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Concussions) on the Cognitive and Academic Functioning of Early Adolescent Rugby Union Players: a Controlled, Longitudinal, Prospective Study

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Concussions) on the Cognitive and Academic Functioning of Early Adolescent Rugby Union Players: a Controlled, Longitudinal, Prospective Study The impact of repeated mild traumatic brain injuries (concussions) on the cognitive and academic functioning of early adolescent rugby union players: A controlled, longitudinal, prospective study. A thesis submitted in fulfillment of the requirements for the degree of PhD (PSYCHOLOGY) in the Department of Psychology, Faculty of Community and Health Sciences, University of the Western Cape NAME: Debbie Alexander STUDENT NUMBER: 2562951 SUPERVISOR: Prof. Charles Malcolm Key words: Concussion/mild traumatic brain injury (MTBI), cumulative MTBI, cognitive deficits, academic deficits, early adolescent, Rugby Union players, brain reserve capacity. SEPTEMBER, 2007 To my husband, Grant Without you little would be possible. Even less would be worthwhile. To my children, Candace, Keaton and Laine You serve as a constant source of inspiration for me. ii ACKNOWLEDGEMENTS I would like to thank the following people; without whose assistance the completion of this thesis would not have been possible: • Professor Charles Malcolm for his calm, confident guidance and supervision, steely determination and endless support; • Dr Martin Kidd for his patience, guidance and assistance with the statistics • Gonzalo Aguilar for assistance and guidance with making sense of the statistics • Brendan Fogarty who had the courage to support the initiation of this project • The headmasters, teachers and coaches for their support and assistance • The parents for their enthusiasm and support and most of all for allowing their boys to participate in the study • The boys for their participation and commitment to the project • Candace Oddy for many hours spent scoring, checking and capturing the data • Laine Alexander for assistance with the referencing • Family, friends and colleagues for providing generous encouragement and support • Grant Alexander for loving support of every kind at every level iii ABSTRACT This study investigated, within the context of Brain Reserve Capacity (BRC) theory, whether repeated concussions resulted in residual deficits in cognitive and academic functioning of early adolescent rugby players relative to non-contact sports controls. Participants were 150 grade 7 preparatory school boys tested pre and post three winter sport seasons using neuropsychological and academic tests. Participants were matched in terms of age, sex, grade, school, language, participation in sport, socio-economic status and estimated IQ. Chi-square analysis revealed that the rugby group reported significantly more concussions than controls (p< 0.01). Wechsler Intelligence Scale for Children WISC III Vocabulary Subtest VOC scores (estimate of BRC) were significantly higher for controls versus rugby players (p< 0.01) (d = 4.5) at baseline. Correlational analysis revealed a strong positive relationship between VOC and Academic Aggregate AGG (r = 0.52) and Similarities SIM (r=0.55) a measure of abstract thinking. Group mean comparisons, using repeated measures ANOVA, across the battery of tests for the rugby and concussion group participants’ responses showed significant time effects (p < 0.01) for some measures, a significant group effect for SIM p = 0.03 (d =3)(rugby), with controls performing better than the rugby group. Analysis of the percentages of deficits for SIM (non-compromised participants) revealed that at baseline 12.5 % of the non rugby group performed below the appropriate norm in contrast to 17.4% of the rugby group. Three years later the outcome was 8.3% and 28.2% respectively. When VOC was factored into the analysis there was a significant difference between the scores of the control group with no concussions and the rugby group with multiple concussions, over time for AGG p=0.02 (d= 2.1)(combined). These findings suggest that: 1. early adolescent rugby players experience more concussions than controls; 2. they may be more vulnerable in terms of BRC; 3. they may be compromised in terms of the development of abstract thinking and over time following repeated concussion there is a decline in their academic scores. iv CONTENTS Page No Title i Dedication ii Acknowledgements iii Abstract iv Table of contents v-x List of appendices viii List of tables ix List of figures ix-x Page No CHAPTER 1: INTRODUCTION 1 1.1. RESEARCH CONTEXT 1 1.2. RESEARCH QUESTIONS 4 CHAPTER 2: LITERATURE REVIEW 6 2.1. TRAUMATIC BRAIN INJURY (TBI) 6 2.1.1. Types of TBI 6 2.1.2. Classification and Indicators of Severity of TBI 8 2.1.3. Classification and Definition of MTBI 16 2.1.4. Epidemiology of MTBI 17 2.1.5. Mild TBI across Age Groups 20 2.1.6. Mild