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Concussed patients with chronic symptoms commonly report dizziness during exposure to environments with complex visual stimuli (e.g. supermarket aisles, busy crossroads). Such visual induced dizziness is well-known in patients with vestibular deficits, in whom it indicates an overreliance on visual cues in sensory integration. Considering that optokinetic after-nystagmus (OKAN) reflects the response of the central network integrating visual and vestibular self-motion signals (velocity storage network), we investigated OKAN in 71 patients [17 (23.9%) females, 30.36 ± 9.05 years old] who suffered from persistent symptoms after a concussion and presented clinical signs suggesting visual dependence. Data were retrospectively compared with 21 healthy individuals [13 (61.9%) females, 26.29 ± 10.00 years old]. The median values of the slow cumulative eye position and of the time constant of OKAN were significantly higher in patients than in healthy individuals (slow cumulative eye position: 124.15 ± 55.61° in patients and 77.87 ± 45.63° in healthy individuals—p = 0.012; time constant: 25.17 ± 10.27 s in patients and 13.95 ± 4.92 s in healthy individuals—p = 0.003). The receiving operating curve (ROC) estimated on the time constant had an overall area under the curve of 0.73. Analysis of the ROC suggests that a test measuring the OKAN time constant could obtain a sensitivity of 0.73 and specificity of 0.72 in determining the origin of the visual-related disturbances in those patients (threshold 16.6 s). In a subset of 43 patients who also performed the Sensory Organization Test (SOT), the proposed OKAN test was twice as sensitive as the SOT. This study suggests that concussed patients with persisting visual symptoms may have an underlying impairment of the velocity storage mechanism and that measuring the OKAN time constant can objectify such impairment.

Observing a rotating visual pattern covering a large portion of the visual field induces optokinetic nystagmus (OKN). If the lights are suddenly switched off, optokinetic afternystagmus (OKAN) occurs. OKAN is hypothesized to originate in the velocity storage mechanism (VSM), a central processing network involved in multi-sensory integration. During a sustained visual rotation, the VSM builds up a velocity signal. After the lights are turned off, the VSM discharges slowly, with OKAN as the neurophysiological correlate. It has been reported that the initial afternystagmus in the direction of the preceding stimulus (OKAN-I) can be followed by a reversed one (OKAN-II), which increases with stimulus duration up to 15 min. In 11 healthy adults, we investigated OKAN following optokinetic stimulus lasting 30 s, 3-, 5-, and 10-min. Analysis of slow-phase cumulative eye position and velocity found OKAN-II in only 5/11 participants. Those participants presented it in over 70% of their trials with longer durations, but only in 10% of their 30 s trials. While this confirms that OKAN-II manifests predominantly after sustained stimuli, it suggests that its occurrence is subject-specific. We also did not observe further increases with stimulus duration. Conversely, OKAN-II onset occurred later as stimulus duration increased (p = 0.02), while OKAN-II occurrence and peak velocity did not differ between the three longest stimuli. Previous studies on OKAN-I, used negative saturation models to account for OKAN-II. As these approaches have no foundation in the OKAN-II literature, we evaluated if a simplified version of a rigorous model of OKAN adaptation could be used in humans. Slow-phase velocity following the trials with 3-, 5-, and 10-min stimuli was fitted with a sum of two decreasing exponential functions with opposite signs (one for OKAN-I and one for OKAN-II). The model assumes separate mechanisms for OKAN-I, representing VSM discharge, and OKAN-II, described as a slower adaptation phenomenon. Although the fit was qualitatively imperfect, this is not surprising given the limited reliability of OKAN in humans. The estimated adaptation time constant seems comparable to the one describing the reversal of the vestibulo-ocular reflex during sustained rotation, suggesting a possible shared adaptive mechanism.

