James R. Clugston

Background: Linemen make up over 90% of all exertional heat stroke (EHS) deaths in collegiate and secondary school American football deaths. Purpose: This document aims to accomplish 3 purposes: (1) briefly summarize the need for specific risk reduction recommendations for EHS in secondary school and collegiate American football linemen, (2) provide new recommendations for the reduction of EHS in football linemen developed with Delphi procedures to build consensus, and (3) summarize the evidence for the existing and new best-practice recommendations that currently exist for EHS risk reduction. Design: Delphi-based Task Force Recommendations. Level of Evidence: Level 3. Methods: A multidisciplinary group of experts was convened to build consensus on EHS risk reduction strategies for secondary school and collegiate football linemen. The process involved a narrative review of relevant literature, followed by iterative rounds of anonymous Delphi surveys to refine and validate the recommendations. Results: A total of 20 recommendations were identified, scored, and retained for EHS risk reduction in American football linemen. Key recommendations include the education of coaches and strength and conditioning coaches on EHS risk reduction and treatment, the implementation of heat acclimatization protocols, and weather-based exercise modifications. The recommendations emphasize the importance of the avoidance of high-intensity aerobic testing during transition periods and the importance of having on-site cooling modalities. Conclusion: The high rates of EHS in American football linemen highlight the need for targeted risk reduction strategies. In American football, the design and implementation of workouts for linemen must differ from other players on the team. Linemen require position-specific work-to-rest ratios and tailored training programs. Clinical Relevance: By adhering to best practices and continuously updating guidelines based on emerging evidence, the safety and well-being of American football players can be significantly enhanced. These recommendations provide a comprehensive framework for reducing the risk of EHS and improving outcomes for American football linemen.

Acute neck pain following a concussion has been identified as a symptom associated with a delay in symptom resolution and persistent post-concussion symptoms (PPCS), but little is known about the relationship between the presence of acute neck pain and other known risk factors of delayed return to play (RTP) such as sex, sport contact level, and race. This study reports the findings of a secondary data analysis of a prospective cohort study sample from the Concussion Assessment, Research, and Education (CARE) Consortium. We examined the possible mediating effects of neck pain severity on known factors of delayed RTP (sex, sport contact level, and race) following a suspected concussion. While neck pain was identified as significant predictor of delayed RTP (b = .046, S.E. = .021, Wald χ²(1) = 4.745, p = 0.029), no interaction effect was observed between neck pain and the explored mediating factors of sex, sport contact level, and race. These results suggest that independent of an individual's sex, sport contact level, and/or race, the presence of neck pain following a suspected concussion should be further evaluated and differentially diagnosed to rule out comorbid pathologies that may be contributing to PPCS following a suspected concussion.

Context: In patients with musculoskeletal (MSK) conditions, pain is the leading contributor to disability and significantly limits mobility and dexterity. This narrative review describes the efficacy and safety of topical analgesics in common use today. Evidence Acquisition: Secondary literature gained via a literature search using PubMed.gov and the Cochrane library were used. Study Design: Recent literature (2000-2023) on several major classes of topical analgesics and topical delivery systems were reviewed to provide strength of recommendation taxonomy (SORT) levels. A total of 86 articles were reviewed. Level of Evidence: Level 2. Results: Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and cabbage leaf wraps (CLW) appear to be best suited for multiple types of acute MSK pain, and topical nitroglycerin is helpful when used specifically for rotator cuff pain in patients seeking relief while performing activities of daily living and willing to treat for long periods of time. For compounded topical formulations, it may be better to offer single agent creams based on patient preferences. Little data support the use of cryotherapy. Traumeel could be a promising natural analgesic that compares with diclofenac. Topical lidocaine appears best suited for postherpetic neuropathic pain. O24 is a reasonable alternative with a low risk profile to treat pain in patients with fibromyalgia syndrome. Conclusion: Choice of topical agents should be guided by current evidence accounting for type of pain, medication side effects, patient comorbidities, as well as patient preference, convenience, and cost. Strength-of-Recommendation Taxonomy (SORT): Of the topical analgesics and modalities reviewed, SORT level A evidence was found for topical NSAID use in decreasing MSK pain, topical lidocaine for postherpetic neuralgia, and nitroglycerin patches for treating rotator cuff pain if used for prolonged periods of time. Alternative treatments such as CLW and Traumeel show promising results (SORT level B).

