Cognitive Risk in High School. Football: A Pilot Study. By: Bernadette Darcy

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1 Cognitive Risk in High School Football: A Pilot Study By: Bernadette Darcy

2 2 Abstract: To assess the cognitive risk football poses for high school players, a study was conducted which tested change in cognition over the 2014 football season. The study involved 13 high school football players and 11 controls. The cognitive assessments used were based on the Sport Concussion Assessment Tool II and the Online Reaction Time Test, and were administered weekly to all participants. These tests evaluate different components of cognition such as reaction time, immediate and recall memory, and concentration. Each participant's overall cognitive change was tracked using the assessment results. Control cognition was expected to be constant throughout the season, but the overall cognitive strength of the players was expected to decline. Introduction: A concussion is a traumatic brain injury caused by a jolt, bump, or blow to the head that often results in headaches, difficulty concentrating, mental fog, and other adverse side effects ( Concussion and Mild TBI ). In the U.S., approximately 1.6 to 3.8 million sports related concussions occur annually (Halstead) and of these concussions, athletes ages 16 to 19 sustain 29% (Ferguson). The high school sport with the highest incidence of player concussions is football (Breslow). The aggressive nature of football and play through the pain mentality surrounding the game are the likely triggers of high concussion incidence. In the past, researchers have studied concussion triggers in high school football and have recorded the frequency of concussions per season. However, the potential negative cognitive consequences of football, such as decreased attention span, difficulty concentrating, and frequent headaches have not been

3 3 widely studied in high school athletes. Although substantial research has been conducted at the college level concerning the relationship between football, cognition, and concussions, research involving high school athletes regarding this relationship is minimal in comparison. Additionally, high school athletes are in critical physical and mental developmental states, and playing such an intensive sport such as football during this development could lead to long term brain damage (Toporek). In order to assess the cognitive risks football poses for high school athletes, I conducted a study involving a control group of 11 non athlete, male, high school students, ages 15 to 18, and 13 male players, ages 15 to 18, from the same high school s varsity football team from September 04, 2014 to October 28, I administered 6 cognitive assessments to the participants over an 8 week period. The cognitive assessments will be based on the SCAT II assessment, ImPACT test, and the Online Reaction Time Test. Throughout the season, I tracked each athlete s and each control s overall cognitive change by using the assessment scores and results. I used the assessment scores and results to track the overall cognitive change for each athlete and each control. Based on previous research done on the college level, I expected the control group participants to experience little to no cognitive change and the athlete participants to experience overall cognitive decline throughout the 2014 football season. Methods: Before the study began, all potential participants and their parents/guardians received written, informed consent, which detailed study procedures, participant rights, and privacy of information. These forms were reviewed and approved by Holy Name Hospital's Institutional Review Board. Consent forms gave participants the right to consciously choose or decline to be

4 in the study. (To see the consent form for both participants and parent/guardians, please see Appendix A.) Potential participants could not join the study until consent was received.

4 4 in the study. (To see the consent form for both participants and parent/guardians, please see Appendix A.) Potential participants could not join the study until consent was received. Once consent was received and verified, all participants were assigned a randomly generated data collection number. Throughout the study, all individual results were associated with this number only. This system maintained the privacy and anonymity of all participants. In order to gather information on the potential cognitive changes posed for athletes playing football, I administered cognitive assessments based on the SCAT II (Sport Concussion Assessment Tool 2), Online Reaction Time Test, and ImPACT test (Immediate Post Concussion Assessment and Cognitive Testing) to all participants on a weekly basis. The Online Reaction Time Test presents a computerized stoplight interface and assesses participant reaction time. The interface initially presents a red stoplight. The participant clicks the Click Here When Green button as soon as the stoplight turns green. The participant repeats this exercise 5 times and the average of the 5 trials is recorded. The Online Reaction Time Test took about 1 minute for each participant to complete.

