Determinants of Intention to Disclose Musculoskeletal Injury in Adolescent Athletes.

CONTEXT: Although research indicates that the key to minimizing the effect of musculoskeletal injury, improving care, and mitigating long-term effects is to improve early injury care seeking, little is known about barriers to early musculoskeletal injury disclosure and care seeking. OBJECTIVE: To identify which determinants predicted sport-related musculoskeletal (MSK) injury disclosure by adolescent athletes. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 564 adolescent athletes (58% male, age = 15.81 ± 1.8 years). MAIN OUTCOME MEASURE(S): Online survey exploring determinants of age, gender, race, socioeconomic status, injury knowledge, attitudes, perceived social norms, and perceived behavioral control surrounding MSK injury disclosure, intention to disclose MSK injury, and actual behavior of disclosing MSK injury. RESULTS: Of the respondents, 457 (80.2%) reported having sustained ≥1 (mean = 3.2 ± 2.2; range = 1-10) MSK injuries related to sport. Those who endorsed having experienced an MSK injury disclosed not reporting or purposefully hiding 77% of their suspected MSK injuries. Several factors influenced a high intention to disclose MSK injury. Specifically, for each unit increase in total MSK injury knowledge (Exp[ß] = 1.061, ß=0.054, P = .020, 95% CI = 1.031, 1.221) and attitude (Exp[ß] = 1.070, ß = 0.064, P < .001, 95% CI = 1.027, 1.115) score, 6% and 7% increases in the likelihood of a high intention to disclose an MSK injury, respectively, were observed. Moreover, for each unit increase in the social norm score (Exp[ß] = 1.178, ß=0.164, P < .001, 95% CI = 1.119, 1.241), an 18% increase in the likelihood of a high intention to disclose an MSK injury was noted. CONCLUSIONS: Designing interventions geared toward increasing the knowledge of signs and symptoms of MSK injury, improving attitudes surrounding disclosure, and better understanding the social context of disclosing MSK injuries may improve MSK injury disclosure behavior and reduce the associated social and economic burdens of these injuries.

The initial visibility of updated recommendations on preseason heat safety in high school athletics among United States athletic trainers.

Updated recommendations on preseason heat safety in high school (HS) athletics ("2021 Consensus Statements") were published in April 2021. This cross-sectional survey study explored the initial roll-out of the 2021 Consensus Statements, including their visibility among United States HS athletic trainers (ATs) and perceived levels of confidence in implementing them. Recruitment occurred first, from a random selection of ATs from the Board of Certification, Inc., and second, an open invitation via social media. An online cross-sectional questionnaire had participating ATs note whether they had seen the 2021 Consensus Statements. If yes, ATs reported their perceived level of confidence in implementing them (5-point-ordinal scale from "not at all confident" to "very confident); if no, ATs disclosed (open-ended) why they had not yet seen them. Descriptive statistics were calculated for quantitative variables; template analysis identified codes related to visibility of and confidence in implementing 2021 Consensus Statements. Nearly half (45.7%) of 116 responding HS ATs reported having seen at least one 2021 Consensus Statements; 23.3% had reviewed all three. Common reasons among the 63 that had not seen them included: not aware they were published (n = 22), have yet to read them (n = 19), and believed they could not access the journal (n = 10). Of the 53 ATs having seen at least one of the 2021 Consensus Statements, 67.9% (n = 36) were very/fairly confident in implementing them at their HS. Reasons for confidence included their schools ensuring up-to-date EHI prevention and management practices (n = 18) and athletics constituent support (n = 8). This exploratory study observed proportions of surveyed HS ATs that had not seen the 2021 Consensus Statements and were not confident in implementing them. Findings highlight the need to continue improving messaging about access to best-practice recommendations. Further, continued efforts inclusive of active and passive dissemination strategies across all athletics constituents are needed to aid proper implementation.

The Identification and Comparison of Factors Affecting Musculoskeletal and Concussion Injury Disclosure.

