Integrative multi-omics analyses to identify the genetic and functional mechanisms underlying ovarian cancer risk regions.

To identify credible causal risk variants (CCVs) associated with different histotypes of epithelial ovarian cancer (EOC), we performed genome-wide association analysis for 470,825 genotyped and 10,163,797 imputed SNPs in 25,981 EOC cases and 105,724 controls of European origin. We identified five histotype-specific EOC risk regions (p value <5 × 10-8) and confirmed previously reported associations for 27 risk regions. Conditional analyses identified an additional 11 signals independent of the primary signal at six risk regions (p value <10-5). Fine mapping identified 4,008 CCVs in these regions, of which 1,452 CCVs were located in ovarian cancer-related chromatin marks with significant enrichment in active enhancers, active promoters, and active regions for CCVs from each EOC histotype. Transcriptome-wide association and colocalization analyses across histotypes using tissue-specific and cross-tissue datasets identified 86 candidate susceptibility genes in known EOC risk regions and 32 genes in 23 additional genomic regions that may represent novel EOC risk loci (false discovery rate <0.05). Finally, by integrating genome-wide HiChIP interactome analysis with transcriptome-wide association study (TWAS), variant effect predictor, transcription factor ChIP-seq, and motifbreakR data, we identified candidate gene-CCV interactions at each locus. This included risk loci where TWAS identified one or more candidate susceptibility genes (e.g., HOXD-AS2, HOXD8, and HOXD3 at 2q31) and other loci where no candidate gene was identified (e.g., MYC and PVT1 at 8q24) by TWAS. In summary, this study describes a functional framework and provides a greater understanding of the biological significance of risk alleles and candidate gene targets at EOC susceptibility loci identified by a genome-wide association study.

A Biopsychosocial Model for Understanding Training Load, Fatigue, and Musculoskeletal Sport Injury in University Athletes: A Scoping Review.

ABSTRACT: McClean, ZJ, Pasanen, K, Lun, V, Charest, J, Herzog, W, Werthner, P, Black, A, Vleuten, RV, Lacoste, E, and Jordan, MJ. A biopsychosocial model for understanding training load, fatigue, and musculoskeletal sport injury in university athletes: A scoping review. J Strength Cond Res 38(6): 1177-1188, 2024-The impact of musculoskeletal (MSK) injury on athlete health and performance has been studied extensively in youth sport and elite sport. Current research examining the relationship between training load, injury, and fatigue in university athletes is sparse. Furthermore, a range of contextual factors that influence the training load-fatigue-injury relationship exist, necessitating an integrative biopsychosocial model to address primary and secondary injury prevention research. The objectives of this review were (a) to review the scientific literature examining the relationship between training load, fatigue, and MSK injury in university athletes and (b) to use this review in conjunction with a transdisciplinary research team to identify biopsychosocial factors that influence MSK injury and develop an updated, holistic biopsychosocial model to inform injury prevention research and practice in university sport. Ten articles were identified for inclusion in this review. Key findings were an absence of injury surveillance methodology and contextual factors that can influence the training load-fatigue-MSK injury relationship. We highlight the inclusion of academic load, social load, and mental health load as key variables contributing to a multifactorial, gendered environmental, scientific inquiry on sport injury and reinjury in university sport. An integrative biopsychosocial model for MSK injury in university sport is presented that can be used to study the biological, psychological, and social factors that modulate injury and reinjury risk in university athletes. Finally, we provide an example of how causal inference can be used to maximize the utility of longitudinally collected observational data that is characteristic of sport performance research in university sport.

A 2D video-based assessment is associated with 3D biomechanical contributors to dynamic knee valgus in the coronal plane.

