI. MAIN OUTCOME MEASURES: Post-Concussion Symptom Checklist, Hopkins Verbal Learning Test, Symbol Digit Modalities Test, Stroop Color-Word Test, Trail Making Test, VIGIL/W, List Learning, Digit Span, Penn State Cancellation Test, and Controlled Oral Word Association. RESULTS: Neuropsychological test data yielded significant differences between injured athletes and controls at 2 hours and 48 hours following cerebral concussion; injured athletes performing significantly worse than controls. Injured athletes reported a significantly greater number of postconcussion symptoms 2 hours following injury but not at the 48-hour assessment. No multivariate group differences were found at 1 week, but univariate analyses suggested significant differences on a few measures. At 1 month postinjury, a statistically significant difference was found on one measure with injured athletes marginally outperforming controls. CONCLUSIONS: Neuropsychological tests are useful in the detection of cognitive impairment following mTBI. The test data appear to be more effective than subjective report of symptoms in differentiating between injured and noninjured athletes at 48 hours postinjury. Although significant individual variability existed, most injured athletes recovered within 1 week of injury. A battery of tests, rather than any single test, is necessary to capture the variability that exists among injured athletes.

No effect of heavy resistance training and creatine supplementation on blood lipids.

In order to examine the effects of heavy resistance training and the influence of creatine supplementation on nonperformance measures of health status, 19 healthy resistance-trained men were matched and then randomly assigned in a double-blind fashion to either a creatine (n = 10) or placebo (n = 9) group. Periodized heavy resistance training was performed 3-4 times per week for 12 weeks. During the first week of training, creatine subjects consumed 25 g creatine monohydrate per day, while the placebo group ingested an equal number of placebo capsules. Five grams of supplement per day was consumed for the remainder of the study. Body composition, fasting serum creatinine, lipoproteins and triglycerides, and reported changes in body function were determined prior to and after 12 weeks of training and supplementation. After training, significant increases in body mass and fat-free mass were greater in creatine (5.2 and 4.3 kg, respectively) than placebo (3.0 and 2.1 kg, respectively) subjects. There was no change in percent body fat. Dietary energy and macronutrient distribution was not significantly different during Weeks 1 and 12. Serum creatinine was significantly elevated in creatine subjects after 1 (11.6%) and 12 weeks (13.8%); however, values were within normal limits for healthy men. There were no effects of training or supplementation on serum total cholesterol, HDL-cholesterol, LDL-cholesterol, or triglycerides. In healthy men, a 12-week heavy resistance training program, with or without creatine supplementation, did not significantly influence serum lipid profiles, subjective reports of body functioning, or serum creatinine concentrations.

The acute neuropsychological effects of heading in soccer: a pilot study.

OBJECTIVE: The main objective of this study was to prospectively examine the acute effects of heading in soccer on cognitive function. DESIGN: This was a prospective cross-over study using a brief neuropsychological battery to assess cognitive function. The tests were performed before and after two separate practice sessions, with athletes serving as their own controls. SETTING: Male and female Division I college athletes. PARTICIPANTS: Members of the men's and women's varsity collegiate Penn State University soccer teams. Forty-four males and 56 females entered and finished the study. All athletes had a normal physical examination. INTERVENTIONS: Before and after both practice sessions, all athletes had a brief battery of neuropsychological tests and a symptom checklist. MAIN OUTCOME MEASURES: Neuropsychological tests symptom checklist compared at baseline with those after the practice sessions. RESULTS: There were no significant differences in pretest scores between groups and no difference on posttest scores between heading and nonheading groups. A significant difference was detected using MANOVA (p = < 0.001) between pre- and posttest scores for measures of attention and concentration, indicating a practice effect. A gender-specific effect in one test measuring attention and concentration was found. There was no difference in symptoms before and after heading as compared with exertional controls. CONCLUSIONS: In this study, soccer players heading the ball does not appear to lead to acute changes in cognitive function as assessed by a brief neuropsychological battery. There are practice effects that occur with repetitive neuropsychological testing and gender differences with certain tests.

