VSCC Quarterly Newsletter Fall 2022
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| Vanderbilt Sports Concussion Center
Vanderbilt Sports Concussion Research
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The FIFA World Cup and Soccer Related Concussions
By Kristen Williams, MS, LAT, ATC and Tyler Hill, MS, LAT, ATC
We discuss the FIFA World Cup and head injuries among soccer players of all ages and genders.
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| Race Reporting in Concussion Research
An interview with Dr. Jessica Wallace, PhD, and Miya Sullivan, LAT, ATC was conducted to discuss the importance of race reporting in concussion research.
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Providers Spotlight
This issues spotlight features Dr. Andrew Gregory, MD, FAAP, a vital founding member of the VSCC team.
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| Student Spotlight
Our student spotlight highlights second-year Meharry student, Carter Burns, B.S.
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Hello from Amsterdam!
Three of us (Scott Zuckerman, Doug Terry, and Aaron Yengo Kahn) recently traveled to Amsterdam for the 6th International Consensus Conference on Concussion in Sport, where over 500 of the world’s top concussion researchers and treatment providers got together to discuss the research progress in sport-concussion and help to identify next steps. This conference, which typically occurs once every 4 years, will inform how providers across the globe diagnose and treat concussions.
We’re also excited to announce being a site in a multi-center study examining head impacts in collegiate football players. In this study, about 40 Vanderbilt University football players are wearing high-tech mouth guards (pictured below) that have a sensor embedded into it so that we can accurately capture the frequency and magnitude of impacts to the head. This is an exciting new initiative for us. To learn more about the study, check out the resources below.
New Channel 5
NFL Player Health and Safety
We hope you all have a a safe and happy upcoming holiday season!
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Best,
VSCC Co-Directors
Scott Zuckerman
Doug Terry
Andrew Gregory
Katie Gifford
VSCC Coordinator
Garrett Perry
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| NFL Instrumented Mouth guards
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Understanding Patient Diversity in Concussion Care and Research
Interview with Miya Sullivan, LAT, ATC and Dr. Jessica Wallace, PhD
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Diversity and healthcare disparities research has received increased and well-deserved attention over the past several years. When treating sport-related concussions, it is imperative to understand how issues of inclusivity, culture, and resources may lead to differential treatment and patient outcomes. Two of our co-directors, Dr. Scott Zuckerman and Dr. Douglas Terry, conducted an interview with Miya Sullivan, an athletic trainer for the Football team at Vanderbilt University and the Ethnic Diversity Advisory Committee (EDAC) Representative for the state of Tennessee, and Dr. Jessica Wallace, Assistant Professor in the Department of Health Science / Athletic Training Program at The University of Alabama, to discuss the importance of understanding diversity, culture, and race in concussion research. Miya has served as an Athletic Trainer for collegiate sports for 23 years and Dr. Wallace is considered an expert on race and health disparities and has published several manuscripts on sport-related concussion care. Below you will find answers to a few fielded interview questions from our two speakers.
Thank you to both Dr. Jessica Wallace and Miya Sullivan for taking the time to discuss this very important topic with us!
Question (Terry): Why do you think discussing race and ethnicity is important for concussion research?
Wallace: "If you look at our student athlete population, we have an abundance of those who identify as a racial/ethnic minority. If we don't have data that is going to be reflective of what our student athlete population looks like, then it's really hard to determine who needs what and if disparities and inequities exist."
Question (Zuckerman): How might race play a role in the high school versus collegiate level?
Sullivan: "In high school, the community you're in heavily influences the resources that are available. These resources can vary by state, income, and education level. If you lack education and/or resources, then you can't properly screen or protect yourself."
Wallace: "I think a big issue is that high school athletes are more likely to go to school within their community. When you have residential segregation and communities living separately for various reasons, that is also going to often lead to segregated resources resulting from education segregation and funding for scholastic sports. I think that this is a bigger factor at the high school level because that trickles down to questions like: Is there an athletic trainer at the school? How are they delivering the mandated law and concussion education? Who’s referring that person for a concussion? Are the parents involved? Individuals who lack resources are more likely to be from a single parent household and have financial restrictions, making it harder for the parent to take off work to attend a doctor’s appointment or afford transportation. So, you often have a whole trickledown effect at the high school and community level that you don't often see at the collegiate level."
Question (Terry): As clinicians and researchers, what do we think some viable next steps are in the field of examining race and health equity?
Wallace: "I think it boils down to just delivering patient-centered care. Somebody's race is just a component of who they are, right? On the spectrum of different things, we also have to think about each individual patient and what patient A might need might be very different from patient B. Just understanding that for each concussion patient, they are all going to bring something different to the table."
