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Context: Little research has examined health-related quality of life in former National Football League (NFL) players. Objective: Examine the association of musculoskeletal injury history and current self-reported physical and mental health in former NFL players. Setting: Cross-sectional questionnaire. Patients or Other Participants: Historical cohort of 2,103 former NFL players that played at least one season between 1940 and 2001. Intervention: Players were grouped by self-reported professional career musculoskeletal injury history and whether injuries affected current health: (1) no musculoskeletal injury history; (2) musculoskeletal injury history, currently affected by injuries; and (3) musculoskeletal injury history, not currently affected by injuries. Main Outcome Measure: The Short Form 36 Measurement Model for Functional Assessment of Health and Well-Being (SF-36) yielded physical and mental health composite scores (PCS and MCS, respectively); higher scores indicated better health. Multivariable linear regression computed mean differences (MD) among injury groups. Covariates included demographics, playing history characteristics, surgical intervention for musculoskeletal injuries, and whether injury resulted in premature end to career. MD with 95% CI excluding 0.00 were deemed significant. Results: Overall, 90.3% reported at least one musculoskeletal injury during their professional football careers, of which 74.8% reported being affected by their injuries at time of survey completion. Adjusting for covariates, mean PCS in the "injury and affected" group was lower than the "no injury" (MD = −3.2; 95% CI: −4.8, −1.7) and "injury and not affected" groups (MD = −4.3; 95% CI: −5.4, −3.3); mean MCS did not differ. Conclusion: Many players reported musculoskeletal injuries, highlighting the need for developing and evaluating injury management interventions. [ABSTRACT FROM AUTHOR]

Context: Concussion management is moving from passive rest strategies to active interventions, including aerobic exercise therapy. Little information is available regarding the feasibility and adherence of these programs. Objectives: To determine whether an aerobic exercise training program intended for rehabilitation in people with concussion is feasible. Healthy, nonconcussed subjects were studied in this phase 1 trial. Design: Phase 1 parallel-group, randomized controlled trial in a sample of healthy (nonconcussed), recreationally active university students. Setting: Laboratory. Patients: 40 healthy university students. Methods: Participants were equally randomized to acute concussion therapy intervention (ACTIVE) training or nontraining groups. All participants completed maximal cardiopulmonary exercise tests on a stationary cycle ergometer at 2 lest sessions approximately 14 days apart. During this 2-week study period, ACTIVE training participants completed six 30-minute cycling sessions, progressing from 60% to 80% of the participant's individualized maximal oxygen consumption. A subset of participants (NACTIVE=12, Nnontraining = 11) wore physical activity monitors throughout the 2-week study period. Main Outcomes Measures: Study protocol and randomization effectiveness, exercise safety and adherence, and progressive intensity of the ACTIVE training procedures. Results: No adverse events occurred during any exercise sessions. Twelve ACTIVE training participants (60%) completed all training sessions, and every participant completed at least 4 sessions. Heart rate increased throughout the training period (P < .001), but symptom changes and training adherence remained stable despite the progressively increasing workload. ACTIVE training participants completed approximately 30 additional minutes of physical activity on training sessions days, although that was not statistically significant (P = .20). Conclusions: University-aged students were adherent to the ACTIVE training protocol. Future research should investigate the safety and feasibility of aerobic training programs in acutely concussed individuals to determine their appropriateness as a clinical rehabilitation strategy. [ABSTRACT FROM AUTHOR]

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

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

Background: Potential links between a history of sport-related concussions and later-life neurobiological and psychological brain health have been studied in former collision-sport athletes. However, empirical studies of how former athletes perceive the future of their brain health as a result of these injuries are missing. Objectives: We aimed to (1) identify the extent to which former National Football League players currently have concerns about their long-term psychological and cognitive functioning as a result of concussions sustained while playing football; (2) examine whether current concerns are different than concerns they had while playing football; (3) examine the relationship between current brain health concerns and self-reported concussion history (SR-CHx); and (4) explore other important factors associated with these concerns. Methods: In this cross-sectional study, former National Football League players with a SR-CHx of one or more concussions (n = 1514; aged mean [standard deviation] = 52.3 [15.7] years) completed a general health questionnaire. Participants reported their lifetime concussion history, as well as both their current concerns and concerns while playing football (i.e., retrospective concerns) regarding the long-term effects of concussions on their memory, thinking skills, and risk of developing chronic traumatic encephalopathy. Current and retrospective concerns were self-reported on a five-point Likert scale. Four concussion history categories were created based on SR-CHx: 1–2 (n = 309); 3–5 (n = 413); 6–9 (n = 356); and 10 + (n = 436) lifetime concussions. Proportions of participants reporting each level of current and retrospective concerns were examined to identify whether concerns presently exist in these former players, and whether their current concerns are different than retrospective concerns. Next, we explored associations between current concerns and SR-CHx. Results: More than one-third of participants reported being currently "extremely concerned" about memory problems (36.9%), thinking skills (37.8%), and developing chronic traumatic encephalopathy (39.5%). In contrast, when asked about concerns while playing, most reported being "not at all concerned" regarding memory = 61.2%, thinking skills = 56.1%, and developing chronic traumatic encephalopathy = 71.2%. Of those who retrospectively endorsed being "not at all" or "slightly" concerned regarding memory (n = 1159/1514), thinking skills (n = 1080/1514), and developing chronic traumatic encephalopathy (n = 1219/1514), approximately half reported being currently "moderately" or "extremely" concerned about those same issues (n = 586/1159; n = 534/1080; n = 619/1219, respectively). Current concerns regarding memory (χ216 = 316.61; p < 0.001; V = 0.264), thinking skills (χ216 = 333.17; p < 0.001; V = 0.271), and developing chronic traumatic encephalopathy (χ216 = 280.85; p < 0.001; V = 0.249) were significantly related to SR-CHx, with more concussions being associated with greater current concerns. Conclusions: Former National Football League players reported significant concerns regarding the potential effects of their prior concussions on long-term brain health, and these concerns are more prevalent now than when they were playing football. Cognitive and mental health concerns are readily identifiable targets for clinical intervention. Clinicians working with former players may wish to explore the extent to which individual players experience these concerns, the nature and depth of these concerns, and the impact of these concerns on the player's functioning and well-being. [ABSTRACT FROM AUTHOR]

