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CTE became national news in the United States in 2007, but it was not until 2016 that the National Institute of Neurological Disorders and Stroke/National Institute of Biomedical Imaging and Bioengineering (NINDS-NIBIB) criteria for the neuropathological diagnosis of CTE were published. and they were refined in 2021. Rare, isolated case studies that reported abnormal findings or used unaccepted diagnostic criteria have been disproportionately emphasized to cast doubt on the link between RHI and CTE.

In a review article in the magazine Acta NeuropathologicaAnn McKee, MD, chief of neuropathology at VA Boston Healthcare System and director of the BU CTE Center, emphasizes that more than 600 CTE cases have now been published in the literature from multiple international research groups. And of the more than 600 cases, 97 percent have confirmed exposure to RHI, mainly through contact and collision sports. CTE has been diagnosed in amateur and professional athletes, including athletes from American, Canadian and Australian football, rugby union, rugby league, soccer, ice hockey, bull riding, wrestling, mixed martial arts and boxing.

Additionally, the study authors revealed that in 82 percent (14 of 17) of alleged CTE cases that occurred without RHI, using current criteria, families were never asked what sports the deceased played.

According to the researchers, despite global efforts to find CTE in the absence of contact sports participation or exposure to RHI, it appears to be exceedingly rare, if it exists at all. “In community brain bank studies, CTE was seen in 0 to 3 percent of cases, and where information is available, positive cases were exposed to brain injury or RHI. In contrast, CTE is the most common diagnosis of neurodegenerative diseases in contact and collision athletes in brain banks around the world. A strong dose-response relationship is perhaps the strongest evidence that RHI causes CTE in athletes,” she added.

“The review presents the timeline for the development of neuropathological criteria for the diagnosis of CTE, begun nearly 100 years ago by pathologist Harrison Martland, who introduced the term ‘punch-drunk’ to describe a neurological condition in low-cost carriers, ” explains McKee. author of the study. The review chronologically describes the multiple studies conducted by independent, international groups examining diverse populations that have found CTE pathology from various sources in individuals with a history of RHI.”

CTE is characterized by a distinctive molecular structural configuration of p-tau fibrils that is different from the changes seen in aging, Alzheimer’s disease, or any other disease caused by tau protein.

Funding for this study was provided by the National Institute of Neurological Disorders and Stroke (U54NS115266; R01NS119651; U01 NS 086659), National Institute on Aging (P30AG13846; U19AG06875; R01AG062348; RF1AG057902; K01AG070326), Department of Veterans Affairs (10 1 BX002466, 101BX004613, BX004349), the Nick and Lynn Buoniconti Foundation, Andlinger Foundation, National Football League (NFL) and World Wrestling Entertainment (WWE) through unrestricted gifts, the Mac Parkman Foundation and the National Operating Committee on Safety for Sports Equipment (NOCSEA).

Effects of cold water immersion compared to other recovery modalities on athletic performance after acute strenuous exercise in physically active participants: a systematic review, meta-analysis and meta-regression.

Moore E, Fuller JT, Bellenger CR, Saunders S, Halson SL, Broatch JR, Buckley JD. Sports Med. December 17, 2022. doi: 10.1007/s40279-022-01800-1. E-publishing prior to printing. PMID: 36527593.

Full text freely available

Take home message

During post-exercise recovery, cold water immersion (CWI) provides similar benefits to other recovery methods, including active recovery.

Background

Cold water immersion (CWI) is one of several methods intended to speed recovery after training and competition. However, it is unclear whether CWI performs better than other commonly used recovery modalities.

Study aim

The researchers conducted a systematic review and meta-analysis to compare CWI with other modalities regarding athletes’ perceptions, physiological changes, and exercise performance outcomes.

Methods

The authors identified 28 articles through a comprehensive literature search for articles that met specific criteria: (1) peer-reviewed randomized controlled trials, (2) included physically active participants, (3) used CWI after acute physical activity, (4) included a other recovery intervention, and (5) outcomes include recovery of exercise performance, muscle strength, or physiological or perceptual markers of recovery. They excluded articles if participants received CWI in combination with another intervention or if participants completed more than one exercise session. The authors extracted data from the included articles: publication information, study methodology, participant information, CWI protocol, comparator recovery protocol, and assessment measures. They then assessed the quality of each study using the SIGN Checklist for Randomized Clinical Trials. During analyses, the authors examined follow-up assessments at 1, 24, 48, and 72 hours after treatment. Alternative treatments typically include active recovery, massage, contrast water therapy, warm water immersion, and cryotherapy.

