"Letter to my future self" as a device for assessing health education effectiveness.

OBJECTIVE: To examine whether a "letter to my future self" analyzed using structural topic modeling (STM) represents a useful technique in revealing how participants integrate educational content into planned future behaviors. METHODS: 453 club-sports athletes in a concussion-education randomized control study wrote two-paragraph letters describing what they hoped to remember after viewing one of three randomly assigned educational interventions. RESULTS: A six-topic solution revealed three topics related to the content of the education and three topics related to the participant behavioral takeaways. The content-related topics reflected the educational content viewed. The behavioral takeaway topics indicated that the Consequence-based education was more likely to generate the Concussion Seriousness[CS:23%] topic while Traditional(24%) and Consequence-based(20%) interventions were more likely to generate the Responsibility for Brain Health[BH] topic. Traditional(21%) and Revised-symptom(17%) interventions were more likely to generate the Awareness and Action topics. CONCLUSION: Unstructured user-generated data in the form of a "letter to my future self" analyzed using structural topic modeling provides a novel evaluation of the present and likely future impact of educational interventions. PRACTICE IMPLICATIONS: Patient educators can enhance the effectiveness of education through the application of these methods to the evaluation of and innovation in programs.

Provision of Concussion Information From Coaches and the Presence of Athletic Trainers: Findings From the 2021 YouthStyles Survey.

Coaches play an important role in concussion safety, and their views on concussion influence those of their athletes and the athletes' reporting behaviors. In this 2021 survey of youth, we examined how often coaches provide concussion safety information to their athletes and the association between coaches' provision of concussion information to athletes and the presence of athletic trainers (ATs) at a team's games and practices. More than 4 in 10 youth who played sports reported that their coaches did not provide any sort of concussion education or information to them in the past 12 months. Among those youth who always or sometimes had ATs at practices or games, 76.3% received some type of coach education on concussion in the past 12 months, compared with 31.9% of those who rarely or never had ATs at practices or games (P < .0001). Increasing access to ATs and adapting current concussion training and educational materials for coaches to increase coach-athlete communication may be beneficial.

Youth Tackle Football Head-Impact Estimation by Players and Parents: Is the Perception the Reality?

CONTEXT: With growing concerns surrounding exposure to head impacts in youth tackle football, players and parents must understand the exposure level when assenting and consenting to participate. OBJECTIVE: To determine whether youth football players and parents could estimate on-field head-impact frequency, severity, and location. DESIGN: Prospective cohort study. SETTING: Football field. PATIENTS OR OTHER PARTICIPANTS: We administered a 10-question head-impact estimation tool to parents (n = 23; mean age = 36.5 years [95% CI = 31.7, 37.3 years]) and players (n = 16 boys; mean age = 11.1 years [95% CI = 10.3, 11.8 years]). MAIN OUTCOME MEASURE(S): Player on-field head-impact exposure was captured using the Triax SIM-G system. We determined the accuracy between player and parent estimates relative to on-field head-impact exposures using κ and weighted κ values. RESULTS: Youth tackle football players and parents did not accurately estimate on-field head-impact frequency (κ range = -0.09 to 0.40), severity (κ range = -0.05 to 0.34), or location (κ range = -0.30 to 0.13). Players and parents overestimated head-impact frequency in practices but underestimated the frequency in games. Both groups overestimated head-impact severity, particularly in games. Most players and parents underestimated the number of head impacts to the top of the head, particularly during practices. CONCLUSIONS: Underestimations of head-impact frequency in games and to the top of the head suggest that informed consent processes aimed at educating players and parents should be improved. Overestimations of head-impact frequency in practices and severity may explain declining rates of youth tackle football participation.

Exploring Age and Sex Patterns for Rehabilitation Referrals After a Concussion: A Retrospective Analysis.