BackgroundAdverse long-term effects of playing football due to repetitive head impact exposure on neurocognition and mental health are controversial. To date, no studies have evaluated such effects in women.AimsTo (1) compare neurocognitive performance, cognitive symptoms and mental health in retired elite female football players (FB) with retired elite female non-contact sport athletes (CON), and to (2) assess whether findings are related to history of concussion and/or heading exposure in FB.MethodsNeurocognitive performance, mental health and cognitive symptoms were assessed using computerised tests (CNS-vital signs), paper pen tests (Category fluency, Trail-Making Test, Digit Span, Paced Auditory Serial Addition Test), questionnaires (Hospital Anxiety and Depression Scale, SF-36v2 Health Survey) and a symptom checklist. Heading exposure and concussion history were self-reported in an online survey and in a clinical interview, respectively. Linear regression was used to analyse the effect of football, concussion and heading exposure on outcomes adjusted for confounders.ResultsFB (n=66) performed similar to CON (n=45) on neurocognitive tests, except for significantly lower scores on verbal memory (mean difference (MD)=−7.038, 95% CI −12.98 to –0.08, p=0.038) and verbal fluency tests (MD=−7.534, 95% CI –13.75 to –0.46, p=0.016). Among FB weaker verbal fluency performance was significantly associated with ≥2 concussions (MD=−10.36, 95% CI –18.48 to –2.83, p=0.017), and weaker verbal memory performance with frequent heading (MD=−9.166, 95% CI –17.59 to –0.123, p=0.041). The depression score differed significantly between study populations, and was significantly associated with frequent heading but not with history of concussion in FB.ConclusionFurther studies should investigate the clinical relevance of our findings and whether the observed associations point to a causal link between repetitive head impacts and verbal memory/fluency or mental health.

Head injuries can result in substantially different outcomes, ranging from no detectable effect to transient functional impairments to life-threatening structural lesions. In high-level international football (soccer) tournaments, on average, one head injury occurs in every third match. Making the diagnosis and determining the severity of a head injury immediately on-pitch or off-field is a major challenge for team physicians, especially because clinical signs of a brain injury can develop over several minutes, hours, or even days after the injury. A standardized approach is useful to support team physicians in their decision whether the player should be allowed to continue to play or should be removed from play after head injury. A systematic, football-specific procedure for examination and management during the first 72 hours after head injuries and a graduated Return-to-Football program for high-level players have been developed by an international group of experts based on current national and international guidelines for the management of acute head injuries. The procedure includes seven stages from the initial on-pitch examination to the graduated Return-to-Football program. Details of the assessments and the consequences of different outcomes are described for each stage. Criteria for emergency management (red flags), removal from play (orange flags), and referral to specialists for further diagnosis and treatment (persistent orange flags) are provided. The guidelines for return to sport after concussion-type head injury are specified for football. Thus, the present paper presents a comprehensive procedure for team physicians after a head injury in high-level football.

AIM OR OBJECTIVE: The objective of this systematic review was to evaluate the evidence regarding rest and active treatment/rehabilitation following sport-related concussion (SRC). DESIGN: Systematic review. DATA SOURCES: MEDLINE (OVID), CINAHL (EbscoHost), PsycInfo (OVID), Cochrane Central Register of Controlled Trials (OVID), SPORTDiscus (EbscoHost), EMBASE (OVID) and Proquest DissertationsandTheses Global (Proquest) were searched systematically. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were included if they met the following criteria: (1) original research; (2) reported SRC as the diagnosis; and (3) evaluated the effect of rest or active treatment/rehabilitation. Review articles were excluded. RESULTS: Twenty-eight studies met the inclusion criteria (9 regarding the effects of rest and 19 evaluating active treatment). The methodological quality of the literature was limited; only five randomised controlled trials (RCTs) met the eligibility criteria. Those RCTs included rest, cervical and vestibular rehabilitation, subsymptom threshold aerobic exercise and multifaceted collaborative care. SUMMARY/CONCLUSIONS: A brief period (24-48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. The exact amount and duration of rest are not yet well defined and require further investigation. The data support interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2016:CRD42016039570.

