OBJECTIVES:To examine test-retest reliability and reliable change of the Sport Concussion Assessment Tool-6 (SCAT6) cognitive and tandem gait components in a large sample of culturally diverse professional ice hockey players. METHODS:National Hockey League (NHL) and American Hockey League (AHL) players undergoing medical evaluations prior to the 2023/2024 (time 1) and 2024/2025 (time 2) seasons completed pre-season NHL Modified SCAT6 evaluations (referred to as SCAT6), including Total Cognitive Score and Tandem Gait components (n=1388). Data were extracted from an existing clinical database. Test-retest reliability was examined in English and English as a second language/non-English language preference speakers (ESL), using the Pearson coefficient (r) and intraclass correlation coefficient, and reliable change indices were developed. RESULTS:Players were re-assessed on average 353.69±46.01 days following their baseline. A regression-based reliable change model incorporating baseline scores and word list form number explained 40% of the variance in time 2 SCAT6 Total Cognitive Score performance. Test-retest reliability for Concentration components for English speakers ranged from r=0.54-0.61 and for ESL speakers from r=0.56-0.60. A 2-point decline represented a reliable change in performance for both language groups. Test-retest reliabilities for Tandem Gait with skates ranged from r=0.69-0.72 compared with r=0.44-0.51 without skates. CONCLUSIONS:Results showed adequate reliability for Tandem Gait in skates and marginal reliability for the Total Cognitive Score. Though cognitive components were still somewhat below commonly accepted clinical thresholds for adequate test-retest reliability, the study provides initial evidence that the test-retest reliability of SCAT6 components is appropriate for both English and ESL speakers in baseline/retest models.

CONTEXT:There is significant interest in jugular venous compression (JVC) devices from multiple parties, including sports physicians, athletic trainers, athletes, and parents. OBJECTIVE:To examine the effects of JVC on repetitive head impacts and evaluate their effectiveness in reducing brain injury and concussion risk in sport. DATA SOURCES:Embase, Cochrane Central Register of Controlled Trials, CINAHL Plus, SPORTDiscus, Web of Science Core Collection - SCI-EXPANDED, SSCI, AHCI, ESCI, American Psychological Association, PsycInfo, WHO International Clinical Trials Registry Platform (ICTRP), ProQuest Dissertations and Theses Citation Index (Web of Science), Europe PMC, and PubMed. STUDY SELECTION:Full-text, peer-reviewed manuscripts of primary research, published between 2010 and 2024. STUDY DESIGN:Scoping review. LEVEL OF EVIDENCE:Level 5. DATA EXTRACTION:A total of 22 articles met the inclusion criteria. These articles were categorized into 4 groups: animal models (n = 4), biomechanics in humans (n = 4), evidence in athletes (n = 11), and evidence in Special Weapons and Tactics Breacher Training (SWAT) (n = 3). Several of the athlete articles used the same cohort of athletes. RESULTS:There was no difference in concussion rates in athletes between collared and noncollared groups during a season, while evidence from animal and tactical populations was limited to mechanistic and imaging outcomes. In both athletes and SWAT personnel, there were no clinically significant differences in neurocognitive performance between groups. There are statistically significant imaging changes between collared and noncollared groups; however, the imaging changes were not consistent and are of uncertain clinical significance. Furthermore, 6 out of 11 studies in athletes are currently under investigation. The available evidence supports that JVC can increase intracranial pressure, but it remains unknown if this results in any clinically meaningful benefit. CONCLUSION:Although no adverse outcomes are reported with collar use, current research does not support the effectiveness of JVC collars for concussion reduction and use for mitigation of repetitive head impact. Additional studies from diverse research teams with independent funding sources are required.