Objective: To explore patterns of postconcussion care at a level 1 trauma center. Design: Retrospective cohort study. Setting: U.S. level 1 trauma center and local satellite units. Participants: Patients of any age with a concussion diagnosis that reported to level 1 trauma center and local satellite units between 2016 and 2018 (N=2417). Intervention: Not applicable. Main Outcome Measures: Age, sex, point of entry, rehabilitation referrals, and pre-existing comorbidity diagnosis. Results: Patient age (mean [SD]) significantly differed among points of entry, from youngest to oldest: 26.0 (14.0) years in sports medicine, 29.3 (23.0) years in the emergency department, 34.6 (23.6) years at primary care providers, and 46.0 (19.7) years at specialty care departments. Sex also significantly differed among points of entry; emergency departments reported more men (55.6%), whereas the other points of entry reported more women (59.3%-65.6%). Patients were more likely to receive a referral from sports medicine (odds ratio [OR]unadjusted=75.05, P<.001), primary care providers (ORunadjusted=7.98, P<.001), and specialty care departments (ORunadjusted=7.62, P<.001) than from the emergency department. Women were more likely to receive a referral (ORunadjusted=1.92, P<.0001), regardless of point of entry. Lastly, patients with a preexisting comorbidity were more likely (ORadjusted=2.12, P<.001) to get a rehabilitation referral than patients without a comorbidity. Conclusions: Point of entry, age, sex, and preexisting comorbidities are associated with postconcussion care rehabilitation referral patterns. Improving concussion education dissemination across all entry points of a level 1 trauma center may standardize the postconcussion rehabilitation referral patterns, potentially improving the time to recovery from a concussion.

Association between Sensation-Seeking Behaviors and Concussion-Related Knowledge, Attitudes, Perceived Norms, and Care-Seeking Behaviors among Collegiate Student-Athletes.

There are limited data connecting personality and behavioral tendencies and traits related to concussion care-seeking/disclosure behaviors and minimal research exists surrounding the relationship between risky behaviors, sensation-seeking, and concussion-related outcomes. This study examined the association between sensation-seeking and a student-athlete's concussion-related knowledge, attitudes, perceived social norms, and concussion care-seeking/disclosure behaviors (intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury). The current study utilized a retrospective cohort of collegiate student-athletes at a single National Collegiate Athletic Association Division I institution. Separate multivariable linear regression models estimating mean differences (MD) and 95% Confidence Intervals (CI) estimated the association between sensation-seeking and concussion knowledge, concussion attitudes, and perceived social norms. Separate multivariable binomial regression models estimating adjusted prevalence ratios (PR) and 95%CI estimated the association between sensation-seeking and intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury. All models were adjusted for sex, sport participation, and concussion history. Higher sensation-seeking was significantly associated with less favorable concussion attitudes (adjusted MD = -1.93; 95%CI = -3.04,-0.83), less favorable perceived social norms surrounding concussion (adjusted MD = -1.39; 95%CI = -2.06,-0.72), and continuing to play while experiencing concussion symptoms (adjusted PR = 1.50; 95%CI = 1.10, 2.06). Student-athletes with increased sensation-seeking could be at risk for failing to disclose a concussion, decreasing athlete safety and resulting in less optimal care post-injury. Results will inform future theory-based concussion education programs which consider behavioral tendencies and traits as well as sport culture to promote concussion care-seeking/disclosure and individualized interventions based on risky behavior engagement.

Psychometric properties of concussion knowledge and cognitive mediators of reporting measures.

