Publications

INTRODUCTION: Long-term brain health profiles following exposure to repetitive head impacts and/or concussions in contact sports are a public health focus and the subject of a national debate. The true prevalence rates of mild cognitive impairment (MCI) or neurobehavioural dysregulation are unknown in the nearly 20 000 current/living former professional football players. Here, we describe the procedures and methodology of the prevalence study of cognitive function in former professional football players from the Brain Health Initiative at the University of Pittsburgh. The objective is to define the prevalence of normal cognitive function versus neurodegeneration in former professional football players through clinical, neuroimaging and biomarker assessments.

METHODS AND ANALYSIS: Participants include former professional football players aged 29-59 years at study onset who played a minimum of three professional football games in three professional seasons and non-exposed controls. Participants are recruited by two mechanisms, a random and non-random sample. The full study protocol includes a 3-4-day, multidomain assessment (eg, neurological, neurocognitive, psychiatric, sleep, vestibular, orthopaedic and cardiovascular) for neurodegenerative disease and overall health and function, including MRI, positron emission tomography scans, analysis of blood plasma and cerebrospinal fluid, neurocognitive assessments, applanation tonometry, overnight sleep study and informant interview. A multidisciplinary clinical panel conducts a blinded diagnostic consensus conference to adjudicate the presence of MCI and/or traumatic encephalopathy syndrome, which serve as the study's primary and secondary outcomes, respectively. Point prevalence of these for both the exposed and unexposed cohorts will be calculated as the primary statistical analysis.

ETHICS AND DISSEMINATION: The University of Pittsburgh Institutional Review Board approved the study prior to recruiting human subjects (protocol numbers STUDY19010008: sIRB - Brain Health Initiative (Part 1) and STUDY19030211: sIRB - Brain Health Initiative (Part 2)). The results will be disseminated in peer-reviewed journals and as presentations at national and international scientific conferences.

Excessive screen time (ST) use has been linked to more depressive and anxiety symptoms, whereas moderate use may confer benefits for psychological health in adolescents. However, its role in psychological health following concussion in adolescents remains unclear. This study examined the effects of ST use on depressive and anxiety symptoms in adolescents following concussion. A total of 102 adolescents comprising 62 (mean [standard deviation (SD)] = 15.2 [1.7] years; 45.2% female) within 10 days of a diagnosed concussion, and 40 age- and sex-matched healthy controls (mean age [SD] = 14.99 [1.62] years; 50% female) participated in the study. Psychological symptoms were assessed using the Children's Depression Rating Scale and the Screen for Child Anxiety Related Emotional Disorders in the first 10 days (V1) and 3 months (V2) postinjury. Recreational ST use was self-reported at V1. K-means clustering classified adolescents with concussion into ST subgroups. Robust regression and false discovery rate correction examined group differences at V1 and V2 postinjury. Three clusters of ST use were identified: low (N = 14; mean [SD] = 1.97 [0.89] h/day), moderate (N = 25; mean [SD] = 5.22 [0.86] h/day), and high (N = 23; mean [SD] = 8.96 [1.42] h/day). At V1, all groups reported higher depressive and anxiety symptoms than controls (p < 0.041). At V2, all symptoms in the moderate-use group returned to control levels; however, the high-use group reported elevated depressive symptoms (F = 12.48, p = 0.001, Q = 0.003), and the low-use group reported elevated anxiety (F = 23.15, p < 0.001, Q < 0.001) compared with controls. Moderate recreational ST use was associated with significant recovery, while low and high ST use were associated with persistent symptoms in adolescents following concussion. Adolescents may benefit from recommendations that support a "Goldilocks" approach to ST use following concussion.