A Custom Face Mask for Sports This molded plastic mask may let an athlete with a facial fracture return to play sooner.

Facial trauma is common in contact sports. Fractures of the face, including orbital, zygomatic, and nasal fractures, generally stem from direct blows. After treatment, many athletes are eager to return to practice or competition before their fractures have completely healed. Depending on the sport, this may pose a risk.

Effects of heavy-resistance training on hormonal response patterns in younger vs. older men.

To examine the adaptations of the endocrine system to heavy-resistance training in younger vs. older men, two groups of men (30 and 62 yr old) participated in a 10-wk periodized strength-power training program. Blood was obtained before, immediately after, and 5, 15, and 30 min after exercise at rest before and after training and at rest at -3, 0, 6, and 10 wk for analysis of total testosterone, free testosterone, cortisol, growth hormone, lactate, and ACTH analysis. Resting values for insulin-like growth factor (IGF)-I and IGF-binding protein-3 were determined before and after training. A heavy-resistance exercise test was used to evaluate the exercise-induced responses (4 sets of 10-repetition maximum squats with 90 s of rest between sets). Squat strength and thigh muscle cross-sectional area increased for both groups. The younger group demonstrated higher total and free testosterone and IGF-I than the older men, training-induced increases in free testosterone at rest and with exercise, and increases in resting IGF-binding protein-3. With training the older group demonstrated a significant increase in total testosterone in response to exercise stress along with significant decreases in resting cortisol. These data indicate that older men do respond with an enhanced hormonal profile in the early phase of a resistance training program, but the response is different from that of younger men.

Influence of exercise training on physiological and performance changes with weight loss in men.

PURPOSE: The purpose of this study was to examine the physiological effects of a weight-loss dietary regimen with or without exercise. METHODS: Thirty-five overweight men were matched and randomly placed into either a control group (C; N = 6) or one of three dietary groups; a diet-only group (D; N = 8), a diet group that performed aerobic exercise three times per week (DE; N = 11); and a diet group that performed both aerobic and strength training three times per week (DES; N = 10). RESULTS: After 12 wk, D, DE, and DES demonstrated a similar and significant (P < or = 0.05) reduction in body mass (-9.64, -8.99, and -9.90 kg, respectively) with fat mass comprising 69, 78, and 97% of the total loss in body mass, respectively. The diet-only group also demonstrated a significant reduction in fat-free mass. Maximum strength, as determined by 1-RM testing in the bench press and squat exercise was significantly increased for DES in both the bench press (+19.6%) and squat exercise (+32.6%). Absolute peak O2 consumption was significantly elevated in DE (+24.8%) and DES (+15.4%). There were no differences in performance during a 30-s Wingate test for the DE and DES, whereas D demonstrated a significant decline in peak and mean power output. Resting metabolic rate (RMR) (kcal x d(-1)) was not significantly different for any of the groups except for the DE group. There were no significant changes in basal concentrations of serum glucose, BUN, cortisol, testosterone, and high density lipoprotein (HDL) cholesterol for any of the groups. Serum total cholesterol and low density lipoprotein (LDL) cholesterol were significantly decreased for all dietary groups. Serum triglycerides were significantly reduced for D and DES at week 6 and remained lower at week 12 for D, while triglycerides returned to baseline values for DES. CONCLUSIONS: These data indicate that a weight-loss dietary regimen in conjunction with aerobic and resistance exercise prevents the normal decline in fat-free mass and muscular power and augments body composition, maximal strength, and maximum oxygen consumption compared with weight-loss induced by diet alone.

Performance and muscle fiber adaptations to creatine supplementation and heavy resistance training.