Primary care providers (PCPs) are evaluating increasing numbers of concussions, but it is unknown how often they are documenting concussion-specific history and physical examination findings vital for this process. This study reviews clinical documentation to determine how PCPs are evaluating concussed patients. PCPs often did not document important aspects of concussion history, including dizziness (48%), nausea (48%), vision changes (54%), cognitive complaints (54%), emotional changes (83%), sleep difficulties (84%), and neck pain (87%). Additionally, they often did not document important aspects of a concussion physical examination, including detailed neurologic examination (73%), clinical cognitive assessment (87%), balance testing (59%), and neck evaluation (54%). Omitting these parts of the history and physical examination could result in a premature return to play. [ABSTRACT FROM AUTHOR]

Objectives: To compare pre-season to post-season changes on a battery of clinical neurological outcome measures between non-contact, contact, and collision sport athletes over multiple seasons of play. Methods: 244 high school and collegiate athletes participating in multiple non-contact, contact, and collision sports completed standardized annual pre-season and post-season assessments over 1–4 years. Pre/post-season changes in 10 outcome measures assessing concussion symptoms, neurocognitive performance, and balance were compared between the groups using linear mixed models. Results: Small, but statistically significant overall pre/post-season change differences were present between the groups for Axon computerized neurocognitive test processing speed, attention, and working memory speed scores (Axon-PS, Axon-Att, Axon-WMS), as well as Balance Error Scoring System (BESS) total score. Small seasonal declines not exceeding reliable-change thresholds were observed in the collision sport group relative to the contact and non-contact groups for Axon-PS and Axon-Att scores. The collision and contact sport groups demonstrated less pre-/post-season improvement than the non-contact sport group for Axon-WMA and BESS, with less BESS improvement also observed in the collision sport group relative to the contact sport group. Overall, longitudinal performance on all 10 outcome measures remained stable in all 3 groups over 4 years. Conclusion: Our findings do not necessarily support the notion that participation in sports associated with exposure to repetitive head impacts has clinically meaningful cumulative effects over the course of a season, nor over four consecutive seasons in high school and collegiate athletes. [ABSTRACT FROM AUTHOR]

Context: Recent evidence has revealed deficiencies in the ability to divide attention after concussion. Objective: To examine the effects of a single vs a dual task on cognition and balance in healthy subjects and to examine reliability of 2dual-task paradigms while examining the overall feasibility of the tasks. Design: Pretest-posttest experimental design. Setting: Sports medicine research laboratory. Patients: 30 healthy, recreationally active college students. Intervention: Subjects performed balance and cognitive tasks under the single- and dual-task conditions during 2 test sessions 14 d apart. Main Outcome Measures: The procedural reaction-time (PRT) test of the Automated Neuropsychological Assessment Metrics (eyes-closed tasks) and an adapted Procedural Auditory Task (PAT; eyes-open tasks) were used to assess cognition. The NeuroCom Sensory Organization Test (SOT) and the Balance Error Scoring System (BESS) were used to assess balance performance. Five 2-way, within-subject ANOVAs and a paired-samples t test were used to analyze the data. ICCs were used to assess reliability across 2 test sessions. Results: On the SOT, performance significantly improved between test sessions (F1,29 = 35.695, P < .001) and from the single to the dual task (F1,29 = 9.604, P = .004). On the PRT, performance significantly improved between test sessions (F1,29 = 57.252, P < .001) and from the single to the dual task (F1,29 = 7.673, P = .010). No differences were seen on the BESS and the PAT. Reliability across test sessions ranged from moderate to poor for outcome measure. Conclusions: The BESS appears to be a more reliable and functional tool in dual-task conditions as a result of its increased reliability and clinical applicability. In addition, the BESS is more readily available to clinicians than the SOT. [ABSTRACT FROM AUTHOR]

