Injuries In Sports Essays - Neurotrauma, Psychiatric Diagnosis

Injuries In Sports Despite the high prevalence and potentially serious outcomes associated with concussion in athletes, there is little systematic research examining risk factors and short- and long-term outcomes. Objectives To assess the relationship between concussion history and learning disability (LD) and the association of these variables with neuropsychological performance and to evaluate postconcussion recovery in a sample of college football players. Design, Setting, and Participants A total of 393 athletes from 4 university football programs across the United States received preseason baseline evaluations between May 1997 and February 1999. Subjects who had subsequent football-related acute concussions (n=16) underwent neuropsychological comparison with matched control athletes from within the sample (n=10). Main Outcome Measures Clinical interview, 8 neuropsychological measures, and concussion symptom scale ratings at baseline and after concussion. Results Of the 393 players, 129 (34%) had experienced 1 previous concussion and 79 (20%) had experienced 2 or more concussions. Multivariate analysis of variance yielded significant main effects for both LD (P*.001) and concussion history (P=.009), resulting in lowered baseline neuropsychological performance. A significant interaction was found between LD and history of multiple concussions and LD on 2 neuropsychological measures (Trail-Making Test, Form B [P=.007] and Symbol Digit Modalities Test [P=.009]), indicating poorer performance for the group with LD and multiple concussions compared with other groups. A discriminant function analysis using neuropsychological testing of athletes 24 hours after acute in-season concussion compared with controls resulted in an overall 89.5% correct classification rate. Conclusions Our study suggests that neuropsychological assessment is a useful indicator of cognitive functioning in athletes and that both history of multiple concussions and LD are associated with reduced cognitive performance. These variables may be detrimentally synergistic and should receive further study. JAMA. 1999;282:964-970 The management of mild traumatic brain injury (MTBI; eg, concussion, defined as a traumatically induced alteration in mental status not necessarily resulting in loss of consciousness) in athletics is currently one of the most compelling challenges in sports medicine. Despite the high prevalence1 and potentially serious outcomes2, 3 associated with concussion, systematic research on this topic is lacking. Many sports medicine practitioners are not satisfied with current return-to-play and treatment options, which do not appear to be evidence based.4-6 There is also little research examining whether long-term cognitive morbidity is associated with concussion. Past research with nonathletes revealed that repeated concussions appear to impart cumulative damage, resulting in increasing severity and duration with a second MTBI occurring within 48 hours.7 No data were presented which addressed more long-term outcomes. Although survey data have shown that a prior history of head injury increases the risk for sustaining subsequent MTBI,8 other potential risk factors associated with sports-related concussion have not been identified. Learning disability (LD), the etiology of which is presumably secondary to central nervous system dysfunction,9 refers to a heterogeneous group of disorders manifested by difficulties in the acquisition and use of listening, speaking, writing, reading, reasoning, or mathematical abilities and which is traditionally diagnosed in early childhood.10, 11 The incidence of diagnosed LD is 11.8% in the general university population.12 However, no study to date has addressed whether LD may represent a risk factor (such as that seen with prior head injury) for poor outcome following sports-related MTBI in college athletes. Previous research has outlined the reliability, validity, and sensitivity of neuropsychological tests in assessing the specific cognitive areas associated with MTBI in the general population.13-15 To date, 3 published studies have examined the use of neuropsychological testing in US football players.16-18 The only multicenter study16 was conducted in the mid-1980s and was designed to address the acute effects of concussion. The current study was designed to address 2 issues: first, to investigate whether a relationship exists between prior concussion and diagnosed LD among college football players and determine the influence of these variables, in isolation and combination, on baseline neuropsychological performance; and second, to evaluate the use of a neuropsychological test battery in diagnosing concussion and delineating recovery of cognitive function following MTBI in athletes. METHODS Subjects Participants in this study consisted of 393 male college football players from 4 Division IA football programs: Michigan State University, East Lansing (n=119); the University of Florida, Gainesville (n=106); the University of Pittsburgh, Pittsburgh, Pa (n=85); and the University of Utah, Salt Lake City (n=83). At the initial preseason baseline session, the following self-reported data were collected: age, playing position, SAT/ACT scores (Scholastic Aptitude Test/American College Testing, ie, college entrance examination scores), history of LD, neurological history (eg, central nervous system neoplasm or epilepsy), history of psychiatric illness (eg, depression and/or mania or anxiety), history of alcohol and/or drug abuse, prior sports played, and history of concussion. Educational records at each