Mild head injury or concussion accounts for as many as 90% of all traumatic brain injuries and can sometime result in long-lasting and disabling post-concussion symptoms (PCS), even in the absence of detectable structural damage to the brain by morphological imaging. To date, the nature of persistent PCS following mild head injury remains poorly understood as objective and scientifically valid diagnostic tools are practically absent. This, in turn, likely accounts for missed diagnoses, prevents accurate assessment of the severity of the injury and creates difficulties for achieving proper patient management. / This dissertation describes 4 functional magnetic resonance imaging (fMRI) studies designed to establish whether there is a pathological basis to persistent PCS following cerebral concussion in male athletes. Study 1 was intended to evaluate the feasibility of using fMRI to detect changes in brain activation following concussion. The results showed that concussed athletes displayed reduced prefrontal activities compared to a healthy control group when performing a working memory task. In Study 2, we examined the relationship between self-reported PCS and the pattern of brain activity measured by fMRI. The severity of self-reported PCS was found to be associated with blood oxygen level dependent (BOLD) activation patterns in the region of interest: the higher the PCS score the lower the BOLD signal. In Study 3, we used serial fMRI approach to investigate brain activation pattern in the course of injury recovery. The results showed that symptom resolution was accompanied by a return to normal BOLD response patterns. Study 4 was designed to investigate the nature of depression, a common PCS, following concussion. Concussed athletes with depression showed less activation in the dorsolateral prefrontal cortex, and attenuated deactivation in the medial prefrontal region, consistent with functional neuroimaging findings in major depression. Again, depression severity correlated with the strength of the fMRI signal in the region of interests. / Taken together, these results demonstrate the value of functional MRI in the evaluation of cerebral concussion, and provide evidence of an underlying pathology in persistent PCS following concussion.

L’âge, le génotype et les traumatismes crâniens (TCC) sont trois facteurs de risque majeurs du développement de la maladie d’Alzheimer (MA). Avec une accumulation d’évidences démontrant la persistance d’anomalies cérébrales suite aux plus légers des TCC, qui affichent d’ailleurs la plus haute incidence, il devient impératif de tester l’hypothèse selon laquelle même les commotions cérébrales puissent interagir avec l’âge et les gènes afin de précipiter la neurodégénération. Trente ex-athlètes de haut niveau (âge M = 60 ans), dont la moitié a subi des commotions cérébrales il y a plus de 30 ans, ont été évalués en neuropsychologie, en neuroimagerie multimodale ainsi qu’en génétique. De nombreuses mesures neuroanatomiques, dont l’expansion du volume des ventricules latéraux, se trouvent à corréler avec divers déficits cognitifs (mémoire différée et de reconnaissance) détectés chez les participants commotionnés. D’un intérêt particulier, certains de ces résultats sont modulés par le polymorphisme nucléotidique simple du gène Apolipoprotéine E. Ces résultats appuient l’hypothèse selon laquelle la commotion cérébrale chez de jeunes athlètes serait un facteur de risque de neurodégénération dans le vieillissement normal. / Age, genotype and traumatic brain injury (TBI) are three of the most important risk factors of Alzheimer’s Disease. With a growing body of evidence showing the persistent deleterious effects of the mildest form of TBI, it becomes imperative to test the hypothesis that sports concussion could interact with aging to precipitate neurodegeneration. Thirty former high-level athletes (mean age = 60 yrs), half of them having sustained sports concussion during their young adulthood, underwent neuropsychological, neuroanatomical and APOE genotype examination. Data analysis revealed numerous neurobiological anomalies, such as ventricular enlargement, correlating with cognitive deficits (delayed and recognition memory) in concussed participants. Of particular interest, some neuroanatomical measures were found to be modulated by APOE single-nucleotide polymorphisms. These findings support the idea that sports concussions sustained in early adulthood are a risk factor of neurodegeneration in late adulthood.

