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Background In the initial autopsy case studies of chronic traumatic encephalopathy (CTE), some researchers have concluded that the proteinopathy associated with CTE is the underlying cause of suicidality and completed suicide in former athletes. Methods A review of the literature on contact sports and risk of completed suicide revealed only one epidemiological study with direct relevant data. Results There are no published cross-sectional, epidemiological or prospective studies showing a relation between contact sports and risk of suicide. One published epidemiological study suggests that retired National Football League players have lower rates of death by suicide than the general population. Outside of sports, there is a mature body of evidence suggesting that the causes of suicide are complex, multifactorial and difficult to predict in individual cases. Conclusions Future research might establish a clear causal connection between the proteinopathy of CTE and suicide. At present, however, there is insufficient scientific evidence to conclude that there is a strong causal relationship between the presence of these proteinopathies and suicide in former athletes. Additional research is needed to determine the extent to which the neuropathology of CTE is a possible mediator or moderator variable associated with suicide.

Objective To provide a critical review of chronic traumatic encephalopathy (CTE) by considering the range of clinical presentations, neuropathology and the strength of evidence for CTE as a distinct syndrome. Data sources Seven electronic databases were searched using a combination of MeSH terms and key words to identify relevant articles. Review methods Specific inclusion and exclusion criteria were used to select studies for review. Data extracted where present included study population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, investigation results and neuropathology results. Results The data from 158 published case studies were reviewed. Critical differences between the older descriptions of CTE (the ‘classic’ syndrome) and the recent descriptions (the ‘modern’ syndrome) exist in the age of onset, natural history, clinical features, pathological findings and diagnostic criteria, which suggests that modern CTE is a different syndrome. The methodology of the current studies does not allow determination of aetiology or risk factors. Conclusions The clinicopathological differences between the ‘classic’ CTE syndrome and the ‘modern’ syndrome suggest that the new syndrome needs a different nomenclature. Further research is required to clearly define the clinical phenotype of the modern CTE syndrome and establish the underlying aetiology. Future research needs to address these issues through large-scale, prospective clinicopathological studies.

ObjectiveTo examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT).MethodsA retrospective cohort (1990–2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland).ResultsThe incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4–6 weeks’ postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia.ConclusionsBased on our population-based study, the number of CSDH patients has increased markedly during the study period (1990–2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

ObjectivesTo examine the added value of the medical bunker surveillance system for identifying possible concussions in the National Rugby League.DesignDescriptive cohort study.SettingThe National Rugby League (NRL) concussion surveillance. Three tiers of injury surveillance exist in the NRL: i. the sideline injury surveillance (SIS); ii. the team medical staff (TMS); iii. the centeralised medical bunker (CMB). The SIS is tasked with tagging all head impact events (HIEs). The TMS and CMB review category I and category II video signs of potential concussion.ParticipantsAll NRL players who participated in the 2019 season.Outcome MeasuresThe main outcome variable was medically diagnosed concussion. All HIEs recorded by the SIS were used as the denominator. The frequency of the TMS and the CMB to identify concussed and non-concussed HIEs was evaluated.Main ResultsThere were 255 Head Injury Assessments (HIAs) conducted during the 2019 NRL season, and 110 medically diagnosed concussions. The CMB uniquely identified 10 HIEs that were not identified by the TMS, and that were ultimately diagnosed with concussion. On 20 occasions the CMB identified HIEs that were not identified by the TMS, but that were not ultimately diagnosed with concussion. There were no occasions were the TMS identified a concussion that the CMB missed.ConclusionsThe CMB independently improved the identification concussion by 10%, while only increasing the Head Injury Assessment (HIA) by 8%. This is a tolerable conservative clinical management false positive rate. Further refinement of the CMB process for identifying HIEs will continue.

