Effects of hours of sleep on ImPACT concussion testing: comparing baseline with postinjury scores

OBJECTIVE

The influence of sleep on baseline and postconcussion neurocognitive performance prior to Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is poorly understood. Since ImPACT is widely used in youth sport to assess neurocognitive performance before and after head injury, it is important to delineate factors that affect testing performance. While some have reported correlations between fewer hours of sleep and lower scores on baseline tests, others have not observed any such associations. Therefore, the authors sought to compare the relationship between sleep and neurocognitive performance on ImPACT at both baseline and postinjury.

METHODS

The authors queried a database of 25,815 ImPACT tests taken from 2009 to 2019 by athletes aged 12-22 years. There were 11,564 baseline concussion tests and 7446 postinjury concussion ImPACT tests used in the analysis. Linear regression was used to model the effect of sleep on baseline and postconcussion ImPACT scores adjusting for sex, age, learning disability, attention-deficit/hyperactivity disorder, number of prior concussions, number of games missed, and strenuous exercise before testing.

RESULTS

Mean composite scores expectedly were all significantly lower in the post-head injury group compared with the baseline group. In the multivariable analysis, at baseline, hours of sleep significantly affected symptom scores (β = -1.050, 95% CI -1.187 to -0.9138; p < 0.0001). In the postinjury multivariable analysis, verbal memory (β = 0.4595, 95% CI 0.2080-0.7110; p = 0.0003), visual memory (β = 0.3111, 95% CI 0.04463-0.5777; p = 0.0221), impulse control (β = -0.2321, 95% CI -0.3581 to -0.1062; p = 0.0003), and symptom scores (β = -0.9168, 95% CI -1.259 to -0.5750; p < 0.0001) were all affected by hours of sleep.

CONCLUSIONS

Hours of sleep did not alter neurocognitive metrics at baseline but did have an impact on post-head injury metrics. These findings suggest that individuals may be able to compensate for lack of sleep at baseline but not immediately after concussion. Concussions may reduce cognitive reserve or detract from the brain's resources, making sleep even more important for proper neurocognitive functioning postconcussion. Future work will analyze the effects of sleep on postconcussion test performance.

Considerations for Developing a Mental Health Emergency Action Plan for High School Football Programs and Athletic Departments

High school students in the United States are being educated during an unprecedented time of social unrest, public health concerns, and gun violence. High school student athletes can be further challenged by sports-related stressors that may lead to anxiety, burnout, depression, disordered eating, sleep difficulty, performance-based identity concerns, and substance use. High school football players, in particular, are at higher risk of concussion, musculoskeletal injury, and may feel excess pressure to compete from coaches, parents, and peers. One way to address these stressors among high school student athletes is to increase athletic department staff members' awareness of the symptoms of mental health disorders. Increased awareness helps staff members recognize when an athlete is in crisis, as well as respond with an established mental health emergency action plan as needed. In this review article, the authors provide a blueprint by which high school personnel can more readily identify and respond to mental health emergencies among student athletes.

Effects of Yoga Intervention on Functional Movement Patterns and Mindfulness in Collegiate Athletes: A Quasi-Experimental Study

High-quality movement patterns and high levels of mindfulness are thought to be beneficial in preventing sports injuries. Yoga is recommended in the field of athlete rehabilitation. This study investigated the effects of yoga intervention on functional movement patterns and mindfulness in collegiate athletes. It is a quasi-experimental study with a pre/post-test control design. The participants were divided into a yoga group and a control group. A Functional Movement Screen and the Mindful Attention Awareness Scale were used to assess participants' basic movement patterns and mindfulness before and after 12 weeks of yoga intervention (two classes per week, 90 min per class). The results show that the yoga group's FMS scores improved more compared to the control group [F(1,78) = 29.08, p < 0.001, ŋp² = 0.27], and that the scores for the deep squat (ŋp² = 0.4), shoulder mobility (ŋp² = 0.17), and trunk stability pushup (ŋp² = 0.36) improved substantially. The dysfunctional score ratio for deep squats (χ² = 18.57, p < 0.001), shoulder mobility (χ² = 26.90, p < 0.001), trunk stability pushup (χ² = 17.07, p < 0.001), and rotatory stability (χ²= 38.29, p <0.001) decreased significantly compared with the control group, but there was no significant improvement in asymmetric movement patterns (χ² = 0.75, p = 0.39). The mindfulness scores in the yoga group significantly exceeded those of the control group [F(1,78) = 13.56, p < 0.001, ŋp² = 0.15]. These results suggest that yoga intervention can improve functional movement patterns and mindfulness levels, but further evidence is needed to determine whether yoga could positively influence sports injuries.