CONTEXT: Despite the increased risk of musculoskeletal (MSK) injury after a concussion, little is known about the determinants of such a risk. Moreover, the authors of previous reports of increased risk of MSK injury after a concussion have neglected to account for the high level of undisclosed concussions. OBJECTIVE: To explore the association between the intention to disclose a possible concussion and the intention to disclose an MSK injury. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: One hundred seven National Collegiate Athletic Association Division I athletes (females = 79%, age = 19.4 ± 1.4 years). MAIN OUTCOME MEASURE(S): Online survey exploring determinants such as injury knowledge, attitudes, perceived social norms, and perceived behavioral control surrounding concussive and MSK injury disclosure. RESULTS: A significant association between high intention to disclose a concussion and high intention to disclose an MSK injury (χ2 = 19.276, P < .001, Cramer V = 0.482) was observed. Spearman rank correlations suggested no correlation between concussion nondisclosure (25%) and MSK injury nondisclosure (52%). Multivariate binomial regressions indicated that perceived social norms were the strongest determinant (ß = 1.365, P = .002) of high intention to disclose concussion, while attitudes toward MSK injury (ß = 1.067, P = .005) and perceived social norms (ß = 1.099, P = .013) were the strongest determinants of high intention to report MSK injury. CONCLUSIONS: Individuals with high intention to report concussion symptoms also demonstrated high intention to report MSK injury. Strong positive associations were seen between known determinants of intention to disclose concussion and adapted versions of those same determinant domains in intention to disclose MSK injury. As those with high intention to disclose concussion also displayed high intention to disclose MSK injury, intention to disclose injuries generally may play a role in explaining the increase in MSK injury after a concussion.

Does the association between concussion measures and social context factors differ in Black and white parents?

CONTEXT: Middle school (MS) parents may benefit from education supporting timely concussion identification and care-seeking in their young children (aged ∼10-15 years). However, such education may not consider individual needs and varying social context factors, including lower socioeconomic status (SES), disadvantaged social determinants of health, or different racial backgrounds. OBJECTIVE: To examine the relationship between social context factors and concussion knowledge, attitudes, and communication in MS parents, while also exploring the potential roles of race and ethnicity (Black vs. White) as an effect measure modifier. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OF OTHER PARTICIPANTS: A nationally representative sample of MS parents who completed an online survey (n=1248). MAIN OUTCOME MEASURE(S): Parent outcomes included history of previous concussion education, concussion symptom knowledge and attitudes, and communication with children about concussion. Main exposures were parent's race and ethnicity (Black vs. White) and social context factors. Uni- and multivariable statistical analyses were performed to achieve the study aims. RESULTS: Black parents were more likely than White parents to have received concussion education (69.5% vs 60.5%, p=0.009), though median concussion knowledge scores were significantly higher in White compared to Black parents (40 vs 37, p<0.001). Few associations were found within social context factors for concussion knowledge, attitudes, and communication in White and Black parents separately. CONCLUSIONS: Among MS parents, race and ethnicity may not influence the association between social context factors and concussion-related knowledge, attitudes. or communication. However, differences were found among participants by race and ethnicity regarding previous concussion education and other parent outcomes, particularly concussion symptom knowledge.

Concussion knowledge, attitudes, and norms: How do they relate?