5 5 The ImPACT is a computerized exam that is utilized in many professional, collegiate, and high school sports programs across the country to successfully diagnose and manage concussions. The SCAT II is a similar test used to assess concussion diagnosis over time, with additional balance and coordination components incorporated into it. However, studies show that both exams also assess cognitive function, based on previous research and their overlapping components with other cognitive assessments, such as the Montreal Cognitive Assessment (Nasreddine). From these exams, I have selected portions that assess working memory, concentration, recall memory, and balance. Specifically, our assessment entails asking participants to recall a list of 5 words (i.e. apple, baby, perfume, saddle, bubble), to count backward from 100 by a number (i.e.7), to list the months in reverse order (Dec., Nov., Oct. ), and to recall as many words as possible from the beginning of the assessment. This ImPACT/SCAT II modified component takes about 3 minutes to complete. Example Cognitive Assessment (Adapted from SCAT II/ImPACT): Immediate memory Read the words at a rate of one per second. Score 1 point for each correct response. Do not inform the athlete that delayed recall will be tested. I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order. The words are: rice makeup star orange car Trial 1 (Bold 1 if athlete says word, 0 if not) Rice 0 1 Makeup 0 1 Star 0 1

6 6 Orange 0 1 Car 0 1 Total Immediate memory score of 5: Concentration Count Backward from 100 by 13 s: Key: 87, 74, 61, 48, 35 Counting score out of 5: Months in Reverse Order: Now tell me the months of the year in reverse order. Start with the last month and go backward. So you ll say December, November... Go ahead Months Incorrect/Correct Dec Nov Oct Sept Aug Jul Jun May Apr Mar Feb Jan 0 1 Months score out of 1: Concentration score of 6: Recall Memory Ask athlete to recall as many words as possible from the second portion of the assessment. Recall Memory Score out of 5: Immediate memory score out of 5 Assessment Total Concentration score out of 6 Delayed recall score out of 5 SAC subtotal out of 16

Cognitive Risk in High School Football: A Pilot Study 7 The balance component incorporates 3 positions: a double leg stance (standing, feet together with hands on hips and with eyes closed, figure

7 Cognitive Risk in High School Football: A Pilot Study 7 The balance component incorporates 3 positions: a double leg stance (standing, feet together with hands on hips and with eyes closed, figure A), single leg stance (standing on non dominant foot with hands on hips and eyes closed, figure B), and tandem stance (standing heel to toe with non dominant foot in back, figure C). Participants stood in each position for 20 seconds. Errors of balance include lifting hands off hips, stumbling or falling, or remaining out of the test positing for greater than five seconds. This test assessed change in balance capacity over time. The balance component took about 2 minutes for each participant to complete. (Bell et al) Figure 3: (Source Bell et.al) Results : BALANCE TESTS

8 8 REACTION TIME

9 9 SCAT 2 RESULTS

10 10 Discussion: Balance test results for controls and football player participants indicate potential change in cognition for football players and consistency for controls. For all balance tests, participants strive for a score of 0, which signifies no points taken off. The double leg stance results for both the controls and football player participants were approximately the same; the average points deducted for each trial were 0 to 0.5. Essentially, the double leg stance acts as a control for the balance testing; it is the normal standing position with hands on hips, and unless the participant has a broken leg or other injury that would affect natural balance, the participant should not receive more than one point off, if any points at all. The tandem leg stance point deductions fluctuated throughout the season for both football players (2 to 4 points off) and controls (0.5 to 1.5 points off). When the football players came in for testing the morning after a tough loss against a larger, more well equipped team, the results of the tandem leg stance would reflect the rough play, through higher point deduction, and therefore, worse scores. Additionally, on the days members of the control group complained of minimal sleep, the group collectively scored worse on the tandem stance assessment. Sleep is crucial to cognitive function (Walker), and a reduction of sleep could affect the results of the tandem leg stance assessment. Out of the three balance assessments, the tandem stance is the most effective measure of proximate cognitive change, but is not an effective measure of cognitive change over time, due to the inconsistent nature of the test results.

11 11 The single leg stance point deductions for football players provides the most conclusive assessment results out of the balance assessments that negative cognitive change occurred throughout the season for the football players. The control group scores on the single leg stance assessment improved over time, which is most likely related to test familiarity and practice of the test. The football player scores on the single leg stance assessment slowly regressed, and spiked to the highest score during the final assessment. In comparison to the controls who improved, the football players did experience negative changes in coordination and balance, which could be a result of cognitive change over time. The Online Reaction Time Test results for both football players and controls present similar trends to the single leg balance test. Football player reaction time primarily increased as the season progressed, from an average of approximately 0.24 seconds to 0.32 seconds. Conversely, control reaction time decreased as the study progressed, from an average of approximately 0.30 seconds to 0.28 seconds. Additionally, the difference in fluctuation between both groups is significant; the range of average scores for controls throughout the study was 0.04 seconds, whereas the range of average scores for the football players was 0.06 seconds. Overall, the football players have a negative trend throughout the season and the controls have a positive trend, which is most likely related to familiarity and ease with the test over time. The most direct assessment of cognitive change is the SCAT 2/ImPACT assessment, which assesses immediate memory, concentration, and recall memory. The average assessment score of immediate memory (proximate recall of words) for both controls and football players during the first assessment was approximately 4.9. However, after the first assessment, average football player scores decreased and the final average was 4.5. The final control average,

