1
|
Parker TD, Zimmerman KA, Laverse E, Bourke NJ, Graham NSN, Mallas EJ, Heslegrave A, Zetterberg H, Kemp S, Morris HR, Sharp DJ. Active elite rugby participation is associated with altered precentral cortical thickness. Brain Commun 2023; 5:fcad257. [PMID: 38025272 PMCID: PMC10667029 DOI: 10.1093/braincomms/fcad257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/31/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
There is growing concern that elite rugby participation may negatively influence brain health, but the underlying mechanisms are unclear. Cortical thickness is a widely applied biomarker of grey matter structure, but there is limited research into how it may be altered in active professional rugby players. Cross-sectional MRI data from 44 active elite rugby players, including 21 assessed within 1 week of head injury, and 47 healthy controls were analysed. We investigated how active elite rugby participation with and without sub-acute traumatic brain injury influenced grey matter structure using whole cortex and region of interest cortical thickness analyses. Relationships between cortical thickness and biomarkers of traumatic brain injury, including fractional anisotropy, plasma neurofilament light and glial fibrillary acidic protein, were also examined. In whole-cortex analyses, precentral cortical thickness in the right hemisphere was lower in rugby players compared with controls, which was due to reductions in non-injured players. Post hoc region of interest analyses showed non-injured rugby players had reduced cortical thickness in the inferior precentral sulcal thickness bilaterally (P = 0.005) and the left central sulcus (P = 0.037) relative to controls. In contrast, players in the sub-acute phase of mild traumatic brain injury had higher inferior precentral sulcal cortical thickness in the right hemisphere (P = 0.015). Plasma glial fibrillary acidic protein, a marker of astrocyte activation, was positively associated with right inferior precentral sulcal cortical thickness in injured rugby players (P = 0.0012). Elite rugby participation is associated with localized alterations in cortical thickness, specifically in sulcal motor regions. Sub-acute changes after mild traumatic brain injury are associated with evidence of astrocytic activation. The combination of cortical thickness and glial fibrillary acidic protein may be useful in understanding the pathophysiological relationship between sporting head injury and brain health.
Collapse
Affiliation(s)
- Thomas D Parker
- Department of Brain Sciences, Imperial College London, London, W12 0BZ, UK
- Dementia Research Institute Care, Research and Technology Centre, Imperial College London, London, W12 0BZ, UK
- UCL Institute of Neurology, London, WC1N 3BG, UK
| | - Karl A Zimmerman
- Department of Brain Sciences, Imperial College London, London, W12 0BZ, UK
- Dementia Research Institute Care, Research and Technology Centre, Imperial College London, London, W12 0BZ, UK
| | | | - Niall J Bourke
- Department of Brain Sciences, Imperial College London, London, W12 0BZ, UK
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK
| | - Neil S N Graham
- Department of Brain Sciences, Imperial College London, London, W12 0BZ, UK
- Dementia Research Institute Care, Research and Technology Centre, Imperial College London, London, W12 0BZ, UK
| | - Emma-Jane Mallas
- Department of Brain Sciences, Imperial College London, London, W12 0BZ, UK
- Dementia Research Institute Care, Research and Technology Centre, Imperial College London, London, W12 0BZ, UK
| | - Amanda Heslegrave
- UCL Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1N 3BG, UK
- UKDRI Fluid Biomarker Laboratory, London, WC1N 3BG, UK
| | - Henrik Zetterberg
- UCL Institute of Neurology, London, WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London, WC1N 3BG, UK
- UKDRI Fluid Biomarker Laboratory, London, WC1N 3BG, UK
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Mölndal, 431 41, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, 413 45, Sweden
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Simon Kemp
- Rugby Football Union, Twickenham Stadium, Twickenham, Middlesex TW2 7BA, UK
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Huw R Morris
- UCL Institute of Neurology, London, WC1N 3BG, UK
| | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, W12 0BZ, UK
- Dementia Research Institute Care, Research and Technology Centre, Imperial College London, London, W12 0BZ, UK
| |
Collapse
|
2
|
Jones CM, Austin K, Augustus SN, Nicholas KJ, Yu X, Baker C, Chan EYK, Loosemore M, Ghajari M. An Instrumented Mouthguard for Real-Time Measurement of Head Kinematics under a Large Range of Sport Specific Accelerations. SENSORS (BASEL, SWITZERLAND) 2023; 23:7068. [PMID: 37631606 PMCID: PMC10457941 DOI: 10.3390/s23167068] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Head impacts in sports can produce brain injuries. The accurate quantification of head kinematics through instrumented mouthguards (iMG) can help identify underlying brain motion during injurious impacts. The aim of the current study is to assess the validity of an iMG across a large range of linear and rotational accelerations to allow for on-field head impact monitoring. METHODS Drop tests of an instrumented helmeted anthropometric testing device (ATD) were performed across a range of impact magnitudes and locations, with iMG measures collected concurrently. ATD and iMG kinematics were also fed forward to high-fidelity brain models to predict maximal principal strain. RESULTS The impacts produced a wide range of head kinematics (16-171 g, 1330-10,164 rad/s2 and 11.3-41.5 rad/s) and durations (6-18 ms), representing impacts in rugby and boxing. Comparison of the peak values across ATD and iMG indicated high levels of agreement, with a total concordance correlation coefficient of 0.97 for peak impact kinematics and 0.97 for predicted brain strain. We also found good agreement between iMG and ATD measured time-series kinematic data, with the highest normalized root mean squared error for rotational velocity (5.47 ± 2.61%) and the lowest for rotational acceleration (1.24 ± 0.86%). Our results confirm that the iMG can reliably measure laboratory-based head kinematics under a large range of accelerations and is suitable for future on-field validity assessments.
Collapse
Affiliation(s)
- Chris M. Jones
- Sports and Wellbeing Analytics, Swansea SA7 0AJ, UK; (K.A.)
- Institute of Sport and Exercise Health (ISEH), Division Surgery Interventional Science, University College London, London W1T 7HA, UK
| | - Kieran Austin
- Sports and Wellbeing Analytics, Swansea SA7 0AJ, UK; (K.A.)