TBI in Contact Sports: 23 2.1.6.1. Epidemiology 23 2.1.6.2. Boxing 24 2.1.6.3. American Football 25 2.1.6.4. Soccer 27 2.1.6.5. Australian Rules Football 28 2.1.6.6. Rugby League 29 v 2.1.6.7. Rugby Union 31 2.2. SEQUELAE OF MILD TRAUMATIC BRAIN INJURY (MTBI) 35 2.2.1. Neuropathology and Pathophysiology of MTBI 35 2.2.2. Neuropsychological Sequelae of MTBI 41 2.2.2.1. The Postconcussive Syndrome (PCS) 42 2.2.2.2. Objective Neuropsychological Sequelae 43 2.2.2.3. Neuropsychological Recovery following MTBI 44 2.2.2.4 Persistent Neuropsychological Deficits 47 2.2.2.5. Neuropsychological Sequelae of Cumulative MTBI 49 2.3. DEVELOPMENTAL DEBATE 53 2.4. NEUROPSYCHOLOGICAL ASSESSMENTS 62 2.5. BRAIN RESERVE CAPACITY THEORY (BRC) 69 2.6. RUGBY UNION RESEARCH IN SOUTH AFRICA 73 2.7. CONCUSSION MANAGEMENT POLICY 80 2.8. RELEVANCE OF THE CURRENT STUDY 81 CHAPTER 3: METHODOLOGY 88 3.1. PARTICIPANTS 88 3.1.1. Demographic Criteria 88 3.1.2. Selection Criteria 90 3.1.3. Exclusion Criteria 90 3.2. SAMPLE SIZE 91 3.3. PROCEDURE 94 3.4. CONSENT FORMS AND QUESTIONNAIRE 96 3.5. NEUROPSYCHOLOGICAL TEST BATTERY 97 3.5.1. General Intellectual Functioning 98 Wechsler Intelligence Scale for Children (WISC III) Vocabulary Subtest 3.5.2. Tests Sensitive to MTBI 99 3.5.2.1. Verbal Memory 99 vi Wechsler Memory Scale (WMS) Verbal Paired Associates (VPA I & II) 3.5.2.2. Processing Speed 101 WISC III Coding Subtest 3.5.2.3. Visual Memory 102 WISC III Coding Immediate and Delayed Recall 3.5.2.4. Abstract Thinking 103 WISC III Similarities Subtest 3.5.2.5. Motor Functioning 103 Detroit Motor Speed and Precision Test 3.6. ACADEMIC BATTERY 104 3.7. DATA PROCESSING AND STATISTICAL ANALYSIS 105 3.8. ETHICAL CONSIDERATIONS 108 CHAPTER 4: RESULTS 111 4.1. SUBJECTIVE MEASURES 111 4.2. OBJECTIVE MEASURES 115 4.2.1. Relationship Measures 116 4.2.2. Repeated Measures ANOVA (Group Mean Comparisons) 118 4.2.2.1. Concussion Measures 118 4.2.2.2. Rugby Measures 123 4.2.2.3. Compromised Measures 127 4.2.2.4. Combined Compromised and Concussion Measures 131 4.2.2.5. Combined Compromised and Rugby Measures 134 4.2.2.6. Combined Compromised Concussion and Rugby Measures 135 4.2.2.7. Combined Compromised Multiple Concussions and Rugby Measures 136 4.3. DESCRIPTIVE MEASURES (Percentages of Deficits) 138 4.4. INDIVIDUAL ANALYSIS / CASE STUDY 141 CHAPTER 5: DISCUSSION 155 5.1. CONTEXT OF THE STUDY 155 vii 5.2. AIMS, RESEARCH QUESTIONS AND HYPOTHESIS OF STUDY 161 5.3. DISCUSSION OF RESULTS 162 5.3.1. Concussions / MTBI 164 5.3.2. Brain reserve capacity within the research context 166 5.3.3. Between group differences 170 5.3.4. Within group differences 181 5.3.5. Individual differences 186 5.4. SUMMARY 189 5.5. IMPLICATIONS 192 5.5.1. Theoretical implications 192 5.5.2. Research implications 196 5.5.3. Policy implications 198 5.6. CRITIQUE OF CURRENT RESEARCH 199 5.7. LIMITATIONS OF CURRENT RESEARCH 201 REFERENCES 203 APPENDICES 1. Appendix A Headmaster consent form 222 2. Appendix B Parent consent form 224 3. Appendix C Pupil information and assent form 226 4. Appendix D Research questionnaire 228 5. Appendix E Assessment battery cover sheet 230 6. Appendix F WISC III Vocabulary Subtest 231 7. Appendix G WMS III – Verbal Paired Associates 233 8. Appendix H WISC III – Coding Subtest 240 9. Appendix I WISC – Coding: Incidental Recall – Immediate 242 10. Appendix J De Troit Motor Speed And Precision Test 243 11. Appendix K WMS III – Verbal Paired Associates: Delayed 245 12. Appendix L WISC III – Similarities 247 13. Appendix M WISC III – Coding: Incidental Recall – Delayed 249 13. Appendix N Percentages of cognitive and academic deficits 250 13. Appendix O Rugby 3 Combined effects 252 13. Appendix P Critical values of the F distribution 254 13. Appendix Q Norms for % of deficits 255 13. Appendix R PUBMED search 256 viii TABLES 1. Table 2.1 Summary of South African Research 75 2. Table 3.1 Rugby players per team per year 89 3. Table 3.2 Number of players in each position per year 89 4. Table 4.1 Percentages of participant’s reports of numbers of concussions 113 5. Table 4.2 Actual number / incidents of concussion reported 113 6. Table 4.3 Number of concussions per concussion grade reported prior to and during the study 114 7. Table 4.4 Concussion related symptoms reported during the study 114 8. Table 4.5 Number of participants falling into each concussion category in terms of Cognitive and academic assessment 118 9. Table 4.6 Results of concussions versus controls 119 10. Table 4.7 Results of rugby versus controls 124 11. Table 4.8 Results of compromised versus controls 128 12. Table 4.9 Number of participants with any concussion- with or without “problems” 133 13. Table 4.10 Percentages of cognitive deficits CD (-1SD in the direction of poor performance). Results reflecting Rugby> Controls 139 14. Table 4.11 Percentages of cognitive deficits CI (-1SD in the direction of poor performance).
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