Dizziness, slow visual tracking, or blurred vision following active head (or body) movements are among the most common symptoms reported following sport-related concussion, often related to concurrent dysfunctions of the vestibular system. In some cases, symptoms persist even if bedside and auxiliary standard vestibular tests are unremarkable. New functional tests have been developed in recent years to objectify neurological alterations that are not captured by standard tests. The functional head impulse test (fHIT) requires the patient to recognize an optotype that is briefly flashed during head rotations with various angular accelerations (2,001–6,000 deg/s2) and assesses the proportion if correct answers (pca). 268 active professional athletes (23.70 ± 5.32y) from six different sports were tested using fHIT. Pca were analyzed both pooling head acceleration in the range of 2,001–6,000 deg/s2 and computing a single pca value for each 1,000 deg/s2 bin in the range 2,001–8,000 deg/s2. No significant difference (p = 0.159) was found between responses to head impulses in the plane of horizontal (pca: 0.977) and vertical semicircular canals (pca: 0.97). The sport practiced had a major effect on the outcome of the fHIT. Handball players achieved a better performance (p < 0.001) than the whole athlete group, irrespective of the direction of head impulses. The pca achieved by athletes practicing snowboard, bob and skeleton were instead significantly below those of the whole athlete group (p < 0.001) but only when vertical head impulses were tested. Overall, pca declined with increasing head acceleration. The decline was particularly evident in the range not included in the standard fHIT exam, i.e., 6,001–8,000 deg/s2 for horizontal and 5,001–8,000 deg/s2 for vertical head impulses. When vertical head impulses were tested, athletes practicing snowboard, bob and skeleton (non-ball sports) showed, beside the lower overall pca, also a steeper decline as a function of vertical head acceleration. The findings suggest that: (1) functional VOR testing can help understanding sport-specific VOR requirements; (2) the fHIT is able to detect and objectify subtle, sport-specific changes of functional VOR performance; (3) if sport-specific normative values are used, the fHIT test procedure needs to be optimized, starting from the highest acceleration to minimize the number of head impulses.

Cerebellar impairment may cause deficits in horizontal gaze holding, leading to centrifugal gaze-evoked nystagmus during fixation of eccentric targets. Healthy individuals show a weak drift leading to physiological nystagmus only at large gaze angles. These drifts are due to imperfect memory of the neural circuitry generating the eye position signals by integration of velocity signals. The cerebellum plays a crucial role in reducing the “leakiness” of this neural integrator. This neural integrator has been traditionally modeled as a first order low-pass filter, implying a linear relation between drift velocity and eye eccentricity. Evidences of a non-linear behavior, however, can be found in the literature. In a recent series of papers we showed that the eye drift velocity ( V ) can be descriptively modeled as a tangent function of gaze eccentricity ( P ) with the following equation: V = k 2 / k 1 tan ( k 1 P ). Notably, the two parameters have distinct roles: k 1 regulates the rate of compression of the tangent, exclusively determining the non-linearity; k 2 is a pure scaling factor. This descriptive model robustly fitted the data of healthy individuals both at baseline ( n = 50) and following transient cerebellar impairment induced by controlled amounts of alcohol [blood alcohol content 0.06% ( n = 15) and 0.1% ( n = 15)] and of patients with chronic cerebellar impairment of various origin ( n = 20). Interestingly, alcohol selectively changed the scaling factor k 2 , evidencing that an overall, transient cerebellar impairment does not impact the non-linear behavior. Patients with cerebellar degeneration, on the other hand, showed a change in both k 1 and k 2 , implying a role of the cerebellum in limiting the range of eye positions where the non-linearity becomes relevant. Non-linearity has been reported in literature for both the neural integrator and the eye plant. While previous models using a neural network attempted to reproduce the non-linear behavior of the brainstem, we propose a block diagram reproducing the observed PV tangent relation by introducing a position dependency in the parameters of the cerebellar feedback loop.

