VSCC Quarterly Newsletter Spring 2022
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| Vanderbilt Sports Concussion Center
Vanderbilt Sports Concussion Research
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Quarterly Lecture Series
Our next lecture series will occur on Tuesday, April 12th, 2022, at 5:30pm EST. Click the sign-up button above to register! For information, click here.
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Patient Spotlight
Featuring an equestrian athlete's recovery process following a sports related concussion.
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Student Spotlight
Our student spotlight highlights third year medical student, Jackson Allen.
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Thank you for tuning in to our quarterly Vanderbilt Sports Concussion Center (VSCC) Newsletter! From all four Co-Directors – Scott Zuckerman (neurosurgeon), Doug Terry (neuropsychologist), Andrew Gregory (pediatric sports medicine), and Katie Gifford (neuropsychologist) – we are delighted to share our quarterly updates. We have continued to expand the clinic services to additional neurology providers to help with post-concussion headache management. We are also working to start a variety of new research initiatives involving technological devices to help diagnose concussion and track recovery in high school and collegiate athletes, in addition to examining the overall brain health of adults who have played contact sports in their youth. We have attained funding for two students to embark on prospective studies for V-SCoRe on various aspects of concussion recovery. In addition, we will have our second lecture Vanderbilt Talks About Sports Concussion (V-TASC) next week on 4/12/2022. Lastly, we have hired a new VSCC Coordinator, Garrett Perry, MA, ATC, to replace Tim Lee as he ascends in the Sports Medicine Department. As always, feel free to reach out to any of us directly, and we thank you for your continued support of VSCC.
Best,
VSCC Co-Directors
Scott Zuckerman
Doug Terry
Andrew Gregory
Katie Gifford
VSCC Coordinator
Tim Lee
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For some people, recovery from sport-related concussions is not a straightforward process. The VSCC providers specialize in providing excellent care to athletes that may be recovering from more complex injuries. We chose to highlight a 12-year-old equestrian athlete who had a successful recovery despite enduring persistent and prolonged symptoms from her concussion. (All names altered).
In January 2021, Sara was riding her horse when the horse got excited and bucked her off. Sara fell forward over the neck of the horse and hit the front of her head on the ground. Although she was wearing a helmet during the incident, she developed immediate headache, confusion, and memory issues and was later taken to the emergency department for evaluation. A computed tomography (CT) scan of her head was normal, and she was diagnosed with concussion. A month later, Sara continued to have persistent symptoms and had difficulty returning to school, which led her and her family to schedule their first appointment with VSCC. Sara was evaluated by neuropsychologist Dr. Katie Gifford, who determined that the best course of action involved a referral to neurology for evaluation and management of her headaches as well as physical therapy (PT) to help with vestibular and ocular issues.
Over the next month, neurologist Dr. Emma Carter helped manage Sara’s persistent headaches with supplements and medications, while physical therapist Dr. Adam Meidinger challenged her with vestibular and oculomotor rehabilitation techniques. These exercises, which involved practicing smooth pursuits and saccades, helped Sara read and focus without pain or strain. Sara’s headaches and other symptoms were improving when she followed up with Dr. Gifford at the beginning of March 2021, now 3 months after her injury, although some triggers continued to exacerbate her symptoms. At this point, Sara was able to perform light activities without worsening symptoms and began helping around the stables again. By the end of April 2021, she was discharged from PT and had a complete resolution of exertional, visual, and vestibular symptoms. By the beginning of June, her headaches were resolving, and she started the new school year in August without difficulty. Since then, Sara has returned to her equestrian sports and is feeling much better.
Recovery from concussions can look different for each patient. Although most concussions recover within 1-2 weeks, some patients need specialty treatments to return to the sport they love. We are impressed with the work that Sara has put into her recovery, and we are excited to see the strides she will make as an equestrian athlete.
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Common Issues in Sport Concussion Care
with Dr. Warne Fitch
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Concussion practices have evolved over the years to ensure athlete safety remains a top priority. While recent literatures outline these changes well, discussing the ever-changing scene of sports concussion care with a sports medicine physician can provide information that research articles cannot. Recently our team had the pleasure of interviewing Dr. Warne Fitch, MD, the Head Team Physician for Vanderbilt Athletics, about the common issues, misconceptions, and changes in concussion care.
