Anthony J. Anzalone

A Positive Vestibular/Ocular Motor Screening (VOMS) Is Associated With Increased Recovery Time After Sports-Related Concussion in Youth and Adolescent Athletes

Background: Vestibular and ocular motor impairments are routinely reported in patients with sports-related concussion (SRC) and may result in delayed return to play (RTP). The Vestibular/Ocular Motor Screening (VOMS) assessment has been shown to be consistent and sensitive in identifying concussion when used as part of a comprehensive examination. To what extent these impairments or symptoms are associated with length of recovery is unknown. Purpose: To examine whether symptom provocation or clinical abnormality in specific domains of the VOMS results in protracted recovery (time from SRC to commencement of RTP protocol). Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: A retrospective chart review was conducted of 167 patients (69 girls, 98 boys; mean ± SD age, 15 ± 2 years [range, 11-19 years]) presenting with SRC in 2014. During the initial visit, VOMS was performed in which symptom provocation or clinical abnormality (eg, unsmooth eye movements) was documented by use of a dichotomous scale (0 = not present, 1 = present). The VOMS used in this clinic consisted of smooth pursuits (SMO_PUR), horizontal and vertical saccades (HOR_SAC and VER_SAC), horizontal and vertical vestibular ocular reflex (HOR_VOR and VER_VOR), near point of convergence (NPC), and accommodation (ACCOM). Domains were also categorized into ocular motor (SMO_PUR, HOR_SAC, VER_SAC, NPC, ACCOM) and vestibular (HOR_VOR, VER_VOR). Cox proportional hazard models were used to explore the relationship between the domains and recovery. Alpha was set at P ≤ .05. Results: Symptom provocation and/or clinical abnormality in all domains except NPC (P = .107) and ACCOM (P = .234) delayed recovery (domain, hazard ratio [95% CI]: SMO_PUR, 0.65 [0.47-0.90], P = .009; HOR_SAC, 0.68 [0.50-0.94], P = .018; VER_SAC, 0.55 [0.40-0.75], P < .001; HOR_VOR, 0.68 [0.49-0.94], P = .018; VER_VOR, 0.60 [0.44-0.83], P = .002). The lowest crude hazard ratio was for ocular motor category (0.45 [0.32-0.63], P < .001). Conclusion: These data suggest that symptom provocation/clinical abnormality associated with all domains except NPC and ACCOM can delay recovery after SRC in youth and adolescents. Thus, the VOMS not only may augment current diagnostic tools but also may serve as a predictor of recovery time in patients with SRC. The findings of this study may lead to more effective prognosis of concussion in youth and adolescents.

Probiotic Streptococcus thermophilus FP4 and Bifidobacterium breve BR03 Supplementation Attenuates Performance and Range-of-Motion Decrements Following Muscle Damaging Exercise

Probiotics have immunomodulatory effects. However, little is known about the potential benefit of probiotics on the inflammation subsequent to strenuous exercise. In a double-blind, randomized, placebo controlled, crossover design separated by a 21-day washout, 15 healthy resistance-trained men ingested an encapsulated probiotic Streptococcus (S.) thermophilus FP4 and Bifidobacterium (B.) breve BR03 at 5 bn live cells (AFU) concentration each, or a placebo, daily for 3 weeks prior to muscle-damaging exercise (ClinicalTrials.gov NCT02520583). Isometric strength, muscle soreness, range of motion and girth, and blood interleukin-6 (IL-6) and creatine kinase (CK) concentrations were measured from pre- to 72 h post-exercise. Statistical analysis was via mixed models and magnitude-based inference to the standardized difference. Probiotic supplementation resulted in an overall decrease in circulating IL-6, which was sustained to 48 h post-exercise. In addition, probiotic supplementation likely enhanced isometric average peak torque production at 24 to 72 h into the recovery period following exercise (probiotic–placebo point effect ±90% CI: 24 h, 11% ± 7%; 48 h, 12% ± 18%; 72 h, 8% ± 8%). Probiotics also likely moderately increased resting arm angle at 24 h (2.4% ± 2.0%) and 48 h (1.9% ± 1.9%) following exercise, but effects on soreness and flexed arm angle and CK were unclear. These data suggest that dietary supplementation with probiotic strains S. thermophilus FP4 and B. breve BR03 attenuates performance decrements and muscle tension in the days following muscle-damaging exercise.

