What are the Protocols and Resources for Sport-Related Concussion Among Top National Collegiate Athletic Association Football Programs? A Cross-Sectional Survey of A5 Schools.

OBJECTIVE: This study summarizes findings from a cross-sectional survey conducted among National Collegiate Athletic Association (NCAA) Division 1 football programs, focusing on sport-related concussion (SRC) protocols for the 2018 season. DESIGN: Cross-sectional survey study. SETTING: 65 football programs within the Autonomy Five (A5) NCAA conferences. PARTICIPANTS: Athletic trainers and team physicians who attended a football safety meeting at the NCAA offices June 17 to 18, 2019, representing their respective institutions. INTERVENTION: Electronic surveys were distributed on June 14, 2019, before the football safety meeting. MAIN OUTCOME MEASURES: Results for 16 unique questions involving SRC protocols and resources were summarized and evaluated. RESULTS: The survey garnered responses from 46 of 65 programs (response rate = 71%). For baseline testing, 98% measured baseline postural stability and balance, 87% used baseline neurocognitive testing, while only 61% assessed baseline vestibular and/or ocular function. Regarding concussion prevention, 51% did not recommend additional measures, while 4% and 24% recommended cervical compression collars and omega-3 supplementation, respectively. In postconcussion treatment, 26% initiated aerobic exercise 1 day postconcussion if symptoms were stable, 24% waited at least 48 hours, 4% waited for the athlete to return to baseline, 11% waited until the athlete became asymptomatic, and 35% determined procedures on a case-by-case basis. CONCLUSIONS: Most institutions assessed postural stability/balance and neurocognitive functioning at baseline and introduced light aerobic exercise within 48 h postconcussion. There was variation in baseline assessment methods and concussion prevention recommendations. These survey findings deepen our understanding of diverse SRC protocols in NCAA football programs.

Age of First Exposure to Contact Sports Is Not Associated With Worse Later-In-Life Brain Health in a Cohort of Community-Dwelling Older Men.

OBJECTIVE: To evaluate whether early age of first exposure to contact sports (AFE-CS) is associated with worse long-term brain health outcomes. DESIGN: A cross-sectional, survey study of older men with a history of contact sport participation was completed. SETTING: Tertiary care facility. PARTICIPANTS: A cohort of community-dwelling older men dichotomized by using AFE-CS (<12 years vs ≥12 years). INTERVENTIONS: Independent variables included a dichotomized group of AFE-CS (<12 years vs ≥12 years). MAIN OUTCOME MEASURES: Brain health outcomes measured by depression, anxiety, cognitive difficulties, and neurobehavioral symptoms. Endorsements of general health problems, motor symptoms, and psychiatric history were also collected. Age of first exposure groups was compared using t tests, χ2 tests, and multivariable linear regressions, which included the following covariates: age, number of prior concussions, and total years of contact sport. RESULTS: Of 69 men aged 70.5 ± 8.0 years, approximately one-third of the sample (34.8%) reported AFE-CS before age 12 years. That group had more years of contact sports (10.8 ± 9.2 years) compared with those with AFE-CS ≥12 (5.6 ± 4.5 years; P = 0.02). No differences were found after univariate testing between AFE-CS groups on all outcomes (P-values >0.05). Multivariable models suggest that AFE-CS is not a predictor of depression or anxiety. Those in the AFE-CS <12 group had fewer cognitive difficulties (P = 0.03) and fewer neurobehavioral symptoms (P = 0.03). CONCLUSIONS: Those with AFE-CS <12 to contact sports did not have worse long-term brain health outcomes compared with those with AFE-CS ≥12. Individuals with AFE-CS <12 had significantly lower British Columbia Cognitive Complaints Inventory and Neurobehavioral Symptom Inventory scores compared with those with AFE-CS ≥12. CLINICAL RELEVANCE: The benefits of earlier AFE-CS may outweigh the risks of head strikes and result in comparable long-term brain health outcomes.

Sport-related concussions in baseball and softball: do mechanisms of injury affect recovery?

OBJECTIVE: Baseball and softball pose unique risks for sport-related concussion (SRC). Although these are not collision sports, concussions in baseball and softball can nonetheless involve high-speed impacts. In a regional, single-institution cohort of baseball and softball athletes who sustained an SRC, the current study sought to 1) describe the mechanisms of injury that led to SRC, and 2) compare initial symptom burden and recovery metrics across mechanisms, including time to return to learn (RTL), time to symptom resolution, and time to return to play (RTP) by mechanism of injury. METHODS: A retrospective cohort study was performed of baseball and softball athletes 12 to 23 years old who sustained an SRC between November 2017 and April 2022. Mechanisms of injury were divided into two categories: 1) contact mechanism (i.e., what initiated contact with the injured player, such as head-to-ball), and 2) player mechanism (i.e., the action the injured player was performing at the time of injury, such as fielding). The recovery outcomes of time to RTL, symptom resolution, and RTP were compared between mechanisms using bivariate analysis and multivariable regression analysis, controlling for sex, age, time to present to concussion clinic, and initial total symptom score. RESULTS: The sample included 58 baseball and softball players (60.3% female, mean age 16.0 ± 1.9 years). Most SRCs (62.1%) occurred during competition. Head-to-ball (50.0%) was the most common contact mechanism, followed by head-to-head/body (31.0%) and head-to-wall/ground/equipment (17.2%). Fielding (63.8%) was the most common player mechanism, followed by drills (20.7%) and running (13.8%). SRCs sustained in practice had significantly longer RTL (median 10.0 [interquartile range (IQR) 3.3-16.3] vs 4.0 [IQR 2.0-8.0] days; U = 421.5, p = 0.031) and symptom resolution (37.0 [IQR 18.0-90.0] vs 14.0 [IQR 7.0-41.0] days; U = 406.5, p = 0.025) compared with SRCs sustained in competition. Multivariable regression analysis revealed that head-to-wall/ground/equipment contact mechanism was associated with longer RTL (ß = 0.30, 95% CI 0.07-0.54, p = 0.013). CONCLUSIONS: The current study found that SRCs in baseball and softball occurred more often in competition than in practice. Head-to-ball and fielding were the most common contact and player mechanisms, respectively. SRCs sustained in practice were associated with longer time to RTL and symptom resolution, and head-to-wall/ground/equipment was associated with longer RTL in multivariable regression analysis. These results provide empirical data to improve concussion safety in baseball/softball.

