The primary purpose of this study was to determine the association between Apolipoprotein E (APOE) genotype and head impact response in high school athletes. The secondary purpose was to determine if quality of life (QoL) and cognitive functioning scores significantly differ between Apolipoprotein (APOE) rare allele carriers versus non-carriers within a poor head impact response (PHIR) group of high school athletes. Thirty (28 males, 2 females) high school athletes playing high head impact sports participated in the study. A between-subjects design was used. Primary aim one independent variable was genotype (i.e., APOE E4 carriers vs. non-carriers and APOE G-219T carriers vs. non-carriers) and dependent variable was group [i.e., normal head impact response (NHIR) vs. PHIR]. Statistical analysis consisted of Fisher's exact tests. Alpha level was set at p p p = .002) in the overall QoL scores between APOE G-219T promoter rare allele carriers versus non-carriers within the PHIR group. No other statistically significant differences were found; however, there was a trend (p = .007) found in the psychosocial subscores in the APOE G-219T promoter rare allele carriers versus non-carriers within the PHIR group. Carrying an APOE rare G-219T rare allele was associated with significantly lower QoL scores within the PHIR group, these results indicate that athletes with intrinsic (e.g., genotype) risk factors may need more education and different treatment following head impacts. / Kinesiology

Post-concussion syndrome (PCS) is a poorly understood sequela of mild traumatic brain injury (mTBI), more commonly referred to as concussion. While PCS is known to affect a subset of individuals following injury, it remains unclear how and why specific individuals incur chronic symptoms. Concussions disrupt normal neurophysiologic function within the brain, however the neurophysiologic underpinnings of PCS are unclear. Using transcranial magnetic stimulation (TMS), it is possible to non-invasively investigate neurotransmission in clinical populations such as those with PCS by stimulating the primary motor cortex (M1) and recording motor outputs in a contralateral hand muscle. A study was conducted using TMS to measure corticospinal excitability, intracortical facilitation and inhibition, and transcallosal inhibition in M1 of a group with PCS and a non-injured, healthy control group. Greater corticospinal excitability, and specific reductions in intracortical and transcallosal inhibition were observed in the PCS group, providing evidence of impaired neurotransmitter receptor activity. Importantly, these findings differed from previous observations in recovered concussion groups using similar stimulation techniques. Furthermore, it was observed that these neurophysiological differences may relate specifically to the presence of depression symptoms rather than general concussion symptoms. The physiologic and clinical implications of the findings of this thesis are discussed, and novel research avenues warranting investigation are identified. / Thesis / Master of Science in Kinesiology

Background: Sleep is commonly disrupted following pediatric concussion. Recently, post-concussion sleep quality has been identified as a potential factor that may influence recovery length. However, few studies have examined this relationship using objective sleep measures in a pediatric population. Nor, have any studies examined the trajectory of objective sleep parameters after pediatric concussion. Objectives: The purpose of this thesis is to: 1) Provide a review of current literature regarding pediatric concussion, healthy sleep quality, and sleep quality in the context of concussion and recovery from concussion; 2) Examine how objective sleep outcomes are affected and change post-concussion in children and adolescents; 3). Explore how post-concussion sleep quality parameters are related to length of recovery, quality of life (QOL), and depression symptomatology; and 4) Discusses the results from the two studies in the context of current literature and of each other. Methods: Sleep quality was inferred from the outcomes of five objective sleep parameters. Sleep parameters were measured using actigraphy in children and adolescents with concussion following return to school (RTA) and return to activity (RTA) protocols. Sleep data during the initial 4 weeks of recovery was assessed as an outcome, as a predictor of recovery length, and as a correlate of quality of life (QOL) and depression symptomatology Results: Most objective post-concussion sleep quality parameters were adversely affected by concussion but show trajectories indicating improvement throughout the initial 4 weeks of recovery. Sleep quality parameters were not associated with time to complete return to school or activity protocols. Sleep parameters were not strongly correlated with QOL or depression symptomatology outcomes. Conclusions: These results indicate that objective post-concussion sleep quality is impaired following concussion, but these outcomes do not appear to be associated with recovery, QOL or depression symptomatology. Other factors, or improvements in sleep quality may better explain recovery outcomes. / Thesis / Master of Science (MSc) / Children and adolescents are at risk for experiencing changes in sleep following concussion that result in poor sleep quality. Given the important role of sleep in maintaining our overall health, sleep likely plays a role in recovery. However, this relationship is poorly understood. The purpose of this dissertation is to identify how sleep changes following concussion and how these changes affect sleep quality and recovery. Study results reveal that the sleep parameters in the initial 4 weeks following concussion are significantly affected by concussion, suggesting that the sleep quality of children and adolescents is poorer than healthy youth. However, sleep quality does appear to improve with time. Further analyses found sleep quality does not appear to be related to recovery length or outcomes. Thus, the sleep quality of youth may be negatively impacted by concussion, but this may not directly influence recovery.