PURPOSE: The purpose of this study was to examine the effect of creatine supplementation in conjunction with resistance training on physiological adaptations including muscle fiber hypertrophy and muscle creatine accumulation. METHODS: Nineteen healthy resistance-trained men were matched and then randomly assigned in a double-blind fashion to either a creatine (N = 10) or placebo (N = 9) group. Periodized heavy resistance training was performed for 12 wk. Creatine or placebo capsules were consumed (25 g x d(-1)) for 1 wk followed by a maintenance dose (5 g x d(-1)) for the remainder of the training. RESULTS: After 12 wk, significant (P < or = 0.05) increases in body mass and fat-free mass were greater in creatine (6.3% and 6.3%, respectively) than placebo (3.6% and 3.1%, respectively) subjects. After 12 wk, increases in bench press and squat were greater in creatine (24% and 32%, respectively) than placebo (16% and 24%, respectively) subjects. Compared with placebo subjects, creatine subjects demonstrated significantly greater increases in Type I (35% vs 11%), IIA (36% vs 15%), and IIAB (35% vs 6%) muscle fiber cross-sectional areas. Muscle total creatine concentrations were unchanged in placebo subjects. Muscle creatine was significantly elevated after 1 wk in creatine subjects (22%), and values remained significantly greater than placebo subjects after 12 wk. Average volume lifted in the bench press during training was significantly greater in creatine subjects during weeks 5-8. No negative side effects to the supplementation were reported. CONCLUSION: Creatine supplementation enhanced fat-free mass, physical performance, and muscle morphology in response to heavy resistance training, presumably mediated via higher quality training sessions.

Exercise and recovery responses of adrenal medullary neurohormones to heavy resistance exercise.

PURPOSE: The purpose of this study was to examine the effect of dynamic resistance exercise on the response patterns of adrenal medullary neurohormones in strength-trained men. METHODS: Ten strength-trained men (21.7+/-0.58 yr) gave informed consent and performed two resistance exercise protocols, high force and high power, of equal total work in a randomized order separated by 1 wk. Blood samples were obtained pre-exercise (baseline), 0 (R-0), 15 (R-15), and 240 (R-240) min postexercise and under resting control conditions for each time point. RESULTS: There were no significant differences in control concentrations for each time point and no difference in pre-exercise values between the two resistance exercise protocols for plasma lactate, epinephrine, plasma peptide F (P-F), or norepinephrine (NE). Plasma lactate significantly (P< or = 0.05) increased from baseline for both protocols; however, concentrations were higher in response to the high force protocol. Plasma epinephrine was significantly increased from baseline at R-0 and returned to baseline at R-15 for both protocols. In contrast, plasma P-F was significantly decreased at R-0 from baseline; however, at R-240 P-F had significantly increased to >80% baseline for both protocols. CONCLUSIONS: These results indicate that the adrenal medulla was activated in response to the acute stress of both types of heavy resistance exercise. Furthermore, during longer recovery periods, the adrenal medulla was also active above baseline conditions as increased concentrations of proenkephalin fragments (i.e., P-F) were detected in the circulation.

Hormonal responses to consecutive days of heavy-resistance exercise with or without nutritional supplementation.

Nine resistance-trained men consumed either a protein-carbohydrate supplement or placebo for 1 wk in a crossover design separated by 7 days. The last 3 days of each treatment, subjects performed resistance exercise. The supplement was consumed 2 h before and immediately after the workout, and blood was obtained before and after exercise (0, 15, 30, 45, and 60 min postexercise). Lactate, growth hormone, and testosterone were significantly (P

Plasma proenkephalin peptide F and human B cell responses to exercise stress in fit and unfit women.