A recently published review of 45 studies concluded that approximately half of individuals who sustain a single mild traumatic brain injury (MTBI) experience long-term cognitive impairment (McInnes et al. Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS ONE 2017;12:e0174847). Stratified by age, they reported that 50% of children and 58% of adults showed some form of cognitive impairment. We contend that the McInnes et al. review used a definition of \"cognitive impairment\" that was idiosyncratic, not applicable to individual patients or subjects, inconsistent with how cognitive impairment is defined in clinical practice and research, and resulted in a large number of false positive cases of cognitive impairment. For example, if a study reported a statistically significant difference on a single cognitive test, the authors concluded that every subject with a MTBI in that study was cognitively impaired-an approach that cannot be justified statistically or psychometrically. The authors concluded that impairment was present in various cognitive domains, such as attention, memory, and executive functioning, but they did not analyze or report the results from any of these specific cognitive domains. Moreover, their analyses and conclusions regarding many published studies contradicted the interpretations provided by the original authors of those studies. We re-reviewed all 45 studies and extracted the main conclusions from each. We conclude that a single MTBI is not associated with a high incidence of chronic cognitive impairment.

Characterizing psychological factors that contribute to persistent symptoms after mild traumatic brain injury (MTBI) can inform early intervention. To determine whether fear avoidance, a known risk factor for chronic disability after musculoskeletal injury, is associated with worse clinical outcomes from MTBI, adults were recruited from four outpatient MTBI clinics and assessed at their first clinic visit (mean = 2.7, standard deviation = 1.5 weeks post-injury) and again four to five months later. Of 273 patients screened, 102 completed the initial assessment, and 87 returned for the outcome assessment. The initial assessment included a battery of questionnaires that measure activity avoidance and associated fears. Endurance, an opposite behavior pattern, was measured with the Behavioral Response to Illness Questionnaire. The multi-dimensional outcome assessment included measures of post-concussion symptoms (British Columbia Postconcussion Symptom Inventory), functional disability (World Health Organization Disability Assessment Schedule-12 2.0), return to work status, and psychiatric complications (MINI Neuropsychiatric Interview). A single component was retained from principal components analysis of the six avoidance subscales. In generalized linear modeling, the avoidance composite score predicted symptom severity (95% confidence interval [CI] for B = 1.22–6.33) and disability (95% CI for B = 2.16–5.48), but not return to work (95% CI for B = −0.68–0.24). The avoidance composite was also associated with an increased risk for depression (odds ratio [OR] = 1.76, 95% CI = 1.02–3.02) and anxiety disorders (OR = 1.89, 95% CI = 1.16–3.19). Endurance behavior predicted the same outcomes, except for depression. In summary, avoidance and endurance behavior were associated with a range of adverse clinical outcomes from MTBI. These may represent early intervention targets.

Background Rugby Union, a popular full-contact sport played throughout the world, has one of the highest rates of concussion of all full-contact sports. Objective The aim of the current review was to systematically evaluate the available evidence on concussion in Rugby Union and to conduct a meta-analysis of findings regarding the incidence of concussion. Methods Articles were retrieved via a number of online databases. The current review examined all articles published in English up to May 2014 pertaining to concussion in Rugby Union players. The key search terms included ‘Rugby Union’, ‘rugby’, ‘union’, and ‘football’, in combination with the injury terms ‘athletic injuries’, ‘concussion’, ‘sports concussion’, ‘sports-related concussion’, ‘brain concussion’, ‘brain injury’, ‘brain injuries’, ‘mild traumatic brain injury’, ‘mTBI’, ‘traumatic brain injury’, ‘TBI’, ‘craniocerebral trauma’, ‘head injury’, and ‘brain damage’. Results The final search outcome following the eligibility screening process resulted in the inclusion of 96 articles for this review. The meta-analysis included a total of 37 studies. The results of the meta-analysis revealed an overall incidence of match-play concussion in men’s rugby-15s of 4.73 per 1,000 player match hours. The incidence of concussion during training was 0.07 per 1,000 practice hours. The incidence of concussion in women’s rugby-15s was 0.55 per 1,000 player match hours. In men’s rugby-7s match-play, concussion incidence was 3.01 per 1,000 player match hours. The incidence of concussion varied considerably between levels of play, with elite level play recording a rate of 0.40 concussions per 1,000 player match hours, schoolboy level 0.62 concussions per 1,000 player match hours, and the community or sub-elite level recording a rate of 2.08 concussions per 1,000 player match hours. The incidence of concussion in men’s rugby-15s as a function of playing position (forwards vs. backs) was 4.02 and 4.85 concussions per 1,000 player match hours, respectively. Conclusions Concussion is a common injury sustained and reported in match play and to a lesser extent during practice by Rugby Union players. Based on the available published data, there appears to be a variation in risk of concussion across level of play, with the sub-elite level having the greatest incidence of injury. Future research focused on studying the acute consequences and best management strategies in current players, and the potential longer term outcomes of concussion in retired players, is needed. A focus on the areas of prevention, injury identification, and medical management, and risk for long-term outcomes will be of benefit to current athletes.