Context: Ankle injuries are common at all levels of American football, and retired National Football League (NFL) players have a high prevalence of osteoarthritis (OA), but little is known about how ankle injuries influence OA prevalence and daily activities in this population or how surgical interventions for such injuries alter the risk of OA. Objective: To examine (1) the association of ankle-injury history with OA prevalence, (2) the association of surgical intervention after ankle injury with OA prevalence, and (3) the relationships among ankle injuries, reported OA, and daily activities in retired NFL players. Design: Case-control study. Setting: Survey. Patients or Other Participants: Data from the Retired NFL Players General Health Survey. Main Outcome Measure(s): We created a 7-category main exposure variable that differentiated respondents by footballrelated ankle injury and surgical intervention. Multivariable binomial regression models were used to estimate prevalence ratios and 95% confidence intervals. Among those reporting OA, we examined the distribution of responses regarding whether OA affected daily activities. Results: Among the 2446 respondents, 920 participants experienced OA in any joint during their lifetime. Compared with those reporting no ankle injuries, the prevalence of OA was higher among those with a history of ankle injury. Also, the prevalence of OA was higher among those who had undergone surgery versus those who had not. The number of retired NFL players who reported that OA often affected their daily activities increased with the number of ankle injuries. Conclusions: Among former NFL players, a history of ankle injury increased the prevalence of OA. More ankle injuries increased the probability that OA negatively affected daily activities. Future prospective research is needed to better determine the influence of surgical intervention at the ankle or foot on OA. [ABSTRACT FROM AUTHOR]

Background: Osteoarthritis is a substantial cause of disability. Joint replacement prevalence relates to the burden of severe osteoarthritis, and identifying risk factors for end-stage disease may indicate intervention opportunities. American football has high youth and elite participation, and determining risk factors for severe osteoarthritis may support future morbidity prevention. Purpose: To (1) determine the prevalence of hip and knee replacement in retired National Football League (NFL) athletes, (2) examine risk factors for replacement, and (3) identify the association between knee injuries and knee replacement. Study Design: Case-control study; Level of evidence, 3. Methods: Retired NFL athletes who participated in a general health survey were included. This historical cohort included those playing between 1929 and 2001. The association between self-reported playing or injury history, and replacement after retirement, was assessed with prevalence ratios (PRs). Models were adjusted for potential confounders of age and weight. Results: Data for 2432 retired male NFL players (69.3% response rate) who had participated in football for a mean 15.2 years were included, in which 277 players reported replacement after retirement (11.4%). More participants reported knee replacement (7.7%) than hip replacement (4.6%). The majority of participants reported previous severe knee injury (53%), and the most prevalent was meniscal tear (32.2%). In multivariable models, age (10-year increase, PR, 2.23; 95% CI, 1.99-2.51), current weight (PR, 1.10; 95% CI, 1.06-1.14), and reporting 1 (PR, 1.78; 95% CI, 1.14-2.77), 2 (PR, 1.91; 95% CI, 1.16-3.15), or ≥3 knee injuries (PR, 3.44; 95% CI, 2.33-5.09) were associated with knee replacement. Age (10-year increase, PR, 1.86; 95% CI, 1.59-2.18), linemen (PR, 1.62; 95% CI, 1.03-2.55), and reporting 1 (PR, 1.72; 95% CI, 1.05-2.80), 2 (PR, 2.77 95% CI, 1.58-4.84), or ≥3 (PR, 2.44; 95% CI, 1.52-3.91) hip injuries were associated with hip replacement. Each reported knee injury type was cross-sectionally associated with replacement after retirement (P <.05). Conclusion: Knee replacement was more prevalent than hip replacement. Risk factors differed between the hip and the knee, with age and severe joint injury associated with hip and knee replacement, weight with knee replacement, and playing position associated with hip replacement. Joint injury and weight management may be prevention opportunities to reduce morbidity and end-stage osteoarthritis in this population. [ABSTRACT FROM AUTHOR]

Context: Aerobic exercise interventions are increasingly being prescribed for concussion rehabilitation, but whether aerobic training protocols influence clinical concussion diagnosis and management assessments is unknown. Objective: To investigate the effects of a brief aerobic exercise intervention on clinical concussion outcomes in healthy, active participants. Design: Randomized controlled clinical trial. Setting: Laboratory. Patients or Other Participants: Healthy (uninjured) participants (n = 40) who exercised ≥3 times/week. Intervention(s): Participants were randomized into the acute concussion therapy intervention (ACTIVE) training or nontraining group. All participants completed symptom, cognitive, balance, and vision assessments during 2 test sessions approximately 14 days apart. Participants randomized to ACTIVE training completed six 30-minute exercise sessions that progressed from 60% to 80% of individualized maximal oxygen consumption ( Vo2max) across test sessions, while the nontraining group received no intervention. Main Outcome Measure(s): The CNS Vital Signs standardized scores, Vestibular/Ocular Motor Screening near-point convergence distance (cm), and Graded Symptom Checklist, Balance Error Scoring System, and Standardized Assessment of Concussion total scores. Results: An interaction effect was found for total symptom score (P = .01); the intervention group had improved symptom scores between sessions (session 1: 5.1 ± 5.8; session 2: 1.9 ± 3.6). Cognitive flexibility, executive functioning, reasoning, and total symptom score outcomes were better but composite memory, verbal memory, and near-point convergence distance scores were worse at the second session (all P values, .05). However, few changes exceeded the 80% reliable change indices calculated for this study, and effect sizes were generally small to negligible. Conclusions: A brief aerobic training protocol had few meaningful effects on clinical concussion assessment in healthy participants, suggesting that current concussion-diagnostic and -assessment tools remain clinically stable in response to aerobic exercise training. This provides normative data for future researchers, who should further evaluate the effect of ACTIVE training on clinical outcomes among concussed populations. [ABSTRACT FROM AUTHOR]