Aim/objectiveThere is ongoing controversy about persistent neurological deficits in active and former football (soccer) players. We reviewed the literature for associations between football activities (including heading/head injuries) and decline in brain structure/function.DesignSystematic literature review.Data sourcesMEDLINE, Embase, PsycINFO, CINAHL, Cochrane-CRCT, SportDiscus, Cochrane-DSR=4 (accessed 2 August 2016).Eligibility criteria for selecting studiesOriginal studies reporting on football-related persistent effects on brain structure/function. Results from neurocognitive testing, neuroimaging and EEG were compared with controls and/or correlated with heading frequency and/or head injuries. Methodological quality was rated for risk-of-bias, including appropriateness of controls, correction for multiple statistical testing and assessment of heading frequency and head injuries.Results30 studies with 1691 players were included. Those 57% (8/14) of case–control studies reporting persistent neurocognitive impairment had higher odds for inappropriate control of type 1 errors (OR=17.35 (95% CI (10.61 to 28.36)) and for inappropriate selection of controls (OR=1.72 (1.22 to 2.43)) than studies observing no impairment. Studies reporting a correlation between heading frequency and neurocognitive deficits (6/17) had lower quality of heading assessment (OR=14.20 (9.01 to 22.39)) than studies reporting no such correlation. In 7 of 13 studies (54%), the number of head injuries correlated with the degree of neurocognitive impairment. Abnormalities on neuroimaging (6/8 studies) were associated with subclinical neurocognitive deficits in 3 of 4 studies.Summary/conclusionsVarious methodological shortcomings limit the evidence for persistent effects of football play on brain structure/function. Sources of bias include low-quality assessment of heading frequency, inappropriate control for type 1 errors and inappropriate selection of controls. Combining neuroimaging techniques with neurocognitive testing in prospective studies seems most promising to further clarify on the impact of football on the brain.

Through a partnership with the National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, and Department of Defense, the development of Sport-Related Concussion (SRC) Common Data Elements (CDEs) was initiated. The aim of this collaboration was to increase the efficiency and effectiveness of clinical research studies and clinical treatment outcomes, increase data quality, facilitate data sharing across studies, reduce study start-up time, more effectively aggregate information into metadata results, and educate new clinical investigators. The SRC CDE Working Group consisted of 32 worldwide experts in concussion from varied fields of related expertise divided into three Subgroups: Acute (3 months post-concussion). To develop CDEs, the Subgroups reviewed various domains, then selected from, refined, and added to existing CDEs, case report forms and field-tested data elements from national registries and funded research studies. Recommendations were posted to the NINDS CDE Website for Public Review from February 2017 to April 2017. Following an internal Working Group review of recommendations, along with consideration of comments received from the Public Review period, the first iteration (Version 1.0) of the NINDS SRC CDEs was completed in June 2017. The recommendations include Core and Supplemental–Highly Recommended CDEs for cognitive data elements and symptom checklists, as well as other outcomes and end-points (e.g., vestibular, oculomotor, balance, anxiety, depression), and sample case report forms (e.g., injury reporting, demographics, concussion history) for domains typically included in clinical research studies. The NINDS SRC CDEs and supporting documents are publicly available on the NINDS CDE website www.commondataelements.ninds.nih.gov. Widespread use of CDEs by researchers and clinicians will facilitate consistent SRC clinical research and trial design, data sharing, and metadata retrospective analysis.

Objectives Amyotrophic lateral sclerosis (ALS) has been reported to occur with increased incidence amongst physically active people. The role of extrinsic risk factors as physical activity, head trauma and drug/pesticide-exposure in the pathophysiology of ALS and especially in the context of practising sports remains controversial. Materials and Methods We retrospectively studied exposure to extrinsic factors in 92 ALS patients in the presymptomatic stage. Metabolic equivalents (METs) were calculated and the association of physical activity, drug intake, head trauma and participation in specific sports (football [soccer], ice hockey) with age at symptom-onset was evaluated. Results Ninety-five percent of patients considered themselves physically active before symptom-onset. Total MET-values varied broadly and there was no correlation between vigorous physical activity and age at symptom-onset. Mild traumatic brain injury (prevalence = 16.7%) was the most frequent diagnosis after head/neck injury. A history of ≥1 head/neck injuries was associated with a younger age at symptom-onset (61.8 ± 11.0 vs. 54.1 ± 13.0, p = .013). In former football and ice hockey players the rate of vigorous physical activities was increased (p