Prognostic models can guide clinical management and increase statistical power in clinical trials. The availability and adequacy of prognostic models for mild traumatic brain injury (MTBI) is uncertain. The present study aimed to (1) identify and evaluate multivariable prognostic models for MTBI, and (2) determine which pre-, peri-, and early post-injury variables have independent prognostic value in the context of multivariable models. An electronic search of MEDLINE, PsycINFO, PubMed, EMBASE, and CINAHL databases for English-language MTBI cohort studies from 1970–2013 was supplemented by Web of Science citation and hand searching. This search strategy identified 7789 articles after removing duplicates. Of 182 full-text articles reviewed, 26 met eligibility criteria including (1) prospective inception cohort design, (2) prognostic information collected within 1 month post-injury, and (3) 2+variables combined to predict clinical outcome (e.g., post-concussion syndrome) at least 1 month later. Independent reviewers extracted sample characteristics, study design features, clinical outcome variables, predictor selection methods, and prognostic model discrimination, calibration, and cross-validation. These data elements were synthesized qualitatively. The present review found no multivariable prognostic model that adequately predicts individual patient outcomes from MTBI. Suboptimal methodology limits their reproducibility and clinical usefulness. The most robust prognostic factors in the context of multivariable models were pre-injury mental health and early post-injury neuropsychological functioning. Women and adults with early post-injury anxiety also have worse prognoses. Relative to these factors, the severity of MTBI had little long-term prognostic value. Future prognostic studies should consider a broad range of biopsychosocial predictors in large inception cohorts.

Individuals who are injured in the workplace typically have a greater risk of delayed return to work (RTW) and other poor health outcomes compared to those not injured at work. It is not known whether these differences hold true for mild traumatic brain injuries (MTBI). The present study examined differences associated with workplace and non-workplace MTBI upon intake to a specialty MTBI clinic, their outcomes, and risk factors that influence RTW. Slow-to-recover participants were recruited from consecutive referrals to four outpatient MTBI clinics from March 2015 to February 2017. Two clinics treat Worker's Compensation claimants and two clinics serve patients with non-work related injuries in the publically funded health care system. Of 273 eligible patients, 102 completed an initial study assessment (M age = 41.2 years, SD age = 11.7; 54% women) at an average of 2-3 months post injury. Participants were interviewed about their MTBI and completed a battery of standardized questionnaires and performance validity testing. Outcomes, including RTW, were assessed via telephone follow-up 4-5 months later. Workplace injuries comprised 45.1% of the sample. The workplace MTBI group had a greater proportion of men and lower education levels compared to the non-workplace MTBI group. The two groups had a comparable post-concussion symptom burden and performance validity test failure rate. Workplace MTBI was associated with greater post-traumatic stress symptoms. Fifteen patients (14.7%) were lost to follow-up. There were no workplace/non-workplace MTBI differences in RTW outcome at 6-7 months post injury. Of the entire sample, 42.5% of patients had full RTW, 18.4% had partial RTW, and 39.1% had no RTW. Greater post-concussion symptom burden was most predictive of no RTW at follow-up. There was no evidence that the workplace and non-workplace MTBI groups had different risk factors associated with prolonged work absence. Despite systemic differences in compensation and health care access, the workplace and non-workplace MTBI groups were similar at clinic intake and indistinguishable at follow-up, 6-7 months post injury.