Introduction: Adolescent athletes involved in sports that involve cutting and landing maneuvers have an increased risk of anterior cruciate ligament (ACL) tears, highlighting the importance of identifying risky movement patterns such as dynamic knee valgus (DKV). Qualitative movement screenings have explored two-dimensional (2D) scoring criteria for DKV, however, there remains limited data on the validity of these screening tools. Determining a 2D scoring criterion for DKV that closely aligns with three-dimensional (3D) biomechanical measures will allow for the identification of poor knee position in adolescent athletes on a broad scale. The purpose of this study was to establish a 2D scoring criterion that corresponds to 3D biomechanical measures of DKV. Methods: A total of 41 adolescent female club volleyball athletes performed a three-task movement screen consisting of a single-leg squat (SLS), single-leg drop landing (SLDL), and double-leg vertical jump (DLVJ). A single rater scored 2D videos of each task using four criteria for poor knee position. A motion capture system was used to calculate 3D joint angles, including pelvic obliquity, hip adduction, knee abduction, ankle eversion, and foot progression angle. Receiver operating characteristic curves were created for each 2D scoring criterion to determine cut points for the presence of movement faults, and areas under the curve (AUC) were computed to describe the accuracy of each 2D criterion compared to 3D biomechanical data. Results: 3D measures indicated knee abduction angles between 2.4°-4.6° (SD 4.1°-4.3°) at the time point when the center of the knee joint was most medial during the three tasks. AUCs were between 0.62 and 0.93 across scoring items. The MEDIAL scoring item, defined as the knee joint positioned inside the medial border of the shoe, demonstrated the greatest association to components of DKV, with AUCs ranging from 0.67 to 0.93. Conclusion: The MEDIAL scoring criterion demonstrated the best performance in distinguishing components of DKV, specifically pelvic obliquity, hip adduction, ankle eversion, and foot progression. Along with the previously published scoring definitions for trunk-specific risk factors, the authors suggest that the MEDIAL criterion may be the most indicative of DKV, given an association with 3D biomechanical risk factors.

Correction: Currie et al. Reality Check 2: The Cost-Effectiveness of Policy Disallowing Body Checking in Non-Elite 13- to 14-Year-Old Ice Hockey Players. Int. J. Environ. Res. Public Health 2021, 18, 6322.

There was an error in our original publication [...].

One-Year Injury History and Safe Dance Practices Among Female Highland Dancers in Canada.

AIMS: Over 8,650 Highland dancers registered to compete in Royal Scottish Official Board of Highland Dancing events worldwide in 2019. While the burden of dance-related injuries is high among dancers, there are few studies examining Highland dance. The purpose of this study was to describe the prevalence of self-reported 1-year injury history and safe dance practices among female Highland dancers. METHODS: Sixty-five female Canadian Highland dancers (median age 18; range 14-47) completed an anonymous online survey at the beginning of the 2019 championship season. Demographics (i.e., age, body mass index), exposure (e.g., months/year dancing), safe dance practices (e.g., environmental, physical, psychological), and 1-year injury history (i.e., yes/no) were self-reported. Three definitions of dance-related injury were used: 1) time-loss (missed ≥1 class, practice, performance, and/or competition); 2) medical attention (requiring professional medical care); and 3) any physical complaint that affected full participation. RESULTS: Most participants were training at the elite standard/premier level (86%, 95%CI 75-93) and for ≥8 months/year (83%, 95%CI 75-93). The proportion of dancers reporting at least one physical complaint in the previous 1 year was 71% (95%CI 58-81). Sixty percent (95%CI 47-71) of dancers reported ≥1 medical attention and/or time-loss injury. All participants reported warming up regularly, with 59% (95%CI 46-70) participating in regular cool-downs. CONCLUSION: The prevalence of 1-year injury history among female Highland dancers is high. Education on the benefits of safe dance practice for Highland dancers may be useful. Prospective cohort studies are needed to understand the dynamic nature of dance injuries across a full competitive season.

Teach Indigenous knowledge alongside science.

Evidence supports the teaching of Indigenous knowledge alongside sciences in the classroom.

Shoulder Check: Investigating Shoulder Injury Rates, Types, Severity, Mechanisms, and Risk Factors in Canadian Youth Ice Hockey.