Dr. Fitch attended college (Bachelor’s in exercise science) and medical school at Wake Forest University. During this time, he worked as an EMT and drove an ambulance in Winston-Salem. Between medical school and being an EMT, he discovered his interest in being a front-line healthcare provider, so he completed his residency in Emergency Medicine at Vanderbilt University Medical Center from 2001-2004. During his residency, Dr. Fitch also became interested in orthopedics and sports medicine. With his interests and skill set, Dr. Fitch was able to complete a fellowship in Primary Care Sports Medicine at Vanderbilt and has been here ever since. The idea of working the sidelines and being in academics was intriguing to Dr. Fitch. He has now dedicated over 20 years of time to Vanderbilt Athletics and has served as the Head Team Physician since 2015.
Over the course of his career, Dr. Fitch has noticed several changes to concussion care including the dissolution of grading concussion severity, an increase in knowledge of coaches, and a better understanding of concussion recovery.
He noted that research has allowed him to recognize the importance of education as it relates to concussions, and how these educational efforts have been pivotal for coaches in addition to medical staff and scientists. Dr. Fitch discussed that, over the years, coaches’ knowledge and awareness of concussions has increased, which has led to less stigma around having an athlete complete a concussion assessment and better concussion management.
Misconceptions like “all concussions involve being knocked out” and the idea that athletes could return to play on the same day are no longer present. Most athletic programs have since implemented education sessions prior to the start of the sport season to ensure that all personnel, coaches, and athletes are on the same page.
Dr. Fitch: “As concussion care has taken off in the last 20 years, education has been a key component.”
SIDELINE CARE
Q: “What do you think is the most important ingredient or skill set in a sideline physician?”
Dr. Fitch: “I think communication and teamwork. I always say that one of my greatest strengths as an ER doc is not really what I know, it’s who I know. When coordinating care, there are certain injuries that I may be able to care for myself but there are many injuries that may be better managed by other expert providers.”
Teamwork for those manning a sideline is key in providing comprehensive concussion care. Dr. Fitch remembers a time when there was just a small group of sideline staff covering a few games, and how coverage now extends to so many more teams and games.
Dr. Fitch: “The demands of athletes have grown over the years and what we can offer them has grown as well.”
A multidisciplinary team of providers working towards the same goal is imperative to athlete safety. Providers such as neurologists, neuropsychologists, physical therapists, and many more have started working cohesively to aid in concussion management. Dr. Fitch is especially interested in continuing to foster the relationships between EMTs and ATCs in order to provide more seamless emergency care for athletes on the sidelines.
Dr. Fitch: “You just have to be willing to work together and learn things outside your wheelhouse.”
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| CHALLENGES
Dr. Fitch explains a few challenges associated with concussion monitoring and why education and future research are imperative.
Dr. Fitch: “The challenge acutely is having the athlete speak to the fact that they aren’t feeling normal because unfortunately, there is still so much of the initial evaluation and diagnosis that relies on someone coming up and saying they don’t feel right.”
Concussion diagnosis can be difficult, due to providers inability to see the injury. Dr. Fitch makes the point that other injuries, such as ankle sprains, can be seen to others, but this is not the case with concussions. In addition, concussion symptoms can manifest at varying times after the initial injury which can be confusing for athletes and further complicate diagnosis.
Dr. Fitch: “Sometimes these things aren’t immediate. You might have an athlete who sustains a hard hit, but they don’t have any symptoms and they do very well on your sideline exam. Then, after the game or the next day, they get a headache or don’t feel well”
The inability to see concussive injuries, as well as the individualized way in which they present, can make them complex injuries to monitor and evaluate.
RETURN TO SPORT/LEARN
Dr. Fitch: “How do you know it’s safe? That’s always been a challenge.”
Returning an athlete to play or school following a concussion can be just as difficult as diagnosing the injury. Dr. Fitch mentions that athletes can often return to sport from other injuries without feeling 100%, and still play effectively. Concussions differ in that complete recovery is a necessary requirement to return to play. Athletes should be able to complete mental and physical stresses with no reoccurring symptoms before returning to play.
Dr. Fitch: “From an academic standpoint, we know that going back to the classroom is a challenge for high school and college athletes. We’ve done a great job educating physicians and trainers who are taking care of the athlete. Now we are educating the teachers and coaching staff, and I think educating society is next.”
