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Until recently, research examining the application of Rational Emotive Behavior Therapy (REBT) in sports settings was virtually absent in South Africa. Despite the growing evidence of REBT's potential as a psychological intervention in Western nations, its use within the multicultural and sports-fervent context of South Africa remains unexplored. Moreover, limited research has addressed the impact of REBT on rugby players, with only a few case studies being reported. The current experiment employs a cluster randomized trial (CRT) to compare the effects of a 7-week preferential REBT program with a 7-week Mindfulness-Acceptance-Commitment (MAC) program on irrational beliefs, competitive anxiety and subjective performance, among adolescent South African rugby players. We also include a wait-list control group who received neither REBT nor MAC. Results indicate that athletes receiving REBT reported greater improvements in irrational beliefs, anxiety, and subjective performance, while that athletes receiving MAC also reported some improvements in anxiety. This study highlights the potential of REBT as a valuable psychological intervention in the context of South African adolescent rugby players., Competing Interests: Declaration of competing interest “A cluster randomized trial of a v-emotive behavior therapy program and a mindfulness-acceptance-commitment program, with South African adolescent rugby players," The aforementioned authors affirm that we tried to adhere to the highest ethical standards and scientific integrity when conducting and writing about this research. We affirm that the results presented in this manuscript are based solely on the data collected and analyzed during the course of the study, and they are reported with objectivity and impartiality., (Copyright © 2024. Published by Elsevier Ltd.)

The dichotomous classification of self-talk statements into goal-directed as a more controlled type of self-talk and spontaneous as a more uncontrolled type of self-talk might be an oversimplification. To address this issue, two studies were conducted aiming to explore the idea that the distinction between the two self-talk types should rather be proportional and not mutually exclusive. In Study 1, football players took part in a penalty competition and were subsequently asked to state the self-talk they had before and after the penalty. In Study 2, table tennis players took part in two activities (i.e., a precision task and a competitive set) and were subsequently asked to state the self-talk they had before the individual rounds in each activity. In both studies, the players subsequently rated for each self-talk statement the extent to which it was spontaneous and the extent to which it was goal-directed. The majority of self-talk statements were rated to some extent as both spontaneous and goal-directed. For Study 1, paired-sample t-tests showed that before a penalty kick self-talk was more goal-directed than spontaneous and after the penalty kick it was more spontaneous than goal-directed. In the more exploratory Study 2, multilevel regression analyses showed that the two types of self-talk could not predict sports performance. While the results support the usefulness of the distinction between spontaneous and goal-directed self-talk, treating the two types of self-talk as proportional rather than dichotomous might reflect more accurately the mental activity. Key words: dual-process, organic self-talk, self-regulation, System 1, System 2., Competing Interests: Declaration of competing interest The authors declare that there is no competing financial interest or personal relationships that influenced the work reported in the paper., (Copyright © 2024. Published by Elsevier Ltd.)

The purpose of the current study was to understand female rugby players' perceptions of menstrual cycle (MC) tracking and identify the impact of MC tracking for the players. Interpretive descriptive methodology was adopted. Interviews were conducted with 12 elite female rugby players (age 25.2 ± 4.3 years), who were all naturally menstruating. Data were analysed following the four stages recommended within Interpretive Description. Results identified that athletes obtain personal benefits from MC tracking by; enhancing understanding of their MC and symptoms, and responding to their MC and symptoms. Athletes also reported that the process of tracking their MC enhanced relationships by; improving communication and interactions with coaches and support staff, and by facilitating team support. Specifically, using tracking increased the opportunities for open conversations with coaches, support staff and teammates regarding their MC. Overall, the findings highlight benefits of menstrual cycle tracking within this group of naturally menstruating rugby players, particularly in helping players and coaches understand the individual nature of the MC, engage in conversations, and establish support from teammates.

Effective communication and rapport building with athletes are key tenets of coaching. As the majority of empirical evidence to date has adopted an androcentric view of strength and conditioning, a potential knowledge gap exists regarding sex-related differences in physical preparation and coaching approaches. Therefore, this study explored the attitudes, beliefs and practices of strength and conditioning coaches ( n  = 8; M/F, 6/2) in elite level (international) women's rugby union using semi-structured interviews (mean ±standard deviation duration 59 ± 15 min). The interviews explored differences in coaching practices for elite female rugby players compared to males, with a specific focus on the interpersonal aspects of the athlete-coach relationship. Reflexive thematic analysis was used to generate a rich qualitative dataset. The analysis resulted in the identification of higher order themes: athlete engagement, and interpersonal approach . The coaches in this study consistently perceived important differences between male and female players in factors related to engagement and interpersonal approach. Coaches adopted differing coaching practices for male and female athletes. This study provides important contextual evidence for the understanding of differences in the interpersonal relationships of female rugby players compared to male athletes from the perspective of elite-level strength coaches.

Research pertaining to the experiences of women in rugby is scarce, which, coupled with the limited visibility of the sport and difficulty accessing resources, suggest that women's rugby remains undervalued. Indeed, evidence of such gender inequalities remains largely anecdotal, with little rigorous research undertaken to understand the perspectives of women in rugby. This study aimed to explore the experiences of a diverse cohort of rugby players in relation to their participation in the sport and their ability to access resources. Twenty UK-based rugby players (10 men, 9 women and 1 non-binary person aged 29.1 ± 8.3 years) from school, university, club, military, and semi-professional environments, volunteered to participate in semi-structured interviews (36 ± 12 minutes) discussing their rugby experiences in relation to their gender and playing level. Interviews were transcribed verbatim, and a reflexive thematic analysis was undertaken. A widespread under-prioritisation of women in rugby was highlighted. Gender biases were apparent in access to changing rooms, pitches, quality coaches, and playing opportunities, and were reportedly propagated at the managerial level. Irrespective of gender, some amateur players reported difficulty accessing a suitable rugby environment. Insufficient player numbers precluded the formation of second teams, often resulting in inexperienced players competing beyond their ability. Women's rugby players experienced considerable gender bias. This exploratory study highlights a need to address such issues to protect player welfare. Interventions to change the culture in rugby clubs and increased representation of women in managerial positions in rugby are recommended to enact meaningful change., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Petrie et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Context: Football sport participation has been linked to both positive and negative effects on overall health. Social support, a network that provides individuals with resources to cope effectively, may positively influence one's stress and mental health. However, little research has been conducted on adolescent football players., Objective: To examine the relationships among social support, psychological stress, and mental health in adolescent football athletes., Design: Cross-sectional study., Setting: High school athletes during the precompetitive and postcompetitive football season in rural Alabama., Patients or Other Participants: Black and African American adolescent athletes (N = 93) competing for a school-sponsored football team., Main Outcome Measure(s): After a competitive season, participants completed a battery of social support, psychological stress, and mental health symptom measures using the National Institutes of Health Toolbox Application and Patient-Reported Outcomes Measurement Information System. The T-score means, Pearson correlations, and multiple regression analyses were calculated., Results: Social support was negatively correlated with psychological stress (emotional support, r = -0.386; family relationships, r = -0.412; peer relationships, r = -0.265) and mental health (depression, r = -0.367 and r = -0.323 for emotional support and family relationships, respectively), whereas psychological stress and mental health (depression, r = 0.751; anxiety, r = 0.732) were positively correlated. In regression analyses, social support measures (ie, emotional support, family relationships, and peer relationships) were used to predict psychological stress (F = 7.094, P < .001, R2 = 0.191), depression symptoms (F = 5.323, P < .001, R2 = 0.151), and anxiety symptoms (F = 1.644, P = .190, R2 = 0.052)., Conclusions: In line with the stress-buffering hypothesis, social support in the form of family relationships and overall emotional support garnered through sport participation may reduce psychological stress and help to preserve the mental health of football athletes. These findings indicate that perceived social support may act as a positive resource for the coping of Black and African American adolescent athletes. Further research is warranted to understand the effects of stress and social support on the mental health of adolescents, particularly racial and ethnic minorities who are underrepresented in the athletic training literature., (© by the National Athletic Trainers’ Association, Inc.)