Sullivan: "I would agree, those are all valid and good points and I know a lot has been done in the last five to ten years with getting information disseminated to different communities. I especially think it is important to have guest speakers come in and speak to athletic programs in schools. I think it would be great if we started these educational and community programs at the elementary level in hopes that educating athletes at a younger age may carry over into high school. Having a parent's night for the parents of contact sport athletes - or doing a community outreach even – may be really helpful in changing the way underserved communities think about concussion."
Question (Zuckerman): "As we know, concussions are a very gray, confusing injury…when you have a nebulous injury like that and there’s already distrust in the medical system, do you think patients are more or less likely to report and believe their provider’s diagnosis?"
Wallace: "That's a good question and I don't know if there's a direct answer to that. However, I think that some athletes may be more likely to not report a potential concussion because they think medical providers are going to keep them from playing for a long amount of time – even though early intervention for concussion is often associated with better recovery times. I think it would be great if we can do more at the community level in terms of increasing exposure to education programs at the beginning of the season, making sure we create a safe space for reporting (whether that be to a teammate or to a coach), getting that coaching buy-in to help change the culture around concussions. I think that we will see a complete paradigm shift because it will be working to change the context and normalizing the environment for them to report it."
Question: "What is something you would like to know when it comes to race and concussions?"
Sullivan: "I feel like it would be interesting to know if people from diverse backgrounds report different symptoms and have different recovery times. I’m also curious to know if this changes based on different levels of play.”
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Below you will find three key points from our interview along with some quotes that we felt best summarized the role of diversity and healthcare equity in concussion research and management.
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Resources make a big difference
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"Collegiate care is going to be a little bit more accessible. Collegiate athletes almost have a second mother and father in their athletic training and healthcare staff, who are going to guide them and care for them and make sure they are evaluated and taken care of properly."
-Sullivan
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| Patient centered care is key
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"I think to really give the best patient-centered care, we have to have an understanding of how different things look within research and data to make sure everybody's getting equitable resources to be healthy and safe."
-Wallace
"You don't want to look at race as a negative medical marker or using that as a proxy but looking at humans as a whole and looking to see what we can do to prevent and how we can help them recover quicker from concussions."
-Sullivan
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| Pre-season education could go a long way in facilitating proper care
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“I created a game called Concussion Bingo, so it’s game-based learning. We play Concussion Bingo at the beginning of the year to learn about all the different signs and symptoms of concussion. For example, “nausea” - when looking at health literacy, there are a lot of 15-year-old kids that don’t know what nausea means. So, we go over all these signs and symptoms in a bingo game, we have lots of videos and pictures and we talk about all of these things.”
-Wallace
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Provider Spotlight: Andrew Gregory, MD, FAAP
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Dr. Andrew Gregory is a Pediatric Sports Medicine provider in the Department of Orthopedics at Vanderbilt University Medical Center. Dr. Gregory is from Huntsville, AL and completed his medical training at University of Alabama at Birmingham (UAB). While at UAB he completed an away rotation at Vanderbilt Sports Medicine with Dr. Paul Stricker. Following his fellowship, he decided to join the team at Vanderbilt in 2011 because of his familiarity with the group as well as their excellent athletic care model.
Dr. Gregory is a founding member of the Vanderbilt Sports Concussion Center along with Dr. Allen K. Sills (neurosurgeon) and Dr. Gary Solomon (neuropsychologist). Our founding members spent countless hours making the VSCC what it is today and continue to show their support. Dr. Gregory is still active in both the clinical and research efforts and we are extremely grateful for his dedication and hard work.
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KW: If you could choose 3 words to describe your approach to athletic training and caring for athletes with concussion, what would they be?
Dr. Gregory: "Practical, definitive, and collaborative.
Practical- giving simple advice on what you should do and not do to recover.
Definitive- providing a solid diagnosis that a concussion occurred and what risks may occur moving forward.
Collaborative- working with athletic trainers, nurse practitioners, rehab specialists and other subspecialists to provide the best care for young athletes."
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KW: What is one thing about caring for sport-related concussions in athletes you would like the public to know?
Dr. Gregory: "Simply that light activity after 1-2 days of rest is good for your recovery."
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KW: As a founding member of VSCC how have you seen the VSCC change and where do you see us going in the future?
Dr. Gregory: "There's certainly been a big change in leadership with young energetic researchers coming on board. They have already increased the number of collaborations within the medical center and the number of ongoing research projects. The future is bright and I see us establishing ourselves as a recognized sports concussion research center."
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KW: As the head Team Physician for the Nashville Soccer Club how have you seen concussion care evolve?
Dr. Gregory: "Major League Soccer (MLS) has a spotter system which is very helpful to determine mechanism of injury and see if there are any red flag signs immediately after."
