College Football Players Underestimate Risk of Injury and Concussion

College football players may underestimate their risk of injury and concussion, according to a new study published today in JAMA Network Open.

Christine Baugh, PhD, MPH, assistant professor of medicine at the University of Colorado School of Medicine and member of the CU Center for Bioethics and Humanities, is the corresponding author of the article, “Accuracy of US College Football Players’ Estimates of Their Risk of Concussion or Injury.”

Baugh and co-authors report on survey results of 296 college football players from four teams in the Power 5 Conferences of the National Collegiate Athletic Association. Athletes were surveyed in 2017. The researchers found that between 43 percent and 91 percent of respondents underestimated their risk of injury and between 42 percent and 63 percent underestimated their risk of concussion.

To measure the accuracy of football players’ risk estimations, the researchers modeled individual athletes’ probabilities of sustaining a concussion or injury and compared model estimates to athlete perceptions. While recognizing that many people underestimate health risks, the authors point out that the risks college football athletes face may be more severe or debilitating than those faced by many in the general population. Given this elevated risk profile, they say it is concerning that athletes tend to underestimate the likelihood of these risks. These results raise questions about informed consent and how much risk should be acceptable in the context of a game, Baugh and her co-authors write.

“That athletes underestimated their risk of concussion and injury in this study raises important ethical considerations,” Baugh and her colleagues write. “What is the threshold for college athletes to be sufficiently informed of the risks and benefits of football to make decisions that align with their values and preferences?”

In addition to Baugh, four co-authors are listed. Those authors are affiliated with the University of Washington, the Seattle Children’s Research Institute, Boston Children’s Hospital, and Harvard Medical School, where Baugh completed a Post-Doctoral Fellowship in Mental Health Policy prior to joining the CU School of Medicine.

Football-loving states slow to enact youth concussion laws

Media Release:

PULLMAN, Wash. – States with college teams in strong conferences, in particular the Southeastern Conference (SEC), were among the last to take up regulations on youth concussions, according to a recent study. The study, which investigated the association between youth sport participation and passage of concussion legislation, uncovered the importance of SEC affiliation, and found a similar connection in states with high rates of high school football participation.

In contrast, states with higher gender equality, measured by the number of women in the labor force, were early adopters.

Washington State University sociologists Thomas Rotolo and Michael Lengefeld, a recent WSU Ph.D. now at Goucher College, analyzed the wave of youth concussion laws from 2007 to 2014, specifically looking at return-to-play guidelines: a mandated 24-hour wait period before sending a player with a possible concussion back on to the field.

“We explored a lot of different ways of measuring college football presence, and the thing that just kept standing out was SEC membership,” said Rotolo, the lead author on the study published in the journal Social Science & Medicine. “Every college town thinks they have a strong college football presence, but the SEC is a very unique conference.”

Co-author Lengefeld, a former high school football player from Texas, knows first-hand how important the sport is throughout the South, but the data showed a specific correlation between resistance to youth concussion regulations among SEC states in particular.

“This SEC variable was similar to the South effect, but not all southern states have an SEC school–and in SEC states the resistance to concussion laws was a bit stronger,” he said.

Lengefeld added that the SEC also stands out since it has the largest number of viewers and brings in more profits than any other conference.

Scientists have known for more than a century that youth concussions were a serious health issue, but the movement to create concussion health policies for youth sports did not gain any ground until a Washington state middle school player was badly injured. In 2006, Zackery Lystedt was permanently disabled after being sent back onto the field following a concussion. The Seattle Seahawks took up the cause in the state, followed by the NFL which took the issue nationwide.

Even though the NFL advocated for youth concussion policy changes, the states responded differently. Washington state, Oregon and New Mexico were among the first to adopt the new return-to-play guidelines, while states like Georgia and Mississippi were among the last.

“There’s clearly something culturally going on that was different in those states,” said Lengefeld.

The researchers also investigated the role of gender equity in concussion adoption since football is often viewed as hyper-masculine. They used women’s participation in the labor market as a rough indicator of a state’s gender egalitarian views and found a statistically significant difference showing that states with higher levels of women’s labor market participation enacted the concussion legislation more quickly.

Lengefeld said the methodology they used in this study can also be applied to analyze how many other health policies are enacted across different states.

“As we were submitting this research for publication, COVID-19 was just starting, and we noticed all the differences in the way states are behaving,” Lengefeld said. “It’s not new for sociologists to study the diffusion of laws at the state level, but this is another way of doing that that incorporates a set of ideas about culture.”

Racket Sports May Worsen Knee Arthritis

Press Release:

OAK BROOK, Ill. — Racket sports like tennis and racquetball appear to accelerate knee joint degeneration in overweight people with osteoarthritis, according to a study being presented at the annual meeting of the Radiological Society of North America (RSNA).

Knee joint osteoarthritis, a gradual wearing down of the protective cartilage that cushions the ends of the bones, is a major cause of pain and disability worldwide, affecting approximately 14 million people in the U.S. alone. Excess body weight is a major risk factor.