Returning to school can be a challenge for many athletes. The mental strain associated with classes and studying can worsen symptoms, making temporary classroom accommodations helpful during the recovery process. Allowing students to reduce screen time, participate in half days, reduced homework load, and have extensions on assignments can go a long way in mitigating unnecessary symptom exacerbation and helping a student be successful in the classroom despite having a concussion. Educating parents, teachers, and administrators on the potential for academic issues when recovering from a concussion could be helpful in successfully returning athletes to the classroom.
FUTURE RESEARCH
Q: “What do you feel is the most understudied aspect of concussions?”
Dr. Fitch: “We’ve come a long way with recovering athletes, obviously rest and time are the best treatment options, but trying to identify early on people who may benefit from vestibular/oculomotor rehab or headache management.”
Investigating potential interventions for those with concussions could allow for a more efficient recovery. Many athletes with persistent symptoms do not start specialty therapy for several days or weeks after injury. Identifying those that may benefit from early interventions could help rehabilitate the athlete effectively and efficiently.
The information we have regarding concussions has come a long way over the years, but there will always be room for more research. We are thankful to Dr. Fitch for his support in our continued research efforts and the time and energy he has put into keeping Vanderbilt athletes on the field.
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Athletic Trainer Spotlight: Justin Wenzel
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Justin Wenzel is the Assistant Director for Athletic Training Services and Rehabilitation Coordinator at Vanderbilt University Medical Center. Justin joined the Vanderbilt Sports Medicine staff in 2005 and has worked primarily with the Football team. During his time at Vanderbilt, Justin has worked tirelessly to care for VU athletes and recognizes the importance of Vanderbilt Sports Concussion Center (VSCC) research to further improve our knowledge of sport-related concussion.
Justin completed his undergraduate degree in Athletic Training at Grand Valley State in Michigan followed by his Master of Arts at Furman University in South Carolina. Justin worked at Furman for two years after getting his master’s and then joined the certified athletic training staff at Vanderbilt. In his first few years at VU, Justin worked closely with colleague Kerry Wilbar (featured in our last issue) to help with the management of concussion injuries and bridge the gap between VU athletics and the VSCC. Justin has recently transitioned into a Rehabilitation Coordinator role in which he focuses on the recovery of long-term musculoskeletal injuries. Justin has contributed countless hours to VU athletics, and we were honored for our own Kristen Neitz (KN) to have had the opportunity to sit down and hear about his vast experience treating VU athletes on the frontlines.
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| Fun facts:
-Married with 2 kids who are both heavily involved in sports. A 10-year-old daughter who plays soccer and dances and 8-year-old son who currently plays baseball, hockey, football, and basketball.
-Enjoys hiking with his family and exploring the outdoors.
-His favorite hiking experiences include the Narrows of the Harpeth and Mount Laconte in the Smoky Mountains.
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KN: How has concussion care evolved over the years?
JW: “I think the introduction and evolution of the stepwise return-to-play progression, which is in place to protect the student athlete has been huge for this field. A lot of times, successful returning to sport is about collaboration and checks-and-balances between the trainer and the athlete, where we tell the athlete something like ‘if you’re going to fail, we want you to fail with us.’ We want to know before we put an athlete back in the game or practice that you’re truly good to go. The emphasis of the gradual progression has certainly made things safer for our athletes.”
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| KN: If you can choose 3 words to describe your approach to athletic training and caring for athletes with concussion, what would they be?
JW: “Effective diagnosis on the front end, being able to go through everything you need to go through from red flags, to their mental status, to make the diagnosis. Patience, because you never know how long it’s going to take for someone to clear. Challenge, I like to challenge the athlete to make sure they are being completely honest and show us that they are ready to get back. It doesn’t matter if it’s going through the concussion protocol, ACL protocol, or even an ankle sprain, you need to show me you’re ready to return because we know that for people that aren’t ready to go back out there, returning too early sets them up for reinjury or a repeat concussion.”
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KN: What is one thing about caring for sport-related concussions in athletes you would like the public to know?
JW: “Everybody thinks it’s that big hit that causes a concussion, but that’s not always the case. Sometimes it’s the smaller little hit that causes that change in that specific athlete’s brain. It’s not the size of the hit that matters but being able to recognize the signs and symptoms of a concussion.”
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| KN: What is a common question you are asked about sports concussion?
JW: “People always ask ‘are you going to let your son play football?’ Yeah, as long as he’s doing things the right way and the coaches are teaching proper technique, I’m not going to keep him from it.”