Due to the highly individualised presentation of sport-related concussion (SRC), multi-domain assessments examining cognitive, migraine, vestibular, ocular, mood, sleep, and neck-related function have been suggested to assist clinicians with diagnosis, management, and rehabilitation. Normative data on such assessments for female, community players from countries outside the U.S. are needed. This study aimed to (i) describe normative data from community-level Ladies Gaelic Football players using a multi-domain assessment, and (ii) compare findings between adolescent and adult players. A total of 138 LGF players without SRC (101 adults, 37 adolescents) completed a multi-domain SRC assessment including Sport Concussion Assessment Tool 5th Edition, Concussion Clinical Profiles Screening, Vestibular/Ocular Motor Screening (VOMS), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®), Patient Health Questionnaire-9, Generalised Anxiety Disorder-7, Pittsburgh Sleep Quality Index, Migraine Disability Assessment, and Neck Bournemouth Questionnaire, and neck dynamometry. Normative data were summarised using descriptive statistics, while differences in test scores between adolescents and adults were examined using parametric or non-parametric tests. While adolescents and adults scored similarly on most measures, adolescents scored worse on ImPACT® visual-motor speed (d = 0.09) and reaction time (r = 0.52), SCAT5 concentration (V = 0.38), total modified Balance Error Scoring System (r = 0.42), and CP Screen vestibular profile (r = 0.38) (p < 0.05). This is the first study to describe and compare normative data for multidomain SRC assessments in adolescent and adult female, community athletes. Differences in some tests between adolescents and adults highlight the need for demographic-specific normative data when interpreting post-SRC assessment results.

INTRODUCTION: Military service members training with heavy weapons systems are exposed to low-level blast (LLB) overpressure, sometimes resulting in acute symptoms similar to mild traumatic brain injury (mTBI). There is a need for a quick and effective screening tool to identify early deficits and changes associated with blast exposure and minimizing potential ensuing effects. Recently, researchers developed the modified Vestibular/Ocular Motor Screening (mVOMS), designed to assess signs and symptoms of mTBI. modified Vestibular/Ocular Motor Screening consists of four physical movement conditions: smooth pursuits, horizontal saccades, horizontal vestibular-ocular reflex, and visual motion sensitivity to capture the provocation of the vestibular system (headache, dizziness, nausea, fogginess). After completing each activity, service members were asked whether the symptoms were present or absent. Modified Vestibular/Ocular Motor Screening offers a practical solution as it can be administered in approximately 2 minutes and is 85% accurate in identifying mTBI. Similarly, military settings, where time is often constrained in addressing potential mTBI can benefit from the efficiency and reliability of mVOMS, making it well-suited for training settings; however, the use of mVOMS to detect acute blast exposure effects in service members has not been explored, which was the primary purpose of this study. A secondary purpose was to explore the relationship between mVOMS and self-reported mTBI symptoms without provocation by physical motion, as well as eye-tracking.

MATERIALS AND METHODS: This was a prospective cohort study design involving 42 male military personnel training with mortar systems and 15 male, healthy, unexposed controls. Participants reported demographics and over three separate visits, a self-reported symptoms questionnaire, mVOMS, and smooth pursuit eye tracking assessment. Independent samples t-tests and chi-square analyses, along with Pearson's and rank-biserial correlations, compared demographic and outcome variables between exposed and control groups from the three visits, including individual measures of blast exposure magnitude. A series of receiver operating characteristic (ROC) curves with area under the curve (AUC) were used to evaluate the accuracy of mVOMS, mTBI symptoms, and eye tracking to identify exposed from control groups. This study has been approved by the Walter Reed Army Institute of Research Institutional Review Board.

RESULTS: Participants' mean age was 25 ± 3.42 years with mean duration of service 4 ± 2.43 years. Service members exposed to blast reported more symptoms after performing the mVOMS physical movement challenges. The discriminatory power of the change from pre-exposure in mVOMS (AUC = 0.72) was comparable with the change in self-reported symptoms. In contrast to the change from pre-exposure, post-exposure single timepoint evaluation revealed mVOMS is superior (AUC = 0.70) compared to self-reported symptoms (AUC = 0.51). Modified Vestibular/Ocular Motor Screening was also positively correlated with blast exposure measures suggesting that increasing blast exposure levels are associated with increasing mVOMS scores.

CONCLUSIONS: These results demonstrate that mVOMS in individuals exposed to LLB elicits a response that may be more sensitive than self-report alone. Our data suggests that mVOMS may be useful to screen for mTBI symptomology in service members following blast exposure when administered as a single timepoint test, as it is quick, simple to interpret, and requires minimal training to administer.

