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Clinical Outcomes Assessment for the Management of Sport-Related Concussion

Tamara C. Valovich McLeod and Johna K. Register-Mihalik

Patient Scenario:

An adolescent female youth soccer athlete, with a previous concussion history, suffered a second concussion 4 wk ago. Her postconcussive symptoms are affecting her school performance and social and family life.

Clinical Outcomes Assessment:

Concussion is typically evaluated via symptoms, cognition, and balance. There is no specific patient-oriented outcomes measure for concussion. Clinicians can choose from a variety of generic and specific outcomes instruments aimed at assessing general health-related quality of life or various concussion symptoms and comorbidities such as headache, migraine, fatigue, mood disturbances, depression, anxiety, and concussion-related symptoms.

Clinical Decision Making:

The data obtained from patient self-report instruments may not actively help clinicians make return-to-play decisions; however, these scales may be useful in providing information that may help the athlete return to school, work, and social activities. The instruments may also serve to identify issues that may lead to problems down the road, including depression or anxiety, or serve to further explore the nature of an athlete’s symptoms.

Clinical Bottom Line:

Concussion results in numerous symptoms that have the potential to linger and has been associated with depression and anxiety. The use of outcomes scales to assess health-related quality of life and the effect of other symptoms that present with a concussion may allow clinicians to better evaluate the effects of concussion on physical, cognitive, emotional, social, school, and family issues, leading to better and more complete management.

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Sport Parent Perceptions of American Youth Football Costs, Benefits, and Safety

Andrew Romaine, J.D. DeFreese, Kevin Guskiewicz, and Johna Register-Mihalik

As head injuries in American football have received increasing publicity, the safety of the sport has become a great concern for parents nationwide. The purpose of this study was to examine perceived safety concerns in youth football using Eccles’ expectancy-value model (Eccles et al., 1983). We hypothesized perceived safety concerns to moderate relationships between parent perceptions of parent cost/benefit, child cost/benefit, and child motivation and enjoyment outcomes for football. Youth football parents (N = 105, M age = 42) completed valid and reliable online assessments of study variables. Regression analyses revealed child safety concerns (as rated by parents) to mediate, rather than moderate, the relationship between parent safety concerns and child cost perceptions (as rated by parents). Furthermore, safety concerns did not significantly associate with child achievement outcomes of motivation and enjoyment. Results provide valuable insight into parent and child attitudes toward youth football safety. Such knowledge may inform future educational interventions targeting sport safety promotion.

Open access

The Effect of Concussive Injury on Individual Game Performance in Professional Collision-Sport Athletes

Corey P. Ochs, Melissa C. Kay, and Johna K. Register-Mihalik

Clinical Scenario: Collision sports are often at higher risk of concussion due to the physical nature and style of play. Typically, initial clinical recovery occurs within 7 to 10 days; however, even this time frame may result in significant time lost from play. Little has been done in previous research to analyze how individual game performance may be affected upon return to play postconcussion. Focused Clinical Question: Upon return-to-play clearance, how does sport-related concussion affect game performance of professional athletes in collision sports? Summary of Key Findings: All 3 studies included found no significant change in individual performance of professional collision-sport athletes upon returning to play from concussive injury. One of the studies indicated that there was no difference in performance for NFL athletes who did not miss a single game (returned within 7 d) and those who missed at least 1 game. One study indicated that although there was no change in performance of NFL players upon returning to play from sustained concussion, there was a decline in performance in the 2 weeks before the diagnosed injury and appearing on the injury report. The final study indicated that there was no difference in performance or style of play of NHL athletes who missed time due to concussive injury when compared with athletes who missed games for a noninjury factor. Clinical Bottom Line: There was no change in performance upon return from concussive injury suggesting that players appear to be acutely recovered from the respective concussion before returning to play. This suggests that current policies and management properly evaluate and treat concussed athletes of these professional sports. Strength of Recommendation: Grade C evidence exists that there is no change in individual game performance in professional collision-sport athletes before and after suffering a concussion.