Physical activity offers a host of benefits for people who are overweight, but the wrong type of exercise could potentially damage knee joints and hasten the need for knee replacement surgery. The effects of different types of exercise on overweight people have seldom been studied with MRI, the most sensitive imaging method for assessing structural changes to the knee joint.

For the new study, researchers used high-powered MRI to assess the rate of degeneration of the knee joint in 415 overweight and/or obese patients, average age 59, drawn from the Osteoarthritis Initiative, a National Institutes of Health-supported study of individuals with mild to moderate osteoarthritis.

Study participants kept detailed records of their participation in six different types of physical activity, including ball sports, bicycling, jogging/running, elliptical trainer, racket sports and swimming. The researchers performed baseline MRIs and then measured changes in the patients’ knees over four years using the modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). A higher score indicates more degeneration.

Patients regularly participating in racket sports saw their overall WORMS score increase significantly, compared to patients regularly using the elliptical trainer over the study period. Surprisingly, the overall WORMS score also increased significantly in the racket sports group compared to the jogging/running group. Racket sports participants saw significantly greater degeneration in the medial tibial cartilage compartment, the compartment on the inside of the knee where arthritis often first appears.

Participants using the elliptical trainer showed the smallest changes in structural degeneration over four years.

“In our study, progression of overall knee joint degeneration was consistently higher in overweight and/or obese patients engaging in racket sports,” said the study’s lead author Silvia Schirò, M.D., from the University of California San Francisco and the University of Parma in Parma, Italy. “We also found that workouts using an elliptical trainer were associated with reduced progression of overall knee joint and cartilage defects. Moreover, our findings showed that when comparing different low impact activities with each other, such as bicycling, elliptical trainer and swimming, the elliptical trainer was associated with the lowest increase in WORMS sub-scores over 48 months.”

The more rapid degeneration of the knee joints in people who participated in racket sports is likely due to the high-speed lateral movements inherent to such sports, Dr. Schirò said. These movements can affect the femoral-tibia compartment, a structure in the knee made up of the femur condyle, the rounded end of the thighbone that helps it slide over the tibia, or shinbone, and the meniscus, the rubbery, C-shaped cartilage between the thighbone and the shinbone.

“A large lateral force imparted at the foot during side-to-side movements may be driving large knee adduction moments, a key feature in medial compartment disease, which imparts high compressive loads on the medial tibia and femoral condyle,” she said. “In support of this premise, the racket sports group showed elevated cartilage degeneration in the medial tibia.”

The researchers theorize that joint mechanics are impaired in overweight and obese individuals, with a harmful joint overload triggering increased contact stress on the meniscus. Damage to the meniscus compromises the protective cushion on the cartilage of the knee.

“High impact physical activity with elevated load and high shear forces may trigger and accelerate this process,” Dr. Schirò said. “Moreover, participants who played racket sports showed significantly more meniscal degeneration when compared to the remainder of the study group.”

The data suggests that overweight individuals who continue to play racket sports could slow degeneration in their knees by making modifications to their activities, such as switching to sports with less fast-paced and high shear loads like badminton or doubles tennis.

However, Dr. Schirò emphasized that the degenerative process is complex and individual joint mechanics are highly variable.

“It is possible that some individuals with sufficient strength and motor control may be able to safely play these sports,” she said. “Our data suggests that as a group, though, overweight and obese individuals who play racket sports are at higher risk for disease progression.”

Co-authors are Sarah C. Foreman, M.D., Magdalena Posadzy, M.D., Gabby B. Joseph, Nicola Sverzellati, M.D., Richard B. Souza, Ph.D., Charles E. McCulloch, Michael C. Nevitt, Ph.D., and Thomas M. Link, M.D., Ph.D.

Former NFL players may not suffer more severe cognitive impairment than others, study indicates

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DALLAS – Nov. 11, 2020 – Even though repeated hits to the head are common in professional sports, the long-term effects of concussions are still poorly understood. While many believe that professional athletes who experience multiple concussions will end up with severe cognitive impairment later in life, a UT Southwestern study suggests that may not necessarily be the case.

The preliminary study, published in Cognitive and Behavioral Neurology, looked at a small cohort of retired professional football players who had a history of concussions and were diagnosed with mild cognitive impairment (MCI), a known risk factor for Alzheimer’s disease. The 10 retired athletes, plus 10 nonathletes, were given a battery of cognitive tests to assess their verbal memory, learning, and language skills. The nonathletes also had MCI but no history of traumatic brain injury.

“For the most part, the athletes had a similar cognitive profile to the nonathletes,” says Nyaz Didehbani, Ph.D., assistant professor in the department of psychiatry and the study’s corresponding first author.” But they did score lower on a couple of items, more specifically on our naming test, which has been showing up in a number of our studies. A consistent complaint from many of our athletes includes word-finding and naming difficulties.”

Name recall, or the ability to see something and name it, diminishes quite frequently with normal aging, says Munro Cullum, Ph.D., vice chair and chief of the division of psychology in the department of psychiatry and the study’s senior author. “It’s not that they have lost the ability, but rather have a reduced ability to quickly retrieve words when they’re shown a picture.”