Introduction: Concussions are a physiologically & psychologically stressful event. Stress markers may provide insight into concussion recovery, but have not been examined. Purpose & Method: To investigate the stress response of concussed athletes compared to controls from injury to post-RTP. Concussed athletes’ Mood states, Perceived Stress, HRV, and Morning & Afternoon Cortisol were assessed at 3 phases of recovery following concussion. Results: Repeated measures ANOVA revealed significant interactions for TMD, Depression, Anger, Confusion, Fatigue, HF norm (rest), LF norm (rest), HF norm (difference between sitting & standing), LF norm (difference between sitting & standing), and LF/HF ratio (difference between sitting & standing). Vigor & Tension demonstrated significant changes over time in the concussed group. Significant difference between the two groups for morning Cortisol levels at phase 3 was revealed. Conclusion: Concussed athletes display elevated levels of stress post-injury. Findings warrant further investigation of stress markers in concussed athletes during recovery.

Introduction: Concussions are a physiologically & psychologically stressful event. Stress markers may provide insight into concussion recovery, but have not been examined. Purpose & Method: To investigate the stress response of concussed athletes compared to controls from injury to post-RTP. Concussed athletes’ Mood states, Perceived Stress, HRV, and Morning & Afternoon Cortisol were assessed at 3 phases of recovery following concussion. Results: Repeated measures ANOVA revealed significant interactions for TMD, Depression, Anger, Confusion, Fatigue, HF norm (rest), LF norm (rest), HF norm (difference between sitting & standing), LF norm (difference between sitting & standing), and LF/HF ratio (difference between sitting & standing). Vigor & Tension demonstrated significant changes over time in the concussed group. Significant difference between the two groups for morning Cortisol levels at phase 3 was revealed. Conclusion: Concussed athletes display elevated levels of stress post-injury. Findings warrant further investigation of stress markers in concussed athletes during recovery.

Introduction-Physical activity can reduce the risk of contracting many of the 'diseases of the sedentary', such as coronary heart disease and cancer (Blair et al., 1996). Recognition of this protective effect has led to the development of many programmes designed to promote the benefit of participation in sport and physical exercise (Hillary Commission, 1993; Nicholl et aI., 1995). With participation in sport, especially contact sport, the risk for injuries increases, including injuries to the head and neck (Wilberger, 1993; Wekesa et al., 1996; Pettersen, 2002). Mild traumatic brain injuries (MTBI) or concussion as used interchangeably in the literature (Maroon et al., 2000; Wills & Leathem, 2001) are an important public health concern, due to the high incidence and frequently persisting symptomatology (Evans, 1992). Mild traumatic brain injury is defined as a complex patho-physiological process affecting the brain induced by traumatic biomechanical forces (Aubry et al., 2002; McCrory et al., 2004). A sub-concussive injury or very mild traumatic brain injury (vMTBI) may be defined as an apparent brain insult with insufficient force to cause hallmark symptoms of concussion (Jordan, 2000; Webbe & Bath, 2003). The high incidence of sport related head injuries in South Africa is alarming, although the prevalence thereof is unknown and difficult to assess, as the seemingly trivial injuries frequently remain unreported (Roux et al., 1987). This is especially applicable in sport where a milder form of head injury is common. This is cause for concern as cumulative head injuries traditionally regarded as trivial or 'minor' may result in players running the risk of increasingly negative consequences following repetitive 'minor' head injuries. In contact sport such as rugby, players are at great risk of sustaining repetitive mild traumatic brain injuries. The negative outcome following these repetitive minor head injuries has been demonstrated by numerous studies on boxers and other athletes exposed to repeated MTBI and vMTBI (McLatchie et aI., 1987). The incidence of vMTBI has not yet been researched in school rugby and this study is the first to report the incidence of vMTBI in a secondary school rugby team. Obiectives - The objectives of this study were to determine the incidence, the neuropsychological consequences and the effect on the academic performance of repeated mild (MTBI) and very mild traumatic brain injuries (vMTBI) in a secondary school rugby team during one playing season. Methods - A cohort of 35 secondary school male rugby players divided into a vMTBI (group 1) (n=26) and a MTBI (group 2) (n=9) from a local secondary school's first and second team, was followed for a full competitive season by a trained Biokineticist, who was present at all the games and contact sessions played. All vMTBI and MTBI and the severity of these injuries were documented. A control (group 3) that consisted of 10 secondary school non-rugby players were compared with the vMTBI and MTBI groups. The incidence of repeated MTBI and vMTBI in a secondary school rugby team were gathered by questionnaires and observation next to the field by a trained Biokineticist. Pre-season and post-season neuropsychological tests were conducted on the research groups and the control group. The neuropsychological tests that were conducted on the three groups were the Colour Trial Test 1 and 2 (CTT 1 + 2), the Symbol Digit Modalities Test (SDMT), the Wechsler Memory Scale-Revised (WMS-R) and the Standardised Assessment of Concussion (SAC). After each match played throughout the season the research group also completed a SAC test. The academic results of the final examination (year 1) of the year of the specific rugby season were obtained, as well as the academic results of the final examination of the preceding two years (year 2 and 3). The programme STATISTICA (version 7.0, Stat soft, Tulsa, OK) was used to analyse the data. Descriptive statistics, one-way ANOVA's, two-way repeated measures ANOVA's, Post-hoc Tuckey HSD analysis and Pearson's product moment correlation were used for all the statistical analyses. Results - This study of a secondary school rugby team has shown 726 vMTBI's and 18 MTBI's throughout one rugby season. This relates to 1951 vMTBI's per 1000 player hours and 48 MTBI's per 1000 player hours. Reductions in delayed memory (p=O.O1)from preseason to post-season in a group of players with repetitive vMTBI's during a single rugby season were found. This was the first evidence of possible neurocognitive deficits towards delayed memory in very mild traumatic brain injuries at secondary school level. Statistically significant (p<=0.05)results of the SAC test totals between both the vMTBI and MTBI groups were documented in the different games throughout the rugby season and compared with the baseline test. No statistically significant differences (p<=0.05) between the pre-season and post-season's scores of the SAC test totals were documented. A decrease in academic performance in the subject Afrikaans (year 1 compared with year 2) with a p-value of p=O.O17(group 1) and p=O.O16(group 2) respectively was found. Conclusion - The findings of this study indicate a high incidence of vMTBI in a cohort of secondary school rugby players in one season, a statistically significant reduction (p=O.O1 )in delayed memory of the vMTBI rugby players and a statistically significant decrease in academic performance p=O.O17 (group 1) and p=O.O16 (group 2) in the subject Afrikaans from year 1 to year 2 final examinations. / Thesis (Ph.D. (Human Movement Science))--North-West University, Potchefstroom Campus, 2006.