- Institute of Sport, Nursing and Allied Health, University of Chichester, Chichester PO19 6PE, UK
| | - Simon N. Augustus
- Department of Applied and Human Sciences, Kingston University London, London KT1 2EE, UK
| | | | - Xiancheng Yu
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (X.Y.)
| | - Claire Baker
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (X.Y.)
| | - Emily Yik Kwan Chan
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (X.Y.)
| | - Mike Loosemore
- Institute of Sport and Exercise Health (ISEH), Division Surgery Interventional Science, University College London, London W1T 7HA, UK
- English Institute of Sport, Manchester M11 3BS, UK
| | - Mazdak Ghajari
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (X.Y.)
| |
Collapse
|
3
|
Rosen G, Kirsch D, Horowitz S, Cherry JD, Nicks R, Kelley H, Uretsky M, Dell'Aquila K, Mathias R, Cormier KA, Kubilus CA, Mez J, Tripodis Y, Stein TD, Alvarez VE, Alosco ML, McKee AC, Huber BR. Three dimensional evaluation of cerebrovascular density and branching in chronic traumatic encephalopathy. Acta Neuropathol Commun 2023; 11:123. [PMID: 37491342 PMCID: PMC10369801 DOI: 10.1186/s40478-023-01612-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/27/2023] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with exposure to repetitive head impacts (RHI) and characterized by perivascular accumulations of hyperphosphorylated tau protein (p-tau) at the depths of the cortical sulci. Studies of living athletes exposed to RHI, including concussive and nonconcussive impacts, have shown increased blood-brain barrier permeability, reduced cerebral blood flow, and alterations in vasoreactivity. Blood-brain barrier abnormalities have also been reported in individuals neuropathologically diagnosed with CTE. To further investigate the three-dimensional microvascular changes in individuals diagnosed with CTE and controls, we used SHIELD tissue processing and passive delipidation to optically clear and label blocks of postmortem human dorsolateral frontal cortex. We used fluorescent confocal microscopy to quantitate vascular branch density and fraction volume. We compared the findings in 41 male brain donors, age at death 31-89 years, mean age 64 years, including 12 donors with low CTE (McKee stage I-II), 13 with high CTE (McKee stage III-IV) to 16 age- and sex-matched non-CTE controls (7 with RHI exposure and 9 with no RHI exposure). The density of vessel branches in the gray matter sulcus was significantly greater in CTE cases than in controls. The ratios of sulcus versus gyrus vessel branch density and fraction volume were also greater in CTE than in controls and significantly above one for the CTE group. Hyperphosphorylated tau pathology density correlated with gray matter sulcus fraction volume. These findings point towards increased vascular coverage and branching in the dorsolateral frontal cortex (DLF) sulci in CTE, that correlates with p-tau pathology.
Collapse
Affiliation(s)
- Grace Rosen
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA
- National Center for PTSD, US Department of Veterans Affairs, Boston, MA, USA
| | - Daniel Kirsch
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
| | - Sarah Horowitz
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA
- National Center for PTSD, US Department of Veterans Affairs, Boston, MA, USA
| | - Jonathan D Cherry
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Raymond Nicks
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Hunter Kelley
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Madeline Uretsky
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Kevin Dell'Aquila
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Rebecca Mathias
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
| | - Kerry A Cormier
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
- VA Bedford Healthcare System, US Department of Veterans Affairs, Bedford, MA, USA
| | - Caroline A Kubilus
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
- VA Bedford Healthcare System, US Department of Veterans Affairs, Bedford, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - Thor D Stein
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Victor E Alvarez
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Michael L Alosco
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
| | - Ann C McKee
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA
- VA Bedford Healthcare System, US Department of Veterans Affairs, Bedford, MA, USA
| | - Bertrand R Huber
- VA Boston Healthcare System, US Department of Veterans Affairs, 150 S Huntington Avenue, Boston, MA, 02130, USA.
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA.
- Boston University Alzheimer's Disease Research Center and Boston University CTE Center, Boston, USA.
- National Center for PTSD, US Department of Veterans Affairs, Boston, MA, USA.
| |
Collapse
|
4
|
Zimmerman KA, Cournoyer J, Lai H, Snider SB, Fischer D, Kemp S, Karton C, Hoshizaki TB, Ghajari M, Sharp DJ. The biomechanical signature of loss of consciousness: computational modelling of elite athlete head injuries. Brain 2023; 146:3063-3078. [PMID: 36546554 PMCID: PMC10316777 DOI: 10.1093/brain/awac485] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 11/17/2022] [Accepted: 12/02/2022] [Indexed: 08/27/2023] Open
Abstract
Sports related head injuries can cause transient neurological events including loss of consciousness and dystonic posturing. However, it is unknown why head impacts that appear similar produce distinct neurological effects. The biomechanical effect of impacts can be estimated using computational models of strain within the brain. Here, we investigate the strain and strain rates produced by professional American football impacts that led to loss of consciousness, posturing or no neurological signs. We reviewed 1280 National Football League American football games and selected cases where the team's medical personnel made a diagnosis of concussion. Videos were then analysed for signs of neurological events. We identified 20 head impacts that showed clear video signs of loss of consciousness and 21 showing clear abnormal posturing. Forty-one control impacts were selected where there was no observable evidence of neurological signs, resulting in 82 videos of impacts for analysis. Video analysis was used to guide physical reconstructions of these impacts, allowing us to estimate the impact kinematics. These were then used as input to a detailed 3D high-fidelity finite element model of brain injury biomechanics to estimate strain and strain rate within the brain. We tested the hypotheses that impacts producing loss of consciousness would be associated with the highest biomechanical forces, that loss of consciousness would be associated with high forces in brainstem nuclei involved in arousal and that dystonic posturing would be associated with high forces in motor regions. Impacts leading to loss of consciousness compared to controls produced higher head acceleration (linear acceleration; 81.5 g ± 39.8 versus 47.9 ± 21.4; P = 0.004, rotational acceleration; 5.9 krad/s2 ± 2.4 versus 3.5 ± 1.6; P < 0.001) and in voxel-wise analysis produced larger brain deformation in many brain regions, including parts of the brainstem and cerebellum. Dystonic posturing was also associated with higher deformation compared to controls, with brain deformation observed in cortical regions that included the motor cortex. Loss of consciousness was specifically associated with higher strain rates in brainstem regions implicated in maintenance of consciousness, including following correction for the overall severity of impact. These included brainstem nuclei including the locus coeruleus, dorsal raphé and parabrachial complex. The results show that in head impacts producing loss of consciousness, brain deformation is disproportionately seen in brainstem regions containing nuclei involved in arousal, suggesting that head impacts produce loss of consciousness through a biomechanical effect on key brainstem nuclei involved in the maintenance of consciousness.
