Associate Professor Andrew Gardner

The tackle is the in-game activity with the greatest risk for injury in collision sports. Qualitative match analysis has associated injury risk with tackle technique (e.g. tackle height, head position before contact). This exploratory study used gold-standard three-dimensional (3D) motion capture to investigate whether prior instructions to a tackler to execute different torso tackle types altered their tackle technique. Fifteen amateur-level rugby code players performed four sets of 10 tackle trials after instructions from an expert coach: two Australian National Rugby League (NRL) coaching manual instructions on upper and lower torso tackle height (UpperNRL, LowerNRL); and two novel variants that altered the tackler¿s contact with the ball carrier¿s upper torso (UpperPop) via a vertical ¿pop action¿, or mid-torso (MidTorso) via increasing the contact height to the mid-torso. 3 D motion capture confirmed a favourable ¿head up and forward¿ gaze focus on ball carrier before contact and a ¿straight back¿ posture was more evident in UpperPop instruction than other instructions, with the least flexion for the head, trunk, trunk-pelvis, thoracolumbar and lumbopelvic (p < 0.01). MidTorso also attained a more optimal ¿head up and forward¿ and a ¿straight back¿ posture than a LowerNRL (p < 0.001). ¿Leg drive on contact¿ revealed ankle, hip (p < 0.01) and thigh angles (p < 0.05) differences, likely to reflect the UpperPop ¿pop action¿ instruction than other instructions. For coaches, this study demonstrated that amateur-level rugby-code players could follow instruction from an expert coach to execute tackling techniques within a session. Inclusion of tackle specific coaching instruction training program may be a viable injury reduction strategy.

Background: There is considerable interest in determining whether later-in-life depression is associated with lifetime history of concussions or the duration of a career in professional contact and collision sports. Rugby league is a high-intensity collision sport involving a large number of tackles per game and a high rate of concussions. We examined predictors and correlates of depression in retired elite level rugby league players in Australia. Methods: Retired elite level rugby league players (N = 141, age: M = 52.6, SD = 13.8; Range = 30¿89 years) completed the Depression, Anxiety, and Stress Scale (DASS), Brief Pain Inventory, Connor-Davidson Resilience Scale (CD-RISC), and Epworth Sleepiness Scale; they also reported on lifetime history of concussions. The DASS depression score was regressed on age, total number of self-reported concussions, years played professionally, CD-RISC score, BPI pain interference score, and ESS score. Results: The retired players reported a median of 15 total lifetime concussions [interquartile range (IQR) = 6¿30], and a median of 8 years playing professional sports (IQR = 3.5¿11). The proportion of the sample endorsing at least mild current depression was 29%. The DASS depression score was positively correlated with the DASS anxiety (r = 0.54) and DASS stress scores (r = 0.58). The CD-RISC score was negatively correlated with the depression score (r = -0.53). Depression scores were not significantly correlated with pain severity (r = 0.14), and were weakly correlated with life interference due to pain (r = 0.20) and years playing professional sports (r = -0.17). Depression scores were not significantly correlated with lifetime history of concussions (r = 0.14). A multiple regression model, with age, total number of self-reported concussions, years played professionally, the CD-RISC, Brief Pain Inventory-pain interference score, and Epworth Sleepiness Scale score as predictors was significant, with 35% of the variance in DASS depression accounted for. The two significant independent predictors of depression were lower resilience and greater life interference due to pain. Conclusions: This is the first large study of depression in retired rugby league players. Depression in these retired players was not meaningfully associated with lifetime history of concussions or number of years playing elite level collision sport. Depression was associated with current anxiety, stress, resilience, and life interference due to chronic pain.

