Influence of Cognitive Performance on Musculoskeletal Injury Risk: A Systematic Review

Background: While a large number of studies have investigated the anatomic, hormonal, and biomechanical risk factors related to musculoskeletal (MSK) injury risk, there is growing evidence to suggest that cognition is an important injury contributor in the athletic population. A systematic review of the available evidence regarding the influence of cognitive performance on MSK injury risk has yet to be published in the sports medicine literature. Purpose/Hypothesis: The purpose was to determine the effects of cognition on (1) MSK biomechanics during sports-specific tasks and (2) MSK injury occurrence in the athletic population. It was hypothesized that athletes with lower cognitive performance would demonstrate biomechanical patterns suggestive of MSK injury risk and that injured athletes would perform worse on baseline measures of cognition as compared with their noninjured counterparts. Study Design: Systematic review. Methods: PubMed and SPORTDiscus were searched from January 2000 to January 2020. Manual searches were performed on the reference lists of the included studies. A search of the literature was performed for studies published in English that reported MSK biomechanics as a function of cognitive performance and MSK injury occurrence after baseline measures of cognition. Two independent reviewers extracted pertinent study data in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 guidelines and assessed study quality using the Quality Assessment Tool for Observational Cohort and Cross-sectional Studies from the National Institutes of Health. A meta-analysis was not performed, owing to the heterogeneous nature of the study designs. Results: Ten studies met inclusion criteria: 4 cognition-MSK biomechanics studies and 6 cognition-MSK injury studies. All 4 cognition-MSK biomechanics studies demonstrated that worse performance on measures of cognition was associated with lower extremity MSK biomechanical patterns suggestive of greater risk for MSK injury. The majority of the cognition-MSK injury studies demonstrated that injured athletes significantly differed on baseline cognition measures versus matched controls or that cognitive performance was a significant predictor for subsequent MSK injury. Conclusion: Although the literature exploring cognitive contributions to MSK injury risk is still in its infancy, it is suggested that sports medicine personnel conduct baseline assessments of cognition-in particular, reaction time and working memory-to identify which athletes may be at elevated risk for future MSK injury.