Collapse
Affiliation(s)
- Karl A Zimmerman
- UK Dementia Research Institute, Care Research & Technology Centre, Imperial College London, London, UK
- Department of Brain Sciences, Hammersmith Hospital, Imperial College London, London, UK
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, UK
| | - Janie Cournoyer
- Neurotrauma Impact Science Laboratory, University of Ottawa, Ottawa, ON, Canada
| | - Helen Lai
- UK Dementia Research Institute, Care Research & Technology Centre, Imperial College London, London, UK
- Department of Brain Sciences, Hammersmith Hospital, Imperial College London, London, UK
| | - Samuel B Snider
- Division of Neurocritical care, Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - David Fischer
- Division of Neurocritical Care, Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Simon Kemp
- Rugby Football Union, Twickenham, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Clara Karton
- Neurotrauma Impact Science Laboratory, University of Ottawa, Ottawa, ON, Canada
| | - Thomas B Hoshizaki
- Neurotrauma Impact Science Laboratory, University of Ottawa, Ottawa, ON, Canada
| | - Mazdak Ghajari
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, UK
| | - David J Sharp
- UK Dementia Research Institute, Care Research & Technology Centre, Imperial College London, London, UK
- Department of Brain Sciences, Hammersmith Hospital, Imperial College London, London, UK
- The Royal British Legion Centre for Blast Injury Studies and the Department of Bioengineering, Imperial College London, London, UK
| |
Collapse
|
5
|
Zuidema TR, Bazarian JJ, Kercher KA, Mannix R, Kraft RH, Newman SD, Ejima K, Rettke DJ, Macy JT, Steinfeldt JA, Kawata K. Longitudinal Associations of Clinical and Biochemical Head Injury Biomarkers With Head Impact Exposure in Adolescent Football Players. JAMA Netw Open 2023; 6:e2316601. [PMID: 37252737 PMCID: PMC10230318 DOI: 10.1001/jamanetworkopen.2023.16601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/19/2023] [Indexed: 05/31/2023] Open
Abstract
Importance Consequences of subconcussive head impacts have been recognized, yet most studies to date have included small samples from a single site, used a unimodal approach, and lacked repeated testing. Objective To examine time-course changes in clinical (near point of convergence [NPC]) and brain-injury blood biomarkers (glial fibrillary acidic protein [GFAP], ubiquitin C-terminal hydrolase-L1 [UCH-L1], and neurofilament light [NF-L]) in adolescent football players and to test whether changes in the outcomes were associated with playing position, impact kinematics, and/or brain tissue strain. Design, Setting, and Participants This multisite, prospective cohort study included male high school football players aged 13 to 18 years at 4 high schools in the Midwest during the 2021 high school football season (preseason [July] and August 2 to November 19). Exposure A single football season. Main Outcomes and Measures The main outcomes were NPC (a clinical oculomotor test) and serum levels of GFAP, UCH-L1, and NF-L. Participants' head impact exposure (frequency and peak linear and rotational accelerations) was tracked using instrumented mouthguards, and maximum principal strain was computed to reflect brain tissue strain. Players' neurological function was assessed at 5 time points (preseason, post-training camp, 2 in season, and postseason). Results Ninety-nine male players contributed to the time-course analysis (mean [SD] age, 15.8 [1.1] years), but data from 6 players (6.1%) were excluded from the association analysis due to issues related to mouthguards. Thus, 93 players yielded 9498 head impacts in a season (mean [SD], 102 [113] impacts per player). There were time-course elevations in NPC and GFAP, UCH-L1, and NF-L levels. Compared with baseline, the NPC exhibited a significant elevation over time and peaked at postseason (2.21 cm; 95% CI, 1.80-2.63 cm; P < .001). Levels of GFAP and UCH-L1 increased by 25.6 pg/mL (95% CI, 17.6-33.6 pg/mL; P < .001) and 188.5 pg/mL (95% CI, 145.6-231.4 pg/mL; P < .001), respectively, later in the season. Levels of NF-L were elevated after the training camp (0.78 pg/mL; 95% CI, 0.14-1.41 pg/mL; P = .011) and midseason (0.55 pg/mL; 95% CI, 0.13-0.99 pg/mL; P = .006) but normalized by the end of the season. Changes in UCH-L1 levels were associated with maximum principal strain later in the season (0.052 pg/mL; 95% CI, 0.015-0.088 pg/mL; P = .007) and postseason (0.069 pg/mL; 95% CI, 0.031-0.106 pg/mL; P < .001). Conclusions and Relevance The study data suggest that adolescent football players exhibited impairments in oculomotor function and elevations in blood biomarker levels associated with astrocyte activation and neuronal injury throughout a season. Several years of follow-up are needed to examine the long-term effects of subconcussive head impacts in adolescent football players.