OBJECTIVES: Various definitions for concussion have been proposed, each having its strengths and weaknesses. We reviewed and compared current definitions and identified criteria necessary for an operational definition of sports-related concussion (SRC) in preparation of the 5th Concussion Consensus Conference (Berlin, Germany). We also assessed the role of biomechanical studies in informing an operational definition of SRC.DESIGN: This is a systematic literature review.DATA SOURCES: Data sources include MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Clinical Trials and SPORT Discus (accessed 14 September 2016).ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Eligibility criteria were studies reporting (clinical) criteria for diagnosing SRC and studies containing SRC impact data.RESULTS: Out of 1601 articles screened, 36 studies were included (2.2%), 14 reported on criteria for SRC definitions and 22 on biomechanical aspects of concussions. Six different operational definitions focusing on clinical findings and their dynamics were identified. Biomechanical studies were obtained almost exclusively on American football players. Angular and linear head accelerations linked to clinically confirmed concussions demonstrated considerable individual variation.SUMMARY/CONCLUSIONS: SRC is a traumatic brain injury that is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature. Limitations identified include that the current criteria for diagnosing SRC are clinically oriented and that there is no gold/standard to assess their diagnostic properties. A future, more valid definition of SRC would better identify concussed players by demonstrating high predictive positive/negative values. Currently, the use of helmet-based systems to study the biomechanics of SRC is limited to few collision sports. New approaches need to be developed to provide objective markers for SRC.

OBJECTIVE: To conduct a systematic review of the literature regarding assessment and treatment modalities in patients with persistent symptoms following sport-related concussion (SRC). DATA SOURCES: We searched Medline, Embase, SPORTSDiscus, PsycINFO, CINAHL, Cochrane library and ProQuest Dissertation & Theses Global electronic databases. STUDY ELIGIBILITY CRITERIA: Studies were included if they were original research, reported on SRC as the primary source of injury, included patients with persistent postconcussive symptoms (>10 days) and investigated the role of assessment or treatment modalities. RESULTS: Of 3225 articles identified in the preliminary search, 25 articles met the inclusion criteria. 11 articles were concerned with assessment and 14 articles with treatment of persistent symptoms following SRC. There were three randomised control trials and one quasi-experimental study. The remainder consisting of cross-sectional studies, historical cohorts and case series. SUMMARY: 'Persistent symptoms' following SRC can be defined as clinical recovery that falls outside expected time frames (ie, >10-14 days in adults and >4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding pathologies. A detailed multimodal clinical assessment is required to identify specific primary and secondary processes, and treatment should target specific pathologies identified. There is preliminary evidence supporting the use of symptom-limited aerobic exercise, targeted physical therapy and a collaborative approach that includes cognitive behavioural therapy. Management of patients with persistent symptoms is challenging and should occur in a multidisciplinary collaborative setting, with healthcare providers with experience in SRC.

Head injuries are considered harmful in children. We analyzed head and neck injuries in organized football in 7- to 12-year-old children. Data for this analysis were obtained from a prospective cohort study over two consecutive football seasons in two European countries, and a randomized intervention trial over one season in four European countries. Football exposure and injuries were documented through an online database. Detailed information regarding injury characteristics and medical follow-up was retrieved from coaches, children and parents by phone. Thirty-nine head injuries and one neck injury (5% of all 791 injuries) were documented during 9933 player-seasons (total football exposure 688 045 hours). The incidence was 0.25 [95%CI 0.15, 0.35] head/neck injuries per 1000 match hours (N = 23 match injuries) and 0.03 [95%CI 0.02, 0.03] per 1000 training hours. Eleven concussions (27.5%), nine head contusions (22.5%), eight lacerations or abrasions (20%), two nose fractures (2.5%), and two dental injuries (2.5%) occurred. The remaining eight injuries were nose bleeding or other minor injuries. Thirty injuries (75%) resulted from contact with another player, and ten injuries were due to collision with an object, falling or a hit by the ball. Whereas 70% of all head injuries (N = 28) were due to frontal impacts, 73% of concussions (N = 8) resulted from an impact to the occiput. The incidence and severity of head injuries in children's football are low. Coaches and parents, however, should be sensitized regarding the potential of concussions, particularly after an impact to the occiput. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