Results

Overall, the quality of the included studies was low, with only one considered ‘high quality’ and 24 ‘acceptable quality’. Compared to other recovery methods, the authors found that CWI generally had limited or no effect on the perception of recovery and recovery from 1) delayed-onset muscle soreness, 2) strength performance, 3) strength, 4) flexibility, or 5) physiological problems. markers of muscle damage. Water temperature and treatment duration were not related to the outcomes after KWI.

Viewpoints

Cold water immersion is comparable to other recovery modalities, if not slightly better. The exception, however, was aerial cryotherapy, which may outperform CWI, but future studies need to confirm this. Ultimately, CWI is more clinically accessible than air cryotherapy and should be acceptable because it is comparable to other recovery methods. In fact, there was virtually no difference between active recovery and CWI, providing a more practical and easily accessible recovery method for recreationally active people and those without access to CWI. It would have been interesting to know if the results for CWI differed if the person did partial or full body immersion.

Clinical implications

Clinicians should be aware that CWI provides no or minimal improvement in recovery compared to alternative recovery methods. They need to communicate these findings to patients so they can make informed treatment decisions about whether to perform CWI, air cryotherapy, or active recovery.

Questions for discussion

Under what circumstances do you, as a doctor, prefer CWI over other recovery methods? What feedback have you received from your patients?

Written by Kyle Harris
Reviewed by Jeffrey Driban

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Cold water immersion for the prevention and treatment of muscle pain after exercise
Colder may not be cool for recovery
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Whole body cryotherapy for proprioception and muscle damage

“While I understand the excitement, we must consider how to prevent injuries as athletes adopt this new footwear,” said lead author Adam Tenforde, MD, physician in Mass General Brigham’s Sports Medicine program and medical director of the Spaulding National Running Center. “We hope this current opinion will help better recognize potential medical problems associated with CFP shoes, the appropriate use of this new technology, and how to develop methods to use these shoes safely.”

In their publication, Tenforde and colleagues describe five patient cases, including junior elite track and field athletes in Europe and two athletes in their mid-30s who participated in endurance sports events in North America. All five experienced foot pain after wearing shoes with carbon fiber plates and were later diagnosed with navicular stress injury (BSI).

“Recognizing possible associations with navicular disease in runners with vague metatarsal or ankle pain wearing CFP shoes may be important to identify this high-risk injury,” the authors write.

Who doesn’t respond to warm-up programs for injury prevention? A secondary analysis of pilot data from neuromuscular training programs in youth basketball, football, and physical education.

Anu M. Raisänen, Jean-Michel Galarneau, Carla Van Den Berg, Paul Eliason, Lauren C. Benson, Oluwatoyosi BA Owoeye, Kati Pasanen, Brent Hagel and Carolyn A. Emery. Journal of orthopedic and sports physiotherapy 0 0:0, 1-28

Full article available for free

Take home message

Although neuromuscular training warm-up programs for injury prevention are effective in reducing one’s risk of injury, not everyone reaps the same benefits. Women and youth with a history of injury in the previous year are more likely to not respond to these programs.

Background

Preventive neuromuscular training programs can effectively reduce an active person’s risk of injury. However, these programs can be more effective if they are tailored to a person’s physical capabilities and characteristics.

Study aim

Räisänen and colleagues conducted a secondary analysis of data from young active individuals (11–18 years old) who performed a neuromuscular training warm-up program during one of four previous clinical trials. They examined whether differences in adherence were associated with non-response to the program (injury) and which factors were associated with non-response.

Methods

The authors used data collected across four studies (1793 participants), including high school basketball (18-week intervention), community football (20 weeks), and two separate high school physical education studies (12-14 weeks). The authors examined age, gender, body mass index (BMI), height, weight, lower limb dominance and balance. They also monitored participants throughout the season for injuries, number of warm-up sessions completed, number of weeks of warm-up completed, and sports participation or exposure. The warm-up programs all lasted 15 minutes and were tailored to the sport or class. All warm-ups include an aerobic and balance component. However, basketball included static and dynamic stretches, while the other two used only dynamic stretches. In addition, the soccer and gym classes included various strengthening exercises, and soccer was the only warm-up that included agility.