Context: Currently, significant attention is focused on improving care for patients with concussions through legislative mandates that include educational interventions. Few researchers have examined young athletes' concussion knowledge and the factors that may influence their knowledge. Objective: To use the socioecological model to examine demographic, parental, and personal factors associated with youth athletes' knowledge of concussion. Our ultimate goal is to inform the planning and implementation of youth sport concussion-related interventions. Design: Cross-sectional survey. Setting: Gymnasium and classroom. Patients or Other Participants: North Carolina and Arizona youth athletes (n = 225; age = 8 to 15 years) active in football, boys' or girls' soccer, boys' or girls' ice hockey, or boys' or girls' lacrosse in 2012-2013. Main Outcome Measure(s): Participants completed a validated, self-administered survey. The intention and belief measures were guided by the theory of planned behavior. Perceptions of concussion and intention to seek care were examined using descriptive statistics. Athletes' concussion knowledge was modeled using linear regressions and generalized estimating equations, with child demographic and personal factors and parental knowledge and attitudes about concussion as predictors. Results: Geography, sport, parental attitudes toward concussion, and athlete age were associated with athlete knowledge in the univariable analyses (P < .10). In the multivariable model, geographic location (North Carolina versus Arizona, mean difference [MD] = 2.2, 95% confidence interval [CI] = 1.1, 3.2), sport (girls' soccer versus girls' lacrosse, MD = 2.2, 95% CI = 0.7, 3.6), more favorable parental attitudes toward concussion (MD = 1.2 for a 2-standard deviation shift; 95% CI = 0.3, 2.1), and older age (>12 years, MD = 1.6; 95% CI = 0.5, 2.6) were associated with better knowledge about concussion. Conclusions: Geographic location, sport, parental attitudes about concussion, and athlete's age influenced athletes' concussion-related perceptions, indicating the need to address multiple levels of the socioecological model when targeting youth sport interventions. Parental interventions that translate to an improved culture of youth sport by improving youth athletes' perceptions and experiences are key areas for future work. [ABSTRACT FROM AUTHOR]

Background: Timely removal from activity after concussion symptoms remains problematic despite heightened awareness. Previous studies indicated potential adverse effects of continuing to participate in physical activity immediately after sustaining a concussion. Hypothesis/Purpose: The purpose was to determine the effect of timing of removal from play after concussion on clinical outcomes. It was hypothesized that immediate removal from activity after sport-related concussion (SRC) would be associated with less time missed from sport, a shorter symptomatic period, and better outcomes on acute clinical measures. Study Design: Cohort study; Level of evidence, 3. Methods: Data were reported from the National Collegiate Athletic Association and Department of Defense Grand Alliance: Concussion Awareness, Research, and Education (CARE) Consortium. Participants with 506 diagnosed SRCs from 18 sports and 25 institutions and military service academies were analyzed and classified as either immediate removal from activity (I-RFA) or delayed removal from activity (D-RFA). Outcomes of interest included time missed from sport attributed to their SRC, symptom duration, and clinical assessment scores. Results: There were 322 participants (63.6%) characterized as D-RFA. I-RFA status was associated with significantly less time missed from sport (R² change = .022-.024, P< .001 to P = .001) and shorter symptom duration (R² change = .044-.046, P< .001 [all imputations]) while controlling for other SRC recovery modifiers. These athletes missed approximately 3 fewer days from sport participation. I-RFA athletes had significantly less severe acute SRC symptoms and were at lower risk of recovery taking ≥14 days (relative risk = .614, P< .001, small-medium effect size) and ≥21 days (relative risk = .534, P = .010, small effect size). Conclusion: I-RFA is a protective factor associated with less severe acute symptoms and shorter recovery after SRC. Conveying this message to athletes, coaches, and others involved in the care of athletes may promote timely injury reporting. [ABSTRACT FROM AUTHOR]

Context: Dynamic balance during functional movement may provide important clinical information after concussion. The Sport Concussion Assessment Tool, version 3 (SCAT3), includes a timed tandem-gait test (heel-to-toe walking) administered with a pass-fail scoring system. Minimal evidence supports inclusion of the tandem-gait test in the SCAT3, especially in high school athletes. Objective: To determine (1) the percentage of healthy high school athletes who passed (best trial≤14 seconds) the tandem-gait test at baseline, (2) the association between sex and test performance (pass versus fail), and (3) the relationships among sex, age, height, and tandem-gait test score. Design: Cross-sectional study. Setting: High school sports medicine center. Patients or Other Participants: Two hundred athletes from 4 high schools (age ± 15.8 6 1.2 years, height ± 170.3 6 10.3 cm, weight ± 64.8 6 14.5 kg). Main Outcome Measure(s): Healthy participants completed 4 trials of the SCAT3 tandem-gait test and a demographic questionnaire. Outcome measures were passing rate at baseline on the tandem-gait test and tandem-gait test score (time). Results: Overall, 24.5% (49/200) of participants passed the test. Sex and performance were associated (v2 ± 15.15, P , .001), with a passing rate of 38.6% (32/83) for males and 14.5% (17/117) for females. The regression model including predictor variables of sex and height, with the outcome variable of tandem-gait test score and time, was significant (R2±0.20, P , .01). Conclusions: Our findings suggest that the tandem-gait test had a high false-positive rate in high school athletes. Given that more than 75% of healthy participants failed the tandem-gait test, the 14-second cutoff appears to have limited clinical utility in the adolescent population. Functional movement deficits after concussion need to be accounted for, but the 14-second cutoff for the SCAT3 tandem-gait test does not appear to be an ideal way to assess these deficits in high school athletes [ABSTRACT FROM AUTHOR]