Context: Concussion education and prevention programs require reliable and valid instruments to evaluate the theory, mechanisms, and outcome of these interventions Objective: To assess the psychometric properties of measures evaluating concussion education and prevention programsDesign: Descriptive epidemiological Setting: 10 NCAA-member universities Patients or Other Participants: 841 student-athletes in an RCT control group testing an ecological, peer-led concussion education program Main Outcome Measures: Instruments adapted for assessing concussion knowledge and Theory of Planned Behavior/Theory of Reasoned Action (TPB/TRA) cognitive mediators of reporting behavior (attitudes, subjective norms, perceived control, and intentions to report concussion). Participants completed measures at baseline, after one hour, and after one month Results: Internal consistency and test-retest reliability were moderate for both the concussion knowledge and cognitive mediator measures. TPB/TRA was supported subscale intercorrelation and item factor analysis in the cognitive mediator scale. Factor analysis of the concussion knowledge measure revealed subscales for physical/cognitive, psychological/affective, and non-symptoms. The intermediate TPB/TRA mediators of attitudes, norms, and perceived control predicted greater intention-to-report, which predicted increased likelihood of reporting concussion one month later.Conclusions: Measures of concussion knowledge and cognitive mediators of reporting adapted from the literature show adequate psychometric properties and support TPB/TRA application for concussion reporting behaviors.

Assessment of HEADS UP online training as an educational intervention for sports officials/athletic trainers.

BACKGROUND: Sports- and recreation-related concussions are a common injury among children. Sports officials (SOs) and athletic trainers (ATs) are integral to setting the stage for safe play and managing concussions when they occur, and significant numbers of both groups have completed the Centers for Disease Control and Prevention's HEADS UP online concussion training course. However, the utility of the course for these audiences has not been assessed. We hypothesized that sports officials' and athletic trainers' concussion-related knowledge, attitudes, and behavioral intentions will improve from pre- and post-test after completing CDC's HEADS UP online concussion training course. METHOD: Respondents' concussion-related knowledge, attitudes, and behavioral intentions were assessed both before and after taking the training course. Differences between pre- and post-test scores were calculated based on the Wilcoxon Signed Rank Test Z-score or McNemar's test. Effect sizes were interpreted. RESULTS: The SOs and ATs who participated in the HEADS UP online training had a high level of concussion knowledge before taking the course: 90% or more of respondents could identify the correct response for at least seven of the 13 knowledge questions in the pre-test. Still, the course was effective at improving the respondents' knowledge about return-to-play protocols and concussion reporting. Further, SOs and ATs demonstrated improvement in their concussion-related attitudes and behavioral intentions between the pre- and post-test. CONCLUSION: SOs' and ATs' concussion knowledge, attitudes, and behavioral intentions improved immediately following completion of the CDC HEADS UP online training. Future research could also focus on the long-term retention of this type of training. Practical Applications: This study provides insight into how to better focus concussion-related educational programs to fit SOs' and ATs' needs.

A Social-Marketing Intervention and Concussion-Reporting Beliefs.

CONTEXT: Concussion-symptom education remains the primary approach used by athletic trainers to address underreporting of possible sport-related concussions. Social marketing represents an untapped approach to promote concussion reporting by communicating the benefits or consequences of reporting or not reporting, respectively. OBJECTIVE: To apply expectancy value theory and identify how marketing the possible consequences of concealing concussion symptoms influenced young adults' concussion-reporting beliefs to increase the likelihood of reporting. DESIGN: Randomized controlled clinical trial. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 468 competitive collegiate club sport athletes at a large US university who engaged in 1 of 46 sports with various levels of concussion risk. INTERVENTION(S): Participants were randomly assigned by team to 1 of 3 conditions. The treatment condition was a social-marketing program focused on the possible consequences of the reporting decision. The control condition was traditional concussion-symptom education based on the National Collegiate Athletic Association's publication, "Concussion: A Fact Sheet for Student-Athletes." An additional condition mirrored the traditional symptom education but included a less clinical delivery. MAIN OUTCOME MEASURE(S): Positive and negative beliefs regarding concussion reporting were assessed. We applied expectancy value theory, which posits that changing beliefs in the short term will produce greater reporting intentions in the long term. RESULTS: Club sport athletes exposed to consequence-based social marketing showed higher levels of positive reporting beliefs and lower levels of negative reporting beliefs than athletes exposed to traditional or revised symptom education. We observed no differences between the traditional and revised symptom-education programs. Exposure to consequence-based marketing decreased negative beliefs about reporting (B = -0.165, P = .01) and increased positive beliefs about reporting (B = 0.165, P = .01). CONCLUSIONS: Social marketing offers athletic trainers another strategic tool for motivating athletes to report concussion symptoms by translating scientific findings into marketable statements and then communicating the benefits of reporting or the negative consequences of concealing concussion symptoms.

