Impact of Playing Surface on Concussion Symptoms in Young American Football Players

ObjectiveTo identify differences in symptoms following sports-related concussion (SRC) on natural grass vs artificial turf in youth and adolescent football players.BackgroundThere is continued interest in reducing risk of SRC in football, with playing surface being one potentially modifiable factor. It is estimated that 15–30% of concussions result from helmet-to-ground contact, and some studies have suggested a higher incidence of SRC on grass in competitive contact sports compared to turf. To our knowledge, our study is the first to investigate reported post-concussive symptoms after SRC as they relate to playing surface.Design/MethodsData were prospectively collected from the North Texas Concussion Registry (ConTex), a longitudinal multi-institutional concussion database. We selected male football players between the ages of 10 and 24 who sustained a helmet-to-ground SRC (GCS 13–15) on either grass or turf. Pre-injury information and post-concussive symptoms (Graded Symptom Checklist from the SCAT-5) were collected at an initial in-person visit within 2 weeks of injury and via electronic follow up at 3 months.ResultsFifty-eight participants were included (grass = 32, turf = 26), and groups were similar in age (p = 0.089), time since injury (p = 0.500), history of headache (χ2 = 0.167), and prior history of concussion (χ2 = 0.868). Athletes who sustained SRC on grass reported significantly higher scores on the Graded Symptom Checklist (p = 0.018, mean 26.0 vs 11.4) and higher numbers of distinct symptoms (p = 0.013, mean 10.2 vs 5.5) compared to those who sustained SRC on turf. Symptoms that were rated significantly higher after SRC on grass included headache (p = 0.010), phonophobia (p = 0.014), dizziness (p = 0.001), fatigue (p = 0.021), blurred vision (p = 0.001), feeling “in a fog” (p = 0.014), difficulty remembering (p = 0.004), and feeling emotional (p = 0.041).ConclusionsYouth and adolescent football players who sustain SRC on grass report higher post-concussive symptom severity and burden. Elucidating differential effects of SRC on grass vs turf is important, as competitive playing surface is a modifiable risk factor.

Vertical Drop Jump Biomechanics of Patients With a 3- to 10-Year History of Youth Sport–Related Anterior Cruciate Ligament Reconstruction

Background: A better understanding of movement biomechanics after anterior cruciate ligament reconstruction (ACLR) could inform injury prevention, knee injury rehabilitation, and osteoarthritis prevention strategies. Purpose: To investigate differences in vertical drop jump (VDJ) biomechanics between patients with a 3- to 10-year history of youth sport–related ACLR and uninjured peers of a similar age, sex, and sport. Study Design: Cross-sectional study. Level of evidence III. Methods: Lower limb kinematics and bilateral ground-reaction forces (GRFs) were recorded for participants performing 10 VDJs. Joint angles and GRF data were analyzed, and statistical analysis was performed using 2 multivariate models. Dependent variables included sagittal (ankle, knee, and hip) and coronal (knee and hip) angles at initial contact and maximum knee flexion, the rate of change of coronal knee angles (35%-90% of the support phase; ie, slopes of linear regression lines), and vertical and mediolateral GRFs (normalized to body weight [BW]). Fixed effects included group, sex, and time since injury. Participant clusters, defined by sex and sport, were considered as random effects. Results: Participants included 48 patients with a history of ACLR and 48 uninjured age-, sex-, and sport-matched controls (median age, 22 years [range, 18-26 years]; 67% female). Patients with ACLR demonstrated steeper negative coronal knee angle slopes (β = –0.04 deg/% [95% CI, –0.07 to –0.00 deg/%]; P = .025). A longer time since injury was associated with reduced knee flexion (β = –0.2° [95% CI, –0.3° to –0.0°]; P = .014) and hip flexion (β = –0.1° [95% CI, –0.2° to –0.0°]; P = .018). Regardless of ACLR history, women displayed greater knee valgus at initial contact (β = 2.1° [95% CI, 0.4° to 3.8°]; P = .017), greater coronal knee angle slopes (β = 0.05 deg/% [95% CI, 0.02 to 0.09 deg/%]; P = .004), and larger vertical GRFs (landing: β = –0.34 BW [95% CI, –0.61 to –0.07 BW]; P = .014) (pushoff: β = –0.20 BW [95% CI, –0.32 to –0.08 BW]; P = .001). Conclusion: Women and patients with a 3- to 10-year history of ACLR demonstrated VDJ biomechanics that may be associated with knee motion control challenges. Clinical Relevance: It is important to consider knee motion control during activities such as VDJs when developing injury prevention and rehabilitation interventions aimed at improving joint health after youth sport–related ACLR.

