Jaclyn B. Caccese

Postural control deficits identify lingering post-concussion neurological deficits

Concussion, or mild traumatic brain injury, incidence rates have reached epidemic levels and impaired postural control is a cardinal symptom. The purpose of this review is to provide an overview of the linear and non-linear assessments of post-concussion postural control. The current acute evaluation for concussion utilizes the subjective balance error scoring system (BESS) to assess postural control. While the sensitivity of the overall test battery is high, the sensitivity of the BESS is unacceptably low and, with repeat administration, is unable to accurately identify recovery. Sophisticated measures of postural control, utilizing traditional linear assessments, have identified impairments in postural control well beyond BESS recovery. Both assessments of quiet stance and gait have identified lingering impairments for at least 1 month post-concussion. Recently, the application of non-linear metrics to concussion recovery have begun to receive limited attention with the most commonly utilized metric being approximate entropy (ApEn). ApEn, most commonly in the medial-lateral plane, has successfully identified impaired postural control in the acute post-concussion timeframe even when linear assessments of instrumented measures are equivalent to healthy pre-injury values; unfortunately these studies have not gone beyond the acute phase of recovery. One study has identified lingering deficits in postural control, utilizing Shannon and Renyi entropy metrics, which persist at least through clinical recovery and return to participation. Finally, limited evidence from two studies suggest that individuals with a previous history of a single concussion, even months or years prior, may display altered ApEn metrics. Overall, non-linear metrics provide a fertile area for future study to further the understanding of postural control impairments acutely post-concussion and address the current challenge of sensitive identification of recovery.

Minimizing Head Acceleration in Soccer: A Review of the Literature

Physicians and healthcare professionals are often asked for recommendations on how to keep athletes safe during contact sports such as soccer. With an increase in concussion awareness and concern about repetitive subconcussion, many parents and athletes are interested in mitigating head acceleration in soccer, so we conducted a literature review on factors that affect head acceleration in soccer. We searched electronic databases and reference lists to find studies using the keywords ‘soccer’ OR ‘football’ AND ‘head acceleration’. Because of a lack of current research in soccer heading biomechanics, this review was limited to 18 original research studies. Low head–neck segment mass predisposes athletes to high head acceleration, but head–neck–torso alignment during heading and follow-through after contact can be used to decrease head acceleration. Additionally, improvements in symmetric neck flexor and extensor strength and neuromuscular neck stiffness can decrease head acceleration. Head-to-head impacts and unanticipated ball contacts result in the highest head acceleration. Ball contacts at high velocity may also be dangerous. The risk of concussive impacts may be lessened through the use of headgear, but headgear may also cause athletes to play more recklessly because they feel a sense of increased security. Young, but physically capable, athletes should be taught proper heading technique in a controlled setting, using a carefully planned progression of the skill.

Validation and calibration of HeadCount, a self-report measure for quantifying heading exposure in soccer players.

ABSTRACT The long-term effects of repetitive head impacts due to heading are an area of increasing concern, and exposure must be accurately measured; however, the validity of self-report of cumulative soccer heading is not known. In order to validate HeadCount, a 2-week recall questionnaire, the number of player-reported headers was compared to the number of headers observed by trained raters for a men’s and a women’s collegiate soccer teams during an entire season of competitive play using Spearman’s correlations and intraclass correlation coefficients (ICCs), and calibrated using a generalized estimating equation. The average Spearman’s rho was 0.85 for men and 0.79 for women. The average ICC was 0.75 in men and 0.38 in women. The calibration analysis demonstrated that men tend to report heading accurately while women tend to overestimate. HeadCount is a valid instrument for tracking heading behaviour, but may have to be calibrated in women.

Reducing purposeful headers from goal kicks and punts may reduce cumulative exposure to head acceleration

ABSTRACT The purpose of this study was to measure peak linear and rotational head acceleration in women’s collegiate soccer and explore the variations in acceleration across different strategic scenarios. Game videos from 14 games were used to identify the strategic scenario in which the athlete headed the ball. Strategic scenarios included: bounce, secondary header, punt, throw-in, goal kick, corner kick, and kick. Peak linear and rotational accelerations were measured using the Smart Impact Monitor (Triax Technologies Inc., Norwalk, CT). Goal kick (38.8 ± 19.4 g, p = 0.001, ß = 8.9; 9.3 ± 3.9 krad/s2, p = 0.004, ß = 1.9) and punt (36.0 ± 15.1 g, p = 0.055, ß = 6.3; 10.1 ± 4.8 krad/s2, p = 0.002, ß = 2.5) impacts resulted in higher linear and rotational head accelerations than the base variable, kick (30.0 ± 19.5 g; 7.5 ± 4.1 krad/s2). This suggests that limiting headers from goal kicks and punts in younger athletes who are still learning proper heading technique may limit cumulative linear and rotational accelerations.