Improving Concussion Reporting across National College Athletic Association Divisions Using a Theory-Based, Data-Driven, Multimedia Concussion Education Intervention.

Although a base level of knowledge is needed to recognize a concussion, knowledge-focused concussion educational materials ignore multifaceted barriers to concussion reporting. We compared student-athlete concussion reporting intentions and behaviors prior to and 1 year after exposure to an intervention or control treatment. We randomly assigned 891 collegiate student-athletes from three universities (Divisions I, II, III) to either the control group (National College Athletic Association [NCAA] Concussion Fact Sheet) or intervention group (theory-based, data-driven, multimedia, simulated concussion reporting module). A final sample of 520 student-athletes (control = 253, intervention = 267, expired eligibility = 189, left university = 182) completed intentions and behaviors surveys immediately prior to and 1 year after the educational intervention, and a second survey to assess the intervention effect. We compared intentions using 2 x 2 mixed model analyses of variance (ANOVAs). Behaviors and educational intervention effect were assessed using logistic regression models (α = 0.05). The intervention group had significantly improved concussion reporting intentions at 1-year follow-up relative to the control group (p = 0.009), but had similar odds for behaviors. The intervention group had 2.42 times greater odds of rating the module as "very effective," rather than "not effective" relative to the control group (95% confidence interval [CI]: 1.10,5.33). Relative to the control group, the intervention group had significantly greater odds of responding that the concussion education "greatly improved" rather than "did not improve" their knowledge (odds ratio [OR]: 2.49, 95% CI:1.25,4.96), attitudes (OR: 2.22, 95% CI: 1.23,4.03), self-efficacy (OR: 1.95,95% CI: 1.05,3.60), and intentions (OR: 1.86,95% CI: 1.03,3.35). The intervention was more effective at targeting elements of the overall sport culture in a way that substantively improved concussion reporting. We recommend use of this intervention in combination with other evidence-based educational materials.

US Centers for Disease Control and Prevention's HEADS UP Branding and Evaluation Process.

Background: For 15 years, the US Centers for Disease Control and Prevention's (CDC) HEADS UP education campaign has focused on increasing awareness of concussion among children to reduce adverse outcomes from this injury. Objective: To keep pace with the rapid expansion in media coverage, research, state laws and education efforts on concussion, the CDC embarked on a comprehensive evaluation effort to assess the campaign's brand. Method: The CDC conducted a multi-step process to evaluate HEADS UP. This included surveying partner organisations and focus groups targeting key audiences. Results: The analysis demonstrated that most (70%) partner organisations have used the materials for 4 years or longer and more than half (51%) found the materials very useful or extremely useful. Focus groups with the campaign's target audiences yielded insights and opportunities to refresh the CDC HEADS UP brand. The need for more compelling images, prevention facts and use of eye-catching colours was signaled by all the campaign's target audiences. Updates focused on the use of data visualisation, more emotionally compelling images, and more engaging colours. The CDC also created a new tagline to focus on concussion prevention that encourages children and young people to think about protecting their brains from concussion so they can have a safer future. Conclusion: This paper describes the process used to update the branding of an educational health promotion campaign in order to meet the needs of key audiences. Findings can help others working to keep their educational campaigns relevant and aligned with an expanding and changing public health problems.

Implementation and effect of concussion education in collegiate women's ice hockey.