Background: Visual perception has been defined as the first step to a football player's decision-making process and it plays an important role in performance in sport. The skill of focussing to prioritize relevant cues has been also considered crucial in sport. This pilot study aims to explore the visual behaviour and attentional effort of three football players (mean age 19 ± 0 years old) in specific-role positions; Right-winger (RW), Centre-Midfielder (CM) and Left-Back (LB), in the five seconds before receiving the ball from their teammate., Methods: Twenty-two male football players performed an 11v11 game, where 24 game sequences (trials) from which 166 fixations were recorded and analysed via the Tobii Pro eye-movement registration glasses and software. The gaze behaviour dependent variables were the mean of fixation duration (FD), time to first fixation (TTF), both measured in milliseconds (ms), and the number of fixations (NF) on eight areas of interest (AOIs). AOIs include teammate with and without the ball, opponent without the ball, space around teammate with and without the ball, space around opponent without the ball, ball and undefined. The mean pupil diameter (PD) correlates to the attentional effort and was measured in millimetres (mm)., Results: Descriptive statistics showed nonregular search rate data between the participants in FD, TTF, NF on the AOIs. Mean FD on the ball: (CM, 270 ms), (RW, 570 ms), (CM, 380 ms). They also presented differences in the mean PD during play; (CM: 2.90 mm ± 0.26), (RW: 2.74 mm ± 0.30), (LB 2.77mm ± 0.27)., Conclusions: Albeit the sample size was small, the findings demonstrated a promising way to measure the on-field perceptual-cognitive abilities of football players according to their specific positions, since different playing roles revealed to present distinctive visual and attentional patterns. This could potentially assist in tailoring players 'visual and focus training., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Ballet C et al.)

Objective: In a retrospective cohort, we evaluated whether age beginning tackle football (ABTF) and more total years of playing football (TYPF) were associated with worse later-in-life neuropsychological change among older retired National Football League (NFL) players., Method: Participants were 19 older NFL retirees aged 54-79, including 12 who returned for follow-up evaluation 15-51 months later. Mixed-linear models evaluated the association between ABTF/TYFP and baseline neuropsychological composite scores (executive functioning/attention/speed, language, memory), and neuropsychological composites over time., Results: ABTF and TYPF were not significantly associated with neuropsychological composites at baseline or over time (all p's > .05). There were no significant differences in neuropsychological performance between those ABTF <12 and ≥ 12 years old (all p's ≥ .475) or between those with TYPF <19 or ≥ 19 years played (median split; all p's ≥ .208)., Conclusions: Preliminary findings suggest that ABTF and TYPF does not worsen neurocognitive decline later-in-life among older NFL retirees., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Objective: Studies have observed variable associations of prior contact sport participation with subjective and objective measures of cognitive function. This study directly investigated the association between subjective self-report and objective performance-based cognition among former collegiate football players, as well as its relationship to self-reported concussion history., Methods: Former collegiate football players (N = 57; mean age = 37.9 years [ SD  = 1.49]) retired from sport 15-years prior were enrolled. Linear regression models examined associations between subjective cognition (Quality of Life in Neurological Disorders Cognitive Functioning-Short Form), and performance on a neuropsychological battery. Domain specific (executive function) metrics of subjective (Behavior Rating Inventory of Executive Function-Adult) and objective cognition were also exclusively examined. Associations between self-reported concussion history with subjective and objective measures were tested. Potential influential factors (sleep quality and distress) were included as covariates., Results: Subjective cognition was not significantly associated with any objective measures of cognitive functioning ( p 's > .05). Greater self-reported concussion history was inversely associated with subjective cognition (B = -2.49, p = .004), but not objective performance-based cognition ( p 's > .05). Distress was significantly related to all metrics of subjective cognition ( p 's < .001) as well as performance on delayed recall and verbal fluency ( p 's < .05). Sleep quality was only significantly related to timed visuospatial sequencing ( p = .033)., Conclusions: Reliance on self-reported measures of cognitive functioning alone is insufficient when assessing cognition in former contact sport athletes. Assessment of other factors known to influence subjective cognitive complaints should also be examined in determining the presence of cognitive deficits.

Objective: To provide preseason reference scores for Canadian youth tackle football players on the Sport Concussion Assessment Tool 5 (SCAT5) and to examine whether age, concussion history, and self-reported medical diagnoses are associated with SCAT5 subcomponent performance., Design: Cross-sectional study., Setting: Calgary, Alberta., Participants: Five hundred one male youth football players (ages 13-18 years) participating in the 2021 season., Assessment of Risk Factors: SCAT5 subcomponents were assessed by age group (13-14, 15-16, 17-18), concussion history (0, 1, 2+, and yes/no), and self-reported diagnoses (headache disorder, attention-deficit/hyperactive disorder, learning disability/dyslexia, and depression, anxiety, or other psychiatric disorder)., Main Outcome Measures: Virtual video administration (vs traditional in-person testing) of the SCAT5 was completed, and subcomponent scores included total number of symptoms (/22), symptom-severity score (/132), Standardized Assessment of Concussion [orientation (/5), immediate memory (/30), concentration (/5), delayed recall (/10)], and modified Balance Error Scoring System (/30). Kruskal-Wallis, one-way analysis of variance , Mann-Whitney U , or independent t tests were used to assess possible associations depending on number of groups and data normality., Results: Virtual SCAT5 assessment scores across all outcomes did not differ by age group or concussion history. The median number of symptoms and median symptom-severity score at baseline was 2, and 173 players (34.5%) reported no symptoms. Median total number of errors on the modified Balance Error Scoring System was 3. Participants with certain self-reported diagnoses (attention-deficit/hyperactive disorder, dyslexia) demonstrated poorer performance on some SCAT5 subcomponents (symptom reporting, Standardized Assessment of Concussion)., Conclusions: Baseline SCAT5 performance did not differ by age group or concussion history in male youth football players. Diagnoses of the self-reported disorders examined may be important considerations for interpretation of the SCAT5 assessment., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patterns of cognitive impairment in former American football players are uncertain because objective neuropsychological data are lacking. This study characterized the neuropsychological test performance of former college and professional football players., Methods: One hundred seventy male former football players (n=111 professional, n=59 college; 45-74 years) completed a neuropsychological test battery. Raw scores were converted to T-scores using age, sex, and education-adjusted normative data. A T-score ≤ 35 defined impairment. A domain was impaired if 2+ scores fell in the impaired range except for the language and visuospatial domains due to the limited number of tests., Results: Most football players had subjective cognitive concerns. On testing, rates of impairments were greatest for memory (21.2% two tests impaired), especially for recall of unstructured (44.7%) versus structured verbal stimuli (18.8%); 51.8% had one test impaired. 7.1% evidenced impaired executive functions; however, 20.6% had impaired Trail Making Test B. 12.1% evidenced impairments in the attention, visual scanning, and psychomotor speed domain with frequent impairments on Trail Making Test A (18.8%). Other common impairments were on measures of language (i.e., Multilingual Naming Test [21.2%], Animal Fluency [17.1%]) and working memory (Number Span Backward [14.7%]). Impairments on our tasks of visuospatial functions were infrequent., Conclusions: In this sample of former football players (most of whom had subjective cognitive concerns), there were diffuse impairments on neuropsychological testing with verbal memory being the most frequently impaired domain., (© 2023. The Author(s).)

