Lynda Mainwaring

Emotional response to sport concussion compared to ACL injury

Primary objectives: To ascertain and compare the nature of emotional response of athletes to concussion and to anterior cruciate ligament (ACL) injury. Research design: Pre-injury, post-injury and longitudinal emotional functioning of athletes with concussion (n = 16), athletes with ACL injuries (n = 7) and uninjured athletes (n = 28) were compared in a prospective repeated-measures design. Methods and procedures: Participants completed the short version of the Profile of Mood States (POMS). ANOVAs and trend analysis were used to examine between and within group differences across time on two sub-scales, Total Mood Disturbance and Depression. Main outcomes and results: Athletes with ACL injury reported higher levels of depression for a longer duration than athletes with concussion. Relative to un-injured controls, athletes with concussion reported significant changes in Total Mood Disturbance and Depression post-injury, whereas athletes with ACL injuries reported significant changes in Depression scores only. Different patterns of post-injury emotional disturbance for the injured groups were observed by trend analyses. Conclusions: Concussed athletes do not report as much emotional disturbance as athletes with ACL injuries. Differential patterns of emotional disturbance were detected between injured groups. The authors recommended that clinical protocols and educational programmes address emotional sequelae associated with sport concussion and ACL injury.

Differential emotional responses of varsity athletes to concussion and musculoskeletal injuries.

Objective: To determine if athletes with concussion and those with minor musculoskeletal injuries experienced differential emotional response to injury. Design: A prospective longitudinal cohort study. Setting: University of Toronto, Ontario, Canada. Participants: Thirty-four injured athletes from Canadian Interuniversity Sport (CIS) and 19 healthy, physically active undergraduate students participated in the study. Intervention: All participants completed the Profile of Mood States (POMS; short version) on 3 nonconsecutive days during a 2-week period after a baseline test. Main Outcome Measures: Emotional responses were assessed using the POMS. The 7 main outcome measures assessed by POMS were tension, depression, anger, vigor, fatigue, confusion, and total mood disturbance. Results: After injury, concussion produced an emotional profile characterized by significantly elevated fatigue and decreased vigor. In contrast, athletes with musculoskeletal injuries displayed a significant increase in anger that resolved to a pre-injury level within 2 weeks. Conclusions: The results revealed that both injured groups experienced emotional disturbance after injury. More importantly, the findings strongly suggest that the emotional reaction after concussion is different from that of musculoskeletal injury. Therefore, we concluded that assessing emotional reactions to concussion is particularly important and recommend that sports medicine professionals assess and monitor emotional functioning as well as somatic complaints and neurocognitive changes during recovery.

Does the Apolipoprotein e4 Allele Predispose Varsity Athletes to Concussion? A Prospective Cohort Study

Objective:To determine the association between the apolipoprotein ϵ4 allele and concussion. We hypothesized that apolipoprotein ϵ4 carriers may be more likely to sustain a concussion. Design:Prospective cohort study. Setting:University of Toronto varsity athletics. Participants:Included 318 of 822 collegiate student athletes who participated in University of Toronto varsity sports from September 2002 to April 2006. Assessment of Risk Factors:The presence of apolipoprotein ϵ4 was described dichotomously after genotyping blood samples collected from participants. Main Outcome Measurements:Concussions were identified by sport-medicine professionals present on the sidelines using on-field assessment forms. All concussion diagnoses were verified by a sports medicine physician. Survival analysis was used to determine the association between apolipoprotein ϵ4 and first concussion. Results:The unadjusted hazard ratio for concussion in the apolipoprotein ϵ4 carriers was 1.18 (95% CI: 0.52, 2.69) compared to noncarriers. Adjustment for sex, weight, height, and team type resulted in a hazard ratio of 1.06 (95% CI: 0.41, 2.72), indicating little effect from confounding factors. Conclusions:There is no important association between carrying the apolipoprotein ϵ4 allele and sustaining a concussion. At this time, we do not recommend preseason genetic testing for varsity athletes as a mechanism for targeting prevention strategies.