Rugby league has been identified as a contact sport with a high incidence of concussion. Research has been conducted to describe incidence and mechanisms of concussion in rugby league, however the risks associated with injury events (shoulder, hip, head to head) are unknown. The purpose of this study was to describe the common injury events leading to concussion in the National Rugby League and compare these events through analysis of dynamic response and brain tissue deformation. Twenty-seven impact videos of concussive injuries were physically reconstructed to obtain linear and rotational accelerations of the head. Dynamic response data were input into the University College Dublin Brain Trauma Model (UCDBTM) to calculate maximum principal strain (MPS). Head-to-head events produced a short duration event with an average peak linear and peak rotational acceleration of 205g and 15,890 rad/s2, respectively, which were significantly greater than the longer duration hip-to-head (24.7g and 2650 rad/s2) and shoulder-to-head (24.2g and 3280 rad/s2) impacts. There were no differences in MPS between events. These results suggest that risk of strain to the brain may be produced by short and long duration acceleration events. Thus, both of these accelerations need to be accounted for in the development of improved head and body protection in rugby. In addition, this data demonstrates that these events cause a risk of concussion requiring efforts to limit or modify how energy is transferred to the head.

Objectives: Current off-field concussion screening instruments have sub-optimal accuracy and additional testing domains may be necessary to detect the full spectrum of concussion presentations. This study aimed to determine if additional cognitive tests add utility to off-field screening for sport-related concussion. Design: Reproducibility and diagnostic accuracy cohort studies were performed in the 2017 and 2018 seasons of the Super Rugby competition, conducted in Argentina, Australia, Japan, New Zealand, and South Africa. Methods: Abridged versions of Stroop (score, time), Spatial Memory (score, failed trials), and Trail Making Trial-B (time, errors) cognitive tests, modified for off-field use, were examined. Players performed baseline testing prior to each season. Cases undergoing off-field screening as part of the World Rugby Head Injury Assessment Process underwent evaluation with the same cognitive tests during competition matches. Agreement between repeated pre-season baseline measurements, and the diagnostic accuracy of off-field testing against a clinical reference standard of concussion, was evaluated. Results: Data were available for repeated preseason baseline testing in 644 players, and 100 cases undergoing off-field concussion screening. There was little individual agreement across pre-season baseline assessments for all tests (Lin's correlation and Gwets AC1 coefficients ranging between 0.2 and 0.3). There was significantly worse performance for the time taken to complete the modified Stroop Test in concussed players undergoing off-field screening, compared to non-concussed players (median time 21.1 v 18.4 s, p < 0.01; area under the receiver operating characteristic curve 0.7 (95% CI 0.5¿0.8)). Other cognitive measures did not discriminate between injured and un-injured players, with no-statistically significant differences in distribution medians (p = 0.6¿0.9) and AUROC values close to 0.5. Conclusions: The time taken to perform a modified Stroop Test may provide additional diagnostic accuracy if added to current off-field concussion screening tools. Abridged Spatial Memory and Trail Making Trial-B tests did not discriminate between concussed and non-concussed players.

Objective: To examine the effect of prior concussion history on cognitive test performance and concussion symptom reporting among adolescent youth rugby league athletes.Participants: Participants were male elite level youth rugby league players (N = 73; Mean Age = 15.8; SD = 0.9; range = 14¿18 years).Main Outcome Measure: CogSport performance based on participants group; those who reported no previous concussions (n = 30),1¿2 previous concussions (n = 19), and =3 previous concussions (n = 29).Results: 73 participants with valid CogSport scores were included in the cognitive analyses. All participants were included in the symptom analyses. There were no differences between the groups with 0,1¿2, or =3 previous concussions for processing speed, attention, learning, or working memory. There was atrend for those with multiple prior concussions to report more baseline preseason symptoms.Conclusions: There were no differences in scores on the CogSport test among those with ahistory of 0,1¿2, or =3 prior concussions. Consistent with prior studies, youth with ahistory of multiple past concussions are more likely to endorse baseline preseason symptoms.