Background: Although the negative psychological impact of the pandemic on athletes is well known, there is currently insufficient evidence regarding mental health (MH) problems among athletes infected with SARS-CoV-2. The aim of the present study was to evaluate the association between MH problems, demographics, and SARS-CoV-2 related variables in football players infected with SARS-CoV-2., Methods: An online survey included demographic questions, SARS-CoV-2 related questions, the Athlete Psychological Strain Questionnaire, and the Depression Anxiety Stress Scales-21 was distributed to male and female professional football players aged between 18-38 and infected with SARS-CoV-2., Results: A total of 261 football players participated in the study. The odds of athlete-specific distress in lower-level football players were up to 5.9 times more than those competing at the highest level (OR=3.06-5.93, 95% CI: 1.27-14.43, P<0.01). The odds of depression and stress in lower-level football players were up to 6.7 times more than those competing at the highest level (both OR=3.70-6.77, 95% CI: 1.18-19.20, P<0.01). In players who reported sleep problems, there was increased risk of athlete-specific distress (OR=2.43, 95% CI: 1.31-4.52, P<0.01), depression (OR=3.71, 95% CI: 1.98-6.95, P<0.01), anxiety (OR=2.93, 95% CI: 1.62-5.28, P<0.01), and stress (OR=7.08 95% CI: 3.52-14.02, P<0.01). There was increased risk of depression and stress in female players (OR=5.78, 95% CI: 2.03-16.4, P<0.01; OR=4.91, 95% CI: 1.57-15.4, P<0.01; respectively). The odds of anxiety in players who reported severe SARS-C0V-2 symptoms were up to 2.2 times more than asymptomatic players (OR=2.28, 95% CI: 1.08-4.82, P=0.03)., Conclusions: MH problems in football players infected with SARS-CoV-2 were associated with female gender, participation in football in the lower-level, performance concerns, and sleep problems. MH assessment is indicated in athletes infected with SARS-CoV-2 to support detection, and appropriate and timely intervention.

Women's participation in sports has recently grown worldwide, including in sports typically associated with men (e.g., rugby and football). Similarly, literature on female athletes has increased, but how they cope with premenstrual (PM) physical and affective symptoms remains a poorly studied topic. Our study aimed to explain which coping strategies elite female rugby and football players use during their PM period to maintain perceived physical ability (PPA) and well-being. A mediation model analysis considering coping strategies (i.e., avoiding harm, awareness and acceptance, adjusting energy, self-care, and communicating) as independent variables, PPA and well-being as dependent variables, and PM physical and affective symptoms and PM cognitive resources as mediators was run on the data collected via an anonymous online survey. A dysfunctional impact of avoiding harm (indirect) and adjusting energy (both direct and indirect) and a functional indirect influence of awareness and acceptance, self-care, and communicating as coping strategies were found on PPA and well-being during the PM period. As predicted, PM physical and affective symptoms as mediators reduced PPA and well-being, while PM cognitive resources enhanced them. These results may inform practitioners on how to support elite female athletes' PPA and well-being by knowing and reinforcing the most functional PM coping strategies for them.

Transition from professional sport to nonsport endeavors has implications for postcareer health and well-being of athletes. The purpose of the current study was to examine associations among transition-related psychosocial factors and current mental health outcomes in former National Football League (NFL) players. Participants were former NFL players (n = 1,784; mean age = 52.3 ± 16.3 years) who responded to a questionnaire assessing the nature of their discontinuation from professional football (i.e., any degree of voluntary choice vs. forced discontinuation), prediscontinuation transition planning (yes vs. no), and current symptoms of depression and anxiety. After adjusting for relevant covariates, having an involuntary discontinuation and no transition plan prior to discontinuation were associated with greater depressive and anxiety symptom severity. Autonomy in discontinuation and pretransition planning are important to former NFL football players' mental health. Increasing autonomy in the discontinuation decision and pretransition planning represent psychoeducational intervention targets for this population.

Objective: To determine the risk of mortality from mental disorders and suicide in professional sports associated with repeated head impacts., Methods: A systematic search was performed in PubMed, Web of Science, Scopus, and SPORTDiscus (since inception to June 8, 2021) to find studies comparing the incidence of mortality from mental disorders or suicide in former or active professional athletes of sports characterized by repeated head impacts vs athletes with no such exposure or the general non-athletic population., Results: Seven retrospective studies of moderate-to-high quality that included data from boxers and from basketball, ice hockey, soccer, and National Football League (NFL) players, respectively (total = 27 477 athletes, 100% male) met all inclusion criteria. Former male NFL players (n = 13 217) had a lower risk of mortality from mental disorders (standard mortality rate [SMR] = 0.30; 0.12-0.77; p = 0.012) and suicide (SMR = 0.54; 0.37-0.78; p < 0.001) than the general population. This finding was also corroborated in male soccer players (n = 13,065; SMR = 0.55; 0.46-0.67; p < 0.001). Male athletes participating in sports associated with repeated head impacts (n = 18,606) had also a lower risk of all-cause, cardiovascular disease (CVD), and cancer mortality (all p < 0.01) than the general population., Conclusions: Participation of male athletes in American football or soccer at the professional level might confer a certain protective effect against mortality from mental disorders or suicide, besides its association with a lower risk of all-cause, CVD, or cancer-related mortality., (© 2021 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.)

Purpose: This study aimed to determine the relationship between age of first exposure (AFE) to repetitive head impacts through contact/collision sports and patient-reported outcomes in community rugby players., Methods: We recruited community rugby players older than 18 yr with at least 1 yr of contact rugby participation to complete an online survey. Participants completed the Brief Symptom Inventory-18 (BSI-18), Short-Form Health Survey 12 (SF-12), and Satisfaction with Life Scale (SWLS) via Qualtrics. We used generalized linear models to examine the association between AFE (continuous) and patient-reported outcomes by sex, while controlling for cumulative years contact/collision sport history, age, and concussion history (yes/no). In addition, we used Mann-Whitney U tests to compare patient-reported outcomes between AFE <12 and AFE ≥12., Results: A total of 1037 rugby players (31.6 ± 11.3 yr (range, 18-74 yr), 59.1% men) participated in this study. Whether analyzed continuously or dichotomously at age 12 yr, younger AFE was not associated with worse patient-reported outcomes for either men or women. Positive concussion history was a significant predictor of worse BSI-18 subscores, SF-12 subscores, and SWLS in women and worse BSI-18 subscores in men. Cumulative contact/collision sport history was a significant predictor of better BSI-18 Depression and SF-12 (Mental Component Summary) subscores in men only. In men and women, older age was a significant predictor of better BSI-18 Depression, Anxiety, and GSI subscores; better SWLS (in men only); and better SF-12 Mental Component Summary, but worse SF-12 (Physical Component Summary)., Conclusions: Younger AFE to contact/collision sport is not associated with worse patient-reported outcomes in early adult rugby players. Concussion history was predictive of worse patient-reported outcomes., (Copyright © 2021 by the American College of Sports Medicine.)

The purpose of this study was to examine the association between young players' perception of mother's and father's responsiveness with their self-esteem, anxiety (i.e., worry), and thriving (i.e., positive affect, vitality, and life satisfaction). In total, 314 male British rugby players with a mean age of 16.23 years ( SD  = 0.26) completed the study in two phases: n = 124 (first dataset), and n = 192 (second dataset). Participants trained on average 3.14 times/week ( SD  = 0.94) and had been involved in rugby for an average of 8.21 years ( SD  = 2.89). Participants completed questionnaires measuring perceived parental responsiveness (PPR) for their mother and father, self-esteem, worry about sport performance, and thriving indicators (i.e., positive affect, vitality, and life satisfaction). The results consistently indicated that participants' perceptions of their mother's and father's responsiveness positively related to thriving, and negatively related to their worry about sport performance, mediated by their self-esteem. Overall, the study highlights the need for parents to be provided with insights into the value of being responsive to their child and being encouraged to regularly talk with their child regarding their needs and desires, and seeking to understand how their child perceives the support they currently receive.

This study aimed to identify the predictive capacity of wellness questionnaires on measures of training load using machine learning methods. The distributions of, and dose-response between, wellness and other load measures were also examined, offering insights into response patterns. Data ( n = 14,109) were collated from an athlete management systems platform (Catapult Sports, Melbourne, Australia) and were split across three sports (cricket, rugby league and football) with data analysis conducted in R (Version 3.4.3). Wellness (sleep quality, readiness to train, general muscular soreness, fatigue, stress, mood, recovery rating and motivation) as the dependent variable, and sRPE, sRPE-TL and markers of external load (total distance and m.min -1 ) as independent variables were included for analysis. Classification and regression tree models showed high cross-validated error rates across all sports (i.e., > 0.89) and low model accuracy (i.e., < 5% of variance explained by each model) with similar results demonstrated using random forest models. These results suggest wellness items have limited predictive capacity in relation to internal and external load measures. This result was consistent despite varying statistical approaches (regression, classification and random forest models) and transformation of wellness scores. These findings indicate practitioners should exercise caution when interpreting and applying wellness responses.