Collapse
Affiliation(s)
- Taylor R. Zuidema
- Department of Kinesiology, Indiana University School of Public Health–Bloomington
- Program in Neuroscience, College of Arts and Sciences, Indiana University, Bloomington
| | - Jeffrey J. Bazarian
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Kyle A. Kercher
- Department of Kinesiology, Indiana University School of Public Health–Bloomington
| | - Rebekah Mannix
- Department of Medicine, Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reuben H. Kraft
- Department of Mechanical and Biomedical Engineering, Pennsylvania State University, University Park
- Institute of Computational and Data Sciences, Pennsylvania State University, University Park
| | | | - Keisuke Ejima
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Devin J. Rettke
- Department of Kinesiology, Indiana University School of Public Health–Bloomington
| | - Jonathan T. Macy
- Department of Applied Health Science, Indiana University School of Public Health–Bloomington
| | - Jesse A. Steinfeldt
- Department of Counseling and Educational Psychology, School of Education, Indiana University, Bloomington
| | - Keisuke Kawata
- Department of Kinesiology, Indiana University School of Public Health–Bloomington
- Program in Neuroscience, College of Arts and Sciences, Indiana University, Bloomington
| |
Collapse
|
6
|
McKee AC, Stein TD, Huber BR, Crary JF, Bieniek K, Dickson D, Alvarez VE, Cherry JD, Farrell K, Butler M, Uretsky M, Abdolmohammadi B, Alosco ML, Tripodis Y, Mez J, Daneshvar DH. Chronic traumatic encephalopathy (CTE): criteria for neuropathological diagnosis and relationship to repetitive head impacts. Acta Neuropathol 2023; 145:371-394. [PMID: 36759368 PMCID: PMC10020327 DOI: 10.1007/s00401-023-02540-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 02/11/2023]
Abstract
Over the last 17 years, there has been a remarkable increase in scientific research concerning chronic traumatic encephalopathy (CTE). Since the publication of NINDS-NIBIB criteria for the neuropathological diagnosis of CTE in 2016, and diagnostic refinements in 2021, hundreds of contact sport athletes and others have been diagnosed at postmortem examination with CTE. CTE has been reported in amateur and professional athletes, including a bull rider, boxers, wrestlers, and American, Canadian, and Australian rules football, rugby union, rugby league, soccer, and ice hockey players. The pathology of CTE is unique, characterized by a pathognomonic lesion consisting of a perivascular accumulation of neuronal phosphorylated tau (p-tau) variably alongside astrocytic aggregates at the depths of the cortical sulci, and a distinctive molecular structural configuration of p-tau fibrils that is unlike the changes observed with aging, Alzheimer's disease, or any other tauopathy. Computational 3-D and finite element models predict the perivascular and sulcal location of p-tau pathology as these brain regions undergo the greatest mechanical deformation during head impact injury. Presently, CTE can be definitively diagnosed only by postmortem neuropathological examination; the corresponding clinical condition is known as traumatic encephalopathy syndrome (TES). Over 97% of CTE cases published have been reported in individuals with known exposure to repetitive head impacts (RHI), including concussions and nonconcussive impacts, most often experienced through participation in contact sports. While some suggest there is uncertainty whether a causal relationship exists between RHI and CTE, the preponderance of the evidence suggests a high likelihood of a causal relationship, a conclusion that is strengthened by the absence of any evidence for plausible alternative hypotheses. There is a robust dose-response relationship between CTE and years of American football play, a relationship that remains consistent even when rigorously accounting for selection bias. Furthermore, a recent study suggests that selection bias underestimates the observed risk. Here, we present the advances in the neuropathological diagnosis of CTE culminating with the development of the NINDS-NIBIB criteria, the multiple international studies that have used these criteria to report CTE in hundreds of contact sports players and others, and the evidence for a robust dose-response relationship between RHI and CTE.
Collapse
Affiliation(s)
- Ann C McKee
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA.
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA.
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA.
- VA Bedford Healthcare System, Bedford, MA, USA.
| | - Thor D Stein
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
| | - Bertrand R Huber
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
| | - John F Crary
- Departments of Pathology, Neuroscience, and Artificial Intelligence and Human Health, Neuropathology Brain Bank and Research Core, Ronald M. Loeb Center for Alzheimer's Disease, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kevin Bieniek
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Glenn Biggs Institute for Alzheimer's and Neurodegenerative Diseases, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Dennis Dickson
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Victor E Alvarez
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
- VA Bedford Healthcare System, Bedford, MA, USA
| | - Jonathan D Cherry
- VA Boston Healthcare System, U.S. Department of Veteran Affairs, Boston, MA, USA
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Kurt Farrell
- Departments of Pathology, Neuroscience, and Artificial Intelligence and Human Health, Neuropathology Brain Bank and Research Core, Ronald M. Loeb Center for Alzheimer's Disease, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Morgane Butler
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Madeline Uretsky
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Bobak Abdolmohammadi
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
| | - Michael L Alosco
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Yorghos Tripodis
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jesse Mez
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Daniel H Daneshvar
- Boston University Alzheimer's Disease Research Center and CTE Centers, Department of Neurology, Boston University School of Medicine, 150 S Huntington Ave, Boston, MA, 02130, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, USA
| |
Collapse
|
7
|
Nocera A, Sbrollini A, Romagnoli S, Morettini M, Gambi E, Burattini L. Physiological and Biomechanical Monitoring in American Football Players: A Scoping Review. SENSORS (BASEL, SWITZERLAND) 2023; 23:3538. [PMID: 37050597 PMCID: PMC10098592 DOI: 10.3390/s23073538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/22/2023] [Accepted: 03/25/2023] [Indexed: 06/19/2023]
Abstract
American football is the sport with the highest rates of concussion injuries. Biomedical engineering applications may support athletes in monitoring their injuries, evaluating the effectiveness of their equipment, and leading industrial research in this sport. This literature review aims to report on the applications of biomedical engineering research in American football, highlighting the main trends and gaps. The review followed the PRISMA guidelines and gathered a total of 1629 records from PubMed (n = 368), Web of Science (n = 665), and Scopus (n = 596). The records were analyzed, tabulated, and clustered in topics. In total, 112 studies were selected and divided by topic in the biomechanics of concussion (n = 55), biomechanics of footwear (n = 6), biomechanics of sport-related movements (n = 6), the aerodynamics of football and catch (n = 3), injury prediction (n = 8), heat monitoring of physiological parameters (n = 8), and monitoring of the training load (n = 25). The safety of players has fueled most of the research that has led to innovations in helmet and footwear design, as well as improvements in the understanding and prevention of injuries and heat monitoring. The other important motivator for research is the improvement of performance, which has led to the monitoring of training loads and catches, and studies on the aerodynamics of football. The main gaps found in the literature were regarding the monitoring of internal loads and the innovation of shoulder pads.
Collapse
|
8
|
A Review of Cyclist Head Injury, Impact Characteristics and the Implications for Helmet Assessment Methods. Ann Biomed Eng 2023; 51:875-904. [PMID: 36918438 PMCID: PMC10122631 DOI: 10.1007/s10439-023-03148-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/11/2023] [Indexed: 03/15/2023]
Abstract
Head injuries are common for cyclists involved in collisions. Such collision scenarios result in a range of injuries, with different head impact speeds, angles, locations, or surfaces. A clear understanding of these collision characteristics is vital to design high fidelity test methods for evaluating the performance of helmets. We review literature detailing real-world cyclist collision scenarios and report on these key characteristics. Our review shows that helmeted cyclists have a considerable reduction in skull fracture and focal brain pathologies compared to non-helmeted cyclists, as well as a reduction in all brain pathologies. The considerable reduction in focal head pathologies is likely to be due to helmet standards mandating thresholds of linear acceleration. The less considerable reduction in diffuse brain injuries is likely to be due to the lack of monitoring head rotation in test methods. We performed a novel meta-analysis of the location of 1809 head impacts from ten studies. Most studies showed that the side and front regions are frequently impacted, with one large, contemporary study highlighting a high proportion of occipital impacts. Helmets frequently had impact locations low down near the rim line. The face is not well protected by most conventional bicycle helmets. Several papers determine head impact speed and angle from in-depth reconstructions and computer simulations. They report head impact speeds from 5 to 16 m/s, with a concentration around 5 to 8 m/s and higher speeds when there was another vehicle involved in the collision. Reported angles range from 10° to 80° to the normal, and are concentrated around 30°-50°. Our review also shows that in nearly 80% of the cases, the head impact is reported to be against a flat surface. This review highlights current gaps in data, and calls for more research and data to better inform improvements in testing methods of standards and rating schemes and raise helmet safety.
