Sally Nogle

A Potential Biomarker in Sports-Related Concussion: Brain Functional Connectivity Alteration of the Default-Mode Network Measured with Longitudinal Resting-State fMRI over Thirty Days

Current diagnosis and monitoring of sports-related concussion rely on clinical signs and symptoms, and balance, vestibular, and neuropsychological examinations. Conventional brain imaging often does not reveal abnormalities. We sought to assess if the longitudinal change of functional and structural connectivity of the default-mode network (DMN) can serve as a potential biomarker. Eight concussed Division I collegiate football student-athletes in season (one participated twice) and 11 control subjects participated in this study. ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) was administered over the course of recovery. High-resolution three dimensional T1-weighted, T2*-weighted diffusion-tensor images and resting-state functional magnetic resonance imaging (rs-fMRI) scans were collected from each subject within 24 h, 7±1 d and 30±1 d after concussion. Both network based and whole-brain based functional correlation analyses on DMN were performed. ImPACT findings demonstrated significant cognitive impairment across multiple categories and a significant increase of symptom severity on Day 1 following a concussion but full recovery by 6.0±2.4 d. While the structural connectivity within DMN and gross anatomy appeared unchanged, a significantly reduced functional connectivity within DMN from Day 1 to Day 7 was found in the concussed group in this small pilot study. This reduction was seen in eight of our nine concussion cases. Compared with the control group, there appears a general trend of increased DMN functional connectivity on Day 1, a significant drop on Day 7, and partial recovery on Day 30. The results of this pilot study suggest that the functional connectivity of DMN measured with longitudinal rs-fMRI can serve as a potential biomarker to monitor the dynamically changing brain function after sports-related concussion, even in patients who have shown clinical improvement.

Examination of the test-retest reliability of a computerized neurocognitive test battery

Background: Test-retest reliability is a critical issue in the utility of computer-based neurocognitive assessment paradigms employing baseline and postconcussion tests. Researchers have reported low test-retest reliability for the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT) across an interval of 45 and 50 days. Purpose: To re-examine the test-retest reliability of the ImPACT between baseline, 45 days, and 50 days. Study Design: Descriptive laboratory study. Methods: Eighty-five physically active college students (51 male, 34 female) volunteered for this study. Participants completed the ImPACT as well as a 15-item memory test at baseline, 45 days, and 50 days. Intraclass correlation coefficients (ICCs) were calculated for ImPACT composite scores, and change scores were calculated using reliable change indices (RCIs) and regression-based methods (RBMs) at 80% and 95% confidence intervals (CIs). Results: The respective ICCs for baseline to day 45, day 45 to day 50, baseline to day 50, and overall were as follows: verbal memory (0.76, 0.69, 0.65, and 0.78), visual memory (0.72, 0.66, 0.60, and 0.74), visual motor (processing) speed (0.87, 0.88, 0.85, and 0.91), and reaction time (0.67, 0.81, 0.71, and 0.80). All ICCs exceeded the threshold value of 0.60 for acceptable test-retest reliability. All cases fell well within the 80% CI for both the RCI and RBM, while 1% to 5% of cases fell outside the 95% CI for the RCI and 1% for the RBM. Conclusion: Results suggest that the ImPACT is a reliable neurocognitive test battery at 45 and 50 days after the baseline assessment. The current findings agree with those of other reliability studies that have reported acceptable ICCs across 30-day to 1-year testing intervals, and they support the utility of the ImPACT for the multidisciplinary approach to concussion management. Clinical Relevance: This study suggests that the computerized neurocognitive test battery, ImPACT, is a reliable test for postconcussion serial assessments. However, when managing concussed athletes, the ImPACT should not be used as a stand-alone measure.