Protection Before Impact: the Potential Neuroprotective Role of Nutritional Supplementation in Sports-Related Head Trauma

Even in the presence of underreporting, sports-related concussions/mild traumatic brain injuries (mTBI) are on the rise. In the absence of proper diagnosis, an athlete may return to play prior to full recovery, increasing the risk of second-impact syndrome or protracted symptoms. Recent evidence has demonstrated that sub-concussive impacts, those sustained routinely in practice and competition, result in a quantifiable pathophysiological response and the accumulation of both concussive and sub-concussive impacts sustained over a lifetime of sports participation may lead to long-term neurological impairments and an increased risk of developing neurodegenerative diseases. The pathophysiological, neurometabolic, and neurochemical cascade that initiates subsequent to the injury is complex and involves multiple mechanisms. While pharmaceutical treatments may target one mechanism, specific nutrients and nutraceuticals have been discovered to impact several pathways, presenting a broader approach. Several studies have demonstrated the neuroprotective effect of nutritional supplementation in the treatment of mTBI. However, given that many concussions go unreported and sub-concussive impacts result in a pathophysiological response that, too, may contribute to long-term brain health, protection prior to impact is warranted. This review discusses the current literature regarding the role of nutritional supplements that, when provided before mTBI and traumatic brain injury, may provide neurological protection.

Fluctuations in blood biomarkers of head trauma in NCAA football athletes over the course of a season

OBJECTIVERepetitive subconcussive head trauma is a consequence of participation in contact sports and may be linked to neurodegenerative diseases. The degree of neurological injury caused by subconcussive head trauma is not easily detectible, and this injury does not induce readily identifiable clinical signs or symptoms. Recent advancements in immunoassays make possible the detection and quantification of blood biomarkers linked to head trauma. Identification of a blood biomarker that can identify the extent of neurological injury associated with subconcussive head trauma may provide an objective measure for informed decisions concerning cumulative exposure to subconcussive head trauma. The purpose of the current study was to examine changes in the blood biomarkers of subconcussive head trauma over the course of an American football season.METHODSThirty-five National Collegiate Athletic Association (NCAA) American football athletes underwent blood sampling throughout the course of a football season. Serial samples were obtained throughout the 2016 season, during which the number and magnitude of head impacts changed. Blood samples were analyzed for plasma concentrations of tau and serum concentrations of neurofilament light polypeptide (NF-L). Athletes were grouped based on their starter status, because athletes identified as starters are known to sustain a greater number of impacts. Between-group differences and time-course differences were assessed.RESULTSIn nonstarters, plasma concentrations of tau decreased over the course of the season, with lower values observed in starters; this resulted in a lower area under the curve (AUC) (starters: 416.78 ± 129.17 pg/ml/day; nonstarters: 520.84 ± 163.19 pg/ml/day; p = 0.050). Plasma concentrations of tau could not be used to discern between starters and nonstarters. In contrast, serum concentrations of NF-L increased throughout the season as head impacts accumulated, specifically in those athletes categorized as starters. The higher serum concentrations of NF-L observed in starters resulted in a larger AUC (starters: 1605.03 ± 655.09 pg/ml/day; nonstarters: 1067.29 ± 272.33 pg/ml/day; p = 0.007). The AUC of the receiver operating characteristic curve analyses displayed fair to modest accuracy to identify athletes who were starters with the use of serum NF-L following periods of repetitive impacts.CONCLUSIONSThe different patterns observed in serum NF-L and plasma tau concentrations provide preliminary evidence for the use of blood biomarkers to detect the neurological injury associated with repetitive subconcussive head trauma. Although further investigation is necessary, such findings might lay the foundation for the further development of an objective measure for the detection of neurological injury caused by subconcussive head trauma.

Effect of post-exercise ingestion of different molecular weight carbohydrate solutions. Part II: The incretin response

Background Gastric inhibitory peptide (GIP) and glucagon like peptide-1 (GLP-1), incretin hormones of the small intestine, are secreted in response to the presence of food in the lumen. Once released into circulation, these incretins stimulate beta cells to increase insulin secretion, accounting for at least 50% of total insulin secreted after glucose ingestion. Post-exercise ingestion of a high molecular weight (HMW) carbohydrate (CHO) solution has been shown to result in greater rates of muscle glycogen synthesis, which are attributed to the higher rates of gastric emptying, compared to a low molecular weight (LMW) CHO solution. However, no studies have examined the effect of post-exercise ingestion of CHO’s of differing molecular weights on incretin response. Therefore, we sought to examine the difference in GIP and GLP-1 secretion after ingestion of HMW and LMW CHO solutions following a glycogen depleting exercise bout.