Progesterone Levels in Adolescent Female Athletes May Contribute to Decreased Cognitive Performance During Acute Phase of Sports-Related Concussion.

Although many outcome studies pertaining to sports-related concussion exist, female athletes with concussion remain an understudied group. We examined whether neurocognitive performance in adolescent females with sports-related concussion (SRC) is related to menstrual cycle-related hormone levels measured at one-week post-concussion, one-month post-concussion, or both. Thirty-eight female athletes, ages 14-18, were matched into two groups: SRC or healthy control. Self-reported symptom scores were higher among concussed females in the luteal phase, when progesterone levels are highest. Results suggest that progesterone levels may contribute to a heightened experience of symptoms during the acute phase of SRC, providing further evidence of a possible link between progesterone and symptom scores following concussion.

Information seeking behaviors and attitudes of wives of former football players regarding chronic traumatic encephalopathy.

This study examines CTE-related knowledge and information-seeking behaviors of caregivers of persons who are at high risk of CTE. Online survey responses were collected from 64 females, ages 18-74, who were married to former college, semiprofessional, or professional football players and were fluent in English. Ranging from 0 to 18, a score was calculated to represent level of CTE knowledge. Participants were classified into groups based on their spouse's reported symptoms and diagnosis. Approximately 87% of participants reported that their spouses have been diagnosed with a football-related concussion and were significantly more likely to seek out information from a healthcare provider, a scientific journal or article, and post/comment on social media compared to spouses of symptomatic/undiagnosed and non-symptomatic groups. Participants reported 77% of available information as probably true, with social media thought to be highly credible. Highest levels of dissatisfaction were reported for league-sponsored websites and physicians/healthcare providers. Although the majority of participants sought CTE related information on regular or social media, and the internet, information sources differed amongst the groups. These findings may help healthcare providers and organizations develop more effective health-related educational programs that will help the wives make informed decisions regarding care for their spouses with respect to CTE.

How long after maximal physical exertion should baseline computerized neurocognitive testing and symptom assessment be administered?

Objective: Prior research suggests maximal physical exertion (MPE) may negatively affect the reliability and validity of computerized neurocognitive testing (CNT); the purpose of this study was to identify aclinically relevant recovery interval following MPE for the administration of baseline CNT.Design: Random-crossover.Participants: Thirty (M = 21.87 ± 2.29 y), moderately-active,healthy participants, without history of ADHD, learning disabilities, psychological disorders or concussion (within the last six months).Intervention: Participants completed four randomly ordered experimental trials. Except for the control trial, CNT was administered following MPE with assigned recovery intervals [Immediate, 10-minutes,or 20-minutes]. Aseries of repeated measures analysis of variance (ANOVAs) were performed on CNT composite and total symptom scores.Results: Total symptom scores were significantly greater (p < .01) at the immediate, 10-minute,and 20-minuterecovery intervals compared to the control trial. Processing speed was significantly faster at the 20-minuterecovery interval compared to the control trials. Visual memory, verbal memory, or reaction time did not differ across recovery intervals.Conclusions: Clinicians should wait more than 20 minutes before assessing baseline concussion symptoms following about of MPE.

Sex, race, ADHD, and prior concussions as predictors of concussion recovery in adolescents.

OBJECTIVE: Concussions in adolescents are a growing public health concern as the popularity of high school sports increases. The aim of this study was to identify clinical (e.g., prior concussion, migraine history, learning disabilities/attention deficit hyperactivity disorders [ADHD]) and demographic factors (e.g., sex, race, health insurance, mechanism of injury/sport, education) that predict concussion recovery times. DESIGN: In a retrospective cohort study of adolescents 13-19 years old evaluated for an acute concussion (≤ 10 days from injury), recovery times were calculated from the date of concussive injury to the date of clearance to return to play or normal activities. RESULTS: The sample (N = 227) was primarily male (75%), and the median age was 15 years. Predictors of protracted recovery were ADHD (hazard ratio [HR] =.449, 95% confidence interval [CI] =.272-.741, p = .002) and prior concussion (HR =.574, 95% CI =.397-.828, p = .003) in all sex and race groups, while shorter recovery times were predicted by Hispanic and African American race (HR = 2.12, 95% CI = 1.30-3.46, p = .003), with White females as the reference group. CONCLUSIONS: Further research is needed to examine the role of sex, race, ADHD, and concussion history on concussion outcomes.