MS is a disease characterised by demyelination of the central nervous system resulting in decreased quality of life, increased anxiety, depression, fatigue, and cognitive dysfunction. Attention is frequently impaired in MS. A previous study demonstrated impairment specifically in the attentional alerting domain. However, this study did not establish whether the impairment was in intrinsic or extrinsic alertness, and did not examine the neural substrates associated with the impairment. To examine the alerting deficit in MS and establish the associated neural substrates, 40 female patients with MS and 40 age and gender match controls completed an alertness-motor paradigm designed to test both intrinsic and extrinsic alertness during functional magnetic resonance imaging. We found the MS group had a significant deficit in extrinsic alertness, which was associated with a lack of dorsal prefrontal cortex (DPFC) activation. In addition, reduced gray matter volume in the dorsal prefrontal cortex, thalamus, and basal ganglia were observed. Both fMRI and VBM correlations were observed between fatigue severity scale (FSS) scores and the DPFC. The combined results of our functional and structural MRI data analysis demonstrate that attention deficits in females with MS are a result of the complex relationship between brain tissue loss having a significant impact on functional brain regions subserving executive control of cognitive functions. Understanding the underlying mechanisms of cognitive performance and how they relate to fatigue are crucial to developing novel treatments for the symptoms of MS.

OBJECTIVE:Despite disease modifying therapies' (DMT) demonstrated efficacy for treating relapsing MS, around 40% of patients discontinue use. This study aimed to understand the mechanism of action of Motivational Interviewing plus cognitive behavioral therapy (MI-CBT) in a previously conducted randomized controlled trial in which the MI-CBT intervention successfully promoted DMT re-initiation of participants compared to a treatment as usual (TAU) condition. METHODS:This secondary analysis (N = 91) explored changes in motivation (a single item motivation "ruler" [Mot∆], and the Brief Motivation Scale [BMS∆]), autonomous motivation (AR∆), personal control (PC∆), treatment control (TC∆), and confidence to reinitiate (Con∆) as potential mediators of the treatment effect, using logistic regression. RESULTS:Logistic regression analysis including all potential mediators as predictors of initiation indicated the BMS∆ was the only statistically significant predictor (OR = 1.61, p = 0.010). When BMS∆ was removed Mot∆ (OR = 1.22, p = 0.002) and PC∆ (OR = 1.67, p = 0.002) were statistically significant predictors of initiation. CONCLUSION:The MI-CBT intervention appeared to work primarily by increasing motivation to initiate DMT.

Abstract Objective A recent randomized-controlled (phase III) clinical trial examined the efficacy of an internet-delivered cognitive behavioral therapy (iCBT) intervention designed to treat depressive symptoms in persons with multiple sclerosis (PwMS). Significant mean reductions in depressive symptoms were found in the stand-alone iCBT and guided-iCBT conditions compared to the control group. The purpose of the current study was to identify the proportion of PwMS who responded to iCBT (stand-alone and guided) for depression compared to a waitlist control group. Method 224 PwMS completed the Beck Depression Inventory-II (BDI-II) to measure depression severity at baseline and post-intervention. Reliable change index (RCI) scores for depressive symptoms were calculated for each participant. Clinical significance was determined using the 95th percentile cutoff (RCI = ± 1.96). Results Combining the stand-alone and guided-iCBT (n = 147) groups, 89 PwMS (61%) demonstrated a reliable decrease in BDI-II scores, whereas 58 PwMS (39%) did not show a reliable decrease. For waitlist controls (n = 77), 19 PwMS (25%) showed a reliable decrease in BDI-II scores, χ2(2, N = 224) = 33.82, p < 0.001, φ = 0.39. Conclusions We found that the iCBT treatment was highly effective, with 61% of PwMS showing a reliable decline in depressive symptoms compared with only 25% of waitlist controls. Still, generally consistent with previous research, almost 40% of PwMS did not respond to iCBT for depression. Future work will investigate baseline cognitive, psychosocial, and disease-related predictors of response to iCBT to better understand treatment outcomes and possible targets to optimize interventions for depression in MS.