Objectives: To examine the relationships among self-reported sport-related concussion (SRC) history and current health-promoting behaviours (exercise frequency, diet quality and sleep duration) with self-reported measures of brain health (cognitive function, symptoms of depression and anxiety and emotional-behavioural dyscontrol) in former NFL players., Methods: In this cross-sectional study, a questionnaire was sent to former NFL players. Respondents reported SRC history (categorical: 0; 1-2; 3-5; 6-9; 10+ concussions), number of moderate-to-vigorous aerobic and resistance exercise sessions per week, diet quality (Rapid Eating Assessment for Participants-Shortened) and average nightly sleep duration. Outcomes were Patient-Reported Outcomes Measurement Information System Cognitive Function, Depression, and Anxiety, and Neuro-QoL Emotional-Behavioral Dyscontrol domain T-scores. Multivariable linear regression models were fit for each outcome with SRC history, exercise frequency, diet quality and sleep duration as explanatory variables alongside select covariates., Results: Multivariable regression models (n=1784) explained approximately 33%-38% of the variance in each outcome. For all outcomes, SRC history (0.144≤|β|≤0.217) was associated with poorer functioning, while exercise frequency (0.064≤|β|≤0.088) and diet quality (0.057≤|β|≤0.086) were associated with better functioning. Sleeping under 6 hours per night (0.061≤|β|≤0.093) was associated with worse depressive symptoms, anxiety and emotional-behavioural dyscontrol., Conclusion: Several variables appear to be associated with mood and perceived cognitive function in former NFL players. SRC history is non-modifiable in former athletes; however, the effects of increasing postplaying career exercise frequency, making dietary improvements, and obtaining adequate sleep represent important potential opportunities for preventative and therapeutic interventions., Competing Interests: Competing interests: BLB acknowledges support from the National Institute of Neurological Disorders and Stroke under the National Institutes of Health under the award NO L301L30NS113158-01. RJE is a paid consultant for the NHL and co-chair of the NHL/NHLPA Concussion Subcommittee. He is also a paid consultant for Major League Soccer and Princeton University Athletic Medicine and occasionally provides expert testimony in matters related to MTBI and sports concussion. WPM receives royalties from 1) ABC-Clio publishing for the sale of his books, Kids, Sports, and Concussion: A guide for coaches and parents, and Concussions; 2) Springer International for the book Head and Neck Injuries in Young Athlete and 3) Wolters Kluwer for working as an author for UpToDate. His research is funded, in part, by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament and a grant from the National Football League., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To scope the relationships between rugby union, and health and well-being., Design: Scoping review., Data Sources: Published and unpublished reports of any age, identified by searching electronic databases, platforms and reference lists., Methods: A three-step search strategy identified relevant published primary, secondary studies and grey literature, which were screened using a priori inclusion criteria. Data were extracted using a standardised tool, to form (1) a numerical analysis and (2) a thematic summary., Results and Discussion: 6658 records were identified, and 198 studies met the inclusion criteria. All forms of rugby union can provide health-enhancing physical activity (PA). 'Non-contact' and wheelchair rugby in particular provide a wide range of physical and mental health and well-being benefits. The evidence is either mixed or unclear in relation to 'contact' rugby union and its effects on a range of physical health domains. Injury and concussion incidence rates are high for contact rugby union relative to other sports., Conclusions: A wide range of stakeholders as well as existing and potential participants can use this information to make a more informed decision about participating in and promoting rugby union as a health-enhancing activity. Industry and policy-makers can use this review to inform policies and strategies that look to increase participation rates and use rugby union as a vehicle to contribute positively to population health. Further research understanding rugby union's contribution to PA as well as to muscle-strengthening and balance is indicated, as well as research examining more health and well-being outcomes across more diverse cohorts., Competing Interests: Competing interests: SAG receives remuneration for clinical work in professional rugby union, and is employed by the Rugby Football Union as a Sports Medicine Training Fellow. AM receives remuneration from Scottish Rugby Union for clinical work. SK is employed by the Rugby Football Union as medical services director. KAS is employed by the Rugby Football Union as medical research lead., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Probiotic supplementation may offer team sport athletes a range of benefits beyond the immune and gastrointestinal systems., Objectives: To examine the effects of a probiotic formulation on perceptual markers of sleep quality and quantity, and muscle soreness, leg heaviness and motivation in elite rugby union athletes., Methods: A double-blind randomised controlled trial involving 19 elite male rugby athletes was conducted over 17 weeks encompassing both domestic and international competition. Psychometric variables and salivary biomarkers were assessed twice a week. Athletes were assigned either a daily probiotic (Ultrabiotic 60™) and Saccharomyces boulardii (during international competition) or a placebo. Associations between psychometric scores for perceptual and salivary biomarkers of sleep (melatonin) and inflammation C-reactive protein (CRP) were investigated., Results: Muscle soreness was ∼0.5 units lower (F(1, 343)=42.646, p<0.0001) and leg heaviness scores ∼0.7 units lower (F(1, 334)=28.990, p<0.0001) in the probiotic group compared to the placebo group. Across both groups, as self-reported muscle soreness scores and salivary CRP concentrations increased, sleep quantity, quality and motivation scores decreased. Conversely as muscle soreness scores and CRP decreased, sleep quantity and quality, and motivation scores improved., Conclusions: A long-term programme of probiotic supplementation in international-level rugby union players may yield favourable effects on self-reported muscle soreness and sleep quality associated with muscle soreness during training and competitions., (Copyright © 2020 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Context: Little research has examined health-related quality of life in former National Football League (NFL) players., Objective: Examine the association of musculoskeletal injury history and current self-reported physical and mental health in former NFL players., Setting: Cross-sectional questionnaire., Patients or Other Participants: Historical cohort of 2,103 former NFL players that played at least one season between 1940 and 2001., Intervention: Players were grouped by self-reported professional career musculoskeletal injury history and whether injuries affected current health: (1) no musculoskeletal injury history; (2) musculoskeletal injury history, currently affected by injuries; and (3) musculoskeletal injury history, not currently affected by injuries., Main Outcome Measure: The Short Form 36 Measurement Model for Functional Assessment of Health and Well-Being (SF-36) yielded physical and mental health composite scores (PCS and MCS, respectively); higher scores indicated better health. Multivariable linear regression computed mean differences (MD) among injury groups. Covariates included demographics, playing history characteristics, surgical intervention for musculoskeletal injuries, and whether injury resulted in premature end to career. MD with 95% CI excluding 0.00 were deemed significant., Results: Overall, 90.3% reported at least one musculoskeletal injury during their professional football careers, of which 74.8% reported being affected by their injuries at time of survey completion. Adjusting for covariates, mean PCS in the "injury and affected" group was lower than the "no injury" (MD = -3.2; 95% CI: -4.8, -1.7) and "injury and not affected" groups (MD = -4.3; 95% CI: -5.4, -3.3); mean MCS did not differ., Conclusion: Many players reported musculoskeletal injuries, highlighting the need for developing and evaluating injury management interventions.