Tibiofemoral contact and alignment in patients with anterior cruciate ligament rupture treated nonoperatively versus reconstruction

Aims Anterior cruciate ligament (ACL) rupture commonly leads to post-traumatic osteoarthritis, regardless of surgical reconstruction. This study uses standing MRI to investigate changes in contact area, contact centroid location, and tibiofemoral alignment between ACL-injured knees and healthy controls, to examine the effect of ACL reconstruction on these parameters. Methods An upright, open MRI was used to directly measure tibiofemoral contact area, centroid location, and alignment in 18 individuals with unilateral ACL rupture within the last five years. Eight participants had been treated nonoperatively and ten had ACL reconstruction performed within one year of injury. All participants were high-functioning and had returned to sport or recreational activities. Healthy contralateral knees served as controls. Participants were imaged in a standing posture with knees fully extended. Results Participants’ mean age was 28.4 years (SD 7.3), the mean time since injury was 2.7 years (SD 1.6), and the mean International Knee Documentation Subjective Knee Form score was 84.4 (SD 13.5). ACL injury was associated with a 10% increase (p = 0.001) in contact area, controlling for compartment, sex, posture, age, body mass, and time since injury. ACL injury was associated with a 5.2% more posteriorly translated medial centroid (p = 0.001), equivalent to a 2.6 mm posterior translation on a representative tibia with mean posteroanterior width of 49.4 mm. Relative to the femur, the tibiae of ACL ruptured knees were 2.3 mm more anteriorly translated (p = 0.003) and 2.6° less externally rotated (p = 0.010) than healthy controls. ACL reconstruction was not associated with an improvement in any measure. Conclusion ACL rupture was associated with an increased contact area, posteriorly translated medial centroid, anterior tibial translation, and reduced tibial external rotation in full extension. These changes were present 2.7 years post-injury regardless of ACL reconstruction status. Cite this article: Bone Joint J 2021;103-B(9):1505–1513.

Apathy and Traumatic Brain Injury

Traumatic brain injury (TBI) is a craniocerebral trauma associated with decreased level of consciousness, amnesia, and potential abnormalities on neuroimaging. Apathy is a common symptom after TBI with a wide prevalence range (11–71%), which may be due to assessment, overlapping symptoms with depression, time since injury, and severity of injury. There is a dearth of studies exploring the neurobiology of apathy after TBI but patterns indicate the involvement of the prefrontal cortex, anterior cingulate cortex, and insula. These areas are also commonly disrupted after a TBI. Little is known regarding the neuropsychology of apathy and TBI with some evidence of executive dysfunction and acquisition memory deficits. Similarly, there is limited evidence for treatment of apathy after TBI. Many interventions implemented to date were based on empirically based interventions for neurodegenerative disorders. This review is intended to raise clinicians’ awareness of apathy after TBI and encourage researchers to explore this emerging phenomenon.

Trends in Pressure Injury Development in Patients With Lower Motor Neuron and Upper Motor Neuron Lesions: A Retrospective Descriptive Study