In vitro studies have connected immune cell function to Peptide F. The primary purpose of this investigation was to examine the responses of plasma Peptide F and epinephrine along with the changes in B cell antibody production in vivo in physically fit and unfit women in response to physical exercise on a cycle ergometer at 60% and 80% of peak oxygen consumption. Seven aerobically fit and eight untrained (i.e., unfit) women between the ages of 18 and 30 volunteered to participate in this investigation. Blood samples (analyzed for plasma Peptide F and epinephrine along with the number of antibody-producing B cells) were obtained 24 hours prior to the exercise session, pre-exercise, during each exercise intensity, and five minutes post-exercise. The fit group had a significantly higher plasma Peptide F concentration after the 80% exercise intensity along with significantly higher numbers of antibody producing B cells compared to the unfit group. The results of this investigation show that physically fit women have an enhanced secondary response of B cells to a specific antigen under conditions where Peptide F is increased. Such data demonstrate that physical fitness as promoted by the Public Health Service (e.g., Healthy People 2000) influences the underlying hormonal and immune cell responses when challenged by physical exercise stress.

Comparison of body composition assessment among lean black and white male collegiate athletes.

Variations in the density of the fat-free mass (DFFM) across ethnic groups is a critical factor that invalidates the use of body fat equations. It has also been suggested that resistance trained athletes may have higher body densities (BDs) than untrained subjects. Thus, the validity of using anthropometric (ANT) equations, which have mainly been derived on white nonathletic groups, has been questioned for athletic white and black men. This study compared BD and percent body fat (%BF) between 34 white (20 +/- 1 yr, 184 +/- 11 cm, 84 +/- 12 kg, 25 +/- 3 BMI) and 30 black (20 +/- 1 yr, 182 +/- 9 cm, 84 +/- 12 kg, 25 +/- 2 BMI) male collegiate athletes and determined the accuracy of 5 ANT equations in estimating %BF. Subjects were underwater weighed (UWW), and skinfold measurements were obtained from the chest, mid-axillary, abdomen, suprailiac, subscapula, triceps, and thigh. BD was obtained from UWW and estimated from the five skinfold equations. From UWW, significant (P < or = 0.05) differences were found for BD (1.075 +/- 0.007 vs 1.0817 +/- 0.009), but not for %BF (10.49 +/- 2.8 vs 11.59 +/- 3.4) for white and black subjects, respectively. Differences were noted for subcutaneous skinfold sites (abdominal (vertical), suprailiac, and thigh), sum of three and seven skinfolds, and proportion of subscapular subcutaneous fat. One out of five and five out of five ANT equations (Siri conversions) yielded significantly lower estimates compared with UWW %BF for the white and black athletes, respectively. Use of the Schutte equation for the black athletes resulted in overpredictions of %BF for five out of five equations. In addition, the Schutte equation offered slightly greater accuracy than did the Siri equation for estimating %BF in black athletes. These data confirm earlier concerns that ANT equations derived on general populations may not be as accurate for athletic populations and also suggest that correction equations are necessary for converting BD into %BF for populations differing with respect to race or training status.

The female athlete triad.

The opportunities for girls and women to play soccer has rapidly grown and gained acceptance in recent years. The benefits of involvement in soccer, both physically and psychologically, are overwhelmingly positive. Despite the benefits, girls and women involved in soccer are also at risk for medical problems as a result of their sports participation. Amenorrhea, disordered eating, and premature osteoporosis are entities known together as The Female Athlete Triad. The triad occurs in all sports and is associated with significant short- and long-term health consequences, and thus remains a concern for all involved in the care of the soccer athlete.

Return to play: making the tough decisions.

When can I play again?" is a question familiar to sports medicine physicians and increasingly to primary care physicians who treat active people, from the third-grade soccer player to the 70-year-old tennis enthusiast. Those who ask this question are often seeking a definitive answer-and usually hoping for a quick return to boot. Unfortunately, medicine is not always a craft practiced in black and white but is often an art with a palette in several shades of gray.

Physiological adaptations to a weight-loss dietary regimen and exercise programs in women.

Thirty-one women (mean age 35.4 +/- 8.5 yr) who were overweight were matched and randomly placed into either a control group (Con; n = 6), a diet-only group (D; n = 8), a diet+aerobic endurance exercise training group (DE; n = 9), or a diet+aerobic endurance exercise training+strength training group (DES; n = 8). After 12 wk, the three dietary groups demonstrated a significant (P