Context: Surveillance data regarding injuries caused by ball contact in collegiate athletes have not been well examined and are mostly limited to discussions of concussions and catastrophic injuries. Objective: To describe the epidemiology of ball-contact injuries in 11 National Collegiate Athletic Association (NCAA) sports during the 2009-2010 through 2014-2015 academic years. Design: Descriptive epidemiology study. Setting: Convenience sample of NCAA programs in 11 sports (men's football, women's field hockey, women's volleyball, men's baseball, women's softball, men's and women's basketball, men's and women's lacrosse, and men's and women's soccer) during the 2009-2010 through 2014-2015 academic years. Patients or Other Participants: Collegiate student-athletes participating in 11 sports. Main Outcome Measure(s): Ball-contact-injury rates, proportions, rate ratios, and proportion ratios with 95% confidence intervals were based on data from the NCAA Injury Surveillance Program during the 2009-2010 through 2014-2015 academic years. Results: During the 2009-2010 through 2014-2015 academic years, 1123 ball-contact injuries were reported, for an overall rate of 3.54/10 000 AEs. The sports with the highest rates were women's softball (8.82/10 000 AEs), women's field hockey (7.71/10 000 AEs), and men's baseball (7.20/10 000 AEs). Most ball-contact injuries were to the hand/wrist (32.7%) and head/face (27.0%) and were diagnosed as contusions (30.5%), sprains (23.1%), and concussions (16.1%). Among sex-comparable sports (ie, baseball/softball, basketball, and soccer), women had a larger proportion of ball-contact injuries diagnosed as concussions than men (injury proportion ratio = 2.33; 95% confidence interval = 1.63, 3.33). More than half (51.0%) of ball-contact injuries were non-time loss (ie, participation-restriction time, 24 hours), and 6.6% were severe (ie, participation-restriction time ≥21 days). The most common severe ball-contact injuries were concussions (n = 18) and finger fractures (n =10). Conclusion: Ball-contact-injury rates were the highest in women's softball, women's field hockey, and men's baseball. Although more than half were non-time-loss injuries, severe injuries such as concussions and fractures were reported. [ABSTRACT FROM AUTHOR]

Background: Despite a high reported incidence rate of concussion, little is known about the on-field characteristics of injurious head impacts in National Football League (NFL) games. Purpose: To characterize on-field features (location, player position, and time during game) and biomechanical features (anticipation status, closing distance, impact location and type) associated with concussions in NFL games over a 4-season period (2010-2011 to 2013-2014). Study Design: Descriptive epidemiology study. Methods: We analyzed video of a subset of reported, in-game concussions for the 2010-2011 to 2013-2014 seasons. These videos represented a sample of injuries that were diagnosed and reported on the same day and that could be clearly associated with an in-game collision as captured on video. We determined anticipation status, closing distance, impact location on the injured player’s helmet, and impact type (helmet-to-helmet, helmet-to-body, or helmet-to-ground). Associations between these variables were analyzed by use of descriptive statistics and tests of association. Results: A total of 871 diagnosed concussions were reported as occurring during NFL preseason, regular season, and postseason games for the 2010-2011, 2011-2012, 2012-2013, and 2013-2014 seasons. A total of 1324 games were played during this period, giving a concussion incidence rate of 0.658 per game (95% CI, 0.61-0.70). From the video-reviewed subset (n = 429; 49.3%), the majority of injurious impacts occurred with good anticipation (57.3%) and <10 yards of closing distance (59.0%). An association was found between anticipation status and play type ( χ32 = 27.398, P < .001), largely because injuries occurring on pass plays were more likely to be poorly anticipated than injuries during run plays (43.0% vs 21.4%; χ12 = 14.78, P < .001). Kick returns had the greatest proportion of well-anticipated impacts (78%) and the greatest proportion of impacts with ≥10 yards of closing distance (80%). The type of impact was approximately equally divided between helmet-to-helmet, helmet-to-body, and helmet-to-ground types. The impact location was broadly distributed over the helmet of the injured player. Conclusion: In-game concussions in the NFL occurred through a diverse variety of mechanisms, surprisingly tended to be well-anticipated, and, also surprisingly, occurred with <10 yards of closing distance. The impacts causing concussion were broadly distributed over the helmet. More concussions occurred during the second half of game play, but we do not have evidence to explain this finding. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe determinants of head impact magnitudes between various play aspects in high school football. METHODS: Thirty-two high school American football players wore Head Impact Telemetry System instrumented helmets to capture head impact magnitude (linear acceleration, rotational acceleration, and Head Impact Technology severity profile [HITsp]). We captured and analyzed video from 13 games (n = 3888 viewable head impacts) to determine the following play aspects: quarter, impact cause, play type, closing distance, double head impact, player's stance, player's action, direction of gaze, athletic readiness, level of anticipation, player stationary, ball possession, receiving ball, and snapping ball. We conducted random intercepts general linear mixed models to assess the differences in head impact magnitude between play aspects (α = 0.05). RESULTS: The following aspects resulted in greater head impact magnitude: impacts during the second quarter (HITsp: P= .03); contact with another player (linear, rotational, HITsp: P < .001); initial head impact when the head is struck twice (linear, rotational, HITsp: P < .001); longer closing distances, especially when combined with a 3-point stance or when being struck in the head (linear: P = .03); the 2-point stance (linear, rotational, HITsp: P < .001); and offensive linemen not snapping the ball compared with those snapping the ball (rotational: P = .02, HITsp: P = .02). CONCLUSIONS: Preventing head impacts caused by contact with another player may reduce head impact magnitude in high school football. Rule or coaching changes that reduce collisions after long closing distances, especially when combined with the 3-point stance or when a player is being struck in the head, should be considered. [ABSTRACT FROM AUTHOR]