BACKGROUND: Persons with spinal cord injury (SCI) are at high risk of pressure injury (PrI) development, but there is limited information about the effect of injury patterns (ie, upper motor neuron [UMN] or lower motor neuron [LMN] presentations) on PrI risk. PURPOSE: This study was conducted to explore the rate of PrI development in patients with LMN and UMN lesions. METHODS: A retrospective descriptive review of data from patients who were treated at a specialized outpatient SCI rehabilitation center in Baltimore, MD, between January 1, 2013, and December 31, 2019. Patients with neurological levels T8 and below, any type of SCI motor ability, and whose records were complete were included in the study. Data extracted included age, sex, date of injury, injury type, modified Ashworth Scale (MAS) score (ie, scale representing resistance to passive movement), date MAS was performed, body mass index, Spinal Cord Independent Measures-III, Braden Scale scores, ambulatory status, antispasticity medication, presence or history of PrI, and method of closure. Patients with a score of 0 on the MAS and without pharmacological management for spasticity were included in the LMN group, and patients with a score greater than 0 on the MAS with or without pharmacological management were included in the UMN group. Variables were compared using mean ± standard deviations, range, t-test, and Pearson’s chi-squared and Fisher exact tests where appropriate. P values < .05 were considered statistically significant. RESULTS: Of the 602 records examined, 194 were complete and met inclusion criteria. Most patients (119, 61.34%) were male and classified in the UMN group (162, 84%). Mean age and time since injury were 35.20 ± 18.78 and 6.20 ± 7.62 years, respectively. Seventy-three (73) of 194 patients (37.6%) had, or had a history of, a PrI; 21 (66%) in the LMN and 52 (32%) in the UMN group (X21 = 12.8; P < .001). Statistically significant differences were noted between persons with LMN and UMN in terms of Braden Scale scores, age, body mass index, Spinal Cord Independent Measures-III, and time since injury. Compared with the UMN group, more patients in the LMN group had motor complete injuries with ISNCSCI levels A/B (P < .001) and were nonambulatory (P < .001). CONCLUSION: The results of this study confirm that patients with SCI have a high rate of PrI development. The percentage of PrIs was significantly higher in the LMN than in the UMN group. Additional studies to examine the other variables that were significantly different between groups and their effect on PrI risk are needed.

A - 07 Post-Concussion Symptom Scale Factors Shift with Longer Time Since Injury in Adolescents with Sport-Related Concussion

Objective To evaluate the role of time since injury on the factor structure of the Post-Concussion Symptom Scale (PCSS) for athletes after sustaining a sport-related concussion (SRC). Methods Adolescent athletes (n = 782) were dichotomized based on time since injury: 0–7 (EARLY; n = 321, age: 15.4 ± 1.9 years, 51.7% female), 8–14 (MIDDLE; n = 281, age: 15.8 ± 2.2 years, 54.8% female) and 15–30 days (LATE; n = 180, age: 15.6 ± 1.8 years, 52.8% female). An EFA was performed on the 22 variables of the PCSS for each of the three cohorts (primary factor loading of 0.6 to retain each item). Results EARLY had a five-component model (64% of total variance): 1) GLOBAL (18.0%; headache/dizziness/photosensitivity/phonosensitivity/difficulty concentrating), 2) FATIGUE/HYPERSOMNIA (16.4%; fatigue/drowsiness/mental fogginess/slowed down/hypersomnia), 3) AFFECTIVE (12.6%; more emotional/sadness), 4) INSOMNIA (9.0%; insomnia/trouble falling asleep), 5) SOMATIC (8.0%; vomiting/numbness). MIDDLE had a four-component model (63.1% of variance): 1) GLOBAL (19.4%; photosensitivity/headache/phonosensitivity/nausea/dizziness), 2) INSOMNIA/AFFECTIVE (14.4%; insomnia/more emotional/nervousness/trouble falling asleep), 3) SOMATIC/MEMORY (12.2%; difficulty remembering/numbness), and 4) HYPERSOMNIA (12.0%; drowsiness/hypersomnia). LATE had a four-component model (65.7% of variance): 1) VESTIBULAR/OCULAR (18.2%; vision/difficulty remembering/balance/fogginess/dizziness), 2) MIGRAINE (16.6%; photosensitivity/phonosensitivity/fatigue/headache), 3) AFFECTIVE (16.1%; sadness/nervousness/more emotional), and 4) INSOMNIA (7.6%; insomnia/trouble falling asleep). Conclusions The results of this study suggest greater time since injury modifies symptom factor structure in adolescent athletes with SRC. Specifically, symptom factors become more distinct with longer time since injury before first clinical visit. A GLOBAL symptom factor was observed for both EARLY and MIDDLE, but not in LATE. SOMATIC (i.e., numbness) was observed in EARLY/MIDDLE, but not LATE. Symptom factors in LATE seem to mirror concussion clinical sub-types from previous research (e.g., vestibular/ocular, migraine, affective, sleep).