Sway Area and Velocity Correlated With MobileMat Balance Error Scoring System (BESS) Scores.

The Balance Error Scoring System (BESS) is often used for sport-related concussion balance assessment. However, moderate intratester and intertester reliability may cause low initial sensitivity, suggesting that a more objective balance assessment method is needed. The MobileMat BESS was designed for objective BESS scoring, but the outcome measures must be validated with reliable balance measures. Thus, the purpose of this investigation was to compare MobileMat BESS scores to linear and nonlinear measures of balance. Eighty-eight healthy collegiate student-athletes (age: 20.0 ± 1.4 y, height: 177.7 ± 10.7 cm, mass: 74.8 ± 13.7 kg) completed the MobileMat BESS. MobileMat BESS scores were compared with 95% area, sway velocity, approximate entropy, and sample entropy. MobileMat BESS scores were significantly correlated with 95% area for single-leg (r = .332) and tandem firm (r = .474), and double-leg foam (r = .660); and with sway velocity for single-leg (r = .406) and tandem firm (r = .601), and double-leg (r = .575) and single-leg foam (r = .434). MobileMat BESS scores were not correlated with approximate or sample entropy. MobileMat BESS scores were low to moderately correlated with linear measures, suggesting the ability to identify changes in the center of mass-center of pressure relationship, but not higher-order processing associated with nonlinear measures. These results suggest that the MobileMat BESS may be a clinically-useful tool that provides objective linear balance measures.

Sex and age differences in head acceleration during purposeful soccer heading

ABSTRACT Differences in head–neck segment mass, purposeful heading technique, and cervical strength and stiffness may contribute to differences in head accelerations across sex and age. The purpose of this study was to compare head acceleration across sex and age (youth [12–14 years old], high school and collegiate) during purposeful soccer heading. One-hundred soccer players (42 male, 58 female, 17.1 ± 3.5 years, 168.5 ± 20.3 cm, 61.5 ± 13.7 kg) completed 12 controlled soccer headers at an initial ball velocity of 11.2 m/s. Linear and rotational accelerations were measured using a triaxial accelerometer and gyroscope and were transformed to the head centre-of-mass. A MANOVA revealed a significant multivariate main effect for sex (Pillai’s Trace = .165, F(2,91) = 11.868, p < .001), but not for age (Pillai’s Trace = .033, F(4,182) = 0.646, p = .630). Peak linear and rotational accelerations were higher in females (40.9 ± 13.3 g; 3279 ± 1065 rad/s2) than males (27.6 ± 8.5 g, 2219 ± 823 rad/s2). These data suggest that under controlled soccer heading conditions, females may be exposed to higher head accelerations than males.

Linear Acceleration in Direct Head Contact Across Impact Type, Player Position, and Playing Scenario in Collegiate Women's Soccer Players

CONTEXT   Heading, an integral component of soccer, exposes athletes to a large number of head impacts over a career. The literature has begun to indicate that cumulative exposure may lead to long-term functional and psychological deficits. Quantifying an athletes exposure over a season is a first step in understanding cumulative exposure. OBJECTIVE   To measure the frequency and magnitude of direct head impacts in collegiate womens soccer players across impact type, player position, and game or practice scenario. DESIGN   Cross-sectional study. SETTING   National Collegiate Athletic Association Division I institution. PATIENTS OR OTHER PARTICIPANTS   Twenty-three collegiate womens soccer athletes. MAIN OUTCOME MEASURE(S)   Athletes wore Smart Impact Monitor accelerometers during all games and practices. Impacts were classified during visual, on-field monitoring of athletic events. All direct head impacts that exceeded the 10 g threshold were included in the final data analysis. The dependent variable was linear acceleration, and the fixed effects were (1) type of impact: clear, pass, shot, unintentional deflection, or head-to-head contact; (2) field position: goalkeeper, defense, forward, or midfielder; (3) playing scenario: game or practice. RESULTS   Shots (32.94 g ± 12.91 g, n = 38; P = .02) and clears (31.09 g ± 13.43 g, n = 101; P = .008) resulted in higher mean linear accelerations than passes (26.11 g ± 15.48 g, n = 451). Head-to-head impacts (51.26 g ± 36.61 g, n = 13; P < .001) and unintentional deflections (37.40 g ± 34.41 g, n = 24; P = .002) resulted in higher mean linear accelerations than purposeful headers (ie, shots, clears, and passes). No differences were seen in linear acceleration across player position or playing scenario. CONCLUSIONS   Nonheader impacts, including head-to-head impacts and unintentional deflections, resulted in higher mean linear accelerations than purposeful headers, including shots, clears, and passes, but occurred infrequently on the field. Therefore, these unanticipated impacts may not add substantially to an athletes cumulative exposure, which is a function of both frequency and magnitude of impact.