Objective: This study aimed to determine whether collegiate women's ice hockey players are receiving pre-season concussion education and evaluate the nature and delivery of this education. Secondarily, we aimed to assess whether players who recall receiving this education have greater knowledge about concussion or are more likely to have reported suspected concussions than their peers.Methods: An anonymous survey was completed by 459 NCAA women's ice hockey players. Players self-reported receipt of pre-season concussion education, year in school, division of competition, player position, and average length of ice hockey career. Players also completed scales assessing concussion knowledge, attitudes and prior reporting behavior for suspected concussions.Results: 65.3% of athletes affirmed that they received pre-season concussion education. Lecture by an athletic trainer was the most common modality. There were no differences in concussion knowledge or attitudes by concussion education status, NCAA division of competition, or year in school. Players with higher knowledge scores were more likely than their peers to have experienced a suspected concussion and to have not reported it (p = 0.056).Conclusions: Not all NCAA women's ice hockey players are receiving (or recall receiving) mandated concussion education from their institution. The inverse association between concussion knowledge and concussion reporting behavior, while not statistically significant, is concerning and warrants further study. More work is needed to develop educational materials about concussion that are acceptable and memorable to this population, and that help increase concussion care-seeking behaviors.

Concussion competencies: a training model for school-based concussion management.

This study reports on the use of ten knowledge competencies related to the behavioral management of concussion in schools. Trainings using these competencies as learning objectives were delivered to school personnel. This aims of the use of competencies in this way are to streamline the education of key stakeholders, to establish clear roles and responsibilities for constituents and equip individuals working with students following a concussion with the relevant knowledge to optimize outcomes. The majority of participants, primarily speech language pathologists working as related service providers in the schools where the trainings occurred, judged the use of the competencies to be informative and useful to their practice both immediately following the training and at a 5-month follow-up. The greatest gains in knowledge were noted by those participants self-reporting the least amount of knowledge pre-training. Participants also ranked the perceived value and relative importance of each of the ten competencies.

The evolving landscape of policies, rules, and law in sport-related concussion.

Beginning in 2009 with the passage of the Zackery Lystedt law in the state of Washington, all 50 states have passed concussion laws that implement a mandatory framework of care for high school and youth athletes. The structure of these laws generally shares the three primary components of the Lystedt law: (1) preseason concussion education; (2) mandatory removal from play with suspected concussion; and (3) clearance from a healthcare professional prior to return to play. These same three policy components are also found at the collegiate and professional levels of sport, either through established policy or labor contracts. This chapter explores concussion-specific legal and policy developments that currently inform concussion management practices across multiple levels of the US athletic system.

Pros and Cons of 19 Sport-Related Concussion Educational Resources in Canada: Avenues for Better Care and Prevention.

Objective: The goal of this research was to assess the effectiveness of available concussion educational resources in Canada, the means used to disseminate this knowledge and the impact of these educational resources on players' concussion prevention knowledge. Methods: We assessed concussion knowledge before and after exposure to one or more of 19 resources introduced through a national program aimed to increase awareness and knowledge of concussion. The effectiveness of the mode of delivery was measured by changes in concussion knowledge scores (CKS) between pre and pro scores. Measures: Concussion knowledge scores (CKS) were calculated for pre- and post- exposure to concussion educational resources and used as a measure of both, the effectiveness of each resource as well as the effectiveness of the delivery method. The effectiveness of each educational resource was also measured by the respondents' rating of each concussion educational resource. Results: Respondents in post-survey had higher CKS than those in pre-survey. Two out of the 19 newly developed concussion educational resources were effective in improving the resource users' CKS. Linear regression showed that using more resources further increased CKS. Four out of six modes of delivery enhanced respondents' concussion knowledge. Conclusion: Our findings demonstrate that the newly developed Canadian concussion educational resources were effective at improving users' concussion knowledge. Our data demonstrates that using three or more resources further enhanced the users' concussion knowledge. Future research, however, is critical to assess whether concussion prevention knowledge is sufficient to reduce injuries and factors influencing it.

What do coaches want to know about sports-related concussion? A needs assessment study.

