Analysis of head impact exposure and brain microstructure response in a season-long application of a jugular vein compression collar: a prospective, neuroimaging investigation in American football

Gregory D Myer, Weihong Yuan, Kim D Barber Foss, Staci Thomas, David Smith, James Leach, Adam W Kiefer, Chris Dicesare, Janet Adams, Paul J Gubanich, Katie Kitchen, Daniel K Schneider, Daniel Braswell, Darcy Krueger, Mekibib Altaye, Gregory D Myer, Weihong Yuan, Kim D Barber Foss, Staci Thomas, David Smith, James Leach, Adam W Kiefer, Chris Dicesare, Janet Adams, Paul J Gubanich, Katie Kitchen, Daniel K Schneider, Daniel Braswell, Darcy Krueger, Mekibib Altaye

Abstract

Background: Historical approaches to protect the brain from outside the skull (eg, helmets and mouthpieces) have been ineffective in reducing internal injury to the brain that arises from energy absorption during sports-related collisions. We aimed to evaluate the effects of a neck collar, which applies gentle bilateral jugular vein compression, resulting in cerebral venous engorgement to reduce head impact energy absorption during collision. Specifically, we investigated the effect of collar wearing during head impact exposure on brain microstructure integrity following a competitive high school American football season.

Methods: A prospective longitudinal controlled trial was employed to evaluate the effects of collar wearing (n=32) relative to controls (CTRL; n=30) during one competitive football season (age: 17.04±0.67 years). Impact exposure was collected using helmet sensors and white matter (WM) integrity was quantified based on diffusion tensor imaging (DTI) serving as the primary outcome.

Results: With similar overall g-forces and total head impact exposure experienced in the two study groups during the season (p>0.05), significant preseason to postseason changes in mean diffusivity, axial diffusivity and radial diffusivity in the WM integrity were noted in the CTRL group (corrected p<0.05) but not in the collar group (p>0.05). The CTRL group demonstrated significantly larger preseason to postseason DTI change in multiple WM regions compared with the collar group (corrected p<0.05).

Discussion: Reduced WM diffusivity alteration was noted in participants wearing a neck collar after a season of competitive football. Collar wearing may have provided a protective effect against brain microstructural changes after repetitive head impacts.

Trial registration number: NCT02696200.

Keywords: Blood; Brain; Concussion; Injury prevention; MRI.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Figures

Figure 1
Figure 1
(A) Visual representation of the jugular vein and intracranial venous system. (B) Visual representation of the collar application located near the omohyoid process. The increased jugular vein dilation superior to the collar application and resultant backfilling of the intracranial venous system are represented to provide the hypothesised tighter fit of the brain inside the cranium. (C) Neck collar device employed in current investigation.
Figure 2
Figure 2
Study participant flow chart. (A) 11 excluded: no post-test (3), movement on MRI (7), season-ending injury (1); 2 reassigned from collar group due to non-compliance of collar wearing. (B) 7 excluded: movement on MRI (5), contraindication to MRI (1), season-ending injury (1). (C) 11 excluded: no post-test (3), movement on MRI (7), season-ending injury (1). (D) 7 excluded: movement on MRI (5), contraindication to MRI (1), season-ending injury (1). ITT, intention to treat.
Figure 3
Figure 3
Visual evidence of IJV dilation superior to omohyoid complex in response to Valsalva manoeuvre and with collar application. IJV, internal jugular vein.
Figure 4
Figure 4
Relative change in IJV dilation from baseline measured superior to collar location for Valsalva and collar conditions. IJV, internal jugular vein.
Figure 5
Figure 5
Histograms showing the distribution of number of impacts at different g-force. (A) No-collar (CTRL) group. (B) Collar group. CTRL, control.
Figure 6
Figure 6
(A) Graphical representation of average magnitude of head impacts (represented by height and colour) distributed about the sphere of the head for the CTRL (left, no-collar) and collar group (right). (B) Graphical representation of average frequency of head impacts (represented by height and colour) distributed about the sphere of the head for the CTRL (left, no-collar) and collar group (right). CTRL, control.
Figure 7
Figure 7
White matter regions with significant within-group AD reduction at postseason compared with preseason baseline. The significant regions (red-yellow regions, p

Figure 8

Bar plots of preseason and…

Figure 8

Bar plots of preseason and postseason AD values from individual athletes. (A) No-collar…

Figure 8
Bar plots of preseason and postseason AD values from individual athletes. (A) No-collar (CTRL) group; (B) collar group. AD, axial diffusivity; CTRL, control.