BACKGROUND: Relationships between the constructs of concussion-related knowledge, attitudes, and norms and their influence on observed care-seeking behaviors have previously been examined. Current models posit that these constructs serve as potential mediators of care-seeking behaviors; however, the dynamics between them have yet to be reconciled. METHODS: A cross-sectional, online survey explored relationships among the latent constructs of concussion-related knowledge, attitudes, and norms in parents of middle school children who participate in sports in multiple settings. A just-identified and two overidentified path models were explored and compared in an effort to understand such relationships. RESULTS: A total of 426 parents of United States middle school students were surveyed and included in analyses (mean age = 38.7±9.9 years; 55.6% female; 51.4% white/non-Hispanic; 56.1% with at least a bachelor's degree). All parents had middle school aged children who participated in sport in both the club and school settings. The best fitting model was a just-identified model with concussion-related norms influencing concussion-related knowledge and attitudes, and concussion-related knowledge influencing attitudes. This model accounted for 14% of the variance in attitude and 12% of the variance in knowledge. CONCLUSIONS: Study findings suggest that the constructs of concussion-related knowledge, attitudes and norms are directly related to one another, yet the dynamics of such relationships may be complex. As such, a parsimonious interpretation of these constructs may not be appropriate. Future research should work to further reconcile the dynamics between these constructs, and the impact these dynamics may have in influencing care-seeking behaviors beyond serving as mediators.

Sport culture and communication among middle school athletes, parents, and staff: A qualitative study.

Middle school (MS) is an intermediary level of education between elementary and secondary school that typically includes students aged 10-15 years. There is limited research within the MS sport setting, particularly related to sport-related injury prevention. This qualitative study aimed to better understand the sport culture within MS sports and the communication strategies used among invested groups (i.e., athletes, parents, staff inclusive of coaches and school nurses). Semi-structured interviews were conducted with 19 athletes, 20 parents, and 18 staff (e.g., coaches, school nurses) from seven MS in two school districts during the 2018/19 and 2019/20 school years. Topics focused on understanding school- and sport-related factors related to education, safety, and communication. Analysis used a consensual qualitative research tradition, in which the research team discussed individually developed themes and categories from transcribed interviews, with the goal of coming to a consensus and creating a codebook. Throughout the coding process, the research team would reconvene to discuss coding decisions until consensus was reached. This study focuses on the themes of sport culture and communication. Dominant categories identified within sport culture related to participants noting why they were interested in MS sports, and their struggles with their perceived roles and engagement (e.g., helping parents stay engaged, finding coaches, oversight of school nurses). Competitiveness and safety could have conflicting roles and priority. Dominant categories identified within communication centered around limited communication between coaches and parents. Technological assistance (e.g., phone apps, websites) was available, but often varied by school and sport. Concussions were seldom discussed unless during the preseason meeting or when one occurred. Findings highlight that the MS sport settings may struggle with incorporating primary prevention into their cultures and ensuring reliable communication among individuals. Novel and tailored approaches to injury prevention are needed to help ensure buy-in and proper implementation.

Epidemiology of Concussions in National Collegiate Athletic Association (NCAA) Sports: 2014/15-2018/19.

BACKGROUND: Updated epidemiology studies examining sports-related concussions (SRCs) are critical in evaluating recent efforts aimed at reducing the incidence of SRCs in National Collegiate Athletic Association (NCAA) sports. PURPOSE: To describe the epidemiology of SRCs in 23 NCAA sports during the 2014/15-2018/19 academic years. STUDY DESIGN: Descriptive epidemiology study. METHODS: SRC and exposure data collected in the NCAA Injury Surveillance Program were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics by sport, event type (practices, competitions), injury mechanism (player contact, surface contact, equipment/apparatus contact), and injury history (new, recurrent). Injury rate ratios (IRRs) were used to examine differential injury rates, and injury proportion ratios (IPRs) were used to examine differential distributions. RESULTS: A total of 3497 SRCs from 8,474,400 athlete-exposures (AEs) were reported during the study period (4.13 per 10,000 AEs); the competition-related SRC rate was higher than was the practice-related SRC rate (IRR, 4.12; 95% CI, 3.86-4.41). The highest SRC rates were observed in men's ice hockey (7.35 per 10,000 AEs) and women's soccer (7.15 per 10,000 AEs); rates in women's soccer and volleyball increased during 2015/16-2018/19. Player contact was the most prevalently reported mechanism in men's sports (77.0%), whereas equipment/apparatus contact was the most prevalently reported mechanism in women's sports (39.2%). Sex-related differences were observed in soccer, basketball, softball/baseball, and swimming and diving. Most SRCs reported in men's sports (84.3%) and women's sports (81.1%) were reported as new injuries. CONCLUSION: Given the increasing SRC rates observed in women's soccer and volleyball during the latter years of the study, these results indicate the need to direct further attention toward trajectories of SRC incidence in these sports. The prevalence of equipment/apparatus contact SRCs in women's sports also suggests that SRC mechanisms in women's sports warrant further investigation. As most SRCs during the study period were reported as new injuries, the prevalence of recurrent SRCs in men's and women's ice hockey is also noteworthy.