Concussions are diffuse injuries that affect areas of the brain responsible for a person's physical, cognitive, and emotional health. Although concussions were once thought only to present transient symptoms, mounting evidence suggests potential for long-term neurological impairments. The deleterious effects of concussion can be from a single, high severity impact event or the accumulation of lower severity impacts. Clinical changes that can result from concussion include an elevated symptom presentation and changes in gait, or an individual's walking pattern. It is not well understood if similar deficits result after an accumulation of subconcussive impacts. The majority of research on human tolerance to head injury has been based on American football, using helmet-mounted sensors in male athletes. Limited studies have attempted to quantify biomechanical tolerance in women, despite the sex-specific nature of presentation and outcome of concussion. Biomechanical, physiologic, and psychosocial factors differ between males and females, likely contributing to this difference. The research presented in this dissertation was aimed at describing sex-specific outcomes of subconcussion in a matched cohort of male and female athletes to gain a better sense of unhelmeted, sex-specific tolerance to head impacts. On-field data were collected from collegiate rugby players using instrumented mouthguards. Rugby involves high energy, frequent head impacts, does not require protective headgear, and is played the same for both men and women. The females in our study sustained fewer impacts per session than the males, but their impacts had similar linear acceleration magnitudes. The kinematics of the concussive male impacts were higher than the kinematics of the concussive female impacts. Both sexes reported concussion-like symptoms in the absence of diagnosed concussion during a season. Females reported more symptoms with a higher severity in-season compared to males after subconcussive and concussive impacts. Female athletes saw deficits in cadence, double support time, gait speed, and stride length post-concussion. The majority of athletes improved in their dual-task gait assessment by the end of the season, suggesting there may not be a negative effect on gait after an accumulation of subconcussive impacts. This work assessed the biomechanics of head impacts and concussions of this population, and evaluated changes in symptom presentation through weekly graded symptom surveys and dual-task gait assessments both after a concussion and as an effect of subconcussive impacts. Understanding the sex-specific clinical effects of head impacts is critical, and can provide insight into concussion diagnostic, management, and prevention tools that are appropriate and effective. / Doctor of Philosophy / Concussions are injuries that affect many areas of the brain, including those responsible for a person's physical, cognitive, and emotional health. Although concussions were once thought only to present transient symptoms, mounting evidence suggests potential for long-term neurological impairments. The harmful effects of concussion can be from a single, high intensity impact event or the build-up of lower intensity impacts. Clinical changes that can result from concussion include an elevated symptom presentation and changes in gait, or an individual's walking pattern. It is not well understood if similar side effects result after an accumulation of subconcussive impacts. The majority of research on human tolerance to head injury has been based on American football, using helmet-mounted sensors in male athletes. Limited studies have attempted to quantify concussion tolerance in women, despite the differences in men and women's symptoms and recovery time after a concussion. Female's neck strength, hormones, and increased honesty in reporting concussion differ from males, likely contributing to this difference. The research presented in this dissertation was aimed at describing how sex affects the results of subconcussion in a group of male and female athletes to gain a better sense of unhelmeted, sex-specific tolerance to head impacts. On-field data were collected from collegiate rugby players using sensor-embedded mouthguards. Rugby involves high energy, frequent head impacts, does not require protective headgear, and is played the same by both men and women. The females in our study sustained fewer impacts per session than the males, but their impacts were similar in magnitude. The impact energies of the concussive male impacts were higher than those of the concussive female impacts. Both sexes reported concussion-like symptoms in the absence of diagnosed concussion during a season. Females reported more symptoms with a higher severity in-season compared to males after subconcussive and concussive impacts. Female athletes had a slower walking pace and walking speed, a shorter stride length, and spent more time with both feet on the ground post-concussion. The majority of athletes improved in their dual-task gait assessment by the end of the season, suggesting there may not be a negative effect on gait after an accumulation of subconcussive impacts. This work assessed the biomechanics of head impacts and concussions of this population, and evaluated changes in symptom presentation through weekly graded symptom surveys and dual-task gait assessments both after a concussion and as an effect of subconcussive impacts. Understanding the sex-specific clinical effects of head impacts is critical, and can provide insight into concussion diagnostic, management, and prevention tools that are appropriate and effective.