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Exploring Early Sport Specialization: Associations With Psychosocial Outcomes

Shelby Waldron, J.D. DeFreese, Brian Pietrosimone, Johna Register-Mihalik, and Nikki Barczak

Sport specialization has been linked to multiple negative health related outcomes including increased injury risk and sport attrition, yet a gap remains in our understanding of potential psychological outcomes of early specialization (≤ age 12). The current study evaluated the associations between retrospective athlete reports of sport specialization and both retroactive and current psychological health outcomes. Early specializers reported significantly higher levels of multiple maladaptive psychological outcomes (e.g., global athlete burnout, emotional and physical exhaustion, sport devaluation, amotivation). Overall, findings suggest that specialization environment factors, in addition to the age of specialization, are potentially critical factors in determining health and well-being outcomes. Findings support prominent position statements suggesting early specialization may be associated with increased health risks. Study findings may also inform the development of guidelines and recommendations to aid parents, coaches, and athletes in positively impacting athlete psychosocial outcomes.

Open access

The Effect of Body Checking Policy Changes on Concussion Incidence in Canadian Male Youth Ice Hockey Players: A Critically Appraised Topic

Brittany M. Ingram, Melissa C. Kay, Christina B. Vander Vegt, and Johna K. Register-Mihalik

Clinical Scenario: Current studies have identified body checking as the most common cause of sports-related concussion in ice hockey across all divisions and levels. As a result, many hockey organizations, particularly in youth sports, have implemented rules making body checking to the head, face, and/or neck illegal. Such a rule, in Canada, makes age 13 the first age in which individuals can engage in body checking. Despite these changes, effectiveness of their implementation on the incidence of concussion in Canadian male youth ice hockey players remains unclear. Clinical Question: What is the effect of body checking policy changes on concussion incidence in male youth ice hockey players? Summary of Key Findings: Of the 3 included studies, 2 studies reported a decrease in the incidence of concussion once a body checking policy change was implemented. The third study showed an increase; however, it is important to note that this may be due, in part, to increased awareness leading to better reporting of injuries. Clinical Bottom Line: Current evidence supports a relationship between body checking policy implementation and decreased concussion incidence; however, more research is needed to understand the long-term implications of policy change and the effects in other leagues. In addition, further data are needed to differentiate between increased concussion incidence resulting from concussion education efforts that may improve disclosure and increased concussion incidence as a direct result of policy changes. Strength of Recommendation: Grade B evidence exists that policy changes regarding body checking decrease concussion incidence in male youth ice hockey players.

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Effects of a Single-Task Versus a Dual-Task Paradigm on Cognition and Balance in Healthy Subjects

Luke M. Ross, Johna K. Register-Mihalik, Jason P. Mihalik, Karen L. McCulloch, William E. Prentice, Edgar W. Shields, and Kevin M. Guskiewicz

Context:

Recent evidence has revealed deficiencies in the ability to divide attention after concussion.

Objective:

To examine the effects of a single vs a dual task on cognition and balance in healthy subjects and to examine reliability of 2 dual-task paradigms while examining the overall feasibility of the tasks.

Design:

Pretest–posttest experimental design.

Setting:

Sports medicine research laboratory.

Patients:

30 healthy, recreationally active college students.

Intervention:

Subjects performed balance and cognitive tasks under the single- and dual-task conditions during 2 test sessions 14 d apart.

Main Outcome Measures:

The procedural reaction-time (PRT) test of the Automated Neuropsychological Assessment Metrics (eyes-closed tasks) and an adapted Procedural Auditory Task (PAT; eyes-open tasks) were used to assess cognition. The NeuroCom Sensory Organization Test (SOT) and the Balance Error Scoring System (BESS) were used to assess balance performance. Five 2-way, within-subject ANOVAs and a paired-samples t test were used to analyze the data. ICCs were used to assess reliability across 2 test sessions.

Results:

On the SOT, performance significantly improved between test sessions (F 1,29 = 35.695, P < .001) and from the single to the dual task (F 1,29 = 9.604, P = .004). On the PRT, performance significantly improved between test sessions (F 1,29 = 57.252, P < .001) and from the single to the dual task (F 1,29 = 7.673, P = .010). No differences were seen on the BESS and the PAT. Reliability across test sessions ranged from moderate to poor for outcome measure.

Conclusions:

The BESS appears to be a more reliable and functional tool in dual-task conditions as a result of its increased reliability and clinical applicability. In addition, the BESS is more readily available to clinicians than the SOT.