The Epidemiology of Ankle Sprains in US High School Sports, 2011-2012 to 2018-2019 Academic Years.

CONTEXT: Continued monitoring of ankle sprain rates and distributions is needed to assess temporal patterns and gauge how changes in incidence may be associated with prevention efforts. OBJECTIVE: To describe the epidemiology of ankle sprains in 16 US high school sports during the 2011-2012 to 2018-2019 school years. DESIGN: Descriptive epidemiology study. SETTING: Online injury surveillance from high school sports. PATIENTS OR OTHER PARTICIPANTS: High school athletes who participated in practices and competitions during the 2011-2012 to 2018-2019 school years. MAIN OUTCOME MEASURE(S): A convenience sample of high school athletic trainers provided injury and athlete-exposure (AE) data to the National High School Sports-Related Injury Surveillance Study (data provided by High School Reporting Information Online [HS RIO]). Ankle sprain rates per 10 000 AEs with 95% CIs and distributions were calculated. Yearly rates were examined overall and by event type, injury mechanism, and recurrence. RESULTS: Overall, 9320 ankle sprains were reported (overall rate = 2.95/10 000 AEs; 95% CI = 2.89, 3.01). The highest sport-specific rates were reported in girls' basketball (5.32/10 000 AEs), boys' basketball (5.13/10 000 AEs), girls' soccer (4.96/10 000 AEs), and boys' football (4.55/10 000 AEs). Most ankle sprains occurred during competition (54.3%) and were due to contact with another person (39.5%) or noncontact (35.0%). Also, 14.5% of injuries were recurrent. Across the included academic years, ankle sprain rates generally increased. Compared with the 2011-2012 academic year, rates in the 2018-2019 academic year overall were 22% higher; noncontact-related and recurrent ankle sprain rates also generally increased by 91% and 29%, respectively. CONCLUSIONS: Time trends suggested that ankle sprain rates have increased across the past decade, particularly among those with noncontact-related mechanisms, contrasting with previous research that indicated decreases in incidence. These findings may pinpoint specific etiologic factors that should direct prevention efforts, including considering both person-contact and noncontact mechanisms by mitigating illegal contact through rule changes and enforcement, as well as bracing and proprioceptive and balance-training programs.

Use of sport-related concussion information sources among parents of United States middle school children.

OBJECTIVE: Parents may use various information sources to obtain information about sport-related concussions (SRC). This study examined SRC-related information sources used by parents of United States middle school children (age: 10-15 years). METHODS: A panel of 1083 randomly selected U.S. residents, aged ≥18 years and identifying as parents of middle school children, completed an online questionnaire capturing parental and child characteristics, and utilization and perceived trustworthiness of various sources of SRC-related information. Multivariable logistic regression models identified factors associated with utilizing each source. Adjusted odds ratios (OR) with 95% confidence intervals (95%CIs) excluding 1.00 were deemed significant. RESULTS: Doctors/healthcare providers (49.9%) and other healthcare-related resources (e.g., Centers for Disease Control and Prevention, WebMD) (37.8%) were common SRC-related information sources; 64.0% of parents utilized ≥1 of these sources. Both sources were considered "very" or "extremely" trustworthy for SRC-related information among parents using these sources (doctors/healthcare providers: 89.8%; other healthcare-related resources: 70.9%). A 10-year increase in parental age was associated with higher odds of utilizing doctors/healthcare providers (adjusted odd ratio (ORadjusted) = 1.09, 95%CI: 1.02-1.16) and other healthcare-related resources (ORadjusted = 1.11, 95%CI: 1.03-1.19). The odds of utilizing doctors/healthcare providers (ORadjusted = 0.58, 95%CI: 0.40-0.84) and other healthcare-related resources (ORadjusted = 0.64, 95%CI: 0.44-0.93) were lower among parents whose middle school children had concussion histories versus the parents of children who did not have concussion histories. CONCLUSION: One-third of parents did not report using doctors/healthcare providers or other healthcare-related resources for SRC-related information. Factors associated with underutilization of these sources may be targets for future intervention. Continuing education for healthcare providers and educational opportunities for parents should highlight accurate and up-to-date SRC-related information.