Objective To describe the sequence of events leading to concussion in NHL players from 2014–15 to 2018–2019 and compare injury characteristics to prior to Rule 48 (i.e., Illegal Check to the Head). Design Descriptive epidemiological study. Setting National Hockey League (NHL) Video Analysis Program. Digital video records were coded and analysed using a standardised protocol. Participants NHL players diagnosed with concussion where digital video footage of the injury was available (2014–19, n=516; 2006–2010 [before Rule 48], n=189). Outcome Measures Player position, period, location, and sequence of events (e.g., player contact, environment, puck possession, game situation) were analyzed for frequency. Comparison to 2006–2010 data was done with randomly resampling (1000 iterations), akin to a one-sample t-test. Main Results For 2014–19 seasons, sequence of events resulting in concussion were characterized by body checks (to the torso) around the perimeter of the ice. Compared to years 2006–2010, 2014--19 was characterized by significantly fewer concussions following open ice hits (47% vs. 37%; p<0.001), hits to the head via shoulder (42% vs. 31%; p<0.001), fights (9% vs. 3.3%; p<0.001), and lateral hits to head (35% vs. 21%; p<0.001). Concussive events were also less likely to occur in the first period (47% vs. 36%; p<0.001). Conclusions This study describes several differences in the sequences of events leading to concussion during the 2014 – 2019 seasons compared to prior years (2006–2010) predating the implementation of Rule 48.

Background: A majority of the people with multiple sclerosis (pwMS) experience sleep disturbances. Frailty is also common in pwMS. The geriatric literature strongly suggests that frailty is associated with worse sleep outcomes in community-dwelling older adults, but this association has yet to be explored among pwMS. This study focused on examining the association between frailty and sleep quality in pwMS.Methods: Seventy-six people with both MS and obesity (mean age: 47.6 +/- 10.9 years, 81.6 % female, mean body mass index (BMI): 37.10 +/- 5.5 kg/m(2), mean Patient Determined Disease Steps (PDDS): 0.82 +/- 1.20) were included in this cross-sectional secondary analysis. A comprehensive frailty index (FI) based on 41 health deficits from various health domains was calculated based on standardized procedures. Sleep quality was determined by the Pittsburgh Sleep Quality Index questionnaire (PSQI).Results: Overall, 67.1 % of the participants were identified as non-frail (FI <= 0.25), and 32.9 % were identified as frail (FI > 0.25). A significant correlation was observed between FI scores and global PSQI scores (rho = 0.43, p < 0.05). Cross-tabulation analyses revealed that frail participants had worse subjective sleep quality, sleep latency, habitual sleep efficiency, sleep disturbances, daytime dysfunction, and higher use of sleep medications compared to non-frail participants (p < 0.05).Conclusions: The current study identified a significant association between frailty and sleep quality in people with both MS and obesity with minimal disability. These findings underscore the importance of untangling the relationship between frailty and sleep quality in pwMS. These results could lead to a more targeted approach for rehabilitation interventions aiming to improve frailty in MS.

Objective To examine game-related factors that are most reliably associated with concussions in which players do not demonstrate on-ice visible signs. Design Retrospective cohort. Setting National Hockey League (NHL) Regular Season Games over two seasons (2014–15 & 2015–16). Participants NHL players diagnosed with concussion; analysis was limited to events where digital video of the injury was available (n=151). Interventions (or Assessment of Risk Factors) Game-related factors: ice location, time zone change from prior game, time of season, hits received and given within the same game and the last 7 days, and whether the injured player played the previous day. Outcome Measures Both univariate and multivariate analyses were completed to examine differences in game-related factors between concussed players with no visible signs (-VS) and those with visible signs (+VS). Main Results Univariate analysis between the -VS and +VS groups found no statistically significant differences. PLS discriminant analysis found that concussions with -VS were associated with fewer hits given in the last 7 days (bootstrap ratio = 2.3, p = 0.02), fewer hits given in the last game (bootstrap ratio = 2.3, p = 0.02), and fewer total hits in the last game (bootstrap ratio = 2.1, p = 0.03). Conclusions The present study found that players who sustained a concussion with no visible signs had fewer hits given and fewer total hits in the proceeding game(s).