Purpose: To examine responses to a simulated rugby league protocol designed to include more stochastic commands, and therefore require greater vigilance, than traditional team-sport simulation protocols., Methods: Eleven male university rugby players completed 2 trials (randomized and control [CON]) of a rugby league movement simulation protocol, separated by 7 to 10 d. The CON trial consisted of 48 repeated ∼115-s cycles of activity. The stochastic simulation (STOCH) was matched for the number and types of activity performed every 5.45 min in CON but included no repeated cycles of activity. Movement using GPS, heart rate, rating of perceived exertion, and Stroop test performance was assessed throughout. Maximum voluntary contraction peak torque, voluntary activation (in percentage), and global task load were assessed after exercise., Results: The mean mental demand of STOCH was higher than CON (effect size [ES] = 0.56; ±0.69). Mean sprint speed was higher in STOCH (22.5 [1.4] vs 21.6 [1.6] km·h-1, ES = 0.50; ±0.55), which was accompanied by a higher rating of perceived exertion (14.3 [1.0] vs 13.0 [1.4], ES = 0.87; ±0.67) and a greater number of errors in the Stroop test (10.3 [2.5] vs 9.3 [1.4] errors; ES = 0.65; ±0.83). Maximum voluntary contraction peak torque (CON = -48.4 [31.6] N·m and STOCH = -39.6 [36.6] N·m) and voluntary activation (CON = -8.3% [4.8%] and STOCH = -6.0% [4.1%]) was similarly reduced in both trials., Conclusions: Providing more stochastic commands, which requires greater vigilance, might alter performance and associated physiological, perceptual, and cognitive responses to team-sport simulations.

Importance: Despite increased concern about the health consequences of contact sports, little is known about athletes' understanding of their own risk of sports-related injury., Objective: To assess whether college football players accurately estimate their risk of concussion and nonconcussion injury and to identify characteristics of athletes who misestimate their injury risk., Design, Setting, and Participants: In this survey study, questionnaires were given to 296 current college football players on 4 teams from the 3 of the 5 most competitive conferences of the US National Collegiate Athletic Association. Surveys were conducted between February and May 2017. Data were analyzed from June 2017 through July 2020., Main Outcomes and Measures: Multiple approaches were taken to compare athlete perceptions of their risks of concussion and nonconcussion injury with individual probabilities of these risks, which were modeled using logistic regression., Results: Of 296 male college-aged athletes from 4 football teams who participated in the survey, 265 (89%) answered all questions relevant for this study. Participating teams were similar to nonparticipating teams across nearly all measured characteristics. One hundred athletes (34%) had sustained 1 or more concussions, and 197 (68% of the 289 who responded to the question) had sustained 1 or more injuries in the previous football season. Logistic regression models of single-season injury and concussion had reasonably good fit (area under the curve, 0.75 and 0.73, respectively). Of the 265 participants for whom all relevant data were available, 111 (42%) underestimated their risk of concussion (χ2 = 98.6; P = .003). A similar proportion of athletes (113 [43%]) underestimated their risk of injury, although this was not statistically significant (χ2 = 34.0; P = .09). An alternative analytic strategy suggested that 241 athletes (91%) underestimated their risk of injury (Wilcoxon statistic, 7865; P < .001) and 167 (63%) underestimated their risk of concussion (Wilcoxon statistic, 26 768; P < .001)., Conclusions and Relevance: The findings of this survey study suggest that college football players may underestimate their risk of injury and concussion. The implications for informed participation in sport are unclear given that people generally underestimate health risks. It is necessary to consider whether athletes are sufficiently informed and how much risk is acceptable for an athlete to participate in a sport.

In sport, testosterone has been positioned as a substrate for motivation with both directional and time dependencies. However, evidence is scarce when considering the complexities of competitive sport and no work has explicitly modeled these dependencies. To address these gaps, we investigated the bidirectional and time-dependent interrelationships between testosterone and training motivation in an elite rugby environment. Thirty-six male athletes were monitored across training weeks before and after eight international rugby matches. Pre-breakfast measures of salivary testosterone and training motivation (1-10 rating) were taken on training, competition, and recovery days (up to 40 tests). Using a continuous-time (CT) model, within-person estimates of autoregressive effects (persistence) and cross-lagged effects (relationships) were derived. A stronger, more persistent temporal association was identified for testosterone than for motivation. Cross-lagged effects verified that training motivation was positively related to testosterone at latter time points (p < 0.001). Discrete-time analyses revealed a non-linear association; increasing in strength from a zero-time lag to peak after 2.83 days (standardized effect = 0.25), before dissipation over longer lagged intervals. The testosterone relationship with ensuing training motivation was also positive, but non-significant. Match effects also appeared (p < 0.001) with a predicted decline in training motivation, but a rise in testosterone, at match onset. In summary, a positive association emerged between within-person fluctuations in self-appraised motivation to train and testosterone concentration in an elite rugby environment. The lagged, non-linear nature of this relationship and match predictions on both outcomes support, and extend, theoretical models linking testosterone and competitive behaviors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Many retired National Football League (NFL) athletes manage pain with opioids during their playing careers and in retirement, though the longitudinal association between opioid use and health outcomes pertinent to an NFL career are not yet known. This study aimed to assess the relationship between opioid use in 2010 and current use, depressive symptoms, and health related quality of life (HRQoL) among NFL retirees., Methods: Former NFL athletes from the Retired NFL Players Association initially recruited in 2010 for a study examining risk factors of opioid use and misuse were re-contacted (N = 89) from 2018 to 2019 and administered measures of pain, opioid use, depressive symptoms, and HRQoL. Binomial regression examined the association between 2010 opioid use with current use, moderate-severe depressive symptoms, and average and above HRQoL (physical and mental) while controlling for covariates., Results: Nearly 50 % of retirees using opioids in 2010 currently used. Compared to non-users, retirees who used opioids in 2010 had greater odds of current use (AOR: 3.71, 95 % CI: 1.02-13.56, p = 0.046) and experiencing moderate-severe depressive symptoms (AOR: 5.93, 95 % CI: 1.15-30.54, p = 0.033). Retirees reporting use in 2010 also evidenced lower odds of reporting average or above mental HRQoL (AOR: 0.13, 95 % CI: 0.03-0.67, p = 0.015) compared to non-users., Conclusions: This study showed that among NFL retirees, early retirement opioid use predicted current use and deleterious effects on mental health, including moderate-severe depressive symptoms approximately nine years later. This investigation further supports the importance of early intervention of pain and opioid use among this population., (Copyright © 2020 Elsevier B.V. All rights reserved.)

It has been suggested in recent research that rational beliefs as conceptualized within rational-emotive behaviour therapy (REBT) can be operationalized as strategic self-talk, but this has yet to be meaningfully investigated. The current study examines the effects of five one-to-one REBT sessions with three amateur American Football athletes to foster rational self-talk. The purpose of the intervention was to reduce the irrational beliefs, but also in line with recent applied REBT research, to increase the self-determined motivation and self-efficacy of the athletes. Using an idiographic single-case, staggered multiple-baseline across participants design, visual analyses revealed meaningful increases in self-determined motivation and self-efficacy, adjunct to decreases in total irrational beliefs across all participants. Social validation data supported these outcomes. These findings add to the growing research indicating that REBT can influence motivational approaches in athletes, such as self-determined motivation and self-efficacy. Results are discussed in relation to processes underlying the mechanisms of change, while also reporting the limitations of the study. The robustness of the research design increases the extent to which target variable changes can be attributed to REBT, but critical reflections are undertaken to assess the veracity of the findings.

Background: Traumatic brain injury (TBI) is a known risk factor for neurodegenerative dementias such as Alzheimer disease (AD); however, the potential risk of mild cases of TBI, such as concussions, remains unclear., Objective: To explore whether a small sample of retired professional athletes with a diagnosis of mild cognitive impairment (MCI)-the prodromal stage of AD-and a history of multiple mild TBIs exhibit greater neuropsychological impairment than age-matched nonathletes with MCI and no history of TBI., Method: Ten retired National Football League players diagnosed with MCI and reporting multiple mild TBIs, and 10 nonathletes, also diagnosed with MCI but with no history of TBI, completed a standard neurologic examination and neuropsychological testing. Independent samples t tests were conducted to examine differences in neuropsychological performance between the two groups., Results: The retired athletes with a history of mild TBI obtained generally similar scores to the nonathlete controls on measures of verbal learning and memory, verbal fluency, and processing speed. However, the retired athletes scored lower than the controls on tests of confrontation naming and speeded visual attention., Conclusion: Retired athletes with MCI and a history of mild TBI demonstrated similar neuropsychological profiles as nonathlete controls despite lower scores on measures of confrontation naming and speeded visual attention. These findings suggest that a history of multiple mild TBIs does not significantly alter the overall neuropsychological profile of individuals with MCI; confirmation of this will require longitudinal research with larger sample sizes.