Results

The authors found that women and participants with a history of injury in the previous 12 months were more likely to fail to respond to a neuromuscular training warm-up. Furthermore, greater weekly compliance with warm-up reduced the risk of injury, only in football.

Viewpoints

Fifteen-minute neuromuscular training warm-up programs reduce the risk of injury in organized sports activities and general physical education courses. Consistent with existing literature, the authors demonstrated the importance of adherence (performing the program more times per week) in reducing the risk of injury in football players. However, adherence may be less relevant in high school physical education and basketball classes. The authors also found that women and people with a previous injury were more likely to be non-responders than men and people without a previous injury, respectively. We should avoid suggesting that women or people with a history of injury won’t benefit from these programs, because they could – just less so than their peers. Instead, we must find ways to optimize these programs for these populations. We should also note that the authors examined all injuries, not just lower extremity injuries, as these programs are typically designed. So it is possible that a ‘non-responder’ in the study was a ‘lower extremity responder’ if he or she had suffered an upper extremity or other injury.

Clinical implications

Clinicians should encourage the use of neuromuscular training programs and consider how these can be better tailored to women or those with a history of injury.

Questions for discussion

Would an ‘a la carte’ approach work for those identified as high risk? This means that a general warm-up can be created with a few additional movements added specifically to the participants and considered high risk?

Written by Shelly Fetchen DiCesaro
Reviewed by Jeffrey Driban

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“We found that high non-contact real-time heart rate is associated with poor performance,” Lu and Zhong said in an interview. “This suggests that even the best professional athletes are negatively affected by psychological stress, even though they are generally well trained to deal with pressure.”

Olympic archery includes several types of individual and team-based competitions, but for this study, Lu and Zhong focused on individual competitions within the gender for which heart rate data was available. During these competitions, the heartbeats of 122 male and female archers were broadcast as they completed 2,247 shots. The World Archery Federation, in collaboration with Panasonic, measured athletes’ heart rates using high frame rate cameras designed to detect skin reflection and can determine a person’s heart rate 96% as accurately as a pulse oximeter or electrocardiogram.

During each competition, individual archers shot a certain number of arrows at a target, with a time limit of 20 seconds for each shot. Archers could earn a maximum of 10 points for a perfect bull’s-eye, with the number of points decreasing the further an arrow landed from the center of the target.

Lu and Zhong found that athletes whose heart rates were higher before taking a shot consistently scored lower on those shots. Although the age and gender of the archers did not appear to significantly influence the relationship between stress and performance, a number of factors related to the nature of the competition did.

Higher heart rates are more likely to reduce the performance of lower-ranked archers and of any archers who shot second in a match or who had a lower score than their opponent at that point in the match. There was also a stronger relationship between stress and performance closer to the end of each competition, possibly due to the increase in pressure as athletes progressed through the competition, the authors wrote.

“Elite athletes typically receive training to cope with psychological stress, but our results suggest that they are still subject to the influence of psychological stress,” Lu and Zhong wrote.

This study not only provides evidence for the link between stress and real-world performance, but also shows that heart rate captured by high frame rate cameras can serve as a reliable source of biometric data, Lu and Zhong said. in situations such as the COVID-19 pandemic where researchers and participants may not be able to meet in person.

“This method could become increasingly important in diverse settings ranging from sports and business to mental health and medicine,” the researchers wrote. “In this regard, our study can be seen as a proof of concept by showing that non-contact real-time heart rate induced psychological stress.”

In future work, this technology could be used to observe how psychological stress affects athletic performance in different sports, Lu and Zhong said. The researchers also want to further investigate how contactless real-time heart rate can be incorporated into behavioral studies in laboratory and field settings.

Platelet-rich plasma does not improve clinical outcomes in patients with rotator cuff disease, but reduces relapse rates. A systematic review and meta-analysis

Feltri P, Gonalba GC, Boffa A, Candrian C, Menon A, Randelli PS, Filardo G. Knee Surgery Sports Traumatol Arthrosc. December 11, 2022. doi: 10.1007/s00167-022-07223-9. E-publishing prior to printing. PMID: 36496450.