12 12 however, was 5.0. These results show a negative cognitive change in recall memory for football players. The two part concentration assessment results fluctuated for the football players throughout the season; the reverse number recall scores ranged between 3 and 4 and the months in reverse order scores ranged between 0 and 1. For the controls, however, the months in reverse order score stayed consistently at 1, and the average score for number recall was 4.5 and was approximately 4.5 for each testing session. Overall, based on these results, control group concentration was better than football player concentration, which is a sign of cognitive change for the football players. However, like the tandem stance of the balance assessment, the concentration assessment is the most effective measure of proximate cognitive change from the SCAT 2 assessment, but is not an effective measure of consistent cognitive change over time, due to the inconsistent nature of the test results. Lastly, the most conclusive results from the SCAT 2 assessment that indicate negative cognitive change for the football players come from the recall memory portion of the SCAT 2. The average recall memory score for football players was a 3.5 and for the control group, was a 3.9. The football players went from an average score of 4 in test 1 to 3.3 in test 6, whereas the controls went from a 4 to a 3.6. (The controls once again spoke of sleep deprivation during test 6.) Recall memory is constant unless acted upon by an outside force, and in this case, the outside force of football decreases the overall score on the recall memory assessment, indicating a potential negative change in cognition for the football players. Before the season began, I asked players through an ID number survey if they had concussions in the past. Three players indicated having 2 concussions, and these three players

13 13 (tracked solely through their ID numbers) scored an average of 1 to 3 points overall lower on the SCAT II assessment per testing session. These results indicate that previous concussions and football are linked with a change in cognition. It is important to consider other factors that could affect the scores of the SCAT 2, balance assessment, and Online Reaction Time Test, such as sleep deprivation, stress, and hunger. These factors can skew results at different intervals, especially for control groups. players. Conclusion: Overall, however, these results are consistent with negative cognitive change for football These results provide preliminary evidence that high school football can result in cognitive change. As a result, precautions need to be taken in order to protect adolescent athletes from further cognitive decline. Additional research needs to be done in order to determine which precautions are best to take. This research may be conducted through the National Football League and an NIH funded project; it is necessary to combine people who understand the game of football and the nature of tackles, hits, and plays, with to people who understand the science behind these tackles and hits, and how they affect player's minds.

14 14 Works Cited Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports Health. 2011;3(3): Breslow, Jason M. "High School Football Players Face Bigger Concussion Risk."PBS. PBS, 31 Oct Web. 19 May "Concussion and Mild TBI." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 15 Aug Web. 19 May Halstead, Mark E., and Kevin D. Walter. "Sport Related Concussion in Children and Adolescents." Official Journal of the American Academy of Pediatrics. American Academy of Pediatrics, 30 Aug Web. 19 May Ferguson RW, Safe Kids Worldwide Analysis of Consumer Product Safety Commission s (CPSC) National Electronic Injury Surveillance System (NEISS) data, Nasreddine, Z. "The Montreal Cognitive Assessment." The Montreal Cognitive Assessment. CEDRA, n.d. Web. Sept Toporek, Bryan. "High School Football Can Lead to Long Term Brain Damage, Study Says." Education Week. Editorial Projects in Education, 6 Dec Web. 19 May Walker, Matthew P. "The Role of Sleep in Cognition and Emotion." Annals of the New York

15 15 Academy of Sciences (2009): Web. Appendix Purpose Consent Form for Parents: Cognitive Change in High School Football The purpose of this study is to gather information on the cognitive changes faced by high school athletes playing football. Specifically, the findings of this study may help scientific researchers determine whether football should be altered in order to make the game safer for athletes. Study Methods In order to gather information on the potential cognitive changes posed for athletes playing football, we will administer cognitive assessments based on the SCAT II (Sport Concussion Assessment Tool 2), Online Reaction Time Test, and ImPACT test (Immediate Post Concussion Assessment and Cognitive Testing) to all participants on a weekly basis. Assessments will be administered by Athletic Trainer Tom Hur and student researcher Bernadette Darcy. The Online Reaction Time Test presents a computerized stoplight interface. It is initially a red stoplight. The participant clicks the Click Here When Green button as soon as the light turns green. The participant repeats this exercise 5 times. We record the average of the 5. This is an assessment of reaction time. The Online Reaction Time Test takes about 1 minute to finish. The ImPACT is a computerized exam utilized in many professional, collegiate, and high school sports programs across the country to successfully diagnose and manage concussions. The SCAT