Persistent Disruption of Brain Connectivity after Sports-Related Concussion in a Female Athlete.

Structural and functional connectivity (FC) after sports-related concussion (SRC) may remain altered in adolescent athletes despite symptom resolution. Little is known, however, about how alterations in structural connectivity and FC co-present in female athletes whose symptom recovery tends to be prolonged. Despite resolution of symptoms, one month after her second SRC, an 18-year-old female athlete had decreased structural connectivity in the corpus callosum and cingulum, with altered FC near those regions, compared with other SRC and orthopedically injured athletes. Findings show persistent effects of SRC on advanced brain imaging and the possibility of greater vulnerability of white matter tracts in females.

Clinical and demographic predictors of concussion resolution in adolescents: A retrospective study.

Concussions in adolescents are a growing public health concern. The aim of this study was to identify clinical (e.g., concussion history, migraine history, learning disabilities/ADHD) and demographic factors (e.g., age, sex, race, health insurance status, mechanism of injury, education) that predict concussion recovery times. In a retrospective cohort study of 118 adolescents 13-19 years old who were evaluated for an acute concussion (≤10 days from injury), recovery times were calculated from the date of concussive injury to the date of clearance to return to play and/or normal activities. The median time to recovery was 17 days. Predictors of longer recovery included ADHD (HR = .221, 95% CI = .095 - .514, p < .001) and prior concussion (HR = .564, 95% CI = .332 - .959, p = .03). Student athletic insurance and public insurance were predictors of shorter recovery times (HR = 3.98, 95% CI = 1.25 - 12.65, p = .02 and HR = 3.33, 95% CI = 1.09 - 10.15, p = .03, respectively). In adolescents with prior concussion or ADHD, clearance to return to play/ normal activities may be delayed. Further research is needed to validate the impact of SES/health insurance on concussion recovery time.

Rehabilitation of an Adolescent Equestrian Athlete With a History of Multiple Concussions: A Case Report Describing an Adapted Return-to-Sport Protocol.

BACKGROUND: Equestrian riding is a sport with a high risk of concussion. Currently, the literature guiding rehabilitation for concussions in equestrian athletes is limited, especially for directing return to sport. CASE DESCRIPTION: In this case report, a 14-year-old female equestrian athlete presented to physical therapy following her third concussion in 3 years. Her primary complaints were headaches, dizziness, difficulty concentrating, light sensitivity, and neck pain. On examination, the patient demonstrated reproduction of symptoms during testing of the vestibular-ocular reflex, showed a 3-line symptomatic loss on the dynamic visual acuity test, and had impairments in the joint position error test (1/5 correct on the left, 4/5 correct on the right) and a Balance Error Scoring System (BESS) score of 38/60 errors. A return-to-riding protocol was adapted from general return-to-sport guidelines and tailored to meet the unique demands of the patient's equestrian sport. The protocol included phased progression through no activity, light aerobic activity, moderate aerobic activity, sport-specific nonjumping skills, sport-specific jumping skills, full practice, and return to competition. During the protocol, the patient participated in 8 physical therapy sessions over 4 weeks for vestibular training, aerobic conditioning, and cervical and core exercises, as well as equestrian exercises at her stables. OUTCOMES: At the final evaluation, the patient reported no symptoms at rest, with exercise, or when testing vestibular-ocular reflex. Improvements were noted in the dynamic visual acuity test, joint position error, and BESS, with changes in the BESS exceeding minimal detectable change. The patient completed the full return-to-riding protocol in 8 weeks and was able to return to equestrian competition without complaints. DISCUSSION: This case report describes the physical therapy management of an adapted return-to-sport protocol for an equestrian athlete with a history of multiple sport-related concussions. LEVEL OF EVIDENCE: Therapy, level 5. J Orthop Sports Phys Ther 2018;48(12):934-942. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8214.