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Fun Facts:
- Enjoys fishing, hiking, volleyball, playing the guitar and reading.
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Married to Vicky Phillips who is a pediatrician at Old Harding Pediatrics. Has a daughter, Sarah, who is in PT school at Belmont University and a young son, Charlie, who just started daycare at Vanderbilt.
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This year marks the 6th International Consensus Conference on Concussion in Sport Group(CISG) which took place in Amsterdam, October 27th and 28th. We are pleased to announce that the VSCC presented a total of 10 abstracts at the conference this year! The following abstracts with primary author listed, were presented:
Predicting Duration of Recovery from Sport-Related Concussion Using Decision Tree Analysis
Jackson H. Allen, BA
Setting or Presentation Predicts Use of Acute HCT in Pediatric Sport-Related Concussion
Jackson H. Allen, BA
Risk of Same-Season Repeat Sport-Related Concussion Among Adolescent Athletes
Kristen L. Williams, MS, LAT, ATC
Acute Cognitive Symptom Cluster Predicts Return-to-Learn Duration Following Spot-Related Concussion
Alan R. Tang, BA
Racial Differences in Sport-Related Concussion Clinical Recovery Appear Mediated by Initial Symptom Burden and Moderated by Concussion History
Alan R. Tang, BA
Symptom Resolution Following an Initial and Repeat Concussion: A Within-Subjects Analysis
Alan R. Tang, BA
The Cost of Concussion in Adolescent Athletes: A Retrospective Cohort Study
Alan R. Tang, BA
Generating Novel Hypotheses in Pediatric Post-Concussion Syndrome Utilizing a Phenome-Wide Association Study
Aaron M. Yengo-Kahn, MD
Simple Interventions Improve Discharge Readiness from the Emergency Department After Pediatric Sport-Related Concussion
Aaron M. Yengo-Kahn, MD
Symptoms of Traumatic Encephalopathy Syndrome in Community-Dwelling Older Adults
Douglas P. Terry, PhD
Congratulations to all of our presenters!!!
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| Pictured are a few of our VSCC Co-Directors at the CISG Conference.
(Left to Right: Dr. Aaron Yengo-Kahn, Dr. Douglas Terry, Dr. Scott Zuckerman)
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Student Spotlight: Carter Burns, B.S.
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Carter Burns, a second-year medical student at Meharry Medical College, has dedicated countless hours to the V-SCoRe research efforts. Carter has been working with V-SCoRe for a little over a year and has a passion for concussion research. Growing up, Carter had his own experiences with concussion when he was injured while playing football. Carter plans to pursue a career in Neurosurgery and hopes that his research efforts will add to the field of concussion recovery.
This summer, Carter was granted the opportunity to be a part of the Vanderbilt-Meharry James Puckette Carter Summer Scholarship program and was able to spend 8 weeks devoting his time and efforts into research with V-SCoRe. The project he completed during the summer program recently earned 3rd place in Meharry's 2022 Student Research Day. Congratulations, Carter! Our own Kristen Williams (KW) sat down with Carter to learn more about his experiences with V-SCoRe.
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KW: What is the most valuable lesson you’ve learned so far working with V-SCoRe?
Burns: "The most valuable thing I have learned so far is the importance of teamwork. Working on a project form the very start is challenging and having the team working with me has made me a better student and researcher."
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KW: What was some of the projects you've assisting with while working with V-SCoRe?
Burns: "I've primarily worked on a systematic review looking at reporting race and ethnicity in concussion literature as well as a study evaluating the subclinical signs of emotional disturbance following a sport-related concussion."
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KW: Can you tell me about your experience working with V-SCoRe this past summer?
Burns: "Through working with V-SCoRe this summer, I have grown as a professional. My writing, organization, and presenting skills have improved greatly. Overall, I had a wonderful experience this summer and learned valuable skills on my journey to become a physician researcher."
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| KW: Why did you want to get involved with V-SCoRe?
Burns: "I initially wanted to work with V-SCoRe to help improve sport-related concussion outcomes and for the amazing mentorship available. Growing up playing football I was personally impacted by concussion and know the struggles it can cause."
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KW: How has V-SCoRe impacted your medical education?
Burns: "Through working with V-SCoRe I have been able to grow as a professional. I've improved in my writing, organization, and presenting skills. I have valued collaborating with colleagues from many different specialties."
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Fun Facts:
From West Point, MS
Played football, soccer, and ran track
Enjoys being outside, exercising, and wake boarding. Likes to spend time with his family, his girlfriend Lexy, and dog Doc.