Cycling is an increasingly popular mode of transportation and a preferred form of exercise worldwide. From 1990 to 2015, commuting via bicycle increased as much as four-fold in cities across North America and Europe. However, this increase in cycling is associated with an increase in cycling related fatalities and head injuries. The best way to prevent severe head injury while cycling is to wear a bike helmet. Bike helmets are designed to decrease the linear acceleration of the head, decreasing the rider's risk of severe head injuries, such as skull fracture. In order to sell a bike helmet, it must meet a minimum standard of protection based on linear acceleration of the head upon impact. However, bike helmet impacts are not completely linear in nature and experience a tangential component through angled impacts of the helmet, resulting in rotational accelerations and shear-strain at the skull-brain interface. This strain cause brain injuries such as concussion. Therefore, recent helmet advancements have aimed to decrease rotational acceleration of the head. To continue the advancement of helmet technology and the subsequent decrease of brain injury risk to riders, investigating the impact conditions of real-world impacts is pertinent. This thesis aimed to increase the current body of knowledge of cycling related head impacts. The first aim was to quantify real-world impact locations and analyze how impact location may influence helmet performance. The second aim of this thesis was to investigate the impact velocities and resulting kinematics of real-world crashes based on the magnitude of corresponding damage conditions. Additionally, this aim analyzed the impact conditions from cases which resulted in concussion. Together these studies aim to provide valuable real-world data to be used for the advancement of helmet technologies and design. / Master of Science / Cycling is an increasingly popular mode of transportation and a preferred form of exercise worldwide. From 1990 to 2015, commuting via bicycle increased as much as four-fold in cities across North America and Europe. However, this increase in cycling is associated with an increase in cycling related fatalities and head injuries. The best way to prevent severe head injury while cycling is to wear a bike helmet. Bike helmets are designed to decrease the linear acceleration of the head, decreasing the rider's risk of severe head injuries, such as skull fracture. In order to sell a bike helmet, it must meet a minimum standard of protection based on linear acceleration of the head upon impact. However, bike helmet impacts are not completely linear in nature and experience a tangential component through angled impacts of the helmet, resulting in rotational accelerations and shear-strain at the skull-brain interface. This strain cause brain injuries such as concussion. Therefore, recent helmet advancements have aimed to decrease rotational acceleration of the head. To continue the advancement of helmet technology and the subsequent decrease of brain injury risk to riders, investigating the impact conditions of real-world impacts is pertinent. This thesis aimed to increase the current body of knowledge of cycling related head impacts. The first aim was to quantify real-world impact locations and analyze how impact location may influence helmet performance. The second aim of this thesis was to investigate the impact velocities and resulting kinematics of real-world crashes based on the magnitude of corresponding damage conditions. Additionally, this aim analyzed the impact conditions from cases which resulted in concussion. Together these studies aim to provide valuable real-world data to be used for the advancement of helmet technologies and design.

The studies presented in this dissertation investigated biomechanical factors associated with sports-related brain injuries on the field and in the laboratory. In the first study, head impact exposure in youth football was observed using a helmet mounted accelerometer system to measure head kinematics. The results suggest that restriction on contact in practice at the youth level can translate into reduced head impact exposure over the course of a season. A second study investigated the effect of measurement error in the head impact kinematic data collected by the helmet mounted system have on subsequent analyses. The objective of this study was to characterize the propagation of random measurement error through data analyses by quantifying descriptive statistic uncertainties and biases for biomechanical datasets with random measurement error. For distribution analyses, uncertainties tend to decrease as sample sizes grow such that for a typical player, the uncertainties would be around 5% for peak linear acceleration and 10% for peak angular (rotational) acceleration. The third and fourth studies looked at comparisons between two headforms commonly used in athletic helmet testing, the Hybrid III and NOCSAE headforms. One study compared the headform shape, particularly looking at regions that are likely to affect helmet fit. Major differences were found at the nape of the neck and in the check/jaw regions that may contribute to difficulty with fitting a helmet to the Hybrid III headform. For the final study, the impact responses of the two headforms were compared. Both headforms were mounted on a Hybrid III neck and impacted at various magnitudes and locations that are representative of impacts observed on the football field. Some condition-specific differences in kinematic parameters were found between the two headforms though they tended to be small. Both headforms showed reasonable repeatability. / Ph. D.