An Interdisciplinary Approach to Sports Concussion Evaluation and Management: The Role of a Neuropsychologist.

Sports neuropsychology is a rapidly emerging field that affords neuropsychologists, the opportunity to work with a diverse group of individuals in terms of age, gender, sports, ethnicity, and language and sports has a way of bringing diverse communities together. Although working with athletes can be associated with unique challenges, neuropsychological assessment with this population and being part of an interdisciplinary sports medicine team is both exciting and rewarding and can merge a passion for sports with professional interests. This paper is intended to highlight the contribution of neuropsychology to the evaluation and management of sport-related concussion as well as describe the neuropsychologist's role as an integral member of interdisciplinary sports medicine teams. Clinical model, special considerations, assessment strategy, and administrative aspects of practice are discussed.

Functional Connectivity Is Altered in Concussed Adolescent Athletes Despite Medical Clearance to Return to Play: A Preliminary Report.

Recovery following sports-related concussion (SRC) is slower and often more complicated in young adolescent athletes than in collegiate players. Further, the clinical decision to return to play is currently based on symptoms and cognitive performance without direct knowledge of brain function. We tested the hypothesis that brain functional connectivity (FC) would be aberrant in recently concussed, asymptomatic athletes who had been cleared to return to play. A seed-based FC analysis measured the FC of the default mode network (DMN) (seeds = anterior cingulate cortex, posterior cingulate cortex (PCC), right lateral parietal cortex, and left lateral parietal cortex) 30 days after SRC in asymptomatic high school athletes cleared to return to play (n = 13) and was compared to the FC of high school athletes with orthopedic injury (OI) (n = 13). The SRC group demonstrated greater FC than the OI group between the PCC and the ventral lateral prefrontal cortex, as well as between the right lateral parietal cortex and lateral temporal cortex (with regions both outside of and within the DMN). Additionally, the OI group demonstrated greater FC than the SRC group between right lateral parietal cortex and supramarginal gyrus. When relating the FC results to verbal memory performance approximately 1 week and 1 month after injury, significantly different between-group relations were found for the posterior cingulate and right lateral parietal cortex seeds. However, the groups did not differ in verbal memory at 1 month. We suggest that changes in FC are apparent 1-month post-SRC despite resolution of post-concussion symptoms and recovery of cognitive performance in adolescent athletes cleared to return to play.

Influence of Language of Administration on ImPACT Performance by Bilingual Spanish-English College Students.

Previous research has suggested that there are performance differences on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery related to language of administration, such that scores are higher with the English than the Spanish version of the battery. This study extended those findings in a within-subjects design, evaluating neurocognitive performance of 58 bilingual English-Spanish-speaking individuals who completed ImPACT in both languages. Results revealed a significant multivariate effect of language of test administration, p < .01; partial η(2) = 0.23, with significantly better English language performance on Verbal Memory and Visual Motor Speed composite scores, but not Visual Memory, Reaction Time, or Total Symptom score. Results are discussed in relation to potential linguistic biases of the ImPACT and functional language dominance that may contribute to the lower scores. These results extend previous findings and suggest a need for separate normative data for Spanish-speaking individuals completing the ImPACT battery if baseline data are not present.

Neurocognitive responses to a single session of static squats with whole body vibration.

