Bifactor Model of the Sport Concussion Assessment Tool Symptom Checklist: Replication and Invariance Across Time in the CARE Consortium Sample

Background: Identifying separate dimensions of concussion symptoms may inform a precision medicine approach to treatment. It was previously reported that a bifactor model identified distinct acute postconcussion symptom dimensions. Purpose: To replicate previous findings of a bifactor structure of concussion symptoms in the Concussion Assessment Research and Education (CARE) Consortium sample, examine measurement invariance from pre- to postinjury, and evaluate whether factors are associated with other clinical and biomarker measures. Study design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Collegiate athletes were prospectively evaluated using the Sport Concussion Assessment Tool-3 (SCAT-3) during preseason (N = 31,557); 2789 were followed at <6 hours and 24 to 48 hours after concussion. Item-level SCAT-3 ratings were analyzed using exploratory and confirmatory factor analyses. Bifactor and higher-order models were compared for their fit and interpretability. Measurement invariance tested the stability of the identified factor structure across time. The association between factors and criterion measures (clinical and blood-based markers of concussion severity, symptom duration) was evaluated. Results: The optimal structure for each time point was a 7-factor bifactor model: a General factor, on which all items loaded, and 6 specific factors-Vestibulo-ocular, Headache, Sensory, Fatigue, Cognitive, and Emotional. The model manifested strict invariance across the 2 postinjury time points but only configural invariance from baseline to postinjury. From <6 to 24-48 hours, some dimensions increased in severity (Sensory, Fatigue, Emotional), while others decreased (General, Headache, Vestibulo-ocular). The factors correlated with differing clinical and biomarker criterion measures and showed differing patterns of association with symptom duration at different time points. Conclusion: Bifactor modeling supported the predominant unidimensionality of concussion symptoms while revealing multidimensional properties, including a large dominant General factor and 6 independent factors: Headache, Vestibulo-ocular, Sensory, Cognitive, Fatigue, and Emotional. Unlike the widely used SCAT-3 symptom severity score, which declines gradually after injury, the bifactor model revealed separable symptom dimensions that have distinct trajectories in the acute postinjury period and different patterns of association with other markers of injury severity and outcome. Clinical relevance: The SCAT-3 total score remains a valuable, robust index of overall concussion symptom severity, and the specific factors identified may inform management strategies. Because some symptom dimensions continue to worsen in the first 24 to 48 hours after injury (ie, Sensory, Fatigue, Emotional), routine follow-up in this time frame may be valuable to ensure that symptoms are managed effectively

The effects of relaxation techniques following acute, high intensity football training on parasympathetic reactivation

BackgroundEvidence shows relaxation techniques reactivate the parasympathetic nervous system (PNS) following physiological stressors such as exercise. As such, these techniques may be useful following exercise training of high intensity sports, like collegiate football.PurposeTo evaluate the impact of mindfulness and rest activities on PNS reactivation following training sessions, in a sample of Division-I collegiate, male football athletes.MethodsThis study employed a cross-sectional, pre-post experimental design among 38 football athletes. Following three training sessions, each separated by one week, athletes were exposed to three groups: mindfulness, rest, and no-intervention. Athletes in the mindfulness group laid supine in a darkened room, while performing 15 min of guided breathing and body scans. The rest group remained seated in a lighted room, performing 15 min of restful activities (e.g., talking). The no-intervention group was instructed to perform usual post-training activities (e.g., showering). Heart rate (HR), respiration rate (RR) and two HR variability (HRV) indices were measured via an armband monitor (Warfighter Monitor, Tiger Tech Solutions, Inc, Miami, FL) equipped with electrocardiographic and photoplethysmography capabilities. HRV indices included standard deviation of the N-N intervals (SDNN) and root mean square of successive RR interval differences (rMSSD). Within and between-group differences were determined via analysis of variance (ANOVA) and corrected for multiple comparisons familywise error.ResultsStatistically significant reductions in HR and RR were observed across all groups: −81.6, −66.4, −40.9 bpm and −31.7, −26.9, and −19.0 breaths⋅min−1, respectively. The mindfulness and rest groups exhibited a larger within-group reduction in HR and RR compared to the no-intervention group, p < 0.0000. Additionally, the mindfulness group showed a larger reduction in HR and RR compared to the rest group, p < 0.05. Post-intervention HR and RRs were significantly lower in the mindfulness group relative to the no-intervention group (77.0 vs. 120.1 bpm, respectively). Similar results were observed for RR (15.0 vs. 23.6 breaths⋅min−1, respectively) and HRV indices (SDNN: 46.9 vs. 33.1 ms and rMSSD: 17.9 vs. 13.8 ms, respectively) Athletes in the rest group showed significantly lower post-intervention HR (−30.2 bpm, 89.9 vs. 120.1 bpm, respectively), RR (−4.3 breaths⋅min−1, 19.3 vs. 23.6 breaths⋅min−1, respectively) and significantly higher HRV (SDNN: 42.9 vs. 33.1 ms and rMSSD: 16.7 vs. 13.8 ms, respectively) compared to their no-intervention counterparts.ConclusionsOur findings suggest that athletes engaging in either 15-minute guided mindfulness or rest activities (e.g., sitting) post training, may facilitate PNS reactivation. Implementing these strategies may accelerate recovery, improving performance. Longitudinal, randomized controlled trials among diverse sports are encouraged