Acute psychological symptom profiles in high school athletes following sport-related concussion.

OBJECTIVE: Psychological symptoms following a sport-related concussion may affect recovery in adolescent athletes. Therefore, the aims of this study were to 1) describe the proportion of athletes with acute psychological symptoms, 2) identify potential predictors of higher initial psychological symptoms, and 3) determine whether psychological symptoms affect recovery in a cohort of concussed high school athletes. METHODS: A retrospective cohort study of high school athletes (14-18 years of age) who sustained a sport-related concussion from November 2017 to April 2022 and presented to a multidisciplinary concussion center was performed. The main independent variable was psychological symptom cluster score, calculated by summing the four affective symptoms on the initial Post-Concussion Symptom Scale (PCSS) (i.e., irritability, sadness, nervousness, feeling more emotional). The psychological symptom ratio was defined as the ratio of the psychological symptom cluster score divided by the total initial PCSS score. The outcomes included time to return to learn (RTL), symptom resolution, and time to return to play (RTP). Univariable and multivariable regressions were performed to adjust for demographic factors and health history. RESULTS: A total of 431 athletes (58.0% female, mean age 16.2 ± 1.3 years) were included. Nearly half of the sample (45%) reported at least one psychological symptom, with a mean psychological symptom cluster score of 4.2 ± 5.2 and psychological symptom cluster ratio of 0.10 ± 0.11. Irritability was the most commonly endorsed psychological symptom (38.1%), followed by feeling more emotional (30.2%), nervousness (25.3%), and sadness (22.0%). Multivariable regression showed that female sex (B = 2.15, 95% CI 0.91-3.39; p < 0.001), loss of consciousness (B = 1.91, 95% CI 0.11-3.72; p = 0.037), retrograde/anterograde amnesia (B = 1.66, 95% CI 0.20-3.11; p = 0.026), and psychological history (B = 2.96, 95% CI 1.25-4.70; p < 0.001) predicted an increased psychological symptom cluster score. Female sex (B = 0.03, 95% CI 0.00-0.06; p = 0.031) and psychological history (B = 0.06, 95% CI 0.02-0.10; p = 0.002) predicted an increased psychological symptom ratio. Multivariable linear regression showed that both higher psychological symptom cluster score and ratio were associated with longer times to RTL, symptom resolution, and RTP. CONCLUSIONS: In a cohort of high school athletes, 45% reported at least one psychological symptom, with irritability being most common. Female sex, loss of consciousness, amnesia, and a psychological history were significantly associated with an increased psychological symptom cluster score. Higher psychological symptom cluster score and psychological symptom ratio independently predicted longer recovery. These results reinforce the notion that psychological symptoms after concussion are common and may negatively impact recovery.

Examining for gender differences in return to learn following sport-related concussion in high school student athletes.

OBJECTIVE: Prior studies have investigated associations between gender, symptom resolution, and time to return to play following sport-related concussion (SRC). However, there is a notable gap in research regarding the association between gender and return to learn (RTL) in adolescents. Therefore, this study 1) compared the patterns of RTL between boys and girls who are high school student athletes, and 2) evaluated the possible association between gender and time to RTL after adjusting for covariates. METHODS: A retrospective cohort study of a prospective surveillance program that monitored concussion recovery of athletes in high schools throughout the state of Maine between February 2015 and January 2023 was performed. The primary independent variable was gender, dichotomized as boys and girls. The primary outcome was time to RTL, defined by the number of days for an athlete to return to school without accommodations. Mann-Whitney U-tests were used to compare RTL between the boys and girls. Each athlete's RTL status was dichotomized (i.e., returned vs had not returned) at several time points following injury (i.e., 1, 2, 3, and 4 weeks), and chi-square tests were performed to compare the proportions who achieved RTL between groups. Multivariable linear regression analyses were performed to evaluate the predictive value of gender on RTL. Covariates included age, number of previous concussions, history of learning disability or attention-deficit disorder or attention-deficit/hyperactivity disorder, history of a psychological condition, history of headaches or migraines, initial Sport Concussion Assessment Tool (SCAT3/SCAT5) score, and days to evaluation. RESULTS: Of 895 high school athletes, 488 (54.5%) were boys and 407 (45.5%) were girls. There was no statistically significant difference in median [IQR] days to RTL between genders (6.0 [3.0-11.0] vs 6.0 [3.0-12.0] days; U = 84,365.00, p < 0.375). A greater proportion of boys successfully returned to learn without accommodations by 3 weeks following concussion (93.5% vs 89.4%; χ2 = 4.68, p = 0.030), but no differences were found at 1, 2, or 4 weeks. A multivariable model predicting days to RTL showed that gender was not a significant predictor of RTL (p > 0.05). Longer days to evaluation (ß = 0.10, p = 0.021) and higher initial SCAT3/SCAT5 scores (ß = 0.15, p < 0.001) predicted longer RTL. CONCLUSIONS: In a cohort of high school athletes, RTL did not differ between boys and girls following SRC. Gender was not a significant predictor of RTL. Longer days to evaluation and higher initial symptom scores were associated with longer RTL.