Objective The SCAT5 introduced Immediate Memory (IM) and Delayed Recall (DR)10-word lists to improve the ceiling effects found on SCAT3 5-word lists. We examined whether the 10-word lists improved the normative distribution of scores over the 5-word lists at baseline among professional hockey players. Design Retrospective Cohort. Setting Outpatient professional hockey. Participants English-language preference professional hockey players completed the SCAT3 5-word lists (n=1123) during pre-season in 2017 and SCAT5 10-word lists (n=1479) in 2019 for a total sample of 2602. Independent Variables 5-word vs. 10-word SCAT lists. Outcome Measures SCAT3 5-word IM and DR, SCAT5 10-word IM and DR scores. Main Results SCAT3 5-word IM lists produced a significant total score ceiling effect (M=14.62, md=15). A perfect score of 15 was achieved by 809 players (72%) on the 5-word list. In contrast, the SCAT5 10-word IM lists total scores were normally distributed (M=21.30, md=21). Only 1 player (0.1%) obtained a perfect score. Older players outperformed younger players (rs=.19, p<.001). Differences were found across language groups, F(7,1863)=7.14, p<.001, and form versions of the lists, F(2,1868)=62.41, p<.001. The 5-word DR component yielded similar distributions (M= 3.89, md=4) with 39% of players obtaining perfect scores. The 10-word mean DR score=7.02 (md=7). Again, older players outperformed younger players (rs=.12, p< .001). No language differences emerged. Conclusions The 10-word lists improved the distribution of scores on the SCAT5 IM/DR tasks, which should improve the detection of impaired performance following concussion. Significant differences were found in age, language preference and form.

Objective The purpose of this study was to create SCAT5 reliable change scores in a large sample of professional hockey players. Design Longitudinal cohort. Setting National Hockey League (NHL) pre-season medical evaluations. Participants All NHL players were given the NHL modified SCAT5 prior to both the 2018–19 and 2019–20 seasons. Valid 10-word List Learning (n=986), Delayed List Recall (n=986), modified Balance Error Scoring System (n=828), and Concentration (n=987) data were extracted for players with 2 consecutive valid baselines and no intervening suspected concussion evaluations. Outcome Measures Paired t-tests were used to examine differences between time 1 and time 2 performance. Pearson correlations were used to assess test-retest reliability and reliable change was calculated using the Iverson method. Main Results Correlations between repeat administrations had mostly small to moderate effects (r =.29 to .51). Due to significant list-learning form differences, .80, .90, .95, and .99 confidence interval reliable change metrics were developed for 3 list administration orders (1,2; 2,3; 3,1) for English Preference and non-English preference speakers. Reliable change metrics and their associated base rates are presented for mBESS and concentration subscores. Conclusions This study offers 1-year test-retest reliability and reliable change metrics for a large group of English and non-English preference professional hockey players. Data represent an initial step in evaluating the psychometric properties of the SCAT5 10-word list and Concentration indices – as well as providing reliable change guidelines to aid instrument interpretation. This abstract has been published in full manuscript format and has the following citation: BMJ Citation https://bjsm.bmj.com/content/early/2022/03/24/bjsports-2021-104851.long

Background: Data obtained from the National Hockey League (NHL) have shown that a risk prediction model, including both visible signs and mechanisms of injury, improves the identification of possible concussion. However, only about half of concussions diagnosed by club medical staff in the NHL exhibit visible signs. At present, the NHL concussion spotter protocol does not include central league spotters’ subjective judgments of the severity of forces associated with a direct hit to the head (perceived force severity [PFS]) or whether players brace before a hit (bracing). Purpose: To examine the interrater reliability, preliminary validity, and association with concussion diagnosis of central league spotter determinations of PFS and bracing. Study Design: Cross-sectional study. Methods: Video footage of 1071 events after a direct or indirect blow to the head were observed from the 2020-2021 and 2021-2022 NHL seasons. These events were classified into 4 groups: concussion with visible signs; concussion without visible signs; no concussion with visible signs; and no concussion without visible signs. A total of 50 events were randomly selected from the total events in each group. Then, 2 raters (NHL central league spotters) coded PFS for each of the 200 video events as low, medium, or high. Bracing was coded as no bracing, insufficient bracing, or full bracing. Results: Interrater reliability was fair to moderate for the categorical and continuous ratings of both PFS (κ = 0.36 and 0.45, respectively) and bracing (κ = 0.40 and 0.49, respectively). There was no significant association between concussion diagnosis and either PFS ( Z = 0.00, P = .99) or bracing ( Z = 0.77, P = .44). Exploratory, post hoc analyses suggested a possible relationship between bracing and reduced concussion risk among a select subsample of events with no visible signs ( r = −0.29, P < .01). Conclusion: The interrater reliability for PFS and for bracing was fair to moderate. Neither PFS nor bracing were significantly related to concussion diagnosis, but they were significantly associated with other visible signs and mechanisms of injury.