Background Injury incidence has been reported for international athletics championships from 2007 to 2012. However, it is unclear whether male or female athletes differ in risk and/or characteristics of injuries. Objective To compare the incidences and characteristics of injuries that occurred during international athletics championships between female and male athletes. Methods The national medical team and the local organising committee physicians reported all injuries daily on a standardised injury report form during 14 international championships from 2007 to 2014. Relative risks (RR) of injury, 95% CI and magnitude thresholds were calculated. Results The rate of injuries per 1000 registered athletes was significantly higher in male (110.3±6.8) than in female (88.5±6.7) athletes (RR=1.25; 95% CI 1.13 to 1.37, small effect size). Male athletes incurred significantly more injuries in the thigh (RR=1.64; 95% CI 1.32 to 2.05, small), lower leg (RR=1.36; 95% CI 1.05 to 1.75, small) and hip/groin injuries (RR=2.26; 95% CI 1.31 to 3.88, moderate), more muscle strains (RR=1.64; 95% CI 1.33 to 2.04, small), cramps (RR=1.81; 95% CI 1.35 to 2.43, small), and especially more thigh strains (RR=1.66; 95% CI 1.25 to 2.19, small), but fewer stress fractures (RR=0.32; 95% CI 0.12 to 0.81, moderate) than female athletes. A higher injury risk of male than of female athletes was observed in sprints (RR=1.32; 95% CI 1.06 to 1.66, small), middle distance runs (RR=1.48; 95% CI 1.06 to 2.06, small), race walks (RR=2.55; 95% CI 1.27 to 5.10, moderate) and jumps (RR=2.13; 95% CI 1.53 to 2.97, moderate). No sex difference was found for cause and severity of injury. Conclusions Injury risk during international athletics championships differed between female and male athletes for location, type and event groups. Injury prevention strategies should be sex-specific, regarding the differences in injury location and type.

Sport-related concussion (SRC) has received much media coverage over the past 5 years. In the face of misinformation about this injury in the minds of parents, coaches and athletes, it is critical that all involved stakeholders receive scientifically sound and up-to-date information regarding SRC and its potential consequences. One of the most significant developments in SRC over the past two decades has been the establishment of the Concussion In Sport Group (CISG). This group has organised the key consensus meetings in this field and has published assessment tools that have …

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement. This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps. A series of specific clinical questions were developed as part of the consensus process for the Berlin 2016 meeting. Each consensus question was the subject of a specific formal systematic review, which is published concurrently with this summary statement. Readers are directed to these background papers in conjunction with this summary statement as they provide the context for the issues and include the scope of published research, search strategy and citations reviewed for each question. This 2017 consensus statement also summarises each topic and recommendations in the context of all five CISG meetings (that is, 2001, 2004, 2008, 2012 as well as 2016). Approximately 60 000 published articles were screened by the expert panels for the Berlin …

Background Scientific studies on the prevalence of mental health problems in elite athletes are rare, and most have had considerable methodological limitations, such as low response rate and heterogeneous samples. Aims To evaluate the prevalence of depression and anxiety in top-level football players in comparison to the general population, and to analyse potential risk factors. Methods Players of all first league (FL) and of four U-21 football teams in Switzerland were asked to answer a questionnaire on player's characteristics, the Centre of Epidemiologic Studies Depression Scale (CES-D) and the Generalized Anxiety Disorder (GAD-7) scale. Results All 10 women's FL teams, 9 of 10 men's FL teams and 4 male U-21 teams (n=471 football players) took part in the study. The CES-D score indicated a mild to moderate depression in 33 (7.6%) players and a major depression in 13 (3.0%) players. The GAD-7 score indicated an at least moderate anxiety disorder in 6 (1.4%) players. Compared to the general population, the prevalence of depression was similar and the prevalence of anxiety disorders was significantly (χ2=16.7; p