Factors associated with concussion symptom knowledge and attitudes towards concussion care-seeking among parents of children aged 5-10 years.

BACKGROUND: Understanding parents' concussion-related knowledge and attitudes will contribute to the development of strategies that aim to improve concussion prevention and sport safety for elementary school children. This study investigated the association between parent- and child-related factors and concussion symptom knowledge and care-seeking attitudes among parents of elementary school children (aged 5-10 years). METHODS: Four hundred parents of elementary school children completed an online questionnaire capturing parental and child characteristics; concussion symptom knowledge (25 items, range = 0-50; higher = better knowledge); and concussion care-seeking attitudes (five 7-point scale items, range = 5-35; higher = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher score levels. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) excluding 1.00 were deemed statistically significant. RESULTS: Select parent and child characteristics were associated with higher score levels for both outcomes. For example, odds of better knowledge level in parents were higher with increased age (10-year increase aOR = 1.59; 95% CI = 1.10-2.28), among females (aOR = 3.90; 95% CI = 2.27-6.70), and among white/non-Hispanics (aOR = 1.79; 95%CI = 1.07-2.99). Odds of more positive concussion care-seeking attitude levels were higher among parents with a college degree (aOR = 1.98; 95%CI = 1.09-3.60). Child sports participation was not associated with higher score levels for either outcome. CONCLUSIONS: Certain elementary school parent characteristics were associated with parents' concussion symptom knowledge and care-seeking attitudes. While the findings suggest providing parents with culturally and demographically relevant concussion education might be helpful, they also emphasize the importance of ensuring education/prevention regardless of their children's sports participation. Practical Applications: Pediatric healthcare providers and elementary schools offer an optimal community-centered location to reach parents with this information within various communities.

Epidemiology of Injuries in National Collegiate Athletic Association Women's Ice Hockey: 2014-2015 Through 2018-2019.

CONTEXT: The National Collegiate Athletic Association (NCAA) has sponsored women's ice hockey championships since 2001, and sponsorship has grown over time. BACKGROUND: Routine examinations of injuries sustained by athletes are important for identifying and understanding patterns that can be used to inform sport safety practices. METHODS: Exposure and injury data collected in the NCAA Injury Surveillance Program from 2014-2015 through 2018-2019 were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios were used to examine differential injury rates. RESULTS: The overall injury rate was 5.89 per 1000 athlete-exposures; preseason injury incidence rose sharply during 2016-2017 through 2018-2019. Head/face injuries (15.2%), knee injuries (13.2%), and shoulder injuries (12.9%) were the most commonly injured body parts, and injuries were most often classified as contusions (18.9%), strains (18.7%), and sprains (15.5%). Concussion (11.9%) was the most commonly reported specific injury, and concussion rates notably increased during 2017-2018 through 2018-2019. SUMMARY: Study findings were generally consistent with the existing epidemiological evidence. Injury incidence in preseason and the etiology of strains warrant further attention in this population.

Epidemiology of Injuries in National Collegiate Athletic Association Men's Ice Hockey: 2014-2015 Through 2018-2019.