Objective: To test a helmetless-tackling behavioral intervention for reducing head impacts in National Collegiate Athletic Association Division I football players. Design: Randomized controlled clinical trial. Setting: Football field. Patients or Other Participants: Fifty collegiate football players (intervention = 25, control = 25). Intervention(s): The intervention group participated in a 5- minute tackling drill without their helmets and shoulder pads twice per week in the preseason and once per week through the season. During this time, the control group performed noncontact football skills. Main Outcome Measure(s): Frequency of head impacts was recorded by an impact sensor for each athlete-exposure (AE). Data were tested with a 2 x 3 (group and time) repeated-measures analysis of variance. Significant interactions and main effects (P < .05) were followed with t tests. Results: Head impacts/AE decreased for the intervention group compared with the control group by the end of the season (9.99 ± 6.10 versus 13.84 ± 7.27, respectively). The intervention group had 30% fewer impacts/AE than the control group by season's end (9.99 ± 6.10 versus 14.32 ± 8.45, respectively). Conclusion: A helmetless-tackling training intervention reduced head impacts in collegiate football players within 1 season. [ABSTRACT FROM AUTHOR]

Objective: To compare the odds of sustaining moderate and severe head impacts, rather than mild, between high school football players with high and low visual performance. Design: Prospective quasi-experimental. Setting: Clinical Research Center/On-field. Participants: Thirty-seven high school varsity football players. Interventions: Athletes completed the Nike SPARQ Sensory Station visual assessment before the season. Head impact bio-mechanics were captured at all practices and games using the Head Impact Telemetry System. Main Outcome Measures: Each player was classified as either a high or low performer using a median split for each of the following visual performance measures: visual clarity, contrast sensitivity, depth perception, near-far quickness, target capture, perception span, eye-hand coordination, go/no go, and reaction time. We computed the odds of sustaining moderate and severe head impacts against the reference odds of sustaining mild head impacts across groups of high and low performers for each of the visual performance measures. Results: Players with better near-far quickness had increased odds of sustaining moderate [odds ratios (ORs), 1.27; 95% confidence intervals (CIs), 1.04-1.56] and severe head impacts (OR, 1.45; 95% CI, 1.05-2.01) as measured by Head Impact Technology severity profile. High and low performers were at equal odds on all other measures. Conclusions: Better visual performance did not reduce the odds of sustaining higher magnitude head impacts. Visual performance may play less of a role than expected for protecting against higher magnitude head impacts among high school football players. Further research is needed to determine whether visual performance influences concussion risk. Clinical Relevance: Based on our results, we do not recommend using visual training programs at the high school level for the purpose of reducing the odds of sustaining higher magnitude head impacts. [ABSTRACT FROM AUTHOR]

Background: An athlete is thought to reduce head acceleration after impact by contracting the cervical musculature, which increases the effective mass of the head. Purpose: To compare the odds of sustaining higher magnitude in-season head impacts between athletes with higher and lower preseason performance on cervical muscle characteristics. Study Design: Cohort study; Level of evidence, 2. Methods: Forty-nine high school and collegiate American football players completed a preseason cervical testing protocol that included measures of cervical isometric strength, muscle size, and response to cervical perturbation. Head impact biomechanics were captured for each player using the Head Impact Telemetry System. A median split was used to categorize players as either high or low performers for each of the following outcome measures: isometric strength (peak torque, rate of torque development), muscle size (cross-sectional area), and response to cervical perturbation (stiffness, angular displacement, muscle onset latency). The odds of sustaining moderate and severe head impacts were computed against the reference odds of sustaining mild head impacts across cervical characteristic categorizations. Results: Linemen with stronger lateral flexors and composite cervical strength had about 1.75 times’ increased odds of sustaining moderate linear head impacts rather than mild impacts compared with weaker linemen. Players who developed extensor torque more quickly had 2 times the increased odds of sustaining severe linear head impacts (odds ratio [OR], 2.10; 95% CI, 1.08- 4.05) rather than mild head impacts. However, players with greater cervical stiffness had reduced odds of sustaining both moderate (OR, 0.77; 95% CI, 0.61-0.96) and severe (OR, 0.64; 95% CI, 0.46-0.89) head impacts compared with players with less cervical stiffness. Conclusion: The study findings showed that greater cervical stiffness and less angular displacement after perturbation reduced the odds of sustaining higher magnitude head impacts; however, the findings did not show that players with stronger and larger neck muscles mitigate head impact severity. [ABSTRACT FROM AUTHOR]

