Brazilian Jiu-Jitsu–Related Post-Concussion Symptoms Ameliorated With Neurorehabilitation

ObjectiveDiscuss neurorehabilitation efficacy in a case of concussion without direct head impact.BackgroundWhile there is growing concern about the prevalence and severity of concussion in mixed martial arts, a grappling component, Brazilian Jiu-Jitsu, is not typically perceived as high risk. Rapid acceleration or deceleration without direct head trauma led to a concussion for a 15-year-old male during jiu-jitsu throwing drills. The subject and parents reported difficulty with academic performance, social interactions, and emotional regulation. Symptoms persisted for 4 months before care was sought by the subject and his parents. Without direct head trauma or impact, concussion was not initially suspected.Design/MethodsThirteen sessions of treatment were performed in a neurorehabilitation setting utilizing joint manipulation, vestibular rehabilitation with a whole-body off-axis rotation device, oculomotor exercises, neuromuscular re-education, and electrical stimulation. C3 Logix was utilized as a baseline (immediately preceding second treatment due to equipment difficulties) and at discharge to measure effects of treatment.ResultsData is reported as “(baseline, discharge, percent-change).” Graded Symptom Checklist score out of 162 (91, 20; −78.02%), Trail Making Test A (sec) (26.8, 19.7; −26.49%), Trail Making Test B (sec) (69.9, 37.9; −45.78%), Digit-Symbol Matching speed (# of symbols) (66, 71; +7.58%), Choice reaction time (msec) (452, 397; −12.17), Static:Dynamic Visual Acuity (line difference) (1, 0.4; −60%). Subjectively, the subject and his parents reported improved academic performance, social interactions, and emotional regulation leading to a better home and educational experience for all involved.ConclusionsThis case displays positive clinical improvements with a functional neurology approach to outpatient neurorehabilitation. Further investigation into this multimodal rehabilitation for post-concussion symptoms, with and without direct head impact, is recommended. Continued concussion education and awareness are recommended for sports with rapid acceleration or deceleration and limited direct head impact.

Comparison of Head Impact Exposure Across Common Activities in Youth Soccer

ObjectiveThe objective of this study was to compare head impact exposure across common training activities in soccer.BackgroundSoccer is a popular youth sport in the United States, but repetitive head impacts during training may result in neurocognitive deficits. Current research has identified factors associated with increased head impact exposure in soccer, but research has yet to contextualize head impact exposure across soccer activities. Modifying practice structure may be an avenue for reducing head impact exposure and concussion risk in soccer.Design/MethodsEight U15 soccer players participated in this study for 2 soccer seasons. Players wore a custom instrumented mouthpiece sensor during all practices and games. On-field activities were recorded with a time-synchronized camera. Research personnel recorded the duration of all practice (e.g., technical training, team interaction) and game activities performed by each player, and film review was performed to identify all head contact events during each session. Head impact exposure was quantified in terms of peak kinematics and impacts per player per hour. The amount of time an athlete was exposed to an activity was also evaluated. Mixed effects models were used to compare peak kinematics and generalized linear models were used to compare impact rates across activity types.ResultsActivity types were associated with peak kinematics and impact rate. Technical training activities were associated with higher impact rates and lower mean kinematics compared to other activity types. Team interaction activities and game play were associated with the highest rotational kinematics, but the lowest impact rates. A similar number of player-to-player contact events occurred within technical training, team interaction, and game play activities.ConclusionsInterventions designed to reduce head impact frequency in soccer may benefit from targeting technical training activities; whereas, interventions designed to reduce head impact magnitude may benefit from targeting team interaction and game activities.