CONTEXT: The National Collegiate Athletic Association has supported men's ice hockey, a distinct sport that mandates high-velocity gamesmanship, since 1974. BACKGROUND: Injury surveillance systems are designed to identify evolving injury trends and their temporal qualities. Continual monitoring of collegiate men's ice hockey athletes remains essential. METHODS: Exposure and injury data collected in the National Collegiate Athletic Association Injury Surveillance Program from 2014-2015 through 2018-2019 were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios (IRR) were used to examine differential injury rates. RESULTS: The overall injury rate was 7.65 per 1000 athlete-exposures. Injuries from competition occurred at a rate nearly 7 times that from practice injuries (IRR = 6.54, 95% CI = 6.08, 7.04). The most common specific injury diagnoses were concussions (9.6%), acromioclavicular sprains (7.3%), and medial collateral ligament tears (3.7%). SUMMARY: Injury rates by event type and season segment were higher than previously reported. Contusions accounted for nearly a quarter of all injuries, and acromioclavicular sprain rates increased notably across the study period.

Epidemiology of Injuries in National Collegiate Athletic Association Women's Field Hockey: 2014-2015 Through 2018-2019.

CONTEXT: The National Collegiate Athletic Association has sponsored women's field hockey since 1981, and team membership as well as student-athlete participation has grown over time. BACKGROUND: Routine examinations of injuries sustained by athletes are important for identifying and understanding patterns that can be used to inform sport safety practices. METHODS: Exposure and injury data collected in the National Collegiate Athletic Association Injury Surveillance Program from 2014-2015 through 2018-2019 were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios were used to examine differential injury rates. RESULTS: The overall injury rate was 6.27 per 1000 athlete-exposures (AEs). Head/face injuries (16.0%) and thigh injuries (12.3%) were the most commonly injured body parts during the 2014-2015 through 2018-2019 academic years. Concussion (8.6%) was the most commonly reported injury, and concussion rates notably decreased between 2017-2018 and 2018-2019. SUMMARY: Study findings were generally consistent with the existing epidemiologic evidence. Incidence rates and trajectories of commonly observed injuries warrant particular attention in the future.

Reporting of Concussion Symptoms by a Nationwide Survey of United States Parents of Middle School Children.

This cross-sectional study assessed concussion symptom knowledge of parents of middle school (MS) children (aged 10-15 years) through a free-response item that solicited concussion symptoms and compared findings to a pre-validated scale-based measure. A self-administered online questionnaire was sent to a panel of randomly selected United States residents who were recruited by a third-party company, aged ≥ 18 years, and identified as parents of MS children. Via a free-response item, parents listed what they believed were concussion symptoms. Multiple sections later, parents identified potential concussion symptoms via a scale measure, which featured 25 items (22 actual symptoms, three distractor symptoms) with three response options: yes, no, maybe. Free-response item responses were coded into specific symptoms. The 1062 eligible parents that provided complete data commonly identified the symptoms of dizziness (90.2%), blurred vision (87.4%), and balance problems (86.4%) on the scale-based measure. However, these and other symptoms were less commonly identified via the free-response item (dizziness: 44.4%; blurred vision: 16.5%; balance problems: 3.5%). Concussion symptoms commonly reported via the scale-based measure were reported less frequently within the free-response item. Future research must explore strategies to help clinicians working with parents and their children to measure and assess concussion symptom reporting and knowledge.

Factors associated with concussion-symptom knowledge and attitudes toward concussion care seeking in a national survey of parents of middle-school children in the US.

BACKGROUND: Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion-symptom knowledge and care-seeking attitudes among parents of MS children (aged 10-15 years). METHODS: A panel of 1224 randomly selected U.S. residents, aged ≥ 18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion-symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 point (range: 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range: 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) (excluding 1.00) were deemed statistically significant. RESULTS: Median scores were 39 (interquartile range: 32-44) for symptom knowledge and 32 (interquartile range: 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71), and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99) and in older parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47). CONCLUSION: Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion-symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention.

