Diffusion Tensor Imaging Indicators of White Matter Injury Are Correlated with a Multimodal Electroencephalography-Based Biomarker in Slow Recovering, Concussed Collegiate Athletes.

There are no validated, objective diagnostic or prognostic biomarkers for sports-related concussion (SRC), which hinders evidence-based treatment for concussed athletes. While quantitative electrophysiology (EEG) and diffusion tensor imaging (DTI) are promising technologies for providing objective biomarkers for concussion, the degree to which they are related has not been systematically investigated in concussed athletes. This study examined whether diffusion metrics differentiated concussed athletes with prolonged recovery (n = 18) from non-conccused athletes (n = 13) and whether observed diffusion alterations related to EEG. Collegiate athletes (N = 31) completed EEG, neurocognitive, and magnetic resonance imaging. White matter diffusivity differed between the groups in multiple white matter tracts, including the corpus callosum, cingulum bundle, thalamic radiations, and inferior fronto-occipital, inferior longitudinal, and uncinate fasciculi, but not after correction for multiple comparisons. The enhanced Brain Function Index (eBFI), a measure that combines EEG and neurocognitive data, significantly correlated with altered diffusion in the concussed athletes. These preliminary findings suggest that the absolute deviation of diffusion metrics in concussed versus non-concussed athletes may have clinically utility. Results also suggested that the eBFI may be sensitive to early changes from sports-related concussion.

The Association between Mandated Preseason Heat Acclimatization Guidelines and Exertional Heat Illness during Preseason High School American Football Practices.

BACKGROUND: The risk of heat-related illness and death may continue to increase in many locations as a consequence of climate change, but information on the effectiveness of policies to protect populations from the adverse effects of excessive heat is limited. In 2009, the National Athletic Trainers' Association Inter-Association Task Force (NATA-IATF) released guidelines to reduce exertional heat illness (EHI) among U.S. high school athletes participating in preseason sports activities, including preseason practice sessions for American football. A subset of state high school athletic associations have implemented state-mandated guidelines consistent with the 2009 NATA-IATF recommendations, but their effectiveness for reducing preseason EHI is unknown. OBJECTIVES: This study examines the association between the enactment of state high school athletic association-mandated NATA-IATF guidelines and the rate of EHI among high school students during preseason American football practice sessions. METHODS: We performed a quasi-experimental interrupted time-series study of EHI during high school American football practices in the 2005/2006-2016/2017 school years. We estimated state-level EHI rates using High School Reporting Information Online injury and athlete-exposure data, and used generalized estimating equations Poisson regression models to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) comparing state-years with and without mandated NATA-IATF guidelines. State-level covariates included state-year-specific average August temperatures, yearly deviations from each state's August average temperature across the study period, and school year. RESULTS: Data were available for 455 state-years from 48 states, including 32 state-years (7.0%) from 8 states when mandated guidelines consistent with the NATA-IATF recommendations were implemented. During an estimated 2,697,089 athlete-exposures, 190 EHIs were reported. Estimated preseason EHI rates were lower during state-years with versus without mandated guidelines (adjusted [Formula: see text], 95% CI: 0.23, 0.87). CONCLUSIONS: Our findings suggest that high school athletes would benefit from enactment of the 2009 NATA-IATF guidelines. Similar analyses of the effectiveness of other public health policies to reduce adverse health effects from ambient heat are warranted. https://doi.org/10.1289/EHP4163.

The Socioecological Framework: A Multifaceted Approach to Preventing Sport-Related Deaths in High School Sports.

The socioecological framework is a multilevel conceptualization of health that includes intrapersonal, interpersonal, organizational, environmental, and public policy factors. The socioecological framework emphasizes multiple levels of influence and supports the idea that behaviors both affect and are affected by various contexts. At present, the sports medicine community's understanding and application of the socioecological framework are limited. In this article, we use the socioecological framework to describe potential avenues for interventions to reduce sport-related deaths among adolescent participants.

Emergency Action Planning in Secondary School Athletics: A Comprehensive Evaluation of Current Adoption of Best Practice Standards.

CONTEXT: Emergency action plans (EAPs) are policies that improve response times and ensure access to emergency equipment for the management of patients with acute injuries and medical conditions, yet the extent to which EAP standards are adopted and implemented is unknown. OBJECTIVE: To describe the extent of EAP adoption and implementation in secondary school (SS) athletics with athletic trainer (AT) services in the United States. DESIGN: Cross-sectional study. SETTING: Web-based questionnaire. PATIENTS OR OTHER PARTICIPANTS: A national sample of ATs (n = 9642) was invited to participate in a Web-based questionnaire. MAIN OUTCOME MEASURE(S): Twelve components of EAP minimum best practices were derived from the "National Athletic Trainers' Association (NATA) Position Statement: Emergency Planning in Athletics." Emergency action plan components were analyzed using descriptive statistics with 95% confidence intervals (CIs) around proportions. Contingency tables (2 × 2) were used to calculate odds ratios (with 95% CIs) to assess adoption of the components (dichotomized as yes or no), employment factors (eg, full time versus part time, employed by clinic/district), and access to emergency equipment. RESULTS: The response rate for the questionnaire was 13.2% (n = 1273). A majority of ATs (89.1%) reported having an EAP; however, only 9.9% described implementing all 12 components cited in the NATA position statement. Athletic trainers stated that they created the EAP in 62.8% (95% CI = 60.1%, 65.4%) of schools with an EAP. Athletic trainers employed full time were at greater odds of adopting 9 or more components of the EAP compared with ATs employed part time (odds ratio = 2.42 [95% CI = 1.66, 3.53]). A total of 85.7% of ATs noted access to an automated external defibrillator. CONCLUSIONS: Although a majority of SSs had EAPs, the EAPs were often incomplete and lacked the necessary components for full compliance with the NATA position statement. These findings demonstrate the need for efforts to promote the adoption and implementation of comprehensive EAPs in SS athletics.