Full text freely available

Take home message

Including platelet-rich plasma (PRP) with rotator cuff surgery reduced the number of relapses compared to surgery without PRP. However, PRP had no other apparent clinical benefits during conservative or surgical treatment.

Background

Rotator cuff injuries are common injuries that can be treated with numerous conservative or surgical treatment options; However, these options are not always effective and can lead to persistent symptoms or retreats. Platelet-rich plasma (PRP) has attracted interest due to its high concentration of proteins involved in the healing process and low rate of side effects. There is mixed evidence regarding the effectiveness of PRP in reducing pain, improving function, and reducing the risk of hernia. Therefore, a systematic review may shed light on the role of PRP in the treatment of people with rotator cuff disorders.

Study aim

The authors conducted a systematic review and meta-analysis to evaluate the efficacy of PRP in terms of functional improvement, pain reduction, and retrauma after conservative or surgical treatment of rotator cuff disorders.

Methods

An initial database search yielded 1,229 articles, and the authors subsequently identified 36 clinical trials eligible for the systematic review. The authors then used 18 of those studies for the meta-analysis. The inclusion criteria required a randomized trial (published in English) that included specific outcomes (functional scores, pain scores and retear rate) and the use of PRP among people receiving conservative or surgical treatment of rotator cuff disease. The authors extracted 1) publication information (e.g. authors, journal), 2) population characteristics (age, gender, type of lesion, tendon involved), 3) tear characteristics (type of lesion, tendon(s) involved), 4) PRP characteristics, 5) repair technique (if applicable), 5) follow-up [split into short term (<6.5 months) and long term (>12 months)]and 6) clinical outcomes.

Results

The 36 clinical trials included 2,443 participants (~49% female, ~54 years old, ~16 months follow-up). Of the 36 articles from the randomized control trial, 16 examined PRP within the context of conservative treatment, and 20 examined PRP within the context of surgical treatment. The authors could not perform a meta-analysis among the studies with conservative management because they varied too much in outcomes, number of PRP injections, PRP volume used, and alternative treatments offered (e.g., corticosteroids, saline, exercise, or physiotherapy). Overall, PRP had mixed results in pain and function compared with other conservative treatments. Nineteen of the twenty surgical studies were included in the meta-analysis. The authors found no differences in self-reported pain or function between participants who underwent surgery with or without PRP. The patients who received PRP and surgery had a recurrence rate of ~7%, while the control group had a recurrence rate of ~14%.

Viewpoints

PRP can be an effective treatment for rotator cuff surgery to reduce the risk of re-tear compared to surgery without PRP. Interestingly, the PRP failed to provide better self-reported pain or function than surgery alone. Unfortunately, it remains unclear whether PRP reduces pain and improves function in people treated conservatively. When a doctor reviews the various studies among people managed conservatively, the doctor must take into account what the other treatment group received, the PRP protocol, and follow-up visits. Clinicians should focus on the studies that reflect their PRP protocol (or what they can offer) and patient population, and also consider whether they want to see how their results compare to usual care, placebo, or an active intervention (e.g., corticosteroids) . Finally, it’s worth remembering that in a clinical trial you should focus on the differences between groups. This comparison is the only one that takes advantage of why we want to classify people into different groups. Results examining changes within a group over time may be influenced by placebo effects, regression to the mean, or other factors unrelated to treatment.

Clinical implications

The use of PRP may reduce the risk of re-tear if used in conjunction with surgery. If a patient is receiving conservative treatment, doctors may look for specific studies that simulate their practice and treatment goals to help patients decide. However, patients receiving conservative care should also understand that the evidence for PRP is murky, but the risk of side effects is low.

Questions for discussion

Have any of your patients received PRP injections? If so, what were their thoughts? Would you use or recommend PRP therapy?

related posts

1. Common medications can affect the effectiveness of PRP
2. The positive effects of various platelet-rich plasma methods on human muscle, bone and tendon cells
3. Platelet-rich plasma is inadequate compared to exercise therapy

Written by Jane McDevitt
Reviewed by Jeffrey Driban

Of more than 350 former National Football League (NFL) players studied an average of 29 years after the end of their playing careers, those who reported experiencing concussion symptoms during their careers performed worse on assessments of episodic memory, sustained attention, processing speed, and vocabulary. However, the number of concussions diagnosed by a medical professional or the length of playing career had no observed effect on cognition.