Age of First Exposure Does Not Relate to Post-Career Health in Former Professional American-Style Football Players.

OBJECTIVE: Prior studies examining small samples of symptomatic former professional football players suggest that earlier age of first exposure (AFE) to American football is associated with adverse later life health outcomes. This study examined a larger, more representative sample of former professional American football players to assess associations between AFE before age 12 (AFE < 12) and clinical outcomes compared with those who started at age 12 or older (AFE 12 +). METHODS: Former professional American football players who completed a questionnaire were dichotomized into AFE < 12 and AFE 12 + . AFE groups were compared on outcomes including symptoms of depression and anxiety, perceived cognitive difficulties, neurobehavioral dysregulation, and self-reported health conditions (e.g., headaches, sleep apnea, hypertension, chronic pain, memory loss, dementia/Alzheimer's disease, and others). RESULTS: Among 4189 former professional football players (aged 52 ± 14 years, 39% self-reported as Black), univariable associations with negligible effect sizes were seen with AFE < 12, depressive symptoms (p = 0.03; η2 = 0.001), and anxiety-related symptoms (p = 0.02; η2 = 0.001) only. Multivariable models adjusting for age, race, body mass index, playing position, number of professional seasons, and past concussion burden revealed no significant relationships between AFE < 12 and any outcome. Linear and non-linear models examining AFE as a continuous variable showed similar null results. CONCLUSIONS: In a large cohort of former professional American-style football players, AFE was not independently associated with adverse later life outcomes. These findings are inconsistent with smaller studies of former professional football players. Studies examining AFE in professional football players may have limited utility and generalizability regarding policy implications for youth sports.

Sport-related concussions in wrestling: does mechanism of injury affect recovery?

BACKGROUND: Sport-related concussions (SRC) represent a significant concern for athletes. While popular contact sports such as football and soccer have been the focus of much SRC research, wrestling has received comparatively little attention. The current study aimed to: 1) describe the mechanisms of injury leading to SRC in wrestling; and 2) compare recovery outcomes based on mechanism of injury. METHODS: A retrospective, cohort study of wrestlers aged 12-18 who sustained a concussion between 11/2017-04/2022 was performed. Contact mechanism was defined as what initiated contact with the athlete's head/body. Player mechanism was defined as the activity the injured athlete was performing when the concussion occurred. Recovery outcomes were compared using Mann-Whitney-U Tests and multivariable regression analysis. RESULTS: Seventy-three (age=15.8±1.4 years; boys=73 [100.0%]) wrestlers were included. SRCs occurred more often in competition than in practice (66.2% vs. 33.8%, respectively). Head-to-ground/wall (56.2%) and takedown (58.9%) were the most common contact and player mechanisms, respectively. Bivariate analysis showed that head-to-head/body SRCs had longer time to symptom resolution compared to head-to-ground/wall SRCs (23.0 [14.8-46.5] vs. 14.0 [6.0-30.0] days; U=149.00, P=0.029), though the difference did not persist in multivariable analysis. For player mechanism, non-takedowns SRCs had longer time to symptom resolution than takedown SRCs (15.0 [6.0-24.0] vs. 28.5 [13.0-49.3]; U=166.5, P=0.019), but the difference also did not persist in multivariable analysis. Bivariate analysis revealed no significant difference in RTL between takedown and non-takedown SRCs (3.0 [2.0-6.0] vs. 4.0 [1.5-7.0]; U=484.50, P=0.708); however, in multivariable analysis, takedown SRCs were associated with longer RTL (ß=0.23, 95% CI: 0.02, 9.27; P=0.049). CONCLUSIONS: The current study found that SRCs occurred more commonly during competitions, and head-to-ground/wall and takedown were the most common contact and player mechanism, respectively. SRCs that occurred during takedowns were associated with longer RTL.

Examining Acute Symptoms After Sport-Related Concussion in Collegiate Athletes With Preinjury Migraines.