Limited research has evaluated the psychological effect of sports-betting advertising (such as embedded promotion) upon consumers considered 'higher-risk'. Students are often considered a higher-risk group given the numerous gambling-related risk factors associated with their lifestyle. Furthermore, students studying sports-related subjects may possess a bespoke vulnerability to sports-betting risk, due to contextual factors such as (mis)perceptions regarding advantages of sports-related knowledge. The pilot study investigated whether exposure to embedded gambling promotions during televised football, elicits urges to gamble amongst students, and whether the severity of reported gambling varies between those who study sports-related and non-sports subjects. An experimental methodology was employed. Sixty students from the University of South Wales were shown one of three videos: (a) televised football match highlights containing a high density of embedded promotion; (b) amateur football match highlights containing no gambling-related cues or embedded promotion; (c) a neutral control video containing footage of a live concert. Urge to gamble and risk of gambling problems were measured following video exposure. Sports-students reported significantly higher risk of gambling problem scores than non-sports students. Correspondingly, sport-students who were exposed to embedded gambling promotion reported significantly higher urges to gamble compared to all other conditions. This effect was also observed amongst sports-students who were exposed to an amateur match containing no gambling-related material. These findings provide evidence for the cue-induced urge effect of sports-embedded gambling promotion, amongst vulnerable audiences. Public health interventions and harm reduction strategies should look to counteract these pervasive forms of gambling advertising.

Context: Individual and team injury burden and performance are 2 key considerations facing practitioners in the daily prescription of an athlete's training load. Whereas a considerable number of researchers have examined univariate relationships between training load and performance, training load and injury, or injury and performance, few investigators have examined all 3 concurrently., Objective: To assess the association among training load, injury burden, and performance in professional rugby union., Design: Descriptive epidemiology study., Setting: The English Premiership competition., Patients or Other Participants: Individual injury and training load data, as well as team performance data, were captured during the 2015-2016 (n = 433 players) and 2016-2017 (n = 569 players) seasons., Main Outcome Measure(s): Data were aggregated into team average scores for each week, including weekly (acute) load, smoothed chronic load, changes in load, injury burden, and weekly performance. Linear mixed modelling techniques were used to assess the association among measures., Results: Injury burden was negatively associated with performance, with a high weekly burden associated with a likely harmful (P = .01) decrease in performance. Training load measures displayed only trivial associations with performance. Only the acute:chronic workload ratio measure was clearly associated with injury burden, with a possibly harmful effect (P = .02). Both squad size and player availability were associated with only trivial changes in performance., Conclusions: Whereas no association between average training load and performance existed, associations between training load and injury burden and between injury burden and performance were clear. Further investigation using more sensitive and individualized measures of load, performance, and injury may elicit a clearer relationship and should be considered for future work., (© by the National Athletic Trainers' Association, Inc.)

Objectives: To explore athletes' past and current experiences and perceptions of the menstrual cycle in relation to its impact on sporting performance., Methods: 15 international female rugby players participated in individual semi-structured interviews (age: 24.5±6.2 years). All interviews were recorded and transcribed verbatim , resulting in 37 376 words of text for descriptive and thematic analysis. Inter-rater reliability checks resulted in a concordance of agreement of 83%., Results: Almost all athletes (93%) reported menstrual cycle-related symptoms. Thirty-three per cent perceived heavy menstrual bleeding and 67% considered these symptoms impaired their performances. Two-thirds of athletes self-medicated to alleviate symptoms. Thematic analysis generated 262 meaning units, 38 themes, 10 categories and 4 general dimensions. The four general dimensions were: (1) symptoms: physiological and psychological menstrual cycle-related symptoms such as dysmenorrhoea, flooding, reduced energy levels, worry, distraction, fluctuating emotions and reduced motivation; (2) impact: perceived impact of menstruation on different aspects of daily lives and performance including negative and neutral responses; (3) resolution: the methods/approaches in dealing with menstruation-related concerns including accepting, or adapting and managing symptoms with self-medication or expert treatment; (4) support: available support and comfortability in discussing menstrual cycle-related issues., Conclusions: This study provides the first in-depth insight into athlete's experiences of the menstrual cycle and perceived impact on training and competition. It highlights individual responses to menstrual 'issues' and emphasises the need for clinicians and support staff to undertake menstrual cycle profiling, monitoring and continue to develop awareness, openness, knowledge and understanding of the menstrual cycle., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Physical activity interventions are an important adjunct therapy for people with severe to moderate and/or enduring mental health problems. Football is particularly popular for men in this group. Several interventions have emerged over the past decade and there is a need to clearly articulate how they are intended to work, for whom and in what circumstances. Aims: To develop a theory-driven framework for a football intervention for men with severe, moderate and/or enduring mental health problems using a participatory realist approach. Methods: A participatory literature review on playing football as a means of promoting mental health recovery with a realist synthesis. It included the accounts and input of 12 mental health service users and the contributions of other stakeholders including football coaches and occupational therapists. Results: Fourteen papers were included in the review. Analysis revealed that interventional mechanisms were social connectedness, identity security, normalising experiences and positive affectivity. These supported mental health recovery. Outcomes were moderated by social stigma and several interventional factors such as over-competitiveness. Conclusions: The context mechanism outcome configuration framework for these interventions map well onto social models of mental health recovery and provide insight into how they work. This now requires testing.

Background: This paper describes a new specific test to asses spatial and orientation abilities: Navigation Ability Test (NAT). The goal of this study was to determine if football players and normal subjects use vestibular information to keep track of their positions while walking through the Navigation Ability Test., Methods: This study was conducted on a total of 120 patients undergoing Navigation Ability Test (NAT): 60 football players and 60 normal subjects were recruited on the basis of no history of vertigo/balance disorders and a negative otoneurological instrumental examination and the second group of the football players were recruited from Division B, Division Under-21 and Women's League. Patients who met the inclusion criteria were enrolled in the study., Results: Our results showed differences between sexes during navigation tasks are not related to spatial learning per se, but appear to be the consequence of difference in ability to effectively use specific types of distal information such as room geometry. The NAT showed that the route-times walked with eyes closed are always longer than in normal people and mistakes improve with training., Conclusions: These results show that NAT could suggest to the coach and trainers valuable information about the characteristics of the players and how they should play in the field. Although there are some intrinsic difficulties, for example in creating patient-specific versions of the test, preliminary normative data indicate that this original test is workable and provides important information in therapy rehabilitation for vestibular disorder.

Purpose: To investigate whether providing global positioning system feedback to players between bouts of small-sided games (SSGs) can alter locomotor, physiological, and perceptual responses., Methods: Using a reverse counterbalanced design, 20 male university rugby players received either feedback or no feedback during "off-side" touch rugby SSGs. Eight 5v5, 6 × 4-minute SSGs were played over 4 d. Teams were assigned to a feedback or no-feedback condition (control) each day, with feedback provided during the 2-min between-bouts rest interval. Locomotor, heart rate, and differential rating of perceived exertion of breathlessness and leg-muscle exertion were measured and analyzed using a linear mixed model. Outcomes were reported using effect sizes (ES) and 90% confidence intervals (CI), and then interpreted via magnitude-based decisions., Results: Very likely trivial to unclear differences at all time points were observed in heart rate and differential rating of perceived exertion measures. Possibly to very likely trivial effects were observed between conditions, including total distance (ES = 0.15; 90 CI, -0.03 to 0.34), high-speed distance (ES = -0.07; 90 CI, -0.27 to 0.13), and maximal sprint speed (ES = 0.11; 90% CI, -0.11 to 0.34). All within-bout comparisons showed very likely to unclear differences, apart from possible increases in low-speed distance in bout 2 (ES = 0.23; 90% CI, 0.01 to 0.46) and maximal sprint speed in bout 4 (ES = 0.21; 90% CI, -0.04 to 0.45)., Conclusions: In this study, verbal feedback did not alter locomotor, physiological, or perceptual responses in rugby players during SSGs. This may be due to contextual factors (eg, opposition) or the type (ie, distance) or low frequency of feedback provided.