Head Impact Exposure and Mechanisms in Female High School Lacrosse via an Instrumented Mouthguard

ObjectiveTo quantify the head impact biomechanics, by impact mechanism, of female high school lacrosse players during games using an instrumented mouthguard.BackgroundThere is growing concern for the neurologic effects of repetitive head impacts in sports, which have been linked with several short-term neurophysiologic deficits. Girls' lacrosse represents a popular but understudied sport with regard to head impact exposure and current debate exists as to the need for enhanced protective equipment.Design/MethodsA female high school varsity lacrosse team wore the Stanford Instrumented Mouthguard during competitive games for the 2019 season. Video footage was reviewed to confirm head impact events and remove false-positive recordings. For each impact event, the mechanism was coded as stick contact, player contact, fall, or ball contact. Head impact rates were calculated per athlete exposure (AE, defined as a single player participating in a single game).ResultsSensor data were recorded for 15 female varsity lacrosse players for 14 games and 97 AEs. During games, 31 sensor-recorded head impacts were video-confirmed resulting in a pooled average head impact rate of 0.32 impacts/AE. The video-confirmed impacts were distributed between stick contact (17, 54.8%), player contact (12, 38.7%), and falls (2, 6.5%). There were no ball impacts. Overall peak kinematics were 34.0 ± 26.6 g, 12.0 ± 9.1 rad/s, and 3,666.5 ± 2,987.6 rad/s2. Stick contacts had the highest peak linear acceleration (42.7 ± 32.2 g), angular velocity (14.5 ± 11.1 rad/s), and angular acceleration (4,242.4 ± 3,634.9 rad/s2).ConclusionsStick impacts were the most common impact mechanism and resulted in the highest peak linear and angular kinematics, which may help explain why they are the most common cause of head injury in female lacrosse. By quantifying the head impact exposure, kinematics and mechanisms in female high school lacrosse, targeted injury preventions can be developed, such as rule changes and protective equipment.

Laboratory assessment of a head impact sensor for youth soccer ball heading impacts using an anthropomorphic test device

Recent advances in technology have enabled the development of instrumented equipment, which estimate the head impact kinematics of athletes in vivo. One such headband-mounted impact sensor is the SIM-G (Triax Technologies, Norwalk, CT, USA), which has been previously used to investigate the biomechanics of soccer heading by human subjects. Previous studies have evaluated the accuracy of the SIM-G for pure rotation and pendulum, impulse hammer and drop rig impacts. The current study used a soccer ball heading model to evaluate the accuracy of the SIM-G. A soccer ball was projected at the head of an anthropomorphic test device (ATD) representing a 10-year-old to replicate the heading maneuver at various impact sites, angles and speeds previously identified in youth soccer. Linear regression revealed that the SIM-G sensor overestimated the peak angular velocity and linear acceleration recorded by the ATD headform by approximately 44% and 105%, respectively. Tests in which the ball directly contacted the SIM-G sensor resulted in the largest peak linear accelerations. Glancing impacts were significantly associated with a decrease in percentage error of the SIM-G sensor peak angular velocity data relative to the ATD reference data. While it may not demonstrate accuracy in estimating the magnitudes of head impacts, the SIM-G remains a useful tool to provide estimates of head impact exposure for soccer players.

Characterizing Head Impact Exposure in Men and Women During Boxing and Mixed Martial Arts

Background: The accumulation of subconcussive impacts has been implicated in permanent neurological impairment. A gap in understanding the relationship between head impacts and neurological function is the lack of precise characterization and quantification of forces that individuals experience during sports training and competition. Purpose: To characterize impact exposure during training and competition among male and female athletes participating in boxing and mixed martial arts (MMA) via an instrumented custom-fit Impact Monitoring Mouthguard (IMM). Study Design: Cross-sectional study; Level of evidence, 3. Methods: Twenty-three athletes (n = 4 women) were provided a custom-fit IMM. The IMM monitored impacts during sparring and competition. All training and competition sessions were videotaped. Video and IMM data were synchronized for post hoc data verification of true positives and substantiation of impact location. IMM data were collected from boxing and MMA athletes at a collaborating site. For each true-positive impact, peak linear acceleration and peak angular acceleration were calculated. Wilcoxon rank sum tests were used to evaluate potential differences in sport, activity type, and sex with respect to each outcome. Differences in impact location were assessed via Kruskal-Wallis tests. Results: IMM data were collected from 53 amateur training sessions and 6 competitions (session range, 5-20 minutes). A total of 896 head impacts (men, n = 786; women, n = 110) were identified using IMM data and video verification: 827 in practice and 69 during competition. MMA and boxers experienced a comparable number of impacts per practice session or competition. In general, MMA impacts produced significantly higher peak angular acceleration than did boxing impacts ( P < .001) and were more varied in impact location on the head during competitions. In terms of sex, men experienced a greater number of impacts than women per practice session. However, there was no significant difference between men and women in terms of impact magnitude. Conclusion: Characteristic profiles of head impact exposure differed between boxing and MMA athletes; however, the impact magnitudes were not significantly different for male and female athletes.