Objective: In recent years, it has been proposed that depression represents one clinical subtype of chronic traumatic encephalopathy (CTE). This is the first study to examine the specificity of the research criteria for the clinical diagnosis of CTE in men with depression from the general population. Methods: Data from the National Comorbidity Survey Replication, an in-person survey that examined the prevalence and correlates of mental disorders in the United States, were used for this study. Men diagnosed as having a major depressive episode in the past 30 days were included (N=101; mean age=39.4 years, SD=12.9, range=18¿71). They were deemed to meet research criteriafor CTE if they presented with the purported supportive clinical features of CTE (e.g., impulsivity and substance abuse, anxiety, apathy, suicidality, and headache). Results: Approximately half of the sample (52.5%) met the proposed research criteria for CTE (i.e., traumatic enceph-alopathy syndrome). If one accepts the delayed-onset criterion as being present, meaning that the men in the sample were presenting with depression years after re-tirement from sports or the military, then 83.2% of this sample would meet the research criteria for diagnosis. Conclusions: The clinical problems attributed to CTE, such as depression, suicidality, anxiety, anger control problems, and headaches, co-occurred in this sample of men with depression from the general population¿illustrating that these problems are not specific or unique to CTE. More research is needed to determine whether depression is, in fact, a clinical subtype of CTE.

Objectives: To prospectively evaluate single/dual-task timed-up-and-go (TUG) and tandem gait performance among children and adolescents with concussion and healthy controls. Design: Repeated measures. Methods: Participants with concussion (n = 23; age = 14.1 ± 2.5 years; 52% female) completed single/dual-task TUG, tandem gait, and symptom assessments 6.7 ± 2.6 and 23.3 ± 6.1 days post injury. The control group (n = 27; age = 14.1 ± 2.3 years; 48% female) completed the same protocol initially and 10.7 ± 16.1 days later. All participants completed single-task (undivided attention) and dual-task (divided attention) tests. The primary outcome variable was test completion time. Results: The concussion group completed single-task (concussion group mean = 11.1 ± 1.9 vs. control group mean 9.9 ± 1.4 s, p = 0.027) and dual-task (concussion group mean = 14.4 ± 3.3 vs. control group mean 12.7 ± 1.9 s, p = 0.047) TUG tests slower than the control group across both time points. The concussion group completed dual-task tandem gait tests slower than the control group at both time points (21.3 ± 6.3 vs. 16.8 ± 5.5 s, p = 0.006), and were slower in the single-task condition at the first test (19.8 ± 5.4 vs. 13.8 ± 4.4 s, p = 0.003). Symptoms were significantly worse for the concussion group compared to the control group at the first (34.1 ± 21.4 vs. 3.9 ± 9.1, p < 0.001), but not the second test (9.1 ± 12.0 vs. 2.2 ± 6.8; p = 0.08). Conclusions: Slower dual-task TUG and tandem gait times were detected across both time points for the concussion group relative to the control group. In contrast, single-task tandem gait deficits appeared to improve in a similar fashion as symptoms, suggesting increased complexity from the addition of a cognitive task allows for the detection of persistent post-concussion deficits that might take longer to resolve.

In the 20th century, chronic traumatic encephalopathy (CTE) was conceptualized as a neurological disorder affecting some active and retired boxers who had tremendous exposure to neurotrauma. In recent years, the two research groups in the USA who have led the field have asserted definitively that CTE is a delayed-onset and progressive neurodegenerative disease, with symptoms appearing in midlife or decades after exposure. Between 2005 and 2012 autopsy cases of former boxers and American football players described neuropathology attributed to CTE that was broad and diverse. This pathology, resulting from multiple causes, was aggregated and referred to, in toto, as the pathology ¿characteristic¿ of CTE. Preliminary consensus criteria for defining the neuropathology of CTE were forged in 2015 and published in 2016. Most of the macroscopic and microscopic neuropathological findings described as characteristic of CTE, in studies published before 2016, were not included in the new criteria for defining the pathology. In the past few years, there has been steadily emerging evidence that the neuropathology described as unique to CTE may not be unique. CTE pathology has been described in individuals with no known participation in collision or contact sports and no known exposure to repetitive neurotrauma. This pathology has been reported in individuals with substance abuse, temporal lobe epilepsy, amyotrophic lateral sclerosis, multiple system atrophy, and other neurodegenerative diseases. Moreover, throughout history, some clinical cases have been described as not being progressive, and there is now evidence that CTE neuropathology might not be progressive in some individuals. Considering the current state of knowledge, including the absence of a series of validated sensitive and specific biomarkers, CTE pathology might not be inexorably progressive or specific to those who have experienced repetitive neurotrauma.

