Detection of Persisting Concussion Effects on Measures of Neuromechanical Responsiveness

Abstract INTRODUCTION Numerous investigations have documented elevated risk for musculoskeletal injury following sport-related concussion, which suggests that an unrecognized vulnerability persists beyond the resolution of symptoms and return to sport participation. Improved clinical testing methods are needed to better assess the interrelated neurocognitive and neuromuscular capabilities of athletes who may have elevated susceptibility to MSK injury, and possible risk for long- term alterations in brain function, despite resolution of overt concussion symptoms. The term “neuromechanics” refers to the study of interactions between neural, biomechanical, and environmental dynamics We use the term “neuromechanical responsiveness” (NMR) to designate the ability to optimally integrate neurocognitive and neuromuscular processes during participation in sport-related activities. NMR testing may play an critical role in optimizing safe return to play circumstances. METHODS A cohort of 48 elite athletes (34 males: 23.8 ± 4.4 yr; 14 females: 25.4 ± 4.5 yr) performed visuomotor reaction time (VMRT) tests involving rapid manual contact with illuminated target buttons that included 2 dual-task conditions: 1) simultaneous oral recitation of scrolling text (VMRT + ST) and 2) simultaneous verbal responses to identify the right or left direction indicated by the center arrow of the Eriksen flanker test (VMRT + FT). A whole-body reactive agility (WBRA) test requiring side-shuffle movements in response to visual targets was used to assess reaction time, speed, acceleration, and deceleration. RESULTS Concussion occurrence at 2.0 ± 2.3 yr prior to testing was reported by 21 athletes. Strong univariable associations were found for VMRT + FT left minus right difference = 15 ms (OR = 7.14), VMRT + ST outer 2-ring to inner 3-ring ratio = 1.28 (OR = 4.58), and WBRA speed asymmetry = 7.7% (OR = 4.67). A large VMRT + FT X VMRT + ST interaction effect was identified (OR = 25.00). Recursive partitioning identified a 3-way VMRT + FT X VMRT + ST X WBRA interaction that had 100% positive predictive value for identification of athletes with concussion history, whereas negative status on all 3 factors provided 90% negative predictive value. CONCLUSION Performance on dual-task VMRT tests and the WBRA test identified NMR deficiencies among elite athletes who reported a history of concussion.

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Dynamic Reaction Time: Jumping into the Future of Concussion Management

Archives of Clinical Neuropsychology ◽

10.1093/arclin/acz026.58 ◽

2019 ◽

Vol 34 (5) ◽

pp. 788-788

Author(s):

R S Johnson ◽

L B Lempke ◽

J D Schmidt ◽

R C Lynall

Keyword(s):

Reaction Time ◽

Dual Task ◽

High Speed ◽

Sport Participation ◽

Cognitive Task ◽

Pearson Correlation ◽

Vital Signs ◽

Return To Play ◽

Single Task ◽

Jump Landing

Abstract Purpose To explore the relationship between reaction time (RT) on a commonly used post-concussion computerized neurocognitive assessment and dynamic RT during sport-like movements, with and without a cognitive task. Methods Fourteen healthy individuals (7 females; age=22.3±2.5yrs, height=169.1±14.0cm, mass=71.1±16.8kg) completed a computerized Stroop task (CNS Vital Signs), where the individual presses the space bar when the color of the word does not match the word, and two dynamic RT tasks (jump landing [4 trials], anticipated cutting [8 trials]). Dynamic RT tasks were performed with (dual-task) and without (single-task) a cognitive task (subtracting by 6’s or 7’s). Participants jumped off of a 30cm box and then either performed a maximum vertical jump landing or an anticipated cut at 45. Dynamic RT, recorded using high-speed 3D-motion capture (Qualisys), was the average time (seconds) between visual stimulus and when participants’ sacrum moved >3cm in the sagittal or transverse plane. Pearson correlation coefficients (α=0.05) were calculated between all RT measures. Results Stroop RT (0.67±0.01s) was not significantly correlated with jump landing single-task (p=0.45; r=0.22), jump landing dual-task (p=0.10; r=0.45), anticipated cutting single-task (p=0.7; r=0.11), or anticipated cutting dual-task (p=0.85; r=0.06) RTs. We found positive correlations between all single- and dual-task dynamic RTs (p=.03, r=.56). Conclusion Stroop RT was not correlated with dynamic RTs, which may more closely reflect RT associated with sport participation. Commonly used computerized RT assessments may not fully represent the dynamic RT athletes need in sport tasks. Further investigation is warranted in order to develop the most appropriate RT assessments for post-concussion return-to-play.