OBJECTIVE: To examine whether a personal history of migraines is associated with worse acute symptom burden after sport-related concussion (SRC). DESIGN: Retrospective cohort study. SETTING: National Collegiate Athletic Association Division III collegiate programs. PARTICIPANTS: Collegiate athletes from a prospective concussion surveillance system between 09, 2014, and 01, 2023. INTERVENTION: Preinjury migraines (yes/no) were self-reported by athletes. MAIN OUTCOME MEASURES: Post-Concussion Symptom Scale (PCSS) were collected within 3 days postinjury. Mann-Whitney U tests compared total PCSS scores and individual symptom scores between athletes with and without preinjury migraines. Chi-squared tests were used to compare proportions of athletes endorsing individual symptoms (ie, item score ≥1) between 2 groups. Multivariable regression analyzed potential predictors of PCSS scores. RESULTS: Of 1190 athletes with SRC, 93 (7.8%) reported a preinjury history of migraines. No significant difference in total PCSS scores was found between athletes with and without preinjury migraines (22.0 ± 16.4 vs 20.5 ± 15.8, U = 48 719.0, P = 0.471). Athletes with preinjury migraines reported greater severity of "sensitivity to light" (1.59 ± 1.59 vs 1.23 ± 1.41, P = 0.040) and "feeling more emotional" (0.91 ± 1.27 vs 0.70 ± 1.30; P = 0.008) and were more likely to endorse "feeling more emotional" (45.2% vs 29.5%, P = 0.002). No differences were found across all other symptoms, including headaches (migraine = 87.1% vs no migraine = 86.3%, P = 0.835). In a multivariable model, a history of migraine was not a significant predictor of acute PCSS scores, but those with a history of psychological disorders (ß = 0.12, P <0 .001) and greater number of days to symptom evaluation (ß = 0.08, P = 0.005) had higher PCSS scores. CONCLUSIONS: Collegiate athletes with a pre-existing history of migraines did not have higher acute symptom burden after SRC.

Stopping at C2 Versus C3/4 in Elective Posterior Cervical Decompression and Fusion: A 5-Year Follow-up Study.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: In patients undergoing elective posterior cervical laminectomy and fusion (PCLF) with a minimum of 5-year follow-up, we sought to compare reoperation rates between patients with an upper instrumented vertebra (UIV) of C2 versus C3/4. SUMMARY OF BACKGROUND DATA: The long-term outcomes of choosing between C2 versus C3/4 as the UIV in PCLF remain unclear. METHODS: A single-institution, retrospective cohort study from a prospective registry was conducted of patients undergoing elective, degenerative PCLF from December 2010 to June 2018. The primary exposure was UIV of C2 versus C3/4. The primary outcome was reoperation. Multivariable logistic regression controlled for age, smoking, diabetes, and fusion to the thoracic spine. RESULTS: Of the 68 patients who underwent PCLF with 5-year follow-up, 27(39.7%) had a UIV of C2, and 41(60.3%) had a UIV of either C3/4. Groups had similar duration of symptoms (P=0.743), comorbidities (P>0.999), and rates of instrumentation to the thoracic spine (70.4% vs. 53.7%, P=0.210). The C2 group had significantly longer operative time (231.8±65.9 vs. 181.6±44.1 mins, P<0.001) and more fused segments (5.9±1.8 vs. 4.2±0.9, P<0.001). Reoperation rate was lower in the C2 group compared with C3/4 (7.4% vs. 19.5%), though this did not reach statistical significance (P=0.294). Multivariable logistic regression showed increased odds of reoperation for the C3/4 group compared with the C2 group (OR=3.29, 95%CI=0.59-18.11, P=0.170), though statistical significance was not reached. Similarly, the C2 group had a lower rate of instrumentation failure (7.4% vs. 12.2%, P=0.694) and adjacent segment disease/disk herniation (0% vs. 7.3%, P=0.271), though neither trend attained statistical significance. CONCLUSIONS: Patients with a UIV of C2 had less than half the number of reoperations and less adjacent segment disease, though neither trend was statistically significant. Despite a lack of statistical significance, whether a clinically meaningful difference exists between UIV of C2 versus C3/4 should be validated in larger samples with long-term follow-up. LEVEL OF EVIDENCE: Level-3.

Subclinical, long-term psychological symptoms following sport-related concussion: are athletes more depressed than we think?

INTRODUCTION: In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms. METHODS: A cohort study was conducted of athletes 12-24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used. RESULTS: Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247-420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04). CONCLUSIONS: Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

Symptoms of Traumatic Encephalopathy Syndrome are Common in Community-Dwelling Adults.

BACKGROUND AND OBJECTIVES: The consensus criteria for traumatic encephalopathy syndrome (TES), the possible in vivo clinical syndrome associated with significant repetitive head impacts, have only been minimally studied to date. This study examined the prevalence of the proposed core clinical features of TES in a sample of healthy adults. METHODS: A cross-sectional survey study was conducted through ResearchMatch, a national health volunteer registry. Participants were assessed for symptoms of TES based on the 2021 consensus criteria, including prior repetitive head impacts and core clinical features. Additional health information (e.g., concussion history, psychological health, sleep, chronic pain) was also evaluated. The consensus proposed research criteria for TES (i.e., reporting at least one progressive core clinical feature of TES, as in progressive difficulties with episodic memory, executive functioning, or neurobehavioral dysregulation) were applied to the sample. RESULTS: Out of 1100 participants (average age = 53.6 ± 17.7 years, 55% women), 34.6% endorsed one or more progressive core clinical features of TES. Participants with a significant history of contact sports (i.e., ≥ 5 years total, with ≥ 2 years in high school or beyond) had similar rates of endorsing a progressive core clinical feature of TES compared to those without significant histories of repetitive head impacts (36.4% vs 32.8%, respectively, χ2 = 0.52, p = 0.47). A significant history of repetitive head impacts in sports was not associated with endorsing a core clinical feature of TES in univariable or multivariable models (p > 0.47), whereas current depression/anxiety (odds ratio [OR] = 6.94), a history of psychiatric disorders (OR = 2.57), current sleep problems (OR = 1.56), and younger age (OR = 0.99) were significant predictors of TES status in a multivariable model. In a subsample of 541 participants who denied a lifetime history of contact sports, other forms of repetitive head impacts, and concussions, approximately 31.0% endorsed one or more progressive core clinical features of TES. Additionally, 73.5% of neurotrauma-naïve participants with current anxiety or depression reported at least one core progressive feature of TES, compared with 20.2% of those without clinically significant depression/anxiety symptoms. CONCLUSIONS: A considerable proportion of adults without a significant history of repetitive head impacts from sports endorsed core TES features, particularly those experiencing mental health symptoms. Having a significant history of contact sports was not associated with endorsing a core progressive clinical feature of TES, whereas other health factors were. These findings underscore the need for validating and refining TES criteria in samples with and without substantial neurotrauma histories.