Objective: To assess the influence of psychosocial determinants from the Theory of Reasoned Action and Planned Behaviour (TRA/TPB) on concussion-reporting intentions. Methods: The present study employed the TRA/TPB to develop a cross-sectional survey to examine contributors to intention to report concussion symptoms. High school athletes ( n = 167, age = 15.7 ± 1.4) completed this survey. The TRA/TPB constructs of attitude (perceptions about concussion reporting), subjective norm (perception of important social referents beliefs about concussion reporting), perceived behavioural control (perceived control over concussion reporting) and intention to report concussion symptoms served as the independent variables. Linear regression models were used to predict intention to report concussion symptoms. Binomial regression models were used to predict concussion-reporting behaviours from intention. Results: Direct attitude, subjective norm and direct perceived behavioural control were all associated with intention to report concussion. Intention was associated with decreased prevalence of participating in practices and games while symptomatic from concussion. Conclusions: Favourable attitudes toward reporting and social referents' beliefs have the greatest impact on intention to report concussion symptoms. Reporting intention may not always be an indicator of concussion-reporting behaviours. Concussion education initiatives should focus on improving attitudes and beliefs among athletes, coaches and parents to promote better care-seeking behaviours among young athletes. [ABSTRACT FROM AUTHOR]

The article reports a study which evaluated the effects of dehydration on the outcome of clinical concussion measures in National Collegiate Athletic Association Division I collegiate wrestlers. The results revealed that weight-cutting tactics of wrestlers may interfere with the concussion diagnosis; therefore, wrestlers should be tested in a fully hydrated (euhydrated) state. These findings suggest that after injury, athletes should be rehydrated and then evaluated for concussion.

Context: Neurocognitive testing is a recommended component in a concussion assessment. Clinicians should be aware of age and practice effects on these measures to ensure appropriate understanding of results. Objective: To assess age and practice effects on computerized and paper-and-pencil neurocognitive testing batteries in collegiate and high school athletes. Design: Cohort study. Setting: Classroom and laboratory. Patients or Other Participants: Participants consisted of 20 collegiate student-athletes (age = 20.00 ± 0.79 years) and 20 high school student-athletes (age = 16.00 ± 0.86 years). Main Outcome Measure(s): Hopkins Verbal Learning Test scores, Brief Visual-Spatial Memory Test scores, Trail Making Test B total time, Symbol Digit Modalities Test score, Stroop Test total score, and 5 composite scores from the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) served as outcome measures. Mixed-model analyses of variance were used to examine each measure. Results: Collegiate student-athletes performed better than high school student-athletes on ImPACT processing speed composite score (F1,38 = 5.03, P = .031) at all time points. No other age effects were observed. The Trail Making Test B total time (F2,66 = 73.432, P < .001), Stroop Test total score (F2,76 = 96.85, P = < .001) and ImPACT processing speed composite score (F2,76 = 5.81, P = .005) improved in test sessions 2 and 3 compared with test session 1. Intraclass correlation coefficient calculations demonstrated values ranging from 0.12 to 0.72. Conclusions: An athlete's neurocognitive performance may vary across sessions. It is important for clinicians to know the reliability and precision of these tests in order to properly interpret test scores. [ABSTRACT FROM AUTHOR]

The article presents information on a study to evaluate the effect of cervical strength on head impact biomechanics. The study evaluates the strength of cervical muscles using methods consistent. The study found that players with greater static neck strength experience lower resultant head acceleration was not supported.

INTRODUCTION: Limited access to sophisticated technology and the unreliability of simple tools prevent accurate and reliable human standing balance assessments outside research laboratory settings. The goal of this study was to develop and validate a simple objective balance assessment tool that provides an accurate, reliable, and affordable alternative to currently available laboratory and clinical methods. METHODS: Thirty healthy subjects were filmed performing the Balance Error Scoring System (BESS) while wearing inertial measurement units (IMU) measuring linear accelerations and angular velocities from seven locations of the body: forehead, sternum, waist, right and left wrist, and right and left shin. Each video was scored by four experienced BESS raters, whose mean scores were used to develop an algorithm computing objective BESS (oBESS) scores solely from IMU data. Interrater reliability and accuracy of oBESS scores were assessed using intraclass correlations (ICC). RESULTS: Raters displayed low variability in scoring (ICC3,1 = 0.91). The oBESS was able to produce scores with accurate fit to raters (ICC3,1 = 0.92) and predicted individual BESS scores (ICC3,1 = 0.90) using data from one IMU placed at the forehead. oBESS was unable to produce accurate scores (ICC3,1 = 0.68) when using IMU data from the subset of conditions (firm surface only) used in popular concussion identification protocols. CONCLUSION: The oBESS can reliably predict total BESS scores in healthy subjects. Pending further validation, oBESS could represent a valid tool to assess balance by offering an objective and reliable alternative to the current scoring methods of the BESS. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little research has examined concussion outcomes in terms of impact location (ie, the area on the head in which the impact occurred). This study describes the epidemiology of concussions resulting from player-to-player collision in high school football by impact location. METHODS: National High School Sports-Related Injury Surveillance Study data (2008/2009-2012/2013) were analyzed to calculate rates and describe circumstances of football concussion (eg, symptomology, symptom resolution time, return to play) resulting from player-to-player collisions by impact location (ie, front-, back-, side-, and top-of-the-head). RESULTS: Most concussions resulting from player-to-player collisions occurred from front-of-the-head (44.7%) and side-of-the-head (22.3%) impacts. Number of symptoms reported, prevalence of reported symptoms, symptom resolution time, and length of time to return to play were not associated with impact location. However, a larger proportion of football players sustaining concussions from top-of-the-head impacts experienced loss of consciousness (8.0%) than those sustaining concussions from impacts to other areas of the head (3.5%) (injury proportion ratio 2.3; 95% confidence interval 1.2-4.2; P = .008). Players had their head down at the time of impact in a higher proportion of concussions caused by top-of-the-head impacts (86.4%) than concussions from impacts to other areas of the head (24.0%) (injury proportion ratio 3.6; 95% confidence interval 3.2--4.0; P < .001). CONCLUSIONS: Among high school football players who sustained concussions due to player-to-player collisions, concussion outcomes were generally independent of impact location. Recommended strategies fo r reducing the proportion of top-of-the-head impacts include improved education regarding tackling with proper “head-up” technique. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to predict baseline neurocognitive and postural control performance using a measure of motivation, high school grade point average (hsGPA), and Scholastic Aptitude Test (SAT) score. Design: Cross-sectional. Setting: Clinical research center. Participants: Eighty-eight National Collegiate Athletic Association Division I incoming student-athletes (freshman and transfers). Interventions: Participants completed baseline clinical concussion measures, including a neurocognitive test battery (CNS Vital Signs), a balance assessment [Sensory Organization Test (SOT)], and motivation testing (Rey Dot Counting). Participants granted permission to access hsGPA and SAT total score. Main Outcome Measures: Standard scores for each CNS Vital Signs domain and SOT composite score. Results: Baseline motivation, hsGPA, and SAT explained a small percentage of the variance of complex attention (11%), processing speed (12%), and composite SOT score (20%). Conclusions: Motivation, hsGPA, and total SAT score do not explain a significant amount of the variance in neurocognitive and postural control measures but may still be valuable to consider when interpreting neurocognitive and postural control measures. [ABSTRACT FROM AUTHOR]