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Essentials for Best Practice: Treatment Approaches for Athletes With Eating Disorders

Journal of Clinical Sport Psychology ◽

10.1123/jcsp.2018-0013 ◽

2018 ◽

Vol 12 (4) ◽

pp. 495-507 ◽

Cited By ~ 2

Author(s):

Jenny H. Conviser ◽

Amanda Schlitzer Tierney ◽

Riley Nickols

Keyword(s):

Eating Disorders ◽

Emotional Regulation ◽

Best Practice ◽

Sport Participation ◽

Emotional Health ◽

Multidisciplinary Treatment ◽

Return To Sport ◽

Multidisciplinary Care ◽

Return To Play ◽

Treatment Team

Eating disorders (EDs) and disordered-eating behaviors (DEBs), pose a high risk of morbidity and mortality, threatening physical health, emotional health, and overall quality of life. Unfortunately, among athletes, prevalence rates continue to increase. This document summarizes the challenges of establishing and navigating the multidisciplinary care needed to effectively treat EDs and DEBs among athletes. The benefits of timely and frequent communication within the multidisciplinary treatment team (MDTT) are emphasized and discussed. Authors advise who should be selected as members of the MDTT and suggest that all personnel, including athletic coaches, athletic trainers, physical therapists, and certified fitness professionals be ED-informed and ED-sensitive. Vital components of care are noted including use of a variety of evidence-based psychotherapeutic modalities, interventions which target emotional regulation, and prioritize values based compassionate care. Authors caution that performance decrements and medical/physiological changes are not always easily observable in individuals with EDs and DEBs and therefore, attuned, consistent, and ongoing monitoring is needed. Consensus regarding previously established parameters for return to play and careful titration of physical activity throughout the ED recovery process are suggested as important for preserving health, preventing re-injury, or relapse and facilitating successful return to sport participation.

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Concussion History and Neuromechanical Responsiveness Asymmetry

Journal of Athletic Training ◽

10.4085/1062-6050-0401.19 ◽

2020 ◽

Vol 55 (6) ◽

pp. 594-600 ◽

Cited By ~ 2

Author(s):

Gary B. Wilkerson ◽

Dustin C. Nabhan ◽

Ryan T. Crane

Keyword(s):