OBJECTIVE: To compare pre-injury and initial subacute clinical characteristics of adolescents with sport-related concussion (SRC) to those with non-sport-related concussion (non-SRC) who present to a specialty concussion clinic.

DESIGN: Cross-sectional analysis of 136 adolescents 10-18 (Mean = 14.4 ± SD = 2.3) years presenting to a specialty concussion clinic 2-30 (M = 9.25 ± SD = 6.3) days post-injury. Main measures included 1) Clinical Interview, 2) Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), 3) Post-Concussion Symptom Scale (PCSS), 4) Vestibular/Ocular-Motor Screening (VOMS), 5) Screen for Child Related Anxiety Disorders - Child Version (SCARED-C), 6) Generalized Anxiety Disorder Assessment (GAD-7).

RESULTS: 101 (74.3%) participants reported an SRC, and 35 (25.7%) reported a non-SRC. Adolescents presenting to the clinic with non-SRC were older, more likely to be female, presented to the clinic later, and reported headache/migraine and depression history (p < 0.05). These adolescents also reported a higher PCSS symptom severity and GAD-7 total score compared to their SRC counterparts (p < 0.01). Forward stepwise logistic regression revealed significant associations between non-SRC and headache/migraine history (adjusted [a]OR = 2.95, 95%CI = 1.17-7.47, p = 0.022), PCSS total score (aOR = 1.04, 95%CI = 1.02-1.06, p < 0.001), and days to clinic (OR = 1.08, 95%CI = 1.01-1.15, p = 0.029).

CONCLUSIONS: The most salient factors associated with non-SRC patients presenting to a specialty concussion clinic were a headache/migraine history, a longer time to clinic, and greater initial visit symptoms. These findings suggest that the factors that lead patients with SRC and Non-SRC to present to a specialty clinic differ, and that studies that are interested in differences in clinical characteristics based on mechanism of injury will need to address substantial referral differences between these two populations that would confound such findings.

OBJECTIVE: To compare initial multidomain clinical outcomes and recovery time between fear-avoidant (FA) and nonfear-avoidant (NFA) adults after concussion.

DESIGN: Prospective cohort study.

SETTING: Specialty concussion clinic.

PARTICIPANTS: Adults aged 18 to 50 years within 30 days of a diagnosed concussion. Based on clinical cutoffs for the Fear Avoidance Components Scale at the initial clinic visit, participants were categorized into FA (41-100; moderate to severe) and NFA (0-40; none to mild) groups. A total of 74 participants (N=74) (M=28.7±8.4y, 68.9% women) were included, 37 (50.0%) in the FA and 37 (50.0%) in the NFA group.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: (1) Clinical intake and interview, (2) Fear Avoidance Components Scale, (3) Concussion Clinical Profiles Screening Tool (CP Screen), (4) Postconcussion Symptom Scale, (5) Immediate Postconcussion Assessment and Cognitive Testing, (6) Vestibular/Ocular Motor Screening (VOMS), (7) Generalized Anxiety Disorder 7-Item Assessment, (8) Patient Health Questionnaire-9, (9) Patient Health Questionnaire-15, and (10) Recovery Time (days to medical clearance).

RESULTS: There were no differences in demographics, medical history, or injury characteristics between groups. The FA group had worse CP Screen anxiety/mood (P=.04), cognitive (P=.04), and total symptoms (P=.04); Immediate Postconcussion Assessment and Cognitive Testing reaction time (P=.01); VOMS visual motion sensitivity (P=.03) and total VOMS (P=.04); Generalized Anxiety Disorder 7-Item Assessment (P<.01); and Patient Health Questionnaire-9 (P<.01) scores than the NFA group. Results from a Cox proportional hazards model demonstrated that the FA group had a 62% lower instantaneous recovery likelihood on any given day than the NFA group (hazard ratio=0.38; 95% confidence interval, 0.15-0.96; P=.04) while controlling for CP Screen total.

CONCLUSIONS: FA adults demonstrated worse concussion symptoms, reaction time, and vestibular impairments compared with NFA adults after concussion. Moreover, after controlling for initial symptom severity, FA adults took significantly longer to recover than NFA adults. Future research should explore potential mechanisms underlying the relationship between fear avoidance and poor outcomes, including reduced adherence to treatment recommendations.