Medical Conditions in Former Professional American-Style Football Players Are Associated With Self-Reported Clinical Features of Traumatic Encephalopathy Syndrome.

Consensus criteria for traumatic encephalopathy syndrome (TES) specify that at least one core clinical feature of cognitive impairment (CI; e.g., difficulties with memory, executive function) or neurobehavioral dysregulation (ND; e.g., explosiveness, rage, and mood lability) be present and not fully accounted for by other health disorders. Associations between self-reported symptoms that mirror the core clinical features of TES-and how they may be related to concomitant medical conditions-remain unclear. The purpose of this study was to evaluate the association of medical conditions and football exposures with TES clinical features (CI+/-, ND+/-) in 1741 former professional American-style football (ASF) players (age, 57.7 ± 13.9 years; professional seasons, 6.6 ± 3.9 years). Demographics (age, race/ethnicity, current body mass index, age of first football exposure, use of performance-enhancing drugs, position played, and past concussion symptoms), self-reported medical conditions (anxiety, depression, attention-deficit hyperactivity disorder [ADHD], sleep apnea, headache, stroke, hypertension, heart disease, high cholesterol, erectile dysfunction, and low testosterone) were collected. Of 1741 participants, 7.4% were CI+ and/or ND+ (n = 129). Participants who were CI+ or ND+ were more likely to report one or more coexisting medical conditions than participants who did not report CI or ND (odds ratio [OR] = 2.04; 95% confidence interval: 1.25-3.47; p = 0.003). Separate general linear models for each medical condition that adjusted for demographics and football-related factors identified significant associations between ADHD, diabetes, erectile dysfunction, headaches, sleep apnea, anxiety, and low testosterone and CI+ and/or ND+ (ORs = 1.8-6.0). Chi-square automatic interaction detection (CHAID) multi-variable decision tree models that incorporated medical conditions and football exposures accurately differentiated former players meeting either CI or ND clinical criteria from those meeting none (accuracy = 91.2-96.6%). CHAID identified combinations of depression, headache, sleep apnea, ADHD, and upper quartiles of concussion symptom history as most predictive of CI+ and/or ND+ status. CI+ and/or ND+ players were more likely to report medical conditions known to cause cognitive symptoms. Concussion exposure and medical conditions significantly increased the likelihood that a former ASF player would demonstrate cognitive or neurobehavioral dysfunction. Clinicians engaged with this population should consider whether treatable coexisting condition(s) could account for some portion of the clinical picture associated with TES presentation.

Mechanisms of Injury Leading to Concussions in Collegiate Soccer Players: A CARE Consortium Study.

BACKGROUND: Few previous studies have investigated how different injury mechanisms leading to sport-related concussion (SRC) in soccer may affect outcomes. PURPOSE: To describe injury mechanisms and evaluate injury mechanisms as predictors of symptom severity, return to play (RTP) initiation, and unrestricted RTP (URTP) in a cohort of collegiate soccer players. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The Concussion Assessment, Research and Education (CARE) Consortium database was used. The mechanism of injury was categorized into head-to-ball, head-to-head, head-to-body, and head-to-ground/equipment. Baseline/acute injury characteristics-including Sports Concussion Assessment Tool-3 total symptom severity (TSS), loss of consciousness (LOC), and altered mental status (AMS); descriptive data; and recovery (RTP and URTP)-were compared. Multivariable regression and Weibull models were used to assess the predictive value of the mechanism of injury on TSS and RTP/URTP, respectively. RESULTS: Among 391 soccer SRCs, 32.7% were attributed to a head-to-ball mechanism, 27.9% to a head-to-body mechanism, 21.7% to a head-to-head mechanism, and 17.6% to a head-to-ground/equipment mechanism. Event type was significantly associated with injury mechanism [χ2(3) = 63; P < .001), such that more head-to-ball concussions occurred in practice sessions (n = 92 [51.1%] vs n = 36 [17.1%]) and more head-to-head (n = 65 [30.8%] vs n = 20 [11.1]) and head-to-body (n = 76 [36%] vs n = 33 [18.3%]) concussions occurred in competition. The primary position was significantly associated with injury mechanism [χ2(3) = 24; P < .004], with goalkeepers having no SRCs from the head-to-head mechanism (n = 0 [0%]) and forward players having the least head-to-body mechanism (n = 15 [19.2%]). LOC was also associated with injury mechanism (P = .034), with LOC being most prevalent in head-to-ground/equipment. Finally, AMS was most prevalent in head-to-ball (n = 54 [34.2%]) and head-to-body (n = 48 [30.4%]) mechanisms [χ2(3) = 9; P = .029]. In our multivariable models, the mechanism was not a predictor of TSS or RTP; however, it was associated with URTP (P = .044), with head-to-equipment/ground injuries resulting in the shortest mean number of days (14 ± 9.1 days) to URTP and the head-to-ball mechanism the longest (18.6 ± 21.6 days). CONCLUSION: The mechanism of injury differed by event type and primary position, and LOC and AMS were different across mechanisms. Even though the mechanism of injury was not a significant predictor of acute symptom burden or time until RTP initiation, those with head-to-equipment/ground injuries spent the shortest time until URTP, and those with head-to-ball injuries had the longest time until URTP.