Reaction Time ◽

Elite Athletes ◽

Area Under The Curve ◽

Musculoskeletal Injury ◽

Whole Body ◽

Lateral Asymmetry ◽

Good Discrimination ◽

Cross Sectional ◽

Concussion History ◽

Sensorimotor Processes

Context Detection of subtle changes in brain sensorimotor processes may enable clinicians to identify athletes who would derive the greatest benefit from interventions designed to reduce the risk for future injury and progressive neurologic or musculoskeletal dysfunction. Objective To develop a generalizable statistical model for identifying athletes who possess subtle alterations in sensorimotor processes that may be due to previous concussion. Design Cross-sectional study. Setting Residential Olympic Training Center sports medicine clinic. Patients or Other Participants A primary cohort of 35 elite athletes and a secondary cohort of 40 elite athletes who performed identical tests the preceding year. Intervention(s) Two upper extremity tests of visual-motor reaction time and 2 tests of whole-body reactive agility were administered. The whole-body tests required lateral or diagonal responses to virtual-reality targets, which provided measures of reaction time, speed, acceleration, and deceleration. Main Outcome Measure(s) Sport-related concussion history, which was reported by 54% (n = 19) of the athletes in the primary cohort and 45% (n = 18) of the athletes in the secondary cohort. Results Univariable analyses identified 12 strong predictors of sport-related concussion history, which we combined to create a composite metric with maximum predictive value. Composite lateral asymmetry for whole-body reactive movements and persisting effects of previous musculoskeletal injury yielded a logistic regression model with exceptionally good discrimination (area under the curve = 0.845) and calibration (predicted-observed probabilities within 7 subgroups: r = 0.959, P = .001). Application of the derived model to compatible data acquired from another cohort of elite athletes demonstrated very good discrimination (area under the curve = 0.772) and calibration (within 8 subgroups: r = 0.849, P = .008). Conclusions Asymmetry in whole-body reactive movement capabilities may be a manifestation of a subtle abnormality in the functional connectivity of brain networks that might be relevant to previously reported associations between sport-related concussion history and musculoskeletal injury occurrence.

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Return-to-Play Considerations Following a COVID-19 Infection in Elite Athletes

Journal of Athletic Training ◽

10.4085/1062-6050-0117.21 ◽

2021 ◽

Author(s):

Ryan Ross ◽

Laura Irvin ◽

Rich Severin ◽

Brian Ellis

Keyword(s):

Sports Medicine ◽

Sport Participation ◽

Elite Athletes ◽

Return To Play ◽

Strength And Conditioning ◽

Unique Challenge ◽

Orthopedic Injuries ◽

High Level ◽

Isolation Period ◽

Prolonged Absence

Abstract The COVID-19 pandemic has created a unique challenge for sports medicine staffs as they are attempting to safely transition elite athletes into sport participation after a COVID-19 infection. Athletes must isolate for a period of time after testing positive for COVID-19 to prevent the spread of the virus within a community. After an isolation period, a battery of cardiac tests must be given to assess whether or not an athlete is ready to begin a reconditioning protocol. A return-to-play plan should be established to safely re-integrate high-level athletes into strength and conditioning, sport-specific drill work, and contact drill work. Elite athletes should also be gradually eased back into full training loads in order to avoid increases in orthopedic injuries after a prolonged absence from training.

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Upper-Extremity Perceptual-Motor Training Improves Whole-Body Reactive Agility Among Elite Athletes With History of Sport-Related Concussion

Journal of Sport Rehabilitation ◽

10.1123/jsr.2020-0337 ◽

2020 ◽

pp. 1-6

Author(s):

Gary B. Wilkerson ◽

Dustin C. Nabhan ◽

Ryan T. Crane

Keyword(s):

Reaction Time ◽

Upper Extremity ◽

Elite Athletes ◽

Whole Body ◽

Training Effect ◽

Characteristic Analysis ◽

Significant Group ◽

Reactive Agility ◽

Conflict Effect ◽

History Of

Context: Sport-related concussion (SRC) elevates risk for subsequent injury, which may relate to impaired perceptual-motor processes that are potentially modifiable. Objective: To assess a possible upper-extremity (UE) training effect on whole-body (WB) reactive agility performance among elite athletes with history of SRC (HxSRC) and without such history of SRC. Design: Cohort study. Setting: Residential training center. Participants: Elite athletes (12 males and 8 females), including 10 HxSRC and 10 without such history of SRC. Intervention: One-minute training sessions completed 2 to 3 times per week over a 3-week period involved verbal identification of center arrow direction for 10 incongruent and 10 congruent flanker test trials with simultaneous reaching responses to deactivate illuminated buttons. Main Outcome Measures: Pretraining and posttraining assessments of UE and WB reactive responses included flanker test conflict effect (incongruent minus congruent reaction time) and WB lateral average asymmetry derived from reaction time, speed, acceleration, and deceleration in opposite directions. Discrimination was assessed by receiver operating characteristic analysis, and training effect was assessed by repeated-measures analysis of variance. Results: Pretraining discrimination between HxSRC and without such history of SRC was greatest for conflict effect ≥80 milliseconds and WB lateral average asymmetry ≥18%. Each athlete completed 6 training sessions, which improved UE mean reaction time from 767 to 646 milliseconds (P < .001) and reduced mean conflict effect from 96 to 53 milliseconds (P = .039). A significant group × trial interaction was evident for WB lateral average asymmetry (P = .004), which was reduced from 24.3% to 12.5% among those with HxSRC. Conclusions: Suboptimal perceptual-motor performance may represent a subtle long-term effect of concussion that is modifiable through UE training, which appears to improve WB reactive capabilities.