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Concussion Injuries in Soccer: A FIFA World Cup Perspective
By Kristen Williams and Tyler Hill
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Whether a soccer fan or not, most have heard of the FIFA World Cup. Every four years an international soccer tournament takes place with men’s national teams from around the world battling to take the win. The World Cup is watched by millions of people and is a great source of entertainment. In addition, it is essential for these elite athletes to practice and play with proper technique - especially heading technique - to prevent injuries. With higher levels of competition comes the need for higher levels of injury prevention. Following lower extremity injuries, head/neck injuries were the second most frequently reported injuries in 2010 and 2014 with 10.4% and 18.3% of all injuries occurring to that region.1 In 2014, 94.7% of head injuries were caused by a contact with another player and 5 of the 19 injuries were classified as foul play1.
One skill that makes soccer unique is the strategy of heading the ball. In fact, soccer is the only sport where players aim to control the ball using their head. In recent years, an increase in public awareness surrounding head impacts has many questioning whether heading the ball is dangerous, asking questions such as “Does heading the ball cause concussions?”, “Does a career of heading the ball have long term effects on the athlete?” A systematic review in 2016 suggested that there was no evidence that heading in youth soccer can cause concussions, but the study also emphasized the importance of proper technique when heading the soccer ball.2
Injury prevention strategies have been adopted to minimize risk of concussion and have become increasingly popular throughout the world. Maintaining proper head-neck-torso alignment when heading can be beneficial in decreasing injury risk. Other techniques such as exaggerated follow through after making impact, avoiding unnecessary impacts, and increasing neck flexor and extensor strength can also help in minimizing injury3. Aside from proper technique, protective equipment often called “concussion headgear” may assist in lowering a player’s risk of concussion. Equipment including the Exoshield Head Guard, Gamebreaker Pro, Don Joy Hat Trick, and Unequal Halo are a mix of headband and helmet type devices that may serve useful in lowering concussion risk. Headgear equipment is often made with a foam layer that works to absorb some of the impact from the ball. Conflicting research exists on the effectiveness of soccer headgear in mitigating concussions but may give players a sense of security and protection while playing.4,5
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Injury rates in FIFA World Cups have been stable since 1998,6 in part because of the notable work from team physicians and coaches. This year, FIFA will be implementing the use of concussion spotters in the stands whose primary job is to identify possible brain injuries. Spotters are being implemented after concussion specific management strategies were placed for the 2014 FIFA World Cup stating that:
“Whenever a suspected incident of concussion occurs, the referee will have the ability to stop the game for three minutes, allowing the relevant team doctor to complete an on-pitch assessment and decide if the player has suspected concussion. The referee will only allow the injured party to continue playing with the authorization of the team doctor, who will have the final decision”7
Proper on field management of concussions is crucial in recognition and proper treatment to avoid further injury. These management strategies come straight from the 2016 Consensus Statement on Sport Concussion which is standard practice across all levels of play. Whether at the World Cup level or youth sports, it is important that all parents, coaches, and providers keep in mind proper playing techniques and initial head injury management to minimize the downstream effects of sport-related concussions.
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References
1. Junge A, Dvořák J. Football injuries during the 2014 FIFA World Cup. Br J Sports Med. 2015;49(9):599-602. doi:10.1136/bjsports-2014-094469
2. O’Kane JW. Is Heading in Youth Soccer Dangerous Play? The Physician and Sportsmedicine. 2016;44(2):190-194. doi:10.1080/00913847.2016.1149423
3. Caccese J, Kaminski T. Minimizing Head Acceleration in Soccer: A Review of the Literature. SPORTS MEDICINE. 2016;46(11):1591-1604. doi:10.1007/s40279-016-0544-7
4. McGuine T, Post E, Pfaller AY, et al. Does soccer headgear reduce the incidence of sport-related concussion? A cluster, randomised controlled trial of adolescent athletes. Br J Sports Med. 2020;54(7):408-413. doi:10.1136/bjsports-2018-100238
5. Delaney JS, Al-Kashmiri A, Drummond R, Correa JA. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. Br J Sports Med. 2008;42(2):110-115; discussion 115. doi:10.1136/bjsm.2007.037689
6. Dvorak J, Junge A, Derman W, Schwellnus M. Injuries and illnesses of football players during the 2010 FIFA World Cup. British Journal of Sports Medicine. 2011;45(8):626-630. doi:10.1136/bjsm.2010.079905
7. MacInnes P. Fifa to introduce concussion spotters in the stands at World Cup in Qatar. The Guardian. https://www.theguardian.com/football/2021/may/06/fifa-to-bring-in-concussion-spotters-for-qatar-world-cup. Published May 6, 2021. Accessed November 7, 2022.
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Look for our next Newsletter
Winter 2023!
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If you have any questions about the VSCC Quarterly Newsletter, please reach out vscc@vumc.org
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