Knowledge of Concussion and Reporting Behaviors in High School Athletes With or Without Access to an Athletic Trainer

CONTEXT Increased sport participation and sport-related concussion incidence has led to an emphasis on having an appropriate medical professional available to high school athletes. The medical professional best suited to provide medical care to high school athletes is a certified athletic trainer (AT). Access to an AT may influence the reporting of sport-related concussion in the high school athletic population; however, little is known about how the presence of an AT affects concussion knowledge, prevention, and recognition. OBJECTIVE To evaluate knowledge of concussion and reporting behaviors in high school athletes who did or did not have access to an AT. DESIGN Cross-sectional study. SETTING Survey. PATIENTS OR OTHER PARTICIPANTS A total of 438 athletes with access to an AT and 277 without access to an AT. INTERVENTION(S) A validated knowledge-of-concussion survey consisting of 83 items addressing concussion history, concussion knowledge, scenario questions, signs and symptoms of a concussion, and reasons why an athlete would not report a concussion. The independent variable was access to an AT. MAIN OUTCOME MEASURE(S) We examined the proportion of athletes who correctly identified knowledge of concussion, signs and symptoms of concussion, and reasons why high school student-athletes would not disclose a potential concussive injury by access to an AT. Frequency statistics, χ2 tests, independent t tests, and linear regression were conducted to analyze the data. RESULTS The underreporting of concussion among high school athletes was 55%. Athletes with access to an AT had more knowledge of concussion than did athletes without such access (P ≤ .001). Chi-square tests did not demonstrate a significant relationship between AT access and a higher percentage reporting concussions. CONCLUSIONS High school athletes with access to an AT had more concussion knowledge, but they did not report suspected concussions to an authority figure more frequently than athletes without access to an AT.

Inguinal mass in a college football player: a case study.

A 22-yr-old male college football player presented with a 3-wk history of a mass in his right inguinal area. Originally thought by the athlete to be a groin strain, evaluation revealed a large indirect inguinal hernia. Surgical evaluation was obtained to confirm the diagnosis of a 4-cm opening at the external inguinal ring. The hernia completely and spontaneously reduced in the supine position. The athlete was successfully allowed to participate with the use of a truss and underwent an uneventful surgical repair at the end of the season. The diagnosis and treatment of inguinal hernias are reviewed.

Concussion Knowledge and Reporting Behavior Differences Between High School Athletes at Urban and Suburban High Schools

BACKGROUND We determined differences in knowledge of concussion and reporting behaviors of high school athletes attending urban and suburban high schools, and whether a relationship exists between underreporting and access to an athletic trainer in urban schools. METHODS High school athletes (N = 715) from 14 high schools completed a validated knowledge of concussion survey consisting of 83 questions. The independent variable was school type (urban/suburban). We examined the proportion of athletes who correctly identified signs and symptoms of concussion, knowledge of concussion and reasons why high school athletes would not disclose a potential concussive injury across school classification. Data were analyzed using descriptive, non-parametric, and inferential statistics. RESULTS Athletes attending urban schools have less concussion knowledge than athletes attending suburban schools (p < .01). Athletes attending urban schools without an athletic trainer have less knowledge than urban athletes at schools with an athletic trainer (p < .01) There was no significant relationship between reporting percentage and school type (p = .73); however, significant relationships exist between AT access at urban schools and 10 reasons for not reporting. CONCLUSION Concussion education efforts cannot be homogeneous in all communities. Education interventions must reflect the needs of each community.

Reliability and Normative Reference Values for the Vestibular/Ocular Motor Screening (VOMS) Tool in Youth Athletes:

Background: The Vestibular/Ocular Motor Screening (VOMS) measure is a newly developed vestibular and ocular motor symptom provocation screening tool for sport-related concussions. Baseline data, psychometric properties, and reliability of the VOMS are needed to further understand the applications of this tool, especially in the youth population, where research is scarce. Purpose: To establish normative data and document the internal consistency and false-positive rate of the VOMS in a sample of nonconcussed youth athletes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 423 youth athletes (male = 278, female = 145) between the ages of 8 and 14 years completed baseline VOMS screening before the start of their respective sport seasons. Internal consistency was measured with Cronbach α and inter-item correlations. Results: Approximately 60% of youth athletes reported no symptom provocation on baseline VOMS assessment, with 9% to 13% scoring over the cutoff levels (score of ≥2 for any individual VOMS symptom, near point convergence distance of ≥5 cm). The VOMS displayed a high internal consistency (Cronbach α = .97) at baseline among youth athletes. Conclusion: The current findings provide preliminary support for the implementation of VOMS baseline assessment into clinical practice, due to a high internal consistency, strong relationships between VOMS items, and a low false-positive rate at baseline in youth athletes.