16 16 II is a similar test used to assess concussion diagnosis over time, with additional balance and coordination components. However, studies show that both exams also assess cognitive function. From these exams, we have selected portions that assess working memory, concentration, recall memory, and balance. Specifically, our assessment entails asking participants to recall a list of 5 words (i.e. apple, baby, perfume, saddle, bubble), to count backward from 100 by a number (i.e.7), to list the months in reverse order (Dec., Nov., Sept ), and to recall as many words as possible from the beginning of the assessment. This ImPACT/SCAT II modified component takes about 3 minutes to complete. The balance component incorporates 3 positions: a double leg stance (standing, feet together with hands on hips and with eyes closed), single leg stance (standing on non dominant foot with hands on hips and eyes closed), and tandem stance (standing heel to toe with non dominant foot in back). Participants will stand in each position for 20 seconds. Errors of balance include lifting hands off hips, stumbling or falling, or remaining out of the test positing for greater than five seconds. This test assesses change in balance capacity over time. The balance component takes about 2 minutes. Overall, our adapted tests take about 6 minutes total to complete for each participant. Assessment of Risk, Anonymity and Volunteer Basis There are no potential risks for any participants in this study. The results of the study will be published ANONYMOUSLY; all participants will be assigned a number and all test results will be associated with this number. Participation in this study is completely voluntary. If you do not want your child to participate, he will not face any negative consequences. Please be aware that if he does decide to participate, he may stop participating at any time and he may decide not to answer any specific question.

17 17 Contact Information If you have any questions regarding this study please contact athletic trainer via or research advisor at. Thank you for your cooperation. _ If you DO NOT want your child to participate in this study, please check the box and sign your name. Parent Signature Date Why are we doing this research? Participant Assent Cognitive Change in High School Football We are doing this research to find out more about the relationship between potential changes in the teenage brain and high school football. Important things to know You get to decide if you want to take part in this study You can say No or you can say Yes If you say Yes, you can always say No later. What would happen if I join this research? If you decide to be in the research, we would ask you to do the following: Participate in weekly cognitive assessments based on the SCAT II, ImPACT, and Online Reaction Time Test. Collectively, the assessments will take 6 minutes to complete. The Online Reaction Time Test presents a stoplight that is initially red. You click the Click Here When Green button as soon as the light turns green. You repeat this exercise 5 times. We record the average of the 5. This is an assessment of reaction time. The Online Reaction Time Test takes about 1 minute to finish. From the ImPACT and SCAT II, we chose parts of the exams that assess working memory, concentration, recall memory, and balance. Specifically, our exam entails asking you to recall a list of 5 words (i.e. apple, baby, perfume, saddle, bubble), to count

18 18 backward from 100 by a number (i.e. 8), to list the months in reverse order, and to recall as many words as possible from the beginning of the assessment. This test takes about 3 minutes to complete. The balance test incorporates 3 positions: a double leg stance (standing, feet together with hands on hips and with eyes closed), single leg stance (standing on non dominant foot with hands on hips and eyes closed), and tandem stance (standing heel to toe with non dominant foot in back). You will stand in each position for 20 seconds. This test assesses change in balance ability over time. The balance component takes about 2 minutes. Are there any risks for me by participating in this study? This study poses no risks to you. The results of the study will be published ANONYMOUSLY; you will be assigned a number and all test results will be associated with this number only Will I receive compensation? Because we do not have the funds and are part of a public school, you will not be paid to be in the study. However, we thank you for your participation. If you have any questions or concerns... You can ask questions any time. You can talk to Bernadette Darcy, Mr. Tom Hur, or Mr. Jeffrey Angus. Ask us any questions you have. Take the time you need to make your choice _ If you want to participate, you can sign write your name below. (To be written by participant/adolescent) Name of Participant Signature of Participant Date Printed Name of Researcher

19 19 Signature of Researcher Date Printed Name of Research Advisor Signature of Research Advisor Date

Military Acute Concussion Evaluation

MACE Military Acute Concussion Evaluation Patient Name: Service Member ID#: Unit: Date of Injury: Time of Injury: Examiner: Date of Evaluation: Time of Evaluation: CONCUSSION SCREENING Complete this section