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We would like to congratulate one of our medical students, Jackson Allen, on being an Abstract Finalist at the 40th Annual Research Forum at Vanderbilt University!
Jackson's abstract 'Predicting Recovery from Sport-Related Concussion Using Decision Tree Analysis' analyzes VSCC patient data to characterize who is going to recover from concussions in less than 2 weeks vs greater than 4 weeks. The variables that were most important in predicting a longer recovery were initial symptom severity score, how long it took patients to present to our clinic, and prior concussion history,
Congratulations, Jackson!
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We are excited to announce that Meharry medical student, Carter Burns, will be joining us this summer for an 8-week intensive research experience. He is a part of the Sixth Annual Class of the Vanderbilt-Meharry James Puckette Carter Summer Scholarship Program. Carter will be examining mental health and academic difficulties following concussion in patients seen in our clinic.
Congratulations, Carter! We are excited to see the work you will accomplish!
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Student Spotlight: Jackson Allen
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Jackson Allen, a third-year medical student at Vanderbilt University, is a valuable member of the V-SCoRe research team. Jackson joined the team last year while completing his Research Immersion project. Jackson was drawn to V-SCoRe, and head injury research in general, after seeing how directly our clinical research projects can impact patient care. Jackson plans to pursue a career in neurosurgery and is excited to be a part of such a broad field that continues to innovate and push boundaries. Our own Kristen Neitz (KN) sat down with Jackson to learn more about him and hear about his experiences with V-SCoRe.
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KN: How has V-SCoRe impacted your medical education?
JA: “I’ve been so fortunate to find an interdisciplinary group like V-SCoRe, which incorporates investigators of all different levels and backgrounds in clinical work and research. I’ve enjoyed working one-on-one with my research mentors, but the chance to talk with and learn from all these different people and perspectives has helped me grow so much in medical school. V-SCoRe provided a collegial, collaborative atmosphere around research that is really unique in such a fast-paced and busy field.”
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| KN: What is the most valuable lesson you’ve learned so far working with V-SCoRe?
JA: “Seeing the entire process of a research project has given me so many chances to learn—from an idea based on our clinical experience, defining a clear research question, looking at the data, and finally to applying what we’ve learned to our own patients. It is so unique to be able to participate in all parts of that experience in different roles - and working on a project from the beginning really gives me the confidence to talk with others in the field at a deeper level.”
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KN: Can you tell us something you value about working with V-SCoRe?
JA:“I really appreciate the structure of projects within V-SCoRe, and working with Dr. Zuckerman, Dr. Terry, and Dr. Yengo-Kahn. I knew that having these mentors early in my medical school experience would help me learn quickly and develop these skills.”
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| KN: What are a few of the projects you’ve worked on since being a part of V-SCoRe?
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Predicting Early and Late Recovery from Sports-Related Concussion
- Decision Tree Analysis
- Head CT scans in the setting of sport-related concussion: who gets one and does it help?
- Return to Learn Following Concussion: A Systematic Review
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Fun Facts:
From North Carolina.
Predominantly played soccer and golf growing up, but won a few 2A state titles in swimming.
Loves camping and hiking and has visited 18 state parks, from Death Valley to Banff in Canada.
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7 Essential Things to Understand about Chronic Traumatic Encephalopathy (CTE)
By Douglas Terry, Ph.D, and Scott Zuckerman, MD, MPH
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1. We have known about CTE for almost a century, yet research about CTE is in its infancy. CTE has been written about in the scientific community since 1928. It was originally called Punch Drunk1 and was later called traumatic encephalopathy,2 dementia pugilistica,3 and finally, chronic traumatic encephalopathy.4 The original studies were largely in ex-professional boxers. In 1969, Roberts5 published the book Brain Damage in Boxers: A Study of the Prevalence of Traumatic Encephalopathy Among Ex-Professional Boxers, which suggested 11% had mild CTE and 6% had moderate-to-severe CTE. However, there were very few rigorous scientific studies examining CTE before 2012. Most of the CTE research has all taken place in the last 10 years.