PURPOSE: This study aims to identify the concussion-related training and education needs of Gaelic Athletic Association (GAA) coaches in Ireland, as well as the preferred method of concussion education delivery. METHODS: We used a self-report questionnaire to collect data from a convenience sample of 108 GAA coaches in Ireland. Data were captured on (1) informational needs and desires, (2) preferred methods of delivery, and (3) concussion practices and procedures. Questionnaires were completed electronically from June 3rd-September 29th, 2015. RESULTS: Coaches indicated that they were most interested in receiving information about the (1) signs and symptoms of concussion, (2) assessment of concussion, and (3) return-to-play guidelines. Over two-thirds of participants indicated that in-person training would be the most effective mode of delivery of concussion education for this population. Additionally, only 10% coaches reported that before the start of the season they talked to their athletes about concussion management and safety, and this was more common among coaches who reported being formally educated about concussion. CONCLUSION: Our findings reveal a disconnect between the concussion education needs and the education that is currently provided to GAA coaches, in terms of content and delivery modality. Our results suggest a need for a multifaceted approach to concussion education, tailored to the needs and learning preferences of the target population.

Demographic, Parental, and Personal Factors and Youth Athletes' Concussion-Related Knowledge and Beliefs.

CONTEXT:: Currently, significant attention is focused on improving care for patients with concussions through legislative mandates that include educational interventions. Few researchers have examined young athletes' concussion knowledge and the factors that may influence their knowledge. OBJECTIVE:: To use the socioecological model to examine demographic, parental, and personal factors associated with youth athletes' knowledge of concussion. Our ultimate goal is to inform the planning and implementation of youth sport concussion-related interventions. DESIGN:: Cross-sectional survey. SETTING:: Gymnasium and classroom. PATIENTS OR OTHER PARTICIPANTS:: North Carolina and Arizona youth athletes (n = 225; age = 8 to 15 years) active in football, boys' or girls' soccer, boys' or girls' ice hockey, or boys' or girls' lacrosse in 2012-2013. MAIN OUTCOME MEASURE(S):: Participants completed a validated, self-administered survey. The intention and belief measures were guided by the theory of planned behavior. Perceptions of concussion and intention to seek care were examined using descriptive statistics. Athletes' concussion knowledge was modeled using linear regressions and generalized estimating equations, with child demographic and personal factors and parental knowledge and attitudes about concussion as predictors. RESULTS:: Geography, sport, parental attitudes toward concussion, and athlete age were associated with athlete knowledge in the univariable analyses ( P < .10). In the multivariable model, geographic location (North Carolina versus Arizona, mean difference [MD] = 2.2, 95% confidence interval [CI] = 1.1, 3.2), sport (girls' soccer versus girls' lacrosse, MD = 2.2, 95% CI = 0.7, 3.6), more favorable parental attitudes toward concussion (MD = 1.2 for a 2-standard deviation shift; 95% CI = 0.3, 2.1), and older age (>12 years, MD = 1.6; 95% CI = 0.5, 2.6) were associated with better knowledge about concussion. CONCLUSIONS:: Geographic location, sport, parental attitudes about concussion, and athlete's age influenced athletes' concussion-related perceptions, indicating the need to address multiple levels of the socioecological model when targeting youth sport interventions. Parental interventions that translate to an improved culture of youth sport by improving youth athletes' perceptions and experiences are key areas for future work.

The Lived Experiences of Retired Collegiate Athletes With a History of 1 or More Concussions.