Collapse
|
9
|
Moro F, Lisi I, Tolomeo D, Vegliante G, Pascente R, Mazzone E, Hussain R, Micotti E, Dallmeier J, Pischiutta F, Bianchi E, Chiesa R, Wang KK, Zanier ER. Acute Blood Levels of Neurofilament Light Indicate One-Year White Matter Pathology and Functional Impairment in Repetitive Mild Traumatic Brain Injured Mice. J Neurotrauma 2023. [PMID: 36576018 DOI: 10.1089/neu.2022.0252] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Mild traumatic brain injury (mTBI) mostly causes transient symptoms, but repeated (r)mTBI can lead to neurodegenerative processes. Diagnostic tools to evaluate the presence of ongoing occult neuropathology are lacking. In a mouse model of rmTBI, we investigated MRI and plasma biomarkers of brain damage before chronic functional impairment arose. Anesthetized adult male and female C57BL/6J mice were subjected to rmTBI or a sham procedure. Sensorimotor deficits were evaluated up to 12 months post-injury in SNAP and Neuroscore tests. Cognitive function was assessed in the novel object recognition test at six and 12 months. Diffusion tensor imaging (DTI) and structural magnetic resonance imaging (MRI) were performed at six and 12 months to examine white matter and structural damage. Plasma levels of neurofilament light (NfL) were assessed longitudinally up to 12 months. Brain histopathology was performed at 12 months. Independent groups of mice were used to examine the effects of 2-, 7- and 14-days inter-injury intervals on acute plasma NfL levels and on hyperactivity. Twelve months after an acute transient impairment, sensorimotor functions declined again in rmTBI mice (p < 0.001 vs sham), but not earlier. Similarly, rmTBI mice showed memory impairment at 12 (p < 0.01 vs sham) but not at 6 months. White matter damage examined by DTI was evident in rmTBI mice at both six and 12 months (p < 0.001 vs sham). This was associated with callosal atrophy (p < 0.001 vs sham) evaluated by structural MRI. Plasma NfL at one week was elevated in rmTBI (p < 0.001 vs sham), and its level correlated with callosal atrophy at 12 months (Pearson r = 0.72, p < 0.01). Histopathology showed thinning of the corpus callosum and marked astrogliosis in rmTBI mice. The NfL levels were higher in mice subjected to short (2 days) compared with longer (7 and 14 days) inter-injury intervals (p < 0.05), and this correlated with hyperactivity in mice (Pearson r = 0.50; p < 0.05). These findings show that rmTBI causes white matter pathology detectable by MRI before chronic functional impairment. Early quantification of plasma NfL correlates with the degree of white matter atrophy one year after rmTBI and can serve to monitor the brain's susceptibility to a second mTBI, supporting its potential clinical application to guide the return to practice in sport-related TBI.
Collapse
Affiliation(s)
- Federico Moro
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ilaria Lisi
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Daniele Tolomeo
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Gloria Vegliante
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Rosaria Pascente
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Edoardo Mazzone
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Riaz Hussain
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Edoardo Micotti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Julian Dallmeier
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Francesca Pischiutta
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Elisa Bianchi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Roberto Chiesa
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Kevin K Wang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Departments of Emergency Medicine, Psychiatry, Neuroscience and Chemistry, University of Florida, Gainesville, Florida, USA.,Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA
| | - Elisa R Zanier
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| |
Collapse
|
10
|
Pavlovic N, Clermont C, Cairns J, Williamson RA, Emery CA, Stefanyshyn D. Differences in head impact biomechanics between playing positions in Canadian high school football players. J Sports Sci 2023; 40:2697-2703. [PMID: 36862832 DOI: 10.1080/02640414.2023.2184824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
The objective of this study was to compare head impact magnitudes and time between impacts among positions in Canadian high-school football. Thirty nine players from two high-school football teams were recruited and assigned a position profile: Profile 1 (quarterback, receiver, defensive back, kicker), Profile 2 (linebacker, running back), and Profile 3 (linemen). Players wore instrumented mouthguards to measure peak magnitudes of linear and angular acceleration and velocity for each head impact throughout the season. A principal component analysis reduced the dimensionality of biomechanical variables, resulting in one principal component (PC1) score assigned to every impact. Time between impacts was calculated by subtracting the timestamps of subsequent head impacts within a session. Significant differences in PC1 scores and time between impacts occurred between playing position profiles (ps<0.001). Post-hoc comparisons determined that PC1 was greatest in Profile 2, followed by Profiles 1 and 3. Time between impacts was lowest in Profile 3, followed by Profiles 2 and 1. This study delivers a new method of reducing the multidimensionality of head impact magnitudes and suggests different Canadian high-school football playing positions experience different head impact magnitudes and frequencies, which is important for monitoring concussion and repetitive head impact exposure.