2. CTE is a neuropathological diagnosis. It cannot be diagnosed in living individuals. CTE is a neuropathological diagnosis, meaning it is diagnosed by examining brain tissue under a microscope. Until recently, there were no widely accepted or empirically-evaluated diagnostic criteria for CTE. The first consensus criteria for CTE were published in 2016;6 these criteria were changed and revised in 2021.7 We anticipate that there will continue to be updates on the criteria for CTE. Changing the neuropathological criteria is important to keep in mind when interpreting studies on CTE; some brains that were originally thought to have CTE may not be thought to have CTE based on the new criteria. Surprisingly, the fact that CTE can only be diagnosed after death is not known by many in the medical field; a recent survey reported that 108 out of 3,093 former NFL players were told they had CTE by a medical professional (2.8% of the sample).8
3. The clinical manifestation of CTE in living individuals is being called Traumatic Encephalopathy Syndrome (TES), but these criteria are new and evolving also. Since CTE can only be diagnosed after death, researchers have spent time defining the clinical symptoms of how CTE might look in the living. There were no agreed upon clinical features of TES until 2021, which is when the first consensus criteria were published.9 To meet criteria for TES, patients must have substantial exposure to repetitive head impacts and a specific constellation of symptoms that get worse over time without the presence of other disorders. At present, the TES criteria are only for research purposes; they cannot be used to diagnose patients in routine healthcare settings because of how new they are.
4. If someone has the clinical features of TES, it does not necessarily mean that they will have the neuropathological changes of CTE on autopsy. For example, one study examined the connection between a living person’s clinical symptoms and their autopsy results after death. Of those with neuropathological CTE, 97% also had the clinical diagnosis of TES.10 However, 79% of the sample without CTE pathology had clinical signs of TES. This suggests it could be easy to falsely believe or diagnose someone with clinical symptoms as having CTE – even though they do not in fact have the neuropathological features needed to diagnose CTE post-mortem.
5. Features of TES are also common in those who have never had concussions, repetitive head injuries, or played sports. The clinical features of TES are often thought to be related to cognitive changes (e.g., memory/executive functioning) and/or poor control of emotions (e.g., anger, explosiveness, impulsivity, mood swings).9 Research has shown that these symptoms may be common in people without a history of professional sports or contact sports.11,12 One study showed that TES symptoms were common in middle-aged men who had never had a concussion or played contact sports,13 suggesting it may be easy to misdiagnose a person as having TES/CTE based on their symptoms.
6. The connection between “age of first exposure” (AFE) to contact sports and later-life brain health may not be as strong as initially thought. A study in 2015 showed that NFL players who started playing football before age 12 had worse cognitive functioning on two measures of cognition compared to those who started playing at age 12 or older.14 These authors suggested that these findings were due to greater exposure to repetitive head impacts during a developmentally sensitive maturational period. However, several other researchers have expressed concern over these findings, noting methodological issues with the original paper. Since then, many research teams have examined age of first exposure and long-term outcomes. A recent review of all studies on this topic concluded that “the accumulated research to date suggests that earlier AFE to contact/collision sports is not associated with worse cognitive functioning or mental health in (i) current high school athletes, (ii) current collegiate athletes, or (iii) middle-aged men who played high school football. The literature on former NFL players is mixed and does not, at present, clearly support the theory that exposure to tackle football before age 12 is associated with later in life cognitive impairment or mental health problems.”15
7. The most widely quoted studies of CTE are based on professional athletes who have agreed to donate their brains to science. One important methodological issue to keep in mind is that some of the most well-known studies describing CTE draw from professional athletes who were experiencing significant symptoms during their life. Elite athletes comprise a very small portion of our population. It is not surprising that elite athletes have longer athletic careers, experience more head impacts, and these impacts are at higher speeds than those at other athletic levels. While elite athletes are important to study and care for, it may be incorrect to extrapolate findings from this unique sample to the average high school athlete. We are unsure how much the findings of CTE studies conducted in former professional athletes apply to former high school or collegiate athletes. Moreover, conducting a study on athletes who have voluntarily donated their brains to science, for a multitude of reasons, introduces a certain element of bias. Future studies can consider drawing a random sample of prior professional athletes and comparing those results to the voluntary group.
References
1. Martland HS. Punch Drunk. J Am Med Assoc. 1928;91(15):1103. doi:10.1001/jama.1928.02700150029009
2. Parker HL. Traumatic Encephalopathy (`Punch Drunk’) of Professional Pugilists. J Neurol Psychopathol. 1934;15(57):20-28. doi:10.1136/jnnp.s1-15.57.20
3. Millspaugh J. Dementia pugilistica. US Naval Med Bull. 1937;35:297–303.
4. Critchley M. Punch-drunk syndromes: the chronic traumatic encephalopathy of boxers. Published online January 1, 1949.
5. Roberts AH. Brain Damage in Boxers: A Study of the Prevalence of Traumatic Encephalopathy among Ex-Professional Boxers. Pitman Medical & Scientific Pub. Co; 1969.
