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Further Research

NEUROPATHOLOGY

There is emerging evidence regarding the long-term effects of concussions and repeated head trauma in sport.

Recent large studies (Crane et al., 2016) in over 7000 subjects showed a single traumatic brain injury (TBI) with loss of consciousness was not associated with later-life cognitive impairment, dementia, clinical Alzheimer’s disease (AD), or AD neuropathology. But was associated with Parkinson’s disease, parkinsonism, and Lewy body dementia. However, emerging evidence is suggesting that repetitive head trauma, with or without concussions, can lead to AD or chronic traumatic encephalopathy (CTE). As a result the National Institute of Health in the USA has released specific criteria to diagnose CTE post-mortem (McKee et al., 2016a).

Further research is required in this area, particularly in Australia, and Smart Head Play is leading the calls for the development of a specific Brain Bank dedicated to sport.

CHRONIC NEUROLOGICAL IMPAIRMENT (CNI)

In Australia, this is the area where the major advancements have been made. Research led by Dr. Alan Pearce, has shown alterations in brain excitability that have been associated with fine motor impairments, and decrements in cognitive-motor performance (Pearce et al, 2014; Pearce et al, 2017). Whilst most of the studies investigating CNI have focused on cognitive impairments (Schretlen and Shapiro, 2003; McKee et al. 2016b), Dr Pearce’s group has also reported in the literature of movement disorders as a result of repeated head trauma (Ozolins et al. 2015).
Smart Head Play is currently supporting the work of Dr. Pearce, allowing him to lead the research in the Australian context.

HEAD TRAUMA AND MENTAL HEALTH


The issue between sustaining a mild TBI (mTBI) and mental illness is controversial. Small sample studies addressing this issue show contradictory findings. For example Stamm et al (2015a) reported mental decline and illness in a sample of retired athletes (n= 66) who had a history of head trauma from a young age. Further, Stamm et al (2015b), using advanced neuroimaging, showed alterations in brain connectivity that they suggest could account for changes in player’s mental health and cognitive abilities. Conversely, a recent study by Martini et al (2017) did not show any observable effects in those who had a history of mTBI or repeated head trauma (n=30) compared to age-matched controls without history of head trauma (Martini et al, In Press). However, two large recent studies from Scandinavia (Orlovska et al, 2014; Sariaslan et al, 2016), with sample sizes of 114,000 and 1.1 million respectively, have shown associations between mTBI exposure in childhood and later impairments across a range of health and social outcomes. These risks in later-life mental illness were shown to be independent of family history.

ASSOCIATION BETWEEN CONCUSSION AND INCREASED RISK OF FURTHER INJURY

It is well known that players with a history of concussion are at higher risk of future concussions (Guskiewicz et al, 2003). However, the last 3 years has seen an increase in research looking at the effects of a concussion injury on both the risk of subsequent concussion injury and/or the risk of sustaining a further injury. While the risk of sustaining a second concussion within the same season of American football has been shown to be increased by 33% (Guskiewicz et al, 2003), recent investigations by Swedish researchers (Nordstrom et al, 2015) showed that following a concussion, the risk for sustaining any injury (e.g. ankle, shoulder etc) is increased by 50% in the proceeding year for soccer players. Similar findings on increased risk have been reported by Lynal et al (2015) in NCAA athletes.

Smart Head Play supports the call for similar research in Australia in Australian Rules and Rugby League.

ACUTE RESPONSES AND RECOVERY FOLLOWING CONCUSSION

With emerging research demonstrating the long-term consequences of chronic neurological impairment and/or neurodegeneration, research is also investigating how the brain responds and recovers following a traumatic event on the sports field.

There are a number of studies that have reported impact forces experienced on the field using a range of technologies (King et al, 2016) including mouthguards, and head sensors. Whilst these studies provide good data on what players are experiencing in situ, research is also investigating how the brain responds and recovers following a traumatic event.
Concussion is known as a functional injury. This means that brain structures are not usually damaged (which differs to a moderate or severe TBI where brain structures are damaged). Therefore, imaging techniques like CT scans and magnetic resonance imaging (MRI) are not able to detect a concussion injury.