The Influence of Musculoskeletal Injury on Cognition: Implications for Concussion Research

Background: Safe return-to-play decisions after concussion can be challenging for sports medicine specialists. Neuropsychological testing is recommended to objectively measure concussion-related cognitive impairments. Purpose: The objective of this study was to measure cognitive functioning among 3 specific athletic groups: (1) athletes with no injuries (n = 36), (2) athletes with musculoskeletal injuries (n = 18), and (3) athletes with concussion (n = 18). Study Design: Case-control study; Level of evidence, 3. Methods: Seventy-two intercollegiate athletes completed preseason baseline cognitive testing and follow-up assessment using the Automated Neuropsychological Assessment Metrics (ANAM) test battery. Injured athletes were tested within 72 hours of injury. A 1-way analysis of covariance adjusted for baseline scores was performed to determine if differences existed in cognitive test scores among the 3 groups. Results: A group of athletes with concussion performed significantly worse than a group of athletes with no injuries on the following subtests of the ANAM at follow-up: Code Substitution Learning, Match to Sample, and Simple Reaction. Athletes with musculoskeletal injuries performed significantly worse than those with no injury on the Match to Sample subtest. No significant differences between athletes with concussion and athletes with musculoskeletal injuries were found on all ANAM subtests. Conclusion: Concussion produces cognitive impairment in the acute recovery period. Interestingly, athletes with musculoskeletal injuries also display a degree of cognitive impairment as measured by computerized tests. Clinical Relevance: Although these findings support previous research that neuropsychological tests can effectively measure concussion-related cognitive impairment, this study provides evidence that athletic injury, in general, also may produce a degree of cognitive disruption. Therefore, a narrow interpretation of scores of neuropsychological tests in a sports concussion context should be avoided.

Evaluating the methodological quality of sports neuropsychology concussion research: A systematic review

Primary objective: Sports-related concussion is a frequently-occurring, serious neurological event that can produce a spectrum of potentially debilitating primary and secondary problems. Many investigators—particularly neuropsychologists—have focused their efforts on identifying cognitive changes that accompany such injuries. As such, the present review evaluated the methodological quality of neuropsychological sports-related concussion research using a comprehensive, systematic method. Research design: Of 349 studies initially selected by search criteria, a total of 43 studies were evaluated using a Cochrane-style review format. Research methods: Studies were assigned a Level of Evidence using the Centre for Evidence-based Medicine (CEMB) framework. Relevant information related to the methods of each study were extracted and rated for methodological quality using a standardized form-based evaluation tool. Results: The review revealed heterogeneity among the studies in terms of research design, as well as a number of methodological weaknesses and inconsistencies. Conclusion: Despite the proliferation of neuropsychological research on sports-related concussion over the past decade, the methodological quality of studies appears to be highly variable, with many lacking proper scientific rigour. Future research in this area needs to be carefully controlled, repeatable and generalizable, which will contribute to developing practical, evidence-based guidelines for concussion management.

Teaching the Dance Class: Strategies to Enhance Skill Acquisition, Mastery and Positive Self-Image.

Abstract Effective teaching of dance skills is informed by a variety of theoretical frameworks and individual teaching and learning styles. The purpose of this paper is to present practical teaching strategies that enhance the mastery of skills and promote self-esteem, self-efficacy, and positive self-image. The predominant thinking and primary research findings from dance pedagogy, education, physical education and sport pedagogy, and psychology are distilled into 16 guidelines for teaching dance. Subsequently, theoretically and empirically informed strategies for best teaching practices are explored by reference to three broad categories: 1. clarifying the process and goals of the class, 2. discussing various influences that affect the dancers progress, and 3. clearly defining the class structure and content.

Psychological and Physiological Markers of Stress in Concussed Athletes Across Recovery Milestones.

Background: Sport-related concussions are associated with a range of physical, cognitive, and behavioral disturbances that are highly variable across individuals. Much remains unknown about the effects of sport concussion, and changes in markers of psychological and physiological stress over the recovery timeline. Objective: To examine psychological (mood, stress, sleep quality, and symptoms) and physiological (heart rate variability and salivary cortisol) measures in concussed athletes over clinical recovery milestones. Setting: University athletic program, sport medicine clinic, Canada. Participants: A sample of 52 interuniversity athletes (32 male and 20 female), 26 with concussion and 26 healthy controls. Design: Case-control repeated measures study at 3 time points of the clinical recovery process. Measures were administered to a matched control sample of uninjured athletes as well. Main Measures: Physiological measures were heart rate variability and salivary cortisol; psychological measures were mood, perceived stress, and quality of sleep. Results: Psychological measures were significantly worse for concussed athletes relative to controls at the symptomatic phase (acute injury), but significantly better at return-to-play (RTP). Multivariate analysis of heart rate variability identified main effects of sex and concussion, with reduced high-frequency heart rate variability for females and concussed athletes extending into the post-RTP phase. An interaction effect was also observed, showing the cardiac response of female athletes was more sensitive to concussion compared with males. Conversely, male athletes showed greater suppression of low-frequency heart rate variability associated with mood disturbances. Conclusion: This integrated study of psychological and physiological markers in concussed athletes confirmed the resolution of mood disturbances, symptoms, and sleep quality by RTP, but identified autonomic nervous system disturbances, as measured by depressed heart rate variability beyond RTP.

