James R. Clugston

Vision testing is additive to the sideline assessment of sports-related concussion

SummaryWe examined the King-Devick (K-D) test, a vision-based test of rapid number naming, as a complement to components of the Sport Concussion Assessment Tool, 3rd edition (SCAT3) for diagnosis of concussion. Baseline and postconcussion data for the University of Florida mens football, womens soccer, and womens lacrosse teams were collected, including the K-D test, Standardized Assessment of Concussion (SAC), and Balance Error Scoring System (BESS). Among 30 athletes with first concussion during their athletic season (n = 217 total), differences from baseline to postinjury showed worsening of K-D time scores in 79%, while SAC showed a ≥2-point worsening in 52%. Combining K-D and SAC captured abnormalities in 89%; adding the BESS identified 100% of concussions. Adding a vision-based test may enhance the detection of athletes with concussion.

Epidemiology of Sport-Related Concussion in an NCAA Division I Football Bowl Subdivision Sample

Background: Concussions are common in football, and knowledge of their incidence rates across settings is needed to develop strategies to decrease occurrence. Purpose: To examine sports-related concussion rates in a National Collegiate Athletic Association (NCAA) Division I Football Bowl Subdivision sample based on the activity setting where injuries occurred, during which type of play, and when relative to the 2010 NCAA concussion management policy. Study Design: Descriptive epidemiology study. Methods: Medical records from January 2006 to January 2015 for an NCAA Division I Football Bowl Subdivision program were analyzed. Concussion rates (per 1000 athlete-exposures [AEs]) were compared among the following settings: spring practice, preseason training camp, regular season high-contact practice, regular season low-contact practice, bowl game practice, and game competition. Play-type analyses examined incidence rates during offensive, defensive, and special teams plays. Changes in concussion rate coinciding with the 2010 NCAA concussion management policy were also studied. Results: Of the 452 unique players on the roster during the 9-year study period, 118 (26.1%) were diagnosed with a concussion. The concussion rate during games was significantly higher than all practices combined (P < .001). However, when game rate (4.46 per 1000 AEs) was compared with preseason training camp alone (3.81 per 1000 AEs), there was no significant difference (P = .433). The concussion rate during special teams plays was significantly higher than that during offensive (P < .001) or defensive plays (P < .001). The concussion rate in the 4 seasons (2010-2014) after the 2010 NCAA concussion management policy was initiated was significantly higher than the 4 seasons (2006-2009) preceding the policy (P = .036). Conclusion: Study results show that (1) based on activity type, games and preseason training camp present the greatest risk of sustaining a concussion; (2) based on play type, special teams plays pose the greatest risk of sustaining a concussion; and (3) the 2010 NCAA concussion management policy coincided with a significant increase in recognition of concussion.

Diffusion tensor imaging (DTI) findings in adult civilian, military, and sport-related mild traumatic brain injury (mTBI): a systematic critical review

This review seeks to summarize diffusion tensor imaging (DTI) studies that have evaluated structural changes attributed to the mechanisms of mild traumatic brain injury (mTBI) in adult civilian, military, and athlete populations. Articles from 2002 to 2016 were retrieved from PubMed/MEDLINE, EBSCOhost, and Google Scholar, using a Boolean search string containing the following terms: “diffusion tensor imaging”, “diffusion imaging”, “DTI”, “white matter”, “concussion”, “mild traumatic brain injury”, “mTBI”, “traumatic brain injury”, and “TBI”. We added studies not identified by this method that were found via manually-searched reference lists. We identified 86 eligible studies from English-language journals using, adult, human samples. Studies were evaluated based on duration between injury and DTI assessment, categorized as acute, subacute/chronic, remote mTBI, and repetitive brain trauma considerations. Since changes in brain structure after mTBI can also be affected by other co-occurring medical and demographic factors, we also briefly review DTI studies that have addressed socioeconomic status factors (SES), major depressive disorder (MDD), and attention-deficit hyperactivity disorder (ADHD). The review describes population-specific risks and the complications of clinical versus pathophysiological outcomes of mTBI. We had anticipated that the distinct population groups (civilian, military, and athlete) would require separate consideration, and various aspects of the study characteristics supported this. In general, study results suggested widespread but inconsistent differences in white matter diffusion metrics (primarily fractional anisotropy [FA], mean diffusivity [MD], radial diffusivity [RD], and axial diffusivity [AD]) following mTBI/concussion. Inspection of study designs and results revealed potential explanations for discrepant DTI findings, such as control group variability, analytic techniques, the manner in which regional differences were reported, and the presence or absence of persistent functional disturbances. DTI research in adult mTBI would benefit from more standardized imaging and analytic approaches. We also found significant overlap in white matter abnormalities reported in mTBI with those commonly affected by SES or the presence of MDD and ADHD. We conclude that DTI is sensitive to a wide range of group differences in diffusion metrics, but that it currently lacks the specificity necessary for meaningful clinical application. Properly controlled longitudinal studies with consistent and standardized functional outcomes are needed before establishing the utility of DTI in the clinical management of mTBI and concussion.