Approaching community priorities in youth sports injury prevention research.

BACKGROUND: Research in youth sports is often complex. As interest in youth sports injury prevention grows, scientists should consider community priorities beyond a specific research study. MAIN TEXT: This commentary discusses the authors' personal experiences researching concussion prevention in middle school sports, as the overarching community faced multiple challenges. These challenges included a series of weather-related emergencies that resulted in a shift in the community's priorities, multi-day school closures, and cancellations of sports activities and meetings. We discuss the importance of considering community priorities and providing support as scientists, colleagues, and members of the communities in which we conduct research. CONCLUSION: Scientists should consider the changing circumstances and dynamics surrounding community priorities in order to help drive their research-based decisions and ensure successful and respectful applications of research based on community values and priorities.

Concussion Knowledge, Attitudes, and Self-Reporting Intentions in Youth Athletes.

CONTEXT: Although it has been suggested that developmental and sociological factors play a role in concussion reporting, the empirical evidence related to this is limited. OBJECTIVE: To examine the influences of sex, school level, school location, concussion-reporting history, and socioeconomic status on concussion-related knowledge, attitudes, and reporting intentions among middle school and high school athletes. DESIGN: Cross-sectional study. SETTING: Master students and High School athletes attending pre-participation examinations (PPEs) were asked to complete paper-based surveys. PATIENTS OR OTHER PARTICIPANTS: Overall, 541 athletes representing 18 sports returned fully completed surveys. MAIN OUTCOME MEASURE(S): Outcomes were concussion-related knowledge, perceived seriousness, positive feelings about reporting, and self-reporting intentions. We examined group differences in these outcomes across levels of the explanatory variables of sex, school level (middle school versus high school), school location (urban versus rural), concussion self-reporting history (yes or no), and socioeconomic status (free or reduced-price lunch versus no free or reduced-price lunch) using Wilcoxon rank sum tests. Then we used multivariable ordinal logistic regression models to identify predictors of higher score levels for each outcome. Odds ratio (OR) estimates with 95% confidence intervals (CIs) excluding 1.00 were deemed significant. RESULTS: Odds of higher levels of knowledge were higher in urban versus rural school student-athletes (ORAdjusted = 1.81; 95% CI = 1.03, 3.17), and lower in student-athletes on free or reduced-price lunch versus those not on free or reduced-price lunch (ORAdjusted = 0.52; 95% CI = 0.36, 0.77). Similarly, odds of higher levels of seriousness were lower in male versus female student-athletes (ORAdjusted = 0.48; 95% CI = 0.32, 0.72). Further, odds of higher levels of self-reporting intentions were lower among male versus female student-athletes (ORAdjusted = 0.53; 95% CI = 0.37, 0.75). CONCLUSIONS: Developmental and sociological factors were differentially associated with concussion-related knowledge, attitudes, and self-reporting intentions. These results can inform medical providers, parents, and coaches with regard to context-specific clinical assessments of concussion symptoms.

Concussion Symptom Characteristics and Resolution in 20 United States High School Sports, 2013/14-2017/18 Academic Years.

