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.

Youth Preseason Performance on the Sport Concussion Assessment Tool 5 Across Multiple Sports.

OBJECTIVE: To examine preseason Sport Concussion Assessment Tool 5 (SCAT5) performance of adolescent sport participants by environment (in-person/virtual), sex, age, concussion history, collision/noncollision sport participation, and self-reported medical diagnoses. DESIGN: Cross-sectional. SETTING: Canadian community and high-school sport settings. PARTICIPANTS: Three thousand eight hundred five adolescent (2493 male, 1275 female, and 37 did not disclose; 11- to 19-year-old) sport participants. ASSESSMENT OF RISK FACTORS: Sport Concussion Assessment Tool 5 administration method (in-person/virtual), sex (male/female/unreported), age (years), concussion history (0/1/2/3+), collision/noncollision sport participant, and self-reported medical diagnoses [attention deficit disorder or attention-deficit/hyperactivity disorder, headache/migraine, learning disability, and psychiatric disorder (ie, anxiety/depression/other)]. OUTCOME MEASURES: Preseason SCAT5 outcomes including total number of symptoms (TNS; /22), symptom severity score (SSS; /132), Standardized Assessment of Concussion (SAC; /50), and modified Balance Error Scoring System (mBESS; /30). RESULTS: Multiple multilevel linear or Poisson regression complete case analyses adjusting for clustering and robust standard errors, with ß-coefficients (95% CI) back-transformed to indicate an increase/decrease in SCAT5 subdomains when relevant for clinical interpretation. Virtual (V) performance was associated with fewer symptoms reported [TNS Difference V-IP = -1.53 (95% CI, -2.22 to -0.85)], lower SSS [-2.49 (95% CI, -4.41 to -0.58)], and fewer mBESS errors (IP) [-0.52 (95% CI, -0.77 to -0.27)] compared with in-person. For every one-year increase in age, more symptoms [TNS = 0.22 (95% CI, 0.01-0.44)], higher SSS [0.52 (95% CI, 0.01-1.06)], higher SAC [0.27 (95% CI, 0.15-0.38), and poorer balance [mBESS = -0.19 (-0.28 to -0.09)] were observed. Differences between males and females were also seen across all SCAT5 outcomes. Individuals reporting any medical diagnosis or 3+ concussion history also reported more symptoms (TNS) and higher SSS than those who did not. CONCLUSIONS: Administration environment, sex, age, concussion history, and medical diagnoses were associated with SCAT5 subdomains and are important considerations when interpreting the SCAT5 results.

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.

Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players.

OBJECTIVE: To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion. DESIGN: Prospective cohort study, Safe to Play (2013-2018). SETTING: Youth hockey leagues in Alberta and British Columbia, Canada. PARTICIPANTS: Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions. INDEPENDENT VARIABLES: Psychosocial variables. MAIN OUTCOME MEASURES: Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit. RESULTS: Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery. CONCLUSIONS: Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review.

OBJECTIVE: To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC. DATA SOURCES: Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically. STUDY ELIGIBILITY CRITERIA: Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery. RESULTS: Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC. CONCLUSION: No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC. PROSPERO REGISTRATION NUMBER: CRD42022155121.

Adjusting to Changing Environments: Virtual Preseason SCAT5 Assessment in Canadian Male Youth Football Players.

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

It Takes Two to Tango: High Rates of Injury and Concussion in Ball Carriers and Tacklers in High School Boys' Rugby.

OBJECTIVE: To examine injury and concussion rates, mechanisms, locations, and types of injury in Canadian high school male rugby. DESIGN: Prospective cohort study. SETTING: High school male rugby. PARTICIPANTS: A total of 429 high school players (2018: n = 225, 2019: n = 256) were recruited from 12 teams in 7 schools in Calgary, Canada. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Injury surveillance included baseline questionnaires, weekly exposure, and injury reports. Injuries included those requiring medical attention, resulted in time loss and/or inability to complete a session. Concussion was defined as per the fifth Consensus on Concussion in Sport, and all players with a suspected concussion were referred to a study sport medicine physician. RESULTS: A total of 134 injuries were captured, leading to an injury incidence rate (IR) of 57.9/1000 hours [95% confidence intervals (CIs): 45.4-73.8]. Median time loss was 6 days (range: 0-90). Injuries to the head were the most common (40%), followed by shoulder (12%) and ankle (10%). The concussion IR was 22.0/1000 hours (95% CIs: 15.9-30.4), which was the most common injury type (38%), followed by sprain (20%) and strain (15%). Sixty-five percent of injuries occurred in the tackle (ball carrier 35%, tackler 30%) and 76% of concussions (ball carrier 41%, tackler 35%). CONCLUSIONS: The rate of injury and concussion in Canadian youth high school male rugby is high, with tackle-related injuries and concussions the most common. Given this, there is a critical need for implementation of prevention strategies, in particular targeting concussion and the tackle event (eg, neuromuscular, tackle training, and law changes).

Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents.

OBJECTIVES: The objective of this study is to evaluate the effect of policy change disallowing body checking in adolescent ice hockey leagues (ages 15-17) on reducing rates of injury and concussion. METHODS: This is a prospective cohort study. Players 15-17 years-old were recruited from teams in non-elite divisions of play (lower 40%-70% by division of play depending on year and city of play in leagues where policy permits or prohibit body checking in Alberta and British Columbia, Canada (2015-18). A validated injury surveillance methodology supported baseline, exposure-hours and injury data collection. Any player with a suspected concussion was referred to a study physician. Primary outcomes include game-related injuries, game-related injuries (>7 days time loss), game-related concussions and game-related concussions (>10 days time loss). RESULTS: 44 teams (453 player-seasons) from non-body checking and 52 teams (674 player-seasons) from body checking leagues participated. In body checking leagues there were 213 injuries (69 concussions) and in non-body checking leagues 40 injuries (18 concussions) during games. Based on multiple multilevel mixed-effects Poisson regression analyses, policy prohibiting body checking was associated with a lower rate of injury (incidence rate ratio (IRR): 0.38 (95% CI 0.24 to 0.6)) and concussion (IRR: 0.49; 95% CI 0.26 to 0.89). This translates to an absolute rate reduction of 7.82 injuries/1000 game-hours (95% CI 2.74 to 12.9) and the prevention of 7326 injuries (95% CI 2570 to 12083) in Canada annually. CONCLUSIONS: The rate of injury was 62% lower (concussion 51% lower) in leagues not permitting body checking in non-elite 15-17 years old leagues highlighting the potential public health impact of policy prohibiting body checking in older adolescent ice hockey players.

Injuries and Concussions in Female High School Rugby: Prevention is Worth a Try.

OBJECTIVES: To describe injury and concussion rates and mechanisms in female high school rugby players. DESIGN: Two-year prospective cohort study. SETTING: High school rugby. PARTICIPANTS: Participants included 214 female High school rugby players (year 1) and 207 female High school players (year 2) from the Calgary Senior High School Athletics Association 2018 and 2019 rugby competition. INTERVENTION: None. MAIN OUTCOME MEASURES: Match and training injury and concussion. Injury definition included any injury resulting in time loss, inability to complete a session, and/or requiring medical attention. Details of reported injuries were collected on injury report forms and validated by a certified athletic therapist on a validated online injury surveillance platform. Exposure hours for players were tracked using paper or virtual weekly exposure forms by team designates. RESULTS: A match incidence rate (IR) = 93.7 injuries/1000 match hours (95% confidence intervals (CI): 78.6-11.7) and training IR = 5.3 injuries/1000 training hours (95% CI: 4.0-6.9) were estimated. The tackle accounted for 109 (70%) match and 37 (44%) training injuries. Tackling was the most frequent mechanism of injury (IR = 37.5 injuries/1000 match hours, 95% CI: 27.5-51.8 and 1.2 injuries/1000 training hours, 95% CI: 0.7-2.4). Sixty-two match concussions (IR = 37.5 concussions/1000 match hours, 95% CI: 26.8-52.3) and 16 training concussions (IR = 1.0 concussions/1000 training hours, 95% CI: 0.7-1.4) occurred. Of 78 reported concussions, 78% for match and 56% for training were physician diagnosed. Tackling was the most frequent mechanism of concussion in matches (IR = 18.1 concussions/1000 match hours, 95% CI:11.4-28.6). CONCLUSIONS: Injury and concussion rates in female high school rugby are high. The tackle accounted for the highest proportion of injuries. Prevention strategies (eg, tackle policy change, tackle-training programs, and neuromuscular training) should be explored to increase sport safety.

Factors Associated With Clinical Recovery After Concussion in Youth Ice Hockey Players.