OBJECTIVE: To describe shoulder-related injury rates (IRs), types, severity, mechanisms, and risk factors in youth ice hockey players during games and practices. DESIGN: Secondary analysis of data from a 5-year prospective cohort study, Safe-to-Play (2013-2018). SETTING: Canadian youth ice hockey. PARTICIPANTS: Overall, 6584 player-seasons (representing 4417 individual players) participated. During this period, 118 shoulder-related games and 12 practice injuries were reported. ASSESSMENT OF RISK FACTORS: An exploratory multivariable mixed-effects Poisson regression model examined the risk factors of body checking policy, weight, biological sex, history of injury in the past 12 months, and level of play. MAIN OUTCOME MEASURES: Injury surveillance data were collected from 2013 to 2018. Injury rates with 95% confidence interval (CI) were estimated using Poisson regression. RESULTS: The shoulder IR was 0.35 injuries/1000 game-hours (95% CI, 0.24-0.49). Two-thirds of game injuries (n = 80, 70%) resulted in >8 days of time-loss, and more than one-third (n = 44, 39%) resulted in >28 days of time-loss. An 83% lower rate of shoulder injury was associated with policy prohibiting body checking compared with leagues allowing body checking (incidence rate ratio [IRR], 0.17; 95% CI, 0.09-0.33). A higher shoulder IR was observed for those who reported any injury in the last 12-months compared with those with no history (IRR, 2.00; 95% CI, 1.33-3.01). CONCLUSIONS: Most shoulder injuries resulted in more than 1 week of time-loss. Risk factors for shoulder injury included participation in a body-checking league and recent history of injury. Further study of prevention strategies specific to the shoulder may merit further consideration in ice hockey.

Preseason Measures of Cervical Spine Function, Vestibulo-Ocular Reflex, Dynamic Balance, and Divided Attention in Youth Ice Hockey Players.

OBJECTIVES: Report typical scores and examine preseason cervical spine, vestibulo-ocular reflex, dynamic balance, and divided attention measures in competitive youth ice hockey players aged 10 to 18 years with and without a previous concussion history. DESIGN: Cross-sectional secondary analysis. METHODS: The exposure of interest was self-reported history of concussion. The main outcomes were cervical spine measures (Cervical Flexor Endurance [CFE; seconds], Cervical Flexion-Rotation Test [normal/abnormal], Anterolateral Cervical Spine Strength [kilograms], Head Perturbation Test (/8), and Joint Position Error [JPE; centimeters]), vestibulo-ocular reflex (Dynamic Visual Acuity [logMAR], Head Thrust Test [Positive/Negative]), dynamic balance (Functional Gait Assessment [/30]) and divided attention (Walking While Talking Test [seconds]). Multivariable linear or logistic regression, adjusted for age-group, sex, level of play, and clustered by team, were used to assess potential differences by concussion history. RESULTS: We included data from 2311 participants in this study (87.2% male, 12.8% female, 39.0% reported a previous concussion). No differences by concussion history were found across any of the measures (P values range: 0.17-0.99). Measures of cervical spine function and divided attention differed by age group (eg, Median Left Anterolateral Cervical Spine Strength [kilograms] for males: U13 = 7.46, U15 = 9.10, U18 = 9.67). CONCLUSION: Clinical outcomes scores in youth ice hockey players did not differ by concussion history. Performance on cervical spine strength, CFE, and JPE test outcomes may improve with age, highlighting the importance of developmental considerations when interpreting test scores. J Orthop Sports Phys Ther 2024;54(3):1-11. Epub 30 November 2023. doi:10.2519/jospt.2023.11958.

Differences in injury and concussion rates in a cohort of Canadian female and male youth Rugby Union: a step towards targeted prevention strategies.