Collapse
Affiliation(s)
- Nina Pavlovic
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Christian Clermont
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Joshua Cairns
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Rylen A Williamson
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Darren Stefanyshyn
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
11
|
In-Depth Bicycle Collision Reconstruction: From a Crash Helmet to Brain Injury Evaluation. Bioengineering (Basel) 2023; 10:bioengineering10030317. [PMID: 36978708 PMCID: PMC10045787 DOI: 10.3390/bioengineering10030317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/23/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Traumatic brain injury (TBI) is a prevalent injury among cyclists experiencing head collisions. In legal cases, reliable brain injury evaluation can be difficult and controversial as mild injuries cannot be diagnosed with conventional brain imaging methods. In such cases, accident reconstruction may be used to predict the risk of TBI. However, lack of collision details can render accident reconstruction nearly impossible. Here, we introduce a reconstruction method to evaluate the brain injury in a bicycle–vehicle collision using the crash helmet alone. Following a thorough inspection of the cyclist’s helmet, we identified a severe impact, a moderate impact and several scrapes, which helped us to determine the impact conditions. We used our helmet test rig and intact helmets identical to the cyclist’s helmet to replicate the damage seen on the cyclist’s helmet involved in the real-world collision. We performed both linear and oblique impacts, measured the translational and rotational kinematics of the head and predicted the strain and the strain rate across the brain using a computational head model. Our results proved the hypothesis that the cyclist sustained a severe impact followed by a moderate impact on the road surface. The estimated head accelerations and velocity (167 g, 40.7 rad/s and 13.2 krad/s2) and the brain strain and strain rate (0.541 and 415/s) confirmed that the severe impact was large enough to produce mild to moderate TBI. The method introduced in this study can guide future accident reconstructions, allowing for the evaluation of TBI using the crash helmet only.
Collapse
|
12
|
Material properties of human brain tissue suitable for modelling traumatic brain injury. BRAIN MULTIPHYSICS 2022. [DOI: 10.1016/j.brain.2022.100059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
13
|
Ji S, Ghajari M, Mao H, Kraft RH, Hajiaghamemar M, Panzer MB, Willinger R, Gilchrist MD, Kleiven S, Stitzel JD. Use of Brain Biomechanical Models for Monitoring Impact Exposure in Contact Sports. Ann Biomed Eng 2022; 50:1389-1408. [PMID: 35867314 PMCID: PMC9652195 DOI: 10.1007/s10439-022-02999-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/22/2022] [Indexed: 02/03/2023]
Abstract
Head acceleration measurement sensors are now widely deployed in the field to monitor head kinematic exposure in contact sports. The wealth of impact kinematics data provides valuable, yet challenging, opportunities to study the biomechanical basis of mild traumatic brain injury (mTBI) and subconcussive kinematic exposure. Head impact kinematics are translated into brain mechanical responses through physics-based computational simulations using validated brain models to study the mechanisms of injury. First, this article reviews representative legacy and contemporary brain biomechanical models primarily used for blunt impact simulation. Then, it summarizes perspectives regarding the development and validation of these models, and discusses how simulation results can be interpreted to facilitate injury risk assessment and head acceleration exposure monitoring in the context of contact sports. Recommendations and consensus statements are presented on the use of validated brain models in conjunction with kinematic sensor data to understand the biomechanics of mTBI and subconcussion. Mainly, there is general consensus that validated brain models have strong potential to improve injury prediction and interpretation of subconcussive kinematic exposure over global head kinematics alone. Nevertheless, a major roadblock to this capability is the lack of sufficient data encompassing different sports, sex, age and other factors. The authors recommend further integration of sensor data and simulations with modern data science techniques to generate large datasets of exposures and predicted brain responses along with associated clinical findings. These efforts are anticipated to help better understand the biomechanical basis of mTBI and improve the effectiveness in monitoring kinematic exposure in contact sports for risk and injury mitigation purposes.
Collapse
Affiliation(s)
- Songbai Ji
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA.
| | - Mazdak Ghajari
- Dyson School of Design Engineering, Imperial College London, London, UK
| | - Haojie Mao
- Department of Mechanical and Materials Engineering, Faculty of Engineering, Western University, London, ON, N6A 5B9, Canada
| | - Reuben H Kraft
- Department of Mechanical and Nuclear Engineering, Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, USA
| | - Marzieh Hajiaghamemar
- Department of Biomedical Engineering, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Matthew B Panzer
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Remy Willinger
- University of Strasbourg, IMFS-CNRS, 2 rue Boussingault, 67000, Strasbourg, France
| | - Michael D Gilchrist
- School of Mechanical & Materials Engineering, University College Dublin, Belfield, Dublin 4, Ireland
| | - Svein Kleiven
- Division of Neuronic Engineering, KTH Royal Institute of Technology, Hälsovägen 11C, 141 57, Huddinge, Sweden
| | - Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| |
Collapse
|
14
|
Yu X, Halldin P, Ghajari M. Oblique impact responses of Hybrid III and a new headform with more biofidelic coefficient of friction and moments of inertia. Front Bioeng Biotechnol 2022; 10:860435. [PMID: 36159665 PMCID: PMC9492997 DOI: 10.3389/fbioe.2022.860435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
New oblique impact methods for evaluating head injury mitigation effects of helmets are emerging, which mandate measuring both translational and rotational kinematics of the headform. These methods need headforms with biofidelic mass, moments of inertia (MoIs), and coefficient of friction (CoF). To fulfill this need, working group 11 of the European standardization head protection committee (CEN/TC158) has been working on the development of a new headform with realistic MoIs and CoF, based on recent biomechanics research on the human head. In this study, we used a version of this headform (Cellbond) to test a motorcycle helmet under the oblique impact at 8 m/s at five different locations. We also used the Hybrid III headform, which is commonly used in the helmet oblique impact. We tested whether there is a difference between the predictions of the headforms in terms of injury metrics based on head kinematics, including peak translational and rotational acceleration, peak rotational velocity, and BrIC (brain injury criterion). We also used the Imperial College finite element model of the human head to predict the strain and strain rate across the brain and tested whether there is a difference between the headforms in terms of the predicted strain and strain rate. We found that the Cellbond headform produced similar or higher peak translational accelerations depending on the impact location (−3.2% in the front-side impact to 24.3% in the rear impact). The Cellbond headform, however, produced significantly lower peak rotational acceleration (−41.8% in a rear impact to −62.7% in a side impact), peak rotational velocity (−29.5% in a side impact to −47.6% in a rear impact), and BrIC (−29% in a rear-side impact to −45.3% in a rear impact). The 90th percentile values of the maximum brain strain and strain rate were also significantly lower using this headform. Our results suggest that MoIs and CoF have significant effects on headform rotational kinematics, and consequently brain deformation, during the helmeted oblique impact. Future helmet standards and rating methods should use headforms with realistic MoIs and CoF (e.g., the Cellbond headform) to ensure more accurate representation of the head in laboratory impact tests.