BACKGROUND: The identification of factors associated with clinical recovery in youth after sports-related concussion could improve prognostication regarding return to play (RTP). PURPOSE: To assess factors associated with clinical recovery after concussion in youth ice hockey players. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Participants were part of a larger longitudinal cohort study (the Safe to Play study; N = 3353). Included were 376 ice hockey players (age range, 11-17 years) from teams in Calgary and Edmonton, Canada, with 425 physician-diagnosed ice hockey-related concussions over 5 seasons (2013-2018). Any player with a suspected concussion was referred to a sports medicine physician for diagnosis, and a Sport Concussion Assessment Tool (SCAT) form was completed. Time to clinical recovery was based on time between concussion and physician clearance to RTP. Two accelerated failure time models were used to estimate days to RTP clearance: model 1 considered symptom severity according to the SCAT3/SCAT5 symptom evaluation score (range, 0-132 points), and model 2 considered responses to individual symptom evaluation items (eg, headache, neck pain, dizziness) of none/mild (0-2 points) versus moderate/severe (3-6 points). Other covariates were time to physician first visit (≤7 and >7 days), age group (11-12, 13-14, and 15-17 years), sex, league type (body checking and no body checking), tandem stance (modified Balance Error Scoring System result ≥4 errors out of 10), and number of previous concussions (0, 1, 2, and ≥3). RESULTS: The complete case analysis (including players without missing covariates) included 329 players (366 diagnosed concussions). The median time to clinical recovery was 18 days. In model 1, longer time to first physician visit (>7 days) (time ratio [TR], 1.637 [95% confidence interval (CI), 1.331-1.996]) and greater symptom severity (TR, 1.016 [95% CI, 1.012-1.020]) were significant predictors of longer clinical recovery. In model 2, longer time to first physician visit (TR, 1.698 [95% CI, 1.399-2.062]), headache (moderate/severe) (TR, 1.319 [95% CI, 1.110-1.568]), and poorer tandem stance (TR, 1.249 [95% CI, 1.052-1.484]) were significant predictors of longer clinical recovery. CONCLUSION: Medical clearance to RTP was longer for players with >7 days to physician assessment, poorer tandem stance, greater symptom severity, and moderate/severe headache at first visit.

Helmet Fit Assessment and Concussion Risk in Youth Ice Hockey Players: A Nested Case-Control Study.

CONTEXT: Injury surveillance has shown that concussions are the most common injury in youth ice hockey. Research examining the criteria for ensuring the correct fit of protective equipment and its potential relationship with concussion risk is very limited. OBJECTIVE: To evaluate the association between helmet fit and the odds of experiencing a concussion among youth ice hockey players. DESIGN: Nested case-control within a cohort study. SETTING: Calgary, Alberta, Canada. PATIENTS OR OTHER PARTICIPANTS: Data were collected for 72 concussed, 41 nonconcussion-injured, and 62 uninjured ice hockey players aged 11 to 18 years. MAIN OUTCOME MEASURE(S): Helmet-fit assessments were conducted across players and encompassed helmet specifications, condition, certification, and criteria measuring helmet fit. Using a validated injury-surveillance system, we identified participants as players with suspected concussions or physician-diagnosed concussions or both. One control group comprised players who sustained nonconcussion injuries, and a second control group comprised uninjured players. Helmet-fit criteria (maximum score = 16) were assessed for the concussed players and compared with each of the 2 control groups. The primary outcome was dichotomous (>1 helmet-fit criteria missing versus 0 or 1 criterion missing). Logistic and conditional logistic regression were used to investigate the effect of helmet fit on the odds of concussion. RESULTS: The primary analysis (54 pairs matched for age, sex, and level of play) suggested that inadequate helmet fit (>1 criterion missing) resulted in greater odds of sustaining a concussion when comparing concussed and uninjured players (odds ratio [OR] = 2.67 [95% CI = 1.04, 6.81], P = .040). However, a secondary unmatched analysis involving all participants indicated no significant association between helmet fit and the odds of sustaining a concussion when we compared concussed players with nonconcussion-injured players (OR = 0.98 [0.43, 2.24], P = .961) or uninjured players (OR = 1.66 [0.90, 3.05], P = .103). CONCLUSIONS: Inadequate helmet fit may affect the odds of sustaining a concussion in youth ice hockey players. Future investigators should continue to evaluate this relationship in larger samples to inform helmet-fit recommendations.

The Association of Saliva Cytokines and Pediatric Sports-Related Concussion Outcomes.

OBJECTIVES: This study aimed to explore cytokine alterations following pediatric sports-related concussion (SRC) and whether a specific cytokine profile could predict symptom burden and time to return to sports (RTS). SETTING: Sports Medicine Clinic. PARTICIPANTS: Youth ice hockey participants (aged 12-17 years) were recruited prior to the 2013-2016 hockey season. DESIGN: Prospective exploratory cohort study. MAIN MEASURE: Following SRC, saliva samples were collected and a Sport Concussion Assessment Tool version 3 (SCAT3) was administered within 72 hours of injury and analyzed for cytokines. Additive regression of decision stumps was used to model symptom burden and length to RTS based on cytokine and clinical features. RRelieFF feature selection was used to determine the predictive value of each cytokine and clinical feature, as well as to identify the optimal cytokine profile for the symptom burden and RTS. RESULTS: Thirty-six participants provided samples post-SRC (81% male; age 14.4 ± 1.3 years). Of these, 10 features, sex, number of previous concussions, and 8 cytokines, were identified to lead to the best prediction of symptom severity (r = 0.505, P = .002), while 12 cytokines, age, and history of previous concussions predicted the number of symptoms best (r = 0.637, P < .001). The prediction of RTS led to the worst results, requiring 21 cytokines, age, sex, and number of previous concussions as features (r = -0.320, P = .076). CONCLUSIONS: In pediatric ice hockey participants following SRC, there is evidence of saliva cytokine profiles that are associated with increased symptom burden. However, further studies are needed.