OBJECTIVE: To examine differences in match and training musculoskeletal injury and concussion rates and describe mechanisms of concussion while considering previous playing experience in female and male Canadian high school Rugby Union ('rugby') players. METHODS: A 2-year prospective cohort study was completed in a high school league (n=361 females, 421 player-seasons; n=429 males, 481 player-seasons) in Calgary, Canada over the 2018 and 2019 rugby playing seasons. Baseline testing was completed at the start of each season and injury surveillance and individual player participation through session attendance was documented to quantify individual-level player exposure hours. Injury incidence rates (IRs) and incidence rate ratios (IRRs) were calculated using Poisson regression, offset by player exposure hours and clustered by team. RESULTS: Overall match IR for females was 62% higher than males (overall IRR=1.62, 95% CI: 1.20 to 2.18) and the overall training IR was twice as high for females (overall IRR=2.15, 95% CI: 1.40 to 3.32). The female match concussion IR was 70% higher than the males (concussion IRR=1.70, 95% CI: 1.08 to 2.69). Females had a 75% greater tackle-related IR compared with males (IRR=1.75, 95% CI: 1.20 to 2.56). Additionally, female tacklers had a twofold greater rate of injury compared with male tacklers (IRR=2.17, 95% CI: 1.14 to 4.14). Previous playing experience was not associated with tackle-related injury or concussion IRs. CONCLUSION: The rate of injury and concussion was significantly higher in females within this Canadian high school cohort. These results emphasise the need for development, implementation and evaluation of female-specific injury and concussion prevention strategies to reduce injury and concussion in female youth rugby.

Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design.

OBJECTIVES: To understand Canadian university athletic programme concussion management needs, and to describe development and content of a tailored online concussion education tool for Canadian university/college athletes. DESIGN: An integrated knowledge translation multiphased, multimethods approach was used. Phases included a needs assessment survey with university representatives and athletes, content selection, mapping behavioural goals to evidenced-based behaviour change techniques, script/storyboard development, engagement interviews with university athletes and tool development using user-centred design techniques. SETTING: Canadian U SPORTS universities (n=56). PARTICIPANTS: Overall, 64 university representatives (eg, administrators, clinicians) and 27 varsity athletes (52% male, 48% female) completed the needs assessment survey. Five athletes participated in engagement interviews. OUTCOME MEASURES: Surveys assessed previous athlete concussion education, recommendations for concussion topics and tool design, concussion management challenges and interest in implementing a new course. RESULTS: Institutions used a median (Med) of two (range 1-5) approaches when educating athletes about concussion. Common approaches were classroom-style education (50%), online training (41%) and informational handouts (39%). University representatives rated most important topics as: (1) what is a concussion, (2) how to recognise a concussion and (3) how to report a concussion (Medall=4.8/5). Athletes felt symptom recognition (96%) and effects on the brain (85%) were most important. The majority of athletes preferred learning via computer (81%) and preferred to learn alone (48%) versus group learning (7%). The final resource was designed to influence four behaviours: (1) report symptoms, (2) seek care, (3) encourage teammates to report symptoms and (4) support teammates through concussion recovery. Examples of behaviour change techniques included: knowledge/skills, problem-solving scenarios, verbal persuasion and social comparison. Athletes are guided through different interactions (eg, videos, flip cards, scenarios, testimonials) to maximise engagement (material review takes ~30 min). CONCLUSIONS: The Concussion Awareness Training Tool for athletes is the first Canadian education tool designed to address the needs of Canadian university/college athletes.

Unravelling the web: Experiences of adolescents returning to school following a concussion.

One in five adolescents will sustain a concussion in their lifetime. A concussion may result in symptoms that affect an adolescent's ability to attend school and engage in learning tasks. This study was guided by interpretivism. We conducted one-on-one semi-structured interviews to explore the perspectives of 20 adolescents (ages 14-18) returning to school after a concussion. Interviews were coded inductively and analyzed using reflexive thematic analysis. Five interconnected themes emerged with returning to school and accessing school supports: (1) concussion symptoms affected adolescents' schoolwork; (2) access to academic accommodations eased adolescents' return to school; (3) having supportive and understanding friends, family, and teachers facilitated adolescents' return to school; (4) communication amongst school stakeholders was desired, but often lacking; and (5) feeling anxious, frustrated, and sad with the return to school process. Adolescents' experiences were multifaceted and many factors contributed to their return to school experiences. Our findings can inform our understanding of the experiences of adolescents returning to school following concussion and can inform the development of concussion management supports at schools.