Mild Traumatic Brain Injury (mTBI), often called concussion, has become a growing public health concern, prevalent in both athletic and military settings. In response, many researchers have explored cognitive outcomes post-mTBI, with a plethora of meta-analyses summarizing these findings; however, these meta-analyses examine solely mean performances on cognitive tasks, ignoring intra-individual variability (IIV) in cognitive performance that may elucidate neuropsychological impairment following mTBI. The current thesis involved two studies, responding to both the growing meta-analytic research and limited IIV findings. Study 1: Many meta-analyses have amalgamated individual study results on post-mTBI neuropsychological outcomes. With the abundance of meta-analyses, a systematic review of meta-analyses stands as the next logical step. Method: A systematic literature search yielded 11 meta-analyses meeting inclusion criteria (i.e., English-language systematic reviews/meta-analyses covering post-mTBI observational cognitive research on late adolescents/adults), with their findings qualitatively synthesized based on moderator variables (i.e., cognitive domain, time since injury, past head injury, participant characteristics, comparison group, assessment technique, and persistent symptoms). Results: The overall effect sizes ranged for both general (range: .07-.61) and sports-related mTBI (range: .40-.81) and differed both between and within cognitive domains, with executive functions appearing most sensitive to multiple mTBI. Cognitive domains varied in recovery rates, but overall recovery occurred by 90 days post-injury for most individuals and by seven days post-injury for athletes. Greater age/education and male gender produced smaller effects sizes, while high school athletes suffered the largest deficits post-mTBI. Control-group comparisons yielded larger effects than within-person designs, while assessment techniques had limited moderating effects. Conclusions: Overall, meta-analytic review quality remained low with few studies assessing publication or study quality bias. Meta-analyses consistently identified adverse acute mTBI-related effects and fairly rapid symptom resolution. Study 2: The long-term outcomes of executive functions and IIV following mTBI are unclear due to inconsistent and limited research, respectively. Further, the relationship between physical activity (PA) and cognitive performance at young adulthood remains almost fully unexplored. In turn, the current study aimed to (a) assess the diagnostic utility of both executive functions and IIV at predicting mTBI history and (b) evaluate the interaction between PA levels and mTBI on both of these cognitive metrics. Method: Altogether 138 self-identified athletes (Mage = 19.9 ± 1.91 years, 60.8% female, 19.6% 1 mTBI, 18.1% 2+ mTBIs) completed three executive-related cognitive tasks (i.e., N-Back, Go/No-go, Local-Global). Ordinal logistic regression analyses examined the joint effect of person-mean and IIV as predictors of mTBI status. Multi-level models examined mTBI and PA levels as predictors of trial-to-trial changes in performance. Results: Only mean response time (RT) for the Local-Global task predicted mTBI status, while no IIV variables reached unique significance. PA levels predicted subtle within-task decreases in RT across Local-Global trials. Conclusions: IIV research on mTBI remains limited; however, the preliminary results do not indicate any additional predictive value of IIV indices above mean performances. For executive functions, shifting appeared most affected, with past researchers identifying post-mTBI impairment in attentional processing. Higher PA levels minutely benefited within-task shifting and mean inhibitory performance, although these finding require cautious interpretation. / Graduate / 0622 / jkarr@uvic.ca