Exposure to airborne respiratory viruses can be a health hazard in occupational settings. In this study, air sampling was conducted from January to March 2023 in two outpatient medical clinics—one primary care clinic and one clinic dedicated to the diagnosis and treatment of respiratory illnesses—for the purpose of assessing airborne respiratory virus presence. Work involved the operation of a BioSpot-VIVAS^™ as a stationary air sampler and deployment of NIOSH BC-251 bioaerosol samplers as either stationary devices or personal air samplers worn by staff members. Results were correlated with deidentified clinical data from patient testing. Samples from seven days were analyzed for SARS-CoV-2, influenza A H1N1 and H3N2 viruses, and influenza B Victoria- and Yamagata-lineage viruses, with an overall 17.5% (17/97) positivity rate. Airborne viruses predominated in particles of aerodynamic diameters from 1–4 μm and were recovered in similar quantities from both clinics. BC-251 samplers (17.4%, 15/86) and VIVAS (18.2%, 2/11) collected detectable viruses at similar rates, but more numerous BC-251 samplers provided greater insight into virus presence across clinical spaces and job categories. 60% of samples from reception areas contained detectable virus, and exposure to significantly more virus (p = 0.0028) occurred at reception desks as compared to the “mobile” job categories of medical providers and nurses. Overall, this study provides valuable insights into the impacts of hazard mitigation controls tailored to reducing respiratory virus exposure and highlights the need for continued diligence toward exposure risk mitigation in outpatient medical clinics.

Background: A sport-related concussion (SRC) is a common injury that affects multiple clinical domains such as cognition, balance, and nonspecific neurobehavioral symptoms. Although multidimensional clinical assessments of concussion are widely accepted, there remain limited empirical data on the nature and clinical utility of distinct clinical profiles identified by multimodal assessments. Purpose: Our objectives were to (1) identify distinct clinical profiles discernible from acute postinjury scores on the Sport Concussion Assessment Tool (SCAT), composed of a symptom checklist, a cognitive assessment (Standardized Assessment of Concussion), and a balance assessment (Balance Error Scoring System), and (2) evaluate the clinical utility of the identified profiles by examining their association with injury characteristics, neuropsychological outcomes, and clinical management–related outcomes. Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: Up to 7 latent profiles were modeled for 1885 collegiate athletes and/or military cadets who completed the SCAT at 0 to 12 hours after an injury. Chi-square tests and general linear models were used to compare identified profiles on outcomes at 12 to 72 hours after the injury. Kaplan-Meier analysis was used to investigate associations between clinical profiles and time to return to being asymptomatic and to return to play. Results: There were 5 latent profiles retained: low impairment (65.8%), high cognitive impairment (5.4%), high balance impairment (5.8%), high symptom severity (16.4%), and global impairment (6.5%). The latent profile predicted outcomes at 12 to 72 hours in expectable ways (eg, the high balance impairment profile demonstrated worse balance at 12 to 72 hours after the injury). Time to return to being asymptomatic and to return to play were different across profiles, with the high symptom severity and global impairment profiles experiencing the longest recovery and the high balance impairment profile experiencing an intermediate-length recovery (vs low impairment profile). Conclusion: An SRC is a heterogeneous injury that presents in varying ways clinically in the acute injury period and results in different recovery patterns. These data support the clinical prognostic value of diverse profiles of impairment across symptom, cognitive, and balance domains. By identifying distinct profiles of an SRC and connecting them to differing outcomes, the findings support more evidence-based use of accepted multimodal clinical assessment strategies for SRCs.