The purpose of this study was to determine if the head accelerations using a common whole body vibration (WBV) exercise protocol acutely reduced neurocognition in healthy subjects. Second, we investigated differential responses to WBV plates with 2 different delivery mechanisms: vertical and rotational vibrations. Twelve healthy subjects (N = 12) volunteered and completed a baseline (BASE) neurocognitive assessment: the Immediate Postconcussion Assessment and Cognitive Test (ImPACT). Subjects then participated in 3 randomized exercise sessions separated by no more than 2 weeks. The exercise sessions consisted of five 2-minute sets of static hip-width stance squats, with the knees positioned at a 45° angle of flexion. The squats were performed with no vibration (control [CON]), with a vertically vibrating plate (vertical vibration [VV]), and with a rotational vibrating plate (rotational vibration [RV]) set to 30 Hz with 4 mm of peak-to-peak displacement. The ImPACT assessments were completed immediately after each exercise session and the composite score for 5 cognitive domains was analyzed: verbal memory, visual memory, visual motor speed, reaction time, and impulse control. Verbal memory scores were unaffected by exercise with or without vibration (p = 0.40). Likewise, visual memory was not different (p = 0.14) after CON, VV, or RV. Significant differences were detected for visual motor speed (p = 0.006); VV was elevated compared with BASE (p = 0.01). There were no significant differences (p = 0.26) in reaction time or impulse control (p = 0.16) after exercise with or without vibration. In healthy individuals, 10 minutes of 30 Hz, 4-mm peak-to-peak displacement vibration exposure with a 45° angle of knee flexion did not negatively affect neurocognition.

Utility of repeated assessment after invalid baseline neurocognitive test performance.

CONTEXT: Although the prevalence of invalid baseline neurocognitive testing has been documented, and repeated administration after obtaining invalid results is recommended, no empirical data are available on the utility of repeated assessment after obtaining invalid baseline results. OBJECTIVE: To document the utility of readministering neurocognitive testing after an invalid baseline test. DESIGN: Case series. SETTING: Schools, colleges, and universities. PATIENTS OR OTHER PARTICIPANTS: A total of 156 athletes who obtained invalid results on ImPACT baseline neurocognitive testing and were readministered the ImPACT baseline test within a 2-week period (mean = 4 days). MAIN OUTCOME MEASURE(S): Overall prevalence of invalid results on reassessment, specific invalidity indicators at initial and follow-up baseline, dependent-samples analysis of variance, with Bonferroni correction for multiple comparisons. RESULTS: Reassessment resulted in valid test results for 87.2% of the sample. Poor performance on the design memory and three-letter subscales were the most common reasons for athletes obtaining an invalid baseline result, on both the initial assessment and the reassessment. Significant improvements were noted on all ImPACT composite scores except for reaction time on reassessment. Of note, 40% of athletes showed slower reaction time scores on reassessment, perhaps reflecting a more cautious approach taken the second time. Invalid results were more likely to be obtained by athletes with a self-reported history of attention-deficit disorder or learning disability on reassessments (35%) than on initial baseline assessments (10%). CONCLUSIONS: Repeat assessment after the initial invalid baseline performance yielded valid results in nearly 90% of cases. Invalid results on a follow-up assessment may be influenced by a history of attention-deficit disorder or learning disability, the skills and abilities of the individual, or a particular test-taking approach; in these cases, a third assessment may not be useful.

Neurocognitive performance and symptom profiles of Spanish-speaking Hispanic athletes on the ImPACT test.

This study documented baseline neurocognitive performance of 23,815 athletes on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test. Specifically, 9,733 Hispanic, Spanish-speaking athletes who completed the ImPACT test in English and 2,087 Hispanic, Spanish-speaking athletes who completed the test in Spanish were compared with 11,955 English-speaking athletes who completed the test in English. Athletes were assigned to age groups (13-15, 16-18). Results revealed a significant effect of language group (p < .001; partial η(2) = 0.06) and age (p < .001; partial η(2) = 0.01) on test performance. Younger athletes performed more poorly than older athletes, and Spanish-speaking athletes completing the test in Spanish scored more poorly than Spanish-speaking and English-speaking athletes completing the test in English, on all Composite scores and Total Symptom scores. Spanish-speaking athletes completing the test in English also performed more poorly than English-speaking athletes completing the test in English on three Composite scores. These differences in performance and reported symptoms highlight the need for caution in interpreting ImPACT test data for Hispanic Americans.