Although cycling offers many health and environmental benefits, it is not an activity free of injury risk. Increases in cycling popularity in the United States over the past 15 years have been paralleled by a 120% growth in cycling-related hospital admissions, with injuries to the head among the most common and debilitating injuries. Bicycle helmets can reduce head injury risk and are presently required to meet safety standard certification criteria specifying a minimal level of acceptable impact protection. However, the conditions surrounding cyclist head impacts are thought to be much more complex than the test conditions prescribed in standards and have important implications related to mechanisms of injury. The overarching aim of this dissertation was thus to investigate the protective capabilities of bicycle helmets in the context of real-world impact conditions and relevant head injury mechanisms. This aim was achieved through a series of studies, the objectives of which were to: compare helmet impact performance across standards impact testing and more realistic, oblique impact testing; to probe how changing boundary conditions of oblique impact testing may influence helmet test outcomes; to use this knowledge to inform the development of an objective helmet evaluation protocol reflective of realistic impact conditions and related head injury risks; and finally, to enhance the body of knowledge pertaining to cyclist head impact conditions via advanced helmet damage reconstruction techniques. The compilation of results across these studies serves to enhance cyclist safety by stimulating improved helmet evaluation and design while simultaneously providing objective, biomechanical data to consumers, enabling them to make safety-based purchasing decisions. / Doctor of Philosophy / Although cycling offers many health and environmental benefits and is increasing in popularity in the United States, it is not always a perfectly safe activity. The number of cycling-related hospital admissions in the US has been increasing over the past 15 years. Cyclists often sustain head injuries from crashes, which can be particularly debilitating. Fortunately, wearing a helmet can protect against head injuries during a crash. Bicycle helmets are presently designed around safety standards that drop a helmeted dummy head onto a horizontal anvil and require the helmet to limit the force on the head to acceptable levels. However, standards tests overly simplify how cyclists actually hit their head during a crash and are consequently unable to assess how well helmets protect against common brain injuries like concussion. The overarching goal of this research was to evaluate how effectively bicycle helmets protect cyclists from concussion in realistic impact scenarios. Several studies were conducted to achieve this goal. Their individual objectives were to: compare how bicycle helmets reduce impact forces associated with standards tests versus more realistic, angled impact tests; to understand how changing constraints of an angled impact setup influences helmet effectiveness; to develop an unbiased evaluation protocol for bicycle helmets based on realistic cyclist crash scenarios and concussion risk assessment; and finally, to further explore how cyclists impact their head in real-world crashes using advanced techniques for reconstructing bicycle helmet damage from actual accidents. All of these studies lead to improved cyclist safety by stimulating improved helmet evaluation and design, while also providing consumers with information on how protective their helmets are.

The research presented in this thesis aims to improve the knowledge of head impact biomechanics in youth football players by analyzing head impact exposure of youth football players and the performance of youth football helmets. The results of the studies presented provide a foundation for researchers, football leagues, and helmet manufactures to implement changes and modifications that aim to reduce concussion risk in youth athletes. The first study presented in this thesis aims to quantify the head impact exposure of 7 to 8 year old football players and determine the cause of variation in player exposure. To conduct this study, 19 players were instrumented with helmet mounted accelerometers that measured real-time acceleration data on the field. This data was analyzed to determine the magnitude, frequency, and location of each impact sustained by players in the 2011 and 2012 football season. From these data, it was determined that the average 7 to 8 year old player experienced 161 impacts per season, 60% of which were in practice and 40% were in games. The median impact for 7 to 8 year old players was 16 g and 686 rad/s². The magnitude of the 95th percentile impact was 38 g and 2052 rad/s². A total of 125 impacts above 40 g were recorded, 67% of which occurred in practices and 33% occurred in games. It was determined that returning players experienced significantly more impacts per season than first time players and practices had significantly higher magnitude impacts than games. These data can be used to further develop practice modifications that aim to reduce total impacts and high magnitude impacts experienced by youth football players. The second study presented in this thesis aims to quantify differences in youth football helmet performance before and after a football season. Currently, the only requirement regarding helmet recertification and reconditioning states that no helmet older than 10 years will be recertified or reconditioned. Quantitative data is needed to either support or refute this guideline and provide data describing how often youth football helmets should be recertified and reconditioned. To conduct this study, 6 youth Riddell Revolution football helmets, 3 that were new and 3 that had been used for one season, were tested on a drop tower from various heights and impact locations before and after the 2013 football season. It was determined that there was no significant difference in helmet performance before and after a season for new helmets or helmets that had been used for one season. In addition, there was no significant correlation between the frequency of impacts, the 95th percentile impact magnitude, or the product of the frequency and 95th percentile impact magnitude with the change in helmet performance. Future studies should be conducted that analyze the performance of youth football helmets over the course of multiple seasons. / Master of Science