U SYNOPSIS: Sport-related concussion is common in full-contact and collision sports. Epidemiology studies use different types of surveillance systems and concussion definitions. Concussion incidence rates vary across age, sex, sport, and level of competition. Incidence rates are increasing, likely due to higher rates of reporting following improved knowledge and increased regulations. In this review, we summarize 7 key concepts related to concussion epidemiology: concussion definition, changes in concussion knowledge, reliability and accuracy of injury surveillance systems, conservative management and return to play, reliability of self-report, incidence of concussion across levels of play, and understanding the behaviors of players, coaches, and medical personnel from a multidisciplinary management perspective.

Objective: In recent years, it has been proposed that problems with anger control and depression define clinical features of chronic traumatic encephalopathy (CTE). The authors examined anger problems and depression in middle-aged men from the general population and related those findings to the proposed clinical criteria for CTE. Methods: A sample of 166 community-dwelling men ages 40¿60 was extracted from the normative database of the National Institutes of Health Toolbox. All participants denied prior head injury or traumatic brain injury (TBI). Participants completed scales assessing anger, hostility, aggression, anxiety, and depression. Results: In response to the item ¿I felt angry,¿ 21.1% of men reported ¿sometimes,¿ and 4.8% reported ¿often.¿ When asked ¿If I am provoked enough I may hit another person,¿ 11.4% endorsed the statement as true. There were moderate correlations between anger and anxiety (Spearman¿s r=0.61) and between depression and affective anger (r=0.51), hostility (r=0.56), and perceived hostility (r=0.35). Participants were dichotomized into a possible depression group (N=49) and a no-depression group (N=117) on the basis of the question ¿I feel depressed,¿ specific to the past 7 days. The possible depression group reported higher anxiety (p<0.001, Cohen¿s d=1.51), anger (p<0.001, Cohen¿s d=0.96), and hostility (p<0.001, Cohen¿s d=0.95). Conclusions: Some degree of anger and aggression are reported by a sizable minority of middle-aged men in the general population with no known history of TBI. Anger and hostility are correlated with depression and anxiety, indicating that all tend to co-occur. The base rates and comorbidity of affective dysregulation in men in the general population is important to consider when conceptualizing CTE phenotypes.

Primary Objective: This study reviewed the available sideline Sport Concussion Assessment Tool-Third Edition (SCAT3) performance of players who were removed from play using the ¿concussion interchange rule¿ (CIR), the available video footage of these incidences, and associated return to play and concussion diagnosis decisions. Research Design: Descriptive, observational case series. Methods and Procedures: Data were collected from all NRL players who used the CIR during the 2014 season. Main Outcomes and Results: Complete SCAT3 and video analysis data were available for 38 (23%) of 167 uses of the concussion interchange rule, of which 20 (52.6%) players were medically diagnosed with concussion. Those with video evidence of unresponsiveness performed more poorly on the modified Balance Error Scoring System (M-BESS; p¿=.04; Cohen¿s d¿=.69) and reported greater symptoms (p¿=.03; d¿=.51). Similarly, players with a vacant stare reported greater symptoms (p¿=.05; d¿=.78). Those who demonstrated three signs (unresponsiveness, vacant stare and gait ataxia) performed more poorly on the M-BESS (p¿=.03; d¿=¿1.4) and reported greater symptoms than those with no observable signs (p¿=.03; d¿=¿1.4). Conclusions: The SCAT3 is sensitive to the acute effects of concussion in professional athletes; however, a minority of injured athletes might go undetected by this test.