Identifying the external training load variables which influence subjective internal response will help reduce the mismatch between coach-intended and athlete-perceived training intensity. Therefore, this study aimed to reduce external training load measures into distinct principal components (PCs), plot internal training response (quantified via session Rating of Perceived Exertion [sRPE]) against the identified PCs and investigate how the prescription of PCs influences subjective internal training response. Twenty-nine school to international level youth athletes wore microtechnology units for field-based training sessions. SRPE was collected post-session and assigned to the microtechnology unit data for the corresponding training session. 198 rugby union, 145 field hockey and 142 soccer observations were analysed. The external training variables were reduced to two PCs for each sport cumulatively explaining 91%, 96% and 91% of sRPE variance in rugby union, field hockey and soccer, respectively. However, when internal response was plotted against the PCs, the lack of separation between low-, moderate- and high-intensity training sessions precluded further analysis as the prescription of the PCs do not appear to distinguish subjective session intensity. A coach may therefore wish to consider the multitude of physiological, psychological and environmental factors which influence sRPE alongside external training load prescription.

Objective: The aim of the current study is to examine whether concussion history and years played are linearly associated with cognitive outcomes in retired National Football League (NFL) players., Method: Thirty-five retired NFL players over the age of 50 who had sustained at least one concussion completed a clinical interview and brief neuropsychological battery. Correlational analyses were conducted between exposure variables [number of total concussions, concussions with loss of consciousness (LOC), and years played] and cognitive performance as characterized by cognitive composite scores based on performance on neuropsychological measures (attention/processing speed, language, memory, and overall composite scores)., Results: Correlational analyses corrected for multiple comparisons did not reveal any statistically significant correlations between exposure variables and cognitive outcomes., Conclusions: We did not find a significant linear association between cognitive outcomes and either number of total concussions, concussions with LOC, or years played in the NFL. These findings do not support a dose-response relationship between sports-related exposure to head impacts and cognitive outcomes later in life. Rather, the findings suggest that cognitive difficulties experienced by some retired players later in life are not directly linearly associated with quantified exposure to head impacts sustained throughout a football career, but related to factors or combinations of factors that have yet to be elucidated., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Some researchers have claimed that former National Football League (NFL) players are at increased risk for suicide as a clinical feature of chronic traumatic encephalopathy (CTE). This review examines the literature on risk for suicide in former professional football players, and the association between suicide and CTE., Method: A narrative review of the literature published between 1928 and 2018., Results: Between 1928 and 2009, suicide was not considered to be a clinical feature of CTE in the literature. The best available evidence from epidemiological studies suggests that former NFL football players are at lesser risk for suicide, not greater risk, compared to men in the general population. However, surveys have revealed that a substantial minority of former NFL players have depression and other mental health problems, chronic pain and opioid use is relatively common, and those with depression and chronic pain also have greater life stress and financial difficulties. That minority would be at increased risk for suicidal thoughts and behaviors., Conclusions: Researchers and clinicians are encouraged to be cautious and circumspect when considering the clinical presentation of former athletes, and to not assume that depression and suicidality are caused by specific types of neuropathology. This represents a reductionistic and Procrustean view. Some former football players have mental health problems, but it should not be assumed uncritically that the underlying cause is an inexorably progressive neurodegenerative disease. Providing evidence-informed and evidence-supported treatments for depression and suicidality might reduce suffering and improve their functioning., (© The Author(s) 2019. Published by Oxford University Press.)

Objective: To determine if concussion history and career status is associated with neurocognitive performance in elite football players., Methods: The study design was a cross-sectional single assessment. Fifty-seven elite football players (age 29.39 ± 7.49 years) categorized as draft prospects, active professional players, and retired professional players were assessed on the Sport Concussion Assessment Tool - third edition (SCAT-3), in an outpatient therapy setting., Results: Common symptoms were the following: fatigue (45.6%), trouble falling asleep (35.1%), difficulty remembering (33.3%) and irritability (22.8%); 36.8% reported no symptoms. The low concussion (0-1) group reported fewer symptoms (U = 608.50, p < .001), less symptom severity (U = 598.00, p = -.001), and produced greater scores on the Standardized Assessment of Concussion (SAC) total scores compared to the multiple concussion (2+) group (U = 253.00, p = .024), but no differences were observed on modified Balance Error Scoring System (m-BESS) scores (U = 501.50, p = .066) on the Mann-Whitney U test. The Kruskal-Wallis test and post-hoc analysis indicated retired players were significantly different from draft prospects and current professional players for total symptom scores (p < .001), total symptom severity (p < .001), SAC total scores (p = .030), and m-BESS (p < .001)., Conclusions: Concussion history and career status appear associated with total symptoms, symptom severity, performance on the SAC, and the m-BESS in elite football players. With this in mind, future research is recommended to determine longitudinal impact for elite football players., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Clinical practice strongly relies on patients' self-report. Former professional American-style football players are hesitant to seek help for mental health problems, but may be more willing to report cognitive symptoms. We sought to assess the association between cognitive symptoms and diagnosed mental health problems and quality of life among a cohort of former professional players. In a cross-sectional design, we assessed self-reported cognitive function using items from the Quality of Life in Neurological Disorders (Neuro-QOL) Item Bank. We then compared mental health diagnoses and quality of life, assessed by items from the Patient-Reported Outcome Measurement Information System (PROMIS ® ), between former professional players reporting daily problems in cognitive function and former players not reporting daily cognitive problems. Of the 3758 former professional players included in the analysis, 40.0% reported daily problems due to cognitive dysfunction. Former players who reported daily cognitive problems were more likely to also report depression (18.0% vs. 3.3%, odds ratio [OR] = 6.42, 95% confidence interval [CI] [4.90-8.40]) and anxiety (19.1% vs. 4.3%, OR = 5.29, 95% CI [4.14-6.75]) than those without daily cognitive problems. Further, former players reporting daily cognitive problems were more likely to report memory loss and attention deficit(/hyperactivity) disorder and poorer general mental health, lower quality of life, less satisfaction with social activities and relationships, and more emotional problems. These findings highlight the potential of an assessment of cognitive symptoms for identifying former players with mental health, social, and emotional problems.

Concerned about potentially increased risk of neurodegenerative disease, several health professionals and policy makers have proposed limiting or banning youth participation in American-style tackle football. Given the large affected population (over 1 million boys play high school football annually), careful estimation of the long-term health effects of playing football is necessary for developing effective public health policy. Unfortunately, existing attempts to estimate these effects tend not to generalize to current participants because they either studied a much older cohort or, more seriously, failed to account for potential confounding. We leverage data from a nationally representative cohort of American men who were in grades 7-12 in the 1994-95 school year to estimate the effect of playing football in adolescent on depression in early adulthood. We control for several potential confounders related to subjects' health, behavior, educational experience, family background, and family health history through matching and regression adjustment. We found no evidence of even a small harmful effect of football participation on scores on a version of the Center for Epidemiological Studies Depression scale (CES-D) nor did we find evidence of adverse associations with several secondary outcomes including anxiety disorder diagnosis or alcohol dependence in early adulthood. For men who were in grades 7-12 in the 1994-95 school year, participating or intending to participate in school football does not appear to be a major risk factor for early adulthood depression., Competing Interests: The authors have declared that no competing interests exist.