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A Novel Approach to Assessment of Perceptual-Motor Efficiency and Training-Induced Improvement in the Performance Capabilities of Elite Athletes

Frontiers in Sports and Active Living ◽

10.3389/fspor.2021.729729 ◽

2021 ◽

Vol 3 ◽

Author(s):

Gary B. Wilkerson ◽

Dustin C. Nabhan ◽

Tyler S. Perry

Keyword(s):

Reaction Time ◽

Performance Metrics ◽

Performance Enhancement ◽

Elite Athletes ◽

Average Distance ◽

Whole Body ◽

Neurophysiological Mechanism ◽

Motor Efficiency ◽

Left And Right ◽

And Training

Standard clinical assessments of mild traumatic brain injury are inadequate to detect subtle abnormalities that can be revealed by sophisticated diagnostic technology. An association has been observed between sport-related concussion (SRC) and subsequent musculoskeletal injury, but the underlying neurophysiological mechanism is not currently understood. A cohort of 16 elite athletes (10 male, 6 female), which included nine individuals who reported a history of SRC (5 male, 4 female) that occurred between 4 months and 8 years earlier, volunteered to participate in a 12-session program for assessment and training of perceptual-motor efficiency. Performance metrics derived from single- and dual-task whole-body lateral and diagonal reactive movements to virtual reality targets in left and right directions were analyzed separately and combined in various ways to create composite representations of global function. Intra-individual variability across performance domains demonstrated very good SRC history classification accuracy for the earliest 3-session phase of the program (Reaction Time Dispersion AUC = 0.841; Deceleration Dispersion AUC = 0.810; Reaction Time Discrepancy AUC = 0.825, Deceleration Discrepancy AUC = 0.794). Good earliest phase discrimination was also found for Composite Asymmetry between left and right movement directions (AUC = 0.778) and Excursion Average distance beyond the minimal body displacement necessary for virtual target deactivation (AUC = 0.730). Sensitivity derived from Youden's Index for the 6 global factors ranged from 67 to 89% and an identical specificity value of 86% for all of them. Median values demonstrated substantial improvement from the first 3-session phase to the last 3-session phase for Composite Asymmetry and Excursion Average. The results suggest that a Composite Asymmetry value ≥ 0.15 and an Excursion Average value ≥ 7 m, provide reasonable qualitative approximations for clinical identification of suboptimal perceptual-motor performance. Despite acknowledged study limitations, the findings support a hypothesized relationship between whole-body reactive agility performance and functional connectivity among brain networks subserving sensory perception, cognitive decision-making, and motor execution. A complex systems approach appears to perform better than traditional data analysis methods for detection of subtle perceptual-motor impairment, which has the potential to advance both clinical management of SRC and training for performance enhancement.

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Symptom free return to sport following supervised exercise and a return to play progression

Neurology ◽

10.1212/01.wnl.0000550665.57781.73 ◽

2018 ◽

Vol 91 (23 Supplement 1) ◽

pp. S10.2-S10

Author(s):

Matthew T. Lorincz ◽

Melvin Darwin ◽

Andrea Almeida ◽

Andrew R. Sas

Keyword(s):