CONTEXT: Concussions remain misunderstood, underreported, and undiagnosed. Although most concussion symptoms resolve within 2 weeks, some patients experience persistent symptoms that adversely affect physical, emotional, social, or cognitive functioning or a combination of these. Minimal evidence delineating the effect of concussions on recently retired collegiate athletes currently exists. OBJECTIVE: To examine the lived experiences of retired collegiate athletes with a history of 1 or more concussions to discern individual concussion histories, knowledge and perceptions of concussions, and postconcussion quality of life. DESIGN: Qualitative study. SETTING: Telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Former National Collegiate Athletic Association Division I athletes (n = 14) with a history of 1 or more concussions and retired from 1 to 5 years. DATA COLLECTION AND ANALYSIS: Fourteen semistructured telephone interviews (8 men and 6 women) were audiotaped. Interviews were transcribed and inductively analyzed by 3 athletic trainers with 34 combined years of professional experience. Themes were negotiated through consensual review. Participant checks were completed to ensure trustworthiness of the findings. RESULTS: Participants sustained their first concussion during adolescence and often experienced difficulties transitioning back into the postconcussion academic environment. Judgments of injury severity were clearly evident in participants' knowledge and perceptions of concussions. Participants experienced an array of emotional, physical, cognitive, and social challenges during the immediate postconcussion period but did not feel their concussion history decreased their current quality of life. CONCLUSIONS: Adolescent exposure to concussions is of concern due to the risk imposed on the developing brain and the potential for adverse outcomes later in life. Although a graduated return to play is heavily emphasized in concussion management, researchers need to investigate barriers inhibiting the implementation of return-to-learn protocols. Concussion education should aim to modify indifferent attitudes toward concussive injuries. Additionally, investigators should continue to assess how a history of concussion affects quality of life in recently retired collegiate athletes.

Sex differences in white matter alterations following repetitive subconcussive head impacts in collegiate ice hockey players.

OBJECTIVE: Repetitive subconcussive head impacts (RSHI) may lead to structural, functional, and metabolic alterations of the brain. While differences between males and females have already been suggested following a concussion, whether there are sex differences following exposure to RSHI remains unknown. The aim of this study was to identify and to characterize sex differences following exposure to RSHI. METHODS: Twenty-five collegiate ice hockey players (14 males and 11 females, 20.6 ± 2.0 years), all part of the Hockey Concussion Education Project (HCEP), underwent diffusion-weighted magnetic resonance imaging (dMRI) before and after the Canadian Interuniversity Sports (CIS) ice hockey season 2011-2012 and did not experience a concussion during the season. Whole-brain tract-based spatial statistics (TBSS) were used to compare pre- and postseason imaging in both sexes for fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD). Pre- and postseason neurocognitive performance were assessed by the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). RESULTS: Significant differences between the sexes were primarily located within the superior longitudinal fasciculus (SLF), the internal capsule (IC), and the corona radiata (CR) of the right hemisphere (RH). In significant voxel clusters (p < 0.05), decreases in FA (absolute difference pre- vs. postseason: 0.0268) and increases in MD (0.0002), AD (0.00008), and RD (0.00005) were observed in females whereas males showed no significant changes. There was no significant correlation between the change in diffusion scalar measures over the course of the season and neurocognitive performance as evidenced from postseason ImPACT scores. CONCLUSIONS: The results of this study suggest sex differences in structural alterations following exposure to RSHI. Future studies need to investigate further the underlying mechanisms and association with exposure and clinical outcomes.

Development, implementation and assessment of a concussion education programme for high school student-athletes.

Although experts have noted that adolescent athletes should be educated about concussions to improve their safety, there is no agreement on the most effective strategy to disseminate concussion education. The purpose of this study was to develop, implement and assess a concussion education programme. More precisely, four interactive oral presentations were delivered to high school student-athletes (N = 35, Mage = 15.94, SD = 0.34) in a large urban centre. Participants completed a questionnaire at three time-points during the season to measure changes in their knowledge (CK) and attitudes (CA) of concussions, and focus group interviews were conducted following the concussion education programme. Questionnaire data revealed participants' post-intervention CK scores were higher than their pre-intervention scores. During the focus groups, the student-athletes said they acquired CK about the role of protective equipment and symptom variability, and in terms of CA, they intended to avoid dangerous in-game collisions in the future. Our study was the first to create and deliver a concussion education intervention across multiple time-points, and to use mixed-methods in its assessment. These findings may be of interest to researchers, practitioners and stakeholders in sport who are invested in making the sport environment safer through concussion education and awareness.