We utilize a contest-theoretic model to demonstrate a version of the alliance formation puzzle that aligns with reception-coverage contests in American football. Namely, secondary defenders can opt for single-coverage-1 v 1 contest. Alternatively, they can choose to ally-form double-coverage or 2 v 1 contest with exogenous intra-alliance prize division-when defending a given receiver. In our theoretical treatment, we find that defenses have a lower equilibrium success rate in preventing the receiver from "getting open" under double-coverage than under single-coverage in the absence of capacity constraints. We also find that this success rate paradox is a necessary condition for the alliance formation puzzle. We then test the theoretical treatment by analyzing 8,508 plays of NCAA and NFL game data within a set of fixed effects, logistic regression models that control for receiver, level-of-play, and season-of-play. We find that equilibrium level of defensive success rises significantly and substantially (p-value < 0.01 and marginal effect of between 13 and 17 percentage points) when moving from single-coverage to double-coverage, ceteris paribus. There is strong evidence that the necessary condition for the alliance formation puzzle does not hold in this setting. We conclude that sufficiently-binding physiological and training-based capacity constraints eliminate the alliance formation puzzle in this setting, as was shown theoretically by Konrad and Kovenock (2009). This empirical result suggests that other contest settings that regularly feature alliance, such as liquidity-constrained conflict, may not be puzzling., Competing Interests: One author, MH, is a paid employee of the National Football League as a football writer/editor. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The National Football League did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The present study examined the psychometric properties of the coach-adapted version of the Empowering and Disempowering Motivational Climate Questionnaire (EDMCQ) using Bayesian structural equation modelling (BSEM). The sample included 780 ( M age  = 36.4; SD  = 10.8; males n = 698; females n = 54; 28 participants did not report sex) youth sport coaches representing five European countries (i.e., England, France, Greece, Norway, and Spain). The results did not support a 34-item five-factor, hierarchical, a two-factor BSEM, or a bifactor BSEM model across the participating countries. However, the results supported a reduced 19-item first-order, two-factor BSEM model that largely showed approximate metric invariance, but not approximate scalar invariance across the five countries. The pool of items constituting empowering and disempowering motivational climates should be refined to further enhance the empirical operationalisation of the coach-adapted version of the EDMCQ. Advancing the quality of translation-back-translation procedures across cultures and conducting multi-national pilot testing seems warranted as well. These recommendations may help to identify the distinctive aspects of each underlying sub-dimension of the EDMCQ, where coaches are the respondents, and pave the way for further examination of the proposed hierarchical multidimensional factor structure and the cross-cultural equivalence of the EDMCQ for this population.

The use of social media is now an established strategy to engage and maintain customer loyalty. The purpose of the present study was to examine the Twitter accounts of ten of the largest online sports betting operators in the UK to determine what marketing strategies were employed. More specifically, this study analyzed 3375 tweets posted by the operators during the opening weekend of the 2018-2019 English Premier League football season using a content analysis methodology. The results demonstrated that multiple strategies, including hashtags, were used to link gambling operator tweets with major sporting events, and the use of numerous promotional campaigns. Notably, over 90% of the tweets contained no responsible gambling information. The quantity and content of social media posts underline the need for a review of the current advertising regulations in the UK. Further research should examine how exposure to sports betting social media marketing influences gambling behavior.

Objective: To examine the self-recalled concussion and bell ringer (BR) prevalence, reporting rates, and reporting behaviors in adolescent rugby players., Design: Cross-sectional survey., Setting: School classroom., Participants: Adolescent male rugby players aged 12 to 18 years (n = 866)., Main Outcome Measures: Concussion and BR prevalence, reporting rates, and reporting behaviors., Results: The sample reported a concussion and BR prevalence rate of 40% and 69.9%, respectively. Of these athletes with a history, 38.4% and 86.4% suffered recurrent concussions and BRs, respectively. The total reporting rates per 1000 suspected concussions and BRs were 474.8 [95% confidence interval (CI), 415.4-534.3] and 238.7 (95% CI, 217.8-259.5), respectively. The athletes highlighted several barriers which hindered their truthful reporting of concussion, including "not thinking the injury is serious enough to report" (70%), "wanting to win the game" (38%), and "not wanting to miss future games or training" (48%)., Conclusions: Educational interventions are an invaluable component within a socioecological framework aimed at improving the concussion reporting rates of adolescent athletes. The self-recalled prevalence, underreporting rates, and behaviors of the sample are alarming, which prompts the need to further explore their motivational beliefs behind their decision to underreport a potential concussion. The information obtained can be used to tailor personalized interventions for specific athlete samples.

This study examined the relationships between daily cognitive appraisals of organizational events, affective responses, and coping. In addition, a 5-year longitudinal relationship between coping and performance outcomes at the senior professional level was assessed. Using an experience sampling method, professional academy rugby union players ( N = 39, M age = 17.23 years, SD = 0.87) completed daily diary measures of appraisals, affective responses, and coping over 5 weeks of training. Hierarchical linear modeling revealed that daily cognitive appraisals were related to daily affective responses and coping functions enacted by behaviours, after accounting for a series of within (e.g., time, day, week) and between-person (e.g., personality, key decision-makers) differences. Zero-inflated negative binomial regression revealed that coping related to eliciting support was associated with minutes played at the senior professional level five years later. This study extends theoretical knowledge of the within- and between-person relationships that explain organizational stress experiences. The findings suggest that some coping functions enacted by behaviours may be early indicators of future performance outcomes in professional sport.

Referees in sports games have a high level of responsibility as they have to make correct and appropriate decisions at any point during a match. Regarding referees' decision-making (RDM) as a perceptual-cognitive process, evidence suggests that physical load might reduce cognitive performance and thus might reduce RDM performance as well. In consideration of increasing game dynamics, referees have to cope with high physical load, but they have to make correct and appropriate decisions further on. Here, we review the current state of research on the relationship between physical load and RDM. A scoping review was performed, in accordance with the PRISMA guidelines, using the following databases: Scopus, PubMed, Web of Science (all databases), SURF and SPONET (both with an English and German search). Only primary studies written in English or German that investigated the relationship between physical load and RDM in sports games were included. Eleven studies included in the review investigated six physical parameters and RDM: match period, velocity, blood lactate, running time, heart rate, distance covered. Most findings of the studies showed no relationship between physical load and RDM ( n = 18). Thirteen findings suggest a negative relationship and three findings indicate a positive relationship between physical load and RDM. Results of the scoping review show contradictory evidence across and within investigated different physical parameters. As RDM consists of multi-factorial components, it is recommended to conduct systematic research programs - field as well as experimental studies - to resolve the missing control of potential confounding variables and to consider the difference of internal and external load., (© Journal of Sports Science and Medicine.)

Context: Version 5 of the Sport Concussion Assessment Tool (SCAT5) was released in 2017 with an additional 10-word list option in the memory section and additional instructions for completing the symptom scale., Objective: To provide reference scores for high school rugby union players on the SCAT5, including immediate memory using the 10-word list, and examine how age, sex, and concussion history affected performance., Design: Cross-sectional study., Setting: Calgary, Alberta high schools., Patients or Other Participants: High school rugby union players (ages 15-18 years) participating in a 2018 season cohort study (n = 380, males = 210, females = 170)., Main Outcome Measure(s): Sport Concussion Assessment Tool 5 scores, including total number of symptoms (of 20), symptom severity (of 132), 10-word immediate memory (of 30), delayed memory (of 10), modified Standardized Assessment of Concussion (of 50), and balance examination (of 30)., Results: The median number of symptoms reported at baseline ranged from 5 to 8 across sex and age stratifications. Median symptom severity was lowest in males with no concussion history (7; range, 0-28) and highest in females with a concussion history (13, range = 0-45). Median total scores on immediate memory were 2-3 (range = 0-4) for males and 21 (range = 9-29) for females. Median total scores were 3 (range = 0-4) on digits backward and 7 (range = 0-20) on delayed memory (all groups). Based on simultaneous quantile (q) regression at 0.50 and 0.75, adjusted for age and concussion history, being female was associated with a higher total symptoms score (q0.75 β female = 2.85; 99% confidence interval [CI] = 0.33, 5.37), higher total symptom severity score (q0.75 β female = 8.00; 99% CI = 2.83, 13.17), and lower number of errors on the balance examination (q0.75 β female = -3.00; 99% CI = -4.85, -1.15). Age and concussion history were not associated with any summary measures., Conclusions: The 10-word list option in the memory section reduced the likelihood of a ceiling effect. A player's sex may be an important consideration when interpreting the SCAT5 after concussion.