Recovery After Sport-Related Concussion in Collegiate Athletes With Self-Reported Pre-Injury Migraines.

Pre-injury migraines might be a risk factor for prolonged recovery after sport-related concussion (SRC). We sought to examine whether a pre-injury history of migraines is associated with worse recovery following SRC in collegiate athletes. Data were collected through a prospective concussion surveillance system in 11 National Collegiate Athletic Association (NCAA) Division III college athletic programs between September 2014 and March 2020. Our primary independent variable, pre-injury migraines, were self-reported by the athletes. Between those with and without migraines, the outcomes of days to return-to-learn (RTL) without academic accommodations and return-to-play (RTP) were compared using Mann-Whitney U tests. Each athlete's RTL and RTP status was dichotomized (i.e., returned vs. not returned) at various time points for RTL (i.e., 7/14/21/28 days) and RTP (i.e., 14/21/28/56 days). Chi-squared tests were performed to compare the proportions of RTL and RTP status between groups. Multivariable regressions analyzed potential predictors of RTL and RTP adjusting for age, gender, prior concussions, other health conditions, and symptom severity. Of 1409 athletes with an SRC, 111 (7.9%) had a pre-injury history of migraines. Compared with those without migraines, those with migraines had longer median (interquartile range [IQR]) days to RTL (migraines = 7.0 [3.0-12.3] vs. no migraines = 5.0 [2.0-10.0], U = 53,590.5, p = 0.022). No differences were found in RTP between the two groups (migraines = 16.0 [10.0-33.0] vs. nχo migraines 15.0 [11.0-23.0], U = 38,545.0, p = 0.408). Regarding RTL, significantly lower proportions of athletes in the migraine group had fully RTL, without accommodations, at ≤14 days (77.5% vs. 85.2%, χ2 = 4.33, p = 0.037), ≤21 days (85.3% vs. 93.0%, χ2 = 7.99, p = 0.005), and ≤28 days (88.2% vs. 95.6%, χ2 = 10.60, p = 0.001). Regarding RTP, a significantly lower proportion of athletes in the migraine group RTP at ≤28 days (72.0% vs. 82.7%, χ2 = 5.40, p = 0.020) and ≤56 days (84.0% vs. 93.0%, χ2 = 8.19, p = 0.004). In a multivariable model predicting RTL that was adjusted for age, gender, acute concussion symptoms, and other health variables (e.g., attention-deficit/hyperactivity disorder [ADHD], history of mental health difficulties), pre-injury history of migraine was associated with longer RTL (ß = 0.06, p = 0.030). In a multivariable model predicting RTP, pre-injury history of migraine was not associated with RTP (ß = 0.04, p = 0.192). In collegiate athletes, pre-injury migraine history was independently associated with longer RTL but not RTP. When comparing the proportions of those with successful RTP by days, significantly lower proportions of those with migraines showed successful RTP at ≤28 days and ≤56 days. Futures studies should study the generalizability of our findings in other school levels.

Symptom resolution following a repeat concussion within the same athlete.

INTRODUCTION: Repeat sport-related concussion (SRC) is anecdotally associated with prolonged recovery. Few studies have examined repeat concussion within the same athlete. We sought to explore differences in symptom burden and recovery outcomes in an individual athlete's initial and repeat SRC. METHODS: A retrospective within-subject cohort study of athletes aged 12-23 years diagnosed with two separate SRCs from 11/2017-10/2020 was conducted. Primary outcomes were initial symptom severity and time-to-symptom-resolution. Secondary outcomes included return-to-learn (RTL) and return-to-play (RTP) duration. RESULTS: Of 868 athletes seen, 47 athletes presented with repeat concussions. Median time between concussions was 244 days (IQR 136-395). Comparing initial to repeat concussion, no differences were observed in time-to-clinic (4.3 ± 7.3vs.3.7 ± 4.6 days, p = 0.56) or initial PCSS (26.2 ± 25.3 vs. 30.5 ± 24.1, p = 0.32). While a difference was observed in time-to-symptom resolution between initial/repeat concussion (21.2 ± 16.3 vs. 41.7 ± 86.0 days, p = 0.30), this did not reach statistical significance. No significant differences were observed in time-to-RTL (17.8 ± 60.6 vs. 6.0 ± 8.3 days, p = 0.26) and RTP (33.2 ± 44.1 vs. 29.4 ± 39.1 days, p = 0.75). Repeat concussion was not associated with symptom resolution on univariate (HR 1.64, 95% CI 0.96-2.78, p = 0.07) and multivariable (HR 0.85, 95% CI 0.49-1.46, p = 0.55) Cox regression. CONCLUSION: No significant differences in symptom duration and RTP/RTL were seen between initial/repeat concussion.