Assessment of Evidence-Based Health and Safety Policies on Sudden Death and Concussion Management in Secondary School Athletics: A Benchmark Study.

CONTEXT:: Implementation of best-practice health and safety policies has been shown to be effective at reducing the risk of sudden death in sport; however, little is known about the extent to which these policies are required within secondary school athletics. OBJECTIVE:: To examine best-practice health and safety policies pertaining to the leading causes of sudden death and to concussion management in sport mandated at the state level for secondary school athletics. DESIGN:: Descriptive observational study. SETTING:: State high school athletic associations (SHSAAs), state departments of education, and enacted legislation. PATIENTS OR OTHER PARTICIPANTS:: United States (including the District of Columbia) SHSAAs. MAIN OUTCOME MEASURE(S):: A review of SHSAA health and safety policies for the 2016-2017 academic year, state department of education policies, and enacted legislation was undertaken to assess the polices related to the leading causes of sudden death and concussion management in sport. Current best-practice recommendations used to assess health and safety policies were specific to emergency action plans, automated external defibrillators, heat acclimatization, environmental monitoring and modification, and concussion management. The total number of best-practice recommendations required for each SHSAA's member schools for the aforementioned areas was quantified and presented as total number and percentage of recommendations required. RESULTS:: Four of 51 SHSAA member schools were required to follow best practices for emergency action plans, 7 of 51 for access to automated external defibrillators, 8 of 51 for heat acclimatization, and 3 of 51 for management of concussion. CONCLUSIONS:: At the time of this study, SHSAA member schools were not required to follow all best-practice recommendations for preventing the leading causes of sudden death and for concussion management in sport. Continued advocacy for the development and implementation of best practices at the state level to be required of all secondary schools is needed to appropriately serve the health and well-being of our young student-athletes.

Acute Sport-Related Concussion Screening for Collegiate Athletes Using an Instrumented Balance Assessment.

CONTEXT: Without a true criterion standard assessment, the sport-related concussion (SRC) diagnosis remains subjective. Inertial balance sensors have been proposed to improve acute SRC assessment, but few researchers have studied their clinical utility. OBJECTIVE: To determine if group differences exist when using objective measures of balance in a sample of collegiate athletes with recent SRCs and participants serving as the control group and to calculate sensitivity and specificity to determine the diagnostic utility of the inertial balance sensor for acute SRC injuries. DESIGN: Cross-sectional cohort study. SETTING: Multicenter clinical trial. PATIENTS OR OTHER PARTICIPANTS: We enrolled 48 participants with SRC (age = 20.62 ± 1.52 years, height = 179.76 ± 10.00 cm, mass = 83.92 ± 23.22 kg) and 45 control participants (age = 20.85 ± 1.42 years, height = 177.02 ± 9.59 cm, mass = 74.61 ± 14.92 kg) at 7 clinical sites in the United States. All were varsity or club collegiate athletes, and all participants with SRC were tested within 72 hours of SRC. MAIN OUTCOME MEASURE(S): Balance performance was assessed using an inertial balance sensor. Two measures (root mean square sway and 95% ellipse sway area) were analyzed to represent a range of general balance measures. Balance assessments were conducted in double-legged, single-legged, and tandem stances. RESULTS: A main effect for group was associated with the root mean square sway measure ( F1,91 = 11.75, P = .001), with the SRC group demonstrating balance deficits compared with the control group. We observed group differences in the 95% ellipse sway area measure for the double-legged ( F1,91 = 11.59, P = .001), single-legged ( F1,91 = 6.91, P = .01), and tandem ( F1,91 = 7.54, P = .007) stances. Sensitivity was greatest using a cutoff value of 0.5 standard deviations (54% [specificity = 71%]), whereas specificity was greatest using a cutoff value of 2 standard deviations (98% [sensitivity = 33%]). CONCLUSIONS: Inertial balance sensors may be useful tools for objectively measuring balance during acute SRC evaluation. However, low sensitivity suggests that they may be best used in conjunction with other assessments to form a comprehensive screening that may improve sensitivity.

State-Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within Secondary School Athletics.