Traditionally, studies have aimed to investigate how an individual responds using symptom checklists and cognitive testing for ongoing signs of transient impairment (such as poor memory or reaction time). Many researchers are now aiming to utilise technologies to provide more robust and objective measures of the injury. Blood biomarkers have been discussed as a potential measure for a number of years, however, the evidence to date is limited and further research is required. Other techniques include using transcranial magnetic stimulation (TMS) being completed by Dr. Alan Pearce. Dr. Pearce has been the only researcher to date to show brain excitability responses and recovery in Australian footballers who sustained a concussion during play (Pearce et al, 2015). His research found that when players were concussed, TMS revealed increased brain inhibition that correlated to slowing of reaction times and visual attention to information. Smart Head Play is assisting Dr. Pearce to undertake further research in determining individual recovery rates following the injury to provide objective data in determining return to play decisions for the player.

ATTITUDES TOWARDS CONCUSSION

Concussion and mTBI in sport is becoming a greater public health issue. Increased media scrutiny about players continuing after a concussion, as well as retired players going public about their struggles with memory, mood or movement disorders, has created greater awareness about the issue. This in turn has influenced many elite athletes change their attitudes towards playing with concussion. Research has explored if greater awareness translates to similar attitudinal changes in individuals who play at non-elite levels of sport.

However, studies have shown disconnect between US college athletes reporting concussion, despite being educated on the dangers of playing with concussions (McCrea et al, 2004; Register-Mihalik et al, 2013). Similarly, recent research conducted by Dr. Alan Pearce and colleagues explored if a similar disconnect is apparent in Australian university students (Pearce et al, 2016). Dr. Pearce et al surveyed 312 exercise science students about their attitudes towards concussion. These students, despite not being funded to play sport for their university, regularly played organized sport at various levels of competition. The findings showed clear contradictions with students agreeing that people should not play on with a concussion and that repeated concussions may cause neurological impairments later in life. However, the data revealed that students themselves would play on with a concussion, with justifications including not letting team-mates down or that it’s not serious enough, and that they admired elite athletes that played on with a concussion. Further work is required to see if these attitudes are also apparent in the wider community and the effectiveness of education programs.

Smart Head Play is aiming to bridge the gap between research and community awareness through their education program.

RESEARCH REFERENCES:

  • Crane et al. 2016 https://www.ncbi.nlm.nih.gov/pubmed/27400367
  • McKee et al. 2016a https://www.ncbi.nlm.nih.gov/pubmed/26667418
  • Pearce et al. 2014 https://www.ncbi.nlm.nih.gov/pubmed/24579780
  • Shretlen and Shapiro 2003 https://www.ncbi.nlm.nih.gov/pubmed/15276955
  • McKee et al. 2016b https://www.ncbi.nlm.nih.gov/pubmed/24366527
  • Ozolins et al. 2015 https://www.ncbi.nlm.nih.gov/pubmed/27120772
  • Stamm et al. 2015a https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4371403/
  • Stamm et al. 2015b https://www.ncbi.nlm.nih.gov/pubmed/26200068
  • King et al. 2016 https://www.ncbi.nlm.nih.gov/pubmed/26545363
  • Pearce et al. 2015 https://www.ncbi.nlm.nih.gov/pubmed/25104044
  • Guskiewicz et al. 2003 https://www.ncbi.nlm.nih.gov/pubmed/14625331
  • Nordstrom et al. 2015 https://www.ncbi.nlm.nih.gov/pubmed/25082616
  • Lynall et al. 2015 https://www.ncbi.nlm.nih.gov/pubmed/26057941
  • McCrea et al. 2004 https://www.ncbi.nlm.nih.gov/pubmed/14712161%20%20
  • Register-Mihalik et al. 2013 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784366/
  • Pearce et al. 2016 https://www.ncbi.nlm.nih.gov/pubmed/27754774