Postprandial Hypotension and Spinal Cord Injury

Postprandial hypotension (PPH) is defined as a fall of ≥20 mmHg in systolic blood pressure (SBP) or a SBP of <90 mmHg after having been >100 mmHg before the meal within two hours after a meal. The prevalence of PPH among persons with spinal cord injury (SCI) is unknown. Ambulatory blood pressure measurement was performed in 158 persons with SCI, 109 men, median age was 59.1 years (min.:13.2; max.: 86.2). In total, 78 persons (49.4%) had PPH after 114 out of 449 meals (25.4%). The median change in SBP during PPH was −28 mmHg (min.: −87; max.: −15 mmHg) and 96% of the PPH episodes were asymptomatic. The occurrence of PPH was correlated to older age (p = 0.001), level of injury (p = 0.023), and complete SCI (p = 0.000), but not, gender or time since injury. Further studies are needed to elucidate if PPH contributes to the increased cardiovascular mortality in the SCI population.

7 Patterns for Monitoring Burn Recovery: Preliminary Results from the LIBRE Journey Study

Introduction While social rehabilitation after burn injury is one of the multiple facets of recovery, there are limited data on long term social participation outcomes. The computer adaptive test LIBRE Profile was developed to examine social participation outcomes across six domains. The objective of the study is to use the LIBRE Profile to measure social integration and explore the trajectories of recovery in multiple outcome domains. Methods Preliminary data from the ongoing LIBRE Journey research study were analyzed. Demographic and clinical characteristics examined included age, gender, race, ethnicity, education level, marital status, burn size and time since injury. LIBRE Profile scores collected at baseline (time of study enrollment), 6 months, and 12 months were used to develop score trajectories for each of the six LIBRE Profile domains (Family and Friends, Social Activities, Romantic Relationships, Sexual Relationships, Social Interactions, and Work and Employment). Recovery was analyzed for time since injury from 1 year to 70 years. Linear mixed models were applied to each domain, adjusting for demographic and clinical characteristics. Models were fit with the score trajectory and 95% confidence intervals to demonstrate change across time and the impact of the covariates. Results The study population included 343 burn survivors with mean age at injury of 45.3 years (SD 15.5) and mean burn size of 18.7% (SD 25.4). The population was 42.1% male, 83.1% white, and 91.6% non-Hispanic. With the exception of Family and Friends and Romantic Relationships, all other domain scores increased with times since injury (p&lt; 0.001).(Example curve: Figure) Those with larger burn size scored worse in Social Activities and Work and Employment. Males demonstrated higher scores than females on Romantic Relationships and Sexual Relationships. Higher education was associated with higher scores on the Family and Friends domain; Marriage was associated with higher scores on Family and Friends, Romantic Relationships and Work and Employment domains. Conclusions Preliminary analysis of LIBRE Journey data demonstrates ability to generate trajectories of recovery for each of the six domains of social participation. Four of the six domains demonstrate evidence of improvement over time, suggesting important positive patterns of social integration occurring in the short- and long-term post injury.

The influence of physiologic and atmospheric variables on spasticity after spinal cord injury

BACKGROUND: A number of physiological and atmospheric variables are believed to increase spasticity in persons with spinal cord injury (SCI) based on self-reported measures, however, there is limited objective evidence about the influence of these variables on spasticity. OBJECTIVE: We investigated the relationship between physiological/ atmospheric variables and level of spasticity in individuals with SCI. METHODS: In 53 participants with motor-incomplete SCI, we assessed the influence of age, time since injury, sex, injury severity, neurological level of injury, ability to walk, antispasmodic medication use, temperature, humidity, and barometric pressure on quadriceps spasticity. Spasticity was assessed using the pendulum test first swing excursion (FSE. To categorize participants based on spasticity level, we performed cluster analysis. We used multivariate stepwise regression to determine variables associated with spasticity level. RESULTS: Three spasticity groups were identified based on severity level: low, moderate, and high. The regression analysis revealed that only walking ability and temperature were significantly related to spasticity. CONCLUSIONS: These outcomes validate the self-reported perception of people with SCI that low temperatures worsen spasticity. The findings refine prior evidence that people with motor-incomplete SCI have higher levels of spasticity, showing that those with sufficient motor function to walk have the highest levels of spasticity.