BACKGROUND: High school (HS) sport-related concussions (SRCs) remain a public health concern in the United States. OBJECTIVE: To describe patterns in symptom prevalence, symptom resolution time (SRT), and return-to-play time (RTP) for SRCs sustained in 20 HS sports during the 2013/14-2017/18 academic years. METHODS: A convenience sample of athletic trainers reported concussion information to the HS RIOTM surveillance system. Symptom prevalence, average number of symptoms, and SRT and RTP distributions were examined and compared by event type (practice, competition), injury mechanism (person contact, nonperson contact), sex, and contact level (collision, high contact, and low contact) with chi-square tests and Wilcoxon rank-sum tests. RESULTS: Among all SRCs (n = 9542), headache (94.5%), dizziness (73.8%), and difficulty concentrating (56.0%) were commonly reported symptoms. On average, 4.7 ± 2.4 symptoms were reported per SRC. Overall, 51.3% had symptoms resolve in <7 d, yet only 7.9% had RTP < 7 d. Differential prevalence of amnesia was seen between practice and competition-related SRCs (8.8% vs 13.0%; P < .001); nonperson-contact and person-contact SRCs (9.3% vs 12.7%; P < .001); and female and male SRCs in low-contact sports (5.8% vs 17.5%; P < .001). Differential prevalence of loss of consciousness was seen between practice and game-related SRCs (1.3% vs 3.2%; P < .001); and female and male SRCs in high contact sports (1.2% vs 4.0%; P < .001). Differential longer SRT (>21 d) was seen between new and recurrent SRCs (9.4% vs 15.9%; P < .001). CONCLUSION: Headache was the most commonly reported symptom. Notable group differences in the prevalence of amnesia, loss of consciousness, and SRT may be associated with more severe SRCs, warranting further attention.

Exertional Heat-Stroke Management Practices and Intentions Among Secondary School Football Athletic Trainers.

CONTEXT: Athletic trainers (ATs) are educated and trained in appropriate exertional heat-stroke (EHS) management strategies, yet disparities may exist between intended and actual uses in clinical practice. OBJECTIVE: To examine the intended and actual uses of EHS management strategies among those who did and those who did not treat patients with suspected cases of EHS during the 2017 high school (HS) American football preseason. DESIGN: Cross-sectional study. SETTING: Online questionnaire. PATIENTS OR OTHER PARTICIPANTS: A total of 1016 ATs who oversaw patient care during the 2017 HS American football preseason. MAIN OUTCOME MEASURE(S): Responding HS ATs recorded whether they had or had not managed patients with suspected EHS events during the 2017 HS American football preseason. Those who had managed patients with suspected cases of EHS reported the management strategies used; those who had not managed such patients described their intended management strategies. For each management strategy, z tests compared the proportions of actual use among ATs who managed patients with suspected EHS with the proportions of intended use among ATs who did not manage such patients. RESULTS: Overall, 124 (12.2%) ATs treated patients with suspected EHS cases during the 2017 HS American football preseason. Generally, the proportions of intended use of management strategies among ATs who did not treat patients with suspected EHS were higher than the actual use of those strategies among ATs who did. For example, ATs who did treat patients with suspected EHS were more likely than those who did not treat such patients to intend to take rectal temperature (19.6% versus 3.2%, P < .001) and immerse the athlete in ice water (90.1% versus 51.6%, P < .001). CONCLUSIONS: Inconsistencies occurred between intended and actual use of EHS management strategies. The standard of care for managing patients with suspected cases of EHS was not consistently used in clinical practice, although ATs who did not treat EHS stated they intended to use these management strategies more frequently. Future researchers should identify factors that preclude ATs from using the standard of care when treating patients with suspected cases of EHS.

Statistical Methods for Handling Observation Clustering in Sports Injury Surveillance.

CONTEXT: Advances in sports injury-surveillance methods have made it possible to accommodate non-time-loss (NTL) injury reporting; however, the analysis of surveillance data now requires careful consideration of the nuances of NTL injury records. BACKGROUND: Injury-surveillance mechanisms that record NTL injuries are more likely to contain multiple injury records per athlete. These must be handled appropriately in statistical analyses to make methodologically sound inferences. METHODS: We simulated datasets of NTL injuries using varying degrees of observation clustering and compared the inferences made using traditional techniques with those made after accounting for clustering in computations of injury proportion ratios. RESULTS: Inappropriate handling of even moderate clustering resulted in flawed inferences in 10% to 12% of our simulations. We observed greater bias in our estimates as the degree of clustering increased. CONCLUSIONS: We urge investigators to carefully consider observation clustering and adapt analytical methods to accommodate the evolving sophistication of surveillance.