Research Objectives To explore the association between frailty and sleep quality in people living with multiple sclerosis (MS). Design Secondary analysis. Setting University research laboratory. Participants A total of 76 individuals with multiple sclerosis (mean age: 47.63±10.89 years, 81.6% female, mean body mass index (BMI): 37.10±5.48kg/m2, PDDS: 0.82±1.20) were included in this cross-sectional analysis. Interventions Not applicable. Main Outcome Measures A comprehensive frailty index (FI) based on 41 health deficits from various health domains was calculated. Sleep quality was determined by the Pittsburgh Sleep Quality Index questionnaire (PSQI). The relationship between FI and sleep quality was examined by means of non-parametric partial correlations. Results Overall, 67.1% of the participants were identified as non-frail (FI ≤ 0.25) and 32.9% were identified as frail (FI > 0.25). A significant correlation between higher FI scores and higher global PSQI scores was observed (ρ=0.43, p< 0.0). In addition, cross-tabulation analyses revealed that frail participants had worse subjective sleep quality, sleep latency, habitual sleep efficiency, sleep disturbances, and daytime dysfunction, and higher use of sleep medications compared to the non-frail (p < 0.05). Conclusions The current study identified a significant association between frailty and sleep quality in people living with MS with minimal disability. These findings underscore the critical importance of untangling the relationship between frailty and sleep quality in people living with MS. This finding could lead to a more targeted approach for rehabilitation interventions aiming to improve frailty in MS. Author(s) Disclosures This study was supported by grants from the National Multiple Sclerosis Society (MB-1807-31633, RG-1907-34376, RG-1901-33239).

Importance:The Sports Concussion Assessment Tool-5 (SCAT5) has been recommended for concussion evaluation and utilizes both a subjective reported symptom grading scale and objective measures of concussion including a cognitive evaluation: the Standardized Assessment of Concussion (SAC). The SAC includes testing for orientation, immediate memory, concentration, and delayed recall; a 10-word list is used to assess immediate memory and delayed recall. Objective:To determine the diagnostic accuracy of components of the SCAT5 and to provide a framework for clinical interpretation. Design, Setting, and Participants:This prospective case-control study of National Collegiate Athletic Association Division I athletes from any sport was conducted from July 2020 to December 2022 at 4 universities. Athletes completed baseline SCAT5 testing using the 10-word list. When an athlete presented acutely with suspected concussion (sideline or within 2 days), the tests were repeated. If a concussion was diagnosed, a control athlete underwent the same tests. Controls were identified and matched on comorbid conditions, sex and gender, sport, season, and baseline scores. Data analysis was conducted from August to October 2023. Main Outcomes and Measures:The primary outcomes were area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive and negative predictive value, and test-retest reliability of the symptom score; symptom severity score; the total SAC score; and the orientation, immediate memory, concentration, and delayed memory subcomponent scores on the SCAT5 compared with clinical diagnosis of concussion. Results:Baseline and postinjury data were collected on 92 athletes with concussion and 92 matched control athletes (96 men [52%] and 88 women [48%]; 110 who played a sport other than football [59%]). Diagnostic utility was considered excellent for symptom score (AUC, 0.93; 95% CI, 0.89-0.96) and symptom severity score (AUC, 0.94; 95% CI, 0.90-0.97). An increase of 2 points on the symptom score was associated with a sensitivity of 86% (95% CI, 78%-92%), specificity of 80% (95% CI, 70%-87I%), and positive predictive value of 81% (95% CI, 72%-88%). The total SAC score had poor to fair diagnostic utility (AUC, 0.70; 95% CI, 0.63-0.77); however, 41 athletes with concussion (45%) had a total SAC score at or above their baseline score (ie, within normal limits). The diagnostic utility was poor to fair for immediate memory (AUC, 0.68, 95%CI, 0.61-0.75) and delayed recall (AUC, 0.69; 95% CI, 0.62-0.77) and not useful for orientation (AUC, 0.49; 95% CI, 0.43-0.56) and concentration (AUC, 0.52 95% CI, 0.44-0.61). Test-retest reliability was fair for total SAC and poor for immediate memory and delayed recall, orientation, and concentration. Conclusions and Relevance:In this case-control study of the diagnostic accuracy of reported symptoms and the SAC, reported symptoms were the most accurate indicator of concussion while the 10-word SAC had limited sensitivity. These findings suggest that understanding the properties of the SAC is important when making the diagnosis of concussion.