Lower Extremity Stiffness Changes after Concussion in Collegiate Football Players.

Purpose Recent research indicates that a concussion increases the risk of musculoskeletal injury. Neuromuscular changes after concussion might contribute to the increased risk of injury. Many studies have examined gait postconcussion, but few studies have examined more demanding tasks. This study compared changes in stiffness across the lower extremity, a measure of neuromuscular function, during a jump-landing task in athletes with a concussion (CONC) to uninjured athletes (UNINJ). Methods Division I football players (13 CONC and 26 UNINJ) were tested pre- and postseason. A motion capture system recorded subjects jumping on one limb from a 25.4-cm step onto a force plate. Hip, knee, and ankle joint stiffness were calculated from initial contact to peak joint flexion using the regression line slopes of the joint moment versus the joint angle plots. Leg stiffness was (peak vertical ground reaction force [PVGRF]/lower extremity vertical displacement) from initial contact to peak vertical ground reaction force. All stiffness values were normalized to body weight. Values from both limbs were averaged. General linear models compared group (CONC, UNINJ) differences in the changes of pre- and postseason stiffness values. Results Average time from concussion to postseason testing was 49.9 d. The CONC group showed an increase in hip stiffness (P = 0.03), a decrease in knee (P = 0.03) and leg stiffness (P = 0.03), but no change in ankle stiffness (P = 0.65) from pre- to postseason. Conclusion Lower extremity stiffness is altered after concussion, which could contribute to an increased risk of lower extremity injury. These data provide further evidence of altered neuromuscular function after concussion.

Concussion-like symptom reporting in non-concussed collegiate athletes

Objective Non-concussed individuals may report a variety of concussion-like symptoms even in the absence of a diagnosed brain injury. Previous studies described concussion-like symptom reporting in adolescent athletes. This study provides complementary data on concussion-like symptoms in collegiate athletes. Methods We analyzed baseline symptom scales from 738 collegiate athletes (452 men and 286 women) who completed either the Sport Concussion Assessment Tool, 3 Symptom Evaluation (S3SE; n = 377) or the Post-Concussion Scale (PCS; n = 361) and determined if subjects met criteria for diagnosis of International Classification of Diseases 10th Revision (ICD-10) postconcussional syndrome. Symptoms were grouped as somatic, cognitive, emotional, or sleep-related. We analyzed associations with medical history factors using chi-square analyses, and examined recovery time of a subset of concussed athletes based on baseline symptomatology (n = 117) with independent samples t-test. Results Across all athletes, 120 (16.3%) reported baseline symptoms meeting criteria for ICD-10 postconcussional syndrome. Women were 1.7 times more likely to meet these criteria (21.7% vs. 12.8%, p = .002). Athletes completing the S3SE were 1.5 times more likely to meet criteria than those completing the PCS (p = .011). Previously diagnosed psychiatric disorder was significantly associated with emotional domain symptom reporting, and attention deficit-hyperactivity disorder diagnosis was associated with cognitive domain symptom reporting. On average, athletes meeting ICD-10 postconcussional syndrome criteria at baseline experienced longer recovery from concussion (t[115] = 2.35, p = .020). Conclusions Non-concussed collegiate athletes report concussion-like symptoms at a clinically significant rate. Pre-injury medical history and reporting rates of concussion-like symptoms may explain variance in post-concussion symptom expression. Measured incidence of baseline postconcussional syndrome may, in part, depend on the symptom report measure that is used.