A follow-up analysis compared the former players to more than 5,000 male volunteers in the general population who did not play professional football, showing that cognitive performance was generally worse for former players than for non-players. While younger former players performed better than non-players on some tests, older retired players likely performed worse than controls on cognitive tasks.

The researchers who led the study said their results underscore the importance of tracking concussion symptoms, as opposed to diagnosed concussions in research. This work also adds evidence of the impact a professional football career can have on accelerating cognitive aging.

“It is well known that people experience some cognitive impairment in the hours and days after a concussion. However, when you look decades ahead, the data on the long-term impact is mixed,” said study senior author Laura Germine. PhD, director of the Laboratory for Brain and Cognitive Health Technology at McLean Hospital and associate professor of psychiatry at Harvard Medical School. “These new findings from the largest study of its kind show that professional football players can still experience cognitive problems associated with head injuries decades after they retire.”

Concussion Symptoms Linked to Cognitive Performance

For the study, 353 retired NFL players completed one-hour neuropsychological tests through an online platform called TestMyBrain, which is supported by McLean Hospital and Harvard Medical School. Players were completely remote and completed tests on a laptop or desktop, including assessments that measured processing speed, visuospatial and working memory, and aspects of short- and long-term memory and vocabulary.

Recalled concussion symptoms were measured by asking the players how often they experienced any of the following symptoms after a blow to the head during play or practice: headache, nausea, dizziness, loss of consciousness, memory problems, disorientation, confusion, seizures, visual problems, or a shaky feeling on the feet. They were also asked if they lost consciousness during their career and if they had ever been diagnosed with a concussion by a medical professional.

The results showed that the cognitive performance of the former players (for example on memory tasks) was associated with the symptoms of a football concussion. For example, the observed differences in visual memory scores between former players with the highest and lowest reported concussion symptoms were equivalent to the differences in cognitive performance between a typical 35-year-old and a 60-year-old.

However, poor cognitive performance was not associated with diagnosed concussions, years of playing professionally or age of first exposure to football. The researchers noted that many head injuries or sub-concussions may not have been diagnosed as concussions due to a lack of awareness at the time or under-reporting of symptoms by players.

When the retired players were compared to a group of 5,086 men who did not play football, the cognitive performance of former players was generally poorer. On two tests of processing speed, age-related differences in cognitive performance were greater among the former player group than among the non-player group, with older players performing worse.

This comparison data suggests that exposure to football could accelerate age-related cognitive decline and cause greater disadvantages in old age, according to the researchers, who added that more studies are needed to track the cognitive performance of former players as they age. Another possibility is that improved awareness and management of head injuries has saved younger retired players more than older players. The researchers also noted that this comparative finding is limited by a lack of data on cognition prior to head injury, and that more research is needed that closely matches former players and non-players and measures their cognitive performance across the lifespan.

“For former players and researchers alike, we can glean some important insights from this study,” said Football Players Health Study principal investigator Ross Zafonte, DO. “Former players can support their cognitive health as they age by taking proactive steps, continuing to consult with their healthcare providers and educating themselves about the symptoms of head injuries. For researchers and healthcare providers, these findings support efforts to develop ways to improve diagnosis and define long-term diagnoses. term consequences of concussion.” Zafonte is president of Spaulding Rehabilitation Network, a Mass General Brigham sports medicine physician, and Earle P. and Ida S. Charlton professor and chairman of the Harvard Medical School Department of Physical Medicine and Rehabilitation.

“The Community Based Participatory Research (CBPR) approach taken in this study is where this field is going,” says Germine. “We are grateful to the players and how much they have taught us. It would not have been possible to conduct a study like this without involving and deeply involving their community.”

Research driven by input from former NFL players

Launched in 2014, the Football Players Health Study at Harvard University is a comprehensive research program aimed at investigating the multifactorial causes that impact the health of former NFL players. The research is based on the players themselves, who provided input on the health issues and conditions they face after a career in football. An interdisciplinary team of researchers from Harvard University and Harvard Medical School and their affiliated teaching hospitals, including those of the Mass General Brigham System, conducts research in neurology, cardiology, sports medicine, rehabilitation medicine, chronic pain and public health . While concussions and head injuries are of paramount importance, the study examines all aspects of players’ health throughout their lives. Former players can find important resources to support their health in this section of the study’s website.