Heart Rate Variability of Athletes Across Concussion Recovery Milestones: A Preliminary Study.

Objective: To assess heart rate variability (HRV) in athletes with concussion across three phases of recovery. Design: A prospective matched control group design included the collection of HRV and symptoms measured by the Rivermead Post-Concussion Questionnaire. These measures were taken at 3 phases of recovery [(1) symptomatic; (2). asymptomatic; and (3) one-week after return-to-play (RTP)]. The same protocol was completed by noninjured athletes. Setting: Interuniversity sports teams at a single institution. Participants: 11 athletes, across 7 sports, diagnosed with concussion, and 11 matched-athlete controls volunteered for the study. Intervention: Physician diagnosed concussion and a sitting to standing protocol for HRV monitoring. Main Outcome Measures: The frequency, time, and nonlinear domains of HRV were assessed along with the absolute difference between sitting and standing for each. Results: A 2 x 3 (group x phase) repeated-measures analysis of variance revealed significant interactions for sitting High Frequency (HF) norm, sitting Low Frequency (LF) norm, the difference between sitting and standing HF norm, and difference between sitting and standing LF norm. Acutely, athletes with concussion displayed increased LF norm and decreased HF norm while sitting and a decreased change in their HF and LF norm measures between sitting and standing. A significant group effect for sample entropy when standing was detected, with the concussed group displaying decreased values compared with the matched controls. Conclusions: Athletes with concussion displayed autonomic dysfunction in some measures of HRV that persisted beyond RTP and were related to a previous history of concussion.

POST-CONCUSSION STRESS IN ASYMPTOMATIC ATHLETES

Background Post-concussion, the body is “stressed” as it attempts to restore metabolic and psychologic equilibrium. Elevated stress can be evaluated by disrupted cortisol cycling, perturbations in Heart Rate Variability (HRV), and reported mood disturbance and perceived stress. Assessing stress in concussed athletes may be informative for optimal recovery, safe return-to-play (RTP), and subsequent injury prevention. Objective To assess the utility of non-invasive stress measures in monitoring concussion recovery. Design A prospective matched control group design included collection of salivary cortisol, HRV, and two self-report measures: the Profile of Mood States (POMS), and the Perceived Stress Scale (PSS). All measures were taken at three phases of recovery (1. Symptomatic; 2. Asymptomatic; and 3. One-week following RTP). The same protocol was completed by non-injured athletes. Setting Interuniversity sports teams at a single institution. Participants 11 athletes, across seven sports, diagnosed with concussion and 11 matched-athlete controls volunteered for the study. Main outcome measurements Primary outcome measures to test the a-priori hypotheses included: HRV, AM and PM salivary cortisol, Total Mood Disturbance, Depression, Confusion, Fatigue, Vigor, Tension, Anger, and Perceived Stress. Results A series of 2 (Group) × 3 (Phase) repeated measures ANOVAs revealed significant interactions for HRV and emotional disturbance. Although no emotional disturbance or perceived stress was reported in the asymptomatic phase, concussed athletes displayed altered HRV [increased Low Frequency norm (P=.041) and decreased High Frequency norm (P=.041)]. In addition, significant differences between groups were found for AM cortisol levels one week after RTP (P=.019). Conclusions Concussed athletes displayed perturbations in HRV, indicating neuroautonomic dysfunction, despite resolution of symptom and mood disturbance. In addition, low levels of morning cortisol following RTP may be indicative of a lingering physiological stress response. These non-invasive markers may be clinically useful in post-concussive recovery assessment and prevention of subsequent injury.

A Teacher's Guide to Helping Young Dancers Cope with Psychological Aspects of Hip Injuries

Abstract Hip injuries are a potentially significant and debilitating condition. In addition to the physical complications, there are serious psychological consequences that can be as incapacitating as the physical damage. This review presents two case studies that describe salient issues that may arise when a young dancer is injured, and outlines practical strategies to help teachers manage psychological recovery in class and rehearsal. The two adolescent females in these examples each suffered a long-term, chronic injury to the hip and were subsequently unable to dance for a period of several months. They each discuss the ongoing progress of the injury, and the resultant devastation they experienced emotionally. Practical strategies for helping young dancers cope with the psychological aspects of hip injuries include: modification of dance activities, alternative activities during dance practice, activities outside the studio, and the encouragement of psychosocial strategies for recovery. Each of these areas is examined and suggestions are provided for dance teachers dealing with injured dancers.