Occipital neuralgia as a sequela of sports concussion: a case series and review of the literature.

Sports and recreation-related concussions are common, with an annual incidence in the United States estimated to be between 1.6 and 3.8 million (19,20,22). The majority of these injuries are considered to be self-limited; however prolonged symptoms of greater than 3 months are not uncommon (5,10,25,27). In particular, delayed headache is associated with delayed recovery from concussion and increased risk of postconcussion syndrome (3,8,10). The pathophysiology of postconcussive headache is likely complex and multifactorial, involving both local injury as well as the activation of peripheral and central pain pathways. Occipital neuralgia (ON) is a known etiology of headaches and may stem from trauma to the neck, such as with a concussion or whiplash injury (23). ON also may feature symptoms such as nausea, dizziness, and photosensitivity that are associated commonly with concussion. Despite these features, ON may be an underappreciated cause of headache in sports-related concussion; a PubMed search returned only one reference when using the terms “sports” and “occipital neuralgia” (26). Due to the prominence of headache as a symptom in concussion, the potential for concomitant conditions such as ON arising from the same traumatic injury, and the overlapping symptomatology between these conditions, it is important that clinicians be able to recognize ON in the management of concussion. In this case series, we will report on our observation of ON as a significant factor in the postconcussion headaches and symptomatology of three patients. We also will present a brief review of the available literature on ON, with attention to its relevant anatomy, presentation, examination, and treatment.

An unusual cause of medial arm pain

A 21-year-old woman came to the student health facility reporting left medial arm pain. The pain had occurred intermittently over the last year after strenuous upper-body weight lifting, especially biceps curls. She had recently noticed a bump on the inside of her left arm at the site of pain. The bump was present continuously despite the intermittent nature of her pain. No numbness, tingling, or loss of arm strength were noted, and she did not have neck, shoulder, elbow, or wrist pain, or similar symptoms in the opposite arm. The patient had no history of fractures, other bone abnormalities, or trauma to this area. She was not currently taking medication and was not using supplements.

Socioeconomic Status and Race Outperform Concussion History and Sport Participation in Predicting Collegiate Athlete Baseline Neurocognitive Scores

OBJECTIVES The purpose of this study was to assess the contribution of socioeconomic status (SES) and other multivariate predictors to baseline neurocognitive functioning in collegiate athletes. METHODS Data were obtained from the Concussion Assessment, Research and Education (CARE) Consortium. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) baseline assessments for 403 University of Florida student-athletes (202 males; age range: 18-23) from the 2014-2015 and 2015-2016 seasons were analyzed. ImPACT composite scores were consolidated into one memory and one speed composite score. Hierarchical linear regressions were used for analyses. RESULTS In the overall sample, history of learning disability (β=-0.164; p=.001) and attention deficit-hyperactivity disorder (β=-0.102; p=.038) significantly predicted worse memory and speed performance, respectively. Older age predicted better speed performance (β=.176; p<.001). Black/African American race predicted worse memory (β=-0.113; p=.026) and speed performance (β=-.242; p<.001). In football players, higher maternal SES predicted better memory performance (β=0.308; p=.007); older age predicted better speed performance (β=0.346; p=.001); while Black/African American race predicted worse speed performance (β=-0.397; p<.001). CONCLUSIONS Baseline memory and speed scores are significantly influenced by history of neurodevelopmental disorder, age, and race. In football players, specifically, maternal SES independently predicted baseline memory scores, but concussion history and years exposed to sport were not predictive. SES, race, and medical history beyond exposure to brain injury or subclinical brain trauma are important factors when interpreting variability in cognitive scores among collegiate athletes. Additionally, sport-specific differences in the proportional representation of various demographic variables (e.g., SES and race) may also be an important consideration within the broader biopsychosocial attributional model. (JINS, 2018, 24, 1-10).