Nutrition Knowledge of Collegiate Athletes in the United States and the Impact of Sports Dietitians on Related Outcomes: A Narrative Review

In the last decade, the number of full-time registered dietitians (RDs) serving intercollegiate athletes in the United States has more than quadrupled. However, many student athletes may be at increased risk of nutrition-related problems that impact physical and academic performance, which include inadequate macronutrients, inadequate micronutrients, and excessive macronutrients. This narrative review reports the current literature to date on nutrition-related knowledge in collegiate athletes and the impact of sports RDs on student athletes’ nutrition knowledge and behaviors. To date, only observational and quasi-experimental studies have been published with regard to changes in nutrition knowledge and behaviors in NCAA athletes. While these studies report benefits of the RD as a member of the interdisciplinary student athlete support team, more well-designed randomized control trials are warranted to determine benefits related to health outcomes and sport-specific performance outcomes.

Machine Learning to Predict Lower Extremity Musculoskeletal Injury Risk in Student Athletes

Injury rates in student athletes are high and often unpredictable. Injury risk factors are not agreed upon and often not validated. Here, we present a random-forest machine learning methodology for identifying the most significant injury risk factors and develop a model of lower extremity musculoskeletal injury risk in student athletes with physical performance metrics spanning joint strength measured with force transducers, postural stability measured using a force plate, and flexibility, measured with a goniometer, combined with previous injury metrics and athlete demographics. We tested our model in a population of 122 student athletes with performance metrics for the lower extremity musculoskeletal system and achieved an injury risk accuracy of 79% and identified significant injury risk factors, that could be used to increase accuracy of injury risk assessments, implement timely interventions, and decrease the number of career-ending or chronic injuries among student athletes.

Nonsuicidal self-injury, suicidal ideation, and suicide attempt among collegiate athletes: Findings from the National College Health Assessment

To evaluate whether collegiate athletes and nonathlete college students differ in nonsuicidal self-injury (NSSI), suicidal ideation, suicide attempt, and help-seeking behaviors. Participants: 165,210 respondents to the American College Health Association's National College Health Assessment (NCHA), a survey administered to college students by participating institutions during Fall 2011 to Spring 2015. Methods: Single-level binary logistic regression with equality of coefficients tests and chi-square analyses. Results: The models for NSSI and suicide attempt differed slightly between student-athletes and nonathletes. Most notably, stress is a stronger correlate of NSSI (Z = 3.03, p < .01) for nonathletes while difficulties with social relationships is a stronger correlate of suicide attempt for student-athletes (Z=-3.13, p < .01). Conclusion: Our findings highlight the salience of relationship problems as a correlate with suicide attempts in student-athletes. Difficulty in romantic or other social relationships could be a marker of risk or an identifiable, actionable target for preventing future suicidal behaviors among collegiate athletes.

Alpine Ski Coaches' and Athletes' Perceptions of Factors Influencing Adaptation to Stress in the Classroom and on the Slopes

Research examining the student-athlete experience proposes a number of factors that can be both sources of stress and/or support. The dual career pathway offers a number of potential positive outcomes including psychological, social, and financial benefits; however, challenges including time management, fatigue, and restricted social activities are well documented. In consideration of the multidimensional student-athlete experience and the numerous factors that influence the complexity of potential stress, a mixed methods research study design was used in the study. First, data collected from surveys completed by 173 elite junior alpine skiers were analyzed to identify the degree to which athletes report experiencing stress associated with specific aspects pertaining to training, life, and organizational factors. These factors were then explored through semi-structured interviews with six coaches at the associated national elite sport schools. Taken collectively, athletes' reports of psychophysiological training stress on the Multidimensional Training Distress Scale were low. Scores on the college student-athletes' life stress scale revealed very low levels of general life stress; although the subscales associated with "performance demand" and "academic requirements" scored marginally higher. Scores on the Organizational Stressor Indicator for Sport Performers indicated low levels of organizational stress. The interviews with coaches elucidated the underlying factors potentially influencing athletes' positive adaptations to stress as they reported programming a number of strategies to reduce negative outcomes. Coaches aimed to teach athletes self-awareness and regulation strategies through the use of the training diaries and ongoing communication to promote positive adaptation to stress. A number of coaches also worked with sport psychology consultants to optimize athletes' training and study situations. Traditionally, research has noted high levels of stress in student-athletes due to co-occurring demands (school & sport); however, the data in the present study suggests that optimizing support mechanisms across domains can promote positive adaptations to potential sources of stress.