BACKGROUND: Sudden death and catastrophic injuries during sport can be attenuated with the implementation of evidence-based health and safety policies. However, the extent of the implementation of these policies within secondary school athletics is unknown. PURPOSE: To provide an assessment of the implementation of health and safety policies pertaining to the leading causes of sudden death and catastrophic injuries in sport within secondary school athletics in the United States. STUDY DESIGN: Descriptive epidemiology study. METHODS: A rubric for evidence-based practices for preventing the leading causes of death and catastrophic injuries in sport was created. The rubric comprised 5 equally weighted sections for sudden cardiac arrest, head injuries, exertional heat stroke, appropriate medical coverage, and emergency preparedness. State high school athletic association (SHSAA) policies, enacted legislation, and Department of Education policies were extensively reviewed for all 50 states and the District of Columbia. States meeting the specific criteria in the rubric, which required policies to be mandated for all SHSAA member schools, were awarded credit; the weighted scores were tabulated to calculate an aggregate score. States were then ranked from 1 (best) to 51 (worst) based on the aggregate score achieved. RESULTS: The median score on the rubric was 47.1% (range, 23.00%-78.75%). States ranked 1 through 10 (from 78.75% to 56.98%) were North Carolina, Kentucky, Massachusetts, New Jersey, South Dakota, Missouri, Washington, Hawaii, Wisconsin, and Georgia, respectively. States ranked 11 through 20 (from 56.03% to 50.55%) were Arkansas, New York, Mississippi, West Virginia, Oregon, Illinois, Tennessee, Arizona, Texas, and District of Columbia, respectively. States ranked 21 through 30 (from 49.40% to 44.00%) were Virginia, Pennsylvania, Florida, New Mexico, Alabama, Maine, Rhode Island, Indiana, Nevada, and Utah, respectively. States ranked 31 through 40 (from 43.93% to 39.80%) were Ohio, Delaware, Alaska, Vermont, Louisiana, Maryland, Oklahoma, Connecticut, Idaho, and South Carolina, respectively. States ranked 41 through 51 (from 38.73% to 23.00%) were Michigan, North Dakota, Nebraska, New Hampshire, Kansas, Wyoming, Minnesota, Montana, Iowa, California, and Colorado, respectively. CONCLUSION: State scores ranged from 23.00% to 78.75% for the implementation of evidence-based best practices for preventing the leading causes of sudden death and catastrophic injuries (sudden cardiac arrest, traumatic head injuries, exertional heat stroke, and exertional sickling) in sport. Continued advocacy for the development and implementation of policies at the secondary school level surrounding sudden death and catastrophic injuries is warranted to optimize the health and safety of these student athletes.

Top 10 Research Questions Related to Preventing Sudden Death in Sport and Physical Activity.

Participation in organized sport and recreational activities presents an innate risk for serious morbidity and mortality. Although death during sport or physical activity has many causes, advancements in sports medicine and evidence-based standards of care have allowed clinicians to prevent, recognize, and treat potentially fatal injuries more effectively. With the continual progress of research and technology, current standards of care are evolving to enhance patient outcomes. In this article, we provided 10 key questions related to the leading causes and treatment of sudden death in sport and physical activity, where future research will support safer participation for athletes and recreational enthusiasts. The current evidence indicates that most deaths can be avoided when proper strategies are in place to prevent occurrence or provide optimal care.

Landing Technique Improvements After an Aquatic-Based Neuromuscular Training Program in Physically Active Women.

CONTEXT: Neuromuscular training programs (NTPs) improve landing technique and decrease vertical ground-reaction forces (VGRFs), resulting in injury-risk reduction. NTPs in an aquatic environment may elicit the same improvements as land-based programs with reduced joint stress. OBJECTIVE: To examine the effects of an aquatic NTP on landing technique as measured by the Landing Error Scoring System (LESS) and VGRFs, immediately and 4 mo after the intervention. DESIGN AND SETTING: Repeated measures, pool and laboratory. PARTICIPANTS: Fifteen healthy, recreationally active women (age 21 ± 2 y, mass 62.02 ± 8.18 kg, height 164.74 ± 5.97 cm) who demonstrated poor landing technique (LESS-Real Time > 4). INTERVENTIONS: All participants completed an aquatic NTP 3 times/wk for 6 wk. MAIN OUTCOME MEASURES: Participants' landing technique was evaluated using a jump-landing task immediately before (PRE), immediately after (POST), and 4 mo after (RET) the intervention period. A single rater, blinded to time point, graded all videos using the LESS, which is a valid and reliable movement-screening tool. Peak VGRFs were measured during the stance phase of the jump-landing test. Repeated-measure analyses of variance with planned comparisons were performed to explore differences between time points. RESULTS: LESS scores were lower at POST (4.46 ± 1.69 errors) and at RET (4.2 ± 1.72 errors) than at PRE (6.30 ± 1.78 errors) (P < .01). No significant differences were observed between POST and RET (P > .05). Participants also landed with significantly lower peak VGRFs (P < .01) from PRE (2.69 ± .72 N) to POST (2.23 ± .66 N). CONCLUSIONS: The findings introduce evidence that an aquatic NTP improves landing technique and suggest that improvements are retained over time. These results show promise of using an aquatic NTP when there is a desire to reduce joint loading, such as early stages of rehabilitation, to improve biomechanics and reduce injury risk.