Higher risk-taking behavioursbehaviors and sensation seeking needs in collegiate student-athletes with a history of multiple sport-related concussions

Objective To investigate differences in risk-taking behaviours and sensation seeking needs between collegiate student-athletes with and without a history of sport-related concussion (SRC). Design Cross-sectional quantitative study. Setting Four National Collegiate Athletic Association (NCAA) universities. Participants A total of 1,398 (68%) of 2,055 collegiate student-athletes completed the survey. There were 146 participants excluded due to: age<18, current SRC/acute musculoskeletal injury, SRC within 3-months, non-NCAA, non-SRC, and incomplete survey. Therefore, 1,252 subjects from 18 sports were included. Assessment of risk factors A10-minute survey was administered that included demographic information, SRC history, Barratt Impulsiveness Scale (BIS) for risk-taking, and Brief Sensation Seeking Scale (BSSS). The independent variable was SRC history: 0(n=938), 1(n=205), 2+(n=109). Outcome measures The dependent variables were BIS total risk-taking impulsivity and BSSS total sensation seeking scores. Main results Significant differences were found between SRC groups for the totalrisk-taking impulsivity [F(1,227)=7.15,p=0.00] and sensation seeking [F(1,214)=4.53,p=0.01] variables. Total risk-taking impulsivity was significantly higher for the 2+ SRC group compared to the 0 SRC group (MD±95%CI=0.18 ± 0.11,p=0.00) and the 1 SRC group (MD±95%CI=0.15 ± 0.12,p=0.02). Total sensation seeking scores were significantly higher for the 2+ SRC group compared to the 0 SRC group (MD±95%CI=0.19 ± 0.17, p=0.03). Conclusions Total risk-taking and sensation seeking scores were higher for collegiate student-athletes with a history of multiple SRC. This finding could be useful when implementing behaviour modifications for safer play. Future longitudinal research should adopt a pre-/post-test design to determine if increased risk-taking and sensation seeking are SRC risk-factors or if multiple SRCs cause an increase in psychological variables. Competing interests None.

Racial disparities in concussion knowledge and awareness in american adolescent athletes

Objective To examine if concussion knowledge and awareness disparities exists between underserved African American (AA) adolescent athletes and Caucasian athletes; and, if disparities exist between AAs with and without access to a full-time athletic trainer (AT). Design Cross-sectional. Setting Participants from 14 US high schools (9 within underserved, AA communities and 5 within predominantly Caucasian communities) completed a one-time paper and pencil knowledge of concussion questionnaire. Participants 577 athletes (372 AA, 205 Caucasian). All participants completed concussion education mandated by the government; participants without documentation of completion were excluded. Intervention Race and AT access were the independent variables. Outcome measures Knowledge of concussion was examined using a validated instrument that included 35 questions. Participants were instructed to identify signs and symptoms of concussion, complications of multiple concussions, and answer questions pertaining to general concussion awareness among distractors. Total knowledge was calculated by summing the number of correct answers out of 35. Scores could range from 0 to 35. Scores closer to 35 represented greater knowledge. Data were analysed with frequency statistics and independent t-tests. Knowledge score was the dependent variable; p=0.05. Main results Caucasian adolescents have greater concussion knowledge than AA adolescents (t (2, 575)=5.47, p<0.001). AA adolescents with access to an AT have more knowledge than AAs lacking access to an AT (t (2, 370)=2.58, p=0.01). Conclusions Participation of AA adolescents in concussion-risk sports, such as football, is very high; therefore, education efforts in underserved communities must address the knowledge gap and disparity of care. Competing interests None.