A systematic review of criteria used to define recovery from sport-related concussion in youth athletes

OBJECTIVE

The Concussion in Sport Group guidelines recommend a multifaceted approach to help clinicians make return to sport decisions. The purpose of this study was to identify the most common multifaceted measures used to define clinical recovery from sport-related concussion in young athletes (high school and/or college level) and to summarise existing knowledge of criteria used to make return to sport decisions.

DESIGN

Systematic review.

DATA SOURCES

The PubMed (MEDLINE), SPORTDiscus and Embase electronic databases were searched from 1 January 2000 to 1 March 2017 by three independent reviewers.

ELIGIBILITY CRITERIA

Inclusion criteria: elementary, high school and college age groups, and a specific definition of clinical recovery that required two or more measures.

EXCLUSION CRITERIA

review articles, articles using the same sample population, case studies, non-English language and those that used one measure only or did not specify the recovery measures used.

STUDY QUALITY

Study quality was assessed using the Downs and Black Criteria.

RESULTS

Of 2023 publications, 43 met inclusion criteria. Included articles reported the following measures of recovery: somatic symptom resolution or return to baseline (100%), cognitive recovery or return to baseline (86%), no exacerbation of symptoms on physical exertion (49%), normalisation of balance (30%), normal special physical examination (12%), successful return to school (5%), no exacerbation of symptoms with cognitive exertion (2%) and normalisation of cerebral blood flow (2%). Follow-up to validate the return to sport decision was reported in eight (19%) articles. Most studies were case-control or cohort (level of evidence 4) and had significant risk of bias.

CONCLUSION

All studies of sport-related concussion use symptom reports to define recovery. A minority of studies used multiple measures of outcome or had clearly defined recovery criteria, the most common being a combination of a self-reported symptom checklist and a computerised neurocognitive test. Future studies ideally should define recovery a priori using objective physiological measures in addition to symptom reports.

Mild Traumatic Brain Injury and Attention-Deficit Hyperactivity Disorder in Young Student Athletes

A recent meta-analysis documented a significant statistical association between mild traumatic brain injury (mTBI) and attention deficit hyperactivity disorder (ADHD) (Adeyemo et al., 2014), but the direction of this effect was unclear. In this study, we hypothesized that ADHD would be an antecedent risk factor for mTBI. Participants were student athletes ages 12 to 25 who had sustained a mTBI and Controls of similar age and sex selected from studies of youth with and without ADHD. Subjects were assessed for symptoms of ADHD, concussion severity, and cognitive function. mTBI subjects had a significantly higher rate of ADHD than Controls, and in all cases the age of onset of ADHD was before mTBI onset. mTBI+ADHD subjects also had more severe concussion symptoms (fatigue and poor concentration) than mTBI-ADHD subjects. These results support ADHD as an antecedent risk factor for mTBI in student athletes and that its presence complicates the course of mTBI.

Suicide in National Collegiate Athletic Association (NCAA) Athletes: A 9-Year Analysis of the NCAA Resolutions Database

Background:

The National Collegiate Athletic Association (NCAA) has recently highlighted mental health concerns in student athletes, though the incidence of suicide among NCAA athletes is unclear. The purpose of this study was to determine the rate of suicide among NCAA athletes.

Hypothesis:

The incidence of suicide in NCAA athletes differs by sex, race, sport, and division.

Study Design:

Retrospective cohort study.

Level of Evidence:

Level 3.