Risk factors for concussion in active-duty military service members are poorly understood. The present study examined the association between self-reported concussion history and genetics (apolipoprotein E [APOE], brain-derived neurotrophic factor [BDNF], and D2 dopamine receptor genes [DRD2]), trait personality measures (impulsive-sensation seeking and trait aggression-hostility), and current alcohol use. The sample included 458 soldiers who were preparing to deploy for Operation Iraqi Freedom/Operation Enduring Freedom. For those with the BDNF Met/Met genotype, 57.9% (11/19) had a history of one or more prior concussions, compared with 35.6% (154/432) of those with other BDNF genotypes (p = 0.049, odds ratio [OR] = 2.48). APOE and DRD2 genotypes were not associated with risk for past concussions. Those with the BDNF Met/Met genotype also reported greater aggression and hostility personality characteristics. When combined in a predictive model, prior military deployments, being male, and having the BDNF Met/Met genotype were independently associated with increased lifetime history of concussions in active-duty soldiers. Replication in larger independent samples is necessary to have more confidence in both the positive and negative genetic associations reported in this study.

Objective Systematic review of possible long-term effects of sports-related concussion in retired athletes. Data sources Ten electronic databases. Study selection Original research; incidence, risk factors or causation related to long-term mental health or neurological problems; individuals who have suffered a concussion; retired athletes as the subjects and possible long-term sequelae defined as >10 years after the injury. Data extraction Study population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, neuroimaging findings and neuropathology results. Risk of bias and level of evidence were evaluated by two authors. Results Following review of 3819 studies, 47 met inclusion criteria. Some former athletes have depression and cognitive deficits later in life, and there is an association between these deficits and multiple prior concussions. Former athletes are not at increased risk for death by suicide (two studies). Former high school American football players do not appear to be at increased risk for later life neurodegenerative diseases (two studies). Some retired professional American football players may be at increased risk for diminishment in cognitive functioning or mild cognitive impairment (several studies), and neurodegenerative diseases (one study). Neuroimaging studies show modest evidence of macrostructural, microstructural, functional and neurochemical changes in some athletes. Conclusion Multiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals. More research is needed to better understand the prevalence of chronic traumatic encephalopathy and other neurological conditions and diseases, and the extent to which they are related to concussions and/or repetitive neurotrauma sustained in sports.

Background Sports concussion is a risk for players involved in high impact, collision sports. Post-concussion, the majority of symptoms subside within 7¿10 days, but can persist in 10¿20% of athletes. Understanding the effects of sports concussion on sensorimotor systems could inform physiotherapy treatment. Objective To explore changes in sensorimotor function in the acute phase following sports concussion. Design Prospective cohort study. Methods Fifty-four players from elite rugby union and league teams were assessed at the start of the playing season. Players who sustained a concussion were assessed three to five days later. Measures included assessments of balance (sway velocity), vestibular system function (vestibular ocular reflex gain; right-left asymmetry), cervical proprioception (joint position error) and trunk muscle size and function. Results During the playing season, 14 post-concussion assessments were performed within 3¿5 days of injury. Significantly decreased sway velocity and increased size/contraction of trunk muscles, were identified. Whilst not significant overall, large inter-individual variation of test results for cervical proprioception and the vestibular system was observed. Limitations The number of players who sustained a concussion was not large, but numbers were comparable with other studies in this field. There was missing baseline data for vestibular and cervical proprioception testing for some players. Conclusions Preliminary findings post-concussion suggest an altered balance strategy and trunk muscle control with splinting/over-holding requiring consideration as part of the development of appropriate physiotherapy management strategies.

Chronic traumatic encephalopathy (CTE) has been described in the literature as a neurodegenerative disease with: (i) localized neuronal and glial accumulations of phosphorylated tau (p-tau) involving perivascular areas of the cerebral cortex, sulcal depths, and with a preference for neurons within superficial cortical laminae; (ii) multifocal axonal varicosities and axonal loss involving deep cortex and subcortical white matter; (iii) relative absence of beta-amyloid deposits; (iv) TDP-43 immunoreactive inclusions and neurites; and (v) broad and diverse clinical features. Some of the pathological findings reported in the literature may be encountered with age and other neurodegenerative diseases. However, the focality of the p-tau cortical findings in particular, and the regional distribution, are believed to be unique to CTE. The described clinical features in recent cases are very similar to how depression manifests in middle-aged men and with frontotemporal dementia as the disease progresses. It has not been established that the described tau pathology, especially in small amounts, can cause complex changes in behavior such as depression, substance abuse, suicidality, personality changes, or cognitive impairment. Future studies will help determine the extent to which the neuropathology is causally related to the diverse clinical features.