Sport-related concussion in 8- to 12-year-olds: an understudied population.

OBJECTIVE: Most studies regarding sport-related concussion (SRC) focus on high school and collegiate athletes; however, little has been published on children younger than 12 years of age. In a cohort of children aged 8-12 years with SRC, the authors sought to describe demographics, initial presentation, and recovery in this understudied population. METHODS: A retrospective cohort study of children aged 8-12 years who sustained an SRC between November 2017 and April 2022 and were treated at a regional sports concussion center was conducted. Demographic information, injury characteristics, traditional Sport Concussion Assessment Tool 5 (SCAT5) and Child/Parent SCAT5 scores, and outcomes, defined as days to return to learn (RTL), symptom resolution, and return to play (RTP), were reported. Outcomes in boys and girls were compared using effect size analyses given sample size constraints. RESULTS: Forty-seven athletes were included. The mean age was 11.0 ± 0.8 years, and the majority were male (34, 72.3%). A sizable proportion of patients visited an emergency department (19, 40.4%), and many received head imaging (16, 34.0%), mostly via CT (n = 13). The most common sport for boys was football (15, 44.1%), and the most common sports for girls were soccer (4, 30.8%) and cheerleading (4, 30.8%). These athletes reported a variety of symptoms on presentation. It took a mean of 8.8 ± 10.8 days to RTL, 27.3 ± 38.3 days to reach symptom resolution, and 35.4 ± 41.9 days to RTP. When comparing boys versus girls, there appeared to be moderate differences in symptom severity scores (Cohen's d = 0.44 for SCAT5, 0.13 for Child SCAT5, and 0.38 for Parent SCAT5) and minimal differences in recovery (Cohen's d = 0.11 for RTL, n = 35; 0.22 for symptom resolution, n = 22; and 0.12 for RTP, n = 21). CONCLUSIONS: In this cohort of concussed athletes aged 8-12 years, a little less than half of the athletes initially presented to the emergency department, and approximately one-third received acute head imaging. Across all athletes, the mean RTL was slightly more than a week and the mean symptom resolution and RTP were both approximately 1 month; however, much of the cohort is missing recovery outcome measures. This study demonstrated a strong positive correlation between Child SCAT5 and Parent SCAT5 symptom reporting. Future efforts are needed to evaluate differences in clinical presentation and outcomes following SRC between children and older populations.

Examining the New Consensus Criteria for Traumatic Encephalopathy Syndrome in Community-Dwelling Older Adults.

In 2021, an expert panel of clinician-scientists published the first consensus research diagnostic criteria for traumatic encephalopathy syndrome (TES), a clinical condition thought to be associated with chronic traumatic encephalopathy neuropathological change. This study evaluated the TES criteria in older adults and assessed associations between TES criteria and a history of repetitive head impacts. This cross-sectional, survey-based study examined the symptoms of TES, previous repetitive head impacts, and a variety of current health difficulties. To meet symptom criteria for TES, participants had to report progressive changes with memory, executive functioning, and/or neurobehavioral dysregulation. To meet the criterion for substantial exposure to repetitive head impacts via contact sports, participants reported at least 5 years of contact sport exposure (with 2+ years in high school or beyond). A sample of 507 older adults (mean age = 70.0 years, 65% women) completed the survey and 26.2% endorsed having one or more of the progressive core clinical features of TES. Those who had a significant history of contact sport exposure were not significantly more likely to meet TES criteria compared with those who did not (31.3% vs. 25.3%, p = 0.46). In a binary logistic regression predicting TES status, current depression or anxiety (odds ratio [OR] = 12.55; 95% confidence interval [CI] = 4.43-35.51), history of psychiatric disorders (OR = 2.07, 95% CI = 1.22-3.49), male sex (OR = 1.87), and sleep problems (OR = 1.71, 95% CI = 1.01-2.91) were associated with meeting TES criteria. The sport exposure criterion, age, and current pain were not significantly associated with TES status (ps > 0.05). A significant minority of participants with no history of neurotrauma endorsed symptoms consistent with TES (22.0% of men and 19.8% of women). Nearly 80% of neurotrauma naïve participants with clinically significant anxiety/depression met criteria for TES. In summary, approximately one in four older adults met the symptom criteria for TES, many of whom had no history of repetitive neurotrauma. Mental health problems and sleep issues were associated with TES, whereas having a history of repetitive head impacts in contact sports was not. These data suggest that the new consensus diagnostic criteria for TES may have low specificity and may carry a higher risk of misdiagnosing those with other physical and mental health conditions as having TES.

Is contact sport participation associated with chronic traumatic encephalopathy or neurodegenerative decline? A systematic review and meta-analysis.