Methods:

NCAA Memorial Resolutions list and published NCAA demographic data were used to identify student-athlete deaths and total participant seasons from 2003-2004 through 2011-2012. Deaths were analyzed by age, sex, race, division, and sport.

Results:

Over the 9-year study period, 35 cases of suicide were identified from a review of 477 student-athlete deaths during 3,773,309 individual participant seasons. The overall suicide rate was 0.93/100,000 per year. Suicide represented 7.3% (35/477) of all-cause mortality among NCAA student athletes. The annual incidence of suicide in male athletes was 1.35/100,000 and in female athletes was 0.37/100,000 (relative risk [RR], 3.7; P < 0.01). The incidence in African American athletes was 1.22/100,000 and in white athletes was 0.87/100,000 (RR, 1.4; P = 0.45). The highest rate of suicide occurred in men’s football (2.25/100,000), and football athletes had a relative risk of 2.2 (P = 0.03) of committing suicide compared with other male, nonfootball athletes.

Conclusion:

The suicide rate in NCAA athletes appears to be lower than that of the general and collegiate population of similar age. NCAA male athletes have a significantly higher rate of suicide compared with female athletes, and football athletes appear to be at greatest risk.

Clinical Relevance:

Suicide represents a preventable cause of death, and development of effective prevention programs is recommended.

Student athletes, sudden cardiac death, and lifesaving legislation: a review of the literature

PURPOSE

The purpose of this article is to present findings of a literature review examining the use of automatic external defibrillators (AEDs) for student athletes experiencing sudden cardiac arrest and variances in state legislation regarding the mandatory placement of AEDs in school gymnasiums and athletic fields.

METHODS

A broad search of computerized databases was conducted utilizing PubMed, Medline, CINHAHL, and the Cochrane Databases, which provided a broad but not exhaustive review of the current literature related to student athletes, sudden cardiac death, and the use of AEDs. The articles were evaluated and graded using Stetler's strength of evidence guidelines.

FINDINGS

A total of 17 articles are included in this literature review (Stetler's Grade I, n = 1; Grade II, n = 2; Grade III, n =2; Grade IV, n = 5; Grade V, n = 3; and Grade VI, n = 4). The literature produced few meta-analyses of controlled studies, experimental studies, and quasi-experimental studies on the topic of student athletes at risk for sudden cardiac death. The majority of the literature is based on expert opinion, case reports, and retrospective data sets. The literature does support the correlation of early cardiopulmonary resuscitation and defibrillation with increased survival rates among persons experiencing sudden cardiac arrest.

CONCLUSIONS

Additional evidence-based research is needed to support the long-term outcomes of AED legislation and its utility in sparing the lives of student athletes. However, the evidence supporting early intervention, a coordinated emergency plan, and rapid emergency medical services response is conclusive enough to warrant state or federal legislation mandating that AEDs be present in all school gyms and athletic fields.

A national study of substance use behaviors among NCAA male athletes who use banned performance enhancing substances

BACKGROUND

Reports of illicit substance use by college athletes have become commonplace in recent years, yet comparatively little effort has been put forth by the research community to understand these behaviors.

METHODS

Data for this study came from a large, national dataset collected by the National Collegiate Athletic Association (NCAA). This study compared substance use behaviors of male undergraduate student athletes who reported using ergogenic performance enhancing substances (e.g., anabolic steroids and peptide hormones) during college (PES users) to those who did not (PES non-users).

RESULTS

A consistent pattern of higher substance use rates was observed among PES users compared to non-users, including heavier drinking, higher prevalence rates of cigarettes, marijuana, amphetamines, narcotics, and a variety of permissible and impermissible dietary supplements. An unexpected finding was that there were large discrepancies in reported prevalence rates between similar or overlapping survey items (e.g., past year use of "narcotics" versus "I have taken Vicodin, Oxycontin or Percocet with/without a prescription").

CONCLUSIONS

These findings suggest that male college athletes who use PES while in college demonstrate a general tendency to engage in alcohol and drug use behaviors, regardless of whether these behaviors improve or impede athletic performance. The results further suggest that college athletes may not fully appreciate drug categorizations that are commonly employed to gauge substance use behaviors. Changes to drug education and prevention programs may be needed to enhance understanding of drug properties and actions.