Prevalence of invalid computerized baseline neurocognitive test results in high school and collegiate athletes.

CONTEXT: Limited data are available regarding the prevalence and nature of invalid computerized baseline neurocognitive test data. OBJECTIVE: To identify the prevalence of invalid baselines on the desktop and online versions of ImPACT and to document the utility of correcting for left-right (L-R) confusion on the desktop version of ImPACT. DESIGN: Cross-sectional study of independent samples of high school (HS) and collegiate athletes who completed the desktop or online versions of ImPACT. Participants or Other Participants: A total of 3769 HS (desktop = 1617, online = 2152) and 2130 collegiate (desktop = 742, online = 1388) athletes completed preseason baseline assessments. MAIN OUTCOME MEASURE(S): Prevalence of = ImPACT validity indicators, with correction for L-R confusion (reversing left and right mouse-click responses) on the desktop version, by test version and group. Chi-square analyses were conducted for sex and attentional or learning disorders. RESULTS: At least 1 invalid indicator was present on 11.9% (desktop) versus 6.3% (online) of the HS baselines and 10.2% (desktop) versus 4.1% (online) of collegiate baselines; correcting for L-R confusion (desktop) decreased this overall prevalence to 8.4% (HS) and 7.5% (collegiate). Online Impulse Control scores alone yielded 0.4% (HS) and 0.9% (collegiate) invalid baselines, compared with 9.0% (HS) and 5.4% (collegiate) on the desktop version; correcting for L-R confusion (desktop) decreased the prevalence of invalid Impulse Control scores to 5.4% (HS) and 2.6% (collegiate). Male athletes and HS athletes with attention deficit or learning disorders who took the online version were more likely to have at least 1 invalid indicator. Utility of additional invalidity indicators is reported. CONCLUSIONS: The online ImPACT version appeared to yield fewer invalid baseline results than did the desktop version. Identification of L-R confusion reduces the prevalence of invalid baselines (desktop only) and the potency of Impulse Control as a validity indicator. We advise test administrators to be vigilant in identifying invalid baseline results as part of routine concussion management and prevention programs.

Group versus individual administration affects baseline neurocognitive test performance.

BACKGROUND: Computer-based tests are widely used for the purpose of documenting baseline neurocognitive function, and athletes are often tested in groups. At present, there is limited research on the effects of administering these tests in a group versus individual setting. HYPOTHESIS: Athletes assessed with neurocognitive tests in groups would show decreased performance compared with those assessed individually. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: High school athletes completed preseason baseline neurocognitive tests either in groups in their school or individually in a private neuropsychological clinic (with no significant between-group differences in sex, history of concussion, and attention deficit disorder/learning disability). All athletes completed the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test battery on 1 occasion, which yielded scores in the area of verbal memory, visual memory, motor processing speed, reaction time, and symptom scores. RESULTS: Athletes in the group setting scored significantly lower on verbal memory (mean 83.4 vs 86.5; P = .003), visual memory (mean 71.6 vs 76.7; P = .0001), motor processing speed (mean 35.6 vs 38.4; P = .0001), and reaction time (mean 0.61 vs 0.57; P = .001), but not symptom scores (mean 6.1 vs 4.4; P = .11), and exhibited a greater rate of invalid baselines. Similar results were obtained after excluding athletes with attention deficit disorder/learning disability and/or a history of concussion. CONCLUSION: Administering baseline neurocognitive testing to athletes in a group setting may introduce extraneous error, negatively affecting test performance.

Long-term neurocognitive dysfunction in sports: what is the evidence?

Although the immediate neurocognitive effects of sports-related concussion are well known, less is known about the intermediate or long-term effects of sports-related concussions. A sample of selected studies of high-school and collegiate athletes is reviewed and the intermediate effects of concussive injuries are discussed, because no long-term empiric data are available with these populations. The evidence for intermediate neurocognitive effects is mixed and not convincing at present in these groups of athletes. Selected studies of professional boxers and American professional football players are also reviewed, and the available data regarding long-term neurocognitive and neuropathologic effects are assessed. The evidence for long-term adverse neurocognitive effects in professional boxers is compelling. Suggestions for future research on relevant biopsychosocial variables affecting response to concussive injury are presented.