Influences of Mental Illness, Current Psychological State, and Concussion History on Baseline Concussion Assessment Performance:

Background: A student-athlete’s mental state, including history of trait anxiety and depression, or current psychological state may affect baseline concussion assessment performance. Purpose: (1) To determine if mental illness (anxiety, depression, anxiety with depression) influences baseline scores, (2) to determine if psychological state correlates with baseline performance, and (3) to determine if history of concussion affects Brief Symptom Inventory–18 (BSI-18) subscores of state anxiety, depression, and somatization. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A sample of 8652 collegiate student-athletes (54.5% males, 45.5% females) participated in the Concussion Assessment, Research and Education (CARE) Consortium. Baseline assessments included a demographic form, a symptom evaluation, Standardized Assessment of Concussion, Balance Error Scoring System, a psychological state assessment (BSI-18), and Immediate Post-concussion Assessment and Cognitive Test. Baseline scores were compared between individuals with a history of anxiety (n = 59), depression (n = 283), and anxiety with depression (n = 68) and individuals without a history of those conditions (n = 8242). Spearman’s rho correlations were conducted to assess the relationship between baseline and psychological state subscores (anxiety, depression, somatization) (α = .05). Psychological state subscores were compared between individuals with a self-reported history of concussions (0, 1, 2, 3, 4+) using Kruskal-Wallis tests (α = .05). Results: Student-athletes with anxiety, depression, and anxiety with depression demonstrated higher scores in number of symptoms reported (anxiety, 4.3 ± 4.2; depression, 5.2 ± 4.8; anxiety with depression, 5.4 ± 3.9; no anxiety/depression, 2.5 ± 3.4), symptom severity (anxiety, 8.1 ± 9.8; depression, 10.4 ± 12.4; anxiety with depression, 12.4 ± 10.7; no anxiety/depression, 4.1 ± 6.9), and psychological distress in state anxiety (anxiety, 3.7 ± 4.7; depression, 2.5 ± 3.6; anxiety with depression, 3.8 ± 4.2; no anxiety/depression, 0.8 ± 1.8), depression (anxiety, 2.4 ± 4.0; depression, 3.2 ± 4.5; anxiety with depression, 3.8 ± 4.8; no anxiety/depression, 0.8 ± 1.8), and somatization (anxiety, 2.3 ± 2.9; depression, 1.8 ± 2.8; anxiety with depression, 2.2 ± 2.4; no anxiety/depression, 0.9 ± 1.7). A moderate positive relationship existed between all BSI-18 subscores and total symptom number (n = 8377; anxiety: rs = 0.43, P < .001; depression: rs = 0.42, P < .001; somatization: rs = 0.45, P < .001), as well as total symptom severity (anxiety: rs = 0.43, P < .001; depression: rs = 0.41, P < .001; somatization: rs = 0.45, P < .001). Anxiety, depression, and somatization subscores were greater among student-athletes that self-reported more concussions. Conclusion: Clinicians should be cognizant that student-athletes with a history of trait anxiety, depression, and anxiety with depression may report higher symptom score and severity at baseline. Individuals with extensive concussion history may experience greater state anxiety, depression, and somatization.

A case of vasovagal syncope in a collegiate swimmer during competition.

Introduction Vasovagal syncope (VVS), also known as neurocardiogenic syncope and vasodepressor syncope, is a frequent and usually benign form of syncope that results from an errant reflex arc of cardiac mechanoreceptors (4,19). It is considered a subset of neurally mediated (reflex) syncope (17). While VVS is common, it rarely occurs during exercise (5). An athlete who presents with exertional syncope should not be diagnosed with VVS until a thorough cardiac evaluation excludes arrhythmias and structural heart disease. The 36th Bethesda Conference Guidelines do not restrict athletes with VVS from returning to participation (12,20). We describe a case of exertional syncope in a collegiate swimmer, which, after thorough workup, was attributed to VVS. The athlete was allowed to return to swimming with individual supervision. To our knowledge, this is the first reported case of VVS during swimming competition.