1. Construct a clinical question using PICO from the scenarios below. What type of clinical question is it (eg, intervention, etiology/risk factor, frequency/occurrence, diagnosis/testing, prediction, or phenomena)?
A: An athlete asks you about using creatine supplements. He has heard it can make a big difference in improving muscle strength and power. He is a cross-country runner and has had little improvement in his performance lately. He is hoping to improve his aerobic capacity. Should he try it?
B: A football coach is considering purchasing a new artificial turf practice field to replace the grass field but is concerned about the effect this may have on athlete injury rates (especially ACL injury). You know there is some relationship between the 2 but want to give him a more precise answer. Develop a clinical question to answer the coach’s concern.
2. Conduct a search using one of the PICO questions. Develop a list of keywords or search terms and a list of synonyms for searching. Then select 2 databases/search engines to locate articles. Finally, record the findings in a research log; include information on search history, terms, combining terms, number of articles retrieved, and how you limited your search.
Although professional sports is the most publicized arena of sports, there are few epidemiological studies of concussion in the professional setting. One of the comprehensive studies of overall concussion epidemiology in the National Hockey League found the incidence rate of concussion to be 1.8/1000 player-hours. Another interesting finding of this same study found that time loss increased on average 2.5 days for every subsequent (recurrent) concussion during the study period (1997 to 2004).30 One of the most recent studies of concussion in the National Football League found the incidence rate to be 64.3/10,000 AEs (6.43/1000 AEs).31
Neurodegenerative conditions potentially from head trauma have been studied in professional athletes, although it is predominately cross-sectional evidence. These studies have observed associations among former professional American football players between previous history of concussion and depression, mild cognitive impairment, and other psychological and memory-related issues.8,32,33 Studies among professional ice hockey players have observed similar findings.34 Varying results for the effects of professional soccer on some of these same measures, particularly heading, have been reported.35 A recent study found that once retired, former elite soccer athletes risk of neurodegenerative issues fell in line with the general population.36 However, others have suggested that exposure to head impacts, even purposeful heading, may be a precursor to neurodegenerative issues as an individual ages.37,38 Boxing has often been the sport of reference when discussing potential long-term and cumulative effects of head trauma because some of the first research positing potential links centered on boxers.39,40
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Another issue that is of increasing concern is chronic traumatic encephalopathy (CTE). CTE is often characterized by mental deterioration (including psychological deterioration), confusion, slowing of speech, and Parkinson-like symptoms. Pathologically, there is typically more a diffuse accumulation of Tau protein in the brain with other specific changes.41 Athletic trainers are often the first health care providers approached if an individual or his or her family has concerns about CTE. Currently, CTE can only be diagnosed postmortem through an autopsy despite many providers claiming that individuals may have CTE. Recent studies suggest that various forms of imaging may be able to pick up the Tau protein deposits characteristic of CTE; however, these are yet to be fully clinically validated.42 The current studies of CTE are laboratory and pathology based. To date, no prospective or causal study has been conducted to fully uncover the factors that place an individual at risk for the disease. It is estimated that approximately 10% of individuals who receive multiple impacts as a result of sport will develop the disease.33,43,44 More research is needed to fully understand the pathology of CTE and what risk factors exist around the disease.
Future research in this area is essential to understanding the true epidemiology of the condition and its relationship to sport participation. Overall, there are few prospective epidemiological studies of concussion among professional sports presented in the literature. This group is often hard to study because data are not widely available for analysis and review. More detailed epidemiological profiles and prospective studies of concussion in this population are needed.
Recovery Patterns Across All Sport Levels
Clinicians want to see postconcussive athletes make a safe and progressive return back to activity. As such, one of the primary indicators of recovery is time to return to play (RTP). A recent study examining high school athletes during the 2007-2009 school years found that following a concussion incident, the probability of RTP within 1 to 2 days of injury was 2.5% (95% CI, 0.3, 6.9), 71.3% (95% CI, 59.0, 82.9) for 7 to 9 days postinjury, and 88.8% (95% CI, 72.0, 97.2) for 10 to 21 days postinjury.45 However, previous studies have illustrated more premature returns, or at least return to participation not in compliance with existing RTP guidelines. The most recent NATA position statement recommends no athlete return to participation while symptomatic. Academic accommodations may be necessary during the recovery period, and, prior to return to activity, a gradual and progressive approach should be used.3 A study during the 2005-2008 school years observed that 15% percent of concussed football athletes who sustained a loss of consciousness returned to play in less than 1 day. In addition, approximately 40% of concussed athletes returned to play prematurely under American Academy of Neurology guidelines and 15% according to International Consensus RTP guidelines. Males were more likely than females to return 1 to 2 days after sustaining more severe injuries (12% vs 5.9%, respectively).46 Few studies have addressed return to learn or school activities.
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