Collapse
Affiliation(s)
- Xiancheng Yu
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, South Kensington, United Kingdom
- *Correspondence: Xiancheng Yu,
| | - Peter Halldin
- Division of Neuronic Engineering, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Huddinge, Sweden
- MIPS AB, Täby, Sweden
| | - Mazdak Ghajari
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, South Kensington, United Kingdom
| |
Collapse
|
15
|
Nowinski CJ, Bureau SC, Buckland ME, Curtis MA, Daneshvar DH, Faull RLM, Grinberg LT, Hill-Yardin EL, Murray HC, Pearce AJ, Suter CM, White AJ, Finkel AM, Cantu RC. Applying the Bradford Hill Criteria for Causation to Repetitive Head Impacts and Chronic Traumatic Encephalopathy. Front Neurol 2022; 13:938163. [PMID: 35937061 PMCID: PMC9355594 DOI: 10.3389/fneur.2022.938163] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/22/2022] [Indexed: 02/05/2023] Open
Abstract
Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with a history of repetitive head impacts (RHI). CTE was described in boxers as early as the 1920s and by the 1950s it was widely accepted that hits to the head caused some boxers to become "punch drunk." However, the recent discovery of CTE in American and Australian-rules football, soccer, rugby, ice hockey, and other sports has resulted in renewed debate on whether the relationship between RHI and CTE is causal. Identifying the strength of the evidential relationship between CTE and RHI has implications for public health and medico-legal issues. From a public health perspective, environmentally caused diseases can be mitigated or prevented. Medico-legally, millions of children are exposed to RHI through sports participation; this demographic is too young to legally consent to any potential long-term risks associated with this exposure. To better understand the strength of evidence underlying the possible causal relationship between RHI and CTE, we examined the medical literature through the Bradford Hill criteria for causation. The Bradford Hill criteria, first proposed in 1965 by Sir Austin Bradford Hill, provide a framework to determine if one can justifiably move from an observed association to a verdict of causation. The Bradford Hill criteria include nine viewpoints by which to evaluate human epidemiologic evidence to determine if causation can be deduced: strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experiment, and analogy. We explored the question of causation by evaluating studies on CTE as it relates to RHI exposure. Through this lens, we found convincing evidence of a causal relationship between RHI and CTE, as well as an absence of evidence-based alternative explanations. By organizing the CTE literature through this framework, we hope to advance the global conversation on CTE mitigation efforts.
Collapse
Affiliation(s)
- Christopher J. Nowinski
- Concussion Legacy Foundation, Boston, MA, United States,*Correspondence: Christopher J. Nowinski
| | | | - Michael E. Buckland
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia,School of Medical Sciences, University of Sydney, Camperdown, NSW, Australia
| | - Maurice A. Curtis
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Daniel H. Daneshvar
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, United States,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Richard L. M. Faull
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Lea T. Grinberg
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, United States,Department of Pathology, University of Sao Paulo Medical School, São Paulo, Brazil,Department of Pathology, University of California, San Francisco, San Francisco, CA, United States
| | - Elisa L. Hill-Yardin
- School of Health and Biomedical Sciences, STEM College, RMIT University, Bundoora, VIC, Australia,Department of Anatomy & Physiology, The University of Melbourne, Parkville, VIC, Australia
| | - Helen C. Murray
- Department of Anatomy and Medical Imaging and Centre for Brain Research, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Alan J. Pearce
- College of Science, Health, and Engineering, La Trobe University, Melbourne, VIC, Australia
| | - Catherine M. Suter
- Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia,School of Medical Sciences, University of Sydney, Camperdown, NSW, Australia
| | - Adam J. White
- Department of Sport, Health Science, and Social Work, Oxford Brookes University, Oxford, United Kingdom,Concussion Legacy Foundation UK, Cheltenham, United Kingdom
| | - Adam M. Finkel
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Robert C. Cantu
- Concussion Legacy Foundation, Boston, MA, United States,Department of Neurology, Boston University School of Medicine, Boston, MA, United States,Department of Neurosurgery, Emerson Hospital, Concord, MA, United States
| |
Collapse
|
16
|
Yu X, Nguyen TT, Wu T, Ghajari M. Non-Lethal Blasts can Generate Cavitation in Cerebrospinal Fluid While Severe Helmeted Impacts Cannot: A Novel Mechanism for Blast Brain Injury. Front Bioeng Biotechnol 2022; 10:808113. [PMID: 35875481 PMCID: PMC9302597 DOI: 10.3389/fbioe.2022.808113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Cerebrospinal fluid (CSF) cavitation is a likely physical mechanism for producing traumatic brain injury (TBI) under mechanical loading. In this study, we investigated CSF cavitation under blasts and helmeted impacts which represented loadings in battlefield and road traffic/sports collisions. We first predicted the human head response under the blasts and impacts using computational modelling and found that the blasts can produce much lower negative pressure at the contrecoup CSF region than the impacts. Further analysis showed that the pressure waves transmitting through the skull and soft tissue are responsible for producing the negative pressure at the contrecoup region. Based on this mechanism, we hypothesised that blast, and not impact, can produce CSF cavitation. To test this hypothesis, we developed a one-dimensional simplified surrogate model of the head and exposed it to both blasts and impacts. The test results confirmed the hypothesis and computational modelling of the tests validated the proposed mechanism. These findings have important implications for prevention and diagnosis of blast TBI.
Collapse
Affiliation(s)
- Xiancheng Yu
- HEAD lab, Dyson School of Design Engineering, Imperial College London, London, United Kingdom
- Centre for Blast Injury Studies, Imperial College London, London, United Kingdom
- *Correspondence: Xiancheng Yu,
| | - Thuy-Tien Nguyen
- Centre for Blast Injury Studies, Imperial College London, London, United Kingdom
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Tianchi Wu
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Mazdak Ghajari
- HEAD lab, Dyson School of Design Engineering, Imperial College London, London, United Kingdom
- Centre for Blast Injury Studies, Imperial College London, London, United Kingdom
| |
Collapse
|
17
|
Yu X, Logan I, de Pedro Sarasola I, Dasaratha A, Ghajari M. The Protective Performance of Modern Motorcycle Helmets Under Oblique Impacts. Ann Biomed Eng 2022; 50:1674-1688. [PMID: 35419767 DOI: 10.1007/s10439-022-02963-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/04/2022] [Indexed: 02/02/2023]
Abstract
Motorcyclists are at high risk of head injuries, including skull fractures, focal brain injuries, intracranial bleeding and diffuse brain injuries. New helmet technologies have been developed to mitigate head injuries in motorcycle collisions, but there is limited information on their performance under commonly occurring oblique impacts. We used an oblique impact method to assess the performance of seven modern motorcycle helmets at five impact locations. Four helmets were fitted with rotational management technologies: a low friction layer (MIPS), three-layer liner system (Flex) and dampers-connected liner system (ODS). Helmets were dropped onto a 45° anvil at 8 m/s at five locations. We determined peak translational and rotational accelerations (PTA and PRA), peak rotational velocity (PRV) and brain injury criteria (BrIC). In addition, we used a human head finite element model to predict strain distribution across the brain and in corpus callosum and sulci. We found that the impact location affected the injury metrics and brain strain, but this effect was not consistent. The rear impact produced lowest PTAs but highest PRAs. This impact produced highest strain in corpus callosum. The front impact produced the highest PRV and BrIC. The side impact produced the lowest PRV, BrIC and strain across the brain, sulci and corpus callosum. Among helmet technologies, MIPS reduced all injury metrics and brain strain compared with conventional helmets. Flex however was effective in reducing PRA only and ODS was not effective in reducing any injury metrics in comparison with conventional helmets. This study shows the importance of using different impact locations and injury metrics when assessing head protection effects of helmets. It also provides new data on the performance of modern motorcycle helmets. These results can help with improving helmet design and standard and rating test methods.