Combined oral contraceptive pill for primary dysmenorrhoea.

BACKGROUND: Dysmenorrhoea (painful menstrual cramps) is common and a major cause of pain in women. Combined oral contraceptives (OCPs) are often used in the management of primary dysmenorrhoea, but there is a need for reporting the benefits and harms. Primary dysmenorrhoea is defined as painful menstrual cramps without pelvic pathology. OBJECTIVES: To evaluate the benefits and harms of combined oral contraceptive pills for the management of primary dysmenorrhoea. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date 28 March 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing all combined OCPs with other combined OCPs, placebo, or management with non-steroidal anti-inflammatory drugs (NSAIDs). Participants had to have primary dysmenorrhoea, diagnosed by ruling out pelvic pathology through pelvic examination or ultrasound. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane. The primary outcomes were pain score after treatment, improvement in pain, and adverse events. MAIN RESULTS: We included 21 RCTs (3723 women). Eleven RCTs compared combined OCP with placebo, eight compared different dosages of combined OCP, one compared two OCP regimens with placebo, and one compared OCP with NSAIDs. OCP versus placebo or no treatment OCPs reduce pain in women with dysmenorrhoea more effectively than placebo. Six studies reported treatment effects on different scales; the result can be interpreted as a moderate reduction in pain (standardised mean difference (SMD) -0.58, 95% confidence interval (CI) -0.74 to -0.41; I² = 28%; 6 RCTs, 588 women; high-quality evidence). Six studies also reported pain improvement as a dichotomous outcome (risk ratio (RR) 1.65, 95% CI 1.29 to 2.10; I² = 69%; 6 RCTs, 717 women; low-quality evidence). The data suggest that in women with a 28% chance of improvement in pain with placebo or no treatment, the improvement in women using combined OCP will be between 37% and 60%. Compared to placebo or no treatment, OCPs probably increase the risk of any adverse events (RR 1.31, 95% CI 1.20 to 1.43; I² = 79%; 7 RCTs, 1025 women; moderate-quality evidence), and may also increase the risk of serious adverse events (RR 1.77, 95% CI 0.49 to 6.43; I² = 22%; 4 RCTs, 512 women; low-quality evidence). Women who received OCPs had an increased risk of irregular bleeding compared to women who received placebo or no treatment (RR 2.63, 95% CI 2.11 to 3.28; I² = 29%; 7 RCTs, 1025 women; high-quality evidence). In women with a risk of irregular bleeding of 18% if using placebo or no treatment, the risk would be between 39% and 60% if using combined OCP. OCPs probably increase the risk of headaches (RR 1.51, 95% CI 1.11 to 2.04; I² = 44%; 5 RCTs, 656 women; moderate-quality evidence), and nausea (RR 1.64, 95% CI 1.17 to 2.30; I² = 39%; 8 RCTs, 948 women; moderate-quality evidence). We are uncertain of the effect of OCP on weight gain (RR 1.83, 95% CI 0.75 to 4.45; 1 RCT, 76 women; low-quality evidence). OCPs may slightly reduce requirements for additional medication (RR 0.63, 95% CI 0.40 to 0.98; I² = 0%; 2 RCTs, 163 women; low-quality evidence), and absence from work (RR 0.63, 95% CI 0.41 to 0.97; I² = 0%; 2 RCTs, 148 women; low-quality evidence). One OCP versus another OCP Continuous use of OCPs (no pause or inactive tablets after the usual 21 days of hormone pills) may reduce pain in women with dysmenorrhoea more effectively than the standard regimen (SMD -0.73, 95% CI -1.13 to 0.34; 2 RCTs, 106 women; low-quality evidence). There was insufficient evidence to determine if there was a difference in pain improvement between ethinylestradiol 20 µg and ethinylestradiol 30 µg OCPs (RR 1.06, 95% CI 0.65 to 1.74; 1 RCT, 326 women; moderate-quality evidence). There is probably little or no difference between third- and fourth-generation and first- and second-generation OCPs (RR 0.99, 95% CI 0.93 to 1.05; 1 RCT, 178 women; moderate-quality evidence). The standard regimen of OCPs may slightly increase the risk of any adverse events over the continuous regimen (RR 1.11, 95% CI 1.01 to 1.22; I² = 76%; 3 RCTs, 602 women; low-quality evidence), and probably increases the risk of irregular bleeding (RR 1.38, 95% CI 1.14 to 1.69; 2 RCTs, 379 women; moderate-quality evidence). Due to lack of studies, it is uncertain if there is a difference between continuous and standard regimen OCPs in serious adverse events (RR 0.34, 95% CI 0.01 to 8.24; 1 RCT, 212 women), headaches (RR 0.94, 95% CI 0.50 to 1.76; I² = 0%; 2 RCTs, 435 women), or nausea (RR 1.08, 95% CI 0.51 to 2.30; I² = 23%; 2 RCTs, 435 women) (all very low-quality evidence). We are uncertain if one type of OCP reduces absence from work more than the other (RR 1.12, 95% CI 0.64 to 1.99; 1 RCT, 445 women; very low-quality evidence). OCPs versus NSAIDs There were insufficient data to determine whether OCPs were more effective than NSAIDs for pain (mean difference -0.30, 95% CI -5.43 to 4.83; 1 RCT, 91 women; low-quality evidence). The study did not report on adverse events. AUTHORS' CONCLUSIONS: OCPs are effective for treating dysmenorrhoea, but they cause irregular bleeding, and probably headache and nausea. Long-term effects were not covered in this review. Continuous use of OCPs was probably more effective than the standard regimen but safety should be ensured with long-term data. Due to lack of data, we are uncertain whether NSAIDs are better than OCPs for treating dysmenorrhoea.