Figure 9

WM areas with significant between-group…

Figure 9

WM areas with significant between-group differences (CTRL vs collar), preseason versus postseason. (A)…

Figure 9
WM areas with significant between-group differences (CTRL vs collar), preseason versus postseason. (A) MD; (B) AD; and (C) RD. The significant regions (red-yellow regions, p

Figure 10

The right superior corona radiata…

Figure 10

The right superior corona radiata (light blue shadow area as determined by John…

Figure 10
The right superior corona radiata (light blue shadow area as determined by John Hopkins University s WM atlas) overlaid on the white matter regions with significant preseason versus postseason AD change (red-yellow area, p
All figures (10)
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References
    1. Daneshvar DH, Nowinski CJ, McKee AC, et al. . The epidemiology of sport-related concussion. Clin Sports Med 2011;30:1–17, vii doi:10.1016/j.csm.2010.08.006 - DOI - PMC - PubMed
    1. Fridman L, Fraser-Thomas JL, McFaull SR, et al. . Epidemiology of sports-related injuries in children and youth presenting to Canadian emergency departments from 2007–2010. BMC Sports Sci Med Rehabil 2013;5:30 doi:10.1186/2052-1847-5-30 - DOI - PMC - PubMed
    1. Schneider DK, Grandhi RK, Bansal P, et al. . Current state of concussion prevention strategies: a systematic review and meta-analysis of prospective, controlled studies. Br J Sports Med Published Online First: 1 Jun 2016 doi:10.1136/bjsports-2015-095645 - PubMed
    1. Barbic D, Pater J, Brison RJ. Comparison of mouth guard designs and concussion prevention in contact sports: a multicenter randomized controlled trial. Clin J Sport Med 2005;15:294–8. doi:10.1097/01.jsm.0000171883.74056.21 - DOI - PubMed
    1. Kemp SP, Hudson Z, Brooks JH, et al. . The epidemiology of head injuries in English professional rugby union. Clin J Sport Med 2008;18:227–34. doi:10.1097/JSM.0b013e31816a1c9a - DOI - PubMed
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Figure 8
Figure 8
Bar plots of preseason and postseason AD values from individual athletes. (A) No-collar (CTRL) group; (B) collar group. AD, axial diffusivity; CTRL, control.
Figure 9
Figure 9
WM areas with significant between-group differences (CTRL vs collar), preseason versus postseason. (A) MD; (B) AD; and (C) RD. The significant regions (red-yellow regions, p

Figure 10

The right superior corona radiata…

Figure 10

The right superior corona radiata (light blue shadow area as determined by John…

Figure 10
The right superior corona radiata (light blue shadow area as determined by John Hopkins University s WM atlas) overlaid on the white matter regions with significant preseason versus postseason AD change (red-yellow area, p
All figures (10)
Similar articles
Cited by
References
    1. Daneshvar DH, Nowinski CJ, McKee AC, et al. . The epidemiology of sport-related concussion. Clin Sports Med 2011;30:1–17, vii doi:10.1016/j.csm.2010.08.006 - DOI - PMC - PubMed
    1. Fridman L, Fraser-Thomas JL, McFaull SR, et al. . Epidemiology of sports-related injuries in children and youth presenting to Canadian emergency departments from 2007–2010. BMC Sports Sci Med Rehabil 2013;5:30 doi:10.1186/2052-1847-5-30 - DOI - PMC - PubMed
    1. Schneider DK, Grandhi RK, Bansal P, et al. . Current state of concussion prevention strategies: a systematic review and meta-analysis of prospective, controlled studies. Br J Sports Med Published Online First: 1 Jun 2016 doi:10.1136/bjsports-2015-095645 - PubMed
    1. Barbic D, Pater J, Brison RJ. Comparison of mouth guard designs and concussion prevention in contact sports: a multicenter randomized controlled trial. Clin J Sport Med 2005;15:294–8. doi:10.1097/01.jsm.0000171883.74056.21 - DOI - PubMed
    1. Kemp SP, Hudson Z, Brooks JH, et al. . The epidemiology of head injuries in English professional rugby union. Clin J Sport Med 2008;18:227–34. doi:10.1097/JSM.0b013e31816a1c9a - DOI - PubMed
Show all 57 references
Publication types
MeSH terms
Associated data
Related information
Full text links [x]
[x]
Cite
Copy Download .nbib .nbib
Format: AMA APA MLA NLM
Figure 10
Figure 10
The right superior corona radiata (light blue shadow area as determined by John Hopkins University s WM atlas) overlaid on the white matter regions with significant preseason versus postseason AD change (red-yellow area, p
All figures (10)

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