6. McKee AC, Cairns NJ, Dickson DW, et al. The first NINDS/NIBIB consensus meeting to define neuropathological criteria for the diagnosis of chronic traumatic encephalopathy. Acta Neuropathol. 2016;131(1):75-86. doi:10.1007/s00401-015-1515-z
7. Bieniek KF, Cairns NJ, Crary JF, et al. The Second NINDS/NIBIB Consensus Meeting to Define Neuropathological Criteria for the Diagnosis of Chronic Traumatic Encephalopathy. J Neuropathol Exp Neurol. 2021;80(3):210-219. doi:10.1093/jnen/nlab001
8. Grashow R, Weisskopf MG, Baggish A, et al. Premortem Chronic Traumatic Encephalopathy Diagnoses in Professional Football. Annals of Neurology. 2020;88(1):106-112. doi:10.1002/ana.25747
9. Katz DI, Bernick C, Dodick DW, et al. National Institute of Neurological Disorders and Stroke Consensus Diagnostic Criteria for Traumatic Encephalopathy Syndrome Embracing the Unknown in the Diagnosis of Traumatic Encephalopathy Syndrome. Published online 2021. doi:10.1212/WNL.0000000000011850
10. Mez J, Alosco ML, Daneshvar DH, et al. Validity of the 2014 traumatic encephalopathy syndrome criteria for CTE pathology. Alzheimers Dement. 2021;17(10):1709-1724. doi:10.1002/ALZ.12338
11. Iverson GL, Gardner AJ. Risk of Misdiagnosing Chronic Traumatic Encephalopathy in Men With Depression. J Neuropsychiatry Clin Neurosci. Published online October 7, 2019:appineuropsych19010021. doi:10.1176/appi.neuropsych.19010021
12. Iverson GL, Gardner AJ. Risk for Misdiagnosing Chronic Traumatic Encephalopathy in Men With Anger Control Problems. Frontiers in Neurology. 2020;11. doi:10.3389/fneur.2020.00739
13. Iverson GL, Merz ZC, Terry DP. Examining the Research Criteria for Traumatic Encephalopathy Syndrome in Middle-Aged Men From the General Population Who Played Contact Sports in High School. Frontiers in Neurology. 2021;12:632618. doi:10.3389/fneur.2021.632618
14. Stamm JM, Bourlas AP, Baugh CM, et al. Age of first exposure to football and later-life cognitive impairment in former NFL players. Neurology. 2015;84(11):1114-1120. doi:10.1212/WNL.0000000000001358
15. Iverson GL, Büttner F, Caccese JB. Age of First Exposure to Contact and Collision Sports and Later in Life Brain Health: A Narrative Review. Front Neurol. 2021;12. doi:10.3389/FNEUR.2021.727089
16. Iverson GL, Terry DP. High School Football and Risk for Depression and Suicidality in Adulthood: Findings From a National Longitudinal Study. Frontiers in Neurology. 2022;12:2640. doi:10.3389/FNEUR.2021.812604/BIBTEX
17. Deshpande SK, Hasegawa RB, Rabinowitz AR, et al. Association of Playing High School Football With Cognition and Mental Health Later in Life. JAMA Neurol. 2017;74(8):909-918. doi:10.1001/JAMANEUROL.2017.1317
18. Gaulton TG, Deshpande SK, Small DS, Neuman MD. Observational Study of the Associations of Participation in High School Football With Self-Rated Health, Obesity, and Pain in Adulthood. Am J Epidemiol. 2020;189(6):592-601. doi:10.1093/AJE/KWZ260
19. Savica R, Parisi JE, Wold LE, Josephs KA, Ahlskog JE. High school football and risk of neurodegeneration: a community-based study. Mayo Clin Proc. 2012;87(4):335-340. doi:10.1016/J.MAYOCP.2011.12.016
20. Janssen PHH, Mandrekar J, Mielke MM, et al. High School Football and Late-Life Risk of Neurodegenerative Syndromes, 1956-1970. Mayo Clin Proc. 2017;92(1):66-71. doi:10.1016/J.MAYOCP.2016.09.004
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Summer 2022!
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If you have any questions about the VSCC Quarterly Newsletter, please reach out vscc@vumc.org
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