Neurodevelopmental Disorders and Risk of Concussion: Findings from the National Collegiate Athletic Association Department of Defense Grand Alliance Concussion Assessment, Research, and Education (NCAA-DOD CARE) Consortium (2014-2017)

Evidence suggests neurodevelopmental disorders (NDs) may be associated with an increased incidence of concussion, but no studies have cross-sectionally and longitudinally assessed the associations of NDs and sex with concussion in collegiate athletes. We sought to assess the odds and relative risk (RR) of concussion in athletes self-reporting a diagnosis of attention deficit/hyperactivity disorder (ADHD), learning disability (LD), and ADHD+LD. Data from the Concussion Assessment, Research and Education (CARE) Consortium (2014-2017) were used to evaluate the likelihood of concussion for male and female athletes with ADHD, LD, and ADHD+LD, relative to controls. Odds ratios (ORs) of concussion history prior to enrollment and relative risk ratios for incurring a concussion following enrollment, with and without concussion history were calculated for all groups. Athletes with self-reported diagnosis of ADHD, LD, and ADHD+LD were more likely to report a single concussion (OR range = 1.528 to 1.828) and multiple concussions (OR range = 1.849 to 2.365) prior to enrollment in the CARE Consortium, irrespective of sex compared with control athletes. While enrolled in CARE, male athletes with ADHD, LD, and ADHD+LD had greater risk of incurring a concussion (RR range = 1.369 to 2.243) than controls, irrespective of concussion history. Male athletes with ADHD+LD with concussion history (RR = 2.221) and without concussion history (RR = 1.835) had greater risk of incurring a concussion than controls. These results suggest NDs may be associated with increased odds of single and multiple concussions, irrespective of sex. However, when we accounted for concussion history, it appears only male athletes with ADHD+LD had greater risk than respective controls. There were no significant differences between females and males with ADHD, LD, or ADHD+LD for either odds of concussion history or risk for incurring concussion

Distal Medial Collateral Ligament Grade III Injuries in Collegiate Football Players: Operative Management, Rehabilitation, and Return to Play

Context Management of isolated grade III medial collateral ligament injuries is controversial, as both nonoperative and operative management can result in return to play. However, operative management is recommended in elite athletes who have a grade III injury with distal avulsion. Objective We present a standardized rehabilitation protocol in a case series of 7 National Collegiate Athletic Association Division I American football athletes who sustained grade III distal medial collateral ligament tears that were repaired operatively, with emphasis on return to play. Results Median time to surgery was 4 days (range = 2–67 days). Median time from surgery to noncontact drills was 120.5 days (range = 104–168 days), and median time from surgery to full-contact sport was 181 days (range = 139–204 days). All athletes returned to play at their preinjury level of competition. Conclusions Our study highlighted how operative management with a standardized rehabilitation protocol can be applied to Division I football players and result in safe return to play