Sport Participation ◽

Clinical Care ◽

Secondary Analysis ◽

Return To Sport ◽

Sports Participation ◽

Return To Play ◽

Return To Sports ◽

Supervised Exercise ◽

Institutional Review ◽

Data Elements

ObjectiveTo determine if completion of a symptom free return to play progression (RTPP) was associated with a symptom free return to sport. A secondary analysis investigated symptom free return to sports participation following supervised exercise.BackgroundThe current consensus statement on concussion in sport recommends a graded return-to-sport strategy but there is limited data on the utility of this approach.Methods200 sequential clinic patients with physician-diagnosed concussion sustained during sport participation were contacted by phone following completion of care from a University-associated Sports Neurology clinic. A survey about their success in returning to their sport was administered. Standardized data elements were extracted from the medical records and analyzed. The study was approved by the university of Michigan Institutional Review Board.ResultsThe survey was completed on 61 (31%) patients. Of these, 57 (93%) returned to sport participation without symptom reoccurrence. Of those who returned to sport 41 (80%) returned to sport without symptom reoccurrence within 2 weeks of completed clinical care. 53 (87%) completed a RTPP and 49 (92%) of those completing a RTPP returned to sport without symptom reoccurrence. Completing a RTPP, compared to those not completing a RTPP, was significantly associated with return to sport participation without symptom reoccurrence (p = 0.0000001). Of those surveyed, 32 (52%) underwent supervised exercise (SE) as part of their clinical care. Completing SE, as compared to those not undergoing SE, was significantly associated with return to sport participation without symptom reoccurrence (p = 0.017).ConclusionsOur results support recommendations for utilizing graded return-to-sport strategy demonstrating that 92% of those completing a RTPP successfully returned to sport. Our data also suggest that completion of SE was a predictor of symptom free return to sport and can be incorporated in to return to play decision making.

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An Exploration of Sports Rehabilitators’ and Athletic Rehabilitation Therapists’ Views on Fear of Reinjury After Anterior Cruciate Ligament Reconstruction

Journal of Sport Rehabilitation ◽

10.1123/jsr.2014-0127 ◽

2015 ◽

Vol 24 (2) ◽

pp. 140-150 ◽

Cited By ~ 3

Author(s):

Fiona McVeigh ◽

Stephen M. Pack

Keyword(s):

Anterior Cruciate Ligament ◽

Anterior Cruciate Ligament Reconstruction ◽

Ligament Reconstruction ◽

Psychological Intervention ◽

Cruciate Ligament ◽

Critical Role ◽

Return To Sport ◽

Return To Play ◽

Cruciate Ligament Reconstruction ◽

Anterior Cruciate

Background:Research involving long-term follow-up of patients after successful anterior cruciate ligament reconstruction (ACLR) has shown that return-to-sport rates are not as good as would be expected despite many patients’ having normal knee-function scores. The psychological component, specifically fear of reinjury, plays a critical role in determining patients’ return to play and is frequently underestimated. Little is known about the recognition and intervention from the therapist’s perspective.Aim:To gain a greater understanding of the views of sports rehabilitators and athletic rehabilitation therapists on recognition of fear of reinjury in clients after ACLR.Method and Design:A qualitative approach, consisting of semistructured interviews with a purposive sample of 8 participants, sports rehabilitators, or athletic rehabilitation therapists. This population has been largely unexamined in this context in previous research.Main Findings:Thematic analysis yielded 2 main themes: communication and education. Participants discussed the importance of communication in the client–therapist relationship and how it is used in addressing misinformation and fear of reinjury. All participants used education in outlining the rehabilitation pathway and dealing with those providing social support around the client. Issues emerged relating to therapists’ recognition of observable signs of fear of reinjury in the clinical setting. Overall, participants thought that fear of reinjury was not a barrier to return to play after ACLR.Conclusion:There is a need for more education of therapists on recognizing fear of reinjury and the appropriate use of psychological intervention skills as a method for dealing with this throughout the rehabilitation process.

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Effects of two 24-week multimodal exercise programs on reaction time, mobility, and dual-task performance in community-dwelling older adults at risk of falling: a randomized controlled trial

BMC Public Health ◽

10.1186/s12889-021-10448-x ◽

2021 ◽

Vol 21 (S2) ◽

Author(s):

Hugo Rosado ◽

Jorge Bravo ◽

Armando Raimundo ◽

Joana Carvalho ◽

José Marmeleira ◽

...