Background: Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes. Hypothesis: New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport. Study Design: Cohort study; Level of evidence, 2. Methods: Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018. Results: A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without ( P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days ( P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) ( P = .592). Conclusion: This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.

Context: Concussion research has primarily focused on sport-related mechanisms and excluded non–sport-related mechanisms. In adult populations, non–sport-related concussions (non-SRCs) demonstrated worse clinical outcomes compared with sport-related concussions (SRCs); however, investigations of non-SRCs in college-aged patients are limited. Objectives: To examine clinical outcomes in collegiate athletes with non-SRCs compared with SRCs and explore sex differences in outcomes among collegiate athletes with non-SRCs. Design: Prospective cohort study. Setting: Clinical setting. Patients or Other Participants: A total of 3500 athletes were included (n = 555 with non-SRCs, 42.5% female) from colleges or universities and service academies participating in the National Collegiate Athletic Association Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. Main Outcome Measure(s): Dichotomous outcomes (yes or no) consisted of immediate reporting, mental status alterations, loss of consciousness, posttraumatic amnesia, retrograde amnesia, motor impairments, delayed symptom presentation, and required hospital transport. Continuous outcomes were symptom severity, days with concussion symptoms, and days lost to injury. Data were collected within 24 to 48 hours of injury and at return to play. Adjusted relative risks (ARRs) compared the likelihood of dichotomous outcomes by mechanism and by sex within patients with non-SRCs. Multivariate negative binomial regressions were used to assess group differences in continuous variables. Results: Athletes with non-SRCs were less likely to report immediately (ARR = 0.73, 95% CI = 0.65, 0.81) and more likely to report delayed symptom presentation (ARR = 1.17, 95% CI = 1.03, 1.32), loss of consciousness (ARR = 3.15, 95% CI = 2.32, 4.28), retrograde amnesia (ARR = 1.77, 95% CI = 1.22, 2.57), and motor impairment (ARR = 1.45, 95% CI = 1.14, 1.84). Athletes with non-SRCs described greater symptom severity, more symptomatic days, and more days lost to injury (P < .001) compared with those who had SRCs. Within the non-SRC group, female athletes indicated greater symptom severity, more symptomatic days, and more days lost to injury (P < .03) than male athletes. Conclusions: Athletes with non-SRCs had worse postinjury outcomes compared with those who had SRCs, and female athletes with non-SRCs had worse recovery metrics than male athletes. Our findings suggest that further investigation of individuals with non-SRCs is needed to improve concussion reporting and management.

Objectives The purpose of this study was to determine sex differences in recovery trajectories of assessments for sport-related concussion using Concussion Assessment, Research and Education (CARE) Consortium data. Methods National Collegiate Athletic Association athletes (N = 906; 61% female) from sex-comparable sports completed a pre-season baseline assessment and post-sport-related concussion assessments within 6 h of injury, 24–48 h, when they initiated their return to play progression, when they were cleared for unrestricted return to play, and 6 months post-injury. Assessments included the Standardized Assessment of Concussion, Balance Error Scoring System, Brief Symptom Inventory-18, Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Sport Concussion Assessment Tool-3 symptom evaluation, Clinical Reaction Time, King–Devick test, Vestibular Ocular Motor Screen, 12-item Short-Form Health Survey, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale. Results Only the Vestibular Ocular Motor Screen Total Symptom Score at the 24–48 h timepoint (p = 0.005) was statistically significantly different between sexes. Specifically, female athletes (mean = 60.2, 95% confidence interval [CI] 51.5–70.4) had higher Vestibular Ocular Motor Screen Total Symptom Scores than male athletes (mean = 36.9, 95% CI 27.6–49.3), but this difference resolved by the time of return-to-play initiation (female athletes, mean = 1.8, 95% CI 1.1–2.9; male athletes, mean = 4.1, 95% CI 1.5–10.9). Conclusions Sport-related concussion recovery trajectories for most assessments were similar for female and male National Collegiate Athletic Association athletes except for Vestibular Ocular Motor Screen symptoms within 48 h of sport-related concussion, which was greater in female athletes. Female athletes had a greater symptom burden across all timepoints, suggesting that cross-sectional observations may indicate sex differences despite similar recovery trajectories.