Objective: Proper concussion assessment is imperative for properly caring for athletes who sustain traumatic brain injuries. Decreased sleep quality and sleep quantity affect cognition and may threaten the validity of clinical measures often used as a part of the concussion assessment. The purpose of this study was to determine if sleep quality or sleep quantity affects performance on clinical measures of concussion. Design: Prospective cohort design. Setting: Clinical research center. Participants: One hundred fifty-five college student-athletes (57 females, 98 males; age = 18.8 ± 0.8 years; mass = 78.4 ± 19.6 kg; height = 177.4 ± 12.3 cm). Interventions: We performed preseason baseline testing by using a well-accepted and multifaceted protocol inclusive of neurocognition, balance performance, and symptom reporting. Information related to sleep quality and sleep quantity was also collected during preseason baseline testing. Main Outcome Measures: The CNS Vital Signs battery (computerized neurocognitive test), Sensory Organization Test (computerized dynamic posturography), and a Graded Symptom Checklist (symptom evaluation) were used. Results: Subjects with a low sleep quantity the night before baseline reported both a greater number of symptoms and higher total symptom severity score. No clinically significant effects for sleep quality were observed. Conclusions: Sleep-deprived athletes reporting for baseline testing should be rescheduled for testing after a normal night's sleep. [ABSTRACT FROM AUTHOR]

A study is presented which compares the measures of head impact frequency, location of head impact, and the kinematic responses to the impact before cases of immediate and delayed concussions were diagnosed in collegiate and high school football players. The study concludes the highest kinematic measurements are associated with the immediate diagnosis of concussion and the higher frequency of impact measurement is associated with delayed diagnosis. Topics include the Gadd severity index, players' history of head impact exposure (HIE), and Head Impact Telemetry (HIT) System helmets.

Research is presented which compares the severity and frequency of head impacts in football players with a focus on identifying the specificity, sensitivity, and accuracy of single-impact severity measures used for diagnosing head injury or concussion. The article notes the study's 1,208 subjects were from college and high school football teams and 95 were diagnosed with concussion. The study concludes the players sustained more severe impacts and more frequent impacts on days they played with diagnosed concussions.

Context: Chronic ankle instability (CAI) commonly develops after lateral ankle sprain. Movement pattern differences at proximal joints may play a role in instability. Objective: To determine whether people with mechanical ankle instability (MAI) or functional ankle instability (FAI) exhibited different hip kinematics and kinetics during a stop-jump task compared with "copers." Design: Cross-sectional study. Setting: Sports medicine research laboratory. Patients or Other Participants: Sixty-three recreational athletes, 21 (11 men, 10 women) per group, matched for sex, age, height, mass, and limb dominance. All participants reported a history of a moderate to severe ankle sprain. The participants with MAI and FAI reported 2 or more episodes of giving way at the ankle in the last year and decreased functional ability; copers did not. The MAI group demonstrated clinically positive anterior drawer and talar tilt tests, whereas the FAI group and copers did not. Intervention(s): Participants performed a maximum-speed approach run and a 2-legged stop jump followed by a maximum vertical jump. Main Outcome Measure(s): An electromagnetic tracking device synchronized with a force plate collected data during the stance phase of a 2-legged stop jump. Hip motion was measured from initial contact to takeoff into the vertical jump. Group differences in hip kinematics and kinetics were assessed. Results: The MAI group demonstrated greater hip flexion at initial contact and at maximum (P=.029 and P=.017, respectively) and greater hip external rotation at maximum (P = .035) than the coper group. The MAI group also demonstrated greater hip flexion displacement than both the FAI (P=.050) and coper groups (P=.006). No differences were noted between the FAI and coper groups in hip kinematic variables or among any of the groups in ground reaction force variables. Conclusions: The MAI group demonstrated different hip kinematics than the FAI and coper groups. Proximal joint motion may be affected by ankle joint function and laxity, and clinicians may need to assess proximal joints after repeated ankle sprains. [ABSTRACT FROM AUTHOR]