INTRODUCTION: We sought to evaluate a potential association between contact vs. non-contact sport participation and long-term neurologic outcomes and chronic traumatic encephalopathy (CTE). EVIDENCE ACQUISITION: PubMed/Embase/PsycINFO/CINAHL databases were queried for studies between 1950-2020 with contact and non-contact sports, longitudinal assessment >10 years, and long-term neurologic outcomes in four-domains: I) clinical diagnosis; II) CTE neuropathology; III) neurocognition; and IV) neuroimaging. EVIDENCE SYNTHESIS: Of 2561 studies, 37 met inclusion criteria, and 19 contained homogenous outcomes usable in the meta-analysis. Domain I: Across six studies, no significant relationship was seen between contact sport participation and antemortem diagnosis of neurodegenerative disease or death related to such a diagnosis (RR1.88, P=0.054, 95%CI0.99, 3.49); however, marginal significance (P<0.10) was obtained. Domain II: Across three autopsy studies, no significant relationship was seen between contact sport participation and CTE neuropathology (RR42.39, P=0.086, 95%CI0.59, 3057.46); however, marginal significance (P<0.10) was obtained. Domain III: Across five cognitive studies, no significant relationship was seen between contact sport participation and cognitive function on the Trail Making Test (TMT) scores A/B (A:d=0.17, P=0.275,95% CI-0.13, 0.47; B:d=0.13, P=0.310, 95%CI-0.12, 0.38). Domain IV: In 10 brain imaging-based studies, 32% comparisons showed significant differences between those with a history of contact sport vs. those without. CONCLUSIONS: No statistically significant increased risk of neurodegenerative diagnosis, CTE neuropathology, or neurocognitive changes was found to be associated with contact sport participation, yet marginal significance was obtained in two domains. A minority of imaging comparisons showed differences of uncertain clinical significance. These results highlight the need for longitudinal investigations using standardized contact sport participation and neurodegenerative criteria.

Collegiate Athletes With Diabetes: Baseline Medical Comorbidities and Preseason Concussion Testing Performance.

CONTEXT: People with diabetes mellitus (DM) are at increased risk for adverse health events and complications throughout their lifetime. Whether DM significantly affects collegiate athletes' concussion baseline testing performance remains unclear. OBJECTIVES: To (1) describe the prevalence of DM and associated comorbidities and (2) compare concussion baseline testing performance between student-athletes with DM and student-athletes without DM (NoDM). DESIGN: Retrospective, cross-sectional study. SETTING: University. PATIENTS OR OTHER PARTICIPANTS: Using the Concussion, Assessment, Research and Education (CARE) Consortium research database, we matched athletes with self-reported DM (N = 229) by institution, sex, age, sport, position, testing year, and concussion history to athletes with NoDM (N = 229; total sample mean age = 19.6 ± 1.4 years, women = 42%). MAIN OUTCOME MEASURE(S): Descriptive statistics and χ2 tests of independence with subsequent odds ratios were calculated. Independent-samples t tests compared baseline symptoms, neurocognitive testing, and balance performance between athletes with DM and athletes with NoDM. Effect sizes were determined for significant group differences. RESULTS: At baseline, athletes with DM had higher rates of self-reported pre-existing balance disorders, sleep disorders, seizure disorders, motion sickness, learning disorders, vision and hearing problems, psychiatric disorders, depression, bipolar disorder, nonmigraine headaches, and meningitis than athletes with NoDM (P values < .05). We found balance differences between groups (P = .032, Cohen d = 0.17) such that, on average, athletes with DM had 1 additional error on the Balance Error Scoring System (DM = 13.4 ± 6.5; NoDM = 12.1 ± 5.9). No other comparisons yielded significant results. CONCLUSIONS: Although athletes with DM had high rates of self-reported balance disorders, sleep disorders, seizures, and meningitis, their baseline neurocognitive testing results were largely identical to those of athletes with NoDM. Our findings suggested that nonclinically meaningful differences were present in concussion baseline balance testing but no significant differences were noted in cognitive testing; however, the effect of DM on concussion recovery remains unknown.

Do Sport-Related Concussions Later in the Season Take Longer to Recover From?

OBJECTIVE: In a cohort of high-school football athletes with sport-related concussion (SRC), we sought to investigate the role of seasonality, defined as time of injury during a season, on recovery. DESIGN: Retrospective cohort study. SETTING: Regional sport concussion center. PARTICIPANTS: High-school football athletes ages 14 to 19 -years old who sustained an SRC from 11, 2017 to 04, 2022. INTERVENTION: Athletes were divided into 3 groups based on seasonality: early, middle, and late season. MAIN OUTCOME MEASURES: The primary outcomes were initial Post-Concussion Symptom Scale score and recovery, as defined by time to return-to-learn (RTL), symptom resolution, and return-to-play (RTP). Descriptive statistics, analysis-of-variance, t tests, and multivariable regressions were performed. RESULTS: Of our cohort of 273 high-school football players who sustained an SRC, 97 (35.5%) sustained an SRC during early season, 107 (39.2%) during middle season, and 69 (25.3%) during late season. Compared with late-season concussions, early-season concussions took less days to symptom resolution (early = 11.5 ± 12.9 vs late = 25.5 ± 27.0, P = 0.03), but no differences were found in days to RTL (early = 5.3 ± 4.8 vs late = 7.2 ± 15.8, P = 0.51) and RTP (early = 13.5 ± 11.8 vs late = 23.0 ± 22.8, P = 0.08). Seasonality was not a significant predictor for any recovery metric in multivariable regressions. CONCLUSION: Sport-related concussions occurring in the early third of the season took significantly less time to symptom resolution than those occurring in the later third of the season; however, this was not statistically significant in multivariable analyses. No association was observed between seasonality and time to RTL and RTP. A trend of worse recovery with concussions later in the season may be present.