Academic Accommodations for Middle and High School Students Following a Concussion: Perspectives of Teachers and School Administrators.

BACKGROUND: An estimated 1 in 5 adolescents have sustained a concussion in North America. Teachers and school administrators are responsible for implementing academic accommodations and other supports for optimal return to learn following a concussion. The primary objective of this study was to describe the prevalence and feasibility of providing academic accommodations to students following concussion from the perspectives of middle and high school teachers and school administrators. METHODS: A cross-sectional survey was administered to teachers and school administrators (grades 7-12) across Canada online via REDCap. Participants were recruited via word-of-mouth and social media sampling. Survey responses were analyzed descriptively using proportions. RESULTS: The survey was completed by 180 educators (138 teachers and 41 school administrators), of whom 86% had previously provided academic accommodations to students following concussion, and 96% agreed that students should have access to accommodations following concussion. Some accommodations (eg, breaks, extra time) were provided more often and were more feasible to provide than others (eg, no new learning, reduced bright light). Educators reported limited preparation time and limited school personnel support to assist students following concussion. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: The most feasible accommodations should be prioritized, ensuring students are supported within the school environment. CONCLUSIONS: Teachers and school administrators confirmed the importance of providing accommodations to students following concussion.

Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis.

OBJECTIVES: To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and/or head impact risk. DESIGN: This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review. ELIGIBILITY CRITERIA: Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English. RESULTS: In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies. CONCLUSIONS: Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC. PROSPERO REGISTRATION NUMBER: CRD42019152982.

Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis.

OBJECTIVE: To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC). DESIGN: Systematic review and meta-analysis. DATA SOURCES: 8 databases searched through 22 March 2022. ELIGIBILITY CRITERIA: Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool. RESULTS: 278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I2=98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I2=99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I2=99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns. CONCLUSION: Most athletes have full RTL by 10 days but take twice as long for an RTS. PROSPERO REGISTRATION NUMBER: CRD42020159928.

Amsterdam 2022 process: A summary of the methodology for the Amsterdam International Consensus on Concussion in Sport.