Head and neck size and neck strength predict linear and rotational acceleration during purposeful soccer heading

Abstract There is increasing societal concern about the long-term effects of repeated impacts from soccer heading, but there is little information about ways to reduce head impact severity. The purpose of this study was to identify factors that contribute to head acceleration during soccer heading. One-hundred soccer players completed 12 controlled soccer headers. Peak linear (PLA) and rotational (PRA) accelerations were measured using a triaxial accelerometer and gyroscope. Head acceleration contributing factors were grouped into 3 categories: size (head mass, neck girth), strength (sternocleidomastoid, upper trapezius) and technique [kinematics (trunk, head-to-trunk range-of-motion), sternocleidomastoid and upper trapezius activity]. Multiple regression analyses indicated size variables explained 22.1% of the variance in PLA and 23.3% of the variance in PRA; strength variables explained 13.3% of the variance in PLA and 17.2% of the variance in PRA; technique variables did not significantly predict PLA or PRA. These findings suggest that head and neck size and neck strength predict PLA and PRA. Anthropometric and neck strength measurements should be considered when determining an athlete’s readiness to begin soccer heading.

Comparing Computer-Derived and Human-Observed Scores for the Balance Error Scoring System.

CONTEXT The Balance Error Scoring System (BESS) is the current standard for assessing postural stability in concussed athletes on the sideline. However, research has questioned the objectivity and validity of the BESS, suggesting that while certain subcategories of the BESS have sufficient reliability to be used in evaluation of postural stability, the total score is not reliable, demonstrating limited interrater and intrarater reliability. Recently, a computerized BESS test was developed to automate scoring. OBJECTIVE To compare computer-derived BESS scores with those taken from 3 trained human scorers. DESIGN Interrater reliability study. SETTING Athletic training room. PATIENTS NCAA Division I student athletes (53 male, 58 female; 19 ± 2 y, 168 ± 41 cm, 69 ± 4 kg). INTERVENTIONS Subjects were asked to perform the BESS while standing on the Tekscan (Boston, MA) MobileMat® BESS. The MobileMat BESS software displayed an error score at the end of each trial. Simultaneously, errors were recorded by 3 separate examiners. Errors were counted using the standard BESS scoring criteria. MAIN OUTCOME MEASURES The number of BESS errors was computed for the 6 stances from the software and each of the 3 human scorers. Interclass correlation coefficients (ICCs) were used to compare errors for each stance scored by the MobileMat BESS software with each of 3 raters individually. The ICC values were converted to Fisher Z scores, averaged, and converted back into ICC values. RESULTS The double-leg, single-leg, and tandem-firm stances resulted in good agreement with human scorers (ICC = .999, .731, and .648). All foam stances resulted in fair agreement. CONCLUSIONS Our results suggest that the MobileMat BESS is suitable for identifying BESS errors involving each of the 6 stances of the BESS protocol. Because the MobileMat BESS scores consistently and reliably, this system can be used with confidence by clinicians as an effective alternative to scoring the BESS.

Examining Ankle-Joint Laxity Using 2 Knee Positions and With Simulated Muscle Guarding

CONTEXT Several factors affect the reliability of the anterior drawer and talar tilt tests, including the individual clinicians experience and skill, ankle and knee positioning, and muscle guarding. OBJECTIVES To compare gastrocnemius activity during the measurement of ankle-complex motion at different knee positions, and secondarily, to compare ankle-complex motion during a simulated trial of muscle guarding. DESIGN Cross-sectional study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS Thirty-three participants aged 20.2 ± 1.7 years were tested. INTERVENTION(S) The ankle was loaded under 2 test conditions (relaxed, simulated muscle guarding) at 2 knee positions (0°, 90° of flexion) while gastrocnemius electromyography (EMG) activity was recorded. MAIN OUTCOME MEASURE(S) Anterior displacement (mm), inversion-eversion motion (°), and peak EMG amplitude values of the gastrocnemius (μV). RESULTS Anterior displacement did not differ between the positions of 0° and 90° of knee flexion (P = .193). Inversion-eversion motion was greater at 0° of knee flexion compared with 90° (P < .001). Additionally, peak EMG amplitude of the gastrocnemius was not different between 0° and 90° of knee flexion during anterior displacement (P = .101). As expected, the simulated muscle-guarding trial reduced anterior displacement compared with the relaxed condition (0° of knee flexion, P = .008; 90° of knee flexion, P = .016) and reduced inversion-eversion motion (0° of knee flexion, P = .03; 90° of knee flexion, P < .001). CONCLUSIONS In a relaxed state, the gastrocnemius muscle did not appear to affect anterior ankle laxity at the 2 most common knee positions for anterior drawer testing; however, talar tilt testing may be best performed with the knee in 0° of knee flexion. Finally, our outcomes from the simulated muscle-guarding condition suggest that clinicians should use caution and be aware of reduced perceived laxity when performing these clinical examination techniques immediately postinjury.