Association Between Antemortem FLAIR White Matter Hyperintensities and Neuropathology in Brain Donors Exposed to Repetitive Head Impacts

Background and Objectives:Late neuropathologies of repetitive head impacts from contact sports can include chronic traumatic encephalopathy (CTE) and white matter degeneration. White matter hyperintensities (WMH) on fluid attenuated inversion recovery (FLAIR) MRI scans are often viewed as microvascular disease from vascular risk, but might have unique underlying pathologies and risk factors in the setting of repetitive head impacts. We investigated the neuropathological correlates of antemortem WMH in brain donors exposed to repetitive head impacts. The association between WMH, and repetitive head impact exposure and informant-reported cognitive and daily function were tested.Methods:This imaging-pathological correlation study included symptomatic deceased men exposed to repetitive head impacts. Donors had antemortem FLAIR scans from medical records and were without evidence of CNS neoplasm, large vessel infarcts, hemorrhage, and/or encephalomalacia. WMH were quantified using log-transformed values for total lesion volume (TLV), calculated using the lesion prediction algorithm from the Lesion Segmentation Toolbox. Neuropathological assessments included semi-quantitative ratings of white matter rarefaction, cerebrovascular disease, p-tau severity (CTE stage, dorsolateral frontal cortex), and Aβ. Among football players, years of play was a proxy for repetitive head impact exposure. Retrospective informant-reported cognitive and daily function were assessed using the Cognitive Difficulties Scale (CDS) and Functional Activities Questionnaire (FAQ). Regression models controlled for demographics, diabetes, hypertension, and MRI resolution. Statistical significance was defined as p<0.05.Results:The sample included 75 donors: 67 football players and 8 non-football contact sport athletes and/or military veterans. Dementia was the most common MRI indication (64%). Fifty-three (70.7%) had CTE at autopsy. Log-TLV was associated with white matter rarefaction (OR=2.32, 95% CI=1.03,5.24, p=0.04), arteriolosclerosis (OR=2.38, 95% CI=1.02,5.52, p=0.04), CTE stage (OR=2.58, 95% CI=1.17,5.71, p=0.02), and dorsolateral frontal p-tau severity (OR=3.03, 95% CI=1.32,6.97, p=0.01). There was no association with Aβ. More years of football play was associated with log-TLV (b=0.04, 95% CI=0.01,0.06, p=0.01). Greater log-TLV correlated with higher FAQ (unstandardized beta=4.94, 95% CI=0.42,8.57, p=0.03) and CDS scores (unstandardized beta=15.35, 95% CI=-0.27,30.97, p=0.05).Discussion:WMH might capture long-term white matter pathologies from repetitive head impacts, including those from white matter rarefaction and p-tau, in addition to microvascular disease. Prospective imaging-pathological correlation studies are needed.Classification of Evidence:This study provides Class IV evidence of associations between FLAIR white matter hyperintensities, and neuropathological changes (white matter rarefaction, arteriolosclerosis, p-tau accumulation), years of American football play, and reported cognitive symptoms in symptomatic brain donors exposed to repetitive head impacts.