Collapse
Affiliation(s)
- Xiancheng Yu
- Dyson School of Design Engineering, Imperial College London, South Kensington, London, SW7 2AZ, UK.
| | - Ingrid Logan
- Dyson School of Design Engineering, Imperial College London, South Kensington, London, SW7 2AZ, UK
| | - Itziar de Pedro Sarasola
- Dyson School of Design Engineering, Imperial College London, South Kensington, London, SW7 2AZ, UK
| | - Atulit Dasaratha
- Department of Mechanical Engineering, Imperial College London, South Kensington, London, SW7 2AZ, UK
| | - Mazdak Ghajari
- Dyson School of Design Engineering, Imperial College London, South Kensington, London, SW7 2AZ, UK
| |
Collapse
|
18
|
Identifying Factors Associated with Head Impact Kinematics and Brain Strain in High School American Football via Instrumented Mouthguards. Ann Biomed Eng 2021; 49:2814-2826. [PMID: 34549342 PMCID: PMC8906650 DOI: 10.1007/s10439-021-02853-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/13/2021] [Indexed: 01/04/2023]
Abstract
Repeated head impact exposure and concussions are common in American football. Identifying the factors associated with high magnitude impacts aids in informing sport policy changes, improvements to protective equipment, and better understanding of the brain's response to mechanical loading. Recently, the Stanford Instrumented Mouthguard (MiG2.0) has seen several improvements in its accuracy in measuring head kinematics and its ability to correctly differentiate between true head impact events and false positives. Using this device, the present study sought to identify factors (e.g., player position, helmet model, direction of head acceleration, etc.) that are associated with head impact kinematics and brain strain in high school American football athletes. 116 athletes were monitored over a total of 888 athlete exposures. 602 total impacts were captured and verified by the MiG2.0's validated impact detection algorithm. Peak values of linear acceleration, angular velocity, and angular acceleration were obtained from the mouthguard kinematics. The kinematics were also entered into a previously developed finite element model of the human brain to compute the 95th percentile maximum principal strain. Overall, impacts were (mean ± SD) 34.0 ± 24.3 g for peak linear acceleration, 22.2 ± 15.4 rad/s for peak angular velocity, 2979.4 ± 3030.4 rad/s2 for peak angular acceleration, and 0.262 ± 0.241 for 95th percentile maximum principal strain. Statistical analyses revealed that impacts resulting in Forward head accelerations had higher magnitudes of peak kinematics and brain strain than Lateral or Rearward impacts and that athletes in skill positions sustained impacts of greater magnitude than athletes in line positions. 95th percentile maximum principal strain was significantly lower in the observed cohort of high school football athletes than previous reports of collegiate football athletes. No differences in impact magnitude were observed in athletes with or without previous concussion history, in athletes wearing different helmet models, or in junior varsity or varsity athletes. This study presents novel information on head acceleration events and their resulting brain strain in high school American football from our advanced, validated method of measuring head kinematics via instrumented mouthguard technology.
Collapse
|
19
|
Duckworth H, Sharp DJ, Ghajari M. Smoothed particle hydrodynamic modelling of the cerebrospinal fluid for brain biomechanics: Accuracy and stability. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3440. [PMID: 33480161 PMCID: PMC8647913 DOI: 10.1002/cnm.3440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 01/11/2021] [Accepted: 01/17/2021] [Indexed: 05/05/2023]
Abstract
The Cerebrospinal Fluid (CSF) can undergo shear deformations under head motions. Finite Element (FE) models, which are commonly used to simulate biomechanics of the brain, including traumatic brain injury, employ solid elements to represent the CSF. However, the limited number of elements paired with shear deformations in CSF can decrease the accuracy of their predictions. Large deformation problems can be accurately modelled using the mesh-free Smoothed Particle Hydrodynamics (SPH) method, but there is limited previous work on using this method for modelling the CSF. Here we explored the stability and accuracy of key modelling parameters of an SPH model of the CSF when predicting relative brain/skull displacements in a simulation of an in vivo mild head impact in human. The Moving Least Squares (MLS) SPH formulation and Ogden rubber material model were found to be the most accurate and stable. The strain and strain rate in the brain differed across the SPH and FE models of CSF. The FE mesh anchored the gyri, preventing them from experiencing the level of strains seen in the in vivo brain experiments and predicted by the SPH model. Additionally, SPH showed higher levels of strains in the sulci compared to the FE model. However, tensile instability was found to be a key challenge of the SPH method, which needs to be addressed in future. Our study provides a detailed investigation of the use of SPH and shows its potential for improving the accuracy of computational models of brain biomechanics.
Collapse
Affiliation(s)
- Harry Duckworth
- Dyson School of Design EngineeringImperial College LondonLondonUK
- The Computational, Cognitive and Clinical Neuroimaging LaboratoryImperial College LondonLondonUK
| | - David J. Sharp
- The Computational, Cognitive and Clinical Neuroimaging LaboratoryImperial College LondonLondonUK
- Care Research and Technology CentreDementia Research InstituteLondonUK
| | - Mazdak Ghajari
- Dyson School of Design EngineeringImperial College LondonLondonUK
| |
Collapse
|