This thesis investigates head injuries (HIs) occurring in sports and recreation (SR) that presented to emergency departments (EDs) in Edmonton, Alberta, from April 1st, 1997 to March 31st, 2008. There were 4,950 SR HIs identified over the 11 years (5.13 HIs per 1,000 ED injury visits). Individuals less than 18 years old were 3.4 times more likely, and males were 1.25 times more likely to present with a head injury from SR (p < 0.0001). A history of one or two previous SR HIs increased the odds of subsequent HI by 2.62 and 5.94 times, respectively, while children aged 7 13 and 14 17 were more than four times more likely to sustain a HIs from SR (p < 0.001). The effects of multiple HIs occurring in children participating in SR activities needs to be addressed, due to the chronic neurobehavioral effects of HIs. / Epidemiology

Following a head concussion the intracranial pressure increases due to the impact, which cannot be adequately relieved because of the stiffness of the skull. Popular strategies aimed at decompressing the head consist in the administration of osmotic agents and skull removal. The mechanical properties of bone can be affected by the administration of different solutions. If the malleability of skull is influenced by the osmotic agents that are administered to the patient then the pressure and volume in the intracranial cavity can also be modified following the treatment. In this thesis research, we hypothesize that administered osmotic agents can influence the mechanical properties of the skull, which can also impact the volume the cavity can hold and subsequently the pressure in the head. This premise was tested by modifying existing mathematical models compiled through two general MATLAB codes that allow the computation of a non-symbolic differential-algebraic initial value problem. Three main features were changed in comparison to current models: the skull's influence on the pressure and volume modulation was tested (inputs were obtained from skull tested under different solutions); pulsatile flow was accounted for on the creation and movement of cerebrospinal fluid; and the input on the mechanical behavior of the cranial vessels was accounted for through previously published continuum-mechanics vessel-behavior models. To complete the model, materials and mechanical properties were obtained through laboratory experiments as well as data collection from existing literature. From our bone test we were able to conclude that there are different factors that affect the mechanical properties of bone in various degrees. There is a mild statistical correlation (p-value 0.05) between the mechanical properties of bone obtained from different regions of the skull samples (2-14mm) and the DPBS and hDPBS solutions. Additionally there is a strong statistical difference (p-value 0.05) between the mechanical properties obtained from cross head speed (0.02, 0.002, and 0.004 (mm/s)) and solution variation (DI, DPBS and hDPBS). Finally, we were able to see that there seems to be a correlation between the mechanical properties of bone, the solution treatments and hypertension; although more test need to be developed to affirm this premise since our results are preliminary.

Diss. (sammanfattning) Umeå : Univ., 2004. / Härtill 4 uppsatser.

Thesis (Ph. D.)--Cornell University, May, 2007. / Vita. Includes bibliographical references (leaves 162-189).