Thirty-second interval patterns for WAIS-III Digit Symbol and Symbol Search.

For Digit Symbol-Coding (CD) and Symbol Search (SS) we tested the hypothesis that young adults (44 males, 60 females) would start out quickly and demonstrate steady increases in symbols/items completed across each of four 30-s intervals. The average number of CD symbols was 23.19 (S.D.=3.46) for 0-30s, 21.11 (S.D.=3.75) for 30-60 s, 21.98 (S.D.=3.70) for 60-90 s, and 22.46 (S.D.=3.55) for 90-120 s. For SS, the average number of items was 11.91 (S.D.=1.91) for 0-30s, 9.96 (S.D.=1.92) for 30-60s, 9.95 (S.D.=1.53) for 60-90 s, and 9.98 (S.D.=2.46) for 90-120 s. The hypothesis was not supported for either subtest. Cluster analysis revealed two CD groups with similar patterns which differed only in level of performance. On SS, cluster analysis identified two groups which differed in level of performance and pattern across the four 30-s intervals.

Relationships among attention deficit hyperactivity disorder, induced labor, and selected physiological and demographic variables.

We investigated whether events associated with physiological maternal and fetal stress during the birth process were associated with diagnosis of attention deficit hyperactivity disorder (ADHD), alone or in combination with demographic variables. We gathered data through maternal responses to a 17-item questionnaire. Sex, mother's educational level, mother's age at delivery, interval between the beginning of labor and birth, and presence or absence of complications during the delivery process accounted for 42% of the variance in the diagnostic (ADHD) category. The model correctly classified 87% of the non-ADHD group (n = 90) and 48% of the children with ADHD (n = 40), for an overall correct classification rate of 75%. A differential effect for sex was indicated, but a low number of females in the diagnostic category limited meaningful analysis. Maternal age at delivery and maternal education level emerged as the strongest predictors, with the exception of sex, of ADHD in the full model.

WAIS-III Digit Symbol-Incidental Learning base rates: findings for college student and patient samples.

Frequencies for Pairing and Free Recall of the WAIS-III Digit Symbol-Incidental Learning procedure were determined separately for 104 college students and 73 patients with substance abuse disorders. Means for age and education were 22.2 yr. (SD=5.1) and 14.7 yr. (SD=1.0) and 46.0 yr. and 12.2 yr. (SD=9.4), respectively. Base rate tables indicated that for Pairing, 93% of students and 89% of patients paired the number 1 with the appropriate symbol. Conversely, only 43% of students correctly paired the number 3 with its associated symbol, while 30% of patients paired the number 4 with its appropriate symbol. When Free Recall was assessed, 98% of students remembered the first symbol, but only 61% recalled the third. The most frequently recalled symbol by patients was the ninth (97%) and the most infrequently recalled symbol was the fourth (50%). The present base rate tables may be helpful for detecting unusual recall frequencies on the Incidental Learning procedures.

Scoring reliability on the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III).

Nineteen psychologists and 19 graduate students scored two Wechsler Adult Intelligence Scale-Third Edition patient protocols. Mean IQs and indexes were similar across groups, but the ranges for Verbal IQ (VIQ), Performance IQ (PIQ), and Full Scale IQ (FSIQ) on one protocol were 25, 22, and 11 points, respectively. For both protocols taken together, percentages of agreement with the "actual" IQs for psychologists were only 26.3 for VIQ, 36.8 for PIQ, and 42.1 for FSIQ. For students, percentages were 15.8 for VIQ, 23.7 for PIQ, and 31.6 for FSIQ. The percentages of FSIQs that fell within +/- 1 standard error of measurement of the actual IQs were 89.5 for psychologists and 76.3 for students. Scoring error also had a negative impact on index scores. Both groups were confident about their scoring accuracy.