When football originated in the 1800s, players wore no protective equipment. Between 1869 and 1905, there were 18 deaths and 159 serious injuries attributed to the sport. Following this, players began to wear protective equipment. The first use of a football helmet was in 1893, made of leather and designed to reduce the risk of skull fracture. Initially, football helmets were intended to protect a player against the most severe hits they would experience on the field. More recently, it has been shown that mild traumatic brain injuries, such as concussions, can induce long-term neurodegenerative processes. Since their introduction, helmets have transformed into plastic shells with padding designed to mitigate accelerations on the brain. With the growing concern for player safety, regulating bodies, like the National Operating Committee on Standards for Athletic Equipment, have implemented standards for protective equipment, including football helmets. On top of these standards, there have been multiple methods developed to assess helmet performance with different testing apparatuses. Manufacturers are interested in how their helmet performs according to multiple testing methods. This could be costly if they do not have the proper testing equipment that a protocol utilizes. This thesis assesses the interchangeability of different test equipment to reproduce a testing protocol. The desire to perform well in testing standards has driven the improvement of helmet performance and continued design innovation. The second aim of this thesis is to evaluate helmet performance and its relationship with design changes in football helmets manufactured between 1980 and 2018. / Master of Science / When football originated in the 1800s, players wore no protective equipment. Between 1869 and 1905, there were 18 deaths and 159 serious injuries attributed to the sport. Following this, players began to wear protective equipment. The first use of a football helmet was in 1893, made of leather and designed to reduce the risk of skull fracture. Initially, football helmets were intended to protect a player against the most severe hits they would experience on the field. More recently, it has been shown that mild traumatic brain injuries, such as concussions, can induce long-term neurodegenerative processes. Since their introduction, helmets have transformed into plastic shells with padding designed to mitigate accelerations on the brain. With the growing concern for player safety, regulating bodies, like the National Operating Committee on Standards for Athletic Equipment, have implemented standards for protective equipment, including football helmets. On top of these standards, there have been multiple methods developed to assess helmet performance with different testing apparatuses. Manufacturers are interested in how their helmet performs according to multiple testing methods. This could be costly if they do not have the proper testing equipment that a protocol utilizes. This thesis assesses the interchangeability of different test equipment to reproduce a testing protocol. The desire to perform well in testing standards has driven the improvement of helmet performance and continued design innovation. Another aim of this thesis is to evaluate helmet performance and its relationship with design changes in football helmets manufactured between 1980 and 2018.

The research presented in the thesis explores the biomechanics of the head and neck during impacts in football. The research related to the head is geared towards advancing the current understanding of the mechanisms of mild traumatic brain injury, specifically by investigating head accelerations experienced by football players during impacts. To do this, a six degree of freedom sensor that could be integrated into existing football helmets and is capable of measuring linear and angular acceleration about each axis of the head was developed and validated. This sensor was then installed in the helmets of 10 Virginia Tech football players and data was recorded for every game and practice during the 2007 football season. A total 1712 impacts were recorded, creating a large and unbiased dataset. No instrumented player sustained a concussion during the 2007 season. From 2007 head acceleration dataset, 24 of the most severe impacts were modeled using a finite element head model, SIMon (Simulated Injury Monitor). Besides looking at head acceleration, the force transmitted to the mandible by chin straps in football helmets was investigated through impact testing. Little research has been conducted looking at the mandible-chin strap interface in the helmet, and this may be an area of helmet design that can be improved. The research presented in this thesis related to the neck is based on stingers. Football players wear neck collars to prevent stingers; however, their designs are largely based on empirical data, with little biomechanical testing. The load limiting capabilities of various neck collars were investigated through dynamic impact testing with anthropomorphic test devices. It was found that reductions in loads correlate with the degree to which each collar restricted motion of the head and neck. To investigate the differences in results that using different anthropomorphic test devices may present, the matched neck collar tests were performed with the Hybrid III and THOR-NT 50th percentile male dummies. The dummies exhibited the same trends, in that either a load was reduced or increased; however, each load was affected to a different degree. / Master of Science