Return to Sport Following Surgery for a Complicated Tibia and Fibula Fracture in a Collegiate Women's Soccer Player with a Low Level of Kinesiophobia

Much attention has been solely paid to physical outcome measures for return to sport after injury in the past. However, current research shows that the psychological component of these injuries can be more predictive of return to sport than physical outcome measures. The purpose of this case report is to describe the successful return to sport following surgery of a complicated tibia and fibula fracture of a Division I collegiate women's soccer player with a low level of kinesiophobia. A 22-year-old female sustained a closed traumatic mid-shaft fracture of her tibia and fibula. During a high velocity play she sustained a direct blow while colliding with an opposing player's cleats. As a result of the play, her distal tibia was displaced 908 to the rest of her leg. She underwent a closed reduction and tibial internal fixation with an intramedullary rod. Outcome scores were tracked using the IKDC and TSK-11. The IKDC measures symptoms, function, and sport activity related to knee injuries. The TSK-11 measures fear of movement and re-injury, which was important to assess during this case due to the gruesome nature of the injury. At 4 months, the subject became symptomatic over the fibula and was diagnosed with a fibular nonunion fracture. This was unexpected due to the low incidence of and usual asymptomatic nature of fibular nonunion fractures, which required an additional surgery. TSK-11 scores ranged from 19-20 throughout, signifying low levels of kinesiophobia. IKDC scores improved from 8.05 to 60.92. The subject ultimately signed a professional soccer contract. The rehabilitation of this subject was complex due to her low levels of kinesiophobia, self-guided overtraining, and the potential role they may have had in her fibular nonunion fracture. This case study demonstrates a successful outcome despite a unique injury presentation, multiple surgeries, and low levels of kinesiophobia. While a low level of kinesiophobia can be detrimental to rehabilitation compliance, it may have benefited her in the long-term. 5

A MULTIDISCIPLINARY APPROACH TO THE REHABILITATION OF A COLLEGIATE FOOTBALL PLAYER FOLLOWING ANKLE FRACTURE: A CASE REPORT

Multiple rehabilitation factors including overall wellness need to be considered when an athlete returns to sport after an injury. The purpose of this case report is to describe a multidisciplinary approach for return to sport of a Division I collegiate football player following a traumatic ankle fracture requiring surgical repair. The assessment and treatment approach included the use of a performance-based physical therapy outcome measure, self-reported functional abilities, body composition assessments, and nutritional counseling. A 21 year-old running back fractured his lateral malleolus due to a mechanism of injury of excessive eversion with external rotation of the ankle. Surgical intervention included an open reduction internal fixation (ORIF) of the fibula and syndesmosis. In addition to six months of rehabilitation, the patient received consultations from the team sports nutritionist specialist to provide dietary counseling and body composition testing. The Comprehensive High-level Activity Mobility Predictor-Sport (CHAMP-S), a performance-based outcome measure, self-report on the Foot and Ankle Disability Index (FADI-ADL, FADI-S), and body composition testing using whole body densitometry (BOD POD®), were administered throughout rehabilitation. The subject was successfully rehabilitated, returned to his starting role, and subsequently was drafted by a National Football League (NFL) franchise. High-level mobility returned to above pre-injury values, achieving 105% of his preseason CHAMP-S score at discharge. Self-reported function on the FADI-ADL and FADI-Sport improved to 100% at discharge. Body fat percentages decreased (13.3% to 11.9%) and fat mass decreased (12.0 kg to 11.0kg). Lean body mass (78.1 kg to 81.5 kg) and lbm/in increased (1.14 kg/in to 1.19 kg/in). His BMI changed from 29.8 kg/m(2) to 30.6 kg/m(2). This case report illustrates the positive effects of a multidisciplinary approach where combining physical therapy and nutritional counseling demonstrated value with return to sport preparation and success following ankle fracture. A targeted physical therapy program combined with a personalized nutrition intervention based on body composition assessment assisted this athlete in avoiding deconditioning (atrophy, decreased aerobic capacities, and increases in body fat) often observed during postoperative care. 5