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Exertional Rhabdomyolysis in 8 Division I Female Lacrosse Athletes: A Case Series

Johna K. Register, Jason P. Mihalik, Christopher J. Hirth, and Thomas E. Brickner

Column-editor : Joseph J. Piccininni

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Comparison of Concussion Sideline Screening Measures Across Varying Exertion Levels Within Simulated Games

Rebecca L. Dubas, Elizabeth F. Teel, Melissa C. Kay, Eric D. Ryan, Meredith A. Petschauer, and Johna K. Register-Mihalik

Context: Currently, there is no gold standard to evaluate the effect of varying game-like exertion states on Sport Concussion Assessment Tool 3rd Edition (SCAT-3) outcomes. Baseline assessments may occur before, during, or after physical activity, while postinjury evaluations predominantly occur following physical activity. Thus, clinicians may be comparing postinjury evaluations completed following exertion to baseline evaluations completed following varying levels of rest or exertion, which may not be a valid method for clinical decision making. Objective: To determine the effect of various physical exertion levels on sideline concussion assessment outcomes and reliability. Design: Within-subjects, repeated measures. Setting: Field. Participants: Physically active participants (N = 36) who regularly participate in basketball activity. Intervention: Subjects participated in 2 simulated basketball games, completing a symptom checklist, Standardized Assessment of Concussion, and Balance Error Scoring System before game play, during halftime, and at the completion of each simulated game. Pulse rate was assessed as a proxy of physical exertion. Main Outcome Measures: Total symptom, Standardized Assessment of Concussion, and Balance Error Scoring System scores. Results: Physical exertion did not significantly predict symptom, Standardized Assessment of Concussion, or Balance Error Scoring System scores, although a trend toward higher symptom scores was observed for females (ß = 0.03, P = .09). All assessments had poor to moderate reliability across sessions (.15 < interclass correlation coefficient [2,1] < .60). Conclusion: Low- to moderate-intensity physical activity did not have a significant effect on clinical concussion sideline assessments; however, the low test–retest reliability observed prevents strong conclusions on these relationships. The poor overall reliability does not allow for clear recommendations for what state of baseline physical exertion (ie, rested or exerted) provides optimal data to make postinjury clinical decisions, although baseline concussion assessments completed at rest have the most valid and conservative normative values for injury comparison.

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Athlete Resilience Trajectories Across Competitive Training: The Influence of Physical and Psychological Stress

Nikki E. Barczak-Scarboro, Emily Kroshus, Brett Pexa, Johna K. Register Mihalik, and J.D. DeFreese

Competitive sport involves physical and psychological stressors, such as training load and stress perceptions, that athletes must adapt to in order to maintain health and performance. Psychological resilience, one’s capacity to equilibrate or adapt affective and behavioral responses to adverse physical or emotional experiences, is an important topic in athlete training and performance. The study purpose was to investigate associations of training load and perceived sport stress with athlete psychological resilience trajectories. Sixty-one collegiate club athletes (30 females and 31 males) completed self-reported surveys over 6 weeks of training. Athletes significantly differed in resilience at the beginning of competitive training. Baseline resilience differences were associated with resilience trajectories. Perceived stress and training load were negatively associated with resilience. Physical and psychological stressors had a small but statistically significant impact on resilience across weeks of competitive training, indicating that both types of stressors should be monitored to maintain athlete resilience.

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Athletic Trainers’ Proficiency in Evaluating Emergency Action Plans and a Subset of Catastrophic Policies and Procedures

Samantha E. Scarneo-Miller, Christianne M. Eason, Zachary K. Winkelmann, Christina Emrich, and Johna K. Register-Mihalik

Written health and safety policies mitigate catastrophic outcomes resulting from sport injuries. The purpose of this project was to evaluate athletic trainers’ proficiency in evaluating catastrophic policies and procedures alignment with best practices. This study found athletic trainers were not able to identify the majority of policy and procedure components based on evidence-based best practice documents. Furthermore, athletic trainers tended to focus more on aesthetics and feasibility versus alignment with current best practices. Results support the need to enhance education specific to policy and procedure development, evaluation, and implementation in order to improve proficiency of clinicians.