Despite differences in their ability to name recall, the retired football players scored similarly to the nonathletes on verbal memory and learning. This is in contrast to findings from other studies in which a history of concussions in athletes has been found to also affect these areas.

“Overall, the study is suggestive that just because you’ve had a history of multiple concussions, it doesn’t mean you will develop a neurodegenerative change or problems later in life,” says Cullum.

The retired NFL players range in age from 64 to 77 and played anywhere from six to 14 years in the NFL. The nonathletes were selected from an Alzheimer’s Disease Research Center database at UT Southwestern. The groups were similar in age, sex, race, and education.

One clue as to why multiple concussions appear to have a selective effect on name recall may lie within the brain itself. Imaging from other studies done by the UT Southwestern group on these athletes demonstrated an interesting phenomenon.

“We had an imaging finding of an abnormality in the white matter deep in the part of the brain where word retrieval is thought to occur,” Cullum says. These studies found that changes in white matter in retired athletes with a history of concussions were linked to poorer performance in naming, though it is still unclear why only this area of the brain appears to be affected. The authors are designing experiments to learn more.

Although the degree of the cognitive impairment wasn’t much worse in retired athletes with MCI, this study provides only a small picture of the issue. There is evidence from other studies that exposure to repeated concussions can lead to earlier onset of MCI and that cognitive impairment may be higher in retired athletes.

The team at UT Southwestern is working to resolve these conflicting results from other studies by following a larger cohort of retired athletes over time. They are seeking to investigate the long-term effects of concussion on the brain by assessing how cognition changes over time, the rates at which it changes, and the effects of comorbidities (the presence of other illnesses) and psychological factors in athletes with MCI and a history of head injuries.

Within the context of this study, the authors are also interested in looking at different ways to evaluate cognition to better understand the state of neurodegenerative changes in athletes and to determine if the link between concussion and MCI is direct or correlative.

“Their being professional athletes does not necessitate automatically falling into this doom-and-gloom category that the cognitive impairment will progress and worsen,” says Didehbani. “Those cases are really just a subset, just like with the normal population.”

For young athletes, inadequate sleep leads to decreased performance

Press Release:

November 9, 2020 – Most young athletes don’t get enough sleep – and that may significantly affect their sports performance, according to a paper in the November issue of Current Sports Medicine Reports, official journal of the American College of Sports Medicine (ACSM). The journal is published in the Lippincott portfolio by Wolters Kluwer.

“There’s growing evidence to suggest that youth athletes don’t get required amount of sleep, and that this negatively affects their performance,” comments Mark F. Riederer, MD, of C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, author of the new review. He believes that the trend toward more-intensive training might contribute to a lack of adequate sleep in in young athletes.

Rested and ready? Youth athletes need more sleep to do their best

Faced with competing demands including school, sports, and social life, young athletes tend to put off sleep in favor of other activities. Generally, the evidence suggests that they don’t meet recommended guidelines for sleep duration: 9 to 12 hours for children aged 6 to 12 years and 8 to 10 hours for adolescents aged 13 to 18 years. For example, one study found that more than 90 percent of teen gymnasts get less than 8 hours of sleep per night.

Most studies find that young athletes get less sleep than non-athletes; they may sleep longer on the weekends, trying to make up their “sleep debt.” The evidence suggests that young female athletes sleep less than their male counterparts. However, elite-level teen athletes of both sexes seem to get more sleep – possibly related to higher sleep need due to higher training loads.

Although studies vary, the evidence suggests that getting less-than-recommended sleep leads to decreased performance on the playing field. Some papers report that inadequate sleep has significant effects on reaction time, strength, speed, cognitive learning, and decision-making.

“[S]tudies consistently demonstrate that lack of recommended sleep results in poor sense of well-being, increased perceived training load, and poor placement in competitions,” Dr. Riederer writes. Sleep deficits may also place young athletes at risk for injury and illness.

Other recent findings include:

Studies of napping and other sleep interventions show inconsistent effects on athletic performance.
Young athletes with symptoms of insomnia may be at increased risk of burnout, along with a higher risk of dropping out of their sport due to injury.
Levels of the stress hormone cortisol are increased after competitive matches, leading to reduced sleep time and quality.
Poor sleep may be linked to obstructive sleep apnea among college football linemen.
Inadequate sleep might be a risk factor for bony stress injuries (such as stress fractures).
Although it has been suggested that using smartphones or other electronic devices before bed can lead to impairments of sleep or athletic performance, one recent study found no such effects.

“The message for young athletes is, getting recommended sleep can improve your performance,” Dr. Riederer comments. He notes that an emphasis on increasing training workload to improve skill and performance may adversely affect young athletes in other ways.

“Trends like early-morning training schedules, two-a-day practices, and late night practices and competitions come at the expense of good sleep habits – as well as leaving kids less time to socialize and do homework,” Dr. Riederer adds. “We need to ensure our youth athletes are getting adequate amounts of sleep, and there is evidence to support this claim.”