Background: Risk for lower extremity musculoskeletal injury increases after sport-related concussion (SRC) and may result from unresolved motor control deficits. Muscle weakness is a deficit that could contribute to musculoskeletal injury risk. Hypothesis: Athletes with SRC will demonstrate quadriceps and hamstring muscle weakness at the time of return to sport and 30 days later compared with controls. Study Design: Prospective matched cohort. Level of Evidence: Level 3. Methods: A total of 31 athletes with SRC (CONCUSSION) were matched by sex, age, and activity level to controls (CONTROL). Testing was conducted at initial assessment and 30 days later; initial assessment in CONCUSSION occurred when cleared for return to play. Isokinetic testing assessed quadriceps and hamstring strength of the dominant and nondominant legs at 60 and 180 deg/s. Peak torque values were normalized to body mass (N-m/kg). Data were analyzed with repeated measures general linear models (group × time), and effect sizes were calculated. Results: Analysis at 60 deg/s included 26 matched pairs (15 male per group) and at 180 deg/s included 30 matched pairs (17 males per group). Time from concussion to initial assessment was 21.3 (7.8) mean (standard deviation) days. No significant interactions or main effects were detected ( P > 0.05). Across muscle groups, legs, and testing speeds, effect sizes at initial assessment were small ( d = 0.117 to 0.353), equating to a strength deficit in CONCUSSION of 0.04 to 0.18 N-m/kg, and effect sizes were further reduced at 30-day follow-up (d = −0.191 to 0.252). Conclusion: In athletes with SRC, quadriceps and hamstring strength were decreased only minimally at return to play compared with controls and the difference lessened over 30 days. Clinical Relevance: Strength deficits may not be a major contributor to increased lower extremity musculoskeletal injury risk after SRC. Strength training could be implemented before return to play after SRC to mitigate any strength deficits.

Background: Approximately half of concussions go undisclosed and therefore undiagnosed. Among diagnosed concussions, 51% to 64% receive delayed medical care. Understanding the influence of undiagnosed concussions and delayed medical care would inform medical and education practices. Purpose: To compare postconcussion longitudinal clinical outcomes among (1) individuals with no concussion history, all previous concussions diagnosed, and ≥1 previous concussion undiagnosed, as well as (2) those who have delayed versus immediate symptom onset, symptom reporting, and removal from activity after concussion. Study Design: Cohort study; Level of evidence, 2. Methods: Participants included 2758 military academy cadets and intercollegiate athletes diagnosed with concussion in the CARE Consortium. We determined (1) each participant’s previous concussion diagnosis status self-reported at baseline (no history, all diagnosed, ≥1 undiagnosed) and (2) whether the participant had delayed or immediate symptom onset, symptom reporting, and removal from activity. We compared symptom severities, cognition, balance, and recovery duration at baseline, 24 to 48 hours, date of asymptomatic status, and date of unrestricted return to activity using tests of parallel profiles. Results: The ≥1 undiagnosed concussion group had higher baseline symptom burdens ( P < .001) than the other 2 groups and poorer baseline verbal memory performance ( P = .001) than the all diagnosed group; however, they became asymptomatic and returned to activity sooner than those with no history. Cadets/athletes who delayed symptom reporting had higher symptom burdens 24 to 48 hours after injury (mean ± SE; delayed, 28.8 ± 0.8; immediate, 20.6 ± 0.7), took a median difference of 2 days longer to become asymptomatic, and took 3 days longer to return to activity than those who had immediate symptom reporting. For every 30 minutes of continued participation after injury, days to asymptomatic status increased 8.1% (95% CI, 0.3%-16.4%). Conclusion: Clinicians should expect that cadets/athletes who delay reporting concussion symptoms will have acutely higher symptom burdens and take 2 days longer to become asymptomatic. Educational messaging should emphasize the clinical benefits of seeking immediate care for concussion-like symptoms.