Keyword(s):

Older Adults ◽

Reaction Time ◽

Task Performance ◽

Dual Task ◽

Intervention Program ◽

Community Dwelling ◽

Whole Body ◽

Control Group ◽

Dual Task Performance ◽

Community Dwelling Older Adults

Abstract Background Falls in older adults are considered a major public health problem. Declines in cognitive and physical functions, as measured by parameters including reaction time, mobility, and dual-task performance, have been reported to be important risk factors for falls. The aim of this study was to investigate the effects of two multimodal programs on reaction time, mobility, and dual-task performance in community-dwelling older adults at risk of falling. Methods In this randomized controlled trial, fifty-one participants (75.4 ± 5.6 years) were allocated into two experimental groups (EGs) (with sessions 3 times per week for 24 weeks), and a control group: EG1 was enrolled in a psychomotor intervention program, EG2 was enrolled in a combined exercise program (psychomotor intervention program + whole-body vibration program), and the control group maintained their usual daily activities. The participants were assessed at baseline, after the intervention, and after a 12-week no-intervention follow-up period. Results The comparisons revealed significant improvements in mobility and dual-task performance after the intervention in EG1, while there were improvements in reaction time, mobility, and dual-task performance in EG2 (p ≤ 0.05). The size of the interventions’ clinical effect was medium in EG1 and ranged from medium to large in EG2. The comparisons also showed a reduction in the fall rate in both EGs (EG1: -44.2%; EG2: − 63.0%, p ≤ 0.05) from baseline to post-intervention. The interventions’ effects on reaction time, mobility, and dual-task performance were no longer evident after the 12-week no-intervention follow-up period. Conclusions The results suggest that multimodal psychomotor programs were well tolerated by community-dwelling older adults and were effective for fall prevention, as well as for the prevention of cognitive and physical functional decline, particularly if the programs are combined with whole-body vibration exercise. The discontinuation of these programs could lead to the fast reversal of the positive outcomes achieved. Trial registration ClinicalTrials.gov Identifier: NCT03446352. Date of registration: February 07, 2018.

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Return to Play after Open Repair for Achilles Rupture in Recreational Athletes

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00322 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0032

Author(s):

Hong S. Lee ◽

Kiwon Young ◽

Tae-Hoon Park ◽

Hong Seop Lee

Keyword(s):

Achilles Tendon ◽

Sport Participation ◽

Open Repair ◽

Return To Sport ◽

Return To Play ◽

Return To Sports ◽

Personal Reason ◽

Recreational Athletes ◽

General Weakness ◽

The Mean

Category: Sports Introduction/Purpose: The management of Achilles tendon ruptures in recreational athletes can be challenging. This study assessed the average time to return to sport after open repair for Achilles rupture in recreational athletes. Methods: Twenty one recreational athletes with prodromal tendinous problems sustained an acute tear of the AT and surgical repair with Krachow method from June 2013 to April 2017. Their average age was 39.7 years, and the average follow-up time was 53.2 months. Each patient was evaluated for postoperative ATRS (Achilles Tendon Total Rupture Score), complication and time to return to sports. Results: The mean postoperative ATRS was 85.1. The mean length of time to return to sports was 8 months. Eighteen patients of 21 athletes returned to full sport participation. Eleven athletes returned to the original sports. Seven athletes changed their sports due to fear of re-rupture (four athletes), discomfort during running or jumping (one athlete), general weakness (one athlete), dissuade of family (one athlete). Three athletes didn’t return to sport participation due to thickening of Achilles tendon (two athletes) and personal reason (one athlete). Conclusion: The return to play was 85 % at 8 months postoperatively. The results provide reference data for sports physician in evaluation surgical results and informing athletes about expectations after surgery in terms of timing of return to sports in recreational athletes.

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