The purpose of this paper is to summarise the consensus methodology that was used to inform the International Consensus Statement on Concussion in Sport (Amsterdam 2022). Building on a Delphi process to inform the questions and outcomes from the 5th International Conference on Concussion in Sport, the Scientific Committee identified key questions, the answers to which would help encapsulate the current science in sport-related concussion and help guide clinical practice. Over 3½ years, delayed by 2 years due to the pandemic, author groups conducted systematic reviews on each selected topic. The 6th International Conference on Concussion in Sport was held in Amsterdam (27-30 October 2022) and consisted of 2 days of systematic review presentations, panel discussions, question and answer engagement with the 600 attendees, and abstract presentations. This was followed by a closed third day of consensus deliberations by an expert panel of 29 with observers in attendance. The fourth day, also closed, was dedicated to a workshop to discuss and refine the sports concussion tools (Concussion Recognition Tool 6 (CRT6), Sport Concussion Assessment Tool 6 (SCAT6), Child SCAT6, Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6). We include a summary of recommendations for methodological improvements for future research that grew out of the systematic reviews.

Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review.

OBJECTIVES: To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6). DATA SOURCES: Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation. ELIGIBILITY CRITERIA: (1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC. DATA EXTRACTION: Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool. RESULTS: Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children. CONCLUSION: Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes. PROSPERO REGISTRATION NUMBER: CRD42020154787.

Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial.

OBJECTIVES: To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs. METHODS: Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care. RESULTS: A total of 2878 unique patients (1164 female, 1713 male) aged 5-17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change - 23.76 min, 95% CI - 37.99, - 9.52). Total physician claims increased significantly at only 1 of 5 sites. CONCLUSIONS: Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient. TRIAL REGISTRATION: ClinicalTrials.gov NCT05095012.

ABSTRAIT: OBJECTIFS: Mettre à l'essai les effets de la mise en œuvre active d'une voie clinique pour le traitement aigu des commotions cérébrales chez les enfants sur l'utilisation et les coûts des soins de santé. MéTHODES: Essai randomisé en grappes d'une voie clinique, échelonné, mené dans cinq services d'urgence en Alberta, au Canada, du 1 février au 30 novembre 2019. Le cheminement clinique mettait l'accent sur l'évaluation normalisée du risque de symptômes persistants, la fourniture de renseignements uniformes aux patients et aux familles, et l'aiguillage vers un suivi externe. Les données administratives dépersonnalisées ont permis de mesurer six résultats : visites de retour à l'urgence; visites de suivi en clinique externe; durée du séjour à l'urgence, y compris le temps total. le temps entre le triage et l'évaluation initiale du médecin, et le temps entre l'évaluation initiale du médecin et la décision; et le nombre total de demandes de remboursement du médecin dans un épisode de soins. RéSULTATS: Un total de 2878 patients uniques (1164 femmes, 1713 hommes) âgés de 5 à 17 ans (médiane 11,00, IQR 8, 14) répondaient aux critères de cas. Ils ont effectué 3009 visites aux 5 sites et 781 visites de suivi aux soins ambulatoires, ce qui représente 2910 épisodes de soins. La mise en œuvre n'a pas modifié la probabilité d'une visite de retour à l'urgence (RC 0,77, IC à 95 %, 0,39, 1,52), mais a augmenté la probabilité de visites de suivi en clinique externe (RC 1,84, IC à 95 %, 1,19, 2,85). La durée totale du séjour à l'urgence est demeurée inchangée, mais le temps écoulé entre l'évaluation initiale du médecin et la décision a diminué considérablement (changement moyen : -23,76 minutes, IC à 95 %, -37,99, -9,52). Le nombre total de demandes de règlement de médecins a augmenté de façon significative à seulement 1 site sur 5. CONCLUSIONS: La mise en œuvre d'un cheminement clinique à l'urgence a augmenté le suivi des patients externes et réduit le temps entre l'évaluation initiale du médecin et son élimination, sans augmenter les coûts des médecins. La mise en œuvre d'un cheminement clinique peut harmoniser davantage les soins de courte durée en cas de commotion cérébrale pédiatrique avec les lignes directrices de pratique clinique existantes tout en rendant les soins plus efficaces. ENREGISTREMENT D'ESSAI: ClinicalTrials.gov NCT05095012.