Objectives: Concussion remains one of the inherent risks of participation in rugby league. While other injuries incurred by rugby league players have been well studied, less focus and attention has been directed towards concussion. Review method: The current review examined all articles published in English from 1900 up to June 2013 pertaining to concussion in rugby league players. Data sources: Publications were retrieved via six databases using the key search terms: rugby league, league, football; in combination with injury terms: athletic injuries, concussion, sports concussion, sports-related concussion, brain concussion, brain injury, brain injuries, mild traumatic brain injury, mTBI, traumatic brain injury, TBI, craniocerebral trauma, head injury and brain damage. Observational, cohort, correlational, cross-sectional and longitudinal studies were all included. Results: 199 rugby league injury publications were identified. 39 (20%) were related in some way to concussion. Of the 39 identified articles, 6 (15%) had the main aim of evaluating concussion, while the other 33 reported on concussion incidence as part of overall injury data analyses. Rugby league concussion incidence rates vary widely from 0.0 to 40.0/1000 playing hours, depending on the definition of injury (time loss vs no time loss). The incidence rates vary across match play versus training session, seasons (winter vs summer) and playing position (forwards vs backs). The ball carrier has been found to be at greater risk for injury than tacklers. Concussion accounts for 29% of all injuries associated with illegal play, but only 9% of injuries sustained in legal play. Conclusions: In comparison with other collision sports, research evaluating concussion in rugby league is limited. With such limited published rugby league data, there are many aspects of concussion that require attention, and future research may be directed towards these unanswered questions.

Prognostic models can guide clinical management and increase statistical power in clinical trials. The availability and adequacy of prognostic models for mild traumatic brain injury (MTBI) is uncertain. The present study aimed to (1) identify and evaluate multivariable prognostic models for MTBI, and (2) determine which pre-, peri-, and early post-injury variables have independent prognostic value in the context of multivariable models. An electronic search of MEDLINE, PsycINFO, PubMed, EMBASE, and CINAHL databases for English-language MTBI cohort studies from 1970-2013 was supplemented by Web of Science citation and hand searching. This search strategy identified 7789 articles after removing duplicates. Of 182 full-text articles reviewed, 26 met eligibility criteria including (1) prospective inception cohort design, (2) prognostic information collected within 1 month post-injury, and (3) 2+variables combined to predict clinical outcome (e.g., post-concussion syndrome) at least 1 month later. Independent reviewers extracted sample characteristics, study design features, clinical outcome variables, predictor selection methods, and prognostic model discrimination, calibration, and cross-validation. These data elements were synthesized qualitatively. The present review found no multivariable prognostic model that adequately predicts individual patient outcomes from MTBI. Suboptimal methodology limits their reproducibility and clinical usefulness. The most robust prognostic factors in the context of multivariable models were pre-injury mental health and early post-injury neuropsychological functioning. Women and adults with early post-injury anxiety also have worse prognoses. Relative to these factors, the severity of MTBI had little long-term prognostic value. Future prognostic studies should consider a broad range of biopsychosocial predictors in large inception cohorts.

Objective: The aim of the current review was to systematically evaluate the available evidence on concussion in Rugby Union and to conduct a meta-analysis of findings regarding the incidence of concussion.

Traumatic brain injury (TBI) is a common condition that is often complicated by neuropsychiatric sequelae that can have major impacts on function and quality of life. An alteration in the sense of smell is recognized as a relatively common complication of TBI; however in clinical practice, this complication may not be sought or adequately characterized. We conducted a systematic review of studies concerned with olfactory functioning following TBI. Our predetermined criteria led to the identification of 25 studies published in English, which we examined in detail. We have tabulated the data from these studies in eight separate tables, beginning with Table 1, which highlights each study's key findings, and we provide a summary/synthesis of the findings in the accompanying results and discussion sections. Despite widely differing methodologies, the studies attest to a high frequency of post-TBI olfactory dysfunction and indicate that its presence can serve as a potential marker of additional structural or functional morbidities. © 2014 Schofield, Moore and Gardner.