The reinforcer pathology model posits that core behavioral economic mechanisms, including delay discounting and behavioral economic demand, underlie adverse health decisions and related clinical disorders. Extensions beyond substance use disorder and obesity, however, are limited. Using a reinforcer pathology framework, this study evaluates medical adherence decisions in patients with multiple sclerosis. Participants completed behavioral economic measures, including delay discounting, probability discounting, and a medication purchase task. A medical decision-making task was also used to evaluate how sensitivity to mild side effect risk and efficacy contributed to the likelihood of taking a hypothetical disease-modifying therapy. Less steep delay discounting and more intense (greater) medication demand were independently associated with greater adherence to the medication decision-making procedure. More generally, the pattern of interrelations between the medication-specific and general behavioral economic metrics was consistent with and contributes to the reinforcer pathology model. Additional research is warranted to expand these models to different populations and health behaviors, including those of a positive health orientation (i.e., medication adherence).

Importance A rule prohibiting a direct hit to the lateral side of the head (ie, Rule 48-Illegal Check to the Head) was introduced in the National Hockey League (NHL) in the 2010-2011 season and refined in the 2011-2012 season to widen the application to include direct contact to all areas of the head.Objective To compare the incidence and proportion of concussions that occurred following hits to the head before and after the implementation of Rule 48.Design, Setting, and Participants This retrospective cohort study used a before and after design to evaluate concussions among NHL players in regular season games. Data from the 4 seasons preceding the implementation of Rule 48 (2006-2007 to 2009-2010) were compared with data from 5 seasons following its implementation (2014-2015 to 2018-2019). Data were analyzed from October 31, 2021, to November 30, 2022.Main Outcomes and Measures The incidence and relative proportion of concussion characteristics and mechanisms before and after the introduction of Rule 48.Results In the analysis of 688 concussions for NHL seasons spanning 2006 to 2010 (n = 231) and 2014 to 2019 (n = 457), there was an overall increase in the incidence of concussion between the 2 time frames, although the incidence of concussions due to hits to the lateral aspect of the head decreased from 1.6/100 games to 1.0/100 games (estimated difference, 0.6/100 games [90% credible interval (CrI), 0.30/100 games to 0.90/100 games). There was also a reduction of 18.8 (90% CrI, 13.0-23.7) percentage points in the proportion of concussions due to hits to the lateral aspect of the head from 80 of 231 concussions (34.6%) to 61 of 457 concussions (13.3%). The incidence of concussions following hits to the head from body checks using the shoulder, arm, and glove was similar before and following the implementation of Rule 48. However, the proportion was reduced 14.7 percentage points from 113 of 231 concussions (48.9%) before to 149 of 457 concussions (32.6%) after implementation of Rule 48 (90% CrI of the difference, 8.9-20.7 percentage points).Conclusions and Relevance The findings of this cohort study of NHL players suggest that after the introduction of Rule 48, the incidence rate and proportion of concussions